Category: Hospitals & Clinics

At the ready for Ebola in L.A. County

Nurses at LAC+USC hospital this week learn how to protect themselves from Ebola with protective gear.

When LAC+USC Medical Center handed out its latest batch of protective gear against the Ebola virus Wednesday, several emergency room nurses eagerly reached out with both hands.

There were impermeable gowns, scarves, booties, hair coverings, face shields, goggles and gloves – boxes and boxes of them. Still, the offered protections were not enough to ease the anxieties of at least a few of the nurses who’d gathered in the facility’s conference room.

After all, two members of their profession had, stunningly, contracted Ebola in a well-known Dallas hospital while extensively treating a patient who would succumb to the deadly disease.

One of the nurses at the LAC+USC training session, for example, worried whether the back of her neck was still exposed after she’d slipped on her blue gown. A tall, male nurse, meanwhile, wondered what might happen if his large feet tore through his protective booties.

Observing the session was nurse Jason Guzman, 33, who’d already been training for more than a week at the Los Angeles hospital, which is operated by the Department of Health Services. He understood the importance of those questions and concerns because before his training, he had them, too. For with Ebola, even the slightest wardrobe malfunction can lead to infection.

The training, he said, “helped me get more comfortable with the gear. It’s really boosted my confidence. It’s helped me feel a bit better about the situation.”

According to the World Health Organization, the current outbreak of Ebola Virus Disease has infected some 8,900 people, killing about 4,500 of them. That’s more than all other previous Ebola outbreaks combined. Among the casualties: 256 healthcare workers.

Although West Africa remains the epicenter of the disease, the patient in Dallas succumbed after a visit to Liberia, infecting two nurses who’d cared for him.

According to Los Angeles County’s interim health officer, Dr. Jeffrey Gunzenhauser, the nurses’ infections underscore the need for healthcare workers and others to take extreme precautions if they come into contact with a patient who may be contagious.

“I feel personally responsible for their safety,” he said.

Ebola, first discovered in 1976, can cause fatal hemorrhagic fever.  A person can get sickened through direct contact with an infected person’s bodily fluids. The first symptom is fever, followed by headache, weakness, diarrhea and severe bleeding.

Gunzenhauser is concerned but calm, even unruffled. That may be because he’s not only a doctor but a retired Army colonel, whose resume includes graduation from West Point, medical training at Walter Reed Army Hospital and drafting health policies for soldiers deploying to the wars in Iraq and Afghanistan. He even learned to parachute out of planes, should that be the only way to reach wounded soldiers on the battlefield.

“Coming out of the military, I’m very accustomed to working in highly stressful operational environments and approaching problems with greatly detailed plans,” he said.

Last week, Gunzenhauser and other county leaders convened a task force to evaluate the response to Ebola if it were to reach Los Angeles. He knows that patients would need more than just medical care.

That’s why beyond medical, emergency and law enforcement agencies, the task force includes such departments as Children and Family Services, Mental Health and Public Social Services.

“Let’s say, for example, we might have a case where we would need to quarantine a family,” he said. “How are they going to get their food? What if they need medications? What if we’re pulling a kid out of school? We need to look at all those contingencies, and plan for them.”

If preparing for Ebola is like mounting a military campaign, then nurse Jason Guzman is among those on the front lines. He feels a “calling” to be a nurse, despite knowing that taking risks is “part of the job description.”

“Nurses are in the field to care for those who need help, and Ebola patients aren’t any different,” Guzman said. “They definitely need care — a little bit more care, perhaps.”

“I just know that if there’s a situation where there’s possibly a patient with Ebola, I’m going to do everything i can to help them,” Guzman said. “I’ll also definitely do everything I can to protect myself.”

Nurse Jason Guzman says his Ebola training has “really boosted my confidence.”

Posted 10/17/14

Cracking the ER “Code”

The acclaimed Code Black captures the intensity and complexities of ER medicine at County-USC.

In the beginning, the idea was simply to produce some archival footage—a project pitched by a young medical student to document life-saving efforts unfolding amid the controlled chaos of the emergency room at Los Angeles County’s old General Hospital.

It was there, on the edge of downtown, that the concept of emergency medicine was born in 1971 and, in some respects, had remained the same in theory and practice throughout the ensuing decades.

Despite medical modernizations that had become the norm at most hospitals, the emergency crew at the renamed Los Angeles County-USC Medical Center still operated more like a battlefield MASH unit. Crowds of doctors and nurses swirled around patients suffering the most catastrophic of injuries. Side by bloody side, the stricken were packed into a cramped trauma bay in the ER called “C-booth,” with barely a curtain between them.

