Prognosis Doesn’t Look Good for Acclaimed Rancho Rehab Center

Raul Lopez is stoic while Dr. Irene Gilgoff taps his lung for fluid. The needle is barely out of his chest when she gently explains her expectation that he will go to college.

“I know you’re very interested in finishing your education,” she says, smiling. The 18-year-old looks at her and manages a nod. It still hurts just to breathe.

Just a month before, he was brought to Rancho Los Amigos National Rehabilitation Center after being shot in his Crenshaw neighborhood. Now he is paralyzed below the waist. He is not yet well enough for physical rehabilitation. But after 22 years at Rancho, Gilgoff, who is head of pediatrics, can pretty much tell who will thrive and who will not.

She isn’t worried about Lopez; he has inner strength. She is far more worried about the fate of the hospital itself, and where patients like Lopez will go if it closes.

The county Board of Supervisors voted Tuesday to shut down the Downey facility after 114 years of operation, citing a looming budget deficit. The decision, though not final, has drawn protests from rehabilitation experts around the county -- and the country -- who see Rancho as one of the best in the business.

Deciding to close Rancho, supervisors said, had been painful. But the health-care deficit, projected to reach $500 million to $750 million in three years, threatens the county’s entire hospital and clinic system, and could drag the county into bankruptcy.

“The pressure we feel is not just about this one closure,” said Supervisor Zev Yaroslavsky. “The pressure we feel is if the entire system goes into meltdown.”

The Department of Health Services determined that Rancho could not sustain itself. Its closing, the department predicts, will save the county as much as $70 million a year.

The county health department director, Thomas Garthwaite, agrees that Rancho takes on “difficult patients and [does] miraculous things.” The issue is how best to serve the greatest number of patients with dwindling funds.

Rancho offers an uncommon constellation of specialized services -- from spinal-cord and neurological care to vocational training. But nearly a third of its patients are indigent.

The county estimates it would have to pay $15 million to $30 million a year just to cover uninsured patients.

“You have to ask, is that the best use of that money?” Garthwaite said. “Shouldn’t that $15 million go to more emergency room visits, more outpatient services, more immunizations for children? There are no good choices here.”

A Costly Commitment

Just caring for a gunshot victim like Lopez, who arrived with no insurance, costs about $200,000 the first year and about five times that over a lifetime. Medi-Cal does not cover all of these costs. And Rancho makes a lifetime commitment to treating its patients -- about 9,500 people a year, most of them outpatients.

The payoff is illustrated on Gilgoff’s office wall, in a photo collage of the young patients she calls “her kids.” They beam back at her in caps and gowns and prom tuxedos.

“This is a sad chapter -- all those who benefited from Rancho will have to either do without or seek care elsewhere,” said Fernando Torres-Gil, the director of the UCLA Center for Policy Research on Aging. “On a larger picture, it’s just another nail in the coffin for the collapse of our overall health-care system.”

Torres-Gil has more than an academic appreciation for Rancho. He’s been both a researcher and a patient there.

He’s being treated for post-polio syndrome, a progressive weakening of muscles that strikes polio survivors anywhere from 10 to 40 years after their bouts with the disease. If Rancho closes, Torres-Gil said, he and about 100 others who need similar care will have to travel to the Bay Area or even to Washington, D.C.

“The reason Rancho is so crucial is that so many of the experts in polio have passed away,” he said. “Rancho Los Amigos is one of the very few places attempting to educate a new generation of doctors, nurses and therapists about treating these millions of polio patients who are now getting old.”

Trauma experts -- especially orthopedic surgeons -- around the country echoed his concerns. Rancho, said Dr. Daniel Lammerste, president of the American Spinal Injury Assn., helps teach the country how to treat the complications of spinal cord injuries.

For many rehabilitation experts, Rancho Los Amigos’ significance should be considered in historic terms, not just practical ones. The field of rehabilitation has its roots there, and the center’s influence has been felt in ways large and small.

Hospital advances now taken for granted, such as identification wrist tags, came from Rancho. Major innovations such as “the halo,” which is used to support the head and neck of a patient with a spinal cord injury, were invented there. Rancho was the first to use plastics for prosthetic limbs instead of wood.

Rancho became a leader in rehabilitation because of the polio epidemics of the 1940s and ‘50s. Enormous black and white photos from that time line its corridors. The grainy images show children and adults encased in tank-like iron lungs, their heads sticking out, while the machines help them breathe.

In 1953, nursing director Clara Miller suggested adapting rehabilitation concepts used with polio survivors to patients with other muscular disabilities.

The influx of patients with nowhere else to turn allowed Rancho’s staff to develop unusual areas of expertise. Spinal cord injuries, for example, are rare. About 40 people out of 1 million annually have injuries that result in paraplegia or quadriplegia.

