Super Medicine
At the Texas Medical Center doctors can rebuild your heart, give you new limbs, treat your cancer, save your children from affliction, and maybe even bring you back from the dead.
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Park Plaza was a disaster for Hermann and UT. Spin-offs are not uncommon in a major medical center—in the years of Park Plaza’s founding, much of the obstetrics-gynecology department at Methodist was walking out and starting Texas Woman’s Hospital on Fannin Street. In the case of Woman’s, Methodist was strong enough and the spin-off minor enough that the storm was weathered without major trouble. But Park Plaza was an unusually vulnerable hospital. Hermann’s main source of business was not path-breaking heart surgery but long years of goodwill built up between private doctors and their patients, and now that was gone.
When Park Plaza opened, the average daily patient census at Hermann immediately fell by one hundred. By the end of 1975, Hermann was only using 400 of its 620 beds. In the fiscal year of Park Plaza’s opening, Hermann lost $7.5 million. Suddenly UT didn’t have enough patients to teach on.
In late 1975 the hospital brought in a new director to get its house in order, a slick, enthusiastic, management-minded 37-year-old named W.F. “Bill” Smith, who was vice president of a national chain of proprietary hospitals. “When I first came here,” says Smith, “I literally signed all checks and looked over all purchase orders. I went through the mail every day. Plus, in the first three weeks I met around the clock with groups of employees in the auditorium. I told them I knew things were bad and they had to help and if they didn’t they could leave. I said it very bluntly. And it worked.” The next year, the hospital’s deficit was $2.2 million; the year after, $1.9 million; the year after that, $920,000. Hermann is also building ambitiously, and Smith is full of plans for new specialty centers, like a Texas Kidney Institute.
Smith’s major task has been not so much managing the hospital as marketing it. A private hospital like Hermann may be technically nonprofit, and it may not be able to advertise, but like any business it must take in more money than it spends and create a public demand for its services. For that reason publicity is essential, and Smith understood that well. His masterstroke was not the financial controls or the new buildings but an unlikely-sounding program that began in the summer of 1976: the leasing of a helicopter to bring emergency patients to the hospital. Life Flight, as the helicopter program is called (the hospital added a second helicopter in 1977 and a third last year), was the first thing Hermann ever did that showed a real understanding of the dynamics of the Texas Medical Center. The three helicopters are dispatched from a room full of oscilloscope screens and blinking lights in Hermann’s emergency center. When an emergency call comes in from anywhere within 135 miles of the hospital, one of the helicopters starts to rev up. A surgical resident, a nurse, and a pilot all dash upstairs to the heliport and climb in amid an impressive array of medical equipment. The helicopter takes off in a blaze of glory to return shortly with a premature baby, a burned oil worker, or a teenage auto accident victim, each of whom without Life Flight would have been a goner.
Another of Smith’s accomplishments has been to increase Hermann’s public relations staff from four to eight, and Life Flight has been filmed, photographed, and written about more than any other feature of the Medical Center in the last two years. Life Flight has been of great help in filling those empty beds—10 per cent of Hermann’s patient load comes from Life Flight, and these patients stay longer (and pay more) than most. More generally it has, in Smith’s words, “helped in building our image as a tertiary-care hospital” and thus pulled in patients indirectly, too. The only non-fans of Life Flight are the doctors at Ben Taub, where Life Flight patients who have arrived at Hermann, been stabilized, and been found to have no insurance (via a procedure known at Ben Taub as “the wallet biopsy”) are sent for treatment.
UT, however, is still not out of the woods. Life Flight has helped it become a leader in the booming medical specialty of trauma but it still needs more patients for teaching. In the emergency room, Dr. James H. “Red” Duke, a popular, aw-shucksing country boy who listens to (and sometimes sings along with) country music tapes in his office, presides over a trauma specialty operation rivaled only by Ben Taub’s, which has been brought to first rank by Dr. Kenneth Mattox, a young surgeon like Duke, but less country and more intense (his nickname is the Roadrunner). In addition, UT has cancer patients at M.D. Anderson, heart surgery patients at St. Luke’s, and private patients at Hermann, St. Joseph’s downtown, and suburban Memorial; but Baylor has all the public patients and hence all the best teaching material. UT was supposed to have 200 students in a class by now, but because of the lack of teaching patients it is still at 150.
