An Emergency Room in Buenos Aires

The store owner had provided some cotton balls to slap onto the laceration, and hustled her back to the hotel. The hotel desk clerk, a medical student just about to graduate, called for an ambulance.

The injuries looked benign. I exchanged the useless cotton balls for a clean towel to stem the bleeding, and within a half hour the ambulance arrived. The attendants went through the usual reassessment, dressed the wound, filled out papers, and took us to the public hospital.

The ambulance was a modified van, with basic equipment. We were informed there would be no charges because the ambulance service had a contract directly with the hotel and "everyone has access to emergency care, paid for through a payroll tax." However, emergencies are sharply defined to exclude minor problems, which are turned away to await normal clinic hours. Perhaps in part for that reason, we were seen very quickly. The facility itself was cold, bare, and uninviting, but the care was fast and appropriate. No intake, no receptionist, no nurse triage assessment, no paperwork. I think it was assumed I was the patient's husband.

The delivery of care was old-style and hierarchic. Doc Big appeared very quickly, spoke good English, asked the history. (The injured woman is a nurse who has Hepatitis C from a needle poke in a dialysis unit, is otherwise in good health, age 74, no meds. Tetanus current. She had had a right hemicolectomy for cecal volvulus four months prior, but in this case, "don't ask, don't tell" seemed acceptable.)

Doc Big looked and explained that sutures were needed, and wished the patient a curious "goodbye-good luck," and left.

Doc Medium arrived and went through the process in almost exactly same way in quite understandable English. I simply listened and didn't disclose my profession.

Almost immediately thereafter, Doc Small arrived, with not so fine English, and repeated the process a third time. In this lovely backward world, no one wrote anything down. The only signature, my own illegible scrawl, was taken by the ambulance crew.

I was asked to step out into the waiting room, and I confessed to being an E.D. doc who would be watching through the wall.

The physician seemed a bit taken aback but said nothing. In about 20 minutes he came out, and gave instructions: keep dry, sutures out 5 days, use povidone iodine topically, change dressing 24 hours, Rx for Amox Clavulinate because a tooth had been moved slightly.

The contusions and abrasions were felt to be insignificant, and the small lip laceration across the vermillion border required no sutures, though these latter injuries would have been differently handled in a fee for service system. The antibiotic could be picked up at the adjacent pharmacy.

I sat in the bare waiting area on one of four hard chairs. It had been only an hour since the injury. There is no Argentine HIPPA, and while the Small Doc did his thing, I overheard the details of two cases. Doc Big discussed the treatment of an M.I. with an anxious clutch of family in terms very like we would use in Sacramento. Because of lowered cardiac output, immediate angiography and possible angioplasty, stent or bypass would be required.

The second case discussion addressed a patient with status epilepticus who wasn't responding to the usual medical treatment, and would possibly require more aggressive measures including, if necessary, anesthesia.

No other cases appeared. No vomiting, no coughs, nothing that would be called minor. I don't know who makes such decision about ED visits, probably patients themselves who are aware of the rules. In yet another feature of underdevelopment, apparently the hospital and staff perceived no legal or political risk to such determinations.

After Doc Small dismissed us, the patient asked to use the toilet; but there was none, so he took us into the hospital area showing her to an empty patient room. I later learned there was no toilet paper there so she resorted to a McDonald's receipt! (I had a partial roll of STP, Sacred Toilet Paper, in my backpack, as usual, but she didn't know that.)

Rejecting the antibiotic, we returned to the ambulance entrance, and peered out into a fierce stream of traffic. I asked the policeman where to hail a taxi. He replied it would be impossible because adjacent to this public hospital was a fútbol (soccer) stadium and a big game had just ended. The four lanes going our way were clotted with cars and busses maneuvering and honking. The sidewalks were thick with pedestrians.

He called for a radio-taxi but the first to be promised would be two hours. The rare empty cab among the flood of vehicles ignored our appeals, and we were told they either had assignments or were afraid to pick up passengers there because it was a conflictive situation(?).

Finally, the policeman stopped a colectivo (a car or bus that runs a specific route where each passenger who boards pays a set fee no matter what the destination). This bus would end its run at a place where we should find a taxi. So we pushed our way up onto the loading steps.

But neither of us had the right kind of change. After searching frantically through pockets and possessions for several minutes, the owner-driver said to just forget it. He was only a few kilometers from the end of the run.

On arrival there was still no taxi to be seen, so we walked about 6 blocks to the hotel, arriving door to door in less than 2 hours.

I suggest only one thought about health care in a federal system: Where medical care is universal and free of direct cost, the program administrator must be free to limit care.

Argentinos seem to stoically tolerate both the advantages and disadvantages of Peron-care and appear to feel that the inevitable aspects of universal care are not worth crying about.

Would we be so tolerant? We may find out.

john@loofbourow.com