County is where over half of Chicago's 1.1 million blacks go for medical care, along with a sprinkling of skid-row whites, Puerto Ricans and Mexicans. By the hundreds, they descend on it each day, bypassing along the way many excellent private hospitals. They must travel, on the average, eight miles to get there. Surprisingly, a minority of the peonlr when come to County are completely indigent; nearly 80 percent are at least partially covered by insurance, Medicare or Medicaid. Theoretically, they are free to choose among 7,000 doctors and 103 hospitals. But doctors don't like to practice in the ghetto, and hospitals don't like to fuss with the red tape of government payments.
|©1997 Archie Lieberman|
And just how indifferent the care is becomes quickly evident once you walk into County's admitting section, where, on a typical Monday, 650 to 800 men and women stream through. Stream is perhaps the wrong word because some patients wait there all day: two hours to be seen; two, three, four or five hours to have an X ray taken; two hours to have a radiologist read it, and sometimes another two hours to have something done for them. And that can be little, because admissions are rationed.
A pneumonia patient may be sent home with a supply of penicillin pills.
A bewhiskered derelict, just starting to have alcoholic shakes, is allowed to sleep on a stretcher for a few hours, and then sent away.
A flushed woman whose blood pressure turns out to be 180/110 is given some phenobarbital tablets and an appointment in the hospital outpatient clinic in two or three weeks (where her doctor will have to wait over three months for an intravenous pyelogram—a special X ray to check the state of her kidneys).
"This is a dumping ground for the other hospitals," declares an angry emergency-room nurse. "They send US the patients they don't want." Dr. Jeb Boswell, director of adult admitting services, still mutters about a nearby university hospital sending over a "medically interesting patient" with instructions to "please delouse him and send him back." Dr. Boswell says proudly: "I sent him back with a note, 'Delouse him yourself.' "
The referring hospitals are supposed to telephone County for permission to transfer patients; this rule is often breached. Either the hospitals delay in calling until the patient is on his way in an ambulance or patrol wagon, or don't call at all, or send the patient along after refusing him admission. There are horror stories:
"A big South Side hospital sent us a mother, still connected by the umbilical cord to a dead baby, after she had been brought over there by a patrol wagon."
"A hospital yesterday sent us a badly disturbed man who had cut off his tongue; we had told them not to, we had a doctor who could sew up the wound, but there was no psychiatrist here to treat him—they sent him and the tongue anyhow."
''Sometimes, nursing homes send over patients who are near death— sometimes, ice cold."
Dr. David Boyd, senior resident in surgery, says: "These transferred patients die from things that even a high-class Boy Scout could treatfractures are not splinted and wounds are not dressed. They are transported on their backs and drown in their own fluids. Patients are sent across town from another hospital without resuscitation or the most simple examination, patients with a gunshot wound."
Dr. Boyd shows me what he means. A black youth lies groaning with a bullet wound through the vitals of his abdomen; fecal matter has spilled into the abdominal cavity from his torn colon, and a terrible peritonitis has begun. "What did they do for you at the hospital where the police first took you?" asks Dr. Boyd. "They put a bandage on and gave me some Maalox," the man groans. Dr. Boyd snorts: "Maalox! That's for heartburn!" A month later, the man died. Pierre de Vise estimates that 50 people died unnecessarily last year as the result of such transfers.
The reason County now turns away sick people is that in February, 1970, residents, interns and attending physicians rebelled against the dumping, and shut off admissions. The medical wards were 125 percent full, with lines of beds down the middle aisles, and trailing out into the halls toward the elevators. Medical-ward admissions now are supposedly on an emergency basis only.
"We've cut them from 17,000 a year to 13,000," says Dr. Rolf Gunnar, chairman of the division of medicine.
"That's a big improvement," he says, "over the 1950's, when we had 120 patients per ward and no nurses, and the one nurse in the building had to walk around and decide who was going to get medicine."
