Saturday, October 1, 2011

Blessed insurance.

"Blessed insurance
Health care is mine
Oh what a foretaste
of co-pays divine!

Not much selection
purchased by y'all
Flexible spending
no referrals . . ."

~ lyrics adapted by yours truly

(Thank you very muuuuch! I'll be here all week!)


"If I get in a car accident take me to Grady."

That's the catchy slogan that was printed onto a big stack of bumper stickers a few years ago.  Pull into the parking garage at Grady, and you'll still see at least five of them before you even get to the third level. Some slapped on the backs of fancy vehicles even--waving that proud flag that says, "I heart Grady."

Well. . . sort of.

Like a lot of county hospitals in major metropolitan areas, Grady is your go-to when it comes to trauma. If you're bleeding, burning, got road rash after someone had road rage, got your rear end smashed by a drunk driver or even by a sober texter--ask anyone in Atlanta and they'll tell you: Go to Grady. No question.

But what about when it isn't a car wreck or a surgical emergency? What about when it's something totally not trauma-induced like pneumonia or a urinary tract infection?

Recently, I cared for this patient who got me thinking about this question. I can't go into detail on the specifics with that actual patient. But here is an adapted story that underscores what we faced that day.

Oh. And details here are dramatically changed, are an amalgamation of true events, or are completely made up. The point, however, is the same.

Mr. Ingle

Mr. Ingle was this gentleman who'd been brought to Grady after calling 911 for a severe headache he had while spending time with friends one evening. Although he was an Atlanta native, Mr. Ingle didn't live here any more. He had a fine job as a Nashville executive and was back in his hometown for a business conference.

On this particular evening, he had slipped away from his Buckhead hotel to hit a cocktail party hosted by an old friend. One minute they were laughing, reminiscing and enjoying a few martinis on the swanky backyard deck. Commenting on the Atlanta skyline and how breathtaking it appeared from this regentrified downtown neighborhood. Clinking frosted art-deco-y glasses filled to the brim with overpriced vodkas. The next minute he was writhing around in pain on an ultrasuede chaise lounge; squeezing his right temple and asking someone to call 911.

"It's the worst headache of my life," he told the EMT when he arrived. Tears were rolling from his eyes and he rocked back and forth on the edge of his seat.

That kicked things into high gear. This could be serious. As in you-might-die-if-we-don't-hurry-up serious. Rushed him to the nearest hospital which, from this Grant Park locale, meant one thing and one thing only: Grady Memorial Hospital.

Oh, just Grady.

"Grady?"  asked one of his friends. "Yikes! Do we have to go there? He has Aetna, you know."

That EMT didn't even bother to answer. He slammed the door shut and whisked Mr. Ingle away. Him and his Aetna. 

A young man who was previously healthy now has the "worst headache of his life?" The ER team heard this story and leaped into action. IV in, CT scanner hot and ready, and lumbar puncture good to go-- all within moments of hitting the door.  This was a subarachnoid hemorrhage (read: a life-threatening brain bleed) until proven otherwise. This requires everyone to move fast because time is brain. Period.

Head scanned. No evidence of bleeding.


Lumbar puncture obtained.  Again, no evidence of blood.

Hmmm again.

The spinal fluid came back from the lab and it had 55 white blood cells in it.  55. Not high. Not normal.

Uhh, okay. What does that mean?

His blood pressure was high, too--that, plus this entire scary headache scenario got him admitted to the Internal Medicine service, which is where we came into the picture.

But here's the thing. This patient didn't exactly fit your standard indigent patient care setting demographic. His friend had tried to clue the EMTs in on that but they weren't having it. But the minute his sister arrived at the hospital, she was determined to make this crystal clear.

"Um, I'm not sure who we need to talk to about getting him transferred to another hospital, but that needs to happen."  His sister stared straight into the eyes of my intern and told her this point blank. She gripped the handle of her designer handbag with one hand and nervously rubbed the end of her sleek pony tail with the other. "I think there's been some mistake. He has insurance."

"Yes, ma'am," answered the intern, "we actually do care for some patients who have insurance."

"That's good. But this isn't where we prefer for him to be. How do we proceed?"

