Never Enough of Anything to Go Around : County-USC--Keeping It Patched Up

At the medical center’s Normal Birthing Center, where licensed nurse midwives handle 3,000 low-risk deliveries a year, umbilical cords are clipped and measured and stored in a refrigerator. From time to time, medical supply firm representatives drop by and shell out 50 cents a running foot for them. The firm in turn sells the cords to other hospitals for use in vein transplants.

“I always tell the mothers that their baby is giving someone else a new life,” midwife Betsy Greulich said. “They get a kick out of that.”

The midwives dip into the umbilical cord kitty to decorate the ward. They are proudest of what they call the Yosemite Suite, Room 831ML, where one wall is covered by a mural of a waterfall.

In the Radiology Department, on the third floor of the General Hospital, a defunct X-ray machine is kept around, like some old front-yard junker, to be stripped of parts when needed to keep other units running.

And down on the first floor of Unit One, in the dark of night, Dr. Larry Mottley of the emergency room can be spotted rounding up a gurney left unattended outside a neighboring ward. You can never have enough gurneys.

“I don’t know where these things go,” he said, pushing the prize of his piracy into the safety of home waters. “There must be something like an elephant graveyard of them somewhere.”

We are talking here about survival.

At the medical center, there seemingly is never enough of anything, except patients, to go around, so you fight to get all you can and to keep all you have.

“The rules of survival,” instructed a veteran nursing administrator, “are:

“Never give away any of your money. . . .

“Never give away any of your space. . . .

“And never allow any of your patient-care space to be converted to another purpose.

“Because at this place, sooner or later, you are going to need it.”

Six years ago, Proposition 13 cost Sam Behmorias about 80% of his medical center pharmacy operation. Since then, his has been a war of attrition, in reverse. Slowly, piece by piece, he has managed to restore much of the program, implementing a “safety net” drug service for the destitute here, opening a cash-and-carry pharmacy there.

For each new reclamation project, Behmorias at first has sold the concept to medical directors, chief nurses, social workers and financial officers. Only then, with his allies established, has he formally proposed the idea to administrators. And he always has conducted his campaign with that most trustworthy of bureaucratic weapons--the memorandum.

“You always put everything in writing,” he said. “People have very short memories.”

Economic Necessities

Behmorias said he does not bother to determine what other proposals he might be bumping up against: “We all compete in a way for money, and it’s up to the administration and downtown to decide where the money is going to go. If you waited until the best time not to compete with anybody it would be doomsday.”

The Normal Birthing Center, where women deliver in a more homelike setting, provides another example of how the hospital hustle works. Middle-class women pay dearly for similar birthing opportunities in private hospitals. But at the medical center, the impetus for a birthing center had more to do with economic necessity than esoteric niceties.

Low-risk pregnancies that would qualify for such a service used to be diverted to other hospitals at county expense to take pressure off the greatly overworked maternity wards.

However, in 1981 a study showed it would be less expensive to bring in midwives to preside over low-risk births. Three months later, the center was opened.

“It was probably one of the quickest programs ever put together in the history of the county of Los Angeles,” said Sherry Smith, nursing director at Women’s Hospital.

The lesson of the birthing center is repeated often around the medical center. To develop a new program or purchase a piece of equipment, it is not always enough to be able to demonstrate how it will improve medical care. For the proposal to have any real chance in the race for money, it also must hold the promise of cost savings.

Three years ago, Dr. Michael Patzakis, an orthopedic surgeon, teamed up with Dr. Jeannette Wilkins, an infectious disease specialist, to develop a unit to deal specifically with infections of bones and soft tissue. They previously were lumped together with other orthopedic cases.

Not only are these wounds dangerous to patients--they can end in the loss of limbs--they are costly to hospitals. They can take six weeks to treat, an expensive proposition, and the longer the patients are on the wards the greater the likelihood their infection might spread to other patients.

“I used to grunt every time I had to come to ortho to do a consultation,” recalled Wilkins, who like Patzakis is an 18-year veteran of the medical center. “The wounds stunk. It was filthy.”

With a new protocol for drug treatment and careful management of the patients, Patzakis and Wilkins have been able to send most patients home in two or three weeks. Not only has their work gained national attention among colleagues, it has satisfied the bottom-line requirement for any proposed change in patient care at the medical center.

