Parkland Memorial Hospital is a tough place-an oppressing, disgusting, nauseating place. There are welfare cases all around. And crazies. And dope-heads. And drunks. I heard yesterday about a 2-year-old boy. Shot in the chest. They took him there.
He’s still alive.
For some, Parkland is a godsend. This poor-people’s hospital has the largest and most-modern burn unit in the United States, excluding the military. Parkland has the largest and busiest trauma center in the United States. Parkland pioneered neonatal intensive care, and the unit there is the busiest in the region. The first kidney transplant done in the state of Texas was performed at Parkland. The hospital’s high-risk maternity unit has significantly reduced infant mortality in our area.
Parkland is horrible only for those of us who would rather not see all of Dallas. It is a public hospital; its primary purpose is to provide care to indigent citizens of Dallas County. Secondly, Parkland offers state-of-the-art medical care to paying patients from the rest of Dallas. “No one wants mediocre care,” says director of community relations Gregory G. Graze, “and anything but state-of-the-art care is mediocre. That doesn’t mean filet mignon and beautifully furnished rooms or any of the other superficial amenities. But it does mean the best technology and expertise we can find.”
In the suite of operating rooms on the first floor, the poor and the affluent come under the same knives. In the hall just outside the sterile area, a group of nurses, technicians and doctors gathers to smoke and talk and look over the blackboard where the daily schedule is written. Except for the surgical greens they wear, they look as though they could be awaiting the buzzer in a factory that would send them off their break and back to work.
When the electrical doors of the surgical suite swing open, after the men and women have scrubbed and prayed or sworn or whatever it takes for another round, they go into the operating room and begin.
“Call me, call me an-y-time. Call me;” Blondie shrieks from a speaker in a room where a colostomy closure is being done. Two nurses argue about who should be going to lunch. In the operating room across the hall, a craniotomy is being performed. The 70-year-old man, an alcoholic, has fallen and hit his head so many times that the hemorrhages in the tissues surrounding his brain have caused increased pressure. His senses are dulled. He is drowsy all the time.
The surgeons use a whirring electric drill to make a dime-sized hole in his skull. Clear fluid and then a liquid the color of motor oil seep out. The doctors and technicians talk a little among themselves. A hospital spokesman explains the meaning of their nonchalance: “Once I was in the Detroit Police Department’s criminal investigation offices. The walls were lined with pictures of various violent-crime victims-raped and strangled female bodies, the corpses of men who had been mugged, murdered and dumped into the Chicago River. Some of the officers joked about the photographs. But the chief explained to me that you have to do something to steel yourself when you see it every day. You can’t let it get through to you.”
In another of the surgery rooms, a handsome, 40ish, sandy blond-haired man sleeps while Dr. Paul Peters, chairman of urology at Southwestern Medical School, performs a vasovasostomy. If the operation is successful, the vasectomy the man had five years ago will be reversed. His chances of being fertile again are about 50-50.
Peters does some of the surgery while looking through a microscope. He will rejoin the tiny tubes of the vas deferens after the blockage that was created during the vasectomy is removed. A nurse will then smear some sperm on a slide and have the sample tested to see if it is in good condition. The longer the man has been infertile, the less his chances of impregnating his wife.
“Most guys that have this operation got married and had kids a few years ago; then they decided they didn’t want any more kids. Then they decided they didn’t love their wives much. They got divorced and married some 20-year-old. She wants kids right away,” Peters says. “The problem is, when this guy got his vasectomy, he told the doctor he never wanted children again. The surgeon made it difficult to reunite the vas . . . With the divorce rate what it is in Dallas, he should know better.”
In another room, doctors are stitching closed their incision on a gall-bladder patient. Down another hall, an oral surgeon is using a slice of bone from the bone bank to rebuild part of an elderly woman’s jaw. “She’s had hell,” says the surgeon, Dr. Robert Walker. The upper part of the woman’s jawbone has begun to recede after long years of wearing dentures. Her operation will require at least six hours of close work.
A poster on a wall of one room is of a little boy covered with lipstick kisses. “Sometimes there just isn’t enough of me to go around,” it reads.
