How often do you encounter patients from other countries with no travel insurance...

[wamcp]

I have encountered almost at least once every couple admitting shifts there are one or two patients who travelled from another country just to take advantage of the healthcare here. But have no insurance or plan to pay, and our hospital eats the costs. Anyone in the ER notice the same? Or just my city?

Had one patient was a grandfather to family living here in the US. This grandfather resided in India and had been told by his doctor there that his diabetic/PVD diseased maggot infested and gangrenous foot there would kill him and there was nothing they could do. His children flew him in and dropped him off at the nearest ER, got admitted to us and had urgent AKA by the vascular surgeon performed to save his life. No intention to pay, plans to fly back to India once diacharged.

Another patient, undocumented gang or cartel member in mexico, 19 yo got shot in the spine during a drug exchange (according to patient). Rendered paraplegic and once discharged from the Mexican hospital, his sister felt American care would be better so drove him into the US and dropped him off at our hospital ER, gets admitted for months long complaint of paraplegia, entire MRI spines, neurosurg consultation, then he gets alcohol withdrawal, stays longer for that, then says is suicidal and transferred to inpt psych for days. Zero insurance of course and zero intention to pay.

Third example, elderly demented and disinhibited/verbally abusive Pakistani grandfather was flown by his children who live in the US for worsening Parkinson’s symptoms. Dropped off in our ER and admitted. Still here on day 108. Family come up with excuses on why he has no safe dispo at home or about paying/choosing a skilled nursing facility and has devolved to straight up not answering our calls or coming to visit for a week at a time. Has no insurance. Hospital is pursuing conservatorship/guardianship over this patient by alleging the family is neglecting him so we can finally kick him out and stop abusing our staff and costing our hospital thousands per day. Basically it feels like the family is trying to dump this patient on the American health system.

Am I way off base in feeling there are patients actually exploiting us like this?

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[Groove]

I have encountered almost at least once every couple admitting shifts there are one or two patients who travelled from another country just to take advantage of the healthcare here. But have no insurance or plan to pay, and our hospital eats the costs. Anyone in the ER notice the same? Or just my city?

Had one patient was a grandfather to family living here in the US. This grandfather resided in India and had been told by his doctor there that his diabetic/PVD diseased maggot infested and gangrenous foot there would kill him and there was nothing they could do. His children flew him in and dropped him off at the nearest ER, got admitted to us and had urgent AKA by the vascular surgeon performed to save his life. No intention to pay, plans to fly back to India once diacharged.

Another patient, undocumented gang or cartel member in mexico, 19 yo got shot in the spine during a drug exchange (according to patient). Rendered paraplegic and once discharged from the Mexican hospital, his sister felt American care would be better so drove him into the US and dropped him off at our hospital ER, gets admitted for months long complaint of paraplegia, entire MRI spines, neurosurg consultation, then he gets alcohol withdrawal, stays longer for that, then says is suicidal and transferred to inpt psych for days. Zero insurance of course and zero intention to pay.

Third example, elderly demented and disinhibited/verbally abusive Pakistani grandfather was flown by his children who live in the US for worsening Parkinson’s symptoms. Dropped off in our ER and admitted. Still here on day 108. Family come up with excuses on why he has no safe dispo at home or about paying/choosing a skilled nursing facility and has devolved to straight up not answering our calls or coming to visit for a week at a time. Has no insurance. Hospital is pursuing conservatorship/guardianship over this patient by alleging the family is neglecting him so we can finally kick him out and stop abusing our staff and costing our hospital thousands per day. Basically it feels like the family is trying to dump this patient on the American health system.

Am I way off base in feeling there are patients actually exploiting us like this?

You mean free unlimited healthcare isn’t an inalienable basic human right to be offered to citizens and illegal aliens alike?

We’ve currently got an ESRD illegal Mexican immigrant who’s family brought her here for dialysis. Since she’s illegal she can’t get into any of the dialysis clinics and they refuse to take her back home because they want her nearby to be with the rest of the family so she gets 3 free sessions of dialysis in the ER every week. Welcome to America.

I was trying to figure out recently if it would be legal to report her but of course there would be bad publicity about that evil Dr Groove letting immigrants suffer in his ER and preventing them from receiving their much deserved free healthcare and the hospital would probably fire me to save face so I just keep my mouth shut.

 

[doctalaughs]

I don’t get how any Democratic-leaning doctor thinks this is a good idea? Seriously- I’m baffled. Someone please explain as a Bernie/Warren/ Harris supporter what we are supposed to think?

Everyone casts this as a “what are we supposed to do - let them die on the street?” But it’s really not that. Stabilize and immediately deport- we aren’t responsible for the lifetime care of every person on earth that decided to come illegally.

 

[GeneralVeers]

I don’t get how any Democratic-leaning doctor thinks this is a good idea? Seriously- I’m baffled. Someone please explain as a Bernie/Warren/ Harris supporter what we are supposed to think?

Everyone casts this as a “what are we supposed to do - let them die on the street?” But it’s really not that. Stabilize and immediately deport- we aren’t responsible for the lifetime care of every person on earth that decided to come illegally.

