Medical Marvel : Care Amid the Chaos at County-USC

There are many ways to wind up at Los Angeles County-USC Medical Center. Membership in what emergency room doctors call the Knife and Gun Club is one popular route. Drinking your liver into jelly is another.

A common path is via the womb. On average, 46 babies are born there each day, more than a few in the parking lot. “You are not initiated,” one house doctor said, “until your first delivery in the back seat of a car.”

Car wrecks and drug overdoses contribute heavily to the daily census of 1,400 patients. Cancer, cardiac trouble, kidney failure, pneumonia--all the major diseases are in evidence. Going crazy can get you there too, limbs lashed to a bed with leather bracelets.

Nearly 100,000 patients are admitted each year, and another 480,000 patient visits are recorded in emergency rooms and outpatient clinics. Seventeen-thousand babies are born there--one out of every 200 in the United States--and 1,300 hospital stays end when patient becomes corpse, is bagged and tagged and stacked in vaults in a basement mortuary.

The medical center is the nation’s largest acute-care hospital, a teaching hospital where doctors come from all over the land to feast on a diagnostic horn of plenty and make new medicine--despite conditions that can be little better than crude.

It is also the county’s hospital for the sick poor, “The hospital of last resort in a system of last resort,” said Executive Director Paul Drozd. Often, it is the only place where transients and illegal aliens and other soldiers in the army of the down and out can find care, and sometimes even comfort.

Birthday Party for Hobo

There was a hobo on one of the wards, and it was his birthday. The nurses surprised him with a bedside party, giving him one of the neatly wrapped packages that a volunteer group supplies for such occasions. The man began to cry.

“He was so moved,” nurse Marcia Behmer recalled. “He said he had to come to the hospital to find friends, and that no one had given him a birthday present for as long as he could remember.

“And then he opened the gift up, and it was shampoo and conditioner.” That he was bald seemed not to matter.

Panhandlers troll the medical center corridors, and some of them are patients.

“On a good day,” said Lloyd, a 31-year-old with a stringy red beard and a pallor approaching translucence, “I can make six bucks.”

Lloyd came to the medical center a year ago. Chased by private demons, he said he had leaped off a freeway overpass in Norwalk and was left paralyzed. Now he is a hospital fixture. Clad in a white gown, legs folded up and fastened tightly to his wheelchair with a sheet, he scoots about the hallways cadging cigarettes from nurses, shepherding patients through the hospital bureaucracy, singing Jethro Tull ballads and, always, always, prowling for spare change.

“The best place,” Lloyd said, “is right over there by the front door. You say, ‘Merry Christmas, Sen-or-i-ta, do you have any change?’ ”

His prime hunting ground is the threshold of General Hospital, also known as Unit 1. A 20-story hulk of gleaming concrete, it sits atop Lincoln Heights in East Los Angeles like some great and terrible ark, its cargo all the kinds of injury and illness known to man.

Connected by Tunnels

Arrayed about Unit 1 are three smaller hospitals and 100 auxiliary structures. A network of subterranean tunnels connects the buildings.

It costs $1 million a day to run the medical center, and all but a scant fraction of the money comes from taxpayers. It is almost never enough.

Contradictions abound. A skillful diagnosis becomes moot because the patient can’t afford to fill a prescription. A doctor speaks glowingly of the quality medicine practiced at the institution, and then admits that, no, he would not put a member of his own family in one of its cramped, chaotic wards, where patients sleep six to a room and where, in a heat wave, dimmed lights and opened windows must pass for air conditioning.

Drum-tight budgets force doctors, nurses and administrators to become Machiavellian strategists, competing among themselves--and other county hospitals--for money and material.

Likewise, patients become quite adept at working the medical center system for their own purposes. Some have been known to bounce around the grounds from hospital to hospital, persuading several doctors in a single day to prescribe them drugs.

Transients wishing relief from the cold will check in first at the emergency room to receive a plastic patient identification bracelet. This will discourage security guards from evicting them from the foyer of General Hospital, where they sleep, warm and peaceful, eyes closed to a magnificent ceiling mural of Hippocrates.

President Threatened

Nurses who notice a patient growing fidgety or grouchy know that it may signal an urge for street drugs. Quite often patients inflicted with this condition will concoct an excuse in order to check out for a day. They generally return on schedule, relaxed and cooperative, ready to resume their recovery.