On an average day, 486 people are admitted to the emergency room; 80 percent of Parkland’s patients begin their stays that way. The emergency “room” is in fact a cluster of about 70 treatment rooms, including six major trauma rooms, two cardiac resuscitation rooms and a special heatstroke room.
Into one of the trauma rooms on a particularly slow Friday night, paramedics wheeled Raphael. After examining him, a young doctor with a day-old beard asked his newest “hit” -his most recently arrived emergency patient -a simple question. “Do you want to die, or do you want an operation?”
The question didn’t seem so simple to Raphael. He had come to Parkland angry and frightened. He could feel the bullet sunk in his belly.
Within seconds of his arrival, Raphael was surrounded by four doctors and two nurses. There is a standard drill for treating such gunshot wounds as the one Raphael suffered. As many as three intravenous lines are inserted. To counteract racing pulse and low blood pressure, the patient receives up to two liters of a saline solution. If blood pressure remains low, nurses will also give Raphael plasma or even a transfusion of whole blood.
Raphael’s abdomen is X-rayed to find the bullet. If a bullet is lodged in a back muscle, instead of in a limb’s joint or along the spinal column, it might not have to be removed. Some surgery will be necessary in any case, however, because a bullet ripping through the body has a blasting effect on surrounding tissue. No tests or X-rays reveal the extent of such damage, and the surgeon must go in and look around.
In broken English, Raphael says that he doesn’t want an operation. Emergency-room patient coordinator Tom Ellis gently urges him to think carefully before giving up his best chance to survive. Raphael calls for his wife. Ellis finds her, tells her what is going on and leaves her alone with her husband. Finally, she emerges from the trauma room and says her husband will sign the consent form for surgery. The surgeons make ready to wheel him to an operating room and repair his stomach.
As it turns out, Raphael is lucky. The bullet has done little damage. He is out of the hospital within 48 hours.
Parkland’s emergency-room coordinators, such as Tom Ellis, or on weekdays, Gracie Vasquez, are not doctors. They hold social science degrees and, as Ellis describes it, they’re in the “Marcus Welby role.” Coordinators are paid to have time to talk with families and be on the patient’s side. Both Ellis and Vasquez are fluent in Spanish, an essential skill in making this particular emergency room run smoothly.
But “smoothly” is perhaps the most inappropriate word imaginable to use in describing an emergency room. Life is anything but smooth for the rows of people waiting in plastic chairs to see a doctor. Their maladies have been registered upon their arrivals as priority or non-priority, depending on how many more severely injured or ill patients have preceded them.
From one hallway, the patients in the waiting area hear the loud retching of a young man, the victim of a car wreck, vomiting blood. In another hall, asthma sufferers, heart-attack victims and trembling drug addicts are cared for. Two dirty little blonde-haired girls in Cinderella dresses run around the plastic chairs. A teen-age girl hugs her uncle and cries when she hears the news of her father’s heart attack. Occasionally sirens signal the arrival of what television’s Hawkeye would call “incoming wounded.” Sometimes they wander in on their own.
Gracie Vasquez is calm through all this. It is, after all, a slow day. She says she’s a Christian; she says the Lord wants her there. “At first, I didn’t know why. But it’s a great opportunity to share. To love.”
Two young white female prisoners shuf-fle through the emergency room after being treated. Their hands are cuffed; their feet loosely manacled.
One floor up from the emergency room, in the main lobby of the hospital, is a bronze copy of an office memorandum. The memo, written by C.J. Price, describes the event that made Parkland a household word that day in November 1963 -the Kennedy assassination: “What is it that enables an institution to take in stride such a series of history-jolting events. Spirit? Preparedness? Certainly. All of these are important. But the underlying factor is people. People whose education and training are sound. People whose judgment is calm and perceptive…. Our pride is not that we were swept up by the whirlwind of tragic history, but that when we were, we were not found wanting.”
