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Voyager Bud Shaw gives up scalpel for pen

April 20, 2017 Leave a comment

If you follow my work via my blog or Facebook page then you may have noticed I like writing about fellow writers. I mean, beyond the natural affinity I feel for anyone who takes up the pen and sticks with it, there are myriad things about the writing life that are universal and singular to each writer I profile. There’s no single path to becoming a writer and every writer’s life around the work and separate from it looks a little different, sometimes a lot different. And then there’s the very different kinds of writing people do and the unique voices they express. The subject of this New Horizons cover story, Bud Shaw, is a medical doctor and writer who’s gained a measure of fame for training his inner eye and ear on his former life as a transplant surgeon through essays, several of them collected in his well-received book, Last Night in the OR. Though it took him until about a decade ago to finally write about his own personal experiences, he’s been writing since he was a child. It can take the better part of a lifetime to find one’s voice, especially that voice residing deep within the inner recesses and nooks and crannies of our subconscious. When Shaw finally did find his, he revealed himself to be a strong, spare writer in the style of his literary heroes. My profile of Shaw will appear in the May 2017 issue of the New Horizons, a free montly newspaper from the Eastern Nebraska Office on Aging. Beginning April 28, look for the new issue at area newsstands or, if you’re a subscriber, in your mailbox,. Order your free subscription by calling 402-444-6654.

 

Voyager Bud Shaw gives up scalpel for pen

©by Leo Adam Biga

Soon to appear in the May 2017 issue of the New Horizons

 

Before Dr. Bud Shaw gained fame as a liver transplant surgeon, first in Pittsburgh, then at the University of Nebraska Medical Center (UNMC), he was a writer. An adventurer, too. He’s a veteran small-engine pilot and hang gliding enthusiast and an avid bicycle trekker.

His wonderment with words goes back to childhood. It continued during his formal education – all the way through undergraduate and medical studies. Even during his surgical career he continued writing whenever he had down time. But since putting down the scalpel for the pen, his writing’s really taken off.

For decades he composed fiction but in recent years he’s turned to nonfiction. Some of his highly personal essays have won recognition. His 2015 book Last Night in the OR was a New York Times Bestseller.

His wife Rebecca Rotert is an award-winning poet, short story writer and essayist whose first novel Last Night at the Blue Angel was well-received.

Shaw leads writing clubs at the Med Center. He advocates students and professionals take writing courses to enrich their humanities education. He cites research showing the health benefits of writing.

“When you write something down as opposed to talking about it, it gets stored in long-term memory – with far fewer details but more indelibly – and it’s in an area where your brain keeps working on it. It’s like the thing where you write something and put it away and come back to it and you start editing it immediately when you couldn’t have done that the day before. But your brain’s been working on it.”

He said studies show that in “patients who wrote for three days in a row their brain did some processing that somehow also helped them deal with their illness.”

 

 

Image result for bud shaw unmc omaha

 

Reading and writing

Prose fed Shaw’s imaginative escapes as a youth.

“I read a lot. As a kid I got sick frequently and I’d end up having to stay home. We had bookshelves full of books. My mother bought a series of classics for kids: Black Beauty, Treasure Island, Bambi. I would pick them out and read them, and then I got into The Hardy Boys and when I read all that I even tried Nancy Drew.”

He became a familiar figure at the local library.

Family trips to Crystal River, Florida got him hooked on diving and his natural curiosity and affinity for reading found him hunting every book he could on the subject.

“My school projects were reports about the aqua lung and the difference between one and two stage regulators and how you could get the bends and prevent that. I knew the decompression tables when i was 12.”

Writing had already become an outlet.

“I began writing seriously in second grade, My mother helped me write a romantic adventure novel involving a boy and his pony. It filled 10 pages of Golden Rod tablet paper we bound with rubber cement and a cardboard cover. She died a few years later and I guess I’ve been looking for that kind of approval ever since.”

His passion for literature was stoked at Kenyon College a small liberal arts school near where he grew up in rural Ohio. There, he said, “reading and writing were paramount and literature became a limitless world for me – a world where anything could happen. I was a chemistry major, but I filled the other spaces with literature and creative writing courses. In the first two years of medical school, those intellectual pursuits were largely replaced with the drudgery of rote memorization. I found myself obsessively writing short stories and sending them off to Redbook, Playboy and Reader’s Digest. It was a useful diversion and the rejections hardly mattered.”

His literary favorites range from John Steibeck, Ernest Hemingway and William Faulkner to Kurt Vonnegut, Gunter Grass and Cormac McCarthy.

 

Image result for last night in the or bud shaw

 

Finding his niche as a transplant surgeon

Though his father was a surgeon, Bud at first resisted following in his footsteps. He said the fact he eventually did was “probably because he didn’t push it on me.” Shaw received his MD at Case Western Reserve University, did general surgery training in Utah and completed a transplant surgery fellowship in Pittsburgh,

There, he made a name for himself as a talented maverick working under the father of transplantation in America, the late Tom Strazl. The two men shared a complicated relationship.

“Most of the advances going on at that time in transplantation were happening in Pittsburgh. I was working with Starzl, who then was by far the most important pioneer in transplantation. I would have stayed there happily and worked with him but it just became more and more difficult.”

Shaw left because he disagreed with the way certain things were being done that he felt hampered surgeons’ learning and endangered patients’ lives.

“I wanted to change the way we did things and I realized I wasn’t going to be able to do that there as much as I wanted. I realized I didn’t want to be part of a program that was chaotic and dangerous for patients.”

Prestigious hospitals coveted having this hot shot young surgeon come start a transplant program in what was a sexy new medical horizon making headlines.

“It was a brand new field. I had probably done more liver transplants in the previous two years than anybody in the world .”

Coming to Omaha and building a world-class transplantation program

UNMC recruited him. It didn’t have the cachet of other courters but it proved the right fit. It helped that the man pursuing him. Layton “Bing” Rikkers, knew him when Shaw trained in general surgery at the University of Utah, where Rikkers had taught.

“Once I got trained in transplant I always intended to go back to the University of Utah but they just didn’t seem to want to do it (start a transplant program).”

When Rikkers took the UNMC job he asked Shaw to join him but Shaw wouldn’t be persuaded – at first.

“I told him I want to go someplace with a seacoast or mountains or preferably both.”

Rikkers wouldn’t take no for an answer. He strategically brought Shaw in as a consultant on the ABCs of starting a transplant program. Shaw met a Med Center contingent, including Mike Sorrell and Jim Armitage, who, he said, were “incredibly enthusiastic about doing liver transplants.” “There was a stark contrast between the attitude here, which was one of ‘We understand we don’t know anything about how to do this – we need you to be the expert,’ and what I found elsewhere.”

Shaw said. “I realized this was a rare opportunity because I’d interviewed at much more famous, high-powered places. I’d told them the same thing I told UNMC – I can’t come alone, I’m going to bring a junior surgeon with me and I need to have an anesthesia team go to Pittsburgh and learn how to do anesthesia and a pathologist go learn how to read the biopsies of the liver. And all these places said, ‘No, we have experts, we’re sure they can handle this, and we have very precious faculty positions to maintain.”

He said other centers didn’t appreciate just what a commitment they needed to make.

“They said, ‘We want you to come start this and we’ll see how it goes,’ and I said, ‘See how it goes? This is a high risk sort of thing.’ That’s when I realized they were mainly interested in doing this not because they were interested in treating liver disease but because it was a cool thing to start doing and they didn’t want to be left out. This place (UNMC) was clearly different. It was one of the only places in the country thinking about this as a long-term prospect they could succeed in, and that’s why I came here.”

One of Shaw’s biggest contentions with the way things were done in Pittsburgh that he changed in Omaha was transplant surgeons not having responsibility for post-op patient care. Some patients get profoundly sick after transplant surgery and lax care can exacerbate already dire situations.

“On a typical Sunday morning I’d find three transplant patients in the ICU and two of them would be bleeding still and I’d have to take them back and fix them in the operating room. I’d go talk to the family and they’d say, ‘Nobody’s talked to us.’ So I found myself cleaning up messes made by other surgeons who weren’t being supervised adequately and hadn’t had enough training.

“I talk about this in the book,” Shaw said. “Tom Starzl never wanted to have a routine, he wanted to change it every time, and you just can’t teach other people what works and what doesn’t work very well if you’re changing it constantly.”

After coming to Omaha in 1985 with his first wife and establishing a world-class solid organ (liver, kidney, pancreas, heart) transplant program here, the city became their home.

“I came here with the idea we’d spend five years and then move to one of those places with seacoast and mountains, but at the end of five years we had a really good program going. We were still growing, we were doing innovative things.

“I got recruited to go look at a couple of jobs right around that time. I just realized it was going to be like starting over and the politics would be worse. There’s no advantage of going to those places other than geography and I can buy a plane ticket.”

Diversions by ground and air

He’s bought plenty of tickets over the years to make bike tours with friends in scenic spots around the globe:

Cuba

Costa Rica

Panama

Argentina

Chile

Scotland

Nova Scotia

Newfoundland

Hungary

Slovakia

Poland

France

Italy

Crete

Australia

Vietnam

Cambodia

Then there’s his life as a pilot. He got his license at 19.

“I bought a 1939 J-3 Cub and flew it back to college. I had another airplane in Utah where I also took up hang gliding. I didn’t have any aircraft in 1981 when I arrived in Pittsburgh, but by 1984 I bought a used seaplane that I also took to Omaha in 1985. I eventually sold it and joined two other guys in a partnership in several airplanes.

“I plan on getting my glider rating this summer.”

Shaw’s logged enough hours behind the controls to have had some harrowing moments in the air.

“Every pilot with that many years experience has many stories to tell, as do I. I’ve been scared several times when weather closed in on me unexpectedly while flying cross-country. I flew aerobatics for half a dozen years in the ’90s. That was always exciting but I never had any close calls doing that. I had a couple of close calls hang gliding. I describe one in the book.”

More often than not, his time in the sky has afforded sublime glimpses of beauty. He recalled a Utah ridge that provided “wonderful soaring” and close encounters with Bald and Golden eagles living in the rocky cliffs.

“They often came out and flew along with us, sometimes showing off their aerobatic skills.”

Unexpected turbulence 

Then there was the 1973 coming-of-age flight he made in his little Cub with an acquaintance of his from Ohio, Scottie Wilson.

“The summer of ’73 was between my first and second year of medical school, which I hated. I’d restored an airplane I kept out at the local airport. Scottie had just gotten his wings for the Air Force. That summer we flew in my little Cub a lot together. Toward the end of the summer he had to get to Tuscon, Arizona for combat training. He was going to drive and I said maybe we should fly my Cub out there.

“There were multiple times during that trip where I was going to quit medical school and become a jet jockey.

When the whole thing was done I had to turn around and fly back by myself, and this was like two weeks before I was getting married. I had sort of abandoned ship and ran away.”

The event proved a crucible for Shaw.

“Right after I crossed the Continental Divide there was a storm up ahead I realized iI couldn’t fly around or above so I just landed on a road. As I was sitting there watching this storm go by I started crying. I had this deep sense of loss.”

Broke and out of fuel, he siphoned gas from every small plane on the line at the airport. Back home. he married. started a family and completed his studies. That summer interlude never left him but it’s only recently he

tried writing about it.

“I told Rebecca about it and she said, ‘There’s a romance there of a kind,’ and there really was. A closeness developed in a short period of time that was very different than any experience I’ve had with another guy.”

Intent on catching up with his old pal, Shaw happened to open a magazine to a story about Wilson restoring a 1938 Bugatti airplane presumed lost during World War II. The plane was rediscovered and Wilson, a retired Air Force officer, was building a replica.

“I tracked him down through Facebook and we ended up spending hours on the phone three or four different times over the space of a couple months. My plan was to go see him. He was in the process of starting to test fly this plane. I talked to him in May 2016 and in December I got an email from his brother that said, ‘I’m sure by now you’ve heard about Scottie dying…’ He’d taken the plane up again and was barely off the ground when it happened.

“He’d sent me some sample writing. He wanted me to help him write the story of this airplane.”

Wilson’s passing marked the latest of four recent deaths of important people in Shaw’s life. He feels compelled to write about what they meant to him.

“I have lots of starts in different directions in talking about the way your relationship with your mentors is more like a love affair than it is like a parenting             relationship. It’s like seeking their love and approval more-so than maybe with a parent.”

Merging his personal, medical and writing lives

When Shaw was still doing transplants he was barraged by life and death events but so cut-off from them emotionally he didn’t write about them.

“I was so busy and chronically sleep deprived I rarely had time or inclination to write. Except on vacation. Once I got away from work, I inevitably started writing. It was always fiction. By the mid-’90s I had the starts of five novels. I took a sabbatical in 1996 to write and came away with a 180,000-word novel that isn’t yet worthy of publication. Of course, family and friends all thought it was wonderful but nobody else did. I was afraid of getting it reviewed by anybody.

“None of my writing then had any direct relationship to my work. I think it was largely a way to escape the stress of that life.”

Shaw’s real growth as a writer began when he confronted his own life on the page at the 2007 Kenyon Review Workshop.

“It was very educational and inspirational to actually have to write something and then to have people critique it. It was the first time I had valuable critique of what I’d written. I began to understand what I needed to do to improve things was to keep writing, to keep having people critique and then keep changing and writing.”

His next evolution came as a participant in the Seven Doctors Project that puts doctors together with writers.

Shaw was in the project’s first group of doctors in 2008 and he participated in several other sessions the next few years. One session in particular proved fruitful.

“I did get some wonderful stuff from the review of what I wrote that year. The most telling thing was from another writer there, Rebecca Rotert” (whom he ended up marrying after he and his first wife split).

“When it was my turn to read, everybody complimented how they liked this or liked that and then all of a sudden Rebecca said, ‘Okay, here’s the deal: I don’t know what this person’s motivations are. We’re missing some of the basic things of a story and by now we should know this.’

I started to feel defensive and then I thought, ‘Oh my God, she’s absolutely right,’ and I can fix that because I know what the answers to those questions are.”

All of it spurred him to explore his own life in nonfiction writing. The more he drew from his personal experience, the more he liberated himself.

“I was finally able to think about some of the experiences I had and to step back from them far enough to actually write about them without having a strong emotional agenda that kept me from doing it before.”

With each story he takes from his own life, he’s puts himself on the line.

“I suppose writing highly personal nonfiction stories is risky for anyone. I felt I couldn’t do it unless I found a way to be more objective about the most difficult and emotional experiences. I had to resist the temptation to ‘set the record straight.’ I had to discover instead the other stories within those moments.”

His first published essay, My Night With Ellen Hutchinson, is about a devastating personal and professional episode early in his career.

“As I sat down to write about it, I discovered just how stubbornly I still held onto a version of that story that blamed others, that let me off the hook for the death of a patient during a liver transplant. I had to revisit that night over and over again for weeks to reconstruct a view that wasn’t about the cause of the failure so much as it was about the results of it. It wasn’t easy.

“That was a very straight forward operation. In my mind, I’d done everything right. I got the new liver sewn into place and blood flowing into it and everything was just great when her heart stopped. And yet, the technical details of why the woman’s heart stopped and how we should have handled it and how today, I know she would not have died because of what we later learned to prevent the problem, none of that was a story worth recounting. I needed a fresh and far more human perspective, and that required me to do a lot of processing I hadn’t done before.