But in 2008, all that was about to change, and first-year resident Ryan McGarry, who also had a keen interest in filmmaking, wanted to capture the era before it was gone. Because of earthquake damage to the old county hospital, the emergency department was moving next door to a new state-of-the-art facility that would rocket the doctors into 21^st century medicine, complete with its emphasis on patient privacy and layers of paperwork.

Although initially modest in scope, McGarry’s ambitions for the project soared with the support of top Los Angeles County officials and the help of a producing team that included USC Distinguished Professor Mark Jonathan Harris, who has won three Academy Awards for documentaries.

Director/Writer Ryan McGarry, an ER physician.

McGarry’s film, Code Black, opened nationwide in June and has become a critical success, a gripping and graphic look at the shifting world of emergency medicine for the destitute and working poor who rely on public hospitals, such as County-USC, for their care. The term Code Black refers to the hospital’s designation for the highest level of emergency room crowding. Among other honors, the film won the Jury Award for best documentary at the 2013 Los Angeles Film Festival.

Focusing on a cadre of idealistic young residents, including himself, McGarry explores the challenging new realities for the next generation of emergency room physicians as they remain committed to maintaining a personal connection with patients while confronting the escalating regulatory demands and settings that emphasize patient privacy.

Dr. Sean Henderson, chairman of the hospital’s emergency department, says his 21-year-old daughter saw the documentary at a film festival in Santa Barbara and was so inspired that she changed her major.

“She decided to become a physician’s assistant because of that movie,” he said.

“Often, doctors are portrayed as overpaid snobs who don’t really care,” he continued the other day, sipping a caffeine-free Coke in his office in the old county hospital. “But I think you’ll see in this movie that this is not always the case. There are people doing things because they really care about the people they serve.”

Still, Henderson said he has some personal reservations about the film—a project he inherited from his predecessor, Edward Newton—and isn’t sure he would have green-lighted it himself.

“I’ve never believed in cameras in the hospital,” he explained. “The fact that you’re in an emergency room with an unplanned, unscheduled, unanticipated event—stressed, waiting, probably less informed than you’d like to be—I think that’s a very vulnerable place to be.”

That said, Henderson praised the filmmaker for getting two sets of consents from patients whose emergency room visits are shown in the film—everyone from a drunken man belting out a romantic ballad in the waiting room to the family of a patient whom doctors unsuccessfully fought to save as they cut into his chest to keep his heart beating.

Henderson, who became department chair in 2012, also appears in the film, but mostly to defend a prominently featured action he imposed in the face of a severe nursing shortage. In a dramatic segment of the documentary, he shut down an area of the new emergency department, creating a monumental patient backlog, to make the point “that we couldn’t continue to care for all these people with inadequate resources.”

“I caused the crisis and I had to defend the crisis. I was the villain,” he said, and then offered a fuller explanation of his actions than he did in the film.

He said that in the past, before Health Services Director Mitchell Katz’s arrival in 2011, “the way you got attention in the county system was to create a crisis. It wasn’t just me. It was throughout the system…If you have a crisis, resources are pulled from someone who’s not having a crisis to take care of your crisis. And so, without permission from the school [USC] or the county, I created a crisis knowing full well that it would create a pushback downtown that would allow them to hear my pleas that heretofore had gone ignored.

“It was manipulative, it was sneaky, and mea maxima culpa. But it worked,” he said, noting that more funding was soon made available for the desperately needed nurses.

Another top L.A. County emergency department official, Dr. Erin Wilkes, said she’s seen her good friend McGarry’s film more than a dozen times in various stages along the way. The two were residents together, beginning in the old hospital’s emergency department. Today, she’s the director of Emergency Medicine Systems Innovation & Quality.

Wilkes said she helped organize various Code Black screenings for county officials, including the Health Services executive team. The feedback was mostly positive, she said, although “there were a lot of questions about what the consent process was like.” Wilkes said McGarry obtained his first consents at the hospital and then got a second round of permissions after showing people the actual footage he wanted to use.

Wilkes said she’d now like to build on Code Black’s positive buzz by holding a panel discussion event at USC that would include McGarry, now an assistant professor of emergency medicine at New York-Presbyterian/Weill Cornell Medical College.

In a recent interview with the emergency medicine publication ACEPNow, McGarry talked about the demands of simultaneously pursuing his residency and filmmaking. “It was three years of no vacation,” he said. But he said he had no regrets.

“One thing that I feel very lucky to have experienced,” he said, “is nonmedical people sitting through some pretty tough stuff in cases we show. And at the end of the film people give us a standing ovation. I wish I could share that with every physician, nurse and X-ray tech who leaves a really tough shift.”

C-booth at the old L.A. County hospital operated more like a MASH unit than a modern ER.

Posted 7/17/14