Clinicians at Rancho have learned, not only about the intricacies of such injuries, but also of their emotional toll.

‘We All Need Hope’

After about a week of stoicism, Lopez had his first breakdown in front of Gilgoff. He tried to sit up and move from the bed to a wheelchair -- something critical to his future independence -- and could not. The pain in his spine was crushing.

“Inside I’m saying to myself, ‘They shot me in the back! They shot me in the back! Why’d they have to shoot me there, anywhere but there,’ and then I realize I’m saying it all out loud and everyone can hear me,” he recounted later.

He tries to push down fear, pain and grief with cold vigilance during the day. But at night, the shooting returns in his dreams.

The afternoon he was shot, a car pulled up beside him and a man asked what neighborhood he was from. “I told him, “Nowhere, man.’ But he thought I was a Crip and shot me anyway,” said Lopez, who added that he is not a member of any gang.

After his first few days at Rancho, he pushed for a firm answer: “I said, ‘Tell me straight, am I ever going to walk again?’ They didn’t want to tell me, but finally they said no,” Lopez says, then pauses. “I can take it, though. I mean, I’m sad about it, but you know ... what’s done is done.”

As his spine stabilizes, Lopez will be surrounded by a team of specialists -- occupational and recreational therapists, psychologists, social workers who consult the nurses, psychiatrists and other doctors -- to create a rehabilitation strategy. The plan will emphasize all that he can do, not what he cannot.

“You don’t ever take away any real hope,” Gilgoff says. “We all need hope.”

Orthopedic surgeon Robert Waters could be making a fortune in sports medicine operating, say, on Shaquille O’Neal’s right big toe. But he has never considered leaving.

“There is no other place that I can do this,” Waters said, referring to the combination of specialized research and surgery that can alter the lives of disabled patients.

“I never, ever wake up and wonder why I came to work or why I went to medical school.”

Waters is Rancho’s medical director and heads the spinal cord injury program, one of 16 “model” programs designated by the federal government nationwide. He is widely regarded as a major influence in the field.

“What he does is not run-of-the-mill orthopedics,” said Dr. Rod Adkins, a research colleague at Rancho. “When you move the tendon of one muscle that is functioning to an unfunctioning muscle so it works both of them, well, that’s pretty sophisticated stuff.”

A bald, ruddy-faced man, Waters describes himself as demanding at work and “fairly driven.”

Colleagues say he is supremely able and businesslike -- keenly interested in his work, with little time for personal chitchat.

By the most refined and delicate procedures, Waters and his team sometimes restore movement where it was thought to have been permanently lost. For a medical school student paralyzed in a car accident, surgery returned use of his wrist, allowing him to use a microscope and become a pathologist.

Many years ago, Waters’ surgeries gave Sharon Riggs, now 53, the ability to walk for the first time. Before a series of operations on her ankles, she had spent 17 years on her back, being wheeled from place to place on a gurney.

“I even went to school on a gurney,” she said. “People were so mean to me, so mean. They’d make fun of me and ask why I had to be there anyway. Why couldn’t I just stay home.”

Though her treatment is long over, Rancho is the place she loves most in the world. Riggs arrives at 6:30 a.m. every day to volunteer her time, usually stopping in twice a day to see Waters and run errands for him. He shows her a side his colleagues rarely see.

“Dr. Waters?” she says, her face lighting up, “He’s a beautiful person. He is so patient. He just always has time to listen, whenever you want to talk.”

Uncertain Prognosis

A final decision on the hospital’s future is expected in January. Some Rancho supporters take heart because supervisors threatened to privatize Rancho in the mid-1990s, then backed off when an audit showed the savings would be minimal.

But Mario and Maria Saucedo of Whittier are worried about the hospital’s prospects. Their 3-year-old son, David, is recovering from a severe head injury, sustained when he fell out of the bleachers at a football game Sept. 7. He is among 50 head-trauma patients treated at Rancho each year.

For two weeks he was in a coma, and the Saucedos could hardly recognize him. When he first awoke, he could hardly recognize them either. One parent stays with him at all times, sleeping beside his crib at night.

He is far better now, though his movements are impaired on his right side and his vision remains distorted. He has started to play.

“Without Rancho being a part of the county, I would have had to take my child home from the hospital the way he was, right after he came out of the coma,” his mother said. “We don’t have private insurance.”

The Saucedos imagine they are like a lot of families: They never thought much about hospitals and trauma and rehabilitation before their son’s fall.

“But if I could talk to the county supervisors, I would tell them they’re deciding the difference between whether my son would have a full recovery and normal life,” she says and pauses, “or not.”

Before voting to close Rancho earlier this week, Yaroslavsky told listeners that the board must consider what is best for the entire county, not just one hospital.

“When you gut $800 million out of a system, it isn’t going to be pretty.”