“Now I don’t seem able to stop.”

For years Shaw erected shields warding off self-reflection when people’s lives were in his hands.

“The protective mechanisms were about dealing with failure, where failure could be somebody’s death. After failure I felt it absolutely necessary to approach the next case with supreme confidence that everything is going to go well. There’s a lot of ways of getting to that point. Maybe the quickest way is to simply say, ‘That last problem – that wasn’t my fault.’ But that’s not the only way. Another way, but it’s not the one I took, is to think about it more and to recognize we’re fallible and I did play a role in that, and what can I do next time to make sure that doesn’t happen again.

“It would have taken the ability of being more mindful as they call it now.”

 

 

            

 

Frailties 

In his book Shaw reveals his own and others’ frailties as counterpoint to the God-like status medical professionals are held in or hold themselves in. His essays chronicle how he didn’t let things touch him, not the lives he saved or lost, not even his own bout with cancer, What opened the flood gates of introspection was the disabling anxiety that overcame him in 2006.

“I didn’t have any problems with social anxiety at all

until one day I was sitting in my living room and suddenly had a panic attack that eventually caused me to crawl into bed and cover up. I had no idea what was causing it. It just came out of the blue.”

Some days at work he couldn’t leave his office. He finally sought help. Drugs help regulate the condition. Writing about it has been freeing.

“What the writing has done is help me understand and accept the fact that I have this problem. It’s also helped me recognize I did have these protective things and the question in my mind is – what if I had been as self-aware and self-reflective when I was in the midst of this incredibly intense surgical career with all this risk?

Would I have been able to continue? I think the answer to that question is probably yes.

“The process of writing about my own experiences really did open up my writing in a way. That, and there were about three books I read around that time that made me become much more spare, to work harder on eliminating stuff. The big problem I had was my need to make sure you understood everything, explaining

everything. Being freed up from the idea that you have to explain everything was like a miracle. You can actually let people figure out stuff on their own.”

He said a UNMC colleague objected to how much medical imperfection he revealed in his book.

“She said, ‘This is a huge mistake. Nobody should pull back the curtain and expose these sorts of things.’ I said, ‘Why, do you think people are going to come after us with torches?’ She said, ‘Well, they might,’ and I said, ‘Well, if they do, maybe we deserve it.’ I certainly got lots of positive feedback from surgeons outside of here. In fact, I’m still getting it.”

A notable exception was his old mentor Tom Starzl, who reacted strongly against the book. It strained the two men’s already tenuous relationship. As a show of respect and peace offering, Shaw attended Starzl’s 90th birthday celebration.

“I gave him a big hug and he started crying. It was very emotional.”

Starzl died a year later.

Before Shaw could get his book published, UNMC made him jump through hoops to change details so as to avoid privacy issues.

“A lot of the essays had been written with the names of the real people involved before I knew these stories were going to be part of a book,” Shaw said. “I had to start looking at how I could contact these people (for their permission). I knew I wasn’t allowed to look in the medical records for that purpose and I knew I couldn’t ask anybody else to do it for that purpose.

“I couldn’t remember some of their names. I was in the process of trying to sort out how to contact them when the privacy officer at the hospital called and said you can’t write about any of your experiences here.”

The decree made Shaw bristle. He resisted the blanket refusal, pointing out there was nothing in his contract or in UNMC’s HIPPA policy preventing him from doing it.

“Eventually I could not get them to allow me to contact the people. So I went in and changed enough of the details that there’s just no way anybody could recognize the real people.”

 

 

Doing what he has to do

Some of his writing does name names. His essay A Doctor at His Daughter’s Hospital Bed recounts the time  he intervened in the care of his daughter Natalie, who was hospitalized with pneumonia and not getting the IV fluids he knew she needed.

“I know I shouldn’t be my daughter’s doctor. They taught us the problems with that during my first week in medical school. It’s a really bad idea, especially in high-risk situations. We doctors are also very superstitious that when dealing with family members … something is always going to go wrong. The more the Special Person hovers over the care of his or her loved one, the worse the complication will be. I’ve had conversations in which doctors feel they change their routine with V.I.P. patients, and it’s that disruption in routine that allows error to creep into their care.

“But right now, I don’t care about any of that. I’m the one with experience taking care of really sick patients, and if I know she needs more fluids, she’s going to get them.

I break into the crash cart … I pull out two liters of saline solution and run both into Natalie’s IV in less than 20 minutes. Natalie’s pulse slows and her blood pressure rises. An hour later, after the nursing supervisor and on-call resident finally arrive, I’ve finished infusing a third liter. Natalie finally looks better.

“This wasn’t the first time during Natalie’s illness … I broke my promise to just be her dad.”

It also wasn’t the first or last time he crossed the medical care barrier with a loved one.

My younger son, Joe, almost died … from septic shock. He became ill while I was out of town. I flew home and by the time I arrived at the hospital, he looked deathly ill to me. I told the nurse I thought he should be transferred to the intensive care unit, but she said the doctors thought he was improving. Joe stopped breathing during the night and I have blamed myself ever since for not insisting they move him.

“Over and over again during my dad’s last few years of life, I felt as if I should have just moved in with him so that I could prevent all the well-meaning doctors and nurses from killing him. Sometimes it was just because his doctors weren’t talking to one another and their conflicting prescriptions sent Dad to the hospital. In the end, he died about 10 minutes after receiving an injection I didn’t want him to receive.”

Shaw’s daughter did recover but, he writes. “I didn’t.” He explains in his essay:

“I stopped operating and taking care of really sick people two years later. I told myself I had become too distracted by my increasing administrative duties to be a safe doctor. I was glad to leave all that behind. Now I just want to sit on the sidelines and marvel as a new generation of doctors performs the miracles. I never again want to step in to rescue someone I love. But I will, if I have to.”

On a pedestal 

He had occasion to operate on public figures or loved ones of celebrities. Such was the case in 1993 when he performed liver transplants on Hollywood icon Robert Reford’s son, Jamie Redford, in Omaha.

As is often the case, patients with good outcomes form an attachment with their surgeons that is one-part gratitude and one-part adulation. It was no different with Jamie Redford, who on Instagram recently posted a photo of himself and his life-saver with this caption: “My hero and good friend, Dr. Bud Shaw.”

Redford regained his health and produced a documentary, The Kindness of Strangers, raising awareness of the need for organ donation. Redford and Shaw saw each other just last year.

“Jamie and I did something at the Sundance Authors Series. I did a reading of my book and then Jamie came up and we sat on a couple stools and we did a kind of give-and-take with each other and people asked questions. Bob (Robert Redford) was there and Jamie’s sister was there. It was standing-room-only.”

But in his essay Real Surgeons Can’t Cry Shaw divulges how he didn’t cope well with the hero worship showed him. For him, surgery was a job to be gotten through, a task to be completed. The human dimensions of it sometimes escaped him or made him uncomfortable, and so he avoided those implications and interactions that required emotional investment.

Taxing times in the crowded OR give way to one-on-one writing-editing critiques 

A transplant operation is always complex and requires a team of professionals/ But these were far riskier procedures in the 1980s and 1990s then they are today because there weren’t the techniques and drugs available then that there are now.

“The longest one in my experience was in Pittsburgh that was 27 hours,” Shaw recalled. “In that case it was a child. When we started out trying to open the abdomen it was like concrete. We had to go ahead and get the liver in there because its time out of the donor’s body was getting too high. We didn’t want it to die – the liver would be nonfunctional. So we put it in and then we had all this sorting out of stuff to do for hours and hours, trying to get the bleeding stopped.

“What would happen is the patient’s own body would start dissolving its clots. That was a pretty common feature of a liver transplant.”

The operating room is a collaborative, dynamic environment of high risk and high reward. Writing, by contrast, is a solitary experience whose rewards are more internal then external. Shaw values having a life partner in Rotert who is a fellow writer. They share everything they write with each other.

“We are our own best editors,” he said. “I think I take her criticism of what I write a lot better than she takes my criticism about what she writes, and I don’t know if that’s because her criticism is more gently delivered because she’s not very gentle with it. But for some reason whatever she tells me often rings so true.

“LIke with these initial essays I wrote, I wasn’t sure what they were really about and she helped me figure out what they were really about.”

He admires her craftsmanship.

“She really writes incredibly well. She writes some beautiful sentences. She also develops characters incredibly well, each with different voices. She’s really a master at that sort of thing.”

The couple live in a multi-story home on the edge of Neale Woods. Books, magazines, paintings (by her) and photographs (by him) adorn the rustic-chic living spaces whose large windows look out on the Missouri River basin and bluffs to the east and pristine forested land to the west.

 

 

Reinventing himself

Idyllic surroundings and professional accolades aren’t salves for the demons inside us as Shaw discovered. Even at the height of his career, politics and egos found him fighting external battles. He eventually became chairman of surgery at the Med Center and after 12 years in that post he headed-up a large point-of-care software development project that got canceled.

He’s felt a bit adrift since retiring from surgery and then having that software project killed.

“There’s almost nothing like having a really difficult job to do with a lot riding on it and you’re afraid going in about what might happen but you do it anyway and you succeed and everything’s okay. It just so happens that liver transplants is one of the best things like that. And so I lost that reward system. The other thing I lost was every day somebody telling me what to do. Even when i was chairman of the department. It’s not like I had to say what am i going to do today? There was always stuff to do and too much to do.

“Not having that and having so called free time to write and to do other stuff was initially fun and easy but the longer it’s lasted the more difficult it’s become

finding reward.”

While a practicing surgeon he once thought of leaving that career to write full-time but he wasn’t crazy or brave enough to try it. “Doing liver transplants is easier.”

Ever the voyager, Shaw has worlds yet to explore in his travels and in his new vocation as author, Having finally given himself permission to write about his past, he’s embracing new adventures as source material for future tales. With so much to draw on, his creative well should never run dry.

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Who’s Going to Pay? Before and After the Affordable Care Act

March 16, 2017 Leave a comment

There’s nothing like getting current, though it’s hard to do when you write for a monthly. Still, in this cover story I wrote for the March 2017 issue of The Reader (http://www.thereader.com) I think I mostly managed to stay relevant to the topic of health care coverage in America, the forces pushing and pulling for and against the Affordable Care Act and what the ACA has meant in terms of gains and what its repeal and replacement would mean in losses. For the piece I spoke to local professionals on the provider and insurer sides of the equation for their take on how we got here and where we might be heading. The story went to press with us knowing Congress was working to repeal and replace Obamacare, though no one knew what that entailed, and then just about the time our story got published that plan was unveiled. As you know by now, the proposed new plan was met with disdain from all quarters, especially consumer rights groups and elected officials, even conservative Republicans, who heard loud and clear from constituents that they they oppose the called for cuts that would cause many people to lose insurance. As the push back continues, town halls and debates ensue, and presumably negotiations, revisions and compromises will get made. Meanwhile, America still can’t get its health care system to work equitably and efficiently.

 

Who’s Going to Pay? Before & After the Affordable Care Act

©by Leo Adam Biga

Appearing in the March 2017 issue of The Reader ((http://www.thereader.com)

One accident, one illness could be catastrophic. Not just medically, but also financially.

Families stood to lose almost everything in medical bankruptcies when health insurance companies rejected those with pre-existing conditions and capped their policies with lifetime limits.

Uncovered costs helped health care expenditures soar, more than tripling in the last 20 years according to the federal National Health Spending Report. In 2015, the federal government was the largest payer of health care, covering 37% of the total cost through its two programs Medicaid and Medicare.

The curve was starting to bend.

According to the Kaiser Family Foundation, health insurance costs increased 63% from 2001 to 2006 and 31% from 2006 to 2011. That number dropped to 20% from 2011 to 2016.

Part of the reason was the Affordable Care Act and a landmark shift in how health care was being offered. Through a series of tax increases targeting high-income earners, the ACA was able to fund experiments in in- novation while subsidizing the cost of bringing almost 30 million Americans into the health insurance system.

With the end of Obamacare at the top of the national conversation, The Reader talked to the major stakeholders about life before and potentially after the Affordable Care Act.

It’s not just the $2 billion in federal revenues Nebraska passed up for health insurance, or the 275,000 Nebraskans with pre-existing conditions that could be denied health insurance, according to the Kaiser Family Foundation. It’s not even the estimated 165,000 Nebraskans that would lose health insurance, an increase of 111% of the uninsured, according to the Economic Policy Institute, leading to almost 3,000 jobs lost and $400 million in federal health care dollars gone that we subsidize.

It’s also about the way we take care of each other.

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Quality of Health Care Over Quantity

America treating healthcare as a commodity helps explain its high delivery and coverage expense. Characterized by historic lack of incentives to drive prices down, providers and insurers dictate terms to consumers. Subsidies to assist low income patients who can’t pay out of pocket get passed along to other consumers. But affording care and its coverage is a burden even for the middle classes.

Amid runaway costs and coverage gaps, America’s clunkily moving from a volume to a value-based system as part of long overdue healthcare reform. The Affordable Care Act was passed in 2010 after contentious bipartisan debate. The statute’s full roll-out began in 2014.

Nebraska Medicine CEO Daniel DeBehnke said, “The tipping point that brought the ACA forward is really the unsustainable growth in our country’s healthcare costs.”

The calculus of people not being able to afford care translates into real life implications. Untreated chronic diseases worsen without treatment. Early diagnoses are missed absent annual physicals or wellness checks.

Championed by President Barack Obama, who promised reform in his campaign, the ACA’s enacted consumer protections and mea- sures holding providers account- able for delivering value.

Nebraska Methodist Health System CFO Jeff Francis said organizations like his have “con- tracts and monies at risk for hit- ting certain quality items, not just with Medicare, but with some of our commercial insurers as well, Five or ten years from now,” he added, “we’ll probably have more at risk financially from a quality and outcome standpoint. Recent federal legislation changed the way physicians get paid by CMS (Centers for Medicare and Medicaid Services). Starting in 2019 they’re having potential penalties depending on whether they’re hitting certain quality metrics or not.”

He said the stick of such punitive measures works.

A new Standard in American Health Care

Aspects of Obamacare, such as the individual mandate and public health exchanges, have detractors. Federal lawsuits challenging it have failed. But its intact survival is in jeopardy today. A chief critic is President Donald Trump, who with the Republican controlled Congress vowed to repeal and replace, though that’s proving more daunting in reality than rhetoric. On February 16, GOP leaders shared a replacement plan with tax credits for buy- ing insurance and incentives for opening healthcare savings accounts, but no details for funding the plan or its projected impact on the insured and uninsured.

Debehnke said, “I don’t think there’s any question, regardless of where you land politically, there are components of the current ACA that require tweaking. Even Democrats will tell you it wasn’t exactly perfect – nobody said it was going to be perfect. It was understood there were going to need to be changes as things move along.”

There’s widespread consensus about the benefits accruing from the ACA. New subsidies allowed millions more people nationwide and tens of thousands more in Nebraska to be insured, in some cases getting care they deferred or delayed. Insurers cannot deny coverage for pre- existing conditions or cancel coverage when someone gets sick. Plans must cover essential care and wellness visits. Adult children can remain on their parents’ insurance until age 26.

