Several years ago, the topic of air ambulances was popular at various workers' compensation events. I penned a piece on the economic conflicts, See Confusion and Disconnects in Medicine (July 2018). This included a couple of premises, such as the inherency of price irrelevance when payor and service recipient are disconnected. Also, the potential financial incentives of those making the care decision.
The second premise focused on the decision of first responders arriving on the scene of an injury. These individuals are largely responsible for the decisions about rendering care, transporting to a hospital, and how.
A patient might be treated and advised to follow up with a doctor or hospital on their own. If the patient needs to be transported, that might be by ambulance or by helicopter. I have often joked about preferring the helicopter because a helicopter ride is on my bucket list.
I was convinced then, and remain so now, that such decisions are difficult for the care provider and the patient. Nonetheless, I was also convinced then that patients would not approach those decisions on a micro-economic level. That is, they would not weigh the cost-benefit factors of such a helicopter ride versus an ambulance. I cling to that belief, but recently ran across an anecdotal instance in which I am dead wrong.
The Associated Press (AP) reported in July about a man hiking the Froze-to-Death Plateau (the name might dissuade some of us), striving for the highest peak in Montana. He "slipped and impaled himself on his trekking pole." Yes, the hiking stick went into his torso. Worse, it came out the other side. He found himself with a "44-in steel-tipped pole" through his chest, high on a mountain. The picture on AP is amazing.
The hiker had one thing in his favor: he is a nurse with wound care experience. He performed a "self-assessment" and concluded that he might persevere without emergency services. He allegedly quipped, "tis but a flesh wound." See Monty Python and the Holy Grail (Python Pictures, 1975)(spoken by the Black Knight after King Arthur chops off his arm).
He then hiked out "about 10 miles and descended roughly 5,000 feet" with the pole stuck in his chest. His group reached the railhead and proceeded by car to the hospital. In all, it is an amazing story of fortitude and determination. Some would say it is one of amazing coincidences—how does one twist, turn, fall, and get such a stick in their torso? The mechanics of such an outcome are themselves mind-blowing.
But, to the point, the patient was in need of care. He was conscious and aware of alternatives. He was trained to know of the alternative of a helicopter. And, more curiously, he considered cost in his decision. He "conferred with his" hiking companions. And he "considered the high cost of a helicopter rescue." He did an economic analysis in the moment, with a pole poking through his chest.
I am often wrong, admittedly. Nonetheless, I am surprised by this anecdotal instance of a patient, albeit a sophisticated and trained patient, performing an informed microeconomic analysis of the best solution to an urgency. The calm and aplomb that could lead to such analysis and the amazing outcome are impressive.
Despite being patently wrong, I nonetheless remain convinced that such an analysis and outcome are beyond the grasp of most of the rest of us, perhaps all of the rest of us. Anyone considering such a decision might want to wonder first if they have sufficient medical knowledge to make such a call?
In the end, the disconnect between care and cost persists for the rest of us. That disconnect is driving much of what is awry in the realm of American medical care.
