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After emergency care in Canada, differences from U.S. approach are evident

By Michelle Andrews,

Afew months ago, I wrote about my experience at a Canadian hospital emergency department following my disastrous encounter with a patch of gravel while cycling in Quebec in July. My impression of emergency care across the border: mostly positive, despite a conspicuous lack of high-tech diagnostic equipment or physician specialists.

When I wrote that story, though, I had just returned home to New York and hadn’t yet organized follow-up care for a broken right thumb, broken left shoulder and very painful pelvis/left hip. I thought a few weeks of bed rest would get me back to some semblance of normal, but the reality was more complicated. What follows is the second and (I hope) final chapter in my tale of two health-care systems.

When I arrived at the Canadian emergency department, they took a series of X-rays that picked up the breaks in thumb and shoulder but showed nothing in my pelvis or hip. Their explanation for my pain and inability to walk: strained tendons and ligaments. The prescription: Get some exercise, walk around.

But walking wasn’t helping, and after I got home a U.S. orthopedist ordered an MRI scan to see what might have been missed. That’s when I learned that I had three breaks in my pelvis and a hairline fracture of the left femur, or thighbone.

To scan or not to scan

In a U.S. emergency department, staff would probably have done head-to-toe CT scans, experts have told me, to identify any bone breaks that didn’t show up on the X-rays. (My earlier story noted a study that found that Americans were almost twice as likely to get CT scans as Canadians when visiting the ED.)

The MRI gave me an explanation for my continuing, disabling pelvic pain. But getting it earlier might not have made a difference in treatment or in the healing process, says Andrew Pollak, chief of the Division of Orthopaedic Traumatology at the University of Maryland School of Medicine.

With minimally displaced pelvic fractures — meaning the broken bone ends are very slightly separated — such as mine, many doctors would suggest exactly what the Canadian ED staff recommended for what they thought were soft tissue injuries: rest and exercise. Other orthopedists would recommend surgery. There’s no data that show which approach is right long-term, says Pollak.

The hip specialist I saw didn’t recommend surgery, and I decided to leave well enough alone.

As I began to follow up on my other injuries I learned a lot about medicine’s increasing specialization: No single orthopedist would treat my myriad injuries, and I eventually acquired three specialists.

I also learned that lack of clarity about treatment was the rule rather than the exception. Take my thumb. The break had knocked it out of alignment by 50 degrees. In Canada, the specialist told me surgery wasn’t necessary.

But ED care, no matter where you get it, is intended to assess your injuries and stabilize you. It’s not necessarily the final word on treatment. Back in the States, the rule of thumb, literally, is that a misalignment of 35 degrees or more should be fixed, says Douglas Hanel, a professor of orthopedic surgery at the University of Washington who specializes in hand and microvascular surgery. But that’s based on the collective wisdom of orthopedists, not on data, says Hanel.

My hand specialist painted a much less ambiguous picture, explaining that I’d have difficulty grasping things if I didn’t get my thumb fixed. Who knows, he may be right. In any case, I agreed to the surgery.

As for my shoulder, it turned out that I had a cyst in the upper arm bone that made it more susceptible to breaking on impact, which it did. Another judgment call: Could my shoulder heal on its own, or had the fluid-filled cyst taken up so much space that there wasn’t enough bone left for it to mend itself? No one could tell me. My shoulder specialist wanted to operate. He’s a surgeon, after all. I agreed to that surgery, too.

No way to know

Advocates of consumer-driven health care argue that patients make smarter decisions if they have more financial skin in the game. For my part, I don’t think having to satisfy a $1,500 deductible and then 20 percent of the charges for most subsequent care made me a wiser consumer. Lacking evidence-based data, I had no way of judging whether I needed the surgeries, or the MRIs and the CT scan. I was just worried about being able to function again, and I opted for the more aggressve treatments.

I do know that all this care will make me poorer, for sure, to the tune of several thousand dollars. I’m grateful that I could make my decisions based on what I thought made sense medically rather than on what I could afford. Many people are not as fortunate.

As for my Canadian emergency department visit, a few weeks ago I finally got an itemized bill. The total charge was about $1,120 in U.S. dollars.

That charge probably would have been higher if I’d had the accident in the United States. In 2009, there were 944 ED trauma center visits for bicycle injuries that resulted in one or more fractures in which the patients were treated and released (as opposed to being admitted), according to the federal Agency for Healthcare Research and Quality. That’s pretty close to my profile. The estimated hospital charges for that type of patient: $6,941.77.

To be honest, I’m not entirely sure what the bill for my Canadian care covers, because it’s all in French. The insert instructing me how to make a payment, however, has been helpfully translated into English.

This column is produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente. E-mail questions@kaiserhealthnews.org.

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