California just enacted unlimited free care for everyone in California. It will be interesting to see how it plays out.

 

[wamcp]

I don’t get how any Democratic-leaning doctor thinks this is a good idea? Seriously- I’m baffled. Someone please explain as a Bernie/Warren/ Harris supporter what we are supposed to think?

Everyone casts this as a “what are we supposed to do - let them die on the street?” But it’s really not that. Stabilize and immediately deport- we aren’t responsible for the lifetime care of every person on earth that decided to come illegally.

How would other countries handle the situations detailed above?

We have EMTALA. But everyone else doesn’t.

Canada: As the BC Council on Human Rights stated in Potter v Korn (1995),2 a physician is not required to treat every patient who comes in the door, but the decision not to treat cannot be exercised in a discriminatory manner.

Basically, Canadian physicans can refuse to treat patients without health insurance.

Responding to a patient without a health card

Considerations for physicians when a prospective patient does not have a health card.

www.cmpa-acpm.ca

 

[GonnaBeADoc2222]

Scrubs gonna scrub

 

[southerndoc]

You mean free unlimited healthcare isn’t an inalienable basic human right to be offered to citizens and illegal aliens alike?

We’ve currently got an ESRD illegal Mexican immigrant who’s family brought her here for dialysis. Since she’s illegal she can’t get into any of the dialysis clinics and they refuse to take her back home because they want her nearby to be with the rest of the family so she gets 3 free sessions of dialysis in the ER every week. Welcome to America.

I was trying to figure out recently if it would be legal to report her but of course there would be bad publicity about that evil Dr Groove letting immigrants suffer in his ER and preventing them from receiving their much deserved free healthcare and the hospital would probably fire me to save face so I just keep my mouth shut.

Get your nephrologist on board with an official protocol. We have about 10 illegal immigrants who come for dialysis. If they do not meet criteria for emergent hemodialysis, then they are discharged. They usually come back the next day. When they meet criteria, they hang in the ER until they are dialyzed, then come back to be reassessed and discharged. Sometimes they can be in the ER for hours waiting on dialysis.

We draw a point-of-care BMP on them. +/- chest x-ray as clinically appropriate. If they meet criteria, then they also get a CBC.

Criteria for emergent hemodialysis:

• K > 5.5 (if 5-5.5, kayexalate and home)
• Documented signs/symptoms of hypervolemia (CXR findings, clinical exam findings, SpO2 <92% on room air) or documented respiratory compromise
• Hypertensive urgency (>180/100) not responsive to multiple medications after 60 minutes (hydralazine, labetalol AND clonidine are given unless contraindicated)
• Point-of-care sodium bicarbonate <18
• Signs and symptoms of acute uremia or BUN >100

 

[GonnaBeADoc2222]

Get your nephrologist on board with an official protocol. We have about 10 illegal immigrants who come for dialysis. If they do not meet criteria for emergent hemodialysis, then they are discharged. They usually come back the next day. When they meet criteria, they hang in the ER until they are dialyzed, then come back to be reassessed and discharged. Sometimes they can be in the ER for hours waiting on dialysis.

We draw a point-of-care BMP on them. +/- chest x-ray as clinically appropriate. If they meet criteria, then they also get a CBC.

Criteria for emergent hemodialysis:

• K > 5.5 (if 5-5.5, kayexalate and home)
• Documented signs/symptoms of hypervolemia (CXR findings, clinical exam findings, SpO2 <92% on room air) or documented respiratory compromise
• Hypertensive urgency (>180/100) not responsive to multiple medications after 60 minutes (hydralazine, labetalol AND clonidine are given unless contraindicated)
• Point-of-care sodium bicarbonate <18
• Signs and symptoms of acute uremia or BUN >100

Nothin' else to do.

 

[GeneralVeers]

Nothin' else to do.

Exactly. We would view it as a punishment, but these people actually enjoy hanging out in the ER. They get free AC, a clean bed, food/liquids and attention. Often it's much better than being at home.

I discharge a lot of these people if they don't meet criteria. The kicking and screaming and drama from patients and family is quite entertaining.

 

[RustedFox]

... and yet, I pay 1600 a month for my health insurance, and don't want to think about meeting my minimums.

#buildthewall

 

[WilcoWorld]

To answer the OP: Not nearly as often as I encounter patients from the USA with no insurance.

Every single shift I get patients transferred in from neighboring counties within my home state for conditions that clearly can be cared for locally, and usually are, but for this patient, today...they aren't.

Yes, this happens to immigrants. It also happens frequently to people who were born, raised, and are currently employed in the midwest. I strongly suspect that most of the people you think are exploiting us would prefer to hold a regular job that assures they will have access to medical care without risking bankruptcy. Why is that so hard to find these days?

 

[RustedFox]

To answer the OP: Not nearly as often as I encounter patients from the USA with no insurance.

Every single shift I get patients transferred in from neighboring counties within my home state for conditions that clearly can be cared for locally, and usually are, but for this patient, today...they aren't.