Actually, conditions are far from right, as you can see on a walk through the eerie underground tunnels that connect the 22 buildings making up the vast medical complex. Building B on the outer reaches dates back to 1909, my guide tells me, showing off two elevators that sometimes break down at the same time. "Then we have to carry food trays up five floors," she says.
Pierre Olivier, R.N., a black man from Haiti, is the head nurse in Building B's Ward 38. He tells me he has two bathtubs for the 46 patients in this ward—a better deal than in the wards that have only one. But he complains about a nursing shortage. County is lucky to be able to supply three hours of patient care a day per patient—hospitals are expected to deliver five hours or more. "Right now on the day shift," says Olivier, "I have only another R.N. and three L.P.N.'s [licensed practical nurses] helping. The food gets cold before we get around to feeding all the patients." On the night shifts, the rambling ward is usually staffed by a single R.N., one L.P.N. and two nurse's aides. | "You can't find a nurse when you need one," complains an old black man. "Last night, I got up twice and wandered all around the ward when the man next to me had a terrible nosebleed. Each time, it took 15 to 20 minutes to get help."
Dr. Shirley Roy, an intern assigned to the ward, tells me how she was awakened at 2 a.m. to sew up a patient after the sutures on his peritoneoscopy had come apart. This is an operation to permit a diagnostic instrument to be inserted through an incision in the abdomen. "There was a trail of blood," she says, "all the way from his bed to the bathroom and all the way to the nursing station. He couldn't find a nurse."
Dr. Roy, a very pretty, very bright graduate of the University of Wisconsin Medical School, where she had a full scholarship, is the second of 11 children in a Maine family descended from French-Canadians. "I am no radical," she says. "I'm no hippie. I vote Republican, and at Wisconsin I stepped over the bodies of the demonstrators so I could register for classes." She sweeps an angry hand toward a bed: "It doesn't take a young radical to be concerned about a patient like this." In the bed is a very old man with bedsores; he is lying in a puddle of urine. He doesn't know his name. He had had a stroke, and an ambulance brought him from a flophouse on West Madison Street. "He should have physical therapy twice a day," Dr. Roy declares, "but for some reason, the therapists never come here."
County's patients are, on the whole, much sicker than patients in other Chicago hospitals. Over ten percent of those in the medical wards die there. They require intensive care that is just not available. Dr. Roy gestures angrily to a signal panel at the nursing station, gaudily lit up in red and green like a Christmas tree. "It's a fake, a dummy," she says. "It's not connected to anything. There's no call button at any patient's bed." The angry hand goes out again to indicate a sputum specimen lying atop a desk. "This was collected on the 19th and still hasn't gone to the lab," she says. Today is the 22nd.
Looking around Building B. a visitor might not realize that it is in the world's richest country. Sheets are doled out daily, only a few to each ward, because the hospital is short many thousands of items of linen. There are enough pajama tops for the patients, but few bottoms, so sick men and women patter around the ward barefoot and half-naked, with a blanket wrapped around them when they seek out the washrooms. One doctor tells me he buys the toilet paper for his ward.
Dr. Roy says she wastes at least a quarter of her time. I walk with her as she pushes a very sick patient on a cart through the block-long tunnel to the main building, where a surgeon must insert a catheter into him. Aided by a medical student, she frequently has to lower the intravenous bottle that is sustaining the patient; it can't clear the steam pipes. The errand costs her and the student 45 minutes. "We have a ward transportation clerk to do things like this," she says, "but he's so busy that if you want somet:hing done quickly for a patient, you have to do it yourself."
Returning the patient to his bed. she puts an aspirating tube, a suction device, down his throat to keep him from drowning in his secretions. "You're better off if you do it yourself," she says. "Normally, a nurse would do this." I notice that before she could perform the chore, she had to send the student to two different floors to ferret out the tube--the one in the ward had disappeared.
Shortly, Dr. Roy wheels an EKG machine over to a bed to take a heart tracing. "Now the fun starts.'' she says, as she and the student begin searching among the dozens of wall outlets in the ward. It seems that the EKG machine requires a threepronged outlet and there is only one three-pronged adapter in the ward— stuck somewhere in one of the twohole wall outlets. "My God, suppose we had to plug in some emergency equipment," says a young doctor. "The patient would be dead before we could find a plug." The ungrounded electrical apparatus, he predicts, will someday kill a patient.