It was not always so. The Harry Hines complex took a long time in coming. The first building was a two-room shack, leased for $10 a month in 1870 at Wood and Houston streets. The structure was dedicated to indigent care and quickly became overcrowded as the railroads, the county and the neighboring towns all sent their sick to this small hospital. The first city-owned structure was built on South Lamar for $1,209.05. In 1877, a second small building was added, and the city generously appropriated $28.50 for the first surgical instruments the hospital owned.
In May 1894, Parkland opened at Maple and Oak Lawn avenues. At the time, the ornate frame building was proclaimed “the most substantial, capacious, and elegant hospital in the state.” That facility was later rebuilt in red brick and eventually became Woodlawn Hospital.
One verbose journalist had this to say about Parkland in 1940: “Humming day and night with the sombre tones of tragedy and the lighter notes of comedy is the emergency room, kept fit for instant action” with “top-notch interns, residents, doctors and staff physicians.”
In September 1954, when the hospital relocated to its present site on Harry Hines, a Dallas Morning News journalist wrote that “The magnificent new building . . . represents all of the best implications of an overworked word: functional.”
The new hospital, with 558 beds and 60 bassinets, was the finest in the United States, according to many medicine men of the time. “The efficiency of the new building,” a reporter wrote, “comes through a generous use of wheels and glass,” including an entirely glass-enclosed nursery, “assuring the fond father a close look at his heir.”
But most of us, including 35-year-old Chief Executive Officer Ron Anderson, remember the days when “horrible” was the most often-used adjective in descriptions of Parkland.
“In the Parkland I grew up in, people were processed like animals. The attitude while I was on the house staff [residency] in 73 through 76 was ’we want Parkland to be adequate.’ I think the poor deserve better than that.”
And from all appearances, Anderson is committed to seeing that patient care is better than adequate. The youthful CEO, a native of Chickasha, Okla., took office January 1, succeeding Dr. Charles Mul-lins, now executive vice chancellor for health affairs of The University of Texas System.
Anderson came to Parkland as an intern in 1973 and subsequently became chief resident in internal medicine and a faculty member of Southwestern Medical School of the University of Texas Health Science Center. He also served as medical director for ambulatory care/emergency services at Parkland and assistant dean of clinical af-fairs at Southwestern. Dr. Charles Sprague, president of the Health Science Center, describes Anderson as a remark-able young man.
“He understands and knows every aspect of the hospital. When someone has a problem, Ron doesn’t have to have someone else evaluate it. He knows. He has a strong commitment to patient care and enormous vigor.”
Anderson says than when he first came to Parkland, it was viewed only as a charity hospital. It was where prisoners and alcoholics went.” The average person in North Dallas wouldn’t ever dream that he or she might use Parkland, he says, “but if you knew about all of Parkland’s programs, and if you were really sick, you would want to go to Parkland. If you were not so sick, then you would want to go somewhere else.”
Dr. Edward R. Johnson, associate professor of anesthesiology and director of clinical anesthesiology at Southwestern Medical School, is on staff at Parkland. He says the ideal would be for Parkland to be a one-class hospital, acceptable to everybody. “We don’t want anyone to feel like they have been dropped in the dregs.
“When people leave,” Johnson says, “we want them to go to cocktail parties and say ’hey, I went to Parkland and I thought it was going to be horrible, but, you know, it was fine.’ “
Doctors would like to see fewer patients arriving via the emergency room. As Anderson says, “We’re the catcher. We’d like to intervene before home plate. This will require increasing emphasis on preventive medicine, taking care of medical problems before they become full-blown emergencies. We need to go out and stop disease if we can.”
To this end, registered nurses and licensed vocational nurses at Parkland are helping with patient education at the hospital. Courses on heart disease, diabetes, hypertension and other subjects are taught regularly to show patients how to take care of themselves.
The role of satellite clinics in high-need areas is a subject of constant debate. “In the ideal circumstance,” Anderson says, “and if we had infinite resources, Park-land would run neighborhood centers. If, however, it is impossible to fund both a central hospital and the satellite clinics, you have to go with that which provides the broadest-based service, and that is a central hospital.”
In doing this, Anderson says you lose accessibility and convenience, but you have specialty work, X-ray laboratories and other things that can’t be duplicated at neighborhood clinics because of their expense.