Yes, this happens to immigrants. It also happens frequently to people who were born, raised, and are currently employed in the midwest. I strongly suspect that most of the people you think are exploiting us would prefer to hold a regular job that assures they will have access to medical care without risking bankruptcy. Why is that so hard to find these days?

Wrong question, homey. Related question, but wrong question.

 

[thegenius]

I have encountered almost at least once every couple admitting shifts there are one or two patients who travelled from another country just to take advantage of the healthcare here. But have no insurance or plan to pay, and our hospital eats the costs. Anyone in the ER notice the same? Or just my city?

Nope man...this happens ONLY in your city. I guarantee it.

I have never seen anything outrageous like that...like I've never seen someone with an acute traumatic SDH from the Dominican Republic getting on a plane and coming to the US. I've never seen > 10 cases of "I need my dialysis I just arrived in this country."

 

[thegenius]

You mean free unlimited healthcare isn’t an inalienable basic human right to be offered to citizens and illegal aliens alike?

We’ve currently got an ESRD illegal Mexican immigrant who’s family brought her here for dialysis. Since she’s illegal she can’t get into any of the dialysis clinics and they refuse to take her back home because they want her nearby to be with the rest of the family so she gets 3 free sessions of dialysis in the ER every week. Welcome to America.

I was trying to figure out recently if it would be legal to report her but of course there would be bad publicity about that evil Dr. Groove letting immigrants suffer in his ER and preventing them from receiving their much deserved free healthcare and the hospital would probably fire me to save face so I just keep my mouth shut.

Anonymously report that s&#@t. There has to be a way to do that. How long has that person been in your ED for? A few months? Bordering on a year?

I was wondering if one could conceivably say when they come into the ED with a complaint "Time for my dialysis" that all you really need to do is ensure they are not severely volume overloaded and their K+ is ok and just discharge them. They only get Emergency Dialysis not regular dialysis.

I'm aware that's a risky game to play. One day their K+ is 5.2, then they come back the next day 7.6 with severe EKG changes.

We've got a guy going on 1 month doing that at our ER. Only difference is he's American.

 

[thegenius]

Get your nephrologist on board with an official protocol. We have about 10 illegal immigrants who come for dialysis. If they do not meet criteria for emergent hemodialysis, then they are discharged. They usually come back the next day. When they meet criteria, they hang in the ER until they are dialyzed, then come back to be reassessed and discharged. Sometimes they can be in the ER for hours waiting on dialysis.

We draw a point-of-care BMP on them. +/- chest x-ray as clinically appropriate. If they meet criteria, then they also get a CBC.

Criteria for emergent hemodialysis:

• K > 5.5 (if 5-5.5, kayexalate and home)
• Documented signs/symptoms of hypervolemia (CXR findings, clinical exam findings, SpO2 <92% on room air) or documented respiratory compromise
• Hypertensive urgency (>180/100) not responsive to multiple medications after 60 minutes (hydralazine, labetalol AND clonidine are given unless contraindicated)
• Point-of-care sodium bicarbonate <18
• Signs and symptoms of acute uremia or BUN >100

I like that...

 

[thegenius]

Yes, this happens to immigrants. It also happens frequently to people who were born, raised, and are currently employed in the midwest. I strongly suspect that most of the people you think are exploiting us would prefer to hold a regular job that assures they will have access to medical care without risking bankruptcy. Why is that so hard to find these days?

Yup, most people would like to have a job making $100,000 / yr or more, as making the median in this country means you go into bankruptcy due to health care costs.

 

[gro2001]

I don’t get how any Democratic-leaning doctor thinks this is a good idea? Seriously- I’m baffled. Someone please explain as a Bernie/Warren/ Harris supporter what we are supposed to think?

I am going to assume your question is genuine and is not aimed at starting a lengthy argument.

Here is the crux of the liberal argument (other than the humanitarian one) for providing healthcare to undocumented immigrants, as I understand it:

1) The key idea is that money spent on medical care doesn't evaporate, but goes into the pockets of doctors, nurses, hospitals, etc who are basically all American tax payers and will spend the vast majority of that also in America (education for their kids, housing for their families, and healthcare costs). This in turn will create jobs too (someone has to teach the kids, build the houses, etc). Actually, if you believe in supply side economics AND the dignity of work (two common conservative talking points) then this should be pretty compelling as it combines both.

2) The second component of the argument is that by making a program truly universal it makes it easier for everyone to apply for it, even folks who would have been eligible for a more restrictive program. For example, lots of people who currently qualify for food stamps or medicaid or other services don't make use of those programs because they are really difficult to apply for in some states. For example, say you want to make healthcare (or whatever program) available to all citizens. You might design that program in a way that requires proof of citizenship to get the benefit. However, you'd be surprised, but lots of native born, totally legal US citizens would have difficulty proving their citizenship. This happens all the time for a variety of reasons, but basically it's a commonly accepted point that whatever extra hoop you introduce, some portion of the working poor won't be able to jump through it even when eligible (https://www.brennancenter.org/sites/default/files/legacy/d/download_file_39242.pdf). So by requiring proof of ctitizenship you will end up effectively excluding some of your own citizens. If it's really important to you that ALL citizens are covered by a program, it might be easiest to just make it available to everyone, regardless of citizenship, and just eat the cost of an the undocumented person using that service occasionally (who are at most about 3% of the population, and some of how might be cautious of using any government service at all, fearing coming into contact with unsympathetic authorities).

