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A night in the life of KMC's ER

BY EMILY HAGEDORN, Californian staff writer
e-mail: ehagedorn@bakersfield.com | Friday, Feb 29 2008 5:41 PM

Last Updated: Saturday, Mar 1 2008 11:14 PM

“Ow! Ow! Ow!”

The disoriented middle-aged woman yells every time someone touches her, trying to find the cause of pain.

They lob questions at her.

“Does this hurt?” “Do you know why you are in pain?” “Can you understand me?”

A nurse pokes her toes.

Lying strapped to the gurney, her angry and bewildered refrain is the same: “Ow! Ow! Ow!”

The woman is another puzzle among many for the staff at Kern Medical Center to figure out.

The county hospital is the safety net for people throughout the southern part of the San Joaquin Valley, a place where the uninsured and underinsured flock for answers and care.

And KMC’s emergency room is ground zero for the worst of the worst. Victims of car wrecks, shootings, stabbings, rapes, heart attacks and major infections — along with people who need basic medical care — are taken to the 23,547-square-foot swath of tile at the northeast side of the hospital.

KMC’s trauma center — the network of specially-trained emergency room, operating room and intensive care unit nurses and physicians who are ready at a moment’s notice — is the third busiest Level II trauma facility in the state, according to the state Emergency Medical Services Authority.

“You’ll see everything that you read in the textbooks in this hospital,” says Dr. Artin Massihi, senior medical resident in the emergency department. “And these are just everyday people.”

This particular night, Feb. 15, isn’t especially busy, but it does come with its share of patient concerns and emergencies.

4 p.m.

The emergency room staff is rushing to treat a patient whose heart has stopped.

They’ve also done some medical clearances of people arrested by law enforcement and people brought in for psychiatric issues. There have been a few assaults, some overdoses and pediatric cases, says Dr. Manish Amin, the attending physician, to whom the medical residents report.

Overall, a slow start.

The waiting room, at about half capacity, is equally mellow.

“I might be miscarrying,” says Sylvia Abrigo, 21, who is sitting in a corner with her sister, at 4:45 p.m. The pair have been waiting for over an hour to get into the ER.

Across the aisle, Gina Delafuente sits with her 74-year-old mother, Virginia Benavides. Benavides was at KMC earlier that week for an infection. It took four hours to get into the emergency room, and they didn’t leave until 3 a.m.

Her symptoms haven’t diminished, and an urgent care center told them to go back to the hospital, Delafuente says.

5 p.m. Amin stands by the large dry-erase board nestled between two large nursing stations.

Patients’ names, bed numbers, ailments and other pertinent information are listed on the board, along with the initials of the resident who treats them.

Patients who haven’t been assigned a resident yet have big plastic magnetic numbers, the kind typically seen on refrigerators, next to them.

Amin goes back to his office, ready to respond to residents who might need him. KMC is a teaching hospital affiliated with UCLA. Twenty-one emergency medicine residents go through the program.

And considering the revolving door of students, the physicians must be up to date on the latest information, he says.

Patients will see at least two physicians during their stay — the resident and attending. This sometimes slows the pace of people getting into the ER and discharged, but it also means there are more eyes on a case, he says.

“I like to say it’s controlled chaos,” Amin says. “At first I was very nervous because you see so many patients that are in, at times, very dire circumstances. But I’ve realized you just have to focus on the task at hand.”

The 35-year-old physician grew up in Bakersfield and “swore I was never coming back to this podunk town,” he says with a laugh. But after completing his KMC residency in 2003, he decided his skills best fit KMC’s ER.

“Maybe we can’t offer them a fix for their cancer or we can’t offer them something that will change their situation, but at least we can sit and we can talk to them and have them understand what’s going on,” he says.

Dr. Len Baker, a second-year resident, sits down across the desk from Amin.

A young man was brought to the emergency room after trying to commit suicide by swallowing two handfuls of Coumadin, a blood thinner that was originally developed as a rat poison.

“He has no qualms about killing people,” Baker says. “I asked if he would kill me. He said, ‘Yes.’”

The two physicians share an awkward laugh, and Amin goes to visit the patient, Adrian Wnuk, 28.

“It’s going to hurt you three days from now,” Amin tells him.

Wnuk understands. He sits Indian style at the end of Bed 13, facing a nursing station. The California City resident is stiff and stares at people who pass.

“It makes you bleed internally until you pop like a zit,” Wnuk says. He will have to be monitored over the next few days.

6:15 p.m. During a lull, Amin and some residents go to the cafeteria for dinner.

“I was going to give up going to the cafeteria for my New Year’s resolution,” Amin says, carrying a tray of fajitas back to his office.

He sits back at his desk, as some of the other residents relax and look up sports news on computers. The room is small, barely holding the desks, computer stations, lockers and bookcase, which carries a fraying Gray’s Anatomy textbook published in 1950.

“I think it’s more sad than anything else,” Amin says, of the uninsured people who come to the hospital for care. “It lets you know how fortunate you are.”

Roughly 50 percent of the cases Amin sees could be treated by a family physician, he says. According to UCLA’s 2005 California Health Interview Survey, almost 16 percent of Kern County residents — 118,000 people — are uninsured, including 31,000 children.