And my intern didn't know what to do.  Fortunately, the senior resident standing beside her had a few ideas of what to say. "Well, ma'am. Right now we're trying to sort out what's going on with your brother. We can't transfer him, but I can assure you that the same doctors who work here at Grady are the ones that work at Emory Hospital. Like, for example, I work at both places."

She could have cared less about that. She politely yet firmly repeated herself. "Yes, but my brother makes good money and has excellent insurance and would prefer to be elsewhere." She looked over her shoulder at her brother who looked slightly embarrassed. Sister ignored him and kept rubbing her pony tail. "How does this work? The transfer?"

All of these questions came up before I got there. Them trying to figure out what the hell was going on with this young out-of-towner with his splitting head pain while keeping his six-figure sister from litigating right then and right there. When I spoke to the team they let out their frustration.

"This is interrupting care," my intern lamented with a heavy sigh. "It's totally distracting us from doing what's needed for him. She is criticizing our every move and it seems like nothing we have done is enough."


The story was intriguing. First the clinical part, and then the rest. Young, healthy guy throws back some martinis and gets a splitting headache. Stabbing like an ice pick, feels like he'll die. Work up is negative for subarachnoid bleed and surprisingly there are a few white blood cells in the cerebral spinal fluid.  The medicine nerd in me combed my mind for a differential diagnosis.

  • Really early viral meningits? I mean it is the summer and it's the time for it. That's possible. Awfully sudden in onset, though. Naaaah.
  • Cluster headache? If I recall correctly, alcohol can set cluster headaches off. More common in the dudes than the ladies. Usually stabbing. Like an ice pick. And he said "ice pick" not me. But why the white blood cells? Beats me.
  • Aseptic meningitis and a cluster headache? Damn. Sure would be an unlucky chap, now wouldn't he. But the story sounds really cluster-y yet those pesky white cells still need to be explained. Can you get white cells with a cluster headache? I don't think so. Hmm. Need to look that up.
  • Atypical migraine headache?
  • Hypertensive emergency?
  • HIV related?

"Had he ever had headaches before?" I queried. I wanted to know. But honestly? That answer got buried under all of this talk of his sister and her stabs she was taking at Grady. Every question I asked was met with distracted mumblings about what to do with not so much him and his headache, but the headache of that situation.

"Were his symptoms all on the right side or also bilateral?" I continued with my questions.

So much for my answers. Instead, it was more and more about how bitter Mr. Ingles' "peoples" were about being here and about how "his sister is a judge or a defense attorney" or something legal up in North Fulton County which makes having her not-in-a-car-wreck brother even scarier for the intern and resident.

"She just won't listen," sighed the senior resident. He was right. To every word they said to try to allay Sister's concerns, all she would say was, "We have insurance, thank you."


Let me tell you. . . .the team found this 100% uncool. It was obvious that they thought this woman was entitled and rude. I never gave them a green light to tear into Mr. Ingle's sister by saying a snide remark. Calling her a "hoity-toity" something-or-other would have nicely broken the seal, allowing for a nice little verbal bashing to vent the frustration. But I didn't, so nobody actually said it. They just huffed and eye-rolled when telling me about it and warned me of the fire pit I was about to walk into as we approached the room.

When I knocked on the door of his room, I was surprised to find him alone. I shook his hand and introduced myself. "Hi, Mr. Ingle, sir. I'm Dr. Manning and I'm the senior doctor on the team."

"Manning?" he asked confirming he heard right.

"Yep," I replied while showing him my badge. I tried not to fall prey to the paranoia my team had about this patient and his family but some tiny voice somewhere said, Mmmm hmmm. He's getting your name right in case his sister needs it later. I shook my head and decided that this was simply a patient that wanted to know his doctor's name.  I smiled and said, "That's right. Manning. Just like the football players but without their money." We both chuckled and I'm pretty sure I caught a twinkle in his blue eyes.  "How are you feeling compared to when you first got here?"

"A little better, actually."  He smoothed out the covers and patted around the bed for his phone. Quickly grabbing his iPhone, he switched it to a silent position.  How gentlemanly of him.

