Tending to Broken Bodies : Heart of County-USC: the Emergency Room

Emergency Room 1350.

C Booth.

Night shift.

One blast from the shotgun had ripped a hole under his right armpit the size of a baseball. It had shorn an artery and the blood was coming in spurts. His left thumb and forefinger had been blown to stumps. He also had been hit in the abdomen.

A muscular 21-year-old, he had been engaged in a game of craps on a sidewalk in South-Central Los Angeles when a trio of gunmen attacked, killing one of his companions and wounding four others.

Now this man, named Alfred, was fading, and he seemed to know it.

“Oh, help me, help me please, please help me.” The voice was pleading, childlike.

A doctor pushed down with his hands on the armpit, the worst wound, attempting to halt the escape of blood that was dangerously sapping the patient’s blood pressure. Another examined Alfred’s stomach. Nurses were inserting intravenous lines into his uninjured arm. They worked incredibly fast and with minimal discussion. No one bothered with Alfred’s hand.

Animated when he first arrived a few minutes ago, Alfred already was growing drowsy. “Are you with us, Alfred?” one of the doctors kept asking him. “Wake up, Alfred. Don’t leave us now. Stay with us.”

Within 20 minutes, his bleeding was stopped, and his blood pressure slowly rose enough to allow Alfred to be rolled off to surgery. “Another save,” one of the residents declared. Another doctor wasn’t so sure. Often patients make it out of the emergency room only to die on an operating table.

“It’s always a bad sign,” this doctor said, surveying the mess left where Alfred’s gurney had been, “when you have blood clots on the floor.”

All institutions, no matter how shapeless they may seem, have a center, a heart. It can be a basement control room or a lofty executive suite or a front desk, wherever a pace is set for the entire institution, its mission defined, the spot where tour guides stop to tell visitors, “Now, this is what it’s really all about.”

The heart of the Los Angeles County-USC Medical Center is the General Hospital emergency room. Four hundred patients a day, approximately 150,000 a year, are brought through the double doors of frosted glass. About half of them arrive in critical shape, having been stabbed, shot, slashed, smashed, run over by cars or run down by a life of alcohol:

His name was David. He was 16 years old. He had been found sprawled on a yard in East Los Angeles, an overdose. He was suspected of taking PCP, the powerful hallucinogen that is a major supplier of medical center patients. He was starting to get wild, squirming and kicking.

“No shots, no shots,” he kept screaming. He wanted to die.

They were trying to tie him down with sheets. A heavyset medical student was instructed to kneel on David’s legs. A swarm of nurses and doctors pushed on him. Security guards were thrown into the fray. The walkie-talkie of one of them was turned up loud, and from it the detached voice of a dispatcher provided a strange addition to the emergency room cacophony: “Attention. We are missing a patient from Ward 3700. He was last seen wearing a hospital gown and has a cast on his left arm.”

Now David was restrained and nurses were preparing to force him to vomit. Other nurses pieced together the boy’s history. He had been suicidal, they learned, because of girlfriend troubles. He had driven his car into a wall three weeks ago. Psychiatrists had interviewed him, but reported no action could be taken until David did “something bizarre.”

“Driving his car into a wall wasn’t bizarre enough?” a doctor asked.

It didn’t sound as though he really expected an answer.

Triage is a term heard often at the medical center. It comes from the French word for sorting and primarily applies to battlefield medicine. Triage doctors sort out wounded soldiers, determining who should be treated first and where. One of the toughest calls is whether a casualty is wounded beyond repair, for these unfortunates are moved to the end of the line and allowed to die.

In the emergency room, triage of incoming patients is done by nurses with consultation from the senior resident. They have several options. Patients, for instance, can be sent over to Room 1050, the so-called emergency ambulatory area.

“If they are walking and not bleeding and dying they go to 1050,” said Leslie Petty, a 21-year-old triage nurse. “The problem with that is they wait three to four hours there until they see a doctor. So you have to make sure they are not going to die during the wait.”

The more critically ill patients are wheeled into one of the 15 booths that rim Room 1350. The booths, just big enough for a gurney, are separated by yellow curtains.

When the booths are filled, which is often, patients must wait their turn on gurneys in the triage zone near the front door. Sometimes, as many as a dozen patients are stalled there with nothing to do but hold where it hurts and wonder why they aren’t moving.