Francis said, “A lot of good things have come out of this. We’re focusing on well- ness, we have fewer uninsured, we’re having better outcomes for patients. I think there’s satisfaction with the improvements. I just think there’s disagreement with how it’s occurring or being done.”

“You can’t believe the difference it’s made by setting minimum standards for health insurance,” said One World Community Health Chief Medical Officer Kristine McVea, “so that things like child immunizations and mammograms are covered.”

Since the ACA’s adoption, uninsured 18-to 24-year-olds in Nebraska dropped from 25.5 percent in 2009 to 12.4 percent in 2015, according to the Kids Count in Nebraska Report.

McVea said, “At One World people get assistance in enrolling for health insurance. Counselors guide them through the market- place. People are really becoming more savvy shoppers. Improved health literacy has been a result of this process, you can really compare for the very first time apples to apples in terms of different plans. That has been a tremendous boon to clients.”

Not everyone included – Nebraska drops the Kick- back

Healthcare disparities still exist though. In Omaha 24% of adults living below the poverty line

lack health coverage while 3% of adults with medium to high in- come are uninsured. Some 36% of Hispanic adults, 15% of black adults and 5% of white adults are uninsured in the metro, ac- cording to numbers reported by The landscape, a project of the Omaha Community Foundation.

McVea said, “The poorest of the poor are not eligible for the marketplace at all because that part of the Affordable Care Act carved them out thinking states would cover them with Medicaid. Well, Nebraska’s elected not to expand Medicaid, so there’s this whole gap of people not insured. Then there’s prob- ably another tier who do get assistance through the marketplace, but considering the economic pressures they’re under, even with the assistance, it still falls outside their reach to get good healthcare.”

The Kids Count Report found 64 percent of uninsured Nebraska children are low-in- come — likely eligible for but not enrolled in Medicaid or Children’s Health Insurance program (CHIP).

Past Nebraska Medical Association president Rowen Zettermen said, “In Nebraska we have somewhere in the neighborhood of 60,000 to 90,000 uninsured people that would have otherwise been eligible for Medicaid expansion. you find the highest percentage uninsured rates in rural counties. We still have 20 some million uninsured in this country. A number may have insurance but they’re underinsured for their various conditions. Ideally, everybody should be able to establish a healthcare proposition with their physician, nurse practitioner or physician’s assistant to access care whenever they need it.”

Then there are federal DSH monies to fund Medicaid expansion the state foregoes because the legislature’s voted against expansion. Gov. Pete Ricketts opposes it

as well. Disproportionate Share Hospital payments are subsidies paid by the federal government to hospitals serving a high percentage of uninsured patients. Nebraska hospitals write off uncompensated care cost while getting no money back for it.

Zetterman said, “We could expand Medic- aid and take advantage of the roughly $2 to $2.5 billion that’s failed to come into the state. It would have paid salaries for more people in physicians offices and a variety of things that would be taxed and bring in more revenue.”

DeBehnke of Nebraska Medicine said, “Being a large hospital health system that takes all comers, we have a Medicaid percentage of our business. We would be better off in a Medicaid expanded state. We would like to see more coverage for the working poor. That’s what Medicaid expansion is – providing coverage to the working poor. Those who don’t currently qualify for it would under an expansion.”

Proposed federal community block grants could expand coverage. DeBehnke cautioned, “We just have to be sure there’s good control around how those dollars are used and they actually go for healthcare coverage. Expanding coverage to all people is really the key.”

Nebraska State Senator Adam Morfield is the sponsor of lB 441, which would expand Medicaid in Nebraska. The bill is scheduled for a March 8 Health and Human Services Committee hearing.

The care-coverage-income gap may be more widespread than thought. Kids Count Report findings estimate 18.5 percent of Nebraskans are one emergency away from financial crisis.

Preventative Care is Long-Term Savings

Having coverage when you need it is a relief. Insurance also motivates people to get check-ups that can catch things before they turn crisis.

“A woman having symptoms for some time didn’t have any insurance and she waited

before she sought care,” McVea said. “By the time she came to us for diagnosis she already had a fairly advanced stage of colon cancer. She’s undergone chemo- therapy and surgery and is now living with a colostomy. That didn’t have to happen. We see things like that every day – people who’ve let their diabetes and other things go to where they have coronary artery dis- ease, and that’s not reversible. We’re trying to get them back to the path of health with treatments, but they’ve lost that opportunity to maintain a high quality of health.”

Zetterman said, “There’s good data to show patients with cancer who don’t have insurance tend to arrive with more advanced disease at the time of initial discovery because they come late to seek care.”

That pent-up need is expressed more often, McVea said, as “people have insurance for the first time or for the first time in a long time.”

“We’ve seen a lot of people come in as new patients saying, ‘I know I should have come in a long time ago, and I’ve just been putting it off.’ Many are middle-aged. They’ve been putting off chronic health conditions or screening tests or other things for years. We see people come in with diabetes or high blood pressure that’s out of control and within three months we get them to a point where everything’s in control, they’re feeling better, they have more energy, they’re feeling good about their health. We’ve maybe given them advice about diet and exercise and ways they can keep themselves healthy.”

More positive outcomes are prevalent across the healthcare spectrum.

“I would say overall the average patient is having a better experience and outcome now than they were five years ago,” Nebraska Methodist’s Jeff Francis said.

One World’s CEO, Andrea Skolkin, said, “We’ve been able to reach more people living on limited income so our services have been able to expand both in terms

of numbers of patients we care for as well as types of services and locations.” One World opened two new satellite clinics with help from ACA generated monies. “As we’ve opened new clinics we’ve seen a number of people that had never been seen or delayed being seen with very complex

medical and sometimes mental health issues – and it’s more costly. We grew from about nine or ten percent of patients with insurance to close to 15 per- cent. For newly insured patients it’s meant some peace of mind.”

 

 

Fewer insured people, Higher Costs

She and her community health center peers favor more afford- able coverage to increase the numbers of those insured.

Zetterman said high premiums and co-pays present obstacles that would be lessened if everybody got covered. “The financial burden on the individual patient and family for health- care right now is too high.”

DeBehnke said, “A lot of the

burdens of those premiums in terms of high deductibles and other things have been shifted to families. There has to be some degree of subsidization if we’re going to make this all work. Regardless of where we land with this, the financial burden on the individual patient and family for health- care right now is too high.”

For the poor, the last resort for care continues to be the ER.

“If you’re uninsured the one place you can go in this country is to the emergency room of a hospital because the laws say you cannot turn anyone away from there,” said Zetterman. “As a consequence the uninsured make use of the ER because it guarantees they’ll get cared for – at least at that moment. The ER is the most expensive place to go for things that could otherwise be handled in a healthcare office.”

Zetterman said America’s handling of its social contract and safety net means “we cost shift in the healthcare environment to pay for things.” “In Nebraska, where we didn’t expand Medicaid,” he said, “we cost shift from private insurance and healthcare providers to people who have private insurance. They help pay for the uninsured-underinsured. We’ve estimated that to be well over a billion dollars. We can’t control costs reliably until everybody is in the system with some kind of a paid healthcare benefit. That can include all the current federal and state programs as well as commercial insurance that’s out there.

“Once we no longer cost shift to pay for healthcare we can begin to address the questions where are we spending our money and why are we spending it in those areas. Then we have a chance to control the growth of healthcare costs.”

Skolkin said, “A lot of hands in the pot helps add to the cost. There’s a lot of system inefficiencies, particularly in billing and credentialing, that could be made a lot of easier. That would save resources.”

DeBhenke said, “As the healthcare industry, we have not been engaged to the degree we need to be to actually decrease overall cost of care because frankly from a pure financial standpoint it’s not been in our best interest. The health systems, providers and other organizations have to really get be- hind this whole idea of providing value, of decreasing overall total cost of care while improving outcomes for patients. That’s got to work in parallel with legislative and subsidization levels at the federal level.”

He said until there’s more buy-in from “young invincibles” – 20-somethings in good health – to broaden or balance the risk pool and thus reduce payouts, costs will be a problem.

“Certainly the pricing needs to be attractive to those individuals to broaden the pool. And frankly the benefits associated with products on the exchange need to be attractive so those individuals feel comfort- able and actually want to have coverage. Those least likely to go to the marketplace and buy individual health insurance plans are exactly the people we want to do that to broaden the pool. Healthy individuals that don’t utilize healthcare much soften the financial blow.”

Repeal Without replace is A mess, Why not repair?

The ACA’s meant adjustments from all healthcare stakeholders. Opponents have resisted it from the start and that fight continues. In early January the Republican-led Senate began reviewing ACA to try and garner enough votes to repeal it through the budgetary reconciliation legislative process.

“Unfortunately President Trump has focused on what he’s going to take away without have a plan in place,” said Kristine McVea, “I think that’s been harmful. There’s a lot of fear and uncertainty among our patients. These are people who struggled without health insurance who finally got a chance at taking care of their health and are now very afraid of the possibility that’s all going to be taken away. We hear this every day from people coming into the marketplace and coming into see us for care, I think the capricious statements made by this administration have fueled that.”

More recently, talk of flat-out repeal has given way to amend or modify in acknowledgment of the gains made under ACA and the difficulty of dismantling its far-reaching, interrelated tentacles, absent a ready-to-implement replacement. The political fallout of taking away or weaken- ing protection people have come to rely on would be severe.

“Once leadership has really started to

dig into what it would mean to repeal this outright and try to replace it they’re finding it is not a simple thing to do and the health and coverage of millions of people are at stake,” said James Goddard, an attorney with the public advocacy group Nebraska Appleseed. “So things are slowing down with the recognition they need to be careful with this, and of course they do.

“I think the change in the way it’s being discussed is a reflection of the reality that this is a dramatic thing you’re discussing altering and they need to do it the right way. Much of the ACA hangs together and one thing relies on another and if you start pulling pieces of it apart, you have the potential for the whole thing to fall down.”

Zetterman said he and fellow physicians favor a cautionary approach.

“Most of us would say the Affordable Care Act should be maintained and improved. There are dangers in taking it away and replacing it because it’s now in so many different places.”

Nebraska Appleseed attorney Molly McCleery said total repeal would affect many. “Initial Congressional Budget Office projections show 18 million people would lose coverage, and then in the out years, 32 million would lose coverage – both private and public. The Urban Institute’s state-by- state impact study found 200,000-plus Nebraskans with a pre-existing condition would be impacted if that consumer protection would be taken away.”

Jeff Francis said, “The new ‘r’ word I’m hearing is repair. The consensus seems to be to keep what’s popular and working and change what’s not.”

EDITOR’S NOTE: Details of the recently proposed GOP replacement had not been released as of this printing.

Daniel DeBehnke said of the current climate, “I think it’s extremely confusing because it’s complicated. It’s like a balloon – you poke in one area and something bulges out in another. I think people are frustrated, and rightly so, they pay a lot for healthcare. It’s not just as simple as I-pay- a-lot-for-my-healthcare, ACA is bad, let’s get rid of it.’ There are layers of complexity. We may not like exactly how things are funded or how some components are dealt with. We may not agree totally with all the tactics to get there, but at the end of the day we’ve got more people covered.

I don’t think anybody has the appetite to change that back.

“We just have to figure out how to incrementally lessen the financial burden while maintaining the real goal – more people covered and providing value for the money being spent.”

He said the best course of action now for providers is to “just take really good care of patents and decrease unnecessary utilization and duplication of services,” add- ing, “It’s what everybody wants anyway.”

 

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Fixing the marketplace

Meanwhile, on the insurers’ side, some carriers have left public health exchanges after incurring major losses. This state’s largest healthcare insurer, Blue Cross Blue Shield, opted out of the volatile marketplace.

“Since we started selling on the ACA marketplace we’ve lost approximately $140 million,” executive vice president Steve Grandfield said. “We have a responsibility to all our members to remain stable and secure, and that responsibility was at risk

if we had continued to sustain losses. The public marketplace is unstable, which has driven increased costs and decreased com- petition and consumer choice. The higher premiums go, the more likely people, especially healthy people, drop their coverage. That means the majority of people remain- ing on ACA plans are sick, with increasingly higher claims, which drives premiums up even further.”

He cited instances of people gaming the system by buying plans when they need care, then dropping them when they longer need it.

Granfield said Blue Cross supports a well modulated ACA overhaul.

“It’s important to put in place a smooth transition. We would like to see regula- tory authority for insurance returned to the states, including rate review and benefit design and closing the coverage loopholes that lead to higher consumer costs.”

He has a long wish-list of other changes he wants made.

The leaders of two major Nebraska health provider systems say they haven’t seen any impact from the BCBS defection because there are many other insurers and products on the market. The executives were not surprised by the move given the fluid healthcare field.

Nebraska Methodist’s Jeff Francis said, “There were a lot of unknowns. I think it takes several years through the insurance cycle to be able to correct those kinds of unknowns, especially the way the federal government handles the bidding and setting of rates That’s why you won’t see craziness or changes in the rates in the years to come because they now have several years of experience with this new population and they’re then able to price accordingly.”

Daniel DeBehnke of Nebraska Medicine said, “Regardless of what happens in Washington, if the exchanges are kept in place there will be some changes made either in the pricing or pool that will help organizations like Blue Cross perhaps get back in that business.”

Quality Health Care Starts with Collaboration

Collaboration is key for containing costs in a system of competing interests. More U.S. healthcare decisions are happening outside silos.

Francis said, “A big change in the last 10 years is opportunities to work more collaboratively. In the past it would have been much more stand-alone. Now the hospitals and physicians are working more closely. Nebraska Methodist is part of an account- able care organization – Nebraska Health Network, along with Nebraska Medicine and Fremont Health. We recognize the importance of learning better practices from each other so we can pass that along to make healthcare better for the community and for employers paying for their employees insurance.”

One result, he said, is “less antibiotics pre- scribed by our family doctors at Nebraska Medicine and Methodist Physicians Clinic.”

I’ll Be Seeing You, An Alzheimer’s Story


Alzheimer’s scares me.  I suspect it does many people.  I cannot hardly think of anything more devastating or tragic than having your mind slip away or watching helplessly as a loved one’s mind fades into confusion, and ultimately oblivion. All of which is to say I was a bit queasy when I got the assignment to profile a woman with Alzheimer’s, or more accurately to profile a family and their odyssey with the afflicted loved one in their care.  But I was struck by the love this family has for each other and for their beloved Lorraine, who was variously a wife, mother, grandmother to them. The way they rallied behind her is a testament to the family.  Of course, not all families are as close or loving, and not all Alzheimer’s victims are fortunate to have such attentive support.  If you’re in the mood for a sentimental story that is based in fact, than this might be your cup of tea.  The piece originally appeared in the New Horizons.

 

 

I’ll Be Seeing You, An Alzheimer’s Story

©by Leo Adam Biga

Originally published in the New Horizons

I’ll be seeing you in all the old familiar places, and in all the old familar faces…

Blessed with the voice of an angel, the former Lorraine Clines of Omaha enchanted 1930s-1940s audiences with her lilting renditions of romantic ballads as the pert, pretty front singer for local bands. Billed as Laurie Clines, she was also featured on WOW radio’s “Supreme Serenade,” whose host, Lyle DeMoss, made her one of his “discoveries.”