UT appears to have no designs on Ben Taub, but it would like a piece of the huge obstetrical service at Jefferson Davis, the nation’s second-largest deliverer of babies, and coequal status with Baylor at Houston’s Veterans Administration Hospital. It looks, however, as if UT will have no such luck. Both the Veterans Administration, which runs VA, and the Harris County Hospital District, which runs JD, are happy with the job Baylor is doing, and it’s conventional wisdom that splitting academic control of a hospital doesn’t work. And DeBakey is unalterably opposed to sharing the two hospitals with UT.
As for Cheves Smythe, he was fired as UT’s dean in 1975, but remains there as a professor of medicine. “When I came here,” he said not long ago, in the course of recounting his experience in the Medical Center, “I didn’t really understand what I have now come to appreciate. And that is that Texas is different.
Birth and Death
Karen Adams is the head nurse of the Neonatal Intensive Care Unit at Texas Children’s Hospital, which opened in 1974 and contains twenty plastic cribs, in which lie tiny, often misshapen babies who could not survive without the tubes and wires running from their bodies to the machinery that fills the ICU. There are machines that monitor the babies’ heartbeats and blood pressures, oxygen pumps, and oscilloscopes, all emitting various blips and beeps. There is a nurse for every one or two babies, and three to five doctors on duty around the clock. Each day in the Neonatal ICU costs at least $350, and total bills can run as high as $30,000. With few exceptions, the Neonatal ICU is for those with insurance.
Adams gave me a tour of the ICU. We saw a tiny baby, two weeks old, that had weighed a little over two pounds at birth. It was as long as a normal baby, but without an ounce of fat. Its skin clung to its ribs, and its legs and arms were like sticks. The baby was suffering from internal bleeding in the ventricles of the brain, an inoperable condition that is one of the main killers of premature babies. “This one’s probably going to make it,” said Adams, “but as far as brain damage, I don’t know.” We saw a baby with hyaline membrane disease—a disorder of the lungs that makes breathing difficult. A tube pumped oxygen into its mouth; its tiny chest expanded and contracted with what looked like incredible effort. We saw a baby born with its intestines outside its body, waiting in the ICU to gain enough strength for an operation.
“Most of our babies are premature, from high-risk mothers,” Adams said. “When we first started, most of them died. Now most of them live, but at least a couple a month die. Working in the ICU can be both depressing and very rewarding. The strain here can be unbearable. You’ve worked with these babies a long time, and sometimes they just die. You can’t do anything.”
Then we came to a baby I’ll call Gwen, the star of the ICU and another hyaline membrane case, who after six months was finally off the respirator and breathing on her own. Adams picked her up, cradled her in her arms, and kissed her. “This is our pride and joy,” she said. “She’s going home after Christmas, but we get to keep her until then. That’s our present.”
Having a baby in the ICU has been very hard on Gwen’s parents, as it is on most. These parents, often young people who have never had a major disappointment, sometimes want desperately to save their babies, even when it can’t be done. Or they just lose interest in the baby, which they have, after all, barely seen, and that is what has happened with Gwen’s parents. Or they ask the hospital to turn off all those machines and let the baby die. The hospital will do this, but never simply at the parents’ request—instead, the parents and doctors hold long conferences, largely to give the parents the feeling that it was the doctors’ decision. They’ve found that otherwise, sooner or later, the parents will be torn apart by feelings of guilt, even if their baby would have spent an entire lifetime in a coma in a hospital.
One thing that quickly becomes apparent at the Medical Center is how little the most famous medical ethics case of the decade, that of Karen Anne Quinlan, reflects the real world of medicine. The Karen Quinlans—people in comas, being kept alive at great expense—are quietly taken off their machines, and they die. At the Medical Center, this happens almost every day. The only real debate on the point among doctors is between the passive euthanasiasts and the active euthanasiasts. The passive euthanasiasts believe it’s permissible to turn off the machines when there’s no hope the patient will return to consciousness. The active euthanasiasts believe that a doctor ought to be able to terminate the life of a patient who is conscious, is in great pain, and wants to die.
THE COOLEY TOUCH
The Texas Heart Institute is nestled somewhere in the bowels of St. Luke’s and Texas Children’s hospitals, a secret place one comes upon after going up an elevator and through a series of labyrinthine corridors. It has no windows or anything else to communicate a sense of what time of day it is. Everything is very modern and spotlessly clean. Machinery is everywhere. There are patients, of course, but when they’re in the Heart Institute they’re generally unconscious, full of tubes, and connected to complicated monitoring machines, so they are like part of the futuristic landscape.
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