‘In my ex­pe­ri­ence, Miami was busier than Afghanistan’

In the months be­fore the hor­rific mass shoot­ing in Or­lando, the big­gest in mod­ern U.S. his­tory, Mod­ern Health­care was ex­plor­ing the toll on providers whose job it is to re­pair the carnage from guns in a work­place that rarely slows down to take stock of th

Modern Healthcare - - NEWS - By Tris­tram Korten

MIAMI— The man on the ta­ble at Ry­der Trauma Cen­ter in Jack­son Me­mo­rial Hos­pi­tal has been shot four times, in

the fore­arm, chest, flank and thigh. Dr. Ge­orge Gar­cia spends two hours op­er­at­ing on him, re­mov­ing bul­let frag­ments, clos­ing blood ves­sels and re­pair­ing tis­sue. By the time he’s tied the last su­ture it’s 2 a.m. Gar­cia tosses his blood-stained gloves in the trash and goes out to tell the vic­tim’s fa­ther his son will be fine.

Then Gar­cia’s pager sig­nals that an am­bu­lance is on its way with an­other shoot­ing vic­tim. And so, he heads to the ob­ser­va­tion bays to greet his next patient.

There is no “typ­i­cal” when deal­ing with blood spilling out of a body and scared fam­i­lies wait­ing for news. But this night is not un­usual.

Dur­ing a re­cent eight-hour shift, Gar­cia worked on four gun­shot vic­tims from dif­fer­ent parts of Miami (in ad­di­tion to two stab­bings and a ma­chete at­tack). As soon as staff sta­bi­lized and moved one patient to the op­er­at­ing room, an­other would come through the door. “It was like a war zone,” re­calls one nurse. Miami so of­ten re­sem­bles a war zone that the U.S. Army chose Ry­der Trauma as its train­ing cen­ter for all sur­gi­cal teams that will treat sol­diers in bat­tle zones.

That’s how Gar­cia, an Army vet­eran, ended up at Ry­der, where he trained be­fore be­ing sta­tioned in Afghanistan.

“In my own per­sonal ex­pe­ri­ence, Miami was busier than Afghanistan,” says the 47-year-old, who still keeps his hair brush cut. “I can’t imag­ine do­ing any­thing other than this.”

Ry­der’s se­lec­tion as a mil­i­tary train­ing site is a du­bi­ous honor, of course. It speaks to the pro­fes­sion­al­ism of the place, but it also un­der­scores this ur­ban area’s con­stant may­hem.

Over the past five years, Ry­der’s med­i­cal teams have treated 2,753 gun­shot vic­tims, an av­er­age of 550 a year, or more than one patient a day, every day of the year.

The de­mo­graphic stays pretty con­stant—mostly young men, mostly poor, of­ten peo­ple of color with­out any way to pay for life­sav­ing surgery. Of those 2,753 vic­tims, 45% were uninsured, ac­cord­ing to Jack­son, a pub­lic not-for­profit hos­pi­tal. Many more were on Medi­care or Med­i­caid. That means the hos­pi­tal has to swal­low the cost of many of the treat­ments.

Jack­son of­fi­cials de­clined to es­ti­mate how much the shoot­ings cost the hos­pi­tal every year, say­ing there are too many vari­ables. In gen­eral, it is dif­fi­cult to es­ti­mate the ac­tual med­i­cal costs of a trauma visit for a gun­shot wound. No na­tional stud­ies have been done.

Fur­ther com­pli­cat­ing the sce­nario, Florida’s Repub­li­can gover­nor, Rick Scott, and the state Leg­is­la­ture de­clined to ex­pand Med­i­caid un­der the Af­ford­able Care Act. That put Jack­son Me­mo­rial in a bind, be­cause fed­eral low-in­come pool fund­ing, used to de­fray the costs for treat­ing the uninsured and un­der­in­sured, is be­ing phased out pre­cisely be­cause the feds an­tic­i­pated Med­i­caid cov­er­age would be ex­panded. State leg­is­la­tors have cob­bled to­gether a so­lu­tion, but Jack­son mean­while lost about $15 mil­lion in fund­ing for treat­ing the poor in fis­cal 2016.

That’s a shame be­cause Ry­der, which is part of the pub­lic Jack­son Health Sys­tem, is the only Level 1 adult, pe­di­atric and burn trauma cen­ter in Miami-Dade County. It has its own he­li­pad, through which about 40% of its pa­tients ar­rive. This is where vir­tu­ally all of the county’s gun­shot vic­tims were brought un­til two other hos­pi­tals opened trauma units in the past three years. If you’ve been se­ri­ously in­jured in the Miami area then you want to go to Ry­der, which is one of only nine Level 1 trauma cen­ters among the state’s 31 trauma cen­ters.

