WhiteCoat

Chronic Hip Pain

“Careful, he’s been in here like six times in the past month and a half. Always looking for his narcs. Check the state database.” That was the report I got from the triage nurse as I picked up the chart.

I humored her and checked the state database. She was right. The patient had received prescriptions for opiates from 6 different physicians in the past two months — two from the hospital across town and the rest from our hospital emergency department. Each time they were only for a handful of pills – usually 10 or 12.

I went into the room with a skeptical eye.

He was moaning in pain. Couldn’t tell if he was acting or not. If he was, he was doing a pretty good job at it.
I examined his hip briefly and was horrified to feel his hip joint grind under my hands and watch his leg flop back and forth. Damn. He’s got a broken hip. I ordered an x-ray.

Then I heard his story.

He was driving to work a couple of years ago and he was broadsided by a drunk driver. Heavy vehicle damage. Suffered a broken hip and an acetabular fracture. He was taken to a trauma center and surgeons fixed his injuries. Unfortunately, the surgical site got infected. They had to remove all the hardware and inserted an antibiotic implant. Later, they planned to go back in and revise the surgery.

In the interim, the patient lost his job and his insurance. He had state minimum auto insurance that didn’t cover his medical bills. The person who hit him was uninsured and undocumented. His wife left him six months ago. He lost his house and had to move several hundred miles away to live with his son a couple of months ago.

After losing his job and his insurance, he applied for and received state insurance – Medicaid. Fortunately, he was insured.
With his insurance change, though, he had to wait almost six months for an orthopedist appointment. He even kept the appointment slip. The orthopedist evaluated him and scheduled him for surgery the following week. When he tried to find a doctor to do a pre-op physical exam, the only doctors/clinics that would take his insurance gave him an appointment three months in the future. So the surgery had to be canceled.
I hate being lied to, so I called the number on the appointment slip and checked his story out. He wasn’t lying.

When he called doctors and clinics in the area, no one in a 45 mile radius would take him as a patient because of his insurance. He’d been to several emergency departments to try to get orthopedic treatment and the orthopedists all referred him back to the original orthopedist who did his trauma surgery.
When I called our orthopedist, he looked at the x-rays and declined the case as well. High incidence of complications given the delay in treatment. Not likely that even the original surgeon will fix this now. The patient would most likely end up using crutches the rest of his life.
I felt sorry for this guy, especially seeing how well his insurance was helping him with his problems. The only assistance he received was a pair of crutches.

So I ended up doing something I’ve never done before. I gave a patient a month’s worth of Norco from the emergency department.

Any of us could be a stop light and skid mark from being in his exact same position.

What would you do?

———————–

This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

 

 

 

12 Responses to “Chronic Hip Pain”

  1. Sometimes a patient this disabled from an injury, who also has a work history, will qualify for Medicare. That would make it a little easier to get private physicians to see him. Sometimes the academic medical centers are a good choice for such complex problems, and more likely to accept a Medicaid patient. Some of the county hospitals with strong academic affiliations might fit the bill (like USC or Harbor-UCLA here in Los Angeles; both excellent). A good social worker might be able to help with the logistics of the referral and to see if he is Medicare eligible. If there is a state program for victims of violent crimes that might also help. If his job duties included the drive to work he might even qualify under work comp. The prognosis will not be great even with ideal treatment now, but a giant shame he doesn’t have access.

  2. Gene says:

    This is one of the many reasons that I support national health care. Before everyone starts howling, let me explain. This man’s health care went into the crapper WHEN HE LOST HIS JOB! It is just criminal that our health care is dependent upon our employment status. I’m a doc, so I will always have good healthcare through my job. My spouse is a scientist. He lost his job a year ago and hasn’t been able to find another one (partly because we moved for my job). I cover both of us plus our kids. But if I lost my job, suddenly, our coverage vanishes. I’m not sure what the answer is to the question of health care. But we need to remove the link from job and insurance.

  3. hashmd says:

    The problem with a national system of healthcare is that the only real Federal example of how they would run it is the VA system. Ask a Vet how happy he or she is with that system. The VA around where I’m at only has a clinic to cover 40 mile radius, only sees the vet once a year (if they remember), and basically only covers a limited formulary of meds. I, as an FP, have to coordinate the rest. All the specialty care goes on Medicare here locally, I see them on Medicare. The VA is an inefficient, underfunded system just like Medicaid is.

