Early on a Tuesday morning on the ninth floor of Nassau University Medical Center, second-year resident Aisha Amjad discussed patient William Bermudez with two fellow residents and Dr. Steven Walerstein, the hospital's chief medical officer.
"He's diabetic, but he doesn't have money to buy his meds," she said.
Bermudez, an uninsured landscaper from El Salvador, had already been in the East Meadow hospital for a week. A CT scan showed one large, complicated fluid-filled cyst around his pancreas. Or was it multiple smaller cysts? It was impossible to tell from the scan.
His white blood cell count was off the charts, a sign he was fighting an infection, and he had been put on the antibiotic vancomycin.
Walerstein listened closely, his tall frame bent over a cart containing medical records.
This was the first day of a week in February he planned to spend as a hands-on doctor with a caseload of patients, teaching residents Amjad, 29, Alejandro Romero Pepen, 30, and Limin Gao, 37, and learning how things really work in the trenches these days.
For Walerstein, who has been NUMC's medical director since 2005, it was a chance to practice medicine and attach faces to the statistics he must review. Faces like Anita Wooten, 52, of Hempstead, who had a seizure while in rehabilitation at NUMC within days of having a stroke. "I'll be OK, right?" she asked, giving a hopeful thumbs-up. "That's the plan," Walerstein said.
For the residents and the rest of the staff, a week with Walerstein meant an opportunity to get up close and personal with the hospital's top doc.
At the end of the week, Walerstein said, he would see yet again how important it is for staff to communicate with patients and families, and the need for good primary care outside of the hospital.
Bermudez's case was just one of many during the week that illustrated how hospitals deal with physical ailments that are often inextricably intertwined with social issues -- especially a safety-net hospital such as NUMC that treats a large number of the poor and uninsured, who often don't get regular health care.
If Bermudez had seen a doctor regularly, "his severely high triglyceride level would probably have been diagnosed, treated and never caused pancreatitis," Walerstein said.
In addition, Bermudez does not qualify for government-supported Medicaid, so the hospital -- which legally must take care of all patients regardless of their ability to pay -- will get little reimbursement for his care. It could involve surgery, extend for weeks and cost more than $100,000. And that doesn't include follow-up care.
Cases like Bermudez's go to the heart of the current health care debate, which is now before the U.S. Supreme Court. President Barack Obama's Affordable Care Act is an attempt to overhaul a health care system that hospitals acknowledge is expensive and often inefficient, with little attention paid to keeping people healthy enough to stay out of the hospital. It was passed two years ago, but in June the high court is expected to rule on whether to throw out parts or all of the law.
During his week of rounds, Walerstein and his team encountered a range of patients:
A man guarded by a sheriff's deputy after he allegedly drove into a police car while intoxicated. He said he wanted his prescription opioids, but he couldn't give the team complete information on his doctor.
An incoherent older man with end-stage liver disease caused by years of what Walerstein said was alcohol abuse. Did he have any relatives?
A woman who had taken steroids for many years to treat severe rheumatoid arthritis. The drugs caused such osteoporosis that a doctor described her pelvis as "melted." She faced having to go to a nursing home.
Besides evaluating a patient's medical condition, each visit also called for an understanding of his or her lifestyle and psychological state. All hospitals must deal with family and personal dynamics, but such issues are often intensified at NUMC because the population it serves is often poorer and sicker.
Patient # 1
Infrequent careBermudez, whose stomach looked distended under his hospital gown, smiled as Walerstein and the residents entered his room. He spoke little English, so he and Pepen communicated in Spanish.
Walerstein asked whether Bermudez had a regular doctor who could manage his diabetes and very high triglycerides -- the cause of his diseased pancreas. Bermudez said no and explained that he had an appointment at a clinic but got lost and never made it there.
This confirmed what Walerstein said he already knew: that trying to treat people in the hospital without preventive and follow-up care is akin to putting a Band-Aid on a large, gushing wound.
"The system is inadequate; the system has huge holes in it," he said. "The lack of insurance, the lack of social support means that people can simply fall through the cracks."
It was his job that week to try to prevent that.
"We'll do a better job before he leaves the hospital," Walerstein said as he left Bermudez's room.
