Tuesday, June 01, 2010

Privatization and the Blood Test

There is much talk about medicare and its possible privatization. Personally, I don't care who delivers my medicare, private or public, as long as I get to choose where I go, they don't require bloated tax dollars, and OHIP (the government) pays. When insurance companies and public policy tell me where to go, that's when I get tetchy. The humble blood test is a good example of how that can look.

What's in a blood test, you ask. How complicated can it be? You go to the lab, get pricked, watch blood flow into vials, patch it up, and go home to await the results. Not so fast. Getting a blood test is an opening to catching an infectious disease -- foreign object into your blood; getting a blood test can not hurt or it can leave a large, long-lasting bruise or make you faint from the pain in the taking; getting a blood test is just one-half of the equation, the other half is the lab that puts the blood through its chemical paces for analysis.

As I've discussed before, the hygiene around getting one's blood tested is important. Techs can use the no-touch method -- they don't touch anything that touches you, like the needle -- the glove method (but have you ever watched them putting on the gloves, their germy hands stretching and touching the outside of the gloves down to the fingertips, so much for hygiene) or the wash-their-hands method just before taking your blood. I prefer the last, but who does that anymore? I've also discovered the lab can institute practices that heighten the risks of infection. Mount Sinai Hospital is the only one that I know of so far that's done this.

The skill of a lab tech comes into play when actually doing the test. The best techs by far are those who work at Toronto General Hospital. They take one look at me and know to use the butterfly needle. Other places don't even know what that needle is or won't use it for budgetary reasons. Money trumps patient care. They also have never, ever taken my blood from a superficial vein. They know how to find the large veins in both arms and how to expertly draw blood from them. In contrast, other labs usually go for the superficial vein until I growl at them. Once I didn't. She stuck me. I pitched forward a bit, went dead white, and somehow managed not to pass out while the lab tech panicked with needle still in my arm. Still, she managed not to make it worse and filled all the necessary vials. Since then I will even snatch my arm back if they so much as look at that superficial vein they're all fond of pricking.

Why are superficial veins worse and show poor skill on the part of the lab tech? First off, they're smaller which equals taking longer to fill a vial, and if you have several vials to fill, it's going to take a long, long time. Pity you. Pity the poor people waiting for their tests. Second, they bruise more easily. Thirdly, they will cause long-lasting pain and may create a pulling sensation whenever you try to stretch your arm straight. When lab techs take blood from a hidden large vein, which they can find by palpating the crook of your arm, blood will zip out. Very little pressure afterwards is needed to stop bruising. And if the needle hurts, like it does for me, the pain will stop as soon as the needle is withdrawn. There is no sensation of pulling, and you'll have thought-less use of your arm almost immediately. Whichever vein blood is taken from, though, it's good to apply pressure for a little bit and to keep that cotton swab on for awhile in order to prevent bruising.

This lesson was brought home to me last week when I had to go to one lab for one doctor and to St. Michael's Hospital for another, over my strenuous objections I might add. Last time I went to St. Mike's they gave me a bruise from elbow to wrist, I kid you not. Anyway, I waited about 30 minutes at the private lab before being called by name. I noticed there were more lab techs than the last time I'd been, and the wait was shorter. The private lab tech took me to a private cubicle, spotted my left arm vein, a big juicy one, skipped the superficial ones altogether, used a needle that was too big for my liking but caused little pain, and filled the several vials up so fast, it was done and the cotton stuck on before I could blink. I left in no pain, with a tiny bruise. Two days later I headed to St. Mike's. As I waited and waited and waited in a very crowded waiting room, I overheard from a regular that St. Mike's had cut its lab staff down to two from four. No wonder waiting for one friggin' blood test (requiring two vials!) was the longest I'd ever waited for any test, like I have nothing better to do than sit around for about an hour. I thought waiting a half hour at other places was a bit much. Anyway, the lab tech at St. Mike's doesn't come get you; you have to know where to go and pay attention to this number clock near the ceiling till it hits your number. The clock is in the opposite direction of the lab. Service, eh? I had to keep reminding myself to look, which gets harder and harder as the minutes tick by and the numbers don't move. Finally, my turn. I sat in an old chair in full view of the waiting room, next to the other patient, with previous patients coming in and standing right in front of me complaining about blood pooling in their arm as I sat there, needle in arm. Anyway, the lab tech swabbed my right arm in the right place. I relaxed -- no worries about superficial veins. Hahahaha! When she pricked me, flames raced up my arm to the elbow. I sucked in air as I waited and waited and waited -- when is that vial going to fill?! -- finally one vial done, second put in, try not to hurl, try not to faint. At last needle out, and I saw she'd stuck a superficial vein a couple of cm below the crook of my arm. No wonder each patient is in the lab longer than at the private lab. That's what poor skill and taking from a superficial vein does. But it wasn't over. Oh no. Although the needle is out, the cotton is on, I had to sit for a minute before being able to stand up, plus it took a few tries to get out of the old, sunken chair. I had to keep pressure on it for 15 minutes to a half hour. Every time I let go, it hurt like hell. Every time I pressed, it felt like pressing on a fresh bruise. I couldn't straighten my arm for quite awhile because the pulling sensation was just too unpleasant on top of the lingering nausea/faintness. All that pressure paid off though. Blood exploded out of three other tiny veins -- surprise, surprise -- but didn't seep into the surrounding tissues. Blood also exploded along the vein that was pricked but it too stayed around the vein and didn't seep elsewhere. So no fat bruise, just bruise-like-tracing of veins and blood dots. Lovely. Especially since it's short-sleeve weather. I'm so vain.