From an early age, she used her fine singing voice to help her poor Irish Catholic family get by during the Great Depression — winning cash prizes in talent contests as a child and, after turning professional in her teens, earning steady paychecks singing with, among others, the Bobby Vann and Chuck Hall orchestras at area clubs and ballrooms. After the war, she gave up her performing career to marry Joe Miklas, an Army veteran, semi-pro baseball player and Falstaff Brewery laborer. The couple raised seven children and boast 17 grandchildren.

The memories and meanings bound up in such a rich past took on added poignancy at a recent Miklas family gathering during which Lorraine, a victim of Alzheimer’s Disease since 1990, sang, in a frail but charming voice, some standards she helped popularize in the big band era. Her family used the occasion to preserve her voice on tape, thus ensuring they will have a record of her singing in her senior years to complement the sound of her voice on platters she cut years before. While even advanced Alzheimer’s patients retain the ability to hum or sing, Lorraine has clung to music with an unusual ardor that reflects her deep feeling for it and the significant role this joyous activity has played in her and her family’s life.

“There was always music in the house — singing, records, dancing,” daughter Kathy Miklas said. “When we were little we each learned two songs Mom recorded, “Playmate” and “Little Sir Echo,” and we all learned how to dance to “Ball and the Jack.” At their mother’s insistence, the Miklas kids took piano lessons and at their father’s urging, they played ball. “We really were lucky Dad loved sports and Mom loved music. It was a great combination. They made sure we did both. It was a nice foundation to have,” daughter Theresa Ryan said, adding the family participated in neighborhood talent shows and competed in softball leagues as the Miklas team.

 

 

 

 

Even though she went from headliner to homemaker, Lorraine never stopped making music. She harmonized doing chores at home. She sang lullabies to her kids. She broke into tunes on holidays and birthdays. Away from home, she taught music at St. Adalberts Elementary School, vocalized in the church choir, led singalongs on family road trips and performed for her children’s weddings. Ryan said she and her siblings knew that whenever Mama made music, she was in a merry mood.

“You would get a yes if you asked her a favor while she was singing. You knew that was a good time.” Even now, despite the ravages of Alzheimer’s, music continues to hold a special place in Lorraine’s mind and heart. In a reflective moment one September Sunday afternoon Lorraine commented, ‘We gotta get all the music we can.” And then, as if remembering how music enriched life for her and her family despite scant material comforts, she said, “We haven’t had a lot of other things, but we sure have had a lot of music.” Accompanied on piano by Carolyn Wright, Lorraine found most of the words, with some prodding from husband Joe, to ballads like “I’ll Walk Alone” and “Girl of My Dreams.” When she got around to singing the bittersweet “I’ll Be Seeing You,” which is about being true to an absent loved one, Joe broke down in tears — the lyrics hitting too close to home.

“Not having her around” is the worst agony for Joe, who loses a little more of his wife each year. “It’s hard to live alone,” said Joe, breaking down with emotion. As he has seen Lorraine slip further and further away into the fog that is Alzheimer’s, he has had to content himself with memories of “the good old days.” He said, simply, “We had some good times.” A son, Joe Miklas, Jr., said the cruel reality of the degenerative disease is that it feels like losing a loved one, only the afflicted is not dead but stranded in a dementia that makes them increasingly unreachable. unknowable, unrecognizable. They are present, yet removed, their essence obscured in a vague shadowland of the mind. “Physically, she’s there, but she’s not Mom anymore. We’ve lost our mother and yet she’s still here.” Kathy Miklas describes the experience as akin to “a slow grieving process.”

Bill Miklas, the youngest among his siblings, is convinced his mother is, on some level, aware of the prison her impaired brain has confined her to, although she is unable to articulate her predicament. Evidence of that came only last year when, Kathy Miklas said, her mother confided to her, “‘I think something’s wrong with me, but I don’t know what it is. It makes me feel bad that people are having to do things for me that I used to have to do for them.’”

The sad thing, Bill said, is “this disease has forced her to be isolated, not only from those around her, but from herself. She has to live within her world. She has to travel this journey, for however long, by herself. It must be very frustrating to her to realize when she talks she’s not making sense. She can see the reactions on our faces, but her pride won’t allow her to show she’s debilitated. It’s hard for her to look me in the face and say, ‘I don’t remember your name.’ Yet even as debilitating as this disease can be…she still likes to sit and talk, and she’s still a happy person.”

As Alzheimer’s evolves, its victim presents changing deficiencies, behaviors and needs. Mirroring the patient’s own journey are the changing emotions and demands felt by family members. Just as no two sufferers are alike, the experience for each family is individual. Every step of the way, the Miklas clan has made Lorraine’s plight a family affair. “Everybody just kind of took their part in it and did what had to be done,” said Ryan. “I don’t know what I would have done without them,” Joe said of his family’s pitching-in. Not everyone always sees eye-to-eye on how to handle things, but the Miklas’s remain united in their commitment to do right by Mom. And, no matter what, they’ve stuck together, through thick and thin, in illness and in health. “We’ve kind of become our own support group,” Joe, Jr. said. “We don’t always agree, but we always communicate, which is the key.”

Married 54 years, Joe and Lorraine hail from a generation for whom the vow “for better and for worse” has real import. That’s why when she was stricken with Alzheimer’s he put his life on hold to become her primary care giver at the couple’s home, where she continued living up until about a year ago. Lorraine’s first symptoms were shrugged off as routine forgetfulness, but as her memory deficits and confused states grew more frequent and pronounced, her family could no longer ignore what was going on. It all began with Lorraine making repeat phone calls to family members without knowing who she was dialing and not remembering she made the exact same call just minutes before.

Ryan said, “At first, we laughed it off among ourselves. It was like, ‘Oh, did Mom call again to ask who’s making the turkey for Thanksgiving? I told her 10 times.’ And then, we got a little upset with her. We’d say, ‘Mom, would you pay attention. You’re just not listening.’ There were other signs. Normally a precise, productive person who kept on top of her large family’s many goings-on, she could no longer keep track of things. She let the house and herself go. She grew disorganized. And she seemed to just shut down. “I think one of the things we first started noticing is that she just wasn’t doing as many things as she was doing before,” Kathy said. “One of the striking differences was she’d always been very organized and efficient” but not anymore.

Concerned, Kathy convinced her mother to be evaluated by the University of Nebraska Medical Center geriatric team. “When the doctors said she didn’t have any physical reason for this — that it’s probably Alzheimer’s — I was totally shocked,” she said. The entire family was. Lorraine went on living at home with Joe. “I think our family…was in denial,” Bill said. “We didn’t want to mention Alzheimer’s in front of Mom. I think a lot of us thought there was a mixed diagnosis. That, you know, it’s not really Alzheimer’s — Mom just forgets things. It’s not that big a deal.” From denial, the family gradually accepted Lorraine’s fate, the diminished capacity that accompanies it and the demands her care requires.

To get to that point, however, the Miklas children first had to come to terms with how their mother’s condition was affecting their father. “We were all kind of going on with our lives,” Ryan said, “but I don’t think we were focused too much on the disease because Dad was there to do the day to day caring.” As the disease progressed and Lorraine grew more unmanageable, the job of caring for her 24/7 consumed Joe’s life. He halted his active recreational life to attend to her needs. “Dad started to give up a lot of the things he likes to do,” Ryan said. It got so that it was dangerous leaving her alone, even for brief periods, and no longer possible for anyone untrained like Joe, now 79, to always be on call. Overwhelmed by it all, he could no longer hack it alone, and that’s when the family began the long, winding odyssey to find the right care giving situation.

 

 

 

 

Kathy, a private practice speech-language pathologist, steeped herself in Alzheimer’s — from possible causes to drug therapies to support services to care providers. “I felt like I could deal with it better if I understood it. So, I started talking to the Alzheimer’s Association and reading lots of stuff. As a family, we shared information about what Alzheimer’s is and what goes on with it. I didn’t want to miss an opportunity to do something or to have something because we didn’t know about it.”

Family members also attended conferences to glean more understanding — from health professionals and family care givers alike — about what to expect from Alzheimer’s and what adjustments the family could make to ease things for themselves and for Lorraine. For further insight about her condition and how to manage it, they consulted one of the world’s preeminent Alzheimer’s experts, Dr. Patricio Reyes, director of the Center for Aging, Alzheimer’s Disease and Neurodegenerative Disorders at Creighton University Medical Center. “We just lived and made adaptations and accommodations as needed,” Kathy said. “We knew not to ask Mom to do certain things because she wouldn’t remember them and we reminded her to do things she maybe still remembered how to do.”

The family explored several care giving options: first, enrolling her in a respite day care program; next, arranging for a home health nurse to come each morning to assist with her personal needs; and, then, when respite/home care was no longer sufficient to accommodate her unfolding illness, they sought more intensive aid.

“In November, we decided it was not a good idea for Dad to have to constantly be on duty all the time,” Kathy said. “We could see his health deteriorating from the stress…so we started looking at nursing homes.” Lorraine was placed in one, but the family found its medically-based approach and strictly-regulated environment stifling for their mobile, verbal, social mother, who felt uneasy in such a restrictive setting.

According to Kathy, the site “just wasn’t set-up to handle somebody like Mom. They had everybody get up at seven, eat breakfast at eight and go to bed by seven-thirty. Well, having been a singer — Mom never gets up at seven and she’s used to going to bed at about one o’clock in the morning. Plus, they had her heavily medicated. One night, they called and said, ‘Your mom is having a behavior episode we can’t manage.’ Well, I got there and she was having ice cream with a nurse. She was fine. Mom was very frustrated because in her mind this was her house and at night she got terrified. She would ask, ‘Why are all these people in my house?’ After a month of that place, we decided it wasn’t working out.”

Searching for the best care facility for a love one means weighing many complex issues and making many difficult decisions, not the least of which are financial. Although the nursing home was unsatisfactory, it did have the advantage of being Medicaid certified. As the Miklas’s looked around for an alternative, they discovered most quality care centers do not accept Medicaid patients, are cost prohibitive on a private pay basis and, even if the family could afford to pay privately, they would face a two or three-year waiting list.

“We were struggling with what we were going to do,” Kathy said. That’s when they found new hope and the right fit in Betty’s House, a residential assisted care facility, where Lorraine resides today. Where, at the large, institutional nursing home, Lorraine was anxious and irritable, the family has seen “a dramatic difference” in her mood at Betty’s House, Kathy said, adding: “It’s been a godsend. It’s small and home-like, not like a nursing home. The lady who runs it, Mary Jo Wilson, cared for her own Alzheimer’s-sticken mother for 10 years. She knows how to do Alzheimer’s. She knows what you say, when you argue, when you don’t argue, what’s important, what’s not important and she teaches her staff…that you give residents praise and tell them how happy you are they’re there, and I really think that positive feedback is part of the reason Mom’s been so calm and so happy the past few months. She’s doing well.”

And, relieved from the pressure of daily care giving, Joe Miklas began doing better, too. “Now, he can relax,” Kathy said.

Joe is just relieved Lorraine is situated where she seems at peace. “She’s safe. She seems to be happy,” he said. “They’re very good out there. The owner does a hands-on job. She’s always around, supervising things. She’s got some good help. It makes a lot of difference. I try to make it out there every other day if I can. Lorraine talks about coming home, and I’m not sure whether she has this (he gestured to mean their home) in mind or what. I thought she considered that (Betty’s House) her home. It’s hard to know.”

He does know she’s content whenever she breaks into song, as she did upon overhearing a conversation he had with another visitor to Betty’s House. “We got to talking about music when Lorraine suddenly sang ‘When Irish Eyes Are Smiling’ and she just took it up right from there.” Anything Irish elicits a response from her, said Kathy. “She’s always been passionate about her heritage. St. Patrick’s Day was a big day at our house. She’d sing Irish songs. Even now, when you mention something about being Irish, she’ll go into her version of an Irish brogue” and maybe start up a song.

Music remains a vital conduit to the past. “Still, in spite of all the things she can’t do, if you put a microphone in front of her, she turns into Laurie Clines, the singer,” Kathy said. “Her body moves as a singer. Her voice changes and her intonation, her breath and her rhythm become that of the singer again.” This transformation was evident the night son Tim Miklas appeared with his band, the Pharomoans, at Harvey’s Casino. “I went down into the crowd where Mom was and we sang “When Irish Eyes Are Smiling” together. That was pretty special,” Tim said.

Family and faith have defined Lorraine’s and Joe’s lives. Growing up within blocks of each other in south Omaha, each lost their father at a young age and each began working early on to support their family during tough times. They attended the same school and church, St. Adalberts, but didn’t start dating until after the war.

“I thought she was the prettiest girl in school,” Joe said, “but I didn’t think I had a chance to get a date with her, so I just kind of put it out of my mind.” After marrying and starting their own family, the pair made sure all their kids attended parochial school, scraping together the tuition from his modest Falstaff salary, and even saved enough for family vacations. “Family was very big to her and she passed that on,” Theresa Ryan said. “I think they both wanted that family environment and worked very hard to achieve it.” Bill Miklas added, “One of their man ambitions was to raise a great family, and I think they did a wonderful job.”

Through the process of Lorraine’s sickness, the Miklas’s, always close to begin with, have drawn ever closer. If there’s anything they’ve learned about dealing with a loved who has Alzheimer’s it is, Tim Miklas said, “to try to maintain the courage to go on and make sure that person is still a member of your family. Maintain your relationship with that person as much as possible. At some level, some of the things get through to them.” Whatever the family occasion, Joe knows his wife still “wants to be part of it, that’s for sure.”

Kathy Miklas advises others to “really value the time and the experiences you have with your loved one because you don’t know what it’s going to be like three months or six months from now. Like many people with Alzheimer’s, physically Mom’s going to last a lot longer than she is mentally.” Another piece of advice she has is: “Give people choices. Give people dignity and the ability to have some control over their lives. For example, giving my mother the choice of when gets dressed eliminated a lot of arguments.”

In the end, this Alzheimer’s story is about the enduring love of a man and a woman and of a resilient family. “Theirs was a very subtle love,” Bill Miklas said of his parents. “It was something you always felt. The same with the faith they lived. It was a constant. There was never a question — never a doubt. It was a very stable reality. I think Mom taught us a lot about faith and about commitment — to ourselves and to our family. She taught us not to focus on what you don’t have but to enjoy what you do have and to find the value in that. Somehow, if I can take that to my family than that will be Mom’s greatest legacy.”

I’ll see you in the morning sun and when the sky is grey.  I’ll be looking at the moon, but I’ll be seeing you…

ER, An Emergency Room Journal

June 16, 2010 1 comment

picture disc.
 The camera rolls as emergency room trauma team goes into action.

To be honest, I was hoping for something dramatic to happen in the ER that agreed to accommodate for a few nights my hanging around, asking medical staff and paramedics and patients questions and taking voluminous notes. Nothing much did.  That is to say, a stream of patients came through presenting all manner of problems, but nothing over the top sensational occurred.  I think I still managed a good story out of the assignment. You be the judge.  The article appeared in The Reader (www.thereader.com) as a kind of companion piece to another story I did based on ride alongs with paramedics.  You can find the paramedics story on this blog as well. It’s titled “Merciful Armies of the Night.”