Federal cutbacks are forcing some fundamental decisions, not just by doctors, but by elected officials as well. Community organizations want to run their own neighborhood clinics, but this has sometimes proved disastrous. The South Dallas clinic at Martin Luther King Center has been closed by the city’s Department of Health and Human Services because of gross mismanagement.
“That one clinic closure won’t hurt us at all,” says Anderson. “We could take the patient volume, but there is more involved. It’s symbolic to the community.”
Already, Parkland’s 80 outpatient clinics see more than 800 people a day. The existing clinic facility, however, sees twice as many patients as it was designed to handle.
Registered Nurse Helen Powell directs the diabetic foot-care clinic. She sees an average of 50 patients a week, all of whom, due to the vascular damage and inability to feel that can accompany diabetes, have developed ulcerated and sometimes gangrenous feet. A patient with this condition can be standing in fire and not realize it until he smells his own burning flesh.
This small clinic’s success underscores the need for human scale in a huge medical machine like Parkland. The patient-care administrators program (PCA) was begun at Parkland in early 1980 and divides the hospital into four principal areas of operation: surgery, maternal/child care, medicine and outpatient clinics, plus the emergency room. The plan allows the staff to provide more response to patients and delegates responsibility and authority more evenly.
The PCA system ensures that the ad-ministration of the hospital is operating not from an isolated and insulated office, but in the thick of intensive medical practice.
Doug Mehling, PCA for surgery, says that through PCA, overhead costs have gone up, but that physicians and patients’ families are much happier. “They can solve problems much more quickly. And people can find an administrator when they need one.”
Any hospital as large as Parkland is bound to have trouble maintaining the link between major decisions at the top and activities in the medical arena where day-to-day problems occur, says Ann Dechairo, PCA for the maternal/child care area. “With PCAs, decentralization pushes decision-making down to the people who have the information.”
With so much federal and state red tape to be dealt with, and with so many administrative and funding concerns, a hospital can easily strangle in bureaucracy. But on the 7th floor, in the neonatal intensive care unit, all the officialdom is reduced to life size. On the wall is the kind of art you would see in any nursery. But a glance at the patients lets you know how special they are.
The average weight of the babies in this unit is less than three pounds. About 40 are admitted each month to the eight-bassinet treatment center. There is one nurse for every two patients.
Over 90 percent of the babies are premature and have significant respiratory problems. Once admitted, a baby has a fighting chance to survive: 80 to 85 percent live after a stay that averages three weeks but may last as long as three months.
Most of these patients are fighting quite literally for the breath of life. Heartbeat, body temperature and breathing are monitored. An alarm sounds when a baby stops breathing – usually for just a harmless moment -or when another danger is electronically detected. An automatic ventilator provides oxygen and expands the lungs. I he amount of lung expansion is crucial. Not enough expansion, and fluids can collect and pneumonia can result. Too much expansion can pop a lung. It’s a constant battle to keep these little people alive, and the war is won more often than it’s lost.
Saving life at its inception would seem among the most noble ventures, but there is debate within the medical community about just how much effort should be expended on these newborn patients. Some doctors argue that the chances for normal development after a major medical crisis at birth are too small to warrant extraordinary care.
The results of the Parkland neonatal unit do much to debunk the “pragmatism” of such arguments (not to mention the moral issues involved). Each year, there is a reunion of “alumni” children who spent a month or more in one of these special-care nurseries. The children’s presence is the most convincing argument in support of this unit’s work.
The quality of the hospital’s staff and the care it gives are the result of a longstanding association between Parkland and Southwestern Medical School. The school and the hospital are actually wed in concrete, connected by long narrow halls that give Parkland patients immediate access to hundreds of different specialists and specialists in training.
Parkland patients are therefore often treated by nationally recognized experts in particular fields who are on the faculty at Southwestern. The school maintains a contract with its faculty members and with the hospital to provide a house staff supervised by faculty members, in exchange for use of the hospital for teaching purposes, says President Sprague. Department heads at Parkland are the corresponding department heads at Southwestern.
