Friday, November 13, 2009


Mr. Baskin came in yesterday with a mass in his neck. He’s 42 years old, smokes a pack of cigarettes each day, and drinks a beer three to four times a week. It’s getting harder for him to swallow. He works hard for a living as a laborer and tends bar part-time to make ends meet. He has no insurance and has yet to see a doctor for this. He’s not eating and has lost twenty pounds over the last year. He’s got a large, rock-hard growth under the skin on the left side of his neck. It’s lumpy, irregular, and fixed to the underlying tissue. Looking into his mouth you see that something under the skin is trying to push his left tonsil out of place. Everything screams bad. I walk out of the room and look at the nurse, who has seen the same things. “He’s going to die, isn’t he?” she asks as a statement of fact. And because his exam is what it is, and because one of the prime rules of emergency medicine is “Nice people get bad disease; dirtballs live forever,” I simply look back at her and nod.

If you have insurance, what I do is arrange an outpatient CT-guided needle biopsy of your neck mass by radiology, and set you up to follow-up a few days after the procedure with an ENT for the results. If you’re uninsured, I tell you that at our hospital we care for anyone regardless of money, and admit you to have the procedure done so you don’t fall through the cracks of the system. And either way I have to tell you, a person who I’ve just met and who doesn’t have any reason to know or trust me, about the thing on your neck. I tell you I can’t be sure exactly what it is. It might be some infection or some glands might be inflamed, or it might be a growth of some kind like a tumor. I explain to you that the best way to find out is to have someone take a piece out of it and look at it under the microscope. You don’t understand, but then you do. Your eyes get wide, and when I ask if you have any questions you shake your head for no reason other than something to do.

I have no idea how health care reform would affect him. I have no idea if his employer would carry insurance or opt to pay a fine. I have no idea if he would opt to take the subsidy to buy insurance or choose to pay a fine. I have no idea if he even works for a salary or works for cash. I have no idea if he could have a doctor to see him weeks or months ago no matter what kind of coverage he has. And in the end, it really doesn’t matter. First he’s going to undergo an operation, to be followed by radiation therapy which will dry out his mouth and cause painful ulcerations. Later, when the cancer comes back as they always do, he’ll have a laryngectomy and use an artificial voice box. Over time he’ll be unable to swallow and need a tube in his stomach for food and water, and the only thing he'll be able to put in his mouth are soft plastic swabs saturated with lemon-flavored glycerin solution and an occasional ice chip. And despite all this, the best care anyone has to offer, he’s still going to die.

Health care has very little to do with policy and politics and insurance plans.

Health care is a 42 year old man who’s going to suffer and die and you can’t do a damn thing about it.

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