For years, on and off, County has been threatened with disaccreditation. This might mean the loss of health-insurance revenue and, undoubtedly, most of the interns and residents. Some say that if County were not the county's hospital, it would never have remained accredited. A major problem has been the turn-of-the-century surgical section, where 15,000 to 16,000 operations are performed every year. The 18 operating rooms have had to do without air conditioning. This is very serious because it means the surgeons have to work with the doors and windows open to outside infection. The surgeons sweat buckets, swallow salt pills and still are uncomfortable. For the patient, it often means a dangerously high body temperature. On warm, humid days, all surgery has to be suspended.
Dr. Frank Folk, head of the division of surgery, tells me that two years ago, six of the rooms were finally airconditioned but, for some reason, the cooling system didn't work. Now, he is trying again; four operating rooms have been in the process of reconstruction for over a year. The nursesupervisor in one operating room looks abashed as I inspect the screened windows, circa 1914, with their fine north view of the Eisenhower Expressway. The screens have holes in them. Two flyswatters are part of the operating room's permanent equipment.
A young surgeon serving his residency complains about the lack of supervision (there are few full-time or part-time teaching doctors all through the hospital). The surgeon sounds ambivalent: He likes the idea of getting to do the quantity of the surgery he is allowed to do, an impossibility for an apprentice surgeon at a place like Mayo Clinic, but he also is genuinely disturbed about making mistakes and about not learning.
The shortage of attending staff physicians, as these.teachers are called, is especially distressing because County attracts mainly graduates of foreign medical schools. Only 30 of 134 interns are U. S. graduates, and only a third of the 350 residents. Most come from India, Pakistan, Iran, Syria, the Philippines, Taiwan and Japan. While many foreigners adapt quickly, they have trouble in being understood by the patients and, often, in understanding them. This can be fatal.
There is a dreadful lack of privacy in County's vast wards. The hospital is making a start, for the first time, in putting draw curtains around beds, but most patients are out in the open. I inspect Ward 51. a maternity ward with 45 beds hardly more than 30 inches apart and no screens. A resident is making vaginal examinations and requests that I leave. "Don't the patients mind being examined in front of one another?" I ask. "Not a bit," retorts the doctor. "They're all in the same boat!" (Yes, they are, I think to myself. Too poor to go anyplace else.) Naturally, no visitors-not even the fathers—are permitted.
In Ward 53, where surgical and problem obstetrical patients are kept, the normal complement of beds is 37, but today. eight beds are set up down the middle aisle, and three patients with intravenous bottles attached are sleeping in the hall. I stop an intern, a young black who recently graduated from Howard University medical school. He says: "Three-quarters of our patients haven't had much, if any, prenatal care. They come in anemic because of poor diet, and since they lose some blood in even normal delivery, their chances of having problems increase."
County delivers 16 percent of all babies in the city (11,010 last year, down from 19,136 in 1963). The babies, naturally, are usually black. The black doctor slaps the rubber tube he is carrying against his white jacket as he says: "Here, we have too few nurses, too few doctors, too few everything. At night, when the residents are not physically present, about 50 percent of the IV's [intravenous feedings] in the maternity ward are not functioning by morning." He slaps the tube again as he gives me another statistic: "We have twice as many premature babies as the average in the city of Chicago—lowweight babies are 20 times more likely to die."
It costs $104 a day for a patient in County-soon it may be $125—and the average stay of 12 days in a medical ward is four or five days longer than in most other hospitals. This means an extra cost to government or insurance companies of as much as $520 a patient. Part of this waste is due to the hospital's gross inefficiency. Here is what the doctors say:
"Half the time, when I call for a patient's X ray, they can't find it."
"This is supposed to be a 24-hour, seven-day-a-week hospital, but you can't get routine X rays on Saturday, Sunday or Monday."