"Your blood pressure looks much better."

"That's good. Thanks."  Mr. Ingle smiled and it was as genuine as genuine could be. Honestly, he didn't look too bothered by the whole Grady thing. In fact, he seemed glad to be getting care and gladder to be getting better.

I briefly recounted the history and asked his permission to examine him. Once he obliged, I found him to be quite trusting. By the time I finished examining him he looked almost completely well. "How are you feeling now?"

"It's kind of weird," he replied, "I feel almost back to myself. Kind of crazy, I know."

And this is what convinced me that he probably had a cluster headache.  No, I still couldn't explain those 55 white blood cells in his CSF (cerebrospinal fluid) but 55 sure isn't 1,055.  The blood pressure was likely from the pain.  Just as I prepared to discuss this, in walked his sister.

Her  body language was terse and suspicious. She smelled like expensive cologne and kept her arms near her body almost as if touching something there could be a lot worse than death. I made direct and firm eye contact with her.  "Hello, ma'am. My name is Dr. Manning. I'm the attending physician on the team. It's good to have family here."

"Are you the person who can get him transferred? We don't want to be here."  Sister didn't waste any time. "Mark has insurance. I don't -- I mean he doesn't want to stay here."  Every time she reached up to rub her sleek brown pony tail her wrist full of David Yurman bracelets made a clinking sound.

I glanced at the patient and he looked away. Sister was in control and he wasn't going to challenge her. I stood there watching her and thinking. What do I say? How do we handle this?  I really wasn't sure.

"Ms. . . ?"

"Katherine Elliot. You can call me Katherine. I'm his older sister."

"Okay, Ms. Katherine. Listen, your brother is doing much better. His headache has resolved and his blood pressure is now normal. We're very pleased with--"

"Look, doctor. I don't really want to keep talking. Can you tell me what needs to happen for him to be transferred?"

"Well, honestly? He is looking so good that I'm not sure he needs to be in the hospital. I'd like to speak with my Infectious Disease colleagues to see what they say about --"

"We'd like another opinion. How do we get him moved to Northside?"

Whew.  This lady was rough.  I felt myself getting a little frustrated--with her for cutting me off and with him for not speaking for himself. Finally, I took a deep breath and decided to stop beating around the bush.

"Listen, Ms. Katherine. I need you to hear me for a moment."  She folded her arms and pulled her elbows in toward her torso. I had her attention. I took a big sigh and called out the elephant in the room. "Okay, so listen. I'm from Los Angeles and you guys are from Atlanta. One thing that most big cities have in common is that they have a hospital where all the poor people and car wrecks go.  In Atlanta, that's Grady." Sister didn't move. But she also didn't interrupt. I kept going. "You turn on television and you hear of the gunshot victims and immigrants coming here. You see the homeless people around the corner and hear of the drug-related incidents that find themselves here. Then you imagine your brother being in the same place or even room as someone addicted to crack or who just came from a shelter,  and the idea of it gives you the willies.  . . . ."

She cleared her throat nervously and continued to hold my gaze. "Well, listen Katherine. I get that. I really do. Like. . .I love Grady. I've worked here for ten years and I know the good we do. But honestly? I had two babies since I've lived here and didn't have either one at Grady.  And I'd like to say that it's because I didn't want to run into people I knew or residents or whatever but maybe it does have something to do with the fact that I had a choice."

The team cast nervous glances to each other.  They weren't sure where I was going with this.

"So what I'll say is that I get your concern. I really do. I won't stand here and insult your intelligence by telling you otherwise. Grady is different than some other places. When you're the only place that doesn't turn people away, your resources get used up fast. Things take longer and yes, you do run into some colorful people.  I get it. But Katherine, your brother is here now. And mostly everything that's going on with him is a lot better. I do need to review his spinal tap results with some specialists but he may not need further hospitalization."

"Well how do you know this isn't something more serious like a stroke?"