ER, An Emergency Room Journal

©by Leo Adam Biga

Originally published in The Reader (www.thereader.com)

 

Hours of Boredom and Minutes of Terror

Hollywood portrayals of hospital emergency rooms depict white hot action zones where medical drama and staff intrigue continue nonstop. What’s a real ER like? Recent visits to the NHS University Hospital ER found a medical treatment center, social laboratory, educational classroom and last refuge all in one. An intersection where the gallery of humanity meets and various trends surface. A mission, a haven, a hell. Or, as one ER nurse put it, “We deal with the heart of Omaha here.”

Like many staff, nurse Susie Needham feels the ER is THE place to be on the frontlines of medical care due to its fluid nature, one she summed up as “hours of boredom and minutes of terror.” Unlike television’s ER, long tedious stretches can grind by before a single trauma arrives. Then again, a run of critical or extreme cases can suddenly pile-up, kicking a slow shift into high gear. As Needham put it, “From moment to moment, it can change.

Most people that work here are attracted to the fast changing pace and the variety of different patients we see. It’s never the same. You have to know a lot about a lot of different things, and that’s what keeps you on your toes. It makes it interesting.” On a Friday night in April Needham, a pretty freckled blonde with an impish smile, tended a diverse mix, including a bronchial pediatric patient with difficulty breathing, an adult drug abuser suffering withdrawal pangs and a drunk woman ostensibly there for stomach pain but whose battered body and frayed psyche told a more sinister story.

For the most part, ERs treat a procession of fevers, coughs, sprains, aches, cuts, bruises, breaks. Purely routine stuff. Unless it’s happening to you, of course. Since one person’s trivial complaint may be another’s dire crisis, everyone is treated the same. No condition is refused. Nothing is taken for granted. Trained to assess and treat serious problems, medical staff try first ruling out any life-threatening cause before looking at non-critical or non-medical issuses. Most ER medical staff possess extensive critical care backgrounds, but it seems all ERs (the step-child of acute medical care) are not equal.

“Unfortunately, emergency medicine is still the only speciality where you just need a license to practice, so it’s kind of a buyer-beware situation,” said NHS Chief of Emergency Medicine Dr. Robert Muelleman. “At University, we require physicians be board certified in emergency medicine (spending a minimum three years residency in emergency medicine and passing written and oral exams). It helps ensure a certain standard of care or level of competency. Nationwide, probably only between 50 and 60 percent of practicing emergency physicians are board certified, but I think there are more, better trained board certified physicians today than there were 10 or 15 years ago.”
picture disc. On busy nights (Sundays are worst) patients stack up and long waits ensue. Triage nurses sort cases on an as-needed basis, with the severest seen promptly and the mildest set aside for a kind of walk-up window service, Fast Track. But again, unlike TV, where patients sweep through the ER unchecked, the real world entails staff documentation-communication for all patient admissions, treatments, releases. In terms of volume, University Hospital recorded 27,018 ER visits last year, a slight rise from 1998. Traumas typically account for about 3.25 percent of all cases.

Not long past dusk on St. Patrick’s Day things were unwinding surprisingly slowly in the ER considering this was a designated trauma night (meaning area rescue services were to feed trauma patients there) on a Friday holiday known for alcohol-related injuries. Earlier in the day, staff treated a 43-year-old Omaha man knocked unconscious in a bar fight. Michael Kimball was brought in comatose. Massive swelling in his brain forced doctors to remove his skull to relieve the pressure. (Editor’s Note: Kimball never regained consciousness and, two weeks later, was pronounced dead. Police cited insufficient evidence to file charges in the case.).

Hours later, during a protracted lull, staff lingered about “the hub,” the ER nerve center,  bantering in the irreverent MASH humor used for stress relief. Attending physician Dr. Paul Tran made a colleague, Dr. Rick Walker, envious by describing his sound sleep the night before, a rarity after the rush of a nine-hour trauma shift. When not hanging at the hub or crashing in the staff lounge, docs, nurses, techs and residents use computers and charts to monitor the condition of patients in surrounding non-critical care rooms and trauma bays (a total of 16 beds), to track the progress of lab workups, x-rays or other procedures and to file paperwork. A large grease board hanging high on the wall is smudged with running patient status reports. This checks and balances system aims to avoid patient-bed-meds. mixups

The staff perked up that night at the static-filled emergency band radio (always droning on in the background) report of a CODE 3 (critical medical) case en route, with an ETA of five minutes. Staff are uncanny at hearing the calls headed their way and ignoring the others. The paramedic’s sketchy details described an elderly man who fell and hit his head outside a Bag ‘N’ Save. The man, whom paramedics found minus vital signs, had been shocked back to life. With the clock ticking, Dr. Tran, a slight Vietnamese native with a gentle bedside manner, conferred with colleagues on whether to summon the trauma team, a kind of in-house medical SWAT squad on call to treat the most severe critical care cases, or to handle things themselves.

 

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It Never Gets Better
Dr. Walker, a beefy man whose pockets are invariably overstuffed with paperback novels and stethoscopes, has spent his entire medical career in emergency medicine. He said part of the appeal for him and others is the extreme nature of the work. “I think it’s very challenging, and that’s a large aspect of it. It’s also a big adrenalin rush, and as I’ve assessed my life and career I’ve come to the conclusion I’m an adrenalin junkie, and I think that’s probably what did it for me.”

He said being exposed to the tragedy that accompanies trauma extracts a certain toll:

“You see bad stuff happening here, and it’s stuff that, you know, can make you cry, like kids dying. It’s tough and it can really get to you emotionally, and so what you have to do is build up a wall because otherwise you’d be breaking down every time you saw something like that and you could not function. That wall tends to stay up most of the time and the last few years it’s become an issue in my personal life.” Nurse Jackie Engdahl said it takes a special breed to work there, “Oh, definitely, Type A personalities make good ER nurses. You have to be very aggressive…very assertive because of what you deal with. You deal with not only ill and injured people, but intoxicated people and drug-induced and psychotic people. You gotta love a good challenge and you gotta be strong enough to whip into shape when the going gets tough.”

For trauma nurse coordinator Kathy Warren, it’s a matter of staying focused no matter how horrendous the reality before her. “Some of these cases are just horrible looking when they come in. You just have to totally ignore that and focus in on the task, so whether you’re starting the IV or helping the docs with procedures, you detach yourself and just click into gear. You can’t get nervous. You have a job to do,” she said. Warren, whose job entails her dealing with family members, said staying composed is hard when working with parents who’ve just lost a child. “Sometimes I have to step back for a few minutes and take a deep breath. When I get home after a case like that, everybody knows its been a bad day as soon as I walk in.”

Added Susie Needham, “People think you get callous or something, but you don’t. Some of the things we see are heart-wrenching and no matter how many times you’ve seen them it still really bothers you. It never gets better.”

Things finally began heating up again on St. Patty’s Day once the Code 3 patient was wheeled in on a gurney by paramedics and lifted onto a bed in the T2 trauma bay. The heavy-set man of about 65 lay there in a coma, a breathing tube inserted in his throat and an IV snaked into one arm, his big hairy belly billowing up and down as a bevy of ER medical staff hovered over him to keep him alive. “I need, STAT, six units of platelets…” a nurse called out. “Tell respiratory to bring a vent, please,” called another.

Then, when someone barked, “I need another set of hands up here,” a tangle of arms belonging to eight nurses, techs and docs converged to perform, seemingly at once, multiple tasks, from hooking up a ventilator to running a blood pressure line to starting a new IV to drawing blood to attaching EKG electrodes. “Sir, there’s going to be a tube going down the back of your throat,” one of them said more out of habit than out of any expectation of a response. Lying there, totally exposed and vulnerable, his life completely in the hands of these angels of mercy, the man, referred to then only as John Doe due to a lack of ID, was an anonymous soul brought back from the very brink.

Time is of the Essence
Time is critical in trauma or near trauma scenarios like these. That night’s charge nurse, Scott Miller, said it involves quick, precise coordination and communication. “Everybody swarms in to get the job done as fast as possible. In a case like this you have Dr. Tran coordinating and everybody trying to feed information to him as to what they’re finding at the same time as they carry out his orders.”

When the whole trauma team is activated, a whole slew of specialists — from surgeons to anesthesiologists to radiologists to lab techs — converge on the spot, making teamwork even more essential. According to Kathy Warren, “You have a lot of people and everyone has a different role and, hopefully, they know their role so they’re not getting in your way and you’re not having to tell them everything. It usually works pretty well, and it’s amazing the amount of things that can be done for a patient in a short amount of time when you absolutely have to. But that’s what a trauma center is supposed to be able to do.”

 

 

Image with caption: Members of the emergency department gather to mark the department's millionth patient since the merger.

Members of the emergency department gather to mark the department’s millionth patient since the merger.

 

 

Emergency care often starts with the rapid response of rescue squads on the scene. Paramedic Tom Quinlan was among those responding to the 911 call that found Doe lying unconscious. “He was not breathing. He didn’t have a pulse. So we started our CODE 99 (for clinically dead cases) protocol, which is intubate him, start an IV and do CPR. We ended up shocking him a couple of times. We finally got a pulse back and he continued to breathe for us on the way to the hospital,” he said.

Added Dr. Tran, “Time is of the essence here. After so many minutes, it doesn’t do any good, so it’s all speed and skill. The man probably experienced sudden death when his heart went into fibrillation, meaning it didn’t pump any blood and, so, the brain promptly became unconscious and he fell down and hit his head and only by actions of the paramedics did he come back. He was extremely lucky to have had everything done in that time, otherwise he would be dead by now.”

Dr. Tran said the fall resulted in “about a five-centimeter hematoma on the back of the head.” Since Doe was found unresponsive and bore a scar on his chest indicating a history of heart surgery, the question on Dr. Tran’s mind was whether the patient’s vegetative state was due to the fall or to some new cardiac event. Not wanting to overlook a potential cerebral cause, he called in part of the trauma team after all. As Scott Miller, explained, “We’re assuming now he had some sort of heart event that caused him to fall and hit his head. We will be doing a CAT Scan to make sure there’s not something else going on, like a big bleed in his head. We don’t think that’s the case, but you can’t always tell for sure.”  Later, it was confirmed a cardiac event did trigger the trauma.

As for the long-term prognosis, Dr. Tran said, “I’m not sure of the condition of his brain function later on.” By then, Doe was identified and his family contacted by nursing resource coordinator Regina Christensen, who met with family members. Part of hers dutie entails fielding inquiries from news hounds looking for material. She noted with incredulity some sound disappointed when a case is upgraded from critical to stable condition.

When treating a trauma, there is no room for bruised feelings. The required care  must be delivered NOW. Hashing out differences can come later. One of the reasons nurse Jackie Engdahl likes working in the ER is the maturity of the people working there. “When I worked in other hospital areas there were very clashing personalities and people always bickering back and forth. But here, it’s not that way. You say whatever you want to say to someone and then it’s over and done with. There’s never hard feelings.” And, she said, where some physicians resent or reject nurse input this ER’s docs welcome it. “The doctors here work really well with the nurses. The doctors trust our judgment and they really listen to us. They allow us to do a lot of things, which is nice.” What about departmental romances? “There used to be between the nurses and paramedics,” nurse Janie Vipond said. “It just depends on the group you have at any given time. But, yeah, it happens.”

I Felt I Was in Good Hands
Amid the controlled chaos of an unfolding ER trauma, staff attend to myriad details, not to mention other patients. For the trauma patient whose life hangs in the balance, it can be a surreal experience of wailing sirens, flashing lights, antiseptic smells, probing instruments, strange faces and endless questions. There is fear, confusion, agony. There is even a strange sense of peace. Beverly Harter, a 62 year-old wife, mother and grandmother, has been there. How she got there is a story in itself.

On May 16, 1999 the Logan, Iowa resident was attending a graduation party at the nearby trailer home of a daughter. Various family members and friends were present. The weather was threatening that afternoon. When the sky turned ominous and a tornado warning sounded, the 12 partiers fled the trailer for their cars in an effort to outrun the storm. But it was too late. With a twister bearing down, they left their vehicles to take refuge in a roadside ditch. Huddled on the ground, exposed to the savage winds, the group was deluged by parts of farm machinery ripped asunder in the cyclone and propelled like shrapnel. The metal shards rained down on them, tearing skin, cracking bone, crushing organs.

When it was over, Beverly’s daughter was dead and two grandkids, both injured, left motherless. Her son endured a broken clavicle. A family friend died. As for Beverly, she suffered a punctured diaphragm, a perforated bowel and two crushed vertebra. Her house was leveled. Ironically, the trailer escaped unscathed. Transported by a local rescue unit to Missouri Valley, Beverly was then taken by ambulance to the nearest trauma center, the University Hospital ER.

Beverly, who remained conscious during much of her ordeal, did not have to be told she was badly hurt. “I knew I’d suffered spinal cord damage because my legs were on fire, and they stayed on fire.” she said. She also knew her daughter “was gone” and other loved ones injured. As for her Omaha ER odyssey, she recalls “bright lights,” a sense of “time standing still” and “a lot of people doing a lot of things and asking a lot of questions. I was really hurting and kind of fading in and out from the sedation, but I was able to answer a lot of questions. They explained to me what they were doing at all times, and that was reassuring.”

Indeed, despite her pain and grief, she recalls feeling calm. “You just have a sense that everybody’s taking care of you and that they’re all working together doing their jobs. I felt I was in good hands.” She also felt the staff’s compassion. “They were extremely sensitive and caring and protective about what happened to me and my family. They knew the devastation and loss we had. I was just overcome by their concern for our well-being,” said Harter, who today is confined to a wheelchair.

Kathy Warren said she used to doubt whether the time she spent with families who suffered a loss made a difference until her own father died in the hospital and she found comfort in the support her colleagues gave her. “I realized how important it is to have somebody treat you with kindness and to let you grieve however you want to and to explain things to you. Ever since then I’ve really pushed staff here to sit down with families and to talk to them. It’s not an easy thing to do as a medical person. Some people are better than others. But people don’t expect us to be super men and women. To save everybody. They just need us to be there.”

Not all exchanges are so pleasant. Patient complaints over long waits get expressed along the sarcastic lines of, “I’m sure glad I wasn’t dying.” Before things get nasty, staff try defusing the matter. “The basic strategy is to make them see you as being on their side,” said Dr. Bob Muelleman. “On the other hand, you want to be very much in control of the situation. If it’s just a matter of them yelling and cussing at you, well, that pretty much comes with the territory. Once in a while there’s kind of a thrashing or flailing out. If you think there’s the potential of them really getting violent you can call in security or police, but normally you can handle it on your own.”

When care complaints cannot be appeased, they are passed-on, in writing, or addressed on-site by managers like Regina Christensen. “It can be anything from somebody upset that their mother’s IV is out to something as complicated as a gang-related situation where the patient himself or his family is threatening staff. It’s just an array of things,” she said.

