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Hospitals sound ER alarm bell

Attack lends urgency to overcrowding concerns

(Published September 24, 2001)

By JOHN DeVAULT

Staff Writer

It could have been much worse — and, next time, it might be.

That’s the consensus view from emergency room officials around the city after the Sept. 11 terrorist attack on the Pentagon.

"We were lucky there were as few victims as there were, though unlucky there were so few survivors," said Robert Malson, head of the D.C. Hospital Association.

Of the 95 casualties of the terrorist attack who were treated at hospitals in Virginia, Maryland and Washington, D.C. hospitals treated 28 people.

"Our hospitals were waiting for victims that never came," Malson said.

Yet already, D.C. emergency room planners are looking to the future. Next time, they say, reports of a plane headed for the U.S. Capitol building might be accurate.

And D.C. hospitals say pressures from the closing of D.C. General Hospital in July make them ill-equipped to deal with a major citywide or regional catastrophe.

Troubling signs appeared even before the Pentagon attack: Emergency rooms have been overflowing all summer, long before the typically frantic winter flu season. Staff shortages have worsened the overcrowding.

Now, as they look toward an uncertain future, some emergency room chiefs are again questioning the city’s decision to close D.C. General, the city’s only full-service public hospital.

That move, they say, took needed beds out of a system already straining to keep up with demand. It closed the only trauma center in Southeast Washington — and the nearest hospital to the Capitol.

Malson, whose organization represents the interests of the city’s hospitals, called for leaders to look at the possibility of re-opening the hospital.

"If we now know that there are bad people operating out there, I think our city and federal leaders are going to have to deal with the question, ‘Does it make sense not to have D.C. General’s trauma center at a location 19 blocks from the U.S. Capitol?’" he said.

Even before the attack, hospitals citywide had seen an increase of 30 percent in their numbers of patients at emergency rooms since D.C. General closed, according to Dr. Margaret Barron, chairman of emergency medicine at Providence Hospital in Northeast Washington.

"We had people on breathing machines backed up in the ER in August, waiting for an intensive care bed upstairs," she said. "We never used to see that at this time of year."

Dr. Mark Smith, head of emergency medicine at Washington Hospital Center, whose burn unit treated most of the seriously injured Pentagon victims sent to D.C. hospitals, concurred.

"There’s no question that city-wide, emergency rooms have been running full," he said. "We have, Georgetown (University Hospital) has, everybody has. People are waiting in emergency rooms for beds to open up upstairs."

Barron said that waiting time at Providence’s emergency room has more than doubled in recent months. "On a bad night in the past, a patient might have waited two or three hours," she said. "Now it’s six or eight hours or even longer."

On some nights, Barron said, when it becomes clear that some patients might have to wait all night before getting care, "We go out at midnight and ask if people with non-critical injuries are willing to leave and come back the next day."

Planners say the crunch will affect the city’s ability to deal with both disease epidemics and terrorist attacks in the future.

"If we have a flu epidemic this winter, we could have a real public health crisis," Smith said. "Because right now, the system has no margin."

Said Malson, "There could have been a lot more victims in the attack two weeks ago, and if there had been, we would have been stretched."

Opinions differ on reasons for the current stresses on the system, but several observers noted the D.C. General closing.

"It was a mistake to take that many beds out of the system all at once," Smith said. "I think the effect of D.C. General’s closing will be to reduce our ability to handle surges from seasonal variations, epidemics and from disasters."

Smith especially noted the loss of D.C. General’s critical care beds.

"As you take beds out of the system, you tighten things at the margins," he said. "And right now the system has no margin."

He argued that in today’s circumstances, the loss of D.C. General’s beds — slightly more than 10 percent of the city’s supply last year of 242 intensive care beds — could have a real impact on the city’s ability to deal in future with crises of all types, including a terrorist attack.

"Certainly, it’s one fewer hospital close to the Capitol, and one fewer hospital to bring people to in a disaster," he said.

Nonetheless, he emphasized that he believes his hospital’s emergency facilities could have handled a bigger casualty load than they saw two weeks ago.

Washington Hospital Center normally sees about 200 emergency room patients a day, Smith said. "I have no question that we could have handled at least 300 patients," he said. "We could have handled what St. Vincent’s (Hospital) did in New York" after the World Trade Center towers were attacked, he said.

Barron called the closure of D.C. General the main reason for the recent emergency room overflows at Providence.

The number of self-paying patients without health insurance at Providence has increased by about 50 percent since D.C. General closed, Barron said. Self-paying patients now account for about half of emergency room visits, up from about 30 percent earlier this year, she said.

And, she said, the biggest increase has been in ambulatory patients — patients who, if they had health insurance, would probably take their problems to a doctor, not a hospital. She said those facts indicate that most of Providence’s increased patient load resulted from D.C. General’s closure, since the public hospital was the main source of medical care for many of the city’s poor citizens.

