Thursday, January 29, 2009

health disparites enrage me

Here is a copy of the email I wrote to the nurse educators on our floor about the patient I took care of yesterday:

Hi [nurse educators],
I would like to pass along the plight of a patient who was recently discharged from our floor. Because you are a nurse I very much respect, I thought I would share his story. This gentleman is 66 years old, a military official from Guinea, Africa, recently arrived in the US to visit his daughter and grandchildren. He collapsed in their home and was brought [here] by EMS. Unable to afford missing work, and caring for four young children, his family did not accompany him to the ER and did not arrive until the next day. He speaks no English, and required a French translator for all communication.

The patient was found to have a blood sugar greater than 500. He was re-hydrated and put on a sliding scale and intermediate acting insulin for meal coverage. Even this did not control his blood sugar, he still had chemsticks consistently in the 200-300s. He told us via interpreter that he took insulin in his home country of Guinea, but did not know what kind, and had not brought it with him to the US because he "felt fine".

His service was Medicine Newburgh, and they decided to discharge him the same day, but had to wait for family members to arrive before he could go. I took care of him both days. When his granddaughter arrived to take him home, she also spoke so little English that she required an interpreter as well. I paged social services and the MN service to come in and talk with her and the patient. The resident came in and told the patient that he could go home now. He did not mention to the patient that he would require insulin injections and frequent blood glucose monitoring. He did not explain to the patient what diabetes was or its consequences. After the physician left the room, I asked him about patient teaching. I was told that it "didn't matter", he was going to "end up in the ER again anyway". His discharge paperwork included prescriptions for a glucometer, insulin syringes, and novolin insulin to be taken 10 units BID.

I brought our glucometer, and insulin to the patient's room and with the interpreter present, I spent more than an hour and a half discussing and demonstrating how to check the blood sugar, what is normal and what is not, what to do if sugar is very low, or very high, what symptoms he might expect, to test and write down his glucose levels four times a day, how to draw up insulin, where to inject it, what to do if he misses a meal, the importance of eating consistently and a healthy diet... etc. I taught everything I'd ever learned and remembered about diabetic care. The patient and his granddaughter are very intelligent, he demonstrated back to me how to check his sugar and inject insulin correctly on his first try, and they both asked intelligent questions. I gave them written materials in French. I could tell that they were very concerned about money, and social work was working with them on temporary insurance. I sent them down to our pharmacy with the interpreter.

The patient is supposed to have a follow-up in the clinic within one week. I asked the physician for the name of his clinic nurse, so I could let her know ahead of time to speak slowly and clearly when scheduling an appointment with the family. I was told that he has "no clinic nurse". I worry that the patient will not receive an appointment time, or that he will not understand instructions on the phone. I also know that the insulin coverage he will administer to himself will not adequately control his blood sugar, and the long-term consequences will be devastating. I am disgusted with the care he received from the MN service, and wonder how it might have been different if he had had insurance, or had a been a white English speaker. The way I see it, those patients who face the great challenge of communicating across a language barrier, or who are unfortunate enough not to have insurance, ought to be given extra attention the best care that we are able to give, not simply sent home as though we do not care what happens to them just because they have no money, or don't speak English.

I have discussed this case with [our nurse manager]. I know that disparities in healthcare for minorities exist, but was shocked to see it playing out right under our noses on [our unit].

Thanks for reading.

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