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Saving Lives And Surviving Paperwork Inside The LA County ER

Jun 22, 2014
Originally published on June 23, 2014 6:09 am

LA County Hospital sees some of the worst possible medical cases. Patients suffering from gunshots, car wrecks and other severe injuries frequently pass through the doors of the Level I trauma center.

At the same time, since it's a public hospital, LA County ER doctors also often see patients who don't have life-threatening emergencies, but who otherwise lack access to health care.

The new documentary Code Black goes behind the scenes at the hospital, depicting the intense efforts of doctors and nurses as they try to resuscitate patients on the brink of death and cope with the massive volume of people in need.

The film's director, Ryan McGarry, is a physician specializing in emergency medicine. He trained at the hospital, which is officially called the Los Angeles County-USC Medical Center.

The film goes beyond the medical drama to show the burdens paperwork can put on the doctor-patient relationship. McGarry tells NPR's Arun Rath that Code Black is both a testament to the people who work at the hospital and a critical look at the U.S. medical system.


Interview Highlights

On visiting LA County Hospital's ER for the first time

I couldn't believe the volume and the amount of perceived chaos. And yet, underneath that chaos was a very well-functioning machine of resuscitation, both for critical illness as well as trauma.

And I thought, "My gosh, I don't think Americans would believe that this is happening here in a major U.S. city ... this type of volume, this type of need. And it's seemingly working out."

On LA County Hospital's legendary trauma bay, known as "C-Booth"

LA County Hospital is one of the first places that emergency medicine was formed as a specialty. And it's important to recognize that emergency medicine — as is 911 — are actually fairly young.

I mean, these are 1960s, 1970s developments in this country. When you look at all the specialties of medicine, emergency medicine is one of the youngest. And so this is where it's thought the specialty was born.

C-Booth — it's been lost to history, but we think that means either "Critical Booth" or "Cardiac Booth" — is kind of where the sickest patients would come. And as a training physician, it's where you would oversee up to six or seven or even more of these critically ill patients.

On the types of patients that go to the emergency room

Even post-Obamacare, we're seeing, throughout the country, emergency room visits go up, and that might be counter-intuitive. But what we're finding is that, yes, more people have access, more people are getting insurance cards, but those cards aren't always premium. And we're already in a system where a lot of specialists won't take a sub-premium insurance card, because you're not seen as profitable enough.

So many people end up coming to public hospital emergency departments, just to see an orthopedist, or an endocrinologist or someone who won't take their probably decent insurance, but it's not good enough.

On what changed in 2008, when LA County Hospital relocated to a new facility

They moved from an effectively historic landmark building to what's probably one of the most impressive, technology-laden medical facilities in the country. It was a $1 billion structure, and it's packed with absolutely incredible features.

But what was lost along the way is not so much a reflection of the LA County's decision to move from one building to another, but really a perfect encapsulation of what modern healthcare has become. It's sort of become depersonalized as a result of a lot of well-intentioned features, whether that be safety regulations or privacy regulations or even a lot of technology.

I mean, think about it. The last time you went to the physician, or even a nurse practitioner's office, a computer and a screen and a lot of charting was probably the mainstay of that experience.

That didn't happen at the old place, because it was just so open and intimate.

On coping with the burden of paperwork in modern medicine

I think the major responsibility here is actually on the physicians. I think that we have to speak up. And probably most [doctors] have lost control over this ...

You know, oftentimes we're the most invested in the patient care. I'm $300,000 in debt. I lost every weekend of my 20s to becoming a physician. And yet I'm the last one who decides what that patient-doctor experience is going to be like. That's now decided by everyone from politicians [to] insurance companies to people who got their MBAs online or something.

I've invested so much into this idea of the patient-doctor experience, and yet I'm the last one to really get to say how that experience is going to go. So really, I think the answer is: Docs need to speak up. And I think partly that's what Code Black was for me, personally — a chance to say, "OK, this is the state of affairs. And I don't that we feel like it's acceptable."

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ARUN RATH, HOST:

We're going to take you now inside of one of the busiest emergency rooms in the United States. The Los Angeles USC Medical Center, commonly known as L.A. County Hospital.

UNIDENTIFIED SPEAKER: Hold on. Hold CPR. Hold CPR. He's going to cut. Does he have a pulse?

RATH: They'll see the worst of the worst when it comes to human trauma - car wrecks, gun shot wounds. And they have to race the clock to save victims from otherwise certain death. The place is the subject of a new documentary called "Code Black." Ryan McGarry directed the film. He's an ER doc himself and trained at County Hospital. He vividly remembers the first time he visited the ER there.