Barron says she blames the current citywide crunch on Mayor Anthony A. Williams’ administration’s failure to foresee the impact of closing the city’s only public hospital.

"Ivan Walks got up at many public meetings and said that closing D.C. General would not add patients at our emergency rooms," Barron said. Walks is the Director of the D.C. Department of Health.

"We said, you’ve got to be kidding," Barron said. "When patients complain about the wait time, I’ve been giving them Ivan Walks’ address," she said. "I tell them, ‘Write to this guy.’"

Walks acknowledged that emergency rooms have been getting patients who used to go to D.C. General. "We have trauma centers, and especially emergency rooms, bursting at the seams," he said last week.

But he blamed opponents of the D.C. General closing for at least some of the spill-over from the network of health care facilities that contracted to take D.C. General’s patients. "They’ve been scaring patients," he said.

He said the city continues to operate a non-critical care medical center at the D.C. General site, but some patients are avoiding using it. "The critics spread the word that it wasn’t reliable," he said.

Nonetheless, he said that Providence and other hospitals should be reimbursed for their added patient load. "There’s money for that in the budget, and we’ll be discussing that" with area hospitals, he said.

Barron said the absence of D.C. General’s facilities during a future terrorist attack would likely have its greatest impact on residents around the Capitol and in Southeast Washington.

Citywide, she and others pointed out that extra beds at area military hospitals, such as Bethesda Naval Hospital, would no doubt be pressed into service in a general emergency.

"But if a plane had hit the Capitol, yes – the capital would have had a problem," Barron said.

And the impact for residents east of the Anacostia River would be even greater, she said. "At least people at the Capitol could get to Washington Hospital Center or Howard," she said.

"But say (the terrorists) had aimed for the Capitol and missed," she said – and struck the residential and commercial neighborhoods just across the Anacostia River. "The problem would be even moreso for those people. It’s a long haul down to Greater Southeast (Community Hospital)."

Greater Southeast, the only remaining hospital in Southeast, is located at the far southern tip of the District along the Maryland border. Greater Southeast leads a network of hospitals and other health-care providers that contracted with the mayor and the control board, over the city council’s objections, to take over services that previously had been provided to the city’s poor and uninsured residents by D.C. General.

Smith noted that D.C. General had the only trauma center in all of Southeast Washington. "We’re leaving a whole area of town without trauma care," he said.

But Walks argued that trauma centers don’t need to be located in the neighborhoods they serve. "Distance is not the issue," he said.

He said that most cases of major trauma in children in Washington are sent to the trauma center at Children’s Hospital, regardless of the child’s original neighborhood.

"Skill is the issue, not distance," he said.

Walks also rejected the idea that closing D.C. General might hurt the city in a future, more devastating terrorist attack.

"The D.C General closing had absolutely no impact on what happened (two weeks ago), and it would not affect us adversely in the future," he said.

Lack of beds and hospital space would not be a problem, he said. "In a mass casualty situation, anything becomes a hospital — a school, a gymnasium," he said.

He said that after the Pentagon was attacked, the city set up an extra 35 beds at an in-patient detoxification center currently operating at the former D.C. General site.

Nor, said Walks, would staff shortages hurt a future response. "We’d bring in people from outside," he said.

Walks said New York City’s experience last week provided an example. "We’d have people in droves, doctors volunteering to come in, like they did in New York," he said.

Finally, he said, no matter what preparations the city made, a significant terrorist attack would overwhelm them.

"A large attack or other disaster would overwhelm our system no matter what we did," he said. "Nobody was prepared for what happened last week."

Smith and others pointed out that another factor — staff shortages — is also contributing to the current emergency room crunch.

Dr. Robert Shesser, head of emergency medicine at George Washington University, said staff reductions are a more important factor in local emergency room overload than the closing of D.C. General.

"I don’t believe this is a capacity problem. It’s a staff problem," he said. "We’ve had management consultants come in and give us staffing benchmarks that don’t give us any margin. The redundancies that formerly were in the system have been eliminated, so whenever we have an unexpected event, it’s going to stress the system."

Said Malson, "We’re living in an era of managed care when most of the margins have been squeezed out of the system."

Shesser said that a further factor in staffing shortages may be an American economy that, until recently, was strong enough to lure nurses and other health care workers such as radiologists and pharmacists into better-paying jobs.

That problem, he said, may ease if the economy weakens. "In an economic downturn, people always come back to health care jobs," he said.

Still, Barron said that she could see no relief in the near future from the overcrowding at Providence’s emergency room.

"Unless I put in bunk beds," she said, "there’s nothing I can do."

Copyright 2001, The Common Denominator