Silver-haired Southwestern President Charlie Sprague has seen many changes transpire at Parkland, at Southwestern and on the boards that govern the two institutions. His office, now on the 12th floor of the administrative tower at Southwestern, has not been a stranger to some high-strung political meetings.
There was a time when Commissioners Court saw Parkland as a place to provide adequate care for the indigent, nothing more. Southwestern’s doctors weren’t satisfied with this; they saw Parkland as their teaching hospital and wanted to develop there the most advanced medical treatment in the world. This implicit conflict put the commissioners and the doctors at cross purposes.
But now, Sprague says, “people realize that the more successful they are, the more successful we are and vice versa. I think the board appointments in the recent past have been absolutely great. The people are interested and committed to the hospital.”
Dr. Ed Johnson says that the commissioners and administrators formerly had certain investments in ego. “They feared Southwestern was outgrowing its parent. Ralph Rogers [see sidebar] deserves credit for bringing the two together. Southwestern is now recognized nationwide as one of the best medical schools, and Parkland is recognized nationwide as one of the best teaching hospitals.”
The medical school needs Parkland, says Sprague, because “teaching medicine requires a patient-care setting. You can’t divorce patient care from the teaching; it’s all intertwined.” Parkland, in turn, needs the medical school, Sprague continues, “because we provide enormous amounts of care for their patients. It would be a tremendous cost if they had to employ the physicians to provide the service our faculty provides without charge.”
The house staff at Parkland is made up of residents – MDs in advance training. The 350 residents provide the lion’s share of the patient care at the hospital, but they are under the supervision of medical school faculty members. Most of these young doctors come from the top 10 percent of their medical school classes. “For thirty or forty residency positions,” Sprague says, “there might be 600 or 700 applicants.”
Undergraduate medical students at Southwestern also have a part in patient care at Parkland. During a student’s third and fourth year of training he participates in a series of rotations-six eight-week periods and a series of electives – in different fields of medicine. Carlin Long, who just completed his fourth year at Southwestern, will enter an internal medicine residency in San Francisco this month. He hopes someday to return to Parkland and Southwestern, perhaps with a fellowship.
“There is no place in the country that has the quality and time for faculty teaching as in the internal medicine department at Parkland,” he says. OB/GYN and pediatrics are less supervised, Long says, but the amount of time faculty members spend supervising the students has a greater effect on how well the student learns, rather than on the quality of patient care. “Some of the faculty has been out of patient care and into academia so long that they aren’t as equipped to provide treatment as an experienced resident.”
Still, Long says, “an incredible parade of people passes by the patient at Parkland.” Residents, interns, medical students, faculty members and attending physicians all come in and ask the same questions. “The patient gets tired of having his sore belly poked and answering those questions, but this procedure multiplies their chances that some symptom will be caught that others may have missed.”
When patient care breaks down at Parkland, Long says, it is because the an-cilliary care groups (support groups that provide such services as X-rays, blood samples and EKGs) aren’t so good. “There just aren’t enough of them,” Long says, “probably because of lack of funds. The residents get stuck with the menial tasks.
“Parkland gets a raw deal, though, as far as what kind of care people think patients get. The definition of health and disease is so blurred for some Parkland patients that they simply don’t know the difference. Many of them have never known the health we know through daily showers and well-balanced meals. The stage of disease at which they present themselves at the hospital is far worse -a train wreck – compared to that of patients admitted to private hospitals. This inability to define health transcends all races.”
In a teaching hospital, there is always concern that continuity is lacking in patient care. Anderson says Parkland is now using an appointment system that allows patients to be treated by the same doctor for three years if the case involves internal medicine and until the person is released if they have had surgery. “Patients know who their surgeon is. They can have as much say in choosing their doctors as they could in a private practice.”
The Parkland-Southwestern relationship benefits the entire Dallas area by making Dallas “a sophisticated medical community,” Sprague says. Once each week in every discipline, there are “grand rounds” that highlight developments in various fields of medicine. Sprague says that a doctor might spend a year preparing for a grand rounds presentation, putting together a book-length report and compilation of data.