"We waste our time doing lab work ourselves if we want to make sure of getting it. The lab equipment is from before the Flood."
"We're paying $54,000 to lease lab equipment for three years that would cost only $36,000 to buy."
"This is the first place I have been that a patient is discharged from the hospital, and his record doesn't go back to the record room. His record sits on the ward, waiting for some doctor to complete it. It gets lost and ends up in some doctor's office. One time, they went to the interns' and residents' quarters and collected thousands of charts.
One of the shorcomings is the lack of psychiatrists, four for a ward of 85 patients—and all the rest of the hospital. Dr. Shantha Narasimhan, a tiny woman resident from India, tells how a 23-year-old patient, sent to her medical ward after taking an overdose of tranquilizers, waited eight days for a psychiatrist. "Young people can be treated for a depression if they are treated promptly," she says bitterly. It bothers her that her disturbed patient had to be tied down in bed, for all the other patients to see, for most of the eight days while the psychiatrist was coming.
The anger of the young doctors has brought formation of the Residents and Internes Association of Cook County Hospital. The association functions as both a trade union for the doctors and as a lobbying group to press for better hospital conditions.
Dr. Shirley Roy, active in the association, says she and her fellow doctors want changes, lots of them, and soon. she poses a threat: "We have to practice as professionals. Rather than practice far below the standards of accepted medical practice--and I mean far below—it would be best to take our talents elsewhere."
Dr. James Haughton, who came from New York City last November to be the hospital's new director, promises changes, lots of them and soon. He calls his institution a "big sea of mismanagement" with "nobody in charge of anything.'' He warns that there is little time left to save the place and that his first priority must be to keep County accredited. Otherwise, it must close. The director, a Panama-born black man who comes from a top job with New York's city hospitals, says that County has already made progress in removing the stranglehold of politics by getting its own Governing Commission with control of the $41.4 million a year the hospital spends. Now, the place has to be reorganized. A first victory, he says, was in getting filthy floors scrubbed--some for the first time in years. (". . . there are something like 235 people around who were just supposed to clean floors....")
Dr. Haughton promises that by m summer he will have hired more attending physicians to beef up supervision, and will reshape the outdated clinic so that the main hospital can function as an emergency room and sick people can walk in off the street 12 hours a day and get prompt care at the clinic. His reorganization, he says, will in time correct many of the terrible things that the accrediting agencies can now see. This calls for better record keeping, X rays and laboratories. Good luck, Doctor.
Should County be closed altogether and the 102 other hospitals made to treat the poor? Dr. Haughton thinks that anybody who advocates that is ''unrealistic, because there is a difference in my mind between what is available [in hospital bedsl and what's accessible.... This is the only place where everybody has access." In other words, this experienced public-health man does not believe that private hospitals will take in the poor sick in any great nurnbers. He suggests that perhaps County can contract with a few outlying hospitals for service to the poor and that it can also staff several federally financed outpatient clinics.
Pierre de Vise, the critic of thel present system, says that with all the money government is already spending for medical care for Chicago's poor ($600 per person a year, as noted earlier), prepaid medical plans like Kaiser-Permanente could be set up to give first-rate complete health care. Kaiser-Permanente charges only $500 for a whole family in California. He believes County should cut its size by about two-thirds, retaining its excellent burn, trauma and pediatric-care units,but become just another community hospital.
"There are outpatient departments in 15 to 20 hospitals," says De Vise. "Make it really illegal for them to refuse to see any patients and transfer them to County. It's illegal now, but it doesn't stick. Emergency care should be paid for by the government for anybody not covered by insurance. Anybody eligible for public housing should be eligible for complete free care, and the Federal Government should pay."
Thinking over De Vise's words as I leave County, I carry away a strong feeling that the patient poor may stop being so patient. After all, even some of the doctors who were so silent for years have finally become angry. The words of a young intern, Dr. Philip Johnson, ring in my ears: "If County closes, where else aretthe black folks going to go? They are going to go to the hospitals that they have been driving past for 20 years. Those hospitals will either have to admit these people or face black anger.