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'Dumping' Patients in Critical Care

June 16, 1987|ALLAN PARACHINI | Times Staff Writer

Until now, the extensive debate over patient dumping--transfer by private hospitals to public ones of people who can't pay--has tended to focus on the shunting from one hospital to another of patients undergoing emergency treatment.

But this justifiable preoccupation with dumping of critical cases may have obscured a far less common but still medically hazardous and emotionally wrenching variation, a County-USC cancer treatment specialist contends.

Involved is the transfer of seriously ill cancer patients to public hospitals after their therapy has already begun.

Such transfers, Dr. Steven Grunberg contends, often occur at the point the cancer victim's medical insurance runs out and the private hospital or physician has collected the last benefits. Thus, cancer victims with limited insurance may find themselves abruptly switching physicians and hospitals in the middle of treatment that itself can often be painful, unpleasant and anxiety-inducing.

May Arrive With Notes

In a telephone interview and in a letter to the editor in the New England Journal of Medicine last week, Grunberg said such dumped cancer patients may even arrive with notes from the transferring physicians saying: "I gave the first course of chemotherapy several weeks ago. I expect you will give the remaining five courses starting tomorrow."

Grunberg emphasized that such dumping episodes are rare--their precise frequency has never been scientifically studied--and that he was commenting on the phenomenon as an individual, not on behalf of county health agencies. But he said the practice not only needlessly disrupts cancer therapy but worsens the already serious financial plight of public health-care facilities, because the private cancer specialist collects all available insurance early in the treatment and leaves county facilities to finish the therapy with no prospect of payment.

Doctors, Grunberg said, almost always know how long a given course of cancer chemotherapy or radiation will take, and they can easily find out what insurance benefits a patient may have. Physicians, he said, should agree to finish cancer therapy if they start it or transfer the patient before treatment.

Heart Rate Risk

A notion that there is a relationship between the rate of the heartbeat and the risk of having a heart attack or dying of heart failure is the subject of a growing medical consensus. Building on this earlier research, one of the nation's best-known research programs has reconfirmed the heart rate-risk relationship and found it extends, in many respects, to women as well as men.

Though there are some minor variations by age and sex, it appears that healthfully slow heart rates are related to a significantly decreased risk of heart disease and sudden death, researchers from the Framingham Heart Study reported. The Massachusetts project has been tracking the health of the same 5,000 people since 1948.

Men had a somewhat more direct relationship of heart rate to underlying heart disease than women, but the overall advantage of a slower heartbeat was unquestionable, the researchers reported in the American Heart Journal.

People with resting heart rates of between 30 and 67 beats per minute--statistically normal is 72--have the lowest incidence of sudden death and death due to underlying heart problems. The highest rates are among people whose hearts beat 92 to 220 times per minute. Slower heart rates are often associated with programs of physical exercise and effective stress management.

Guns and Injuries to Children

The similarity in appearance between small-caliber firearms and toy guns, combined with the absence of effective, child-resistant safety catches, is being blamed for an unsettling series of California incidents involving young children who have unwittingly shot themselves or other youngsters. The study investigated 88 fatal shootings between 1977 and 1983.

Among the cases, according to a UC Davis research team led by Dr. Garen Wintemute, shootings in children 4 and under were most likely to be self-inflicted, but among those 10 to 14, children were far more apt to shoot other youngsters. Several of the incidents began when children found handguns kept in the home for self-protection at night, but they had not been properly stored during the day.

Because of the clear, deadly risk of children mistaking guns--particularly .22-caliber pistols--for toys and the failure to realize the guns are loaded, the Wintemute team urged changes in gun design. Writing in the Journal of the American Medical Assn., the UC Davis researchers urged gun makers to alter designs so it is easy to see if a gun is loaded and to redesign safety catches so the safety must be continuously pressed while the trigger is pulled.

Reduced availability or accessibility of handguns would have the greatest effect of all, the researchers said. They warned that the recent introduction of plastic guns--whose light weight and appearance is apt to make them seem even more like toys than current models--may worsen the rate of children shooting children.

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