COLUMN ONE : Cutbacks Fray ‘Thin White Line’ : For years, the doctors and nurses at Harbor-UCLA Medical Center have struggled to help their community. Now, they worry about how to do even more with even less.

The man on his back on the operating table was awake while a four-foot-long, plastic-coated wire pierced an artery in his groin, coursed up that vessel through the torso, and then arced into the crown of arteries atop his throbbing heart.

He was 47 years old, a retired builder without health insurance. Because he was locally anesthetized and lightly tranquilized, he could still understand Dr. William French, a cardiologist, who stood at the man’s waist as he guided the heart catheter home with gloved and bloodied hands.

The time was 12:30 p.m. The place was the Harbor-UCLA Medical Center in Torrance, a 48-year-old Los Angeles County institution that is questioning how much longer it can tend to people who are unlucky enough to be sick and poor simultaneously.

“My friend,” French shouted over the humming and whirring of the machines. “Do you take care of your blood pressure?”

“Yeah, I’ve been trying to,” the man said.

Looking at TV screens that showed the man’s coronary arteries--blackish branching scrawls undulating to the beep beep beep of a pulse monitor--French saw that they were enlarged, betraying a history of untreated hypertension.

“What are you doing to yourself?” shouted French, Harbor’s associate chief of cardiology and a UCLA professor of medicine, his Boston-Irish brogue clanging like a cowbell. “You don’t know how important that blood pressure problem is. I can see everything is dilated here, my friend.”

Here is the wonder of public medicine, in which a distinguished cardiologist, assisted by another doctor and two technicians, wields state-of-the-art equipment worth $1.5 million for the sake of a man of no evident means.

And here too is the problem. For it appears that the public cannot afford such costly medicine anymore, even though the demand for it, to judge by the booming population of inadequately insured or uninsured Angelenos, is greater than ever.

In July, Harbor-UCLA Medical Center appeared on the financially strapped county’s list of hospitals to be closed or relinquished to the private sector. While that cataclysm was averted for now, next year’s budget crisis looms. “I think a hospital closure is still a possibility,” said Dr. William Swanson, Harbor-UCLA’s medical director.

Harbor’s besieged workers are part of what might be called the “Thin White Line”--the ragged human boundary protecting the community’s health. A city within a city, receiving and usually coping with more than its share of trauma and morbidity, Harbor has always been a tumultuous place. Now, as revealed in recent visits intended to gauge the human effects of the sweeping cutbacks, it is a place in turmoil.

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In the past month, hundreds of Harbor employees were laid off to be replaced by other county workers with more Civil Service seniority--the so-called cascade, loathed by many physicians and nurses for displacing highly trained health providers. More important, 319 of Harbor’s 3,500 employees were fired and are not scheduled to be replaced.

While patients are being inconvenienced or, as some staff members worry, possibly endangered, anxiety among the employees is rampant because even those who kept their jobs depended on those who didn’t.

Firings are common in numerous industries in the Southland these days, but county health workers, as their unions angrily point out, are something of a special case. The sight of an intensive care unit nurse emptying a bedpan is all the proof you need that these are public servants in a sense that no bureaucrat can ever hope to be.

Wrapping up the heart catheterization, French told his supine patient that the news was basically good: no blocked arteries, no heart attack after all. Harbor, said French, who has worked there for 20 years, “is a great mother. We’ve got to provide heart-and-soul stuff. This is big time. This is poor people. Something like a third of the people in Los Angeles are uninsured--and they want to close the public hospitals?”

Experts in Trauma

At 2:15 p.m., Dr. Frederic S. Bongard, director of trauma services, beheld a fresh corpse: a hefty man stretched out on a gurney behind a blue curtain in the emergency room, a red smear across his chest and a bullet hole in his heart. “Wounds to the heart are surprisingly salvageable,” Bongard said with a win-some, lose-some shake of his head.

For a public hospital, geography is destiny. The area of southwestern Los Angeles County served by the Harbor-UCLA Medical Center includes 2 million people and embraces the rough-and-tumble Long Beach wharves and the frenzied San Diego and Harbor freeways, as well as communities such as Inglewood and Compton that witness more than their share of gunfighting.

Thus Harbor’s expertise in trauma. An average of 125 trauma patients a month--four or five a day--stream into the hospital. About 60% are victims of so-called blunt trauma, mainly motor vehicle accidents, while the rest are victims of penetrating trauma, wounded by bullet or blade.

Over the years, Harbor has pioneered the subspecialty of emergency medicine for children. And Harbor physicians, working with a local fire engine company, basically created the paramedic more than two decades ago. The 1970s TV drama “Emergency” was based largely on Harbor’s trauma unit.

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Although no one from the trauma unit was fired recently, Bongard suggested that reductions in other departments hurt. Orderlies, X-ray technicians, clerks, nurses, physicians--all play a vital role in the complex ecology of trauma care, the most interdependent of medical disciplines.

