Kind of a demoralizing day in the ER. Well, a demoralizing case. 24 year old guy comes in with some swelling on the right side of his neck. He saw a Fam Med doc about it 2 weeks ago and was told to go get a CT scan. Well, since he doesn't have any insurance this was not the most helpful advice. Predictably he did not get the CT scan and ended up coming in to the ER when things didn't get bettter. I have to admit, the neck did not look good. Obviously fuller on one side, and with multiple prominent palpable lumps that I could only assume were lymph nodes. I did some basic lab work, plus thyroid function tests, and ordered a CT of the neck with contrast. About an hour later the CT tech called to ask if I wanted him to go into the chest as well, because whatever the hell was growing in the guy's neck was extending into his mediasteinum, and thirty minutes after that the radiologist called me with bad news. This was probably Hodgkins lymphoma. Cancer. I gave him the news and he took it so well and so philosophically that I suspected he wasn't getting the whole picture. Still, I used the words cancer and chemotherapy so I felt comfortable I hadn't sugar coated it for him. His main concern was whether there were going to be any needles or scalpels in his neck ("Because i can't handle that, man!" said the guy with six square feet of tatoos on his body) and whether he could still work during the chemo. I called Family Medicine to see about the admission. Technically he wasn't really their responsibility, but a) their guy had seen him 2 weeks ago and failed to make the diagnosis and so there was some ass covering to be done and b) for God's sake--the kid has cancer. Aside from basic human decency there was also the really attractive opportunity to actually help someone. Most of what I do, and most of what they do, is little more than playing nursemaid to people deliberately destroying their helath over the course of many years. So rarely do we actually have the chance to help someone. And here it was--a 24 year old kid with no insurance and a new diagnosis of cancer. We could admit him, work him up, start the treatment, and since he was coming in through the ER, emergency MediCal would cover the expenses on admission as well. Family Medicine really did their part, but then Hem Onc was called in and her decision was that this could all be handled as an outpatient. Yeah, right. Technically, sure, I'm sure she's right. But come on--is that the BEST way to manage it? Surely not. But there we are--he'll be turfed out and left to fend for himself. Almost certainly he'll just be told to go to USC with his scary CT report and his giant neck and hope they can squeeze him into their schedule. As I told the FM resident--this is why I pay taxes. So our nation can pay to have this kid taken care of when he suddenly gets diagnosed with cancer. Not to support the economy of Mexico, not to imprison people who smoke pot, not to provide agricultural subsidies, etc., etc. But here, in the state that has the fifth largest economy in the world, we can't manage to provide decent care to a 24 year old father of 3 with a new diagnosis of cancer. How do they expect doctors to commit themselves to this system? The system is letting done its end of the deal. U-561