The Truth is Stranger Than Fiction
Meanwhile, back on St. Patrick’s, a drunk middle-aged woman involved in a domestic dispute came in with an aching gut. However, the night’s triage nurse, Susie Needham, recognized bruises and marks as signs of physical violence and sexual assault. After questioning the woman, a horrific tale of prolonged torture and bondage emerged that prompted ER staff to follow procedure and report their suspicions to police. Acting on the medical staff’s input two officers, who earlier arrested the woman’s boyfriend on misdemeanor assault charges, returned to open a rape investigation.

According to Needham, “If people come in here with traumatic injuries that don’t really fit their stories, we call the police.” Often, she said, such patients prove to be victims or perpetrators of a crime. Surrounded by staff and police in a room concealed by drawn curtains, the woman cried out, “I can’t take it anymore. I don’t want to take it anymore.”

After examining the woman a visibly shaken Dr. Tran said, “It’s one of the most remarkable cases of domestic violence I’ve ever seen. She has multiple problems. Number one is domestic violence and sexual assault. Number two is chronic alcoholism. Number three is a low platelet count. Number four is what appears to be an upper GI bleed.” As part of hospital policy in such cases, staff called in a domestic violence-sexual assault counselor to apprise the woman of her rights and refer her to appropriate community resources. But, as ER staffers say they’ve seen far too many other victims do, the woman rejected police-medical entreaties to undergo a forensic exam, something required for a criminal inquiry, and declined pressing rape charges. She was admitted and treated for medical problems.

“What do you do?” a frustrated Needham asked. “That’s tough,” Dr. Tran said, “because once enough time passes, the evidence is lost. We can’t do anything. You have to respect the patient’s wishes. Patient autonomy is everything. Why did she refuse? Oh, fear, love rejection, sensitivity. Who knows? Unfortunately, it’s common.”

Bizarre, believe-it-or-not episodes are also common in the ER. Take the time an obnoxious drunk showed up with a fierce but inexplicable pain in his belly. After sleeping it off, he staggered up from his cot and only then did the ER doc notice a speck of blood, on the sheets, which upon closer inspection turned out to be from a tiny hole, splayed by burn marks, in the man’s back. Apparently, he had been shot but was too drunk to recall it. Sure enough, an x-ray revealed a bullet lodged in the abdomen.

Or, take the time a stabbing victim arrived cut entirely from stem to stern, his entire rib cage exposed, yet conscious enough to describe the whole bloody fillet job some whore performed on him. Or, the time a man fell at home on a fireplace iron and walked in the ER with a small wound on his neck which, upon further exam, proved to be a deep puncture penetrating his cervical spine. For Dr. Muelleman, who treated all these cases while working in a Kansas City, Mo. ER, such incidents fall under the heading of “the truth is stranger than fiction.”

 

 

 

 

 

Perhaps the most frustrating cases are those involving entirely preventable injuries, especially those incurred while victims engaged in some high-risk, reckless behavior, like a young man Dr. Muelleman treated in Omaha who crashed his car while out joy riding and ended up paralyzed from the neck down. “I don’t call them accidents anymore,” he said, “because an accident suggests an act of God. I call them injuries because when people put themselves in these circumstances something is going to happen that didn’t have to happen.”

Anybody-Anytime-Anything
As ERs are traditionally the 24-7 stop-gap or catch-all of American medical care, the entire spectrum of need shows up there. In most public hospitals, no one is turned away, regardless of insurance status or ability to pay. “The emergency department is the safety net for many people seeking care who really have no other place to go, said Dr. Paul Tran. “Admittedly, there’s going to be abuse of the resources because this is reserved for emergency cases, but who’s definition of emergency is it? A toothache at 2 a.m. may be an emergency to you, but it may not be to someone else. We are here to take care of people from all walks of life and with conditions as minor as a toothache or as serious as a heart attack. And from that standpoint, it is very satisfying to provide people the last resort they need and to get the instantaneous gratification of turning them around.”

Given its open door policy, “the ER is where you really see the cross-section of humanity and so, if there are social ills, you seem them in the ER,” Dr. Muelleman said. “Some of the ills we deal with are domestic violence, drug and alcohol issues, child abuse, lack of immunization and lack of access to health insurance. Another segment the ER picks up on are the acute psychiatric and homeless populations.” He said in an era of managed care, ERs play an increasingly large social service and public health role. “

So, if we’re dealing with intoxicated people we try to get them in a shelter or detox center. If it’s an abuse case we bring in social workers, police and protective agency professionals. If we’re dealing with domestic violence, we make sure patients understand the resources available to them.” Nurse Scott Miller is “troubled” by how many kids he treats who “are not well cared for” at home and “very frustrated by the large number of people with legitimate psychiatric problems who can’t get seen” due to a lack of psychiatric beds locally. He said, “I’ve spent many hours fighting on the phone, calling medical staff at home, to get people admitted in the hospital when they don’t really have a medical problem. But when no psychiatric place will take them, we can’t just send them home.”

Dr. Muelleman said where ERs have always tried educating patients about prevention safeguards and optional resources, “Some have gone to the extent of smoking cessation and substance abuse counseling. I’m just reviewing a grant for a hospital to screen Type II Diabetes, which is not something you’d traditionally think of as an ER doing. There is a real move toward ERs getting involved with public health, even things like bike helmet giveaways. Some have even gone as far as to give pneumonia and flu shots. Even here, during seat belt awareness week, we do educational stuff to let people know about the importance of seat belts.”

As a survey of ER web sites will attest, there is debate in the medical community over the all-encompassing role of the ER. On this subject, Dr. Muelleman takes a pragmatic position. “You can’t select why people use the ER. Once they’re here, you can’t ask, Why are you here again?, although you may be tempted to. I mean, I support the notion public health policy in America should be changed to help take care of people’s health needs in a more comprehensive fashion than just having them go to the emergency room, but given that’s not the case, the mantra in the ER continues to be — anybody, anytime, anything. That’s exactly what it is. Should we change medicine so that doesn’t happen? Well, yes, we should, but in the meantime we’ve got to do what we can to help people.”

 

Merciful Armies of the Night, A Ride-Along with Paramedics

June 16, 2010 1 comment

To date, the only ride along I’ve done as a journalist was for this story following paramedics.  I enjoyed the challenge of reporting and scene description the assignment presented.  It’s the type of project I do from time to time in order to push myself out of the comfort zone I sometimes get stuck in.  The story, which originally appeared in The Reader (www.thereader.com), was meant to mimic and ultimately transcend the television and film depictions of first responders. Perhaps I’ll do a ride along with police officers or detectives sometime.  A companion piece of sorts to this one is also posted on the site — a report I filed based on a few nights observing things at an ER.

 

 

OFD Medic 1

 

Merciful Armies of the Night, A Ride-Along with Paramedics

©by Leo Adam Biga

Originally published in The Reader (www.thereader.com)

The Paramedics Corps
Cutting through the humid summer night, Medic 21 is a rattling five-ton metal box of thunder-on-wheels. The Omaha Fire Department (OFD) rescue squad rushes to another emergency on the near north side. Flashing red, yellow and blue lights pulsate with the same urgency as the wailing siren’s cry that help is on the way.

Two licensed paramedics are assigned Medic 21 on the C shift: Capt. John Keyser, 38, a fair-haired, well-chiseled 12-year veteran of the OFD and Kathy Bossman, 28, a pretty brunette in her third year on the force after a short stint with the Lincoln Fire Department. Partners since last October, the pair work out of a firehouse at 3454 Ames Avenue, one of nine stations in the city housing rescue squads alongside fire engine companies. Anymore, every Omaha firefighter is trained in at least basic Emergency Medical Technician (EMT) skills. Some own intermediate or EMTI ratings. Others, like Keyser and Bossman, are full-fledged paramedics with the most rigorous Advanced Life Support (ALS) training on the force. Paramedics are usually attached to rescue squads, although some serve on fire rigs.

The OFD paramedics corps numbers 147, nearly triple the total from five years ago. Omaha Fire Department Emergency Medical Services (EMS) Battalion Chief Jim Love said this planned jump in personnel came in response to an increasing workload caused by an ever-expanding city: “Last year our medic units responded to 23,558 calls for medical assistance and transported 16,400 of those people. The year before, we responded to 21,272 calls. Our calls are growing at a rate of 4 to 6 percent a year. The population is not only getting larger but it’s getting older, so we’re seeing an increase in the elderly and their associated medical problems.”

Paramedic training is intensive, entailing some 1,000 hours of classroom and field experience, including interning in clinic (hospital) settings and on ride-alongs. A more rigorous curriculum is being implemented in 2001. Omaha EMS Chief Medical Director Dr. Joseph Stothert, head trauma surgeon at NHS University Hospital, said today’s paramedics are more skilled than in the past: “They have better education and better quality assurance in place and I think generally the care in the streets is much better than it was 10-20 years ago. Not only are they able to do more, but they are able to understand more and sort out what’s going on with the patient and to begin treatment before they reach the hospital.” He said things have progressed to the point that medics follow protocols or standing orders to guide their assessment and care in the field where before they called hospitals and awaited orders via radio phone. “Through the years I think the level of confidence has increased in the paramedics because of their training,” he added.

Here I Come to Save the Day
As the gleaming ambulance barrels through traffic (most of which parts to let it past) to the scene of an emergency the vibe inside the squad is part thrilling and part somber as the laconic medics steel themselves for whatever crisis awaits them. With their hearts racing, they are like soldiers driving into a battlefield. Their reactions must be swift. Their minds sharp. As they run through routes and protocols in their head, they keep an eye out for rogue motorists and cock an ear to the radio for updates. They take seriously their role as rescuers. Theirs is a single-minded mission of mercy — responding to a frantic plea for help. It can be anything. A diabetic reaction. An asthma attack. A cardiac event. A gun-shot wound. A personal injury accident. Poisoning. Heat exhaustion. Childbirth. It can be anybody. A child. An adult. Someone hurt in a car, on the street or in their own house. It can be a cop or fellow firefighter, victim or assailant, average citizen or public figure. You name it — these professionals have seen it in the line of duty.

Medics pull 24 hour shifts and no matter when the 911 call comes in — the middle of the night or the fat of the day — and regardless of what it is — a routine health problem or a genuine medical crisis — they show up ready to lend aid. Even when driving conditions stink or the medics are starving sleep, they respond the same. There is a temptation to view them as heroic Calvary riding-in to save the day. That is not how they see themselves, however. “I certainly don’t feel like any knight in shining armor. We’ve just doing our job,” Keyser said. “I really do enjoy helping people. That’s probably the biggest reason why I chose this profession.” His partner, Bossman, added, “It’s nice to be able to help people and to be able to change their life or improve their life in some way. Every time they call us it’s an emergency to them. They appreciate us being there, and that’s a good feeling.”

The anytime-anything-anybody drama of the job is one of its major draws. Even though most runs are routine, no two are ever quite the same. “One of the most appealing things is the excitement,” Bossman said. “It’s a big adrenalin rush. When you get the blood and guts, it makes it more exciting and interesting. You know you’ve got to step it up. You’ve got to move faster. You’ve got to get more things done. You’ve got to use all your skills and training.” Said Keyser, “One of the reasons I went into this is because it’s very challenging. The sleep deprivation is hard to deal with and the stress level is very high.” That stress — of being on call all hours of the day and night to make emergency medical interventions — has a flip side too. “You can get too wrapped up in this job. If you let the pressure and stress mount, all it does is kill you a little bit at a time. That’s why I’ve always thought one aspect of being a good paramedic is recognizing when you need to get away from it,” Battalion Chief Love said. Field medics like Keyser know the demands can overtake them if not careful. “I’ve got at least another 12 years on the job, but I don’t want to be on the rescue squad that long because I don’t want to get burned-out. After a 5-day rotation, I’m exhausted. I have a wife and three kids I want to enjoy,” he said.

On the Run
Medic 21 is among the two busiest EMS units in Omaha. It annually vies with Medic 40, at 45th and Military Avenue, for the title of most runs. The unit is responsible for a wide swath of Omaha — from Bedford Avenue north and from the Missouri River to 72nd Street west. Given that Medic 21 serves a low income area, some residents rely on the EMS system as a mobile clinic and taxi service. “In our territory we seem to have a lot of patients who don’t have transportation to the hospital, so they call 911 even if they have the flu. You treat them the same even though you’re frustrated because it’s 3 in the morning and you’ve seen this patient before and you know there’s nothing seriously wrong with them,” Bossman said. “We tend to see a lot of really young mothers who don’t know much about caring for their kids. We try to educate them a little.” Then there are the repeat customers. “We’ve got quite a few regulars. Most have legitimate medical conditions, but some don’t necessarily take care of themselves very well. They don’t take their medicines like they should and that can worsen their condition.”

Jim Love was a firefighter-paramedic on the streets before taking a desk job. He worked out of Station 21 and said his field experiences there opened his eyes to some things. “I didn’t realize the abject poverty that exists in certain parts of our city until I actively went there, walked into these places, took care of these people and transported them to the hospital,” he said. “I mean, I’d seen poverty on TV and read about it in the newspaper, but until you actually touch it and work with it, you really can’t imagine. For lots of people, we’re their source of medical care. They don’t go to doctors.”

With 3,113 runs made last year by its three crews, Medic 21 is the reigning champ among Omaha EMS units. Through August Keyser and Bossman are averaging 9 runs per 24-hour shift and are 50 ahead of last year’s pace, but on this day (August 10) they are still awaiting their first more than half-way through their shift. “This is highly unusual,” Bossman said. “That’s the thing about this job. A lot of times you’re waiting for something to happen and other times you leave the station and then don’t get back for six hours,” said Keyser. No sooner do the words leave his mouth than an alarm sounds on the overhead speaker alerting personnel to a rescue call. Keyser and Bossman clamber aboard the squad, fire up its engine, roll out of the garage and tear onto rush hour-choked Ames Avenue. With Keyser manning the wheel and Bossman the radio, a 911 dispatcher relays the nature of the call. “Medic Unit 21, there’s a 90 year-female with difficulty breathing…a neighbor became concerned when she didn’t her from her…called police…the female was found on the floor…apparently fallen…police are on the scene.”

Lady in Distress
Less than 10 minutes elapse from the time the call is received to the medics’ arrival on the scene. It is a red brick apartment house at 52nd and Northwest Street. Police cruisers and a fire engine are already there. Curious neighbors and onlookers gather on the small porch or watch from the street corner as Keyser and Bossman stride into the residence carrying an arsenal of emergency medical supplies, including a portable heart monitor/defibrillator and a case filled with meds, IVs, airway supports, bandages, slings, etc.

Police deny access to a reporter along for the ride, citing the tight quarters. The officer guarding the front door, Juan Fortier, describes the situation while Keyser and Bossman treat the elderly patient inside. “A friend hadn’t heard from the resident since Tuesday night at 8. She came by, hollered for her and got no response. She tried entering, but the inside chain was locked. So she called us. We came, we assessed the situation, notified our supervisors what we had and we decided to go ahead and force the lock open. We got inside and the 90 year-old resident was lying on her back on the floor next to her bed with one leg kind of folded up under her. She was still conscious but somewhat discombobulated. She had obviously been there awhile. We just tried to comfort her with our voice and let her know help was here,” he said. Police and rescue squads respond to several such calls each week. Most turn out fine.

