Sunday, November 9, 2008

Deported in a coma, saved in the U.S.

International Herald Tribune
Deported in a coma, saved in the U.S.
Sunday, November 9, 2008
Antonio Torres, a legal immigrant badly hurt in a crash, is back in Arizona after a hospital deported him to Mexico. (Josh Haner/The New York Times)
GILA BEND, Arizona: Soon after Antonio Torres, a husky 19-year-old farmworker, suffered catastrophic injuries in a car accident last June, a Phoenix hospital began making plans for his repatriation to Mexico.
Torres was comatose and connected to a ventilator. He was also a legal immigrant whose family lives and works in the purple alfalfa fields of this southwestern town. But he was uninsured. So the hospital disregarded the strenuous objections of his grief-stricken parents and sent Torres on a four-hour journey over the California border into Mexicali.
For days, Torres languished in a busy emergency room there, but his parents, Jesús and Gloria Torres, were not about to give up on him. Although many uninsured immigrants have been repatriated by American hospitals, few have seen their journey take the U-turn that the Torreses engineered for their son. They found a hospital in California willing to treat him, loaded him into a donated ambulance and drove him back into the United States as a potentially deadly infection raged through his system.
By summer's end, despite the grimmest of prognoses from the hospital in Phoenix, Torres had not only survived but thrived. Newly discharged from rehabilitation in California, he was haltingly walking, talking and, hoisting his cane to his shoulder like a rifle, performing a silent, comic, effortful imitation of a marching soldier.
"In Arizona, apparently, they see us as beasts of burden that can be dumped back over the border when we have outlived our usefulness," the elder Torres, who is 47, said in Spanish. "But we outwitted them. We were not going to let our son die. And look at him now!"
Antonio Torres's experience sharply illustrates the haphazard way in which the U.S. health care system handles cases involving uninsured immigrants who are gravely injured or seriously ill. Whether these patients receive sustained care in the United States or are privately deported by a hospital depends on what emergency room they initially visit.
There is only limited federal financing for these fragile patients, and no governmental oversight of what happens to them. Instead, it is left to individual hospitals, many of whom see themselves as stranded at the crossroads of a failed immigration policy and a failed health care system, to cut through a thicket of financial, legal and ethical concerns.
The two American hospitals treating Antonio Torres approached his case from distinctly different perspectives. St. Joseph's in Phoenix, with a focus on keeping down the rising cost of uncompensated care, repatriates about eight uninsured patients a month.
"We're trying to be good stewards of the resources we have," said Sister Margaret McBride, a hospital vice president. "We're trying to make sure that the acute-care hospital is available for individuals who need acute care. We can't keep someone forever."
By contrast, El Centro Regional Medical Center in California said it never sends an immigrant over the border. "We don't export patients," said David Green, its chief executive. "I can understand the frustrations of other hospitals, but the flip side is the human being element."
Hospitals are required to screen and treat all those who arrive at their emergency rooms. But they receive only partial compensation for illegal immigrants, and it ends when the patient is stabilized.
But hospitals are also required to discharge safely patients who need continuing care, leading to their quandary: They generally cannot find nursing homes to accept illegal immigrants, or legal ones with less than five years' residency, because long-term care is not covered by emergency Medicaid.
Hospitals in New York face dilemmas as complex as do their counterparts in the Southwest, with the added dimension of a more diverse immigrant population and prospective repatriations to Africa and Asia. The case of Kong Fong Yu has stymied a community hospital in Lower Manhattan.
Yu, 53, suffered a stroke on May 14, 2007. He awoke with slurred speech and then collapsed on his bathroom floor. By the time he arrived at New York Downtown Hospital, it was too late to try to reverse damage to the brain, the hospital said in court papers.
The hospital admitted Yu for tests and to regulate his high blood pressure, which he had been treating with Chinese herbs. Almost immediately, Yu was considered medically stable and ready for discharge to a skilled nursing home. But since he was uninsured and ineligible for Medicaid, no nursing home would take him. He had no relatives in the United States.
So he stayed, and stayed. And he was not the only one. Jeffrey Menkes, the hospital's president, said Downtown housed a few uninsured immigrants like Yu at any given moment, which costs the hospital $1.5 million to $2 million a year. It also costs patients like Yu the chance to receive the intensive rehabilitation that they need.
Yu, according to a hospital document, can "perform some independent activities of daily living, including turning in bed and feeding himself." But he is "dependent on staff for other daily necessities" and suffers from "limited cognition and limited independent judgment."
Yu said that he entered the United States legally 11 years ago and then overstayed his visa to work "on the black market" as a cook. Speaking in Mandarin that was translated by a hospital employee, Yu said he was grateful to Downtown. "American hospitals are very humane," he said. "I have no money. This hospital is giving me food, a bed and care."
But the hospital does not want him to stay indefinitely. Last winter, Menkes said, at a moment when he had patients "stacked up in the emergency room," he realized that he needed to find a way to discharge patients like Yu. Shortly thereafter, the hospital went to court to get a guardian appointed.
