A Night in the Tub
This definitely wasn't the planned destination for the evening. On the bed across the ward from me, two men in white were forcibly catheterizing a very drunk, very beat-up Hispanic guy who kept shouting, "Man, I'm pissing on myself!"
"No, you're not," one of the interns replied in a sensible tone. "You've got a tube up your penis. It just feels that way."
My view of that encounter was somewhat limited -- watching only out of the corner of one eye. Trying to turn to follow the action was futile, because my head was immobilized by a neck brace. But that hardly kept my ears from picking up the yelling protests.
"Man, what am I doing here!" repeated the patient, who had been strapped down after trying to take an unauthorized stroll through the ward a few minutes earlier. "What the fuck am I doing here?"
It was the same question I'd been asking myself for the last six hours or so at Ben Taub General Hospital. Bicycle rides invariably make me feel better at the end of the trail than at the beginning. And this one hadn't quite worked out that way.
The hike-and-bike trail along Buffalo Bayou looks like a ribbon curling through a verdant park, a six-mile loop of gravel, sand and asphalt that veers back and forth from the curbs of Allen Parkway and Memorial Drive down to the banks of the waterway. Swooping along the course on a ten-speed bike almost always drains the sour tension of a workday in a setting that seems far removed from the center of the metropolis.
Nearing the end of the loop on the evening of July 10, I leaned forward on the handlebars into a favorite downhill sprint just past Eleanor Tinsley Park. Whatever happened next became only a blur in the memory -- a jolt, an instantaneous sensation of flight, and the abrupt ending in a paralyzing hammer blow.
The bike's front wheel apparently jammed into a rut on the trail, flinging me forward over the handlebars and slamming me face first into the ground. A helmet protected the scalp, but the impact splintered my wire-rimmed glasses into the right brow. The lens sliced through the forehead and, according to one bystander, exposed a shiny patch of white skull.
Without even trying, I'd joined a disturbing new national trend: increasing numbers of cyclists suffering severe head injuries despite the use of protective headgear.
Within seconds, a couple out for an evening stroll raced over and took charge. Nick Miller, an off-duty medic, used the bike helmet as a cushion to keep me immobile. Scholastica Carter, a community college student and young mother who lives in the new Allen Parkway Village, flagged down a jogger to get water and make a cell-phone call for an ambulance.
The emergency ride recalled old memories of an autumn evening in 1988. While jogging on the same trail, I had encountered a slithery yellow, red and black character who bit the hand that picked him up. The mugger, who also went by the name East Texas coral snake, accompanied me in a tennis ball can on the ambulance trip to the hospital -- though he fared a lot better afterward.
The snake got a private room at the Houston Zoo reptile hotel. After processing through the emergency room and ICU at Ben Taub, his human victim spent a night in a public ward that could have doubled as a set from Snake Pit. A disoriented gentleman strapped down several beds away ranted about razor blades for most of the night, guaranteeing that the ostensibly sane patients around him got little sleep.
However, much had changed since that episode 13 years ago. Just getting into Ben Taub was no sure thing, an EMS team member told me as we rode to the hospital. On two previous passes earlier in the day, the medics had been diverted to other facilities.
The reason for the rerouting was obvious: patient overload. A month earlier, Tropical Storm Allison had decimated Memorial Hermann Hospital and other mainstays of the Texas Medical Center. My routine exercise break had suddenly turned into a ticket into the post-flood Houston health care morass. The next 14 hours provided a patient's-eye view of the high and low points of an ER stretched to its limits.
Ben Taub is a little bit like that old definition of home -- the place where when you have to go, they usually have to take you in. It's also deceptive. A trauma victim spends his or her first hours at "the Tub" in the chilled atmosphere of a world-class emergency complex surrounded by a medical team working with military precision.
Unfortunately, that first impression doesn't last long.
Lesson one about Ben Taub: After being stabilized, any accident victim with medical alternatives should use them and get the hell out. As patients get better and move down the priority list, the quality of care goes down as well. Before long, those who can walk are begging to be released.
Back in 1988 I had the opportunity to transfer to a private hospital. But fooled by the high quality of the Ben Taub emergency room, I didn't relocate -- and wound up in that Snake Pit ward.
This time around, I couldn't follow my own advice. In the flood-ravaged Medical Center, there was simply no place else to go.
Amazingly, during the aftermath of the June 9 deluge, Houstonians seemed to respond to appeals from the medical community not to get hurt. The number of patients treated at the Ben Taub emergency facility actually dropped in both June and July compared to the previous year. But the number of trauma and surgery cases rose, primarily because the Hermann facility next door -- Houston's only other top-tier trauma center -- had been flooded out. From 2,220 the previous June, those serious cases admitted to the Ben Taub ER rose 16 percent to 2,575. In July the numbers were up from 2,533 to 2,603, including me.