RYAN MCGARRY: I couldn't believe the amount of volume and the amount of perceived chaos.

UNIDENTIFIED DOCTOR: Is it in? Is the tube in?

SPEAKER: Oh, yeah. It's in.

DOCTOR: OK, this is not - this isn't very good.

SPEAKER: What happened?

MCGARRY: And yet underneath that chaos was a very well functioning machine of resuscitation both for critical illness as well as trauma.

DOCTOR: We're going to help you, OK? Just relax a little bit, OK?

DOCTOR: This hurt here? This hurt here on your leg?

RATH: When McGarry started filming, the hospital was in a facility built in the 1930s. And at the center of the emergency room was a tiny and chaotic area reserved for the most critical patients. It was called C-booth. As one doctor says in the film, more people have died in that small square footage than anywhere else in the country. But more people have also been saved there than anywhere else. McGarry explained what made C-booth so legendary.

MCGARRY: L.A. County Hospital's one of the first places that emergency medicine was formed as a specialty. And it's important to recognize that emergency medicine, as is 911, are actually fairly young. I mean, these are 1960s and 1970s developments in this country. And so this is where it's thought the specialty was born. And C-booth, which - it's been lost to history - but we think that means either critical booth or cardiac booth. It's kind of where the sickest patients would come. And as a training physician, it's where you would oversee up to six or seven or even more of these critically ill patients.

RATH: And the types of cases that you're seeing at County Hospital, you know, aside from like the trauma cases - there's a type of patient that comes there because you don't turn anyone away.

MCGARRY: That's right. So even post-Obamacare, we're seeing throughout the country emergency room visits go up. And that might be counterintuitive, but what we're finding is that yes, more people have access - more people are getting insurance cards. But those cards aren't always premium. And we're already in a system where a lot of specialists won't take a sub-premium insurance card because you're not seen as profitable enough. So many people end up coming to public hospital emergency departments just to see an orthopedist or endocrinologist or someone who won't take their probably decent insurance, but it's not good enough.

RATH: Now, you are there to film a major shift. L.A. County Hospital underwent a renovation in 2008 and they moved to a new earthquake-resistant building. You wouldn't think it would be so dramatic a change because they're basically moving almost across the street to a new facility. It's the same people, but things changed dramatically. Can you explain what happened?

MCGARRY: They moved from a historic - effectively historic landmark building to what's probably one of the most impressive technologically laden medical facilities in the country. It was a $1 billion structure. And it's packed with absolutely incredible features. But what was lost along the way is not so much a reflection of the L.A. County's decision to move from one building to another, but really a perfect encapsulation of what modern healthcare has become. And it's kind of become depersonalized as a result of a lot of well-intentioned features, whether that be safety regulations or privacy regulations or even a lot of technology. I mean, think about it. The last time you went to the physician or even a nurse practitioner's office, probably a computer and a screen and a lot of charting was probably the mainstay of that experience.

UNIDENTIFIED FEMALE DOCTOR: I just had a patient with the simplest of complaints. It took me about two minutes to see her. And what turns into a very simple complaint, there's just tons of things I have to do in terms of documentation. And basically, it took me four times as long to document as it took for me to talk to her and do the exam at the same time.

MCGARRY: That didn't happen at the old place because it was just so open and intimate.

RATH: You yourself say this is well-intentioned stuff. It's about, you know, trying to protect the patient in different ways. Do you see any way through to like make a balance here?

MCGARRY: I think the major responsibility here is actually on the physicians. I think that we have to speak up. And probably most docs feel like we have lost control over this or at least our voice. You know, often times we're the most invested in the patient care, right? I'm $300,000 in debt. I lost every weekend of my 20s to becoming a physician. And yet I'm the last one who decides what that patient-doctor experience is going to be like. That's now decided by everyone from politicians, insurance companies to people who got their, you know, MBAs online or something. And I've invested so much into this idea of the patient-doctor experience. And yet I'm the last one to really get to say how that experience is going to go. So really, I think the answer is docs have to speak up. And I think partly that's what "Code Black" was for me personally - was a chance to say OK. This is the state of affairs and I don't think that we feel like it's acceptable.

RATH: That was Ryan McGarry. He's an ER doctor and the director of the new documentary "Code Black." Transcript provided by NPR, Copyright NPR.