I entered the world of surgery with a desire to help those in need. Kings County Hospital is one of my hospitals, and a place where I thought I could do the most good. It is, after all, a public hospital smack in the middle of one of the poorest, most violent neighborhoods in Brooklyn. Therefore, the events of the last several days have been especially gut-wrenching for me.
The low point came when I was watching "Countdown" last night. Keith Olbermann came on television and called the psychiatric staff involved runner-up to the "worst person in the world," and this right next to Karl Rove of all people. As I stared at the screen in shock and disbelief, I thought to myself, can this hospital sink any lower?
But I should not be surprised. The problems at King's County Hospital have been festering for years.
The events that transpired with this psychiatric patient occured in the G building, an area physically separate from the rest of the Kings County campus. I myself have never been there--the only physicians there are the psychiatrists. Make no mistake however, this death could have happened anywhere at Kings County.
The County
We physicians at Kings County refer to the hospital as simply "The County." I have called it that since my intern days, and this name carries with it a certain imagery.
To me, that name first brings to mind a spectrum of patient pathologies. Due to the lack of primary care among this population, we frequently see diseases that we would never see at a private hospital. Infections that have been allowed to progress far too long. Tumors which have grown to immense sizes and caused great personal hardship before being brought to attention, because the person had no insurance and was afraid of the costs. Patients who show up to the ER in florid kidney failure requiring dialysis because of long standing diabetes or hypertension--permanent kidney damage from disease complications that could easily have been prevented had the patient seen a doctor at some point earlier in their lives.
The County is also a place of violence. In a period of relatively lower crime rates, the County often seems untouched by these trends. At times I reminisce on some of the more devastating gunshot wounds that I have taken to the operating room--the many liver injuries, the stab wounds to the heart that have had their chests opened in the emergency room, the patients that arrive with varies objects impaled on their persons. The County's name in my mind summons these survivors of the urban battlefield. The name also summons many ghosts--those that we could not save.
The County also brings to mind those people most in need in our society, those at the very bottom wrung of the social ladder. This hospital is one of the places where you feel you can really make a difference in people's lives. These patients have nowhere else to turn to. Private hospitals either won't take them or won't pay for their surgery, unless they are literally dying at their doorstep. If the doctor here chooses not to help them, nobody will.
Unfortunately, everything is stacked against the physician. The reason for this is simple: Kings County Hospital is a third world hospital. A third world hospital smack in the middle of New York City, a major metropolis in one of the world's wealthiest countries.
The things that transpired in the psych ER to this unfortunate patient, Esmin Green, could have happened anywhere in this hospital. This sort of negligence has happened before--it just happens to have been caught on camera this time.
One Word: Understaffed
The hospital is chronically understaffed. The hospital is understaffed during the day, and the problem increases a hundredfold overnight.
At night, frequently there are only four nurses taking care of upwards of 20 patients in the intensive care unit (ICU), something that should never happen in this country. In many private hospitals I have worked at, the ratio is two patients to one ICU nurse. Why should this hospital be any different?
Patients wait many months on end for their surgery, as the ORs also have a lack of personnel. There is not enough staff to run all the rooms, and with huge wait times between operations, often only a fraction of the operations for the day get done. Patients who need semi-urgent procedures are forced to wait as more urgent cases get done. These semi-urgent cases sometimes then have to be done at night, which is never optimal patient care, or they are forced to wait for the next day as an "add-on" case, and risk the same thing happening over again.
Several months ago, a patient of mine came to this hospital with a stab wound in the neck. This patient was unstable and required life-saving procedures by the interventional radiologists. Typically, ancillary staff must accompany these patients, including a respiratory therapist to work the ventilator and aid in transport, and a nurse from the ED to help monitor the patient, change the IV fluids, and administer sedation. As is all too typical at this hospital, there was nobody to help. The valuable manpower of the residents on-call overnight was used for this purpose, making them unavailable for other emergencies which may occur in the hospital. It was not the fault of nurses--there was simply too few of them to spare one to come to interventional radiology with us.
Kings County has recently built a new, multimillion dollar physical plant. Yet the same problems from the old County persist at the new site. Wouldn't the money have been better spent on hiring new, well-trained staff?
Poor Administration
In some of the services in the hospital, there are a select few staff members who are consistently lazy and careless. People who are simply working the system in order to get their paychecks, and doing very little patient care whatsoever. These people are thankfully few, but they exist.
I cannot tell you how many patients I have seen die unnecessarily, because nurses or ancillary staff have been grossly negligent in ignoring the warning signs of a patient's impending demise, whether this be in the form of a patient's altered mental status, or rapid, shallow breathing that they carelessly overlook. Sometimes the problem is that the nurses are too few and far between, or too overworked to see these symptoms. Other times, it is simple incompetence.
These people would not last five minutes at another health care institution, either public or private. It is inexplicable to me why they still have jobs. They clearly contribute to the hospital's morbidity and mortality rate.
In my mind, this is a failure of the hospital administration, all the way up to the highest level. Is it that they don't have enough money to hire other staff, and therefore can't fire the negligent ones? If that is the case, the administration should be complaining loudly to anyone who will listen. Certainly they have not implied any such thing to date. Or maybe the administration knows this is going on, but just doesn't care.
Do people have to die on camera and this footage be broadcast on national television before negligence is noticed by the hospital administration? This is beyond the pale. I am sure that the individuals who were fired, if they were really the ones to blame, had mishaps before this. This sort of thing is never an isolated episode.
Solution
The administration needs to be overhauled. It is not enough for the staff immediately involved to be fired. Those individuals high up in the administration must be made to answer for this and the long running shortcomings of Kings County. The new administration needs to keep a tighter rein on the hospital staff. This will sometimes mean making some hard decisions and letting go some individuals who probably should not be working here in the first place. This should be done by looking for efficiency, quality of care, and carefully studying patient satisfaction. It will mean no longer tolerating a two hour turnover time between cases in the operating room. The new administration also desparately needs to hire more staff, especially to cover at night.
New York City should set an example by conducting an intense, broad investigation of this and other public city hospitals in order to shed more light on the sources of these problems. Are the shortcomings from a budget shortfall, or simply a misappropriation of funds by those in charge? Are appropriate hiring decisions being made? Exactly which services are most lacking?
I still consider myself the idealistic young surgeon. I still want to help society, but even I have been frustrated by the brick wall I run into at King's County sometimes. I am a younger staff member, with little or no political power of my own. But now I have some reason to hope, that maybe some good will come of Ms. Green's death. Maybe the right thing will be done, and other deaths will be prevented.
Please Help
Kings County is run by the New York City Health and Hospitals Corporation (HHC). Send a message to the HHC president and CEO, Mr. Alan Aviles, and demand a broad investigation and meaningful change. I could not find a published number for him, but it would be great if somebody is able to find one.
Don't stop there. Complain to Mayor Bloomberg, and demand that something other than superficial changes be done. Let him know your disgust with how the system is falling apart. Mail him or call him at 212-NEW-YORK.
Thank you.