Walking through the radiology service, which lost the equivalent of 10 staff members, Bongard wondered if there would always be enough X-ray technicians on hand when a major injury rolled in.

Down at the blood bank, he said, “On a bad trauma case, I might need 40, 50, even 60 units of blood.” A shortage of technicians means, at the very least, a delay in typing and delivering blood to the emergency room or operating room--and delay is the trauma surgeon’s archenemy. Bongard remembered one motor vehicle case, a girl who needed 100 units. Fast. They saved her. A shorthanded staff might not have. “You start laying people off,” he said, “and that girl is dead.”

In mid-September, practically the entire 3-to-11 p.m. shift of operating room nurses was given layoff notices; by mid-October, though, thanks to a federal bailout of the collapsing county health system, only four of the 43 registered nurses were laid off, and they will be replaced from elsewhere in the system. Still, two operating room nurses quit in frustration--and a hiring freeze will keep those positions vacant.

Joan Taylor, the operating room’s nurse manager, said: “We’re not having any problem conducting business as usual.” But like many Harbor health workers, Taylor lamented the polarized, “us-them” thinking that allows the county (us) to trim services to the poor (them). Taxpayers, she said, “seem less willing to pay for trauma care because it doesn’t make money. But if you’re traveling down the 110 and get in a major wreck, you’re going to be brought here.”

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Bongard continued his trauma tour in the intensive care unit. A hiring freeze a year ago left the unit so short-staffed that only 12 of the 14 beds could be used. A nurse and two nurse-custodians were recently fired, victims of the financial crisis. The personnel crunch was made clear by the sight of the ICU charge nurse, 27-year veteran Margaret Malone, putting on rubber gloves and hauling the bright blue bags of dirty ICU linen.

Bongard, like most physicians and nurses interviewed, harshly criticized the hospital cutbacks as possibly being dangerous--and at the same time insisted that the place delivered the same high standard of care. “We’ll take all the trauma we can get,” he said. But then he added, “What the nurses are working under can be optimistically described as adversity.”

Strained Services

“We find guns and knives on our patients,” said emergency room nurse Diane Walsh. “We used to have safety police right outside the door. Now you have to call them, and 10 minutes can go by before they show up. It’s tense in there.”

It was 3:05 p.m., and the four patients assigned to Walsh were a woman with upper abdominal pain, a woman with degraded heart muscle and chest pain, a man with a transplanted kidney and an inflamed heart, and a woman gasping with acute asthma.

About 100,000 people last year walked, limped, rolled or were carried into Harbor’s emergency room service. The emergency room’s adult acute care ward is called the “big room,” though it doesn’t look very big, what with 10 beds crowded along one wall and three trauma beds at one end. At the other is a semicircle of half a dozen plastic chairs for sick people who don’t need a bed or who were admitted when no bed was free.

Patient privacy, never mind dignity, doesn’t exist in the big room, as the rainbow of the city’s ill and injured suffer cheek by jowl. Of the hospital’s patients, 54% are Latino, 19% African American, 17% Anglo and 7% Asian/Pacific Islander.

Of the more than 90 registered nurses assigned to the emergency room, three were recently fired, even though the staff was already stretched thin, Walsh said, racking up 2,300 hours a month of overtime.

Russell Wright, a Harbor trauma nurse for 1 1/2 years, was among those recently fired. He’s taken a new job at a private hospital. “Even before they did any of the cuts” at Harbor, he said, “I felt we were running behind time [in the emergency room]. We were understaffed.”

“There are times when patients who are extremely sick are left alone,” he said. He recalled an elderly woman with end-stage cancer who had a heart attack and died in the emergency room while her nurse was dealing with a trauma victim. “Patients should be getting more one-on-one care and they’re not always getting it.”

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What is further straining the emergency room is that it must now absorb patients turned away from Harbor’s closed or cutback outpatient clinics. The oral surgery clinic, formerly open five days a week, has been cut to two half-days. Dr. John Villano, an oral surgery resident, said that patients’ “only recourse will be to go to the ER and be triaged there, which usually takes 12 hours,” he added, because dental problems, maddeningly painful though they may be, get low priority.

Even one of the inpatient wards--5-West, with three dozen beds--has been closed. The doors to the patient rooms are shut, and across each threshold is a heavy steel bar held by a padlock.

Dr. Eric P. Brass, chairman of the department of medicine, says the “temporary” closing of 5-West poses no threat to patient care because beds remain available in other wards. Still, the barred rooms are a potent reminder that Harbor’s future as a public hospital remains uncertain.

Walsh, a nurse at Harbor since 1991, speculated that it may be only a matter of time before the cost-cutting measures backfire. She imagines a car crash victim who--despite a reasonable prognosis--winds up paralyzed or dead because emergency room resources are stretched so thin. In other words, she imagines a lawsuit and a settlement that obliterates all these hard-won savings.