 

[thegenius]

I am going to assume your question is genuine and is not aimed at starting a lengthy argument.

Here is the crux of the liberal argument (other than the humanitarian one) for providing healthcare to undocumented immigrants, as I understand it:

1) The key idea is that money spent on medical care doesn't evaporate, but goes into the pockets of doctors, nurses, hospitals, etc who are basically all American tax payers and will spend the vast majority of that also in America (education for their kids, housing for their families, and healthcare costs). This in turn will create jobs too (someone has to teach the kids, build the houses, etc). Actually, if you believe in supply side economics AND the dignity of work (two common conservative talking points) then this should be pretty compelling as it combines both.

2) The second component of the argument is that by making a program truly universal it makes it easier for everyone to apply for it, even folks who would have been eligible for a more restrictive program. For example, lots of people who currently qualify for food stamps or medicaid or other services don't make use of those programs because they are really difficult to apply for in some states. For example, say you want to make healthcare (or whatever program) available to all citizens. You might design that program in a way that requires proof of citizenship to get the benefit. However, you'd be surprised, but lots of native born, totally legal US citizens would have difficulty proving their citizenship. This happens all the time for a variety of reasons, but basically it's a commonly accepted point that whatever extra hoop you introduce, some portion of the working poor won't be able to jump through it even when eligible (https://www.brennancenter.org/sites/default/files/legacy/d/download_file_39242.pdf). So by requiring proof of ctitizenship you will end up effectively excluding some of your own citizens. If it's really important to you that ALL citizens are covered by a program, it might be easiest to just make it available to everyone, regardless of citizenship, and just eat the cost of an the undocumented person using that service occasionally (who are at most about 3% of the population, and some of how might be cautious of using any government service at all, fearing coming into contact with unsympathetic authorities).

You're in Qatar? What would you do in the ER if some homeless, ETOH dude from, say, Switzerland came in saying he needs dialysis? Or maybe the better question is what would the standard ER doc in Qatar do?

 

[gro2001]

You're in Qatar? What would you do in the ER if some homeless, ETOH dude from, say, Switzerland came in saying he needs dialysis? Or maybe the better question is what would the standard ER doc in Qatar do?

As far as the public hospital system is concerned (which sees the bulk of patients and is far more capable than the private system), the typical ER doc would assess the patient, and if they thought that either emergent dialysis would be indicated, or it was safest to dialyze them now (say it's unclear when a regular outpatient dialysis would be arranged), they would dialyze them and/or admit them. Any care that is emergent, including emergent dialysis and admission afterwards if necessary, would be covered by the state. So would most of the medications. And yes, this applies to those who are here "illegally". Outpatient treatment without documents is harder to arrange, and the patients are charged the full unsubsidized fee (though the charges are nowhere near US prices).

There is no equivalent of EMTALA here, so a private hospital could demand payment upfront and/or turf them to the public hospital. Then again, the way things are set up here, the private hospitals aren't really fully capable, so I am not even sure if they are set up to do emergent dialysis.

I recently took care of a patient that had a stroke on an airplane and landed here. Received ER care, mechanical thrombectomy, stroke unit admission, follow up imaging, and subacute rehab stay, free of charge. Had to pay for their own statin after discharge though. Also recently had a European patient who is here "illegally" with abdominal pain. Received ER care, CT scan, admission to surgical service free of charge. Followed up for colonoscopy, got billed for it around $500.

There are some biases here about EtOH among some of the docs (a fair number of whom don't consume alcohol for religious reasons), but it's more along the lines of anchoring (being willing to attribute a little too much to alcohol intoxication when a patient who has had alcohol is acting weird), not being very good at managing the agitated intoxicated patient, or alcohol withdrawal, not having a good sense of how long it will take them to "metabolize to freedom". But no one here would deny somebody care because of alcohol intoxication, being a foreigner, or being homeless. It would be seen as an immoral thing to do.

 

[GonnaBeADoc2222]

Stroke on a plane is a far different situation from hey let's get some non emergent dialysis

 

[gro2001]

Stroke on a plane is a far different situation from hey let's get some non emergent dialysis

If you read the rest of the post, I gave some additional context.

Again, if it wasn't safe to send them on their way (unclear when/how they'd get their dialysis, no way to get it as an outpatient, etc), we'd just dialyze them. If they were totally stable and there was a reasonable discharge plan, we'd discharge them.

 

[GonnaBeADoc2222]

If you read the rest of the post, I gave some additional context.

Again, if it wasn't safe to send them on their way (unclear when/how they'd get their dialysis, no way to get it as an outpatient, etc), we'd just dialyze them. If they were totally stable and there was a reasonable discharge plan, we'd discharge them.

Why is it the ED's responsibility to secure outpatient dialysis in a stable patient?