And Dr. Steven Horowitz of the Psychiatric Hospital tells of a patient who threatened the life of the President in order to secure a trip home to Pennsylvania. He had come to Los Angeles on business, but only had enough money to arrange for a one-way trip.

“He called the Secret Service several times, making his threats, and then he walked in the door and said, ‘I was the one who threatened the President.’ They brought him here, and when I talked to him it became clear he only wanted to go back to Pennsylvania.”

And?

“It worked.”

Many medical center patients live in East Los Angeles and speak only Spanish. Doctors and nurses not fluent in the language often rely on pidgin communication. Each service develops survival phrases. For example, the key word for nurse midwives is empuje.

“It means ‘push,’ ” Nancy Bolles, the head midwife, explained. “You go, Empuje! Empuje! Empuje! “

In the emergency room, the words are donde, “where,” and duele, “pain,” essential for determining where it hurts. Patients with stomach pains are called “ duele bellies.”

Women come from Mexico to have their babies at El Hospital, as the institution is known along the border from Nogales west. One reason is that babies born in this country automatically become citizens. Increasingly, pregnant women from El Salvador and other troubled Central America countries are showing up at the medical center. “You can always tell where the revolution is by our patient population,” one old hand said.

Some patients seem to care little about their health. Doctors and nurses speak of the frustration of making someone just well enough to leave the hospital and return to the streets to do more damage to his or her body. “I mean, I discharge patients to a rescue mission, “ said one doctor.

Basic Priorities

“It has been suggested,” a medical center pediatrician added, “that the best thing we could do for some of these patients is give them a television set. That’s because their priorities are food, shelter, entertainment and health care, in that order. So if we gave them a television, at least health care would move up a notch.”

Other members of the clientele are just the opposite, impoverished mothers who manage to bring their children great distances in order to receive care, or outpatients who come each week for checkups. They spend much of their day standing in a line, waiting to see a financial counselor (always the first stop), waiting to see a doctor, waiting to schedule their next appointment.

It can be argued that medical center patients give more than they take, serving as teaching tools for more than 900 interns, residents and fellows each year. “All of us owe a great debt to these patients,” said Dr. Alexandra M. Levine, a medical center cancer specialist. “The patients in this hospital, without knowing it, have taken on the responsibility for training a tremendous number of physicians in this country.”

Handling heavy trauma is what the medical center does best. The emergency room of the General Hospital is its pride, a source of national acclaim, each day fielding a succession of frightfully wounded or gravely ill patients.

An apocryphal story told throughout the institution is that Los Angeles doctors carry cards or notes in their pockets instructing ambulance drivers, in the case of an acute injury or illness, to transport them directly to the medical center.

“Of course,” added Medical Director Sol Bernstein, providing the equally popular punch line, “most of them also say that as soon as they are over that acute injury or illness, take them someplace else.”

Prolonged Waits

All this traffic in acute cases has a downside. The moderately hurt, sick or deranged often must wait ungodly measures of time to receive treatment while more critical cases play through.

“This is not the place to come for a nose job,” is how one staff member put it.

Not all patients, of course, can be saved. Sometimes, they appear to be headed for recovery and then, in the parlance of doctors, “go sour.” Other times, they are terminal to begin with, and essentially come to the hospital to die.

Mortality can be as tricky as a fun house mirror. Intensive care nurses point out patients who “have been on the other side,” only to be brought back with chillingly similar descriptions of lights and tunnels. In the emergency room, a doctor lamented, “bad guys always live and good guys die. It seems to be a rule.”

And then there is this:

A woman drank ant poison after she fought with her husband. He rushed her to the medical center and house experts on toxins were summoned. She came around, it seemed, and husband and wife consoled one another, made amends, hugged and wept and vowed to do better.

Then a doctor took the husband outside. Even though his wife looked well and wanted to go home, the man was told, the truth was that the poison had begun a lethal chemical process and it could not be stopped.

“She probably won’t make it through the day,” the doctor said.

The husband was furious, disbelieving. The doctors were crazy, he said. Anyone could see his wife was fine. He demanded to take her away at once.

Four hours later she was dead.

