The evening you came to us, you were critically ill.  Your diabetes had gone totally out of control, and you had a life-threatening condition known as diabetic ketoacidosis.  You needed an insulin pump and special electrolyte management.  Your foot was so infected that bacteria had entered your bloodstream. Your blood pressure was very low, and you needed multiple antibiotics and fluids and infusions of medicine to keep your blood pressure up. You needed, in fact, to be in an intensive-care bed, but we had none available.  So we put you in a side booth, and we looked after you.

The second day, still on the insulin pump, you could talk to us.  You told us that you had run out of your diabetes medication and had not been able to afford more.  You told us that when your foot became infected, you delayed for a while and tried to take care of it yourself until you collapsed and were brought to us by ambulance.  That is so common. The patients we see typically have no primary care and have waited. Consequently, they are much sicker when they arrive. There was still no ICU bed available for you or the other patients lined up in our booths waiting for monitored beds, so you stayed with us another night.

Several years ago, someone gave me a cartoon that I still have.  It shows a busy nurse sitting at her desk with a list of things to do.  The first thing was “check today’s booth for yesterday’s patients.”  I think it was meant to be funny.
 
The third day you came off the insulin pump.  The good news is that you no longer needed an intensive-care bed -- you were being downgraded to a regular medicine bed for admission.  The bad news was that we didn’t have any of those beds available, either.  You were pushed from your booth and back to the front of the Emergency Room, where you were parked with 10 to 40 other patients packed up there waiting for admission to any bed. I don’t know what we are going to do when another 100 beds are closed in this medical center. 

Please understand that you were pushed from your booth so abruptly because we needed the monitor for an incoming critically ill patient.  I know it is horrible up front.  There is no privacy, and you are all jammed together.  There is no nearby bathroom.  There was a man vomiting on one side of you and a mentally ill patient crying on the other side.

You told me more about yourself today.  You were employed, but you were laid off and were unable to purchase health insurance. A recent report published by the Robert Wood Johnson Foundation said that 75 million nonelderly Americans (nearly one in three) had gone without health-care coverage for some period in the last two years. Forty-one million Americans were totally uninsured in 2001.  California leads the nation with more uninsured individuals (11.1 million) than any other state.  In this county, Los Angeles County, only one in four is uninsured. Your husband is employed, so your income level did not qualify you for medical help. However, your husband works for a small service-based industry that does not offer health insurance in its benefits package.  The report stated nearly four in five of those lacking health insurance were in the labor force.

The orthopedic surgeon saw you today and said he is worried that your foot infection may have gone to the bone. You will need an MRI and probably surgery.  You will be with us quite a long time.  It makes me angry -- all of this was so totally preventable.

You are on your fourth day with us now.  The good news is that you will get a bed later today, and you will finally move upstairs. I know you haven’t slept for three nights. The lights are always on down here, and the noise level is horrendous -- alarms and bells going off, telephones ringing, people yelling and screaming.  I know you have seen some pretty frightening things.

You will be going to a room with five other patients, but you will have a bed instead of a stretcher, and will be able to pull the curtains around your bed. You finally will be able to sleep.
I want you to know how proud I am of my colleagues down here and what we do. We see and care for everyone who comes to us regardless of their ability to pay, and we take care of them seven days a week, 24 hours a day.  We struggle to provide for the ever-increasing number of uninsured with ever-dwindling resources. Fifteen percent of California’s emergency rooms have been closed. The remainder are overwhelmed, saturated, with shrinking numbers of staffed in-patients beds for admission.  Most of the time we are on diversion to incoming ambulances, but that is dangerous, and many come anyway.

We are the last safety net of medical care for our nation.  Albert Schweitzer had a sign over the door of his missionary hospital that read: “Here at whatever hour you come, you will find light, love, health, human kindness.”  I like to think of that sign above our medical center, too.
And I want you know how proud I am of you, also. You never complained once, and you demonstrated to us the grace and dignity and fortitude of the human spirit.

I want you know that I prayed for you, and I hope you will pray for us.
May God bless you.

                                                    (Signed)
                                                    Kathryn R. Challoner M.D., FACEP
                                                    Faculty and Attending Staff
                                                    Department of Emergency Medicine
                                                    LAC+USC Medical Center.