Tuesday, May 18, 2010

Thoughts on an ER

I spent last night with a friend at the ER. It was a long, long night, but a good experience overall.

I've lived here for 20 years, but have had very few experiences with the public health system. My poor friend M. was immersed in it less than a month after her arrival. It was a valuable experience for me because it helped demystify the system, to which I am entitled to full access, and of which I would like to avail myself sometime this year to get a long-term, non hormonal birth control solution, in addition to catching up on routine preventive care.

Of course, this won't take place through the ER, but I spent many many hours inside the hospital and got a feel for what it really means to go through the system.

The first impression is not a good one. M. had been there since about 6:30 pm (having spent several hours at the smaller local clinic earlier in the day). I was able to go down to the hospital and find her around 8:00 pm. The waiting room was crowded with the usual cross-section of humanity: many parents with young children, a few non-catastrophically injured adults and a lot of people who clearly just felt like crap. The benches were hard, the room bright but shabby, and there was an actual (if small) smear of blood on the wall behind my friend. There wasn't room to sit together (and M. really didn't need to be getting up and moving around the room), so I sat on the floor while we waited for her name to be called.

When she finally was, we figured out where to go and were briefly questioned by the security guy at the door - only the patient is supposed to go on through, but I told him she didn't speak Spanish and he let me go in. I was allowed to stay with her almost the whole time.

Back at the nurses' station, there were six gurneys lined up in a space designed for three, with people who had apparently been admitted lying there trying to sleep. More patients in hospital garb (either blue or salmon colored, it was more like scrubs than johnnies, with a wrap-around robe style for some of the women) were seated in a row of chairs, and two (three?) more gurneys were crammed in behind the nurses' station.

We approached the desk and said we had been called, and the guy who was standing there turned out to be the doctor. He motioned us and the other patient he had called toward a tiny room that had one desk and two gurneys (these divided by a curtain) . One was occupied by a bleeding man with an IV and the other by a woman with a persistent cough. The doctor took the other new patient first, while we stood in everyone's way. I found M. a chair.

...okay, if I keep going like this, this post could get epically long, and I'm not sure I'm up to that. Let's see if I can switch over to general observations.

The place was crowded and we would be told things like, "go to _____" without it being clear where _____ was. Asked for clarification, most of the time people would point. It was quite a small space, but with so many people between "here" and "there" it still felt overwhelming.

The space was shabby and obviously too crowded (and, to a lesser extent, understaffed) to adequately handle the demand they were facing. We kept getting told where to go, and then (except for the reception desk, which we revisited several times over the course of things) finding just a muddle of people instead of a line, so you had to kind of push for your turn.

The people on the gurneys were lying there, suffering whatever brought them to the ER in the first place, in full view of everyone (not that many people were paying them any attention). They were so closely packed the doctors and nurses had to push them apart to get close enough to give any care. If someone needed a shot in the butt, a shot in the butt was administered then and there.

Those were the first impressions.

The doctor who saw M. around 9:00 pm was friendly and asked the right sorts of questions, and had a computer into which to enter the answers. The examining room was, as I said, already occupied and privacy was simply not a consideration. No one was asked to disrobe, and for the most part nobody was paying attention, but I heard plenty of peoples' conversations with the doctors, saw the (clothed) exams, and watched the bleeding guy trying to get someone's attention. Our doctor was interrupted several times by other personnel needing him to do something for them on the computer.

Something I already knew about the public health care system here, is what I decided last night to call the "brute force" approach. It's kind of a "broad side of the barn" thing. Almost everyone is entitled to care, and the system is operating with limited resources. There are a few standard treatments and most people receive them as an initial measure. I can't tell you how many little plastic bags filled with cards of acetaminophen and penicillin I have seen in my Costa Rican families' homes over the years.

In the ER, the "brute force" approach consists of either oxygen or an IV. Almost everyone I saw had one or other - or had already gotten past that stage, as almost all the patients had an IV stent in the back of one hand. Medications were administered via those two means as well, either in a small IV bag or injected into the nebulizer.

I've always heard, and I think last night bears it out, that the Costa Rican health care system improves, the sicker you are. You're in the ER for a minor injury or sudden illness, you're going to get the "brute force" treatments, no matter what. But if you need actual surgery or advanced care, there is some highly specialized expertise out there that will be made available to you.

Our initial experiences were more of the former sort. M was uncomfortable and needed some attention to her IV, and the answer was basically, "that kind always hurts" and, later, "she's already had some pain medication, and we only have so much we can give out."

Those were some of our second impressions.

Things that you don't immediately notice in the confusion and overwhelmingness of a foreign ER, but which we did eventually pick up on make up my final impressions:

  • There was no particular smell. It didn't smell unclean or even medicinal.

  • There was a sign up in the initial waiting room, saying "If you have two or more of these [flu] symptoms, use the facility around the corner." There were lots of people there, but hardly any of them appeared contagious.

  • The personnel seemed to have a good rapport with each other. They spoke casually as well as professionally to each other, asked for and received help. They touched each other supportively.

  • In nearly 10 hours, the most overt sign of frustration I saw anyone exhibit toward a patient was an eyeroll, which the patient (who was reluctant to be moved to make room for someone else) did not see. An elderly man who was there the whole time became noisy and then disruptive, and he was verbally rebuked and physically removed, but in appropriate ways.

  • Everyone was at least civil and often cordial in their treatment of the patients, including the security guard asking family members to leave the nurses' station which is meant to be for patients only.

  • Although I felt at first that my requests for some additional attention to my friend were probably being perceived as Gringo Entitlement, when they learned more about the nature of her discomfort and reached a probable diagnosis, the level and quality of care she received improved noticeably.
...There's probably more, but I've had two two-hour naps today and I can't think of it now. All in all, a good experience to have had for me, as a consumer of this system, and for M., who is satisfied with the results she obtained, and knows what she wants to do next in pursuing her own care.

Oh. That's right.

As someone who has no coverage whatsoever, M received a 2-hour IV drip, four different medications, an x-ray, and was seen by two different doctors (one of them twice) and countless nurses. Nobody asked until we went to leave if she had coverage. In fact the final receptionist, who appeared to be new, appeared to assume she was covered, and I had to ask her if M owed anything.

She was charged $20.

In addition to fixing a couple of typos above, I've remembered a few more things I meant to include on the bulleted list above:
  • There were very few bodily fluids to be seen. Not that there weren't any being produced, but cleanup was called for and provided.

  • We were there for about 10 hours, and many of the people we saw toward the end had also been there early on. Apparently this is just how long it takes to go through the system.

  • Most of the patients seemed...content? accepting? resigned? I heard no complaining about the wait from anyone around me. There were plenty of children, but none of them were whining or fussing.

  • It wasn't noisy. There were a few crying kids, mostly in the oxygen room, and one crying mother whose child was in an ER operating room, and who was subsequently whisked away by ambulance (with his mother).

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