 

[southerndoc]

Why is it the ED's responsibility to secure outpatient dialysis in a stable patient?

It's not. That's why they're discharged if they do not meet emergent dialysis criteria. It's no different than discharging a stable pneumonia, stable diverticulitis, or a fracture that doesn't require immediate/emergent surgery.

 

[doctalaughs]

If you read the rest of the post, I gave some additional context.

Again, if it wasn't safe to send them on their way (unclear when/how they'd get their dialysis, no way to get it as an outpatient, etc), we'd just dialyze them. If they were totally stable and there was a reasonable discharge plan, we'd discharge them.

This is all well and fine (and doctors everywhere feel similarly I think for emergent care). — However it has to be in the context of a reasonable societal stance on enforcement of illegal immigration.

Do you also have the problem of the same illegal immigrant showing up for emergent dialysis over and over for years? Do you have sanctuary cities? What is border enforcement like?

 

[Groove]

Anonymously report that s&#@t. There has to be a way to do that. How long has that person been in your ED for? A few months? Bordering on a year?

I was wondering if one could conceivably say when they come into the ED with a complaint "Time for my dialysis" that all you really need to do is ensure they are not severely volume overloaded and their K+ is ok and just discharge them. They only get Emergency Dialysis not regular dialysis.

I'm aware that's a risky game to play. One day their K+ is 5.2, then they come back the next day 7.6 with severe EKG changes.

We've got a guy going on 1 month doing that at our ER. Only difference is he's American.

Dude, I wish.... It would be my luck for them to find a lawyer who would plaster my name all over the local newspapers as refusing her dialysis. I'd probably make it on CNN as an out of touch, rich, heartless, republican doctor causing undue suffering to a Mexican immigrant here for (take your pick of sympathetic platitudes). Then some leftist group would make a push to report me to the state medical board. So not worth it, but....tempting! We've been taking care of this lady for months now.

Get your nephrologist on board with an official protocol. We have about 10 illegal immigrants who come for dialysis. If they do not meet criteria for emergent hemodialysis, then they are discharged. They usually come back the next day. When they meet criteria, they hang in the ER until they are dialyzed, then come back to be reassessed and discharged. Sometimes they can be in the ER for hours waiting on dialysis.

We draw a point-of-care BMP on them. +/- chest x-ray as clinically appropriate. If they meet criteria, then they also get a CBC.

Criteria for emergent hemodialysis:

• K > 5.5 (if 5-5.5, kayexalate and home)
• Documented signs/symptoms of hypervolemia (CXR findings, clinical exam findings, SpO2 <92% on room air) or documented respiratory compromise
• Hypertensive urgency (>180/100) not responsive to multiple medications after 60 minutes (hydralazine, labetalol AND clonidine are given unless contraindicated)
• Point-of-care sodium bicarbonate <18
• Signs and symptoms of acute uremia or BUN >100

Yeah, we have a similar list but to what end does it serve? These people just end up coming back the next day and simply don't care about the long delays in the emergent department. Agree with @GeneralVeers They get snacks, AC, a bed to nap on, TV in the room. It must be like the Holiday Inn to most of these people. The only thing I accomplish is to create an oftentimes heated confrontational interaction with a pt and increase my liability since when they leave....they always have a chance of coming back with a K of 8, pulmonary edema leading to respiratory decompensation or something else. Plus, they aren't going to go back to Mexico. They are going to stay right here and keep coming back tot he ER day after day. Why? Because they know they can. They know that eventually they'll get dialysis. If I call renal to buff my d/c, I end up shooting myself in the foot because most of them recommend dialysis. After all, it's no sweat off their back. The pt isn't taking up a room in their clinic. All they have to do is make a single phone call to the dialysis nurse. I used to get all Rambo and take satisfaction in kicking these people out for not meeting criteria for emergent dialysis but it doesn't accomplish anything for me, especially in this type of pt. She's not going anywhere.

 

[thegenius]

Yea man easy for us to say these things. And southern docs solution, while good, means then those people get dialysis 7-9 times a month and not 12.

I do think we over-estimate the public reaction if it ever got out that the ER discharged someone wanting dialysis who didn't have a medical emergency. "ER discharges an illegal Mexican immigrant who has gone to the ER for 6 months, every other day, to get dialysis." Your hospital would get a lot of sympathy in the court of public opinion, in my opinion.

It's a hospital problem, not an ER problem, certainly not your problem. Even the chief of your department can't do anything about this. It has to be handled by your hospital admin. It just sucks that they take up a bed for 8 hours a day.

 

[southerndoc]

If someone comes to your ER with a request to have their cardiac cath done today instead of waiting until next week, would you call the cardiologist and have them do it if they're asymptomatic?

 

[thegenius]

I've had that..I've called the cardiologist and he requested that I admit the patient. That kind of thing usually happens due to insurance problems.

 

[thegenius]

If someone comes to your ER with a request to have their cardiac cath done today instead of waiting until next week, would you call the cardiologist and have them do it if they're asymptomatic?

Actually this very thing has happened, and continues to happen around hospitals across the nation. Although most patients do feign a symptom (unlike your asymptomatic patient above).