The most critical of the critical--the heavy trauma cases, the sick who appear close to death--are placed immediately in what is called C Booth. (Critical cardiac cases are an exception. These patients used to be placed in C Booth, but it was decided that all the screaming and flowing blood was not doing their hearts any good at all, and they are now placed in a section of the side booths.)

Just as the emergency room is the heart of the medical center, C Booth is the heart of the emergency room. It is really nothing more than space for four gurneys surrounded by curtain partitions. A work table lines one wall and houses supply cabinets.

“This,” said Dr. Larry Mottley, standing at the C Booth entrance, “is where the action is.”

Dark-haired, bearded, with sad eyes and a steady manner, the 34-year-old Mottley grew up in New Jersey and 16 years ago took a summer job as an orderly in an emergency room and has “never been out of one since.”

He worked his way through college and medical school with jobs in emergency rooms and ambulances. He was running a helicopter rescue program in Ohio three years ago when he took a 50% pay cut to come to the medical center’s Department of Emergency Medicine as a staff doctor.

“I guess I just wanted to be part of the edge,” he said. “This is the place to be for emergency medicine.” Indeed, the Department of Emergency Medicine is the medical center’s primary source of national recognition. Each year 1,000 young doctors apply to participate in the emergency medicine residency program, which will give them the training needed to become specialists in this relatively new discipline. Eighteen are chosen.

Mottley’s job as a staff doctor is to teach the residents and oversee their work, and to help out when needed on more difficult cases. He spends much of his time picking among the patients, trying to maintain a handle on the flow without becoming bogged down in individual cases.

To tag along with him for a couple of weekend nights is to begin to understand his addiction to emergency rooms. It is possible to get absorbed in the flow, the weave, the pace. It is like watching a heated tennis rally, with doctors whacking away at an unending assortment of medical crises that spin in at all angles and speeds:

There was a woman with maggots burrowing into her head. She said her name was 90. The nurses shaved her head and neurosurgeons were summoned to determine whether there was any brain damage. “I think I better go shower,” one of the nurses said.

A man with a belly as big as a medicine ball, a symptom of advanced alcohol damage. “I only ate too many beans,” he kept insisting in Spanish.

And a street tough, an accused murderer, who was struck in the penis by a shotgun pellet. “What can you do for an injury like that?” a police officer waiting to escort the patient back to the jail ward asked. He and his partner made an effort to appear lighthearted about their inquiries into the nature of the wound and chances for recovery. But they were persistent, and it became clear they really wanted to know. Soon they would be back on the streets themselves.

There was a grizzled old man whose wife called for an ambulance after he suffered his 10th epileptic seizure in a day. “After a while,” Mottley said, “you learn not to ask non-productive questions, like, ‘Why did you let him have 10 seizures before you called anybody?’ ”

A man with a gunshot wound to the neck. It looked ghastly. There was a hole on either side of his throat, one where the bullet had entered, one where it had left. Mottley, however, wasn’t much concerned. The weapon, he explained, had been a small handgun, and the bullet had cut a clean path on its way through the neck, missing any vital veins or parts.

And a diabetic who had been drinking, a deadly combination. He was belligerent. He tried to climb off his gurney and was put into restraints. He screamed for his clothes and wallet, punctuating his demands with a barrage of obscenities.

There was an emergency room doctor who had left for home only to become the victim of a hit-and-run car collision. Still in her scrub suit, she lay on a gurney looking up at her colleagues. Her head was taped down so that it could not be jiggled, a precaution against neck injury.

“I’m fine, I’m really fine,” she insisted.

“We’ll be the judge of that,” Mottley told her.

Two booths away was another colleague--a paramedic who had suffered chest pains earlier in the day after he brought in a patient. The doctors were trying to determine if it was a heart attack.

There was a young woman in the throes of an asthma attack. She had trouble talking, all her energy directed toward breathing, but her eyes documented her terror. Mottley was concerned. She appeared close to reaching a point of no return. He needed more information from her, but she had no breath to waste on conversation. So he asked only questions that could be answered with a nod of the head.

A man with a broken neck. As he was wheeled into C Booth a nurse wearing a T-shirt that read “Beside Every Good Doctor is a Great Nurse” sweetly greeted him: “Well, how are you doing tonight?”

And a transient propped up on his gurney with an open briefcase on his knees. It contained dozens of brown plastic prescription bottles. “That’s trouble,” Mottley said. The patient’s portable pharmacy would make it difficult to determine what was wrong with the man, and what, if anything, to prescribe for it.

