Mar 21 2014
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The Lucky One

Vanessa Grubbs, MD, MPH, is an assistant professor at the University of California, San Francisco, School of Medicine, and a scholar with the RWJF Harold Amos Medical Faculty Development Program. She is writing a book about what she calls the “sometimes irrational use of dialysis in America,” which will include a version of this narrative essay.

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It is a Monday afternoon like any other and time to make my weekly rounds at the San Francisco General Hospital outpatient dialysis center. I push my cart of medical charts down the long aisle of our L-shaped dialysis unit and see Mr. Rojas, my dialysis patient for over a year now. He is in his mid-40s and slender, sitting in the burgundy-colored vinyl recliner. His blue-jeaned legs and sneakered feet are propped up on the extended leg rest. The top of his head shines through thinning salt and pepper hair. White earbud headphones peek through gray sideburns. He is looking intently at his Kindle, rarely glancing up at the activity around him.

I roll my cart up to his recliner, catching his eye. His right hand removes the earbuds as the left pauses his movie. He looks up at me, smiling. “Hola, Doctora. How are you?” he says with emphasis on the “are.”

“I am good. How are you doing?” I smile back at him as I grab his chart from the rack. I write down his blood pressure and pulse—both normal—and the excellent blood flow displayed on the dialysis machine. My eyes shift to his fistula, the surgically thickened vein robustly coursing halfway up his left forearm like a slithering garden snake. It is beautiful to me. Through it, Mr. Rojas is connected to the dialysis machine.

“I am good, Doctora. No problems. I feel healthy. Strong.” His brown eyes glint.

I smile at him. Besides kidney failure, he has no other major illnesses. He shows up for dialysis as scheduled, every Monday, Wednesday, and Friday. He stays for his full three-hour treatment. His blood test results are almost always within goal ranges. He won’t need me to repeat again the importance of limiting high potassium foods between treatments. He knows what his medications are—and he takes them. When I press my thumb against his outer ankle during the visit, it won’t create a dimple as it does in other patients who drink too much fluid between dialysis runs, which can weaken the heart over time. He has never used drugs, doesn’t smoke, works a steady job as a dishwasher, and has supportive friends and family in the area. He is young. Mr. Rojas is an ideal kidney transplant candidate.

But none of these details matter. Even though transplant promises a significantly longer and better quality of life, I will not refer Mr. Rojas to the transplant center for evaluation, because the only detail that does matter is that Mr. Rojas is a poor, undocumented immigrant. And America does not give transplants to poor, undocumented immigrants.

In a sense, Mr. Rojas is lucky to even get regular dialysis. California is one of only a handful of states where regular dialysis is an option for undocumented patients with end-stage renal disease (ESRD). California’s Emergency Medicaid program pays for regular dialysis, while most states’ programs only pay for emergency dialysis treatment as required by the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1985, which mandated provision of emergency care for all uninsured people with life-threatening conditions. However, because it is up to the individual states to decide what constitutes “life-threatening,” most states provide an emergency dialysis treatment every five days or so only to those undocumented immigrants with potassium levels high enough to stop their hearts from beating—at an annual cost nearly four times that of regular dialysis, which is itself three times the cost of kidney transplant after the first year.

So, while immigration opponents fear anything beyond emergency care to the undocumented population would impose additional financial burden on taxpayers already hobbling under the strain of uncompensated care for our 50 million uninsured citizens, the current system actually relegates our undocumented ESRD patients to more expensive care.

I am not an immigrant or the daughter of immigrants. Nor am I an expert on the complicated story of immigration in this country or the 1,000 or so pages of recently proposed immigration reform legislation. I have no horse of my own in this race to bias my position. I just want to take care of the patient in front of me in the way that I know is best for him. Considering that the best option for Mr. Rojas also happens to be the least expensive option as well, changes in national policy should be a given.

I tell Mr. Rojas about the fragmented system of care around this country for undocumented immigrants with kidney failure. A quick squint of the eyes and wrinkle of the forehead betray his surprise.

“What do you think of this?” I ask, hoping for some insight into his world.

There is a long pause. But then he shrugs into a toothy grin. “I feel lucky,” he says. “I never feel racismo—you know this word in English, Doctora?” The slight quiver in his brow tells me that he is not so sure. I nod.

I watch the glint in his eye fade. He stares ahead at nothing, focused on his own thoughts. I walk away, regretting that I’ve given him information he is powerless to do anything about.

Tags: Emergency care, Harold Amos Medical Faculty Development Program, Health care delivery system, Human Capital, Latino or Hispanic, Underinsured, Underserved populations, Voices from the Field