The Harris County Hospital District is often described by the media -- and treated by politicians -- as if it were strictly a medical system for the indigent. Yet the inner city continues to redevelop with middle-class, highly insured folks taking to the jogging trails and sidewalks of streets that were urban battle zones after dark only a few years ago. The result is that just about anybody -- regardless of income -- can find themselves heading to the Ben Taub ER.
If it could be done painlessly, I'd prescribe a night in the Tub for Harris County Commissioner Steve Radack, a frequent critic of the hospital district, and all those pricky Young Conservatives so gung ho to cut off "illegal socialized medicine" to undocumented immigrants. My unanticipated visit drove home the point that funding good public health care is not strictly an altruistic proposition.
When President George W. Bush comes to town, he has first call on an operating room and an ICU bed at Ben Taub. And while their lives hang in the balance, trauma patients get that same presidential treatment.
When the medics unloaded me from the ambulance onto a stretcher and rolled me into one of the five ground-floor shock rooms, an eight-person surgical team was ready, one of three rotating units that staff the facility 24 hours a day.
First came the quick evaluation and cleaning of the head wound. Then it seemed like only minutes before needles were stabbing along my right brow, cheek and ear, deadening the way for what would be at least 42 stitches. The chief of the surgical team on duty, Francis Paul "Trip" Buckley III, took on the particularly messy and potentially disfiguring main wound over the right brow. That gash was the worst I've suffered in 54 years on the planet, although Buckley later described it as "run of the mill" for Ben Taub.
The sewn-up gash came out shaped like an inverted Y, with the bow creating a sort of second eyebrow highlighted by an exclamation point. I listened in a fog as Buckley instructed several junior residents in the fine art of tightening up the wound and quilting the flaps without leaving any space.
After complaining of pain, I got a shot of Toradol, an anti-inflammatory that didn't have much effect. But for a while, the shock of the injury seemed to be numbing enough. After garnering a few compliments from colleagues for the sew-up, Buckley moved on to other matters, and a junior resident stitched up the remaining cuts to the cheek and ear. Within 45 minutes it was finished, a first-class surgical treatment and a quality of medical care rivaling anything available in Houston.
As the doctor applied the finishing touches, I tentatively suggested that now might be the time to transfer me to Hermann Hospital next door. Chuckles sounded around the room. Hermann had been closed nearly a month.
As an attendant wheeled me out into the ER holding area, Ben Taub had shown the best it had to offer. Then came the rest of the night -- and a very different experience.
The subject of painkillers never surfaced again. I lay immobilized in a neck brace, looking up into a bright light from a portable bed in the ground-floor ER holding area. An ombudsman for patients took a message to pass along to my friends. They immediately came to Ben Taub but were bounced from one section to another. No one seemed to know my location.
I was ready to hit the streets but couldn't receive clearance without the completion of diagnostic X-rays and a facial CAT scan. First up was the scan, but apparently there was a long waiting line.
Around 10:30 p.m., a friend found me in the holding ward. With a growing sense that a very rough night lay ahead, I told my pal to go home and get some sleep while I prepared to tough it out. Ahead were 12 hours mostly spent in the neck brace and on my back.
Sometime after 1 a.m. I managed to get a cup of ice from the only nurse on the floor who seemed motivated to do anything more than take periodic blood pressure and temperature readings. Her name was Grace Hernandez. What's not so surprising is she was a visiting nurse on a short-term contract out of Chicago. Apparently she hadn't been around the Tub long enough to absorb the culture, a hands-off tough-love approach. Grace even struck up a conversation, soliciting directions on how to get to Garden in the Heights for Latino Night.
As Grace explained it, she's engaged in a rather unconventional tour of the United States via short-term nursing contracts. Her next planned stop was San Antonio.
At that point the large, belligerent, battered drunk driver was wheeled in and strapped into a mobile bed near me. Then came the steady mantra of "Fuck, man! I don't want to be here," a sentiment with which I could agree in substance, if not style. He eventually discovered the bedside buzzer to summon assistance and kept punching it for the next half-hour or so. Nurses and orderlies eyed him warily but did little to shut him up. I didn't feel up to the task, either.