There was a portly, older man in a baseball cap who had fallen off a bicycle and broken a hip, an injury that somehow seemed almost refreshingly mundane. The doctors paid him little attention; there were worse cases in C Booth at that time, all of them moaning and screaming. Occasionally, the fallen bicyclist lifted his head, looked around to see if anyone was in earshot and cried out loudly. “Oooowwww!!!” It seemed intended to remind the staff of his presence.

An 82-year-old woman who appeared to be in terrible condition, lying still on the gurney with her eyes shut and mouth open. Her kidneys appeared to have failed, but the doctors weren’t sure why. In their search for clues, they scanned a brief letter that had accompanied the woman to the medical center. It was from an outside doctor who no longer either could or would care for her. The letter was simply addressed: “To Whom It May Concern.”

And there was a pale, bearded young man, with a gaunt physique and scraped shins. A vagrant, he looked like a grim character from a Russian novel. He was having some sort of toxic reaction. His speech was slurred, his brain foggy.

“Do you know where you are?” Mottley asked.

“Hothpital. Hothpital.”

“Which hospital?”

“UCLA.”

“No, it’s USC. Do you know how old you are?”

“UCLA.”

Emergency medicine attracts hip-shooters. “First and foremost,” Mottley said, “you have to be able to work under pressure. Second, you have to be able to prioritize many patients and their needs at once. And you have to be self-confident and dexterous.”

They are generalists whose primary mission is to make critical patients well enough to be moved to a ward or operating room where they will be treated by specialists.

“You have to know your limits,” Mottley said. “You do as much as you can for a patient, but there comes a point when you have to hand off.”

The doctors and nurses who work in the emergency room seem to thrive on variety, on pace, and on the fact that lives depend on their abilities. “I think what I like most,” said Carlla Jean Varga, a head nurse in 1350, “is the unknown. Never knowing what is going to come through the door next. Every day is different.”

Emergency room doctors and nurses rarely have time to become attached to patients. They don’t receive calls late at night. They also don’t do follow-ups and cannot tell you if a gunshot victim they sent off to surgery lived or died. So they pull hard for each patient until he is stabilized, and then move on. They can, for instance, labor furiously to save a man peppered with bullet holes, and then drift off to an adjoining conference room to dine on take-out Chinese food.

“One of the things that bothers me,” Mottley said, “is if I had a bad night here I can go home and go right to sleep. I don’t stay up at nights worrying about it. I can’t remember a case that kept me up.”

Perhaps because they cannot get close to individual cases, the emergency room doctors and nurses seem particularly protective of the patient population in general, proponents for the poor, proud of the fact that they care for clientele that private hospitals don’t want.

“We sort of feel like we are the last patient advocates,” Mottley said. “Sometimes, it’s a source of pride. Other times, you feel sad. You see all these poor patients and no one wants to take care of them.”

In fact, when other hospitals or private doctors determine that a patient has no assets or medical insurance a transfer to the medical center is quickly forthcoming. The practice is known as dumping.

The transfers most often go first to the emergency room. Hospitals are not supposed to transfer patients, no matter how destitute, unless they are in stable condition, but it does not always work that way. A neck said to have been only sprained turns out to actually be broken. A man said to have received two non-threatening gunshot wounds is discovered on arrival also to have been hit a third time, in the back.

No one is turned away at the medical center emergency room; it is not allowed. “Other hospitals say, ‘We’re full,’ ” said supervising nurse Stephanie McKintosh. “We can’t. They just keep coming. Three-quarters of the emergency rooms in Los Angeles County are empty tonight. And we have got six people waiting here in triage. How come?”

As hospitals begin to experience increasing financial pressures, they tend to be even more concerned about quickly dumping non-paying patients off on the medical center. “Administrators are feeling the crunch now,” Mottley said. “We’ve had patients transferred who never had been checked out by doctors. They were moved out by administrators.”

And it’s not always enough to have medical insurance when a patient arrives at a private hospital’s emergency room. Once a man in a Brooks Brothers suit was diverted from a private hospital emergency room to the medical center simply because he could not prove he had insurance. He could not prove he had insurance because someone had snatched his wallet before he was pulled from the wreckage of his Mercedes Benz.

The emergency room is a chaotic place. Street brawlers sit in chairs nursing their wounds as they wait to be examined. Patience is not their best virtue, and they grow rowdy, taunting the nurses.

“To me,” said Petty, the triage nurse, “a good day is when all the patients get taken care of and don’t have to wait a long time and no one hits me or kicks me.”