The medical center can be a rough place. Employees who work nights speak of walking with fear to their cars. Security guards watch the ambulance entrance. Late last year, a patient was shot to death by a security guard in the emergency room after he allegedly reached up from his gurney, grabbed another guard’s gun and opened fire.

It can, at rare times, be a boring place--drowsy, doctors hunched over desks in the late afternoon, plowing through stacks of patient histories, medical students slumped in chairs as a lecturer drones on about the intricacies of a respirator.

And at all times, everywhere, around every corner, along every hallway, behind every door, there are people on crutches, people in wheelchairs, people in casts, grizzled hobos who look like Walt Whitman, skeletal transients who scream out that they are being “kidnaped, kidnaped I tell you, this is a kidnaping.” And mothers with swollen bellies, and street brawlers with swollen faces, patients all.

On a November morning in the General Hospital’s orthopedic infection ward, many of the patients were young men who lay flat on their backs, each with a single injured hand propped up on a pillow and covered with a green towel, faces sullen. They were there because they had punched someone in the mouth and neglected to clean the ensuing cut, allowing it to fester into a horribly infected wound.

“We always get a rush of these after a championship fight,” one doctor said.

Not all the patients were fallen combatants. There was a woman who had cut her hand with a dirty kitchen knife, a young man who plunged into the Colorado River and received a gash on his leg that became infected and a bulky weightlifter who infected his buttocks when he injected vitamin B-12 with a dirty needle. He kept at his bedside a mirror, a copy of Muscle and Fitness magazine, a Bible, and several snapshots of himself, with which he intended to illustrate a free-lance story on the demise of his derriere.

There was a somewhat crazed looking young man. A regular, he was in this time because he repeatedly punched his hand into the wall. “He comes here to get the TLC (tender loving care) he can’t get on the street,” a doctor said.

“Where do you live?” a skinny old man with a drawn, yellowish face was asked.

“I don’t live anywhere,” he said, his voice rising excitedly, as if he couldn’t believe it himself.

On the next bed was man whose feet were ripped apart by swelling and were infected.

“I live in a mission and you have to sit up to sleep and my feet swole up,” he explained.

“Don’t they give you a bed to sleep in?”

“You only get a bed five nights out of 15.”

Call for Codeine

Next to him was a dark, handsome man with a gallant mustache and a gold chain around his neck. He had been transferred from a private room at UCLA after his boss canceled his medical insurance, and now he was telling the doctors he wanted codeine at night to help him sleep. The snoring was keeping him awake.

And to his right was a burly red-haired man with an injured knee. He was propped up against a wall. He took a long drag on his cigarette and exhaled slowly, satisfaction written across his face as clearly as the sign over his head that read, “No Smoking/ No Fumar. “

Near his bed was the room’s only television set. It was tuned to “The Flintstones,” and the theme song that opens the cartoon was blaring loudly, promising everyone “a yabba-dabba-doo time.”

The medical center employs 340 staff doctors. They train and supervise the 900 interns, residents and fellows. Interns are medical school graduates who must serve a year at the hospital before becoming doctors. Residents are doctors there to become specialists. Fellows are specialists developing sub-specialities. Together, they are called house doctors, and they handle the bulk of the day-to-day patient care. There are also 1,700 nurses. Another 2,300 private doctors from the community also put in time as volunteers.

With all this brainpower, the conflict of ideas flourishes. Medicine is an imprecise science, and the hallways rattle with discussion about how best to handle difficult cases. The most profound ethical questions facing modern medicine today are everyday issues in the wards of the medical center.

Perhaps the toughest questions are asked in the several intensive care units scattered about the medical center.

“Here,” said Robert Swinney, a 38-year-old staff doctor in one such unit, “we have an elderly lady who was bedridden at home and may have had another stroke and got pneumonia and, I think, represents one of the problems we have to deal with, those of us who work in a critical care environment.”

He had stopped at the bedside of an 85-year-old woman. She lay motionless among a tangle of tubes and machines, mechanical devices to perform essential bodily functions that her own organs could no longer muster.

“For whom should we be utilizing these scarce resources?” Swinney asked. “It is a terrible problem. She is bedridden and unable to take care of herself at home. . . . But her family is very interested and very concerned and wants lots done for her. And we are doing it.