Mt. Sinai Controversey

A snippet:

The most explosive charge in the story by David Armstrong, Peter Waldman and Gary Putka is that hospital physicians scheduled emergency room appointments for patients lacking insurance and coached them to say they were having symptoms of an acute coronary syndrome. Because they were treated in the emergency room the patients could then receive a cardiac catheterization they couldn't otherwise afford and the hospital could receive reimbursement from Medicaid, according to the Bloomberg story.

"On a pair of representative Sundays in 2012, 10 patients told ER workers they’d been instructed to arrive there before their cath-lab appointments, according to internal hospital correspondence. Two of them said they’d been coached to say they were having acute symptoms of heart disease, according to the exchanges."

 

[gro2001]

Yea man easy for us to say these things. And southern docs solution, while good, means then those people get dialysis 7-9 times a month and not 12.

I do think we over-estimate the public reaction if it ever got out that the ER discharged someone wanting dialysis who didn't have a medical emergency. "ER discharges an illegal Mexican immigrant who has gone to the ER for 6 months, every other day, to get dialysis." Your hospital would get a lot of sympathy in the court of public opinion, in my opinion.

It's a hospital problem, not an ER problem, certainly not your problem. Even the chief of your department can't do anything about this. It has to be handled by your hospital admin. It just sucks that they take up a bed for 8 hours a day.

I can't imagine there would be outcry over someone being discharged from the ER, whatever the circumstances (unless they ended up having a bad outcome).

There would totally be a ****storm if it got out than an ER doc reported a patient to ICE.

 

[thegenius]

Get your nephrologist on board with an official protocol. We have about 10 illegal immigrants who come for dialysis. If they do not meet criteria for emergent hemodialysis, then they are discharged. They usually come back the next day. When they meet criteria, they hang in the ER until they are dialyzed, then come back to be reassessed and discharged. Sometimes they can be in the ER for hours waiting on dialysis.

We draw a point-of-care BMP on them. +/- chest x-ray as clinically appropriate. If they meet criteria, then they also get a CBC.

Criteria for emergent hemodialysis:

• K > 5.5 (if 5-5.5, kayexalate and home)
• Documented signs/symptoms of hypervolemia (CXR findings, clinical exam findings, SpO2 <92% on room air) or documented respiratory compromise
• Hypertensive urgency (>180/100) not responsive to multiple medications after 60 minutes (hydralazine, labetalol AND clonidine are given unless contraindicated)
• Point-of-care sodium bicarbonate <18
• Signs and symptoms of acute uremia or BUN >100

Do your ER's have a similar protocol for blood transfusions?

 

[Siggy]

I don’t get how any Democratic-leaning doctor thinks this is a good idea? Seriously- I’m baffled. Someone please explain as a Bernie/Warren/ Harris supporter what we are supposed to think?

Everyone casts this as a “what are we supposed to do - let them die on the street?” But it’s really not that. Stabilize and immediately deport- we aren’t responsible for the lifetime care of every person on earth that decided to come illegally.

Is it a good idea?
No.

But until we can refuse to treat patients who refuse to pay, I'd at least like to be reimbursed for the care provided under Federal mandate.

 

[alpinism]

I have encountered almost at least once every couple admitting shifts there are one or two patients who travelled from another country just to take advantage of the healthcare here. But have no insurance or plan to pay, and our hospital eats the costs. Anyone in the ER notice the same? Or just my city?

Had one patient was a grandfather to family living here in the US. This grandfather resided in India and had been told by his doctor there that his diabetic/PVD diseased maggot infested and gangrenous foot there would kill him and there was nothing they could do. His children flew him in and dropped him off at the nearest ER, got admitted to us and had urgent AKA by the vascular surgeon performed to save his life. No intention to pay, plans to fly back to India once diacharged.

Another patient, undocumented gang or cartel member in mexico, 19 yo got shot in the spine during a drug exchange (according to patient). Rendered paraplegic and once discharged from the Mexican hospital, his sister felt American care would be better so drove him into the US and dropped him off at our hospital ER, gets admitted for months long complaint of paraplegia, entire MRI spines, neurosurg consultation, then he gets alcohol withdrawal, stays longer for that, then says is suicidal and transferred to inpt psych for days. Zero insurance of course and zero intention to pay.

Third example, elderly demented and disinhibited/verbally abusive Pakistani grandfather was flown by his children who live in the US for worsening Parkinson’s symptoms. Dropped off in our ER and admitted. Still here on day 108. Family come up with excuses on why he has no safe dispo at home or about paying/choosing a skilled nursing facility and has devolved to straight up not answering our calls or coming to visit for a week at a time. Has no insurance. Hospital is pursuing conservatorship/guardianship over this patient by alleging the family is neglecting him so we can finally kick him out and stop abusing our staff and costing our hospital thousands per day. Basically it feels like the family is trying to dump this patient on the American health system.

Am I way off base in feeling there are patients actually exploiting us like this?

Happens on a daily basis here in Detroit.