Time passed excruciatingly slowly, in the faintest of pulses. Bright lights bored into my face. Head wounds throbbed. There were no painkillers and almost no water. In the Ben Taub ER, drugs to relieve the pain are generally off the menu du jour because they can mask symptoms of internal injuries. Likewise, water may induce nausea and vomiting, not the most optimal behavior when one is in line for X-ray and CAT scans. All of that makes good sense if the diagnostics are completed in reasonable time. If they're not, the interminable wait becomes an ordeal heightened by thirst, pain and conditions that make sleep impossible.
Sometime after 4 a.m., when I had just about hit the wall, Grace returned with a sensible suggestion: Wouldn't I feel better if she wiped the dried blood off my face? I hadn't even seen myself in a mirror yet and didn't realize I was smeared in clotted red from head to foot. Grace slowly sponged my face and neck, murmuring, "Let's see if we can find any more cuts." It made me start to feel like a human being again.
Wherever Grace is now, that hospital and its patients are very lucky to have her.
By 6 a.m. radiology was as backed up as ever, with no opening in sight. A doctor and several assistants made the rounds, stopping briefly by my bed to summarize the case. My complaints about the night-long delay didn't seem to register. I might as well have been talking to the wall -- as some of my peers in the holding area had been doing much of the evening.
Two hours later I had finally been C-scanned by a dreadlocked, fiftyish technician who lives in Louisiana and shuttles back and forth to Houston for his shifts. He confirmed what had already been obvious. The patients had been stacked up in line for scans all night, like jets grounded at a fog-bound airport. With the scan out of the way, the X-rays followed, and I was soon out of the hard neck brace and walking around.
At 10:30 a.m. friend and writer Mimi Swartz found her way to the holding area, and life began to improve rapidly. While waiting for my final paperwork to get processed, Mimi began translating for a couple from Monterrey, Mexico. After a few more minutes, Mimi and I were strolling out of the hospital; she in a sharp pullover and tailored trousers, me in a borrowed orderly smock and blood-soaked jogging shorts.
We got in her car, then I noticed my shirt was pasted to my back. Later examination revealed that skin had been scraped raw in a swath along the back shoulder and was still peppered with grit from the bayou trail. It had never been seen or cleaned, because I spent almost all of the hospital stay immobilized on my back.
During the stop at the Montrose Walgreens, the final bad joke played out. There was no problem getting the doctors to write the prescriptions for antibiotics and pain medication.
But Ben Taub physicians are apparently a bit shy about including Drug Enforcement Administration ID numbers on their scripts. Pharmacists would have to get the number from the hospital. After a day of trying and getting no response, they gave up the effort.
My friends pitched in with help of their own -- in the form of leftovers from their medicine cabinets. The prescription snafu soon dissolved into just another dark dream punctuating fitful sleep.
One month later, on a steamy afternoon at the West Alabama Icehouse, it is reunion time. Although the remnants of Trip Buckley MD's autograph on my forehead are clearly visible, it takes a few minutes for us to recognize each other.
Trip, a 32-year-old native of Wildwood, Tennessee, wore a midnight pallor attesting to his current lifestyle as a hospital rat on a work treadmill that would grind most people into dust. Over icy Rolling Rocks, Trip and I compared notes on how we got to the Ben Taub ER.
His career path to medicine was as winding at the bayou bike trail. There are no other doctors in the family. His father owns a construction company outside Knoxville, and his mother is a retired stockbroker.
After earning a liberal arts degree at Skidmore College in upstate New York, Trip signed on as a sales executive for Coca-Cola but was bored by that prospective career. He began leaning toward medicine, primarily because a close friend was heading off to med school.
"He was so excited, it made me excited for him," remembers Trip. "I went around with some different doctors in Knoxville for a while and thought, 'If I could do anything, that's what I would do.' And I also, having met some people in sales, was unimpressed with my new group of peers."
Trip finished premed studies for admission to Tulane Medical School while working in a hospital that had no trauma center. A particular incident fed his growing fascination with surgery.
"I was an orderly, picking up urine and getting whatever the patients needed and stuff. There was a car wreck right out in front of the hospital, and they brought the person right into the hospital 'E' room, and she was in really bad shape."
A surgeon came out of an operation upstairs and took over. "He's says, 'Everybody shut up. I want you and you out of the room.' " Trip ran to get blood and returned to watch the impromptu operation.
"This guy is cutting into her chest -- she's dying right there," he recalls. "The surgeon stabilized her and took her up to the operating room. I was in shock. I was so impressed, I said to myself, 'I want to be like that guy.' "
Trip's five-year Baylor surgery residency schedule mandates a cycle of on-duty and on-call shifts that has him and his surgical team awake for stretches of up to 40 hours. Considering that federal law limits professional truck drivers to 12-hour shifts, the residency pace seems potentially unhealthy -- both for physician trainees and their patients.