“Whether or not it’s the best thing for her I don’t know, because I think she doesn’t have a really good chance of making it out of here alive. . . . The larger perspective is you have got 10 beds, and only one bed is available out of those 10, and there are two patients who need intensive care, and you have to choose between an 85-year-old with a terminal disease and an 18-year-old with a reversible disease.”

A few days later, the woman was gone. “We had basically shot our wad,” one of the doctors explained. She was now on a general ward, presumably awaiting death. In her place was a young man with a severe case of pneumonia. They were inserting a long tube down into a lung in an effort to assess the nature of the pneumonia. He had been transferred to the medical center from a private hospital, ostensibly because there were no slots open in its intensive care unit.

The medical center can be a place of dark humor. On the 13th-floor jail ward in General Hospital, a troubled soul tied to his bed told the doctors he had been carved up by unidentified enemies, and eaten. The devil, he said, had taken him away. “That’s right,” one of the residents said, chuckling. “This is hell, all right.”

It can be a sad place. Viveca Hazboun is a 35-year-old child psychiatrist. The children who come to her small ward tend to be severely disturbed.

Hazboun told of a 5-year-old patient, a girl. One day on the ward, she covered a shower drain with paper towels, turned on the water and put her face to the floor. She was discovered before suicide was accomplished.

Why would a 5-year-old want to kill herself?

“She said life just wasn’t worth living,” Hazboun recalled.

“I had another little kid,” she said, “who was sleeping with her dead sister, who her parents had allegedly killed. They were force-feeding her and she died.”

The parents refused to accept what they had done and left the dead girl in the bed. As the body began to decompose, the other little girl became convinced that her sister had the better deal and attempted to join her.

“These kind of things happen in the City of Angels,” Hazboun said.

Frayed Nerves

The medical center can be a cruel place. It was midnight on the fifth floor of Women’s Hospital, and a pregnant woman whose horrible screeching had dominated the ward for what seemed an hour finally had delivered. Now she was being wheeled to a recovery room, her baby nestled to her bosom.

“What’s her name?” a staff member at the ward desk hollered, preparing to complete a chart.

“Screamin’ Mimi,” one of the nurses called back. Everyone laughed. The new mother did not appear to understand, or at least was consumed by other thoughts.

Finally, the medical center can be a place of beauty:

At 5:15 a.m. one fall day, from the window of Room 8L36 in the Women’s Hospital, it was possible to look west across a sprawl of wrecking yards and railroad tracks that separate the hospital from downtown and watch a city wake up.

Lights winked on in tall buildings. Freeways started to fill. The sky lightened. A fascinating process, it seemed to unfold in a succession of jerky moments, like those old time-lapse photography film shorts depicting the entire life cycle of, say, a tulip.

On the other side of the window, however, a distraction was developing to a rhythm of its own. A spotlight bathed a woman’s belly with eerie whiteness. Her name was Sandra Lopez. She was 19 years old and had come to give birth to a child, her first.

“ Sople . . . sople . . . sople . . . sople . . .” The word is the Spanish command “blow out.” Pat Alamos Donnelly, a 32-year-old nurse midwife standing at the foot of the birthing table, chanted it softly, like a prayer.

The expectant mother’s large dark eyes eyes appeared glazed, conveying both fear and weariness. She focused on a wall opposite the window. Her screams grew louder. “Push with your belly,” Donnelly coached, “not with your mouth.”

But the baby was not coming. The midwife took a pair of surgical scissors and with a few snips widened the passageway. A human scalp emerged. A few more moans, and then, an entire head popped out, delightfully. Soon the entire body was wiggled from the womb.

“ Nina, senora, “ Donnelly said. It’s a girl.

A tickle induced the baby girl’s first cry. The mother laid back her head and sighed. The baby was placed on her stomach, nature’s incubator.

On the other side of the window, the day had grown lighter by several degrees.

In its 106 years, the medical center has endured doctor strikes and threatened doctor strikes, scandals, polio epidemics and Proposition 13 of 1978. It has been investigated by hospital commissions, supervisors, grand juries, district attorneys, television commentators and even a newspaper reporter named Alloysius Blatt, who in 1932 went to the newly opened General Hospital to snoop around on roller skates, a form of transportation intended to underscore his belief that at a cost of $13 million the county had purchased a lot more hospital than it could ever possibly need.

