'Medical tourists' are unique ED challenge

Different meds, no records, problematic follow-up

They call them "medical tourists." They may be in the United States on a vacation, or they may be here for a specific procedure, but either way they can end up in your EDs. You and your staff must be prepared to deal with the incredible constellation of unique treatment issues they raise.

Managers tell ED Management that the challenges presented by medical tourists go far beyond the obvious language and cultural issues. Here are just a few of the issues they cite:

  • ensuring follow-up care when medical issues are not completely resolved;
  • treating a disease not normally seen in the United States;
  • finding the right specialists;
  • overcoming different naming systems for medications;
  • completing a history without medical records, or records written in a language for which a translator is not readily available;
  • addressing housing and transportation issues for family members.

Even if people from other countries are in the United States for a specific procedure, they still can end up in the ED, notes Frank Peacock, MD, FACEP, vice chairman of the ED at the Cleveland Clinic. "They may fly in the day before [and become ill or injured], or perhaps they had a procedure and are in the follow-up period, and developed a problem," Peacock says. "Just because they are here for reconstructive surgery on their foot does not mean they can't get appendicitis."

The clinic owns three nearby hotels that can house these visitors, and ambulance service is provided, but that convenience can be a problem for the ED. "They are all told exactly where the ED is, and I bemoan that sometimes," Peacock says. These patients can be brought in from their hotel at 4 a.m. for the same conditions as typical ED patients. If they have a cold, they go back to the hotel, Peacock says. "But if their scrips run out, we have to try and fill them," he says

Mayo Clinic Hospital in Phoenix, sees patients from outside the country who come in for routine things such as a blood pressure check, says Laurie Zessin, RN, BSN, MBA, manager of the ED. "They may have a problem at home and just want to make sure everything is OK," she says. "If it's high, we'll treat them like anyone else who comes in [with hypertension]."

The biggest challenges

Zessin says that follow-up and arranging for specialist care are among her greatest challenges. "We are here to see and treat and stabilize the patients so as to not cause harm to life and limb, but we are often not able to totally resolve the problem," she says. "The patient might need more tests done or a follow-up visit to see how they are doing."

Getting patients to the right specialists can be very challenging, Zessin adds. "The patient may have a complex set of problems and need to have several specialists providing service," she explains.

Local specialists try to accommodate those needs, "but sometimes we need the patient to be seen within two days and they can't see them for a month," she notes. What usually happens in those cases is "they bounce back to the ED, and we make sure nothing untoward has happened."

Peacock and Zessin note that sometimes these patients will have diseases not normally seen in their EDs. "Some patients are from the Third World and will have diseases I have never seen," notes Peacock. For example, U.S. EDs don't see dengue fever, he says. "This makes treatment decisions difficult," Peacock says.

A lot of the Mayo patients present with malaria, "and we do not normally see that," says Zessin, who adds that she has taken steps to overcome this challenge. "First of all, your staff needs to be able to recognize signs and symptoms, and what tests to order," she says. To make sure they are prepared, she has held an inservice on diseases such as this one.

While most language barriers are overcome today with the use of on-site interpreters and phone line translations, Peacock notes that some issues still remain.

"I had one patient who came in with a 50-page chart, but it was all in Italian," he recalls.

In addition, he says, some countries have completely different naming systems for medications. "Sometimes we can figure them out, or they are generic [drugs] and we then understand what they are," he says. "But if they are written in Arabic, you can't do that."

In such a case, he says, they obtain an Arabic translator, although it can take one-half hour for them to reach the ED. The hospital has a large list of translators, many of whom work on-site. Others may be called at home.

For several more mundane issues, both hospitals have separate departments that can address housing, transportation, and other issues for patients. The Cleveland Clinic has a Global Patient Services Department, while Mayo has a Regional Medicine Department. At Cleveland Clinic, for example, the ED simply contacts the department and an advocate is provided for the patient.

Finally says Peacock, some of his greatest challenges have been the result of cultural differences. For example, many of his patients are from the Middle East, where modesty is of particular concern. "I have examined some women completely through their clothes while being watched by a guard," he shares.

Sources

For more information on how to treat medical tourists, contact:

  • Frank Peacock, MD, FACEP, Vice Chairman, Emergency Department, The Cleveland Clinic. E-mail: peacocw@ccf.org.
  • Laurie Zessin, RN, BSN, MBA, ED Manager, Mayo Clinic Hospital, Phoenix. Phone: (480) 342-1738.