Trip shrugs it off. "You get used to it. Some people can't hack it, and that's why not very many people go into surgery. It's a small specialty; we don't have that much room for people anyway."
For Trip and crew, 100-hour weeks are standard. Annual pay is around $36,000, working out to an hourly rate of $5.25. Professional prestige and high income are still years into the future.
We met on a Friday -- Trip's one day of the week to himself. Even that luxury is a recent improvement in residency work conditions, a decision by Baylor to humanize the grind.
"Surgery is fun to us," says Trip. "Otherwise it wouldn't be worth working the kind of hours that we do. You're really privileged to do the things that we do -- and it's a lot of fun. Exciting to see all the trauma, exciting to operate on people and then follow them as they get better. The whole thing is pretty nice."
In the third year of residency, Trip works shifts at Methodist, the Veterans Administration and Ben Taub. The latter is the most difficult.
"Most of the people we get there are, you know, drunk when they come in and not very appreciative when they leave. You have to be really self-satisfied with your work in particular, and not gaining appreciation from patients."
He cites an example from a recent shift: "It's a very rough-and-tumble environment, when you are trying to take care of somebody and they jump up and start pissing on the floor. We found $2,500 on him and some crack cocaine."
I tell Trip that had I gotten out of the hospital two hours after he sewed me up, my impression of the facility would be totally different. An impatient nod indicates it's a complaint he's heard many times before.
"As soon as you are downgraded from life-threatening to merely an emergency room patient, you really feel the Harris County Hospital District system," says Trip. "The problem is we have too few people, who are paid too little, that work too hard."
"People routinely stay there in the emergency room close to 24 hours," he explains. "It's absurd. But in the believe-it-or-not category, it's easier, even if a patient is going to get admitted to the hospital, to get something done in the emergency room than it is on the floor. Once they go up to the floor, it's really difficult to get scans done."
The problem is that once a patient is stabilized, incoming emergencies have priority. On a busy night, that relegates everyone else to limbo.
The prescription, in this doctor's view, is simply more money to hire the backup staff to prevent gridlock in the treatment chain.
Shortages range from the critical-care nursing staff to radiology technicians, "where the bottlenecks are," says Trip. "When you hear on TV that Ben Taub is on 'drive-by' because of saturation, it's usually not because we lack the beds but because we lack the staff to take care of patients appropriately."
"Every night can turn into mayhem," he says. "People wait for X-rays, scans, usually radiology -- as you found out -- for umpteen hours. That's just the way it is, and there's nothing any of us can do about it. You have nights where people decide just not to come in -- radiology doesn't come in -- and you're just killed."
He's referring to the doctors, of course, not the patients.
A few days after that reunion, I returned to the Ben Taub ER on a Tuesday evening, about the same time as my previous visit. This time around the trauma gods must have been in a good mood, or out getting drunk themselves. The center, Trip noted, was about as calm as it ever gets.
While waiting for the inevitable emergency call, Trip spent part of his time in an examination room with a young Hispanic woman we'll call Maria. She suffered from severe abdominal pain.
Trip gently pressed above the woman's pelvis. "Does that hurt, in your belly?" he asked. "Where does that hurt?"
Trip suspected the problem was appendicitis. But after viewing her scans later in radiology, the source of the pain became obvious. Both of Maria's ovaries were badly swollen.
It's a problem that could have been detected in earlier stages during routine preventative treatment. Texas Attorney General John Cornyn issued an opinion recently that public hospitals can't provide that kind of treatment to undocumented residents. Cornyn's ruling was followed by a formal complaint by the Young Conservatives of Texas and a subsequent criminal investigation of the hospital district by Harris County District Attorney Chuck Rosenthal.
From ground zero in the county public health care crisis, Trip's take is that the humanitarian view is also the most cost-effective.
"If it becomes an offense to treat someone who is an illegal alien [on a nonemergency basis], then these people are going to end up in the hospital district emergency rooms no matter what," the young physician says. "If they think it's going to save money, it's not. That's a general problem in medicine right now, with people who, without degrees or any training in medicine, are making these kinds of decisions. It's very shortsighted."
Following Trip through the same holding area where I'd spent that long, long night, we walked along the line of beds, looking at one person after another immersed in their own hours of pain.
"Anybody can end up here," Trip explained earlier. "You want to end up here if you're in really bad shape. But when it comes time to pay your property taxes and you see that Harris County Hospital District amount on that, people balk at that and they don't want to fund the district."
Keep in mind, it's just a bike ride away.
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