And considering KMC is the catch-all for trauma from the Fresno County border to Los Angeles, from the coast to the desert. The hospital sees everyone, rich or poor, despite being only a Level II center.

Designated by the county Emergency Medical Services Department and the American College of Surgeons, KMC is lacking the burn unit and cardiac surgery capabilities needed to be Level I.

But that doesn’t mean the hospital doesn’t get people with those needs. It’s the only trauma center for almost 100 miles around.

Amin likened KMC to a transmission shop. “It says it’s a transmission shop, but you can go get your tires done there too.”

7 p.m.

Virginia Benavides, the woman with the infection in the waiting room, is led back to a room. She’s been at KMC since before 3 p.m.

Dr. Edward Lin, a third-year resident, is on his way to see a patient with a rash.

Forty-year-old Darryl Bateman, of Bakersfield, holds his right arm tenderly until Lin stretches it out for a better look.

A yellow dime-size sore pops out from the crook in his arm. The skin around it is red and waxy. “Have you been in a hospital recently?” Lin asks.

Bateman was at KMC a few days before, when the rash took up most of his arm. Now he’s back for more antibiotics and pain medicine.

Lin puts gel on an ultrasound probe and rubs it up Bateman’s arm, looking for puss to drain. “Have you heard of staph?” Lin asks. “That’s probably what it is.”

Staphylococcus aureus, or staph, is a common bacteria that can cause infection. The drug-resistant form of staph, known as MRSA, is harder to treat and can be life-threatening (a Bakersfield teen died from an MRSA infection a couple of days after Bateman’s night in the ER).

Dr. Royce Johnson, KMC’s Department of Medicine chairman and infectious disease chief, has called MRSA’s incidence an epidemic. On any given day, 10 people are treated at KMC for MRSA. Bateman gets some more Bactrim, which treats MRSA, and pain medicine.

About an hour later, Sylvia Abrigo, who worries she’s miscarrying, is taken to a room in the ER.

9 p.m. A Code Blue is called, which means a patient has no heart or respiratory rate. A flurry of people rush up three flights of stairs.

Amin runs, his thin yellow jacket flapping in the breeze he creates.

The patient suffers from respiratory failure; about seven people rush around the bed.

“Can you lower the bed please?” “Can you feel a pulse?” “Has it been two minutes?”

ER physicians respond to any code blue called in the hospital.

Dr. Christopher Dong, another attending physician, beats Amin to the code. Amin leaves the scene. A nurse is over the body doing compressions.

10 p.m. “There’s a guy complaining of a pimple on his cheek in one of the rooms,” says registered nurse John Pipes, in his thick Louisiana drawl. “I have a baby with a 105-degree fever. I need the room.”

The pimple man came because he thought the blemish was MRSA. It’s not.

Pipes and his wife are traveling nurses, part of a cadre of nurses brought in from other states and even other countries to fill gaps left by the nursing shortage.

Roughly 90 of the 470 KMC nurses are travelers, who cost more to employ, says Toni Smith, director of patient care services, a couple weeks after this night at the hospital.

12:30 a.m.

As the night goes on, more law enforcement officers grace the ER, standing sentry over rooms housing sick inmates and arrestees.

“You’re violating the rule of God Almighty,” an elderly man rants from the psychiatric side of the ER as nurses chat at the desk. “This is a totalitarian government.”

The night has been unusually light. Maybe Valentine’s Day sobered people up, some residents joke. In one of the trauma bays, Gregory Swain stands by his wife, Carolyn, the woman who repeatedly yelled

“Ow!” earlier that day.

Lin and other physicians have several quandaries to answer.

“Is she diabetic?” “Could a bleed in the brain be causing her condition?” “Could it be something with her thyroid?”

Gregory Swain strokes her forehead. The two came to Bakersfield to visit her father. She seems more subdued now, smiling even.

The couple live in Mesa, Ariz. Gregory Swain drives a non-emergency ambulance van, which is how they met.

“I fell in love with one of my clients,” the 57-year-old says.

Carolyn Swain, 59, is later diagnosed with spinal meningitis, according to her husband.

The hum of machines, drone of chitchat and beeping of monitors create a haze where time speeds by or stops, depending on the day.

Always ready for the next emergency that walks through the door, the staff continues rushing from patient to patient, into the night.

ER wait times

Some people heeded a recent official request to avoid local emergency rooms for minor illnesses, a county official said Friday.

But that effort was short-lived.

Local hospitals are now back to the “normal level of crazy,” said county Department of Emergency Medical Services Coordinator Paula Isbell-Caughron.

On Feb. 13, EMS sent out a release saying local hospitals were overloaded and that people should try to treat flu-like symptoms at home.

“It seemed to definitely improve the next day and then creep back up,” Isbell-Caughron said.

The local hospitals are “always overloaded” with all beds full, but they’re currently not at the crisis level seen in mid-February, she said.

Expect to wait several hours to get inside an emergency room, she said.

The February announcement made a difference the following day or two at Kern Medical Center, said Dr. Rick McPheeters, an emergency medicine physician.

Some patients were expected to have to wait four hours to get into KMC’s ER on Friday, he said. McPheeters doubts the flu was the reason behind the onslaught of patients.

“Our hospital systems are just overloaded in Kern County,” he said. “Our hospitals haven’t expanded enough to accommodate the population.”