But Gar­cia doesn’t spend too much time pon­der­ing the pol­i­tics, fund­ing is­sues or so­cial prob­lems that spawn ur­ban vi­o­lence. He just wants to do his job.

“There are peo­ple whose job is to worry about those things,” he says. “Un­til we solve all the prob­lems that bring dis­en­fran­chised youth in here, I see us as the van­guard. We’re just ready to take care of them.”

His job is not to worry. Wor­ry­ing doesn’t save pa­tients.

Gar­cia’s sto­icism is prac­ti­cally in his DNA. His fa­ther was a ca­reer Marine who served three tours of duty in Viet­nam. His un­cle flew in bombers dur­ing World War II. His brother and late sis­ter-in-law served in the Army. An­other un­cle was a Green Beret in Viet­nam. So it was not en­tirely sur­pris­ing when Gar­cia an­nounced plans to at­tend the mil­i­tary’s med­i­cal school af­ter grad­u­at­ing from the Univer­sity of Cal­i­for­nia at Irvine.

“My mom was fairly dis­traught when I told her,” he re­calls. “She had en­vi­sioned an­other life for me.” Some­thing in the civil­ian world, away from dan­ger.

Gar­cia served in Army med­i­cal fa­cil­i­ties in Hawaii, North Carolina and Ken­tucky and did a trauma fel­low­ship in Miami at Ry­der. Then in Jan­uary 2008, he shipped out to Afghanistan with the 126th For­ward Sur­gi­cal Team. He flew on a C-5 from Fort Hood, Texas, to Ba­gram Air­field, in Afghanistan. He worked in a for­ward op­er­at­ing base in the moun­tains of north­east Afghanistan.

The heli­copter flew in at night. “They don’t like to fly dur­ing the day,” Gar­cia says. “Eas­ier to shoot at.” Gar­cia was ex­cited. “It was what I signed up for. If you take that route, Army surgery, the pur­pose is to de­ploy and take care of sol­diers.”

And de­spite be­ing far from a mod­ern hos­pi­tal, in a place where am­bushes and mor­tar at­tacks were routine, Gar­cia says he felt ready. “Be­cause of the train­ing in Miami, I was as con­fi­dent as I could be that I could do what I needed to do.” Ur­ban vi­o­lence had pre­pared him for war.

Grim as it is to say, trauma surgery has ben­e­fited from our wars in Afghanistan and Iraq, Gar­cia says. One ex­am­ple is that med­i­cal pro­fes­sion­als fig­ured out that pa­tients do bet­ter if they are given a 1-to-1-to-1 ra­tio of platelets, blood cells and plasma.

Gar­cia has used a lot of these skills in both en­vi­ron­ments. He re­turned to the States more in­spired than ever to con­tinue in trauma surgery. Af­ter a brief stint in Wash­ing­ton, D.C., he was as­signed to run the Army Trauma Train­ing Cen­ter at Jack­son Me­mo­rial. Af­ter his com­mis­sion ended, he joined the hos­pi­tal as a trauma sur­geon, which comes with a fac­ulty po­si­tion at the Univer­sity of Miami’s Miller School of Medicine.

“I like the chaos,” he says about his de­ci­sion to stay in trauma. “I like not know­ing what the next case is. I’m around the pres­sure, but I don’t feel the pres­sure.”

And his time spent in the moun-

tains of Afghanistan in­flu­enced his prac­tice in in­ter­est­ing ways. They op­er­ated in tents, with­out a lot of high-tech equip­ment, like CT scan­ners.

“Not hav­ing a lot of stuff stream­lines your think­ing,” he says. “To­day, I’m com­fort­able tak­ing ac­tion. I tend to see things in a straight­for­ward line. I don’t see the tech­nol­ogy as a ne­ces­sity, but as a lux­ury.”

Gar­cia’s de­vo­tion to this type of medicine is not unique to the health­care teams in the trauma wards. Many of the nurses in Ry­der spend en­tire ca­reers there. One week­end shift, charge nurse Robert Tu­dor— who has been at Ry­der for 27 years, even be­fore it was a free-stand­ing unit—ends his shift just as nurse Natalee Wrisk, 25 years in the unit, and Anne Hig­gins, 18 years in the unit, are start­ing theirs.

“You need to be a lit­tle crazy to work here, but in a good way,” says Vic­to­ria Franco, also start­ing her shift. She’s been a nurse in the trauma cen­ter for only three years, but you can hear her pas­sion for the place when she talks. “You know you’re com­ing to work to see the worst. There is no happy day at work.”

