Facing a Real Emergency

In the windowless emergency room at Harbor-UCLA Medical Center, there is one way to tell the sun is rising. Doctors pick up their already frenetic pace as the sick, slouched in plastic chairs, nervously watch the clock.

Patients like Jessica Short have to get to work.

Short, 19, has no insurance and cannot afford to miss a single shift as an usher at the local multiplex. A doctor at a county clinic had told her she needed surgery to stop some bleeding. The only place she could find a surgeon in the middle of the night was Harbor, where doctors cater to the ills of the working poor between treating gunshot wounds and heart attacks.

Short got to the emergency room after her shift ended at 6:30 p.m., hoping to be in and out of surgery in time for her 11:30 a.m. shift the next morning.

“People come to this ER every night after they put the children to bed and before the next morning’s shift,” said Dr. Sam Stratton. “There’s no other way possible for them.”

For years, the Torrance-area hospital has provided patients with almost any type of medical care they needed, at any hour and for a nominal fee. Staff members say a low-income person like Short--who lives with her parents on a combined income of $35,000--pays a maximum $202 for any outpatient service. But that may soon be a thing of the past. Harbor is one of two large public hospitals that the county has threatened to shut down, piece by piece, starting in October, to solve a budget crisis.

If no new money is found, departments would close as the cash dries up. First would be the psychiatric emergency room. Then the general emergency room. Then the surgical wards. Then support for the research labs that developed such commonly used medical procedures as the blood test for cholesterol. Then the intensive-care units that treat the sickest of the sick. Finally, the hospital would be converted to an outpatient clinic.

Those changes would directly affect a vast area of southwestern Los Angeles County, home to more than 2 million people. Even the cost-cutters admit it would leave a gaping hole in a regional medical system that serves an area including the gritty Long Beach wharves, the frenzied San Diego and Harbor freeways and the southern half of Los Angeles International Airport.

During the last county funding crisis, in 1995, Harbor appeared on a list of hospitals slated to close. A $1-billion federal bailout kept it open.

Los Angeles County supervisors now find themselves in the midst of another budget crisis--with Harbor once again on the chopping block--because they have resisted pressure to reduce the services it offers to the poor and uninsured and have counted on aid from Washington to cover the funding gaps.

But the Bush administration, grappling with its own deficits, is not believed to be as eager to assist Los Angeles County as the Clinton administration, which authorized the last bailout. That leaves the network of county hospitals and clinics with a deficit expected to reach $800 million by 2005.

As a result, supervisors are showing a new willingness to make tough changes. In June, they voted to close 11 clinics and cut $150 million from the health department. They will ask voters this fall to approve a $168-million tax to preserve trauma and emergency care at Harbor and other hospitals, though they acknowledge it will be tough to get the two-thirds vote needed to ratify the tax.

Health planners say that, if the tax does not pass, in the worst case, all inpatient care would be centralized at the largest public hospital, County-USC Medical Center in Boyle Heights. King-Drew Medical Center in Watts--the county’s second-busiest trauma center--would be the only other hospital to survive, and even it would undergo cutbacks. Harbor and Olive View-UCLA Medical Center in Sylmar would become clinics.

The health department is to decide by October how much of Harbor it will recommend that supervisors close. Department planners say it is a foregone conclusion that Harbor’s psychiatric emergency room will be shuttered.

It is not quite a room, actually, but an eerily vacant, pale hallway lined with locked treatment cubicles, where video cameras monitor patients at all times. Last year the department logged 6,214 patient visits. Most are brought in against their will by police or family members.

Many of those treated in the psychiatric emergency room also have life-threatening physical ailments. A stroke victim can suffer from dementia; a schizophrenic might arrive with slashed wrists.

“I don’t think it’s very easy to close just one part of the emergency room,” said Dr. Roderick Shaner, medical director of the Department of Mental Health. “People will come anyway.”

They will end up in the next department slated for closing--emergency medicine, which runs the hospital’s general ER.

The ER is so flooded with patients that they back up into a cavernous waiting room off a hallway. Some patients there, like Jessica Short, the movie usher who needs surgery, require high-end treatment elsewhere in the hospital. Others, like 7-month-old Ariel Whitmer, just need a doctor to treat their fever.

“They treat her good here,” said her mother, Stacy Whitmer, one of many who make repeated visits to the emergency room. “They’re the only ones that take the time to look at her and tell me what’s wrong with her.”

The main ER is what is called “the big room,” though it’s not that big. Ten beds are jammed along one wall. There’s a little more space on the opposite wall for the three beds reserved for patients suffering from severe trauma. Sick people waiting for beds sit in a semicircle of plastic chairs.

The remaining empty space is often lined with gurneys, despite a state order that mandates privacy for patients. “Some days we’re busting at the seams,” said Dr. Frederic S. Bongard, director of trauma services. “Other days we’re just full.”