Dire Predictions

There have been dire predictions aplenty about its impending demise. An authorized centennial history of the institution concluded with the somber appraisal that “beyond a few years, the future of the LAC-USC Medical Center is uncertain.” That was six years ago.

Just last fall, medical center staff feared that passage of Proposition 41, a welfare-cutting measure, could cripple the institution; it failed.

Now there is discussion at USC about building a private hospital so that medical students can practice treating a wealthier clientele, and some staff members fret that this could siphon attention away from the medical center and eventually undercut care.

It is a curiosity that the medical center enjoys a better reputation in medical circles than it does in its own community.

Dr. Larry Opas, director of inpatient services at the Pediatrics Pavilion, grew up in Los Angeles and did his residency at Childrens Hospital, providing him with a good perspective of the medical center from both sides of its creamy white walls.

“I think in general one is frightened of the County Hospital,” he said. “The story one hears on the outside is that it is a zoo. It’s chaotic. Disorganized. No teaching. Mediocre patient care. That it’s a step below everyplace else.

“Most of these comments are made by people who have never set foot inside this place. And it’s not the Taj Mahal of medicine, I guarantee you that. But it is far different once you are inside, to the point where you can only take two attitudes toward County--you either love it and want to fight for it or you can’t stand it. And those who can’t stand it usually find a way to get out of it.”

Strong Defenders

Indeed, those who stay at the medical center tend to be its strongest defenders. Medical center doctors boast about how they are summoned to national conferences to lecture on their latest work, or they let it be known how frequently they receive calls from other doctors at famous institutions seeking their counsel on difficult cases.

At the same time, these same doctors point out torn chairs that they requested be replaced months ago.

Or they nod disgustedly toward a long line of pregnant women waiting for hours to pay in advance for a clinic visit.

They say they need more lab technicians and social workers, and less paper work. They complain of dirty toilets and the requirement that they fill out time cards.

Hurting for Personnel

“It’s the personnel shortages that hurt the most,” one doctor said. “For example, because there aren’t enough X-ray technicians and transport people you can’t always get an X-ray when a patient’s health depends on it, and that is very frustrating. Or patients won’t receive proper wound treatment or care for bedsores because there aren’t enough nurses.

“I don’t mean to say that medical care is being compromised, because it isn’t. It’s just that these kinds of things make it harder, more frustrating to deliver it.”

In Women’s Hospital, its annual load of 17,000 babies exceeds by 7,000 the maximum number of deliveries that the 10-story facility was intended to accommodate. Things can move so fast and frantically on the maternity wards that nurses sometimes scribble vital patient information on gurney bed sheets, a concession to the likelihood that birth will begin long before the paper work can catch up.

Only one operating room services the entire 106-bed Pediatrics Pavilion.

Delayed Delivery

In the General Hospital emergency room, patients with breathing problems until this month had to be assisted manually, with nurses’ aides pumping a bag to blow air into their lungs. A ventilator, a fairly common tool of the emergency room trade, was on order for a year before it finally arrived. “Inexcusable,” one doctor said.

Ward 1234, the so-called red blanket room, is where critical cases are moved after being stabilized in the emergency room. There, doctors determine on which ward the patients belong. But often there is no room in the wards and so the patients stack up in the red blanket room and even adjoining hallways, waiting for hours on gurneys jammed closely together, medical gridlock.

Even those who wind up in the medical center mortuary sometimes face a final indignity brought on by overcrowding. The vaults are intended to hold four corpses in a bunk-like arrangement. Often, however, an overflow requires the dead to be stored eight to a vault, with two bodies sharing a single berth.

Lloyd, the panhandling patient, has been at County-USC for a year now and he’s seen a lot from the seat of his wheelchair.

“I’ve seen arrests. Guys all beat up. Girls screaming and yelling. All sorts of weird stuff,” he said.

“But most of the people are pretty original.”

Original?

“Just normal, everyday people,” he said. “You know, married and have kids and all that, O-rig-in-al.”

It eventually became clear that he was confused. What most people would call ordinary he defined as something original. Remember, he’s been at the medical center quite a while.

NEXT: The hospital hustle.