"Right now, the information we have doesn't suggest a stroke. His cat scan was negative. His spinal tap had no signs of blood--just some white blood cells but not really that many.  Our exam doesn't suggest a stroke either."  She loosened the grip on her elbows. Those icicles were beginning to melt. "I can't transfer him anywhere now. All I can do is tell you that I get your concern and that I'm not trivializing it. But at this point, it's hindering your brother's care to keep talking about moving him. Even though we have less resources here sometimes, as far as this goes, he got the same thing he would have gotten elsewhere."

He finally chimed in and said, "Thanks, Dr. Manning. Kath, I'm okay with this.  They've been great so far." She darted her eyes over to her brother and parted her lips to speak but nothing came out.

I added, "Again, I get it."

Katherine just stood there for a few beats and then slowly nodded her head. "You know what?  Thanks. Seriously, thanks for your honesty."

"Thanks for yours," I replied.

"Okay, so now what?"

"Now, we talk to Infectious Diseases to see if we need to do more about these white blood cells in the spinal fluid. If they say it's okay, we will discharge him. If not, we'll do what they recommend."  I turned my attention to Mr. Ingle. "How does that sound, sir?"

He gave me a thumbs up sign. "It sounds great."

So as the story goes, Infectious Diseases said that the white cells could have been some aseptic meningitis but more than likely weren't anything infectious. We even ran it by Neurology who agreed that this was all a bad cluster headache and that, though unusual, maybe those cells were from the inflammation of it all.  Mr. Ingle was discharged later that day.

I ran into his sister near the elevator a few hours later. She grabbed my hand and said, "I really appreciate you admitting what you admitted to me."

I smiled and shrugged.  I wasn't exactly proud of that fact.

"Dr. Manning? You know, doctors can really be some hypocrites. That's what made me appreciate that so much."

I didn't know what to say, so I just said "thanks" and waved good bye.

No. I am not marching through Grady announcing that I have insurance to every person who will listen. But . . . .not unlike her... . . something at some point has made me feel entitled to something other than Grady.  And right now, I'm just reflecting on that.  I'm also reflecting on how annoyed everyone was with Mr. Ingle's sister that day. . . .

And now I'm wondering just how many of the people on my team that day receive their care at Grady. I had to admit that I haven't. So? Who among us Grady doctors gets their paps and prenatal care and prostate exams and elective surgeries amidst our beloved indigent patients? Well?


Guess I'm reflecting on that word "hypocrite"  a little bit, too.



  1. Well, I'm a white girl from Atlanta and at one point in my life, I would have felt terrified to be at Grady. But, you know what? Now I'm a wiser white girl from Atlanta living in Los Angeles who has seen the insides of some of the best AND worst hospitals in the country, and it's all up in the air, still. I think the trouble with our country is that we declare greatness when the most bells and whistles abound -- in my life with a disabled child I have found that to be smoke and mirrors -- frankly, bullshit.

    I love your honesty, Dr. Manning -- I just love your posts. I think you might be just about perfect. :)

  2. I'm thinking that perhaps the family you speak of who used to live in Atlanta recall the days when the word was "if I get into an accident, please don't take me to Grady" (and this came from people I know of every color). I also grew up in Los Angeles, but have lived in Atlanta for over 20 years and that used to be the saying but not anymore. Many people here realize now Grady's strengths and qualifications.
    This reminds me of many years ago when I was camping with my husband in North Carolina. He had an accident and I had to drive to the nearest hospital and he needed surgery. The doctors saw me hesitate admitting him (and my husband was reluctant too) because we thought he'd get better care in a bigger city. The doctor understood and like you, spoke to us honestly. He said that the doctors who work in his hospital choose to work and live in this small town with their families but could have worked in Atlanta or other big city. He also explained that it would not be wise to drive 2 hours back to Atlanta and then sit and wait in an emergency room. Doctors with "people skills" who can communicate are awesome.

  3. I have grown up in Atlanta, but the line I heard was "don't take me to Grady unless I've been shot." I'll admit, this East Cobb girl grew up on a different side of the city, and Grady only existed when we drove by on the way to a Braves game. But now I live on the other side of the city, and I go to school right down the street. Now, I'm not gonna lie...walking by Grady gives me the willies. It for reals doesn't attract the most, um, pleasing clientele outside it's doors. And going to the McDonalds is an "at your own risk" endeavor. But I have told my husband that if I do end up at Grady, please call Dr. Manning. :-)

  4. I don't understand why some people do not like Grady. When I was working at Dekalb, I saw a patient come in and she was an orphaned patient (no PCP) and she spoke about her former doctors at Grady with such disgust that I was wondering if the Grady that I know and the Grady that she knew are two separate groups. She boasted about finally having insurance.