Be­cause of the in­her­ent un­pre­dictabil­ity of trauma and emer­gency units, hos­pi­tals must staff doc­tors and nurses of vary­ing skills and abil­i­ties. Franco lists the re­quire­ments for a nurse to work there, in­clud­ing a bach­e­lor’s de­gree and cer­ti­fi­ca­tions in burn treat­ments and pe­di­atric life sup­port. They ride with EMTs in am­bu­lances and he­li­copters.

“Once they’re here, they stay here. They die here,” Franco says, rib­bing her col­leagues, many of whom, stud­ies have shown, choose emer­gency de­part­ment ap­point­ments be­cause it’s one of the few sched­ules with flex­i­bil­ity, a draw for mil­len­nial doc­tors.

In a sense, they’re mask­ing ways to say they love their job, which could sound in­sen­si­tive if taken out of con­text. But when a patient ar­rives, it’s easy to see how ex­hil­a­rat­ing the work is.

The process is a bal­let of ef­fi­ciency. As soon as the call comes in, the ob­ser­va­tion bay is prepped; IVs are read­ied for flu­ids and a blood in­fu­sion ma­chine is prepped with uni­ver­sal blood (O pos­i­tive and O neg­a­tive). The tho­ra­co­tomy tray is brought out—scalpels, su­ture clamp and the “adult rib spreader” for open­ing a chest cav­ity to mas­sage the heart by hand in the most dire cases. De­fib­ril­la­tors are charged. When the vic­tim is wheeled in, clothes are cut away and mo­bile X-rays are taken. When they are done, and the patient is ei­ther sta­bi­lized or moved to an op­er­at­ing room, the floor is heaped with dis­carded pads, pack­ag­ing, plas­tic wraps and gloves.

If you’re a med­i­cal pro­fes­sional in trauma, there is no greater sense of ful­fill­ment than us­ing the avail­able min­utes, even sec­onds, to save some­one’s life like this. But when the shift is over? What kind of toll does this work take? A 2012 sur­vey of 133 trauma sur­geons, us­ing a sec­ondary stress trauma scale, found ev­i­dence of post trau­matic stress dis­or­der in two-thirds of re­spon­dents.

There have been a dozen times when a child or teenager has come in, and Gar­cia, who is di­vorced, has gone back to his of­fice af­ter surgery to call his two sons, 13 and 11. “Any­time a kid comes in it’s like that. I’ll call them; I just need to hear their voice,” he says. “It’s prob­a­bly part of our cop­ing mech­a­nism.”

Most of the staff need some way to de­com­press af­ter work. Some do yoga or med­i­tate. Oth­ers im­merse them­selves in fam­ily life. “Some just sit in­side their car for 20 min­utes be­fore go­ing in­side their home,” Franco says.

“I think you’re ei­ther nat­u­rally good, or you be­come good, at com­part­men­tal­iz­ing,” Gar­cia adds.

A friend once tried to get Gar­cia into yoga. “It wasn’t for me,” he says.

In­stead, he ex­er­cises—re­lent­lessly. Gar­cia likes to com­pete in triathlons. To train he takes long runs in his leafy north Miami neigh­bor­hood. He rides his bike on Key Bis­cayne. He swims laps in his gym’s pool at 5 a.m. Work­ing out is his ther­apy. The more miles he can put on his shoes or tires, the fur­ther away last night’s shift— and the woman whose pelvis was smashed by a bul­let while she was sit­ting in a car with her boyfriend—drifts from mem­ory.

Un­til the beeper goes off again.

LILLY ECHEVERRIA

Miami trauma sur­geon Ge­orge Gar­cia, on fac­ing page and at left, waits with his team on the Ry­der Trauma Cen­ter’s he­li­pad for a gun­shot vic­tim be­ing chop­pered in by Miami-Dade Fire Res­cue.

JACK­SON HEALTH SYS­TEM

Jack­son Me­mo­rial Hos­pi­tal’s Ry­der Trauma Cen­ter has treated 2,753 gun­shot vic­tims in the past five years, or more than one patient a day, every day of the year. It also serves as a train­ing cen­ter for all U.S. Army sur­gi­cal teams that will treat sol­diers in bat­tle zones.

LILLY ECHEVERRIA

Gar­cia on serv­ing in Afghanistan: “Not hav­ing a lot of (tech­nol­ogy) stream­lines your think­ing. To­day, I’m com­fort­able tak­ing ac­tion. I tend to see things in a straight­for­ward line. I don’t see the tech­nol­ogy as a ne­ces­sity, but as a lux­ury.”

LILLY ECHEVERRIA

“Un­til we solve all the prob­lems that bring dis­en­fran­chised youth in here, I see us as the van­guard. We’re just ready to take care of them,” Gar­cia said.

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