There always seems to be someone voicing a complaint in a lusty monologue. “Oh, I’m all wet and dirty,” a skinny old man with a body speckled with lesions moaned from his gurney. “Nurse, nurse. Why don’t you help me? Oh, your hands are cold. Oh, goddamn it. Go away.” This went on for hours.

Police officers hang around the emergency room. Some come to interview suspected drug users; the more street-wise ones say nothing. Other police officers wait to haul the wounded off to jail. A few come to just cool out, knowing they share with the emergency room staff a confusing mix of fascination and frustration with the onslaught of human suffering that keeps them employed.

The sounds and smells of retching seem constant. A solitary janitor works the place, his mop rarely leaving the linoleum floor.

He seems not to notice any of the crazy activity that surrounds him:

“What is your name?”

“Ben.”

“Ben what?”

“You’re going to kill me. Oh, God, you’re killing me.”

“Ben what?”

Drunken Driver

The questioner was an officious young man from records. The patient was a 48-year-old drunken driver. He had smashed his pickup into a car, knocking his chest hard against the steering wheel. It was feared he had a collapsed lung, so a surgeon was cutting a hole into his chest in order to insert a tube and pop the lung back out.

The patient’s left arm was cocked back awkwardly over his head. He was in great pain.

“What was your mother’s name before she married your father?”

A nurse leaned over, and with the manner of a schoolteacher addressing an errant pupil scolded: “You shouldn’t drink and drive.” Ben said nothing.

A portable X-ray unit was brought in and a chest picture taken. It showed signs--they later proved to be erroneous--that the patient had partially ruptured his aorta, the main vessel leading out of the heart. If it tore away completely it could kill him, fast.

“Can you sign this, Ben?” the man from records asked, thrusting a clipboard in front of the patient’s ashen face.

“Ooohhh.”

“Ben, you have to sign this.”

Finally, a doctor leaned over and quietly, but with authority, told the record-keeper that Ben was in no condition to sign anything at present.

The record-keeper shrugged and marched out of the room.

But in a minute he was back.

“Just one more question, Ben, what state were you born in?”

Ben, through gritted teeth: “New Mexico.”

There can be lulls in the pace. A priest wandered in a little before midnight. C Booth was nearly empty. “I was just passing through on my way to bed,” he said, “and I thought I better stop by and see if there was any business. If I don’t stop, usually as soon as I get home and get in my jammies I get called.”

The lulls can last minutes, or hours, or even a day. But they always end:

A resident approached Mottley. Another hospital was sending over an ambush victim, the resident said. The victim, a teen-ager, was riddled with seven bullets. The other hospital was transferring him because its on-call surgeon refused to leave his home.

A bearded young man with wild eyes was wheeled in. He had shot himself in the chest with a derringer.

“What do we have here?” a nurse asked the new patient.

“A maniac!” he replied fiercely. A real gunslinger type, he demanded his gurney be propped up so “I can see what’s going on,” and he made sure his cowboy boots were kept at his feet. They might not let him die with his boots on--all critical patients are stripped on arrival--but at least he would keep them in view.

A teen-age girl was next. Her car had rolled over three times on the freeway. She was the least serious.

The ambush transfer arrived. He turned out to be deaf and mute, a curious candidate for a drive-by shooting. His stares hit like a loud scream.

Then a nurse announced in a voice charged with something like tension and excitement, “We got a real bleeder here.” Everyone started moving fast.

It was a young man who had stuck his arm through a window, cutting it to the bone and severing an artery. His blood pressure was plummeting as the nurses cut away his clothing and got to work. The gurney was surrounded by doctors and nurses, all busy.

Suspected Drug User

Now all four slots were filled, but in came a fifth C Booth candidate. A suspected drug user, he had crashed out of a second-floor window and fell 20 feet onto concrete. He refused to talk about it. The paramedics parked him in the hallway, and chatted with the police about the remarkable human-shaped figure his exit had cut in the window, like something out of a Saturday morning cartoon.

C Booth was bustling again, crowded with X-ray technicians, attendants waiting to transport patients to surgery, specialists called in to look at the worst cases, police officers and paramedics, doctors and nurses.

But something seemed different, changed, and it took a moment to pin it down. These were all new faces working on the patients. Sometime between the arrival of the self-described maniac and this leaper, a full shift of nurses and doctors had gone home and another had taken its place.

NEXT: The doctors.