On a recent Sunday night, the emergency room was somewhere between those two states.

Stratton, the attending physician, was joined by a clutch of medical residents. They hovered over a beefy patient high on “sherms,” a marijuana joint dipped in PCP, which had sent him into an intermittent coma. Every few minutes, the man emerged from the coma and croaked out a plea for water. There are only six academic papers giving direction on how to treat a patient like the PCP smoker, Stratton told the residents. What he did not say until the residents prodded him is that he had written two of them.

The discussion ended when a traffic victim was rolled in on a stretcher--a teenage boy with a dislocated hip. The youth’s face turned white as three doctors slowly pushed his leg back into its socket, taking care not to jostle the PCP patient, still twitching in the next bed.

Harbor takes car crash victims from stretches of the San Diego, Harbor, Long Beach and Imperial freeways, as well as the streets of the South Bay. While three-quarters of the county health system’s patients are uninsured, some, like the youth with the dislocated hip, come to the emergency room with their insurance cards in hand.

Harbor’s fate “affects everyone, whether you’re homeless or a millionaire in Palos Verdes,” said Dr. Robert Hockberger, chairman of the emergency medicine department.

It was the fate of a man from Wilmington, though, that worried doctors the most on this night.

The middle-aged Latino was wheeled in by paramedics at the end of the shift. He had two bullets lodged in his thigh, and a cracked jawbone hanging limply. He was choking on his own blood.

After Stratton managed to guide a tube down his throat to pump air into his lungs, doctors rushed the man out of the emergency room and up an elevator to the operating rooms. One room is always on standby for emergency patients like this one, but the others are busy around the clock as surgeons perform a steady stream of heart bypasses and gall bladder procedures.

The Wilmington man would never survive, physicians say, if management were to choose one cost-cutting option: preserving the emergency room but shutting surgery down. Patients like him would be stabilized at Harbor, then taken to County-USC, 20 miles away, for surgery.

A committee at Harbor is already devising a plan to divert ambulances to nearby hospitals should Harbor’s ER be shuttered.

Stratton is on that committee.

“It’s pretty crazy,” he said. “You work here and they put you on the committee to figure out how to close it.”

A shut-down would be daunting. Harbor accepted 68,426 emergency room visits last year, 20% of all county emergency admissions. No one knows where those sick and injured would have found help otherwise.

While the effect of closing the ER would be profound, there is an even more far-reaching scenario. If no additional money is found, plans call for the entire inpatient operation--everything that makes Harbor a hospital--to shut down. The 340 beds that fill eight floors would close.

The effects would be felt all the way to Westwood, where Harbor’s closing would deprive UCLA’s medical school of coveted slots for medical students. Harbor’s physicians are also members of the UCLA faculty, and they are assisted by interns and residents who are technically UCLA students.

More than inpatient care would end. So would support for Harbor’s prestigious Research and Education Institute, which has an annual budget of $58 million to fund UCLA physicians’ studies.

There are nearly 1,000 research projects or clinical trials underway at the hospital, seeking to advance the treatment of cancer, diabetes and pediatric health problems, among others.

Hoping to protect its funding, the institute recently hired an attorney with experience in community relations and fund-raising to lead the organization.

“Even in the South Bay, not enough people know about the outstanding quality of our research, the number of scientists we train,” President and CEO Kenneth P. Trevett said. “We have been an underappreciated resource.”

The research arm of Harbor pays for itself with grants. But it could vanish without the raw materials of patients, doctors and machines.

Besides providing a base for research, public hospitals such as Harbor operate under conditions that force the medical staff to develop rare expertise.

Because of the hospital’s mandate to treat all comers, doctors at Harbor become accustomed to treating seldom-seen diseases, some of them serious, many of them infecting recent immigrants. Recent ailments seen at the hospital have included tetanus, whooping cough and necrotizing fasciitis, the contagious skin-eating bacteria. “We see a case of the flesh-eating bacteria every week,” Bongard said. “It’s so frequent that we don’t even bother reporting it anymore.”

A tour of the intensive-care unit shows why public hospitals are financial burdens.

The dimly lit wards are nearly silent, punctuated only by the beeping of machines monitoring the vital signs of patients. Some are so sick they need nurses at their bedsides constantly.

Bongard pointed to a man who required so many machines to keep him alive that he had his own room. The elderly man lay in bed, eyes closed, mouth agape, as six monitors tracked his vital signs. His body was drained through three cavities. He required regular dialysis and could breathe only with the aid of a ventilator.

It cost many thousands of dollars to keep the man alive, Bongard said. He saw no alternative.

“I do what I need to do,” he said, “and let someone else consider the bills.”

Times staff writer Nicholas Riccardi contributed to this report.