We’ve got a large immigrant population and It’s very common for many people to bring their elderly or debilitated grandma or grandpa here for care. What usually happens is that people go home to find their parents unable to take care of themselves and decide take them back here to the states. Because they’re not citizens and don’t have insurance they essentially drop them off in the ER with vague complaints and generalized weakness for months. The patients don’t speak English and are severely demented so most docs just pan scan them and order every lab test available and they end up getting admitted until they can be placed in a nursing home.

 

[RustedFox]

Happens on a daily basis here in Detroit.

We’ve got a large immigrant population and It’s very common for many people to bring their elderly or debilitated grandma or grandpa here for care. What usually happens is that people go home to find their parents unable to take care of themselves and decide take them back here to the states. Because they’re not citizens and don’t have insurance they essentially drop them off in the ER with vague complaints and generalized weakness for months. The patients don’t speak English and are severely demented so most docs just pan scan them and order every lab test available and they end up getting admitted until they can be placed in a nursing home.

Here too.
They bring papi from the Dom.Rep or mama from Haiti and the exact same sequence of events transpires.

 

[Ceez]

Out of all the numerous inappropriate uses of emergency care, immigrants coming in for care isn't top on my list of annoyances. You seem to have a problem with immigrants, or maybe you just need a vacation. I'll trade you 10 of my American born drug seekers for one of your Indian dialysis patients any day. I get paid either way.

 

[southerndoc]

Do your ER's have a similar protocol for blood transfusions?

Yes, hemoglobin must be <7 for transfusion unless there are other circumstances (active bleeding, hemodynamic instability, active cardiac ischemia, etc.). This is official health system policy. We see people referred by their PCP for a transfusion because their hemoglobin is 7.6 and they get discharged with iron supplements (after a repeat CBC to confirm it's >7). Any blood transfusion requires hospitalist observation admission. We get no push back on it.

 

[thegenius]

This appears to be more of a PR problem than a legal one...we are able to discharge people who are weak, debilitated, want dialysis, and a variety of other things. But if we discharge them I fear hospital admin backlash...because someone will post on social media how "Free Care Hospital" isn't helping my grandma who is 86 and is so weak she can't even walk up and down the stairs!

I don't mind giving real emergency care to those who need it...doesn't matter if you are American or from half-way around the world. If I'm in Germany or Brazil and get into a car accident, I hope I get good emergency care. Likewise if those people come into my ER who are really sick, I'll be happy to take care of them.

 

[Groove]

We also don't perform transfusions in the ED unless it's emergent. All transfusions get admitted per hospital policy for obs. The worst offenders are nephrologists who send their ESRD pts over for a transfusion and their HGB is 7.3. I usually send them right back home.

Though, admittedly...in the last few years as I've developed better relationships with our renal docs, I've been known to get softy on them and will admit to the hospitalist and order the transfusion to help them out. We have one who I really like and I try to soften my inner Gengis Khan with a little bit of Mister Rogers to help maintain good relations with some of these guys but it's admittedly frustrating. Luckily, they got the point awhile back and I don't get many of these anymore.

 

[GonnaBeADoc2222]

Out of all the numerous inappropriate uses of emergency care, immigrants coming in for care isn't top on my list of annoyances. You seem to have a problem with immigrants, or maybe you just need a vacation. I'll trade you 10 of my American born drug seekers for one of your Indian dialysis patients any day. I get paid either way.

It has nothing to do with being an immigrant.

It has everything to do with expecting non emergent care on demand, with no financial skin in the game, with no gratitude.

There are patients from all backgrounds and all socioeconomic statuses that are extremely humble, respectful and thankful for physicians time and effort. These patients are a pleasure to work with.

It's the same attitude I display towards my fellow physician when I show up for my scheduled non-emergent care, still have to wait about an hour for it, and contribute to the system through premiums and copayments.

 

[RustedFox]

I don't mind giving real emergency care to those who need it...doesn't matter if you are American or from half-way around the world. If I'm in Germany or Brazil and get into a car accident, I hope I get good emergency care. Likewise if those people come into my ER who are really sick, I'll be happy to take care of them.

See; but your plan isn't - "I'm going to intentionally take my chronic and poorly managed problem and illegally enter Germany when it gets unmanageable with no plans on either paying or leaving."

Oranges to Cadillacs, amigo.

 

[NYEMMED]

I used to work in NYC near a major international airport. It happened several times per shift.
Elderly or sick person flew to US, walk out of the airport, call 911, and now are at my ED. Usually with something infectious, or malignant. They are treated/admitted/discharged and then go back to their country. The hospital/city are left with the bill.

 

[GeneralVeers]

This thread is more evidence of why we are the stupidest country the world. Not a US Citizen and want dialysis? Great, we should dialize you once, then US border patrol picks you up, and you're on the first flight back to your home country that day.

 

[deleted109597]

I can't imagine there would be outcry over someone being discharged from the ER, whatever the circumstances (unless they ended up having a bad outcome).

There would totally be a ****storm if it got out than an ER doc reported a patient to ICE.