Minutes later, firefighters hustle to fetch a backboard and gurney and soon are carrying the patient out on the stretcher, a bag valve mask applied to her mouth, and secure her in place on the squad. With the patient, Olive, designated a CODE 3 (critical condition) Keyser and Bossman tend to her in back while a firefighter takes the wheel. It turns out Olive lives alone and has no family in state. The only prescribed medication found is for some unknown cardiac condition. In cases like this, when a patient cannot provide answers and there is no family member to consult, medics lack basic information to complete a patient history.

Teamwork
“A big part of our job is information gathering,” Keyser said. “Our first job is to assess the patient and determine if there’s a life threatening situation. Then, the most important thing is to find out the history of what brought this person to require our care. We try to get as much of the history as we can for the doctors.”

 

 

 

Firefighters often reach a scene first and provide care up to their level of training. Once medics arrive to take over, firefighters remain to assist — providing extra sets of hands and eyes. This team concept is at the heart of EMS. “Most of us have worked together for a long time and everybody knows what needs to be done,” Keyser said. “Firefighters will get a stretcher or set-up an IV or get oxygen going. If we don’t see it being done, we’ll ask for it.” Bossman added, “The firefighters we work with are real good about helping out. They’ll jump in and do whatever needs to be done.” Love said having EMT-qualified firefighters on-site is essential to the continuum of care that extends from pre-hospital settings to the ER. “The important thing about having EMTs on the fire trucks is that not only do they get there quickly, but they take base-line vitals which give the paramedics something to compare with when they take their vitals. It gives us another indication as to whether the patient is getting better, getting worse or staying the same.”

In critical or trauma scenarios, time is everything. “We’re always racing the clock,” Love said. “Our goal is to get somebody to the patient’s side with at least basic level training within 5 minutes and to get someone there with advanced training within 8 to 11 minutes. We try to reach those goals at least 90 percent of the time.” According to Keyser, “Depending on how critically injured that patient is, their best survivability is if they can be treated in the ER within an hour of their injury. It’s called the Golden Hour. We try to get everything done we can in 10 minutes before the patient is loaded on the squad and we’re on the road to the nearest trauma center. We’ll do everything else en route.”

In Dr. Joseph Stothert’s view, “For about 90 percent of the patients paramedics see, their care is absolutely vital and life-saving, including persons in or near cardiac arrest and persons involved in (serious) motor vehicle accidents. Now that there is a defibrillator on every fire and rescue apparatus, there’s been a steady increase of patients we’ve been able to resuscitate earlier.”

With Olive in tow, Medic 21 speeds to the nearest hospital, Immanuel Medical Center, as Keyser radios her condition: “We’ve got a 90-year-old female who has been down apparently since…” During the bump-and-grind ride Olive is dimly conscious. She cannot speak, responding to questions with only her tired eyes or feeble nods of her head. “Can you point for me where it hurts?” Keyser asks. “Olive? Olive, we’re going to give you some nitro on your tongue. Your lungs are full of water. I want you to lift your tongue up for me. There you go. Good girl. Here it comes. Open wide.” Olive weakly responds. Her mottled face is splayed by vomit and pinched in pain. Her eyes close. She is barefoot. Totally vulnerable. Her vital signs are continually taken and any abrupt changes noted. All the while, Bossman comforts Olive by holding her hand and applying pressure to a bag valve mask over her mouth, timing her squeezes in concert with the patient’s inhalation.

“For the short amount of time you’re with patients you just want to try to do something positive. Sometimes, that’s nothing more than holding their hand and talking to them while you’re riding to the hospital,” Love said.

Keyser tries getting Olive to respond again (“Olive, we’re going to help breathe for you, okay? Olive, can you open your eyes again?”), but she has fallen unconscious. The medics scramble to intubate her with a breathing tube and suction out excess fluid clogging her airway. Amid the cramped space the medics handle equipment and perform procedures in a kind of choreographed dance. They anticipate each other’s moves well. Few words need to be spoken. They work with calm precision and dispatch, forming what Love likes to call “a fine-tuned patient care machine.”

Later, after delivering Olive to the ER, Bossman recaps the run. “She had fallen out of her bed and was on the floor since Tuesday night. She was already dehydrated. She’d been vomiting and had it in her mouth and in her lungs. That caused her to choke and quit breathing. It could have been real bad. If her neighbor hadn’t checked on her and called the police she could have choked to death. She got a little bit worse en route. She quit responding, although her vital signs stayed pretty good. We intubated her to clear her airway. She’s actually pretty stable now. Her airway’s secure. She’s getting plenty of oxygen. They’re going to x-ray her to make sure she didn’t injure her back when she fell.”

Breathing difficulty is a call medics often respond to and make a life-saving difference in. “Outside of critical emergencies, the assessment and treatment of airway problems is where they tend to help people the most, such as people with asthma or people with chronic airway diseases,” Dr. Stothert said. Medics also routinely help diabetic reactive patients make dramatic turnarounds.

Heeding the Call Again
After its crew restocks supplies and completes paperwork in the ER, Medic 21 no sooner pulls out of Immanuel when a new call presses them back into service. It is a  new mother seized by severe back pain. The squad heads east and in no time at all reaches the wood frame residence near 46th and Bedford, where a fire engine crew is present. The petite patient, Sandy Dace, sits in a kitchen chair doubled-over in a spasm of pain. Her tall bearded husband Dennis stands over her, holding their red and wrinkled 5-day old baby boy in his arms. At the bottom of a staircase a boy of perhaps 8 peers with wide-eyed wonder and fear at the rescuers tramping in and out. It turns out Sandy underwent a prolonged labor marked by acute contractions, before a Caesarean section was performed. It is thought her pain is related to the childbirth.

“I got up to go to the bathroom when I heard Sandy crying. I found her just like that. She couldn’t get up. And with him (the baby) here, I had to call somebody. It was maybe 40 seconds before I heard the sirens. It was great when you showed up. You guys are excellent,” Dennis tells the medics. As he follows his wife to the door, he says, “I’ll be up at St. Joe’s as soon as your mom gets here. Okay, dear?” “Okay,” she replies through clenched teeth.

En route to St. Joseph Hospital Sandy grimaces with each jolt during the shake-rattle-and-roll run. She tightly clutches the handles at the side of the gurney to brace herself. “It’s kind of a bumpy ride, so we’ll take it easy on the way there,” Bossman tells her, but while the ride proceeds at a slower than normal pace it is just as jarring as ever. Dace remains stoic, only uttering a sound when answering Bossman, who tries taking her mind off her discomfort with easy chatter.

Built on an unforgiving truck frame, rescue squads are notoriously noisy clatter-traps that ride like bucking broncos. Many have been in service for a decade or more. It is not unusual for odometers to read 100,000 plus-miles. And those are hard, stop-and-go miles. Units often break down with a wide array of mechanical problems, forcing even older, less reliable reserve units into service. “Our rescue squads are on their last legs,” is how one paramedic put it. With so much wear-and-tear, it is no surprise then that perhaps the number one complaint by customers is that “the ride is terrible,” said Love. Squads are nicknamed “puke boxes.” Three brand new units were purchased recently (for $117,000 each) and their increased size and smoother ride makes medics stuck with older models rather envious.

 

 

 

 

The squad transports Sandy Dace to the ER just before 7 p.m. and by the time Keyser brings the empty gurney back out, a LifeNet helicopter lands to stretcher-in a middle-aged patient critically injured in an industrial accident. As for Dace, she is logged in as a CODE 1, which signifies no real medical emergency and no treatment performed in the field. She simply gets a check-up in the ER.

Stories from the Frontlines
On the way back to the station, the medics make a fuel stop at a City of Omaha depot where broken-down cruisers, squads, rigs and plows are warehoused for repairs and spare parts in what is known as “the boneyards.” Life at “21s” or any firehouse is a communal thing. Except for captains, who rate their own rooms, everyone, men and women, share spartan dormitory-style sleeping quarters. It is a high testosterone environment. We’re talking big men wielding axes and saws and handling mammoth rigs.

As the lone female (one of 20 among 600-plus fire division field personnel) Bossman is still something of a curiosity. While a Clint Eastwood pic plays on a big screen TV in the rec room, she explains how it takes a certain kind of woman to thrive there. “If you’re the type who gets real upset at a crude joke, you’re not going to last very long. You can’t be overly sensitive to those things. You just have to go with the flow.” She said when she started she was subject to a “feeling out” process that closely scrutinized her ability to handle the job and to be, “one of the boys,” in effect. “Once they saw I was okay with their cracks and I could pull my own weight, then there was no problem.”

Down time is variously spent doing paperwork (a detailed record of every run must be logged in a book and on the computer), washing down or cleaning out rigs, rapping with the guys, grabbing a bite to eat, zoning out in front of the TV or catching some Zs. When a visitor asks Keyser, Bossman and Love to share some stories from the frontlines, they gladly oblige. Like other EMS professionals, they say the toughest cases usually involve children.

“I remember the first SIDS (Sudden Infant Death Syndrome) case I ever went on. At the time I was an EMTI with a little baby of my own, so it really kind of hit me hard,” Keyser said. Bossman recalls a CODE 99 (CPR in progress) case. “What was thought to have been a SIDS baby was revived but it never regained consciousness. It later turned out to be a shaken baby. That had an impact on me because in the ER I was comforting the mother and father and, later, when I found out it was (allegedly) the parents that had done this to the baby, it really bothered me,” she said.

Suicide runs are hard to forget. “You go there and, of course, there’s nothing you can do. You call the police and while you’re waiting you see pictures on the wall of family and friends. It hits home that this was a human being that had a life. It gets you thinking, What got them to the point they felt they had to do what they did? Those are the ones that really stick with me.” Love said.

Bossman said a disturbing run she and Keyser made was to the residence of a man with critical pulmonary edema. “It appeared to be treatable when we first got there,” she said. “At his house he was talking to us, but then he went downhill real fast in the squad. And at the hospital, despite everyone’s best efforts, he died. Sometimes, despite a perfect treatment, the patient may still not make it. It can change at any time. That affects you because you see this person getting worse and worse, and you want to help them, but you can’t…Over time, I guess you just learn that regardless of what you do the outcome is sometimes out of your control. It’s kind of hard.”

“Bad runs” of this sort often prompt a Critical Incident Stress Debriefing or CISD, an informal talk therapy session for every EMS staffer at the scene. The fire division’s chaplain, Rev.. Chuck Swanson, leads the sessions. Select cases are also chosen for run reviews, where crews and supervisors analyze what went right and wrong.

Ready for Anything
At 8:50 that August night, the crew’s brief R & R respite is interrupted by another call. A young woman has dislocated a shoulder fending off an assailant near 24th and Camden Avenue. She screams in agony, “Oh my God. It hurts. Oh my God.” The police are there sorting out the incident. “They’re are always a welcome sight to us,” Keyser said. The patient, tears streaking her face, screams all the way to Immanuel. This is the first in a series of four straight runs Keyser and Bossman make that evening. Next, it is a young asthmatic, Reggie, with difficulty breathing. He’s tried his inhaler, but it’s brought no relief.

The medics arrive at his house and find a scared little boy struggling for breath. They administer Albuterol with oxygen. He breathes easier but a trip to the ER is advisable. Aboard the squad an IV is started. The medics calm the boy down, assuring him how brave he is. Calming kids is “half the battle,” say the medics. When Keyser asks “Have you ever ridden in an ambulance before?” Reggie replies, “Yeah,” and reminds them they treated him once before — for bruised ribs. On the way to Immanuel a much-improved Reggie points out the rear squad window, shouting, “There’s my mom,” waving to her following closely behind in the family van. Upon arrival at the ER a relieved Reggie announces, “I can actually talk now.”

The last two runs are routine. A woman complains of a host of problems, including difficulty breathing. She is quickly stabilized with oxygen, yet continues acting distressed. Her husband explains, “She gets like this when she’s upset.” It seems the couple had been arguing. The patient declines a trip to the ER. Later, Keyser attributes her symptoms to anxiety, which he said can mimic many medical conditions. Then it’s off to an assault call only two blocks from the Medic 21 home base. Police surround the victim lying in the middle of Ames Avenue. The intoxicated man has been beaten about the face by two or three assailants and has  suffered cuts and bruises. Keyser and Bossman dress his wounds and take him to University Hospital. He smells of alcohol, sweat and blood.

By the end of the run it is around midnight and the medics are ready for a break. “When you’re super busy or you’re up many times over the course of the night you’re sleep deprived,” Bossman said, “and that just makes your reaction time slower. You have to think longer and harder about decisions that during the day might come real quick. That’s when it’s helpful to have a good partner. You work together and figure things out.” When a call awakens crews from a sound night’s sleep it is not uncommon, Keyser said, for hazy mates to slam into doors or each other amid the darkness and the mad dash that ensues to reach a rig or squad.

The wee hours find medics intersecting a surreal scene of crowds hanging out in parking lots or cruising the jammed streets. “It’s a different world down here at night,” Keyser said. “Once, we saw a family pushing a baby in a stroller at 2:30 in the morning.” Added Bossman, “It’s odd. There’s bumper-to-bumper traffic. We somewhat gauge how busy our night is going to be by how many people are out.” At time like these the intrepid medics are urban explorers in search of their next adventure. “It’s always something different,” she said. “Part of being a professional is being ready for anything.”

Seafarer Doug Hiner and His Cuban Medical Supply Runs

May 11, 2010 3 comments

Sailboat in San Francisco Bay

Image via Wikipedia

A couple acquaintances introduced me to Doug Hiner and he immediately got on my radar as someone I’d like to profile when I learned he regularly sailed down to Cuba on missions that were partly about delivering medical supplies and partly about secreting back contraband, as in cigars.  Hiner is a wheeler-dealer type who denied the illegal trafficking at the time I interviewed him, then expressing upset at my story’s suggestion that he engaged in anything like that, but subsequent events confirmed his smuggling activity because he got caught in the act down in Florida and faced serious federal charges.  He pleaded guilty to one count and received 36 months probation.

Aside from the intrigue, which occurred after my story appeared, his story is really a classic tale about his taste for adventure and his passion for all things Cuban.  A version of the following story appeared in The Reader (www.thereader.com).

Seafarer Doug Hiner and His Cuban Medical Supply Runs

©by Leo Adam Biga

A version of this story appeared in The Reader (www.thereader.com)

More than any other country, Cuba both seduces and vexes Americans. This island of paradoxes is at once a natural paradise fulfilled and a socialist promise unrealized. In a place where bare necessities do not go for want, chronic shortages make hustlers out of peasant and professional alike. Within a closed society and controlled economy, anything, for a price, is a black market possibility.

Fidel Castro may or may not own Cubans’ hearts and minds, but the land and culture definitely hold residents and exiles transfixed.

Social/economic problems don’t change the fact that Cuba, at least geographically, is a tropical island idyll. Sun, ocean, jungle, mountains — much of it pristine. Politicians/bureaucrats aside, the people embrace life with a live-and-let-live Latino insouciance. Music, dance, food, art, love, sun, surf. Fun prevails, if not for all, for tourists.

Omahan Doug Hiner sees the schizoid nature of Cuba every time he sails there on his 53-foot cutter, the Vitamin Sea. He captains the Tampa-docked boat on voyages that transport medical equipment to hospitals and clinics on the island. He’s been making runs like this to Cuba for seven years, a period when official American policy toward that intransigent Caribbean nation has gone from rigid to ultra hard-line. Embargoes of one kind or another have limited trade with Cuba and, in some cases, denied aid.