The reason I had to go to two labs was because of lack of choice. Up until about two years ago, doctors would hand me a form, and I'd trot off to Toronto General. They'd send the results back in the standard week or less. But then specialists started telling me I had to go their lab because only their lab at hospital x could test the blood for substances y properly. I resented deeply being subjected to the unhygienic practices at Mount Sinai, and I'm now equally pissed at being subjected to the inadequately staffed and poor skill level of St. Mike's. Meanwhile, my GP wants me to go to private lab z because they send him the results electronically. The hospital labs, as far as I know, fax their results still. After all the brouhaha about changing to eHealth, you'd think at least the labs would be capable of sending results directly to doc's computers. Although, I'm not too keen on the private lab, after some experimentation, I've found one of their locations that is hygienic and does a decent job. The hospital lab gives me no such choice. Having choice of location means each location has to step up their game if they want to retain patients. And though you'd think the demand is so great, what does it matter, you quickly learn some locations have far longer wait times than others.

The complicating factor in all this is that the province has begun centralizing testing. So does it really matter which lab you go to to get your blood extracted? There is some discussion, perhaps valid, in which case it's up to the province to regulate better, that some labs are better than others when analysing blood and urine samples. But I had one occasion where one doctor insisted I go to his hospital's lab because blah blah blah. I get a copy of the test and guess what, it's from another hospital. Another hospital, considered inferior in testing the sample, analysed my blood anyway. Oh brother. And that brings up my final point.

Under Ontario law, I'm not allowed to see my results but must ask for them from my doctor. Some outright refuse; they won't even show me them in the office, never mind give me a copy, even though they are required to upon my request. It's an unnecessary piece of bureaucracy, and as I discovered when my cortisol tests were royally fucked up and I went searching for how they're supposed to be tested, in the US, the labs automatically send you your results at the same time they send them to the doctor. Twenty years ago, when I worked at the Ministry of Health, there was much discussion about a Patient Bill of Rights. The two most against it were the insurance industry and police. If that Bill had gone through, I doubt I'd be forced to ask my doctors for a copy. In truth, if you only go to see your GP for the flu or an annual, this is not a big deal, but when you see specialists who don't talk to each other and barely talk to your GP, you are it. You are the only one who knows the full story (and if you have a brain injury, that's pretty scary). I am the only one who has a copy of all of my blood, urine, and brain scan tests, assuming I managed to get them. When the law says I cannot have them sent to me directly, the law is seriously hampering my health care and my ability to manage my health. If someone doesn't want to see their results, there could be a box for them to refuse. Otherwise, it should be standard.

So to sum up: private delivery gives me some choice and -- except for Toronto General, which now refuses non-TGH patients, probably because they'd become too popular for their excellent service and skill -- provides a higher skill level and better service than public. OHIP pays regardless, well, except for the blood tests they're busily delisting. Private clinics also do it for fewer of my taxpayer dollars, I bet. I know that more complicated procedures cost less at a private clinic than when done at a hospital because of the hospital's bureaucratic rules. Privatization is already here and has been since medicare was instituted. The lessons learned from the humble blood test are a metaphor for all other procedures and care. What matters most is not whether the clinic is private or public but patient care, treating the patient as a person not a number, service, skill level, knowledge, keeping up with the research, hygiene practices, choice, and patient rights. Only then shall we receive good care.

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