“Dallas is an attractive place for physicians to come to practice because they can keep on the cutting edge by participating at the medical school,” Sprague says. Of the residents who come to Parkland from outside of Texas, about 40 percent remain in Texas to practice.
Dr. Adolph Giesecke, chairman of anesthesia, began his residency at Parkland in 1960 and has spent most of his years since then at the hospital. He says he is there because he likes to teach and do research on new ideas and drugs -and, he adds, “I’m not too concerned about money.”
During his tenure, the change he mentioned first at Parkland was in the quality of food. “When I was on house staff, we staged food rebellions, the stuff was so bad. We’d leave our trays overturned in the cafeteria. It’s a lot better now, and other improvements have been made in cleanliness, ambiance, nursing care and administration.”
But the patients haven’t changed much, Giesecke says. “They’ve always been fascinating and extremely interesting. Their charts are like reading the blotter at the police station. One guy I remember had been shot six times. As we took him into surgery, right before we put him under, he looked up and said, ’You know, I think that if the guy had had one more bullet he would have tried to kill me.’ “
TAX DOLLARS are the hospital’s main source of income. Of fiscal 1981’s $102.2 million in revenue, $59.3 million (58 percent) came from Hospital District taxes levied by the Dallas County Commissioners Court. Happily, Parkland’s expenses totaled only $93.5 million, making it one of the rare public hospitals able to operate in the black.
“This is the third year we’ve had without a tax increase,” Anderson says. “We could go two more years without one if the economy stabilizes. We’ve had a seven percent indigent-load increase this year; we might have an increased demand that would change our finances.
“But I’m concerned about Medicaid cut-backs. They have increased the strain on Parkland because community hospitals that had eased the load in the past are closing due to lack of funds. Their patients come to Parkland, and we could be impaled by that. What we need is controlled growth.”
Whether controlled or not, Parkland is growing. In January 1980, Dallas taxpayers overwhelmingly approved an $80 million hospital district bond issue for Parkland. The money, to be used for expansion and renovation, will mean a new nine-story patient care tower. A new seven-story outpatient clinic. Twenty-eight new bassinets for neonatal intensive care. One hundred-ninety new beds.
Another windfall will come this year from the Crystal Charity Ball, which has designated Parkland as a beneficiary of its fund-raising gala. The $366,755 will go to provide a pediatric trauma center for the hospital. The results of motor vehicle accidents, fires, child abuse, poisonings and other accidents are considered trauma and account for half the deaths of youngsters under the age of 14. The new center will include 10 intensive-care beds and will provide money for research and education related to the treatment and prevention of childhood injuries.
Parkland has also been named one of 20 sites around the country chosen to participate in a $12 million pilot program to improve health care for high-risk young people. The program, sponsored by the Robert Wood Johnson Foundation, will combine health and social service in hopes of reducing the incidence of venereal disease, teen-age pregnancy, substance abuse, accidents, homicides, suicides and mental illness among young people between the ages of 15 and 24.
With these projects, plus the $80 million expansion, under way, Parkland is a survivor while in other cities, public hospitals are dying. Philadelphia General Hospital, for example, is gone, the victim of poor planning and inept political maneuvering. Anderson says that “Philadelphia made the mistake of thinking clinics could supplant a hospital. It didn’t work. The clinics failed to develop and the poor in Philadelphia were left without medical aid.”
Among hospital administrators around the country, there is much discussion about the impact of federal aid cutbacks. What happens to the people who can’t afford medical care? Their health in many ways depends on the fiscal and operational health of public medical institutions. Some worry also that the current expansion will require more support dollars than Parkland can afford. Even so, this is one of the few successful public hospitals in the nation. It may be the best.
Parkland does have much to crow about. But it also has a long way to go. “With all our expansion, we’re not trying just to build empires,” Anderson says. “They built great pyramids with nothing in them but mummies.”
So Parkland looks ahead, threatened byfederal cutbacks and an economy thatcould deliver more patients to the hospital’sdoorstep than it can possibly handle. Undaunted and building for the future,Parkland goes about her business of athousand daily dramas.