Coming to America

"I paid $1000 to come to America, hoping to get some medication to cure my illness"

The County hospitals notoriously have a number of patients who, for one reason or another, sneak into the country for medical care. Sometimes it's to give birth to an "American" baby. Other times it's because they have a weird disease and the resources of their home country won't allow for definitive treatments. But at the kingdom it's usually chronic diseases, that are hard to treat in Mexico...especially if you have no money.

The other day there was this girl, 19 years-old, who presented to the ED with a note from her PMD in Mexico:

"Patient with multi-drug resistant TB; medications taken to date are not effective. We have nothing more to offer. Go to America to a County hospital for further treatment."

In triage she's sitting among everyone for...30 minutes or so before her vitals are taken. Then, per protocol, she is taken thru the registration process. She changes her name a few times before settling on 'Maricella.'

After her vital signs reveal she's hypotensive and tachycardic (low BP and high heartrate), she is 'expedited.' At King, this means she gets the 'next bed'...which may be in 5 minutes, or it may be in 3 hours. In the meantime, she's hanging out with everyone in the waiting room.

Finally, she comes to the back. Because of her note, she is placed in 1 of 2 isolation rooms. This is when I meet her.

I peak thru the window on the door and see a very thin, wasted, silhouette, sitting on the edge of the bed with her hands clasped on her lap. She has on a mask, despite the fact that she's in isolation. And the monitor overhead is indicating that she's quite ill. I see her, talk with her...
...she is *really* 17 years old. Other family members in Mexico had already died of this TB, and she was dying as well. Her doctor in Mexico told her that her only chance to live was to sneak across the border and seek help in America. She passed San Diego since her perception of SD is that of hostility towards Mexicans. She saved $1000 over 9 months, begged, borrowed, and prostituted in Tijuana. Then, she met someone, who knew someone, who had a truck. She paid the driver the $1000 for a trip to just past the border. From there she hitchhiked. At the time of her ED presentation, she had traveled, non-stop, for 3 days. She was tired. She was very sick. But, she was very hopeful!!

My intern examines her, we order appropriate studies, initiate treatment, and subsequently consult medicine/ICU.

They see her, admit her to ICU, but...there are no isolation, ICU beds. So this girl sits in the ED isolation room for (count them) 6 shifts. That's 3 days!!

During this time, she decompensates. She becomes increasingly lethargic, tachycardic, hypotensive, is on pressors, and 4 TB meds. Eventually, we have to intubate her.

Herein lies the dilemma: The isolation room isn't a critical care area. There isn't enough room in this tiny closet of a space for a ventilator, crash cart, monitors, and her bed. Additionally, it's difficult for a nurse to tend to her since she's behind a closed door with only a tiny window.

So, we are told to move her to our critical area (by the "suits" who sit behind big desks, and have no understanding of the workings of the ER; those mighty people who never see a patient face to face, and are not risking their own well being by 'just moving her to the critical area'). The critical area is an open space separated by curtains. This area is where the febrile seizure kids go. This is the area where babies are born (if they didn't make it to L&D). This is an area where all the air is shared, with no isolation capability.

So we fight. We throw a tantrum. We refuse to move her.

"but she will die in there"

But she'll take us all with her...and our families...and our friends...if she contaminates the entire ER. Can you imagine coming into the ED with an arm laceration...and leave with multi-drug resistant TB?

This was a recurring theme at the Kingdom. Inadequate number of isolation rooms, and lack of critical care isolation space. We wrote letters, called hospital chiefs/CEOs, etc. We even threatened to call the press...(I think someone may *have* called the press...and eventually lots of 'someones' called the press)...

...eventually she did die...but not in the ED. After 5 days, she was finally moved to the ICU (after the other critical isolation patient in the ICU finally died).

Given Maricella's circumstances, most of us would have done something similar to what she did. It's not appropriate to punish individuals for systemic failure.

...it is concerning that in an era post 9-11, our government has decided to not deal with the issue of 'safe' immigration.
...it's concerning that in an era post 9-11, and the threat of SARS, bird flu, etc., that in a major, busy hospital ED, in a major metropolis, we cannot isolate 1 patient!!

The real threat to national security...


Nicole said...

I worked as an epidemiologist in TB surveillance for several years. This seems like a nice opportunity for me to share a few pearls about TB to anyone reading.

One of the reasons Mexico has a pretty bad problem with MDR TB is because you used to be able to buy cough syrup containing isoniazid (INH) in Mexico without a prescription (those were the bad old days).

Of course, for a patient with active TB disease, treating with isoniazid alone meant developing resistance to INH. Monotherapy in active TB disease equals development of drug resistance (noting that TB disease is not the same thing as TB infection).

When and if that patient was eventually treated with two meds, it would often be IHN plus Rifampin. Of course, if the patient was already resistant to INH, now he or she is on monotherapy with Rifampin, so the patient ends up with resistance to both INH AND Rifampin. Keep adding one new drug at a time, and eventually you can get a patient who is resistant to 5 or 6 different meds.

Outcome data on the treatment of MDR-TB is pretty bleak -- mortality in these folks is pretty close to what it used to be before we had any treatments at all for TB.

Reminder to all clinicians that potentially see TB: always add two or more NEW medications to a failing anti-TB regimen. Always start a patient on at least 3 anti-TB meds if you don't have resistance data yet (and pyrazinamide/PZA does not count as one of those 3). Adults usually get INH, Rifampin, ethambutol and PZA. Where EMB is contraindicated, substitute streptomycin (your friends at the health department can help you get the streptomycin).

As far as what to do about ignorant administrators that don't understand anything at all about TB transmission, sorry I can't help you there...maybe your hospital's infection control practitioner could try an educational intervention (or, perhaps more correctly, ANOTHER educational intervention).

Best of luck!

Anonymous said...

Our border is a crock. Large parts of southern Ca are tuning into Tijuana.

My hospital is 100 miles north of the border. The border can't be too secure or hard to cross if those with massive brain tumors, end stage leukemia, femur fracures, completed strokes, or 4cm dilated and contracting can make it across the border to my hospital.

And yes, every hospital in the country is unprepared for any more than just a few critical isolation patients.

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