The number of people at my system with the SSN of 777-77-7777 numbers in the 5 digits. We often have 30-40 people who show up every morning to be screened for emergent dialysis. 95% of them are sent home to come back again tomorrow.
And yes, being here illegally is a misdemeanor. But since we have mandatory reporting of many conditions, I fail to see why this one should be any different. Honestly, I think DUIs should be mandatory reporting as well.
Between this and private insurance not paying for emergency visits anymore, realize that we are all looking at serious pay cuts in the near future. I may check out Qatar while I'm an there next month...

 

[Lexdiamondz]

This thread is more evidence of why we are the stupidest country the world. Not a US Citizen and want dialysis? Great, we should dialize you once, then US border patrol picks you up, and you're on the first flight back to your home country that day.

Honestly it's probably cheaper to do that than to keep dialysing them.

 

[GeneralVeers]

The number of people at my system with the SSN of 777-77-7777 numbers in the 5 digits. We often have 30-40 people who show up every morning to be screened for emergent dialysis. 95% of them are sent home to come back again tomorrow.
And yes, being here illegally is a misdemeanor. But since we have mandatory reporting of many conditions, I fail to see why this one should be any different. Honestly, I think DUIs should be mandatory reporting as well.
Between this and private insurance not paying for emergency visits anymore, realize that we are all looking at serious pay cuts in the near future. I may check out Qatar while I'm an there next month...

Been to Qatar. I would never live there. Definitely would consider Dubai or Abu Dhabi as they are much more tolerant, with decent nightlife.

 

[thegenius]

We also don't perform transfusions in the ED unless it's emergent. All transfusions get admitted per hospital policy for obs. The worst offenders are nephrologists who send their ESRD pts over for a transfusion and their HGB is 7.3. I usually send them right back home.

Though, admittedly...in the last few years as I've developed better relationships with our renal docs, I've been known to get softy on them and will admit to the hospitalist and order the transfusion to help them out. We have one who I really like and I try to soften my inner Gengis Khan with a little bit of Mister Rogers to help maintain good relations with some of these guys but it's admittedly frustrating. Luckily, they got the point awhile back and I don't get many of these anymore.

It's so easy to transfuse while getting dialysis. Why can't the nephrologists just transfuse a unit of blood at the next dialysis session? Too hard to set up at the outpatient DaVita or Fresenius centers?

 

[CajunMedic]

It's so easy to transfuse while getting dialysis. Why can't the nephrologists just transfuse a unit of blood at the next dialysis session? Too hard to set up at the outpatient DaVita or Fresenius centers?

Checked with Mrs. Medic on this one, she’s been on Hemo for about 10 years now. She can’t recall ever seeing a transfusion in any of the centers she’s dialyzed at.

It Probably is difficult to set up. there’s usually only 1 RN per shift, and 1 tech for every 2-4 machines and they stay busy with taking people on and off. Doubtful any of them have ever been trained to work with blood products, or all the steps for receiving and hanging it like what’s required in the hospital

 

[gro2001]

Been to Qatar. I would never live there. Definitely would consider Dubai or Abu Dhabi as they are much more tolerant, with decent nightlife.

I've spent a fair amount of time in all of the above. Yeah, Dubai has a better nightlife than Qatar, though Qatar has gotten better in the last few years. Still not great, but much better than it was even 5 years ago. I feel Abu Dhabi is still pretty boring. Dubai is somewhat more tolerant, but still in the same ballpark.

 

[gro2001]

The number of people at my system with the SSN of 777-77-7777 numbers in the 5 digits. We often have 30-40 people who show up every morning to be screened for emergent dialysis. 95% of them are sent home to come back again tomorrow.
And yes, being here illegally is a misdemeanor. But since we have mandatory reporting of many conditions, I fail to see why this one should be any different. Honestly, I think DUIs should be mandatory reporting as well.
Between this and private insurance not paying for emergency visits anymore, realize that we are all looking at serious pay cuts in the near future. I may check out Qatar while I'm an there next month...

30-40 every morning is a lot. I can see how that would put a significant strain on your system and your patience.

Something that makes me uncomfortable about people's willingness to snitch to law enforcement is that being unlawfully present is not like other reportable conditions. We report things that are an obvious threat to the public. TB and such. I could see the argument that DUIs might be in the same kind of ballpark. But the date of expiry of someone's visa or something like that is just not turning them into a public menace. It's not like it's contagious.

Also, immigration law is strange. You'd be surprised at what can make you "illegal". It's not all people crossing the border under cover of darkness. It's people overstaying their visa, messing up renewal of their status paperwork, etc. It's also often something stupid like not informing the USCIS of an address change (or the USCIS losing that paperwork; you have to inform them by mail and they don't send a confirmation, lose your notification and bam you're illegal) or a myriad other things. Anyway, it's complicated, and I don't see people being so willing to be oh so extra cooperative with law enforcement in other non violent crimes.

 

[deleted109597]

30-40 every morning is a lot. I can see how that would put a significant strain on your system and your patience.

Most get screened in triage. But yeah, every now and then one of them dies suddenly because their K is 8 or whatever. And then there's the fact that by noon we have no dialysis slots for the rest of the day. So for the other people that need it, they get to wait until tomorrow, or die.