 

 

Doug Hiner

 

 

 

With Fidel’s recent stomach surgery making his mortality and his grip on power a renewed subject of world interest, Hiner prepared for a late December sail to bring in another boatload of supplies. But the gringo’s boat blew an engine, pushing the trip back until this month. He arrived February 10 in Havana, where the gear still sits, waiting for the red tape to be cut so he can move stuff inland.

His artist wife, Christina Narwicz, usually joins him on these maritime adventures but she wasn’t feeling up to it when he shoved off this time around.

The Man and the Sea
Hiner, 67, is a former hair dresser and a retired real estate developer and landlord. He made and lost a fortune. He’s not oblivious to the political realities that hold Cuba hostage in a state of suspended animation. Far from it. He has strong views on what Cuba and its paternalistic neighbor to the north should do to ease restrictions and tensions. His awareness of Cuban medical needs drives his missionary trips there, even as he brings in and takes back his share of contraband.

His journeys go well beyond idol curiosity. Hiner and his wife feel they have a fair handle on Cuba by virtue of not only having traveled there several times — it’s 15 trips and counting for him and about the same for her — but their stays usually last weeks or months at a time. They get around to different parts of the island and really immerse themselves in the place.

“We’re not tourists, we’re travelers,” Hiner said. “A tourist wants to have MacDonald’s no matter where he’s at. We like to enjoy the cultures of different countries and not live like Americans. We try to blend and be friendly with the people, and that’s all it really takes to be accepted. They love Americans, especially if you’re friendly to them. They don’t like the ugly-American types.”

Whatever motivates him, he ultimately makes these journeys because they put him in touch with three of his favorite things — sailing, the sea and people.

Though he grew up in landlocked South Dakota and Nebraska, Hiner long ago felt the call of the open sea.

“I’ve always been fascinated by the sea,” he said, “and I’ve always had this dream of having a boat to sail around the world.”

Years ago he and Christina “were planning to do a sail around the world …” when his “business fortunes changed,” making such a trip “impractical.” Circumnavigating the globe is not such a passion now, not with the expanse of warm southern waters to explore. “You can spend your whole life in an area like that and never see everything,” he said. “The Caribbean is a whole chain of islands. We’ve never been to Colombia or Central America, so eventually I’d like to do that.”

Besides, it’s the carefree, unrestricted, port-of-call lifestyle he enjoys, more than the challenge of seeing how far Hiner can push his sailing skills.

“A boat is like your home. You’ve got everything on it. You’re totally self-sustaining … It’s a real nice feeling,” he said. “You can anchor anywhere you want for nothing. We spent a couple New Years Eve’s anchored off of Key West, one of the liveliest New Years places in the world.”

Still, the allure of cruising wave and wind is like the call of the sirens — hard to resist. Half the challenge is dealing with weather and the other half comes with the inevitable mishaps.

“Weather on the high seas — that’s your biggest danger,” Hiner said. “We’ve gone through some pretty turbulent stuff, some accidentally, some on purpose because we had to. But it’s never been a safety issue. You’re never really out of ear shot of weather” reports via radio/radar.

Nature-related or not, things do go wrong. Take the couple’s 1999 trip to Cuba for instance.

“Going down on the second trip we blew out the sail. We ran into some bad weather. We had to have it repaired. It’s usually mechanical problems. It’s like, not if it’s going to break, but when it’s going to break. The last time we left Cuba the autopilot failed and we had to hand steer for 40 hours. Oh, and coming back from Cuba once we lost our fresh water pump, so we had no engine. There was no wind and we drifted for a day-and-a-half or two days before we finally got close enough to Key West to get a boat to tow us in.

“Our boat is about 20 years old and it needs extensive rewiring and stuff and I really haven’t been able to afford that, so we just kind of patch things together. It’s safe but it’s always a little bit of an adventure.”

Sea-faring is an apt avocation for an inveterate beach bum who, whether inland or coastal, enjoys kicking it with friends over drinks in the Old Market, where he developed some of the first condos, or partying on his boat.

He enjoys the simple, well-done pleasures of good food, good drink and good company. His wife’s the same. The residence they fashioned from an old brick-faced bar and parking lot on South 13th Street reflect their shared interests. The grounds’ richly decorated Great Wall that fronts 13th Street has a gated entry whose mammoth door opens onto a large courtyard filled with her plantings.

Hiner’s no stranger to graceful living, as he once owned a Fairacres mansion “back,” as he likes to say, “when I was rich and famous.” He made big bucks and moved in tony circles in the ’70s and ’80s. Then it all crashed. He alludes to a business partner running his development company into the ground.

The house, featured in the Spring 2000 edition of Renovation Style magazine, is designed with walkouts along the length of the courtyard that connect to a wood deck, creating a veranda. The interior opens up to a loft master bedroom and guest quarters, revealing a 32-foot-high ceiling and a bank of large windows that stream light in. At one end of the property is a screened-in porch. At the back of the lot is Christina’s well-lit studio. It all works toward a cozy hacienda feel.

As soon as he laid eyes on the spot he knew “it was exactly what I had in mind.” When he bought the former Glass Front Bar it was only a shell. But, he said, “I had this vision.” He designed the place himself. The work fit neatly into his years of “retrofitting old buildings. I’ve always had a knack for design and style and just living comfortably.” The result, he said, adheres to “the European concept of zero lot lines…where you basically use the whole property. We don’t have a back yard or front yard or side yard — we have a court yard. The same with our house. We utilize the whole house. We don’t have formal spaces. It’s just more practical and creative in my estimation. It’s just a feeling of well-being.”

His passion for this getaway within the city dovetails neatly with his ardor for Cuba. It always comes back to communing with people.

“It’s just a wonderful country. The people are so friendly and so caring and loving,” he said. “It’s hard to explain. I’ve traveled all over the world and I don’t think I’ve ever been to a country that is so warm and safe. There’s virtually no crime in Cuba. It’s true there’s a policeman on almost every corner, but the people there are so law-abiding. They’ll steal, but their attitude is, ‘If you don’t lock your bicycle up with a chain or padlock, then you must not want it.’ I’ve never had anything stolen off my boat in the marina and I can’t say that in almost any other country.”

Years living under the thumb of a dictatorship has its palliative effects.

“If a policeman on the corner points to a driver and signals him to stop,” Hiner said, “he’ll almost come to a panic stop to obey the order. They wouldn’t even think of not [stopping]. A police chase over there would be unheard of.”

Back to the contradictions bound up there, he said Cuba can seem chaste one minute and carnal the next. “It’s a real straight-laced island. Pornography is totally illegal. Drugs — zero tolerance. One marijuana cigarette would throw you in jail for a week before you’d be expelled from the country and told never to come back.” On the other hand, he said, “Cuba’s a very sexually open country. Even though prostitution is illegal…a lot of people are shocked by the young women that are readily available for sexual encounters. One, there’s a serious lack of men on the island. And two, their culture is not uptight about sex at all. I mean, geez, if some foreigner wants to give you twenty bucks, that’s even better.”

Besides, he said, “Cuba’s all extended families — there’s four-five generations that live under the same roof, and so it’s everybody’s responsibility to help support the family group.”

While Cuba prides itself on a system that accounts for citizens’ basic needs, rampant poverty compels most everyone to be on the make.

“You see very little begging, yet the young Cuban kids and the old folks are out hustling for the family,” Hiner said. “Everybody is sort of doing whatever needs to be done to provide extras. They have to have some access to dollars to really have any quality of life.”

Amid all this naked human need, Cuba takes great pains to put on a good face. “They sweep each block of Havana every day. If you don’t have anything to do, they’ll put a broom in your hands,” he said.

By Western standards, he said, Cubans lack everything we take for granted. He tries to give friends there some creature comforts otherwise unavailable to them.

“I’ve taken personal things down for people, like a microwave oven or VCR or DVD player, because all that stuff is illegal. Everything’s illegal in Cuba. Mainly, if it plugs into the wall, it’s illegal. They have an energy problem and they’re just trying to keep people’s lives basic.”

 

 

Even more basic than that, he said, he brings items like toothbrushes and razor blades that are “not a big deal here, but are a big deal there.”

He’s also brought back, on consignment, works by Cuban artists he and Christina sold in Old Market art shows, the proceeds going toward supplies for the artists.

Beat the Bushes, ‘Bend a Few Rules’
He’s sympathetic to the plight of the Cuban people, whose deprivation goes deeper than a lack of material things, to essential services. Sure, Cuba provides free health care, but many clinics and hospitals lack equipment and technology that can not only improve care but save lives. And while average Cubans and natives of nearby Latin American countries have access to free care, some medical centers are reserved for the elite. It’s why he got involved as a medical supplier in the first place. His awareness began on his inaugural visit to Cuba in 1998. The marina in Havana introduced him to fellow travelers, including many Americans, some of whom became a model.

“I met a lot of people that first time. A lot of just normal people. Some were bringing medical equipment on their boats down there,” he said. He soon discovered an informal network of doctors and suppliers. “As I met people in the marina and friends of theirs I was put in touch with various doctors and got lists of things they needed.”

Over the next year Hiner beat the bushes and made contact with “various organizations” that run aid into Cuba.” He cultivated the names of key suppliers, like Jack Oswald in Chicago, and key recipients, like surgeon Gilberto Fleites in Havana. When Oswald, who works with a group called Caribbean Medical Transport, ran a check on Hiner’s then-fledgling medical mission activities he was duly impressed.

“The medical equipment he gets is a cut above most of the stuff humanitarian aid groups get and I’ve been doing this a long time. His stuff is absolutely flawless,” Oswald said. “I went with him on his last trip because he was packing some really heavy equipment…I came from Chicago to help him figure out a way to put some of this stuff on the boat without it sinking. We put thousands of pounds on the bow…and you no longer could see to navigate…so we had to have somebody at the front of the boat calling instructions out to the captain just to avoid the reefs and boats and weather we came across on our way to Cuba. It got a little adventurous here and there.

“I’ll tell you, the guy’s fearless, he really is. He’s mission-oriented, there’s no question about it. Almost militaristically I might add. He doesn’t really let anything get in his way. Some of the stuff he does is a bit risky. And sometimes he doesn’t have the money, the equipment or even the plan…but he just keeps doing it. I think both sides are willing to let him operate, maybe even bend a few rules here and there…because they know what he’s doing is valuable.”

 

 

Joining Oswald, Hiner and his wife Christina on the voyage was a Cuban American physician who brought medical supplies to a cousin physician in Cuba. The Americans also brought art supplies for an artists collective there. Oswald said of Hiner and Narwicz, “They just know a whole lot of people and they just really enjoy Cuba. The folks I met that know them are like family.”

On Hiner’s first supply run in 2000 he was introduced to Dr. Fleites. “I met Gilberto and his wife Teresa and they were really neat people and we became really close friends and we had a really wonderful time there,Hiner said.

Hiner calls Dr. Fleites “a bit of a renegade. He ran the national cancer institute in Havana. He was on the Cuban ethics board. He tried to get some doctors removed from practice because he thought they were killing more people than they were saving,” Hiner said. “But his superiors kicked him off the board because he wasn’t ‘a team player.’ He still performs surgeries … but only on important people because they know he’s very, very good. He’s sort of like freelance. It’s kind of a bizarre situation.”

The Omahan’s “become sort of an emissary” to Dr. Fleites. “I get lists of stuff from him” the Cuban medical community “needs,” he said, “and come back and hustle my friends. I know a lot of doctors from when I used to be rich and famous.” As Hiner’s refined his networking, tons of things get donated — once, an entire operating suite. Omaha’s Children’s Hospital donated an anesthesia machine. He works with established humanitarian nonprofits that authorize him use of their license for delivering free medical goods abroad. Much of what he takes there goes to Pedro Kouri Institute of Tropical Medicine, an AIDS hospital directed by Dr. Jorge Perez. It’s not an impersonal process for Hiner, who’s visited there and other sites he’s supplied. He’s impressed by Cuba’s “incredible medical system.”

What began as annual trips became twice-a-year voyages. Their last trip, in 2005, they were in Cuba four months.

He’s transported medical gear worth hundreds of thousands of dollars, including mechanical operating tables and surgical instruments ranging from forceps to retractors to endoscopic devices. The goods ship to a central location and, when there’s enough for a full haul, he loads a truck and drives it to his boat in Tampa. After everything is securely stored and lashed aboard, he rigs his boat and sails for Cuba. Once there everything must be checked and approved by customs officials, a process that can take weeks. Various government stamps and seals are needed. From start to end, a single supply mission can take months.

He cuts what red tape he can with “gifts” to marina workers and ministry officials.

For the current trip, he amassed a large inventory that includes an entire delivery room donated by a hospital, complete with delivery table, incubators and monitors. So large is the haul he left half the load in Florida for a return trip next month.

Donations have never been better, but he said navigating the bureaucratic waters to get them to Cuba has become more problematic. He blames the Bush administration for “tightening travel restrictions,” especially since 9/11. He said the feds have made it harder for the nonprofits he works with to obtain or renew licenses. The main clearance he needs is from the U.S. Coast Guard that grants free passage through “an imaginary security zone between Key West and Havana that no one can define.” Without the permit, he said, “they can seize your boat, fine you $250,000 and put you in jail for 10 years.” When things were more “more relaxed,” he could slide by. Not now.

There are also new Commerce Department and Council of Foreign Currency Control approvals needed.

Cuba’s hardly immune from bureaucracy, but the tropics make the paperwork and graft more bearable. Besides, as “well accepted” as Hiner is there, he can play Lord Jim. He hopes a meeting he’s been angling for with Fidel, whom he admires, happens one day. He knows just what he’d say to the dictator. “I would tell him he needs to make more opportunities. The people there are very industrious but he keeps stifling any kind of private enterprise,” Hiner said. “He’s getting old and overly restrictive. I would tell Fidel, ‘You’ve got to loosen up. If you were a young man today you’d start a revolution against yourself.’”

To Cuba with Love
Ironically, Hiner’s romance with Cuba may never have happened if not for an accident. It was late 1998. Doug and Christina were on one of their Caribbean sailing jags and had put into port in Jamaica. There, Christina took a fall and broke her ankle, putting her in a cast. He hired a young Jamaican boy to help him crew. The trio sailed to the Camyan islands, where Christina’s pain worsened. Doug sent her home by plane. That left Doug and the boy. The idea was to make for Florida, but Doug knew the boy would be denied entry without papers.

“So, we decided to go to Mexico,” Hiner said. “I got in big trouble there because, unbeknownst to me, a Jamaican needs a visa to get into Mexico. They almost threw us in jail. I talked my way out of that.”

Next, Hiner set his sights on Key West, but learned that, too, was off-limits. Desperate, he asked officials, “Where can we go?’ ‘Cuba,’ they told him. “So, the next morning off we went to Cuba. That was my first time. We were there almost 10 days before I was able to get a plane to fly him out to Montego Bay. And while in Cuba I just loved the country. When I got back home I told Christina, ‘I loved it so much we need to go back there.’” Go back they did.

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