“We’ve saved them millions or hundreds of millions of dollars,” Wilkins said. “Oh, the administration loves us. This idea was just eaten up by them.”

Dr. Larry Platt is a champion survivor. The 37-year-old obstetrician has been at the medical center for nine years--long enough to know the ropes, but not so long that he has lost his taste for institutional combat.

He is a medical center believer, willing to work for a quarter of the money he could earn elsewhere in order to reap research possibilities and a sense of self-worth not so readily available in smaller, more well-to-do hospitals.

“There are inadequacies here,” he said. “No one is going to deny it. Patients have to wait long times. Patients are assigned six to a room. There is understaffing. . . . But the way to fight it is to keep fighting.

“And,” he added, “you have to have good timing.”

When Platt first came to the medical center as a research fellow his mentors told him that if he developed a name for himself, he might be able to overcome the financial limitations of a public hospital and generate the dollars needed to fund high-caliber work. The lesson took.

International Acclaim

Today Platt enjoys an international reputation for his work in fetal medicine. He is an ultrasound wizard. It is magical what he can do with the machine, the vital nuances he can detect in what appears to the novice as merely an elusive fuzz of black, white and gray images bouncing wobblingly across a screen.

Because of his reputation, ultrasound manufacturers farm out prototypes to Platt. Acting as a consultant, he in turn reports back to the companies on the strengths and shortcomings of the machines. The companies are not allowed to advertise overtly their association with Platt, but the relationship is nonetheless not unlike that of Dr. J and the maker of his basketball sneakers.

Platt estimates that he has $1 million worth of ultrasound equipment at his disposal, and it hasn’t cost taxpayers a single dime.

“It’s not ideal,” he said, “but it keeps us ahead of most institutions.”

Platt gave a tour of Women’s Hospital, peeking into several rooms. “That’s my machine,” he said in one room. “And that one is mine, too,” he added in another. Most of the ultrasound equipment was locked in a single room, a precaution that Platt took after “someone walked off with one, a $35,000 machine.”

Signs posted in the various ultrasound examination rooms described the boundaries of Platt’s domain. Said one: “Do not remove this machine without special permission from Dr. Larry Platt.” Or, “Please leave this room cleansigned, Larry Platt.”

When he reached his second-floor clinic, where he would oversee examinations of a long line of pregnant women, a nurse greeted Platt with a complaint that a third telephone line they had ordered still had yet to be installed.

Platt motioned a reporter over and dialed administration.

“You know that telephone in the clinic,” he told an administrator. “We still don’t have it and we need it.”

The conversation continued until Platt could work into the conversation that, yes, the reporter was with him as scheduled. In fact, Platt went on, smiling, “He’s standing right here now, taking all this down.”

Platt hung up and told the nurse: “We’ll get all the phones we need today.”

Then he turned to the reporter and said: “Remember what I told you about timing.”

The medical center’s relationship with USC dates back to 1885. It was not until the mid-1960s that USC was added to the formal name as a way to polish the place’s image. The tie with the university is crucial, attracting top-notch teaching doctors and residency recruits.

The county supplies the medical center plant and the administrators, personnel and equipment to run it. The university provides the staff doctors who run the medical programs and serve as faculty for interns and residents.

Thus, there are dual chains of command, with medical department heads and county department heads. In medical center shorthand, these are known as “Medicine” and “County” and they are the principal players.

County administrators often are criticized by medical staff as being more concerned with climbing the bureaucratic ladder than patient care. Some doctors blame the administrators for rules that inconvenience their patients, like making them pay in advance before every visit, or wait all day to see a doctor at an outpatient clinic because they are not given a definite appointment time.

Administrators in turn say some doctors would give away the store if they could. Some contend that doctors are egoists more bent on building national reputations as researchers than healing poor people.

At the same time, mutual respect can be found among some doctors and administrators. And the degree of ill-feeling, or detente, seems to vary from hospital to hospital, service to service, ward to ward.

Interns, the medical school graduates who are at the medical center to complete their training as doctors, and residents, the young doctors there to become specialists, sometimes agitate the medical center mix.

Many of these so-called house doctors are filled with youthful zeal, and historically they have not been hesitant to go public with what they perceive as poor conditions or medical malfeasance, contributing significantly to the institution’s reputation.