When Katherine Huang, a Chinese-American lawyer, was appointed his guardian last spring, the hospital planned to transfer Yu to a Brooklyn nursing home and support his stay.
But the hospital later changed course. In late September, Yu entered the courtroom of New York State Supreme Court Judge Lottie Wilkins on a taxi-yellow gurney. Dressed in a hospital gown, he smoothed his thin hair and saluted the judge in English. Squeezing a small rubber ball for exercise, he was then wheeled behind closed doors, accompanied by his guardian, for what Wilkins called a status conference, closed to the news media.
No record was made of the proceeding. But the guardian said that she learned then that the hospital was contemplating sending him back to his relatives in China.
"All of a sudden, it became, 'Great, the family wants him back,' after the hospital repeatedly told me the family did not," said Huang, the guardian.
The hospital declined to discuss the case, citing patient confidentiality. Menkes said, "We are not going to force people back" to their homelands.
After the September hearing, The New York Times contacted Yu's 30-year-old son in Ningbo, China. Cheng Jun Yu, the son, said he and his mother had been estranged from Yu since he left for the United States. "The family situation wasn't merry," he said.
"We do not wish for him to return," he continued. "He will be a burden for me, and I do not have the time or resources to care for him. My mother has established a new family, and I do not wish for this matter to disrupt her life. If they want to send him back, they will have to negotiate with the Chinese government to see if the government will care for him."
Antonio Torres's journey through the American - and Mexican - health care systems began at dawn on June 7, when the 19-year-old, driving to work across a rutted, gravelly dirt road on the ranch where his family lives, flipped his pickup truck. He was found, unconscious, about 150 feet, or 45 meters, from his vehicle by a ranch hand.
That June morning, the Torreses followed behind an ambulance that took Antonio to St. Joseph's, the flagship hospital of Catholic Healthcare West, where he was admitted to the intensive care unit with a severe traumatic brain injury, bruised lungs and abdominal injuries. Two days later, his parents were unprepared for a hospital social worker's frank assessment of their son's prognosis.
"She said there was no hope for our son and that it would be best to unplug him," Mr. Torres said. "She said, 'You have to think what kind of life this is, hooked up to a ventilator. And if he wakes up, he will not be able to do much.' When we said, 'No!' the social worker said that, well, then, without insurance, they couldn't keep him."
Five days after the accident, the social worker, using an interpreter, called the public hospital in Mexicali to arrange Antonio Torres's repatriation. "Patient accepted for admission," her notes say. The following day, the notes add, "Parents upset."
The hospital delayed the repatriation for a few days, giving the elder Torres time to search for a nursing home. He came up empty, so the hospital moved to repatriate his son even though he was not only comatose and dependent on a ventilator but also had a very high white blood cell count, indicating infection.
Antonio Torres had pneumonia. A hospital physician temporarily blocked his transfer.
Two days later, early on June 20, his white blood cell count was still too high to meet the physician's condition for transfer, according to the social worker's notes. Nonetheless, a few hours later, with the same physician's consent, Antonio Torres was placed on a portable ventilator for his departure.
He spent several days in an emergency room in Mexicali before a bed opened up in a crowded ward. His parents said Mexican doctors advised them to take their son back to the United States if possible. Through their church, the Jehovah's Witnesses, the parents made contact with a church leader in El Centro, California, who took them under his wing, introduced them to the local hospital and raised money for "the best ambulances in the border area," the elder Torres said.
Within a week, his son was on his way back to the United States, where the El Centro hospital was waiting to take him in and write off his care as charity.
"This was a kid who came to this country legally, worked here legally and had an accident," said Green, president of the city-owned hospital. "For God's sake, don't we take care of our folk? To me, this case shows one of the disastrously broken pieces of our health care system."
Torres arrived from Mexico in septic shock, a potentially fatal condition caused by overwhelming infection. After 18 days at El Centro, he woke forcefully from his coma. "They took out his trach tube, he cleared his throat and said, 'Where's my mom?"' his father said.
Told of the progress that the younger Torres had made, McBride said, "That's wonderful," adding that she thought it a testament to the emergency care at her hospital. "Maybe if he had been in a different setting, he may not have survived," she said.
The Torreses have filed a detailed complaint against St. Joseph's with the Arizona health department, and the matter is under investigation.
Now Torres walks with a cane and speaks slurred but comprehensible Spanish. He is itching to climb back onto a combine and cut alfalfa alongside his father. For the moment, though, he is commuting with his mother from Arizona to California for therapy.
Back in Arizona, his father sat stolidly for hours on a worn couch in the concrete barracks-style housing where his family lives, letting the conversation swirl around him.
"Imagine if I had said, 'O.K., disconnect him,"' Jesús Torres said.
Pilar Conci contributed reporting from New York and Tina Lee from Ningbo.