    I'm a white boy on the outskirts of Atlanta. I'm fortunate enough to have insurance. There are only a few hospitals in this area that I would trust with my healthcare and Grady is one of them. Heck, I almost left my private practice family doctor in order to transfer to your primary care center because I've seen how good the doctors are there. I've never seen such good doctors.

    If I'm in an accident, please take me to Grady. As a matter of fact, if I am ever in Atlanta and I have an emergency, I think I would rather go to Grady. I know Grady will do whatever they need to do to keep me alive and they will do it with a smile on their face.

  5. Hey Dr. Manning, I've asked myself that question too. I am an intern in an IM residency program at a similar kind of hospital. We're known as the "place where trauma related/uninsured folks are treated and experimented on" ---yes "experimented" and employees get a discount for using the services at the hospital/related facilities. We provide excellent care and the people are friendly as well. I've thought about getting my care there (still haven't decided yet) but the issue I have is my colleagues and how they like to be in your business. "What happened with Dr. Such and such"...whisper whisper whisper. It's not the fact that we serve a mostly uninsured/"colorful" population. Plus I don't want them to see me sick or vulnerable. I like the perception of being a strong intern/person who is able to handle


  6. Well, I'm glad that Grady does take patients with insurance, because my daughter is now living on campus at GA State and we can see it from her bedroom window. The only thing is that we both have a rare heart condition, and I probably would be asking that they call her cardiologists at Piedmont and Sibley. I'd also be standing there with the five page list of medications she can't take. That fact alone usually makes me persona non grata in emergency situations. Still, I'd rather her be at Grady than the major hospital that serves north Cobb and Cherokee, which I won't name. Believe me, I hate that she can't be seen at CHOA anymore. Anyway, I learned to respect Grady when my brother-in-law was being treated for lung cancer there. His treatment was every bit the same quality that I received at Northside and St. Joes.

  7. I know that if I lived in the US, I wouldn't be able to get health insurance. I would not be alive if there wasn't socialised medicine in NZ, and my parents would never have been able to pay for my hospital treatments. I'm so grateful for this.

    I'm so so glad that there's Grady.

  8. Wooo! That was an awesome post. Living in Inglewood all three of my children were born at Cedars Sinai(the hospital where all the celebs go), all of our doctors work out of Cedars Sinai. However a couple of years ago, my son was experiencing terrible chest pains. He said that he felt like he was having a heart attack. I rushed him from Inglewood to Cedars to sit for hours and to only be seen for 10 mins. Two days later my son was outside playing and crawled home on his skate board in tears. I was so upset I called 911. Then EMT's had to rush him to the nearest emergency which was Centinela Hospital. I was like NO!, We go to Cedars. They looked at me and rolled their eyes and said lady we are taking him to the nearest hospital. Well I said all that to say that my son received the best treatment and the best care. To sum up his condition in a non-medical term, his body was bones were growing faster than the rest of his body and the pain that he was feeling was his cartilige tearing away from his bones. My son said there for nearly two hours until they investigated every possibility. They told us to follow up with a ped cardiologist to confirm the diagnosis. And they were right. Never did that come up at Cedars. He gave me a print out and told me to look it up on the internet. Booooo!

  9. From a Grady ER nurse, thank you! I always said I would never work at Grady, but I landed here fresh out of nursing school and never left. I've grown to appreciate it for what it is and I always tell people "we may take 12 hours to see about your sore throat, but if you're REALLY sick we WILL figure out what's wrong with you." I was a paramedic before coming to Grady, and I have never seen people who work as hard and investigate as thoroughly as the staff at our hospital. If you ever visit us down in the ER, I'd love to meet you!


"Tell me something good. . . tell me that you like it, yeah." ~ Chaka Khan

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