Go or Die

"We're all in the same boat, staying afloat for a moment." -Gotye, Eyes Wide Open

One of the most simultaneously heartbreaking and frustrating things in clinic is encountering a patient who needs to go to the Emergency Department or else they'll die, but refuses to go.

Certainly people have their reasons, and the top 3 that I've encountered include A) being concerned about the cost, B) not having the time, and C) being terrified of getting shipped around a hospital in an unfamiliar country, where they don't know what's going on and when they'll be able to leave.

As someone who has gotten a $2,300 bill from the hospital (which thankfully, was mostly covered by student health insurance) and someone whose little brother was moderately ill in India (he's fine now since my mom and I, who both have medical expertise, took care of him for a few days), I understand. I try to be conscientious of my advice telling folks to go to the hospital, and often make it clear when I believe someone will die or face a crippling disability if they don't go immediately.

This is one thing that healthcare providers see over and over again, and we all have our methods for dealing with patients who don't take us seriously, or might be subconsciously seeking permission to drop everything else and unabashedly go get medical care NOW. Of course, we have to document when a patient refuses to take medical advice. I have been told that in the event that they get seriously hurt or die, they or their family may try to come after us by suing for malpractice. I expect that lawyers will be looking for evidence that we tried our best to save them.

So, I like to tell people how things will progress.

Kidney failure? You will feel nauseous, maybe throw up, and generally feel awful and dizzy and die a slow painful death.

Diabetic ketoacidosis? I hear so many stories of people who fall asleep alone and never wake up again.

Threatened miscarriage? If you bleed out in a matter of minutes, there is no way an ultrasound scheduled in a week will save you in time. If you go to the hospital now, they will act immediately to stop the bleeding.

I reassure folks that it's against federal law for a hospital to refuse treating you because you can't pay. If they don't want to take an ambulance due to its cost, I'll consider that to some degree based on how sick they are. I reassure non-English speakers that large hospitals have translation lines and that the U.S. values patient autonomy, at least in theory, so nobody can force you to do anything you don't want to do.

The bottom line is that money doesn't matter when your life is on the line. However, the reality of practicing medicine in the United States, especially at a federally qualified health center, is that your patients are often limited by money. You have to ask yourself, what would it take for someone to value their own life over the fear and anxiety of paying off medical debts when already in dire financial straits? What a world we live in, where death is comparable to the threat of living out a debt saddled existence.

Squid Game is fictional but it's also real in many ways - that people would risk it all for the biscuit (money).

Sometimes I feel like the healthcare system is the last line of defense for my patients against the horrors of capitalism. It's like being an allegorical goalie when someone gets evicted, there's an unintended pregnancy, a perpetrator commits domestic violence, health insurance is too expensive, someone gets shot at school, someone is not welcomed at a shelter, or temperatures drop below freezing. Things in our society happen, the effects of these things quickly add up, and then trouble ensues where someone's life is literally on the line. The cost of living is so high that the ordinary working class person is at risk of losing everything, and healthcare is one of those things that comprises the undertow.

Times are tough, but if you can, please do things to prioritize your health and access preventive care. Make the time for it, as everybody is busy until the day that they die, and money has no use for those who are not living.