WHEN THE PATIENT HAS NO MONEY |
Wentiirim B. Annankra
“Namaste,’’ I greeted the triage nurse as I pushed the door open into the Emergency Room. I felt the warmth of the heated room on my face like a welcoming embrace as I stepped in from the Nepali cold. The setting was quite familiar. Although I had trained in Israel, I grew up in Ghana. Many of the sights within and outside this hospital in Nepal reminded me of home. It was early in the morning, so most of the beds still lay empty. The few green drapes that offered a perfunctory privacy for some beds were pulled aside. The cleaners mopped the floors, wiped down beds and changed sheets, while the gentleman in charge of performing patient electrocardiograms stood in the corner of the large ward wiping down his machine.
I moved towards the workstation at the center of the room, joining the medical interns as they gathered their reports, in preparation for morning rounds. This was my fifth week as a visiting medical student and the last day of my first week in the Emergency Department (ER). Over these weeks, I had slowly morphed from a lone standby observer who was repeatedly queried about her origins to an assistant to the on-call Pediatric ER resident. Some medical interns, who understood the plight of a visiting medical student who spoke no Nepali, greatly eased my difficulty by inviting me to work with them. They translated Nepali to English and explained what was happening in the medically familiar but culturally strange environment.
I worked side-by-side with the pediatric resident. She was diligent and meticulous, taking time with each child and parent. She would then turn to me, explain everything in English, and give me practical tips on recognizing signs that could help point towards a diagnosis. She never seemed to grow tired, repeating herself as the background din drowned out her voice. The noise coupled with my inability to read her masked lips (even in those pre-COVID -19 days as we were obliged to wear face masks in the ER), and my long-standing hearing impairment made her repetitions mandatory. But, not at all discouraged, she seemed indefatigable.
“This is a case of diarrhea; can you tell me what degree of severity you think it is?’’ she would ask. That week, we had assessed many such children. Most had acute gastroenteritis, and the majority of these were mild cases.
Towards midday, I was sitting with the resident and other interns when the triage nurse suddenly rushed in, urgently calling for the pediatric resident and the ER nurses. At her side was a young mother holding a limp toddler wrapped in layers of clothing. The young father followed closely behind. The mother was asked to remove most of the wrappings and lay the toddler on the bed in the trauma room. The team stood by expectantly, while the child’s clothing, streaked with feces, was removed. The ER nurses were ready, armed with their IV sets, and the pediatric resident was rapidly questioning the parents.
When we finally saw the child, despite my five weeks' experience in this resource-restricted environment and my prior experience from home, I was stunned. This was the most severely dehydrated toddler I had ever seen. Barely three years old, he had suffered from diarrhea for the past 8-10 days and his inexperienced parents were bringing him in only now when they finally realized he was not getting better. All extremities were clammy, pulse barely palpable and the skin around his abdomen was loose. Capillary refill was delayed, and the child's eyes were very sunken. Clearly our little patient was presenting with severe dehydration, probable shock, which called for aggressive measures —finding IV access as quickly as possible and giving bolus replacement fluids. I held my breath as the nurse prepared to find a vein. The week before in the pediatrics department, a six-month infant had presented in septic shock, and it had been so difficult to locate a usable vein that the staff had to resort to an intraosseous approach. Fortunately, in this case the experienced ER nurses found the vein in no time, and we started infusing fluids.
The child’s mother was crying. Anyone could see they came from a very low socioeconomic background. Unfortunately, patients had to pay out of pocket here and I glanced at the bill the young father held. The initial costs amounted to 2705 Nepali rupees (approx. US $24 then). I knew even this was expensive for them. He pulled out a few bank notes from his pocket and started laying them out. I cringed. The bills were small denominations: 10s and 50s and some 100s. Looking at this collection, I gauged he barely had 1000 rupees; let alone 2705 rupees. While he was doing this, the child’s mother watched him count the money. I watched her eyes glance at his hands and then back at the almost limp child in her hands, and she again started weeping inconsolably. Everyone was observing the commotion, even the patients on other beds. Unfortunately, the flimsy green drapes offered little privacy.
As all this was going on, I saw the EKG tech sidle up close and pull out his wallet, and then some more bills came out. The father gathered the papers and walked out to the cashier—precious money in one hand and orders for lab tests in the other. Later he came back with stamped papers and the interns hurried to get more tests done. At this point, one of the ER senior doctors came and decided the drip was running too slowly. The child’s varying state of consciousness and feeble pulse required a more aggressive approach. The child’s frail but painful wail pierced the atmosphere with each push of an extra bolus of fluids. Then I saw a movement. Was he beginning to respond? The father stepped aside and began wiping his eyes (the first tears I had seen him shed))—my eyes too started stinging with tears, but I blinked hard to keep them dry.
I could not help but remember instances when other doctors I knew back in Ghana had reached into their pockets and pulled out money to help patients in need. My own mother, a hospital dermatologist, had told me so many stories. There was the man with a severe exacerbation of eczema who had sat in the ward for a day without treatment simply because he had no money, until her colleague pitched in and bought his medication.
This incident in Nepal occurred four years ago and the medical landscape may have changed, yet as a medical trainee, I have seen almost identical scenes repeatedly in the various hospitals I have worked in across various resource-restricted countries in Southeast Asia and Sub-Saharan Africa. I have come to realize a primary complexity in global health involves barriers to accessing care in many developing countries, and one of these barriers is cost. Though the World Health Organization has proposed a universal healthcare system such that all individuals and communities receive the full spectrum of essential and quality healthcare services ranging from preventative care, treatment, and palliative care without suffering financial hardship, catastrophic out-of-pocket costs are still present. Those kinds of costs incurred during an unexpected illness increases the risk that people will be pushed into poverty and prevents poor people from accessing care early, promoting a vicious cycle of illness and destroying the futures of their families.
A few hours had passed, and our little charge lay asleep in his mother’s arms. The mother was not crying anymore but still looked very distraught. The father had gone out for a while. The pediatric resident walked up to me and explained her plans—the child was stable now, so he was being admitted to the pediatric ward for further monitoring. She looked at her watch; it was now hours past noon and past lunchtime. The mother carried the sleeping toddler, and the resident began wheeling the IV stand with the precious intravenous fluids still hanging and motioned to the mother to follow her.
“You go eat,’’ she looked at me and nodded towards the exit. I walked out of the ER leaving the scene of that day’s events. I could not shake off the uncomfortable feeling the young father had used all the money he had. How were they going to pay the next bill? How were they going to eat the next meal?
Four years later as a global health Neonatal Perinatal fellow, this same question perpetually rings in my head searching for the right sustainable answer. Until we achieve health equity across all regions, I will not be surprised if I find myself reaching into my pockets to pull out a few bank notes to help my patients.
Wentiirim Annankra is a Neonatal-Perinatal Medicine fellow at Mayo Clinic in Rochester, Minnesota. She is also a Clinical Educator scholar at Mayo Clinic. Her educational journey has led her through four countries (three continents) and counting. Her research interests include the use of bubble CPAP in neonates in resource-limited settings, Medical Education, Global Health and Health Equity. When she is not engaged in clinical care, she loves to write about her experiences and is also involved in travelling through the African continent learning from and teaching healthcare professionals. IG: @Wentii17