And even though the emergency room cuts were not as sweeping as anticipated, resentment lingers toward a tight-lipped Harbor administration and seemingly indifferent Department of Health Services. “You work hard, you ad-lib, doing what you can,” Walsh said. “You just have so much pride when you come here. But since we got the pink slips, I feel no allegiance.”

But she hasn’t quit yet. She dashes around the big room in white jeans and red clogs. “We’re still here,” she said. “You can’t let your cohorts down. You just rock ‘n’ roll and hope it’s going to be OK.”

The Personal Touch

At 5:30 in the afternoon, Dr. Julie Noble was seeing her last patients of the day. They were sisters, 15 and 17, both with asthma, from Inglewood. In a 20-minute checkup, Noble gave the girls a physical exam and prescribed pills and inhalants. Just as important, the girls got to visit with a doctor they trusted. It was their fifth visit with her this year. “I know my patients,” Noble said.

She is an anomaly, a pediatrician out of a Norman Rockwell past thriving in this steely era of capitated costs and managed care. For 1 1/2 years she has run the pediatric service of the Community Health Plan at Harbor. In essence, that is a county-run health maintenance organization that handles U.S. citizens who qualify for Medi-Cal, the joint state-federal medical insurance program.

Proficient in Spanish, Noble has 1,100 children and adolescents in her care, while an additional 800 are assigned to the pediatric residents she supervises. On a typical day, she sees about 25 patients. She says her department brings Harbor $150,000 in Medi-Cal funds a month.

On Sept. 15, the county rewarded her efforts with a pink slip.

Medical Director Swanson, commenting on the Civil Service mandate to fire people solely according to seniority, said: “The system is terribly flawed when by following the rules and regulations we’re forced to lay off one of the most productive people we have here.” After a month in which she passed through the stages of shock, depression, and anger that are familiar to much of the Harbor staff, Noble’s termination was stayed on the day that was supposed to be her last, the result of heavy lobbying by Harbor officials.

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In the frantic casting about for solutions to the county’s, if not the nation’s, health care crisis, reformers might be wise to study the service that Noble oversees. Unlike patients at most public clinics, hers can make an appointment, which makes them “better medical consumers,” she said. And the patient usually sees the same doctor, a familiarity that encourages people to come in for treatment before things get more serious--and more expensive.

Explaining why she left private practice 1 1/2 years ago, she said that she spent so much time ministering to the “worried well”--mothers upset about their children’s bed-wetting or nail-biting--that work got humdrum.

“Everybody here is in poverty, which means they’re all at risk for serious disease,” she said. “I love it because it uses more of my skills.”

Among her gravely and sometimes exotically ill patients was a child with whooping cough, long-gone from the mainstream but still smoldering among newly arrived immigrants. “I hadn’t seen that since I was an intern in the ‘70s,” she said.

She and her husband, also a doctor, live in Rancho Palos Verdes, a relatively wealthy community that is within the hospital’s catchment area but not much represented among its patients. Her well-to-do friends “don’t realize the ramifications if this hospital disappears,” she said. “ ‘It won’t affect me,’ they say.”

She tries to correct her friends’ misapprehension, pointing out that while they may not use the hospital, Harbor screens their housekeepers for tuberculosis and cures their gardener’s child of pneumonia.

To her, trimming Harbor’s services is like dismantling a dam while the floodwater crests. “It becomes more likely that other children will get whooping cough from that one who isn’t treated,” she said.

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More cutbacks in the Harbor staff are likely in coming months, further thinning the ranks of the “Thin White Line.” The cutbacks represent a blow to not only the local community but to a shaky old American ideal: In spite of the huge divide between rich and poor, there should at least be an equal distribution of health care.

Ironically, the retreat from that ideal comes at a time when medical services such as the one run by Noble had developed a way of delivering a remarkably individual kind of public medicine.

“The reason I think the [clinic] works well is the personal relationship that develops between providers and patients. It’s a trusting relationship. They want to come to us. This is their medical home.”

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About This Series

In this series, The Times goes behind the scenes of Los Angeles County’s massive public health system as it tries to resuscitate itself after a near-fatal collapse brought on by too many patients, too little money and too many questionable decisions.

* Sunday: How the nation’s second-largest public health system ended up at the brink of disaster.

* Monday: Who really uses the system, and why many working people must depend on the taxpaying public--not their employers--to bankroll medical care.

* Today: Behind the Thin White Line: the view from inside the operating room.

* Wednesday: The hidden costs of public health care--and how private hospitals are trying to lure Medi-Cal patients away.

* Thursday: From New York to San Diego, a look at how other large metropolitan health systems are coping with the present--and thinking creatively about the future.