But a discharge could be weeks away.
Drug dilemmaIt was Wednesday, and Mary Ellen Romer was supposed to go home the next day. But Walerstein was worried she wouldn't take care of herself.
She had a severe and widespread rash -- possibly the result of a reaction to the blood thinner warfarin -- that had put the Franklin Square resident back in the hospital.
In November, Romer, 54, had been hospitalized after suffering a potentially fatal pulmonary embolism, and she had pulmonary hypertension and heart failure, a condition in which the heart can't pump enough blood for the body's needs. She needed to stay on a blood thinner.
But the only option was to give her a drug that had to be injected. Romer had recently lost her job and had no health insurance; her application for Medicaid was pending.
Would Romer be able to pay for a drug that would cost hundreds of dollars a month compared with warfarin, which cost far less? And would she give herself the injections? She had a history of not keeping health care appointments and so far had resisted the idea of a home-care nurse.
But this day, Romer, her arms still covered in sores from the allergic reaction, agreed to allow someone to come to her home. That was the good news.
The bad news was that the hospital was able to send her home with only 10 days' worth of the injectable blood thinner.
Walerstein said the hematologist wanted to make sure the allergic reaction was indeed caused by the warfarin. If it wasn't, the hope was that Romer could go back on it. If it was, it was unclear where she would get the injectable medication after her supply ran out.
But keeping her in NUMC, which, like all hospitals, is under pressure to discharge patients as quickly as possible to save on health care costs, was not an option.
"You're damned if you do and damned if you don't," Walerstein said.
Follow-up is keyIt was 10:55 a.m. on Friday as Walerstein pushed the button for the elevator. He had just finished making rounds -- almost the end of his shift for the week.
As the elevator door opened, he suddenly spied one of his patients, Mary Hall of Roosevelt, still dressed in her hospital gown, trying to maneuver her wheelchair onto the elevator.
"Where are you going, Ms. Hall?" he stammered.
Less than an hour earlier, Walerstein and the residents had examined Hall, 73. Although she had fluid in her stomach and has diabetes, chronic obstructive pulmonary disease and heart failure, the CT scan showed nothing acutely wrong with her. Walerstein told her it was possible she would go home the next day.
But that apparently was not soon enough for Hall. "I can't take it anymore. I'm going home," she declared. "I'm tired. I have to have some sleep."
It took a minute or so for Walerstein to coax Hall back to her room. He asked her a series of questions: Did she know what day it was? "Friday," Hall promptly answered.
But the month and year she got wrong, and she was confused about how long she had been in the hospital.
"I'd like to make a deal with you," Walerstein said. "Be a little more patient, and we'll try to get you home as soon as possible."
Afterward, he and the team huddled: Could Hall's medications have caused her to become confused? No, they decided. They should check her blood sugar and give her some oxygen, Walerstein said.
Hours later, Hall was less confused. She went home the next day, but Walerstein worried whether she would get follow-up care.
"Like everyone else, if she sees a primary care doctor, then her chances are pretty good," he said. "If there's no follow-up, that's an issue."
Final diagnosisAround 4 p.m., Walerstein once again punched the elevator button to take him back to his office on the first floor. On Monday he would be back to meetings, money issues and statistics. He said the week had left him feeling "a mixture of exhilaration and exhaustion . . . of renewal and frustration."
But he had given himself new orders: He would continue his weekly rounds -- not just once annually, but four times a year.
How patients have fared in the months since they were hospitalized:
William Bermudez, who entered NUMC on Jan. 27, was discharged April 4 after doctors drained an abscess near his pancreas. Although he is unable to work, he said he can move around, eat and is in no pain. He has been back to an outpatient clinic once for a follow-up visit and has several more scheduled, he said.
After her discharge Feb. 1, Mary Ellen Romer was readmitted in March for three days for cellulitis in her leg. Her Medicaid application is pending, according to hospital officials. NUMC was able to get her a steady supply of an injectable blood thinner through the manufacturer's patient assistance program.
Mary Hall has not returned to the hospital but has been back for seven clinic appointments since her discharge Feb. 3, one of which was to NUMC's eye clinic earlier this month. She said she is now facing an operation for her cataracts.