“Instead of wasting money on nuclear bombs and military spending,” Gary Novatt, a 28-year-old intern assigned to the General Hospital Intensive Care Unit, said earnestly one afternoon, “they should spend more here. One MX Missile would run this place for a long time.”

Many staff doctors and administrators listen when the interns and residents make noise. Some are envious that these young doctors, to whom the medical center serves only as a way station on the road to a lucrative career, can speak out freely without worrying about repercussions, either personal or institutional.

A few staff doctors say the residents in fact are the best patient advocates--”They are the ones who care for them, who stick needles in them, who deal with the families when there are deaths.” Others see the house doctors as impatient at best, petulant at worst.

Nurses are another force. Many hold the view that they are the hospital, noting that sick people don’t check into a ward to see a doctor but rather because they need the around-the-clock attention that only nurses provide. As one put it, nurses are “the one constant, the center of the wheel for all the other spokes.”

Each July, when new residents come aboard, the nurses must suffer through what they call “the July 1st Syndrome.”

“Those young doctors,” a nursing administrator from the Psychiatric Hospital said, “hit the floor thinking they know everything there is to know, and they think they don’t have to answer to anybody but the medical director himself. They come in thinking they are the fourth part of the Holy Trinity. And then they run into that first nurse. . . .

“They come in wanting everything done by the numbers, one through 10, like they learned in medical school. But they don’t know yet that you can skip four through eight.”

Much of the medical center business is conducted by committee, in conferences, and on rounds where staff doctors can tutor residents and backstop their work. There are several important committees, committees to ponder ethical questions, to approve research projects, to decide what new drugs to add to the medical center formulary, to review in great detail cases that end in death.

Sometimes conferences can have hidden agendas. For instance, last fall an infection had spread among the sickly newborns in the neonatal unit. It became necessary to shut down the unit temporarily and place new patients at hospitals throughout Southern California.

Wilkins, the expert in infectious disease, was called in to address the problem at a conference organized by the neonatal doctors.

A medical center loyalist, Wilkins is nonetheless not afraid to speak her mind and is described by her colleagues in such terms as a “human torpedo.” Unlike most doctors, Wilkins can talk plain and direct, and it all comes coated in a Mississippi-born accent.

“These bugs don’t fly,” she told the conference. “They do not swim. They have to be carried from patient to patient. . . . We know where the bugs are. They were here first, and if you believe in any theory of evolution they are not going to go away. I always said, ‘It’s not nice to fool mother nature.’ You have to learn to stay out of their way.”

After some back and forth with the baby doctors, Wilkins appeared convinced that the infection outbreak had been caused by placing relatively older infants in the same room with newborns. The longer any patient is around a hospital, the greater the chance an infection will develop that can be passed to others on the ward--no matter how careful the doctors and nurses are about cleanliness.

The solution, she said, was to move the older babies out sooner, or devise a new system to separate them from the younger ones.

“But we can’t,” one of the neonatal specialists said. There was no place else to put the older babies.

“Well, if you can’t,” Wilkins replied in a scolding tone, “you can’t. But don’t waste my time by calling me here. Just resign yourself to these infections. . . . If you have to accept it, then you have to accept it, and don’t lament it. Don’t cry over what happened.

“But I’m telling you”--and by now all 30 of the doctors, nurses and administrators in the room were completely quiet, riveted on this feisty dissertation--”if you can’t do anything about these infections, don’t document them. Because the litigation will cost more than a new hospital.

“You know the way this hospital works,” Wilkins said, finally. “You know it takes a crisis before anything happens around here. So, you have to declare a crisis.”

Wilkins’ performance left them dazzled. Not only had Wilkins shed light on their specific problem, she also had provided a nifty crash-course on the inner workings of the institution itself.

A month later, Wilkins provided a postscript that was as instructive as her initial sermon. She said that when the neonatal doctors invited her to speak, they already had known what she would tell them. They knew as well as she what the problem was, and they knew what it would take to fix it.

So then, why did they set themselves up for a Wilkins tongue-lashing?

“They called me in,” she said, “so they can go to the administration and say, ‘Someone from Infectious Disease has come in and said this needs to be looked into.’ Infectious Disease has more clout. It’s like your American Express Card; you don’t leave home without it. It’s better than if they just went in themselves and asked for something.

“You know, they already are making some changes over there in that nursery.”

NEXT: The Emergency Room.