ER drama offers glimpse into Gary health system

GARY — The Gary Fire Department ambulance delivers a patient shortly after 9 p.m. and his arrival ignites a whirlwind of activity in the emergency room of Methodist Hospital's Northlake Campus. 

Like a burst beehive, doctors, nurses and technicians buzz over the patient, a 40-something black man who is paraplegic. The patient’s sister unintentionally scalded the skin on his legs while bathing him, not realizing how hot the water had become. The ER staff gently removes his burned skin, which peels off like sheets of wet paper. He is silent and his face betrays no emotion. Dr. Nicholas Johnson, a preternaturally calm board-certified emergency physician, observes his crew caring for the man.

Johnson said because of his paralysis, the patient probably didn’t suffer any pain and didn’t realize anything was wrong until he noticed the skin fleeing his legs. The patient is surrounded by two physicians and four nurses, who insert tubes to hydrate him and administer pain medication.

“All we can do is clean and stabilize and transfer him to a higher level trauma center,” Johnson said.

That’s because even though Methodist offers highly skilled emergency care, this patient requires advanced trauma burn treatment found only at Level I and Level II Trauma Centers, none of which exist in Northwest Indiana. The ER staff contacts the trauma center at Loyola University Medical Center in Maywood, Ill., which agrees to accept him and dispatch a helicopter. However, heavy snows make flying unsafe and ground all transport flights. Methodist switches to Plan B and soon a new high-tech ambulance from Prompt Ambulance speeds him to Loyola.

On this blustery winter night, there are no gunshot or stabbing victims to treat, an otherwise common occurrence in this ER. The Northlake ER treated 235 blunt force or penetrating trauma victims in 2007, including 111 gunshot victims, 49 who were in vehicular accidents and 18 stabbings. In 2008 that total trauma figure rose to 300, 111 of whom were gunshot victims and nearly double the number of vehicular accident patients over the previous year. Acute asthma was the most common diagnosis for patients coming to the ER last year, but chest pain and heart failure were the most common reasons ER patients were admitted to the hospital, according to Methodist ER records.

A retinue of the usual suspects arrives at the ER: two children with fever-induced seizures, a kidney failure patient who hasn’t been to a dialysis center in more than two weeks and a child nearly killed in a fire. There are stroke and heart failure patients as well as those seeking treatment for colds and flus. The 25-bed ER also includes a psychiatric holding room. A Gary police officer stands watch on the overnight shift.

Hospital couldn’t exist without ER

For many Gary residents and other patients, Methodist’s emergency department is the gateway to the hospital. Methodist’s ER also serves as a primary care physician to many of Gary’s poor and uninsured patients who have no family doctor and lack access to primary care and preventive services. The department recorded 30,031 patient visits in 2009, an increase of nearly 300 over the previous year, according to Methodist figures. The emergency department, once the busiest in Northwest Indiana, continues to serve some of the sickest and neediest patients in the region, handling more gunshot, knife wound and violent trauma cases than other area ERs, along with the chronically ill.

The ER also produced $23.6 million in revenue, nearly 7 percent of the hospital’s total revenue. More important, it accounted for nearly 60 percent of the Methodist Northlake’s inpatient admissions. The hospital could not exist without it. Methodist’s ER also serves as a primary care physician to many of Gary’s poor and uninsured patients who have no family doctor and lack access to primary care and preventive services.

As the night wanes, the inclement weather begins to claim its own casualties, and fire department paramedics wheel in a patient who crashed his car into a concrete lane divider along Interstate 94. He arrives moaning incoherently, waving his arms as if swatting imaginary flies while the ER staff cuts off his clothing. He has suffered severe chest trauma from the impact of the collision, which drove his car’s engine into the cab, snapping the steering wheel and cracking his ribs. Bloody cuts and abrasions pepper his chest.

An Indiana State Police officer who was at the scene said the man was excised from the car by the jaws of life. A nurse asks his name and where he feels the pain, requesting he wiggle his toes. “I’m pinching your toes, can you feel that?” He seems oblivious to their questions and cries out in anguish.

ER physician Johnson observes as a second year Northwestern resident directs more questions. Nurses ask his age, height and weight and whether he has had anything to drink. He winces and continues to gyrate his arms and legs spasmodically. The state cop asks if he can speak to the victim, and Johnson responds that he has only a minute. The patient refuses to say he was drinking and declines an alcohol test, though that refusal would constitute a traffic violation. The staff spreads a cold, blue jelly on the man’s chest before applying wire connections for an electrocardiogram. Soon after a team from the hospital’s imaging department applies a portable ultrasound machine giving the medical staff a better look at what’s happening inside the patient.

The staff reads off monitor results and comments on the ultrasound images. “His spleen is the size of a football,” one notes. He is administered a tranquilizer and pain medication through the tubes in his arms.

The man is naked, vulnerable and now blessedly still and quiet. The team of seven prepares him for a ventilator and suctions fluid from his lungs. Tears trickle from his closed, unconscious eyes. The 45-year old man is transferred to an operating room for surgery and taken after to the intensive care unit.

You need ‘the right kind of heart’

Emergency Department Medical Director Dr. Michael McGee, a Gary native who returned to his hometown after ER physician stints in Atlanta and New York City, said: “You have to have the right kind of heart to be here,” he said. “We (Methodist’s ER) don’t have all the resources that some area hospitals have. There is not a lot of excess staff here.  But we have some of the best physicians in the area working here now, well-trained physicians who wanted responsibility and were invested in this community.”

McGee hired nurse managers he said bring dedication, strong clinical backgrounds and good customer service skills. “That’s even more important now because the emergency department is also a business, and we have to exemplify strong customer service.”

Rhonda Sonson, Methodist’s director of critical care and emergency services, said many ER visitors have a choice.

“We’re trying hard to improve the process and experience. We’re timing visits, cutting out inefficiencies, measuring customer perceptions of the physicians, nurses and lab testing. It’s all about evidence-based practices and clinical initiatives, measuring the time from the door to the procedures to see how we meet national benchmarks. To the community it should be seamless.”

Methodist ER nurse Detra Hernandez of Michigan City said the patient volume this winter evening was steady. “We usually don’t say the word quiet,” she chuckled.

Hernandez, who served as a U.S. Navy corpsman and emergency medical technician in Spain, Florida and Virginia, joined Methodist seven years ago.

“You have to be a solid nurse to work in the ER,” Hernandez said. “You have to have a strong backbone. You have to be ready for anything that comes through those doors and you can’t second-guess yourself.”

Frequent fliers, also known as Friends of the ER, are patients whose names and faces are familiar to ER staff, typically those with chronic conditions like diabetes, asthma, obesity and high blood pressure. Hernandez said sometimes based on the ambulance driver’s call describing the patient symptoms the ER staff can guess who’s coming in.

She said it’s frustrating sometimes to treat the same patients because she knows many lack insurance and can’t afford the medicines they need, meaning their conditions will deteriorate and they will likely return to the ER soon.

“Some people have a mindset that they can come to the ER and get treated for anything,” she said. “They forget it’s called an emergency room for a reason. We’ve had some people call EMS (an emergency ambulance transfer request) for a hangnail. We can’t refuse them. We try to change that mindset, but it’s hard.”

Hernandez said reform is needed to broaden access to care.

“If we don’t change something soon, our health care system is going to hit a brick wall.”