    • At the VA this man would have access to care. There are robust services for eligible veterans, including those who are unemployed or homeless. In fact one way for an honorably discharged veteran to become eligible is to become impoverished or disabled. This man would have access to subspecialty surgical care and rehabilitation it they were indicated. Sure the VA has problems and imperfections that can be criticized, but it is not accurate to imply that this man would not have access to the treatment he needs. Even the formulary is done in an intelligent way, reviewed by pharmacists and physicians based on what is in the best interest of patients, and with the ability to request off formulary treatments when there is medical justification. The formulary is not limited in a way that limits the ability to provide needed care. Perhaps if we had mandatory military or equivalent service requirements for all we would gradually provide access to care for many who will have earned it by virtue of their service. I agree that we should constructively criticize and improve the VA, and agree the VA is underfunded, but I don’t find your inaccurate criticism constructive in this case.

  4. Gene says:

    Agreed, Hash. The VA system sucks. And Medicaid is an underfunded mess. There just has to be something better than the for profit, bureaucratic nightmare system we have now.

  5. Gwen says:

    I am here to say how good the VA health care system has taken care of me personally. I am 100% service connected and am able to get everything I need from the VA. I have had emergency abdominal surgery there with a colostomy bag, and had that reversed there. I get every medication I take from there. I have been in the system since ’99. Personally I think having a system like the VA throughout the USA would not be such a bad thing. Sure things would be run on the bare minimum. I am able to go to see a Psychiatrist. I just had a Tympanoplasty last week! I get all my needs met and am quite thankful every day that I get to go to the VA for my health care. I would be sunk without it.

  6. Noah says:

    “If you lose your job your healthcare vanishes.”

    Of course. But so does food, shelter and clothing. You can’t have these without a job. Life and its sustenance requires activity. You cant sit around without a job and survive.

    So this is an argumant for universal job care and universal shelter care. Universal everything care?

    • Wendell says:

      All jobs don’t have insurance for one, and with preexisting conditions as a limitation many people couldn’t get it even if they could afford it. If you get sick enough for along time you can’t work, so then no insurance. I have been turned down by blue cross ins with no reason given. This happened when I was much younger and healthy. Yes and some countries do provide housing for you if you are unable to do it for yourself!

  7. Jos says:

    Apparently, Noah, you’ve not experienced the flip side of your argument. I’m glad that’s the case. As a career counselor to transitioning service members, I help people make informed decisions about unemployment insurance, finding work, and taking care of their families in the event of a transition problem (like a long turn-around between leaving the military or maybe homelessness). Unemployment insurance has a place in a society that proclaims its “civilized state.”

    Ironically, most of the people who argue against unemployment aren’t aware that we all pay taxes into the unemployment funds, including the people who lost their jobs in the first place. They paid to use that money while they worked; that is why it’s called Unemployment INSURANCE. But I assume you do know that, and I assume that if you ever were unfortunate enough to need it, or COBRA, you would know it was available.

  8. Gene says:

    Really, Noah? Clothing? A job loss means that suddenly your clothes combust? And there are plenty of jobs out there that will cover basic needs like food and shelter that DO NOT OFFER INSURANCE. Your argument smacks of the “I’m not paying for THEM” mentality. The poor in the country get Medicaid, the wealthy either self pay or have excellent insurance through their jobs. The working poor get CRAP insurance, if any.

    I know a blue collar carpet installer who works like a dog to support his family. He and his wife have four boys and he won’t let them play sports because he’s afraid they will get injured and he won’t be able to pay for it. All four births paid fully IN CASH. His company caps its employees at 45 to stay below the required insurance population. He makes around $50,000/yr, the median household income for that county. His family is otherwise completely healthy. And he CANNOT AFFORD private insurance.

    We MUST figure out a way to divorce health insurance from employment.

  9. Chris says:

    For the most part, I don’t like single payer systems and don’t think they would work here, but it really does break my heart to hear stories like this. The guy had a job and had insurance, and then he lost his job (very possibly due to the complications he was having) and also his health insurance.

    It’s very unfortunate that his orthopedist didn’t work with him more closely to get the operation. Throwing him to the wolves to get an H&P and then walking away was a bit cold. Agree with the above comments that sending him to an academic center is probably his best bet.

  10. Reese Vaughn says:

    Since his accident and subsequent job loss were caused by an uninsured, undocumented worker, perhaps the Open Borders people would like to pick up the tab for his surgery. And really, Noah, I hope you’re not a doctor practicing with that Ayn Rand mentality.

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