Emergency Room: Hospital pulses with critical activity

PALMER -- When Terry Bettis came into the Valley Hospital emergency room in Palmer on the evening of Thanksgiving Day, the place was already busy. Some patients had flu symptoms, others suspected they had broken bones. Within minutes, Bettis would suffer a cardiac arrest and -- at least momentarily -- die, before being resuscitated with electric jolts from a defibrillator and a drug mix that included aspirin, Lidocaine and nitro-glycerin.

In an adjacent examination room Don Trigg was waiting for an X-ray on what he suspected was a fractured wrist. Across the hall, four-year-old Heather Johnson and her parents Sharon and Rick Johnson were waiting to see an X-ray of Heather's foot. Heather had tripped on her nightgown.

"She fell, and we both heard [Heather's foot] pop," Sharon said.

Heather and Mr. Trigg were both past the emergency room counter and under the care of staff before Bettis came in, but their treatment is interrupted as the emergency room staff and Dr. Michael Alter scrambled and re-focused their attention on Bettis.

When Bettis arrived, his main symptom was a sharp pain in his upper back and shoulders that went up into his neck and skull. His wife Diane took his blood pressure at home and brought him to the ER because she thought it was abnormally high and his pulse abnormally slow.

"When I took his blood pressure and his pulse it was way off. His blood pressure was 161 over something -- I can't remember exactly -- and his pulse was 45 and I knew neither one of those was normal." Diane said. "I did it either two or three times to make sure it was right."

When they arrived at the hospital, Terry sat down in the waiting area and Diane went to the counter to describe his symptoms to staff.

"I wasn't there probably 30 seconds -- she could hardly get it out before there were two guys coming out and escorting me in like I was a criminal. They had one guy on each arm," Terry said.

Next thing he knew, he was waking up wearing an oxygen mask over his face, he said. His body was reclined on a stretcher and -- except for the mask -- he was clothed only in a hospital gown.

"I thought I was having a dream," Terry says.

Dr. Alter bends down to look Terry in the eyes.

"You were having a bad dream my friend," he says.

There are three nurses in the room and an internal medicine physician. Soon, Alter will pass Bettis on to the internist who checks the patient into Valley Hospital's intensive care unit, but for now, Alter works with the internist on the patient's immediate needs.

Alter calls for aspirin, Lidocaine, nitro-glycerin and other necessities. His words tumble out in a rapid stream of medical jargon. The requests are repeated out loud by the staff members in a rigid sort of confirmation of what they are doing. At one point, Alter lifts the oxygen mask off Bettis in order to drop a large pill in his mouth.

"Are you with me big guy?" Alter says, in an overt attempt to hold his patient's attention.

"This is aspirin. Chew it and swallow it -- tastes bad, works great."

Bettis has a needle poked in his stomach, an IV placed in his arm, sensors taped to his torso and an X-ray of his chest hanging next to him on the wall within 15 minutes.

All the while, Trigg is in the room next door with the pain in his wrist.

"It's a lot of pain, but I can live with it. I feel a little guilty when I heard stuff like that going on next door," Trigg says.

Trigg is a mechanic who maintains turbine engines that power pumps in the oil fields on the North Slope. On Sept. 17, Trigg had an elective surgery to reduce pain in his wrist that was so severe he thought he might not be able to work. On Thanksgiving Day his arm was in a splint and he hurt it while rough-housing with his teen-age son.

"I just want to clear my mind. I had X-rays on Monday, and everything was OK then," he said.

Both the Johnsons and Trigg said they would have been at Valley Hospital's AIC urgent care clinic had it not been for the holiday. Trigg went by to check and AIC was closed. The Johnsons suspected AIC would be closed and drove with their daughter straight to the emergency room in Palmer.

Urgent or emergent?

Throughout the 1980s and 1990s clinics called urgent care facilities opened up inside malls and offices building across the country. The clinics have been a growth segment in the health care industry and are helpful to emergency rooms because they reduce the traffic there. But they also present sort of a double-edged sword for patients and doctors because they often attract patients who either don't know the clinic's limitations, aren't aware of how serious their own medical condition is, or assume they will get a better deal at the urgent care facility but underestimate their condition.

Many urgent care facilities can handle minor emergencies, such as a broken thumb or pneumonia if it's caught early. In those cases, urgent care clinics can charge less than an emergency room and save the patient money.

"The other side of the coin is that we don't want to get those patients [with serious emergency needs] in here," said Ed Manning, a physician assistant and partner at Lakes Medical Clinic. "You end up putting in an IV line and calling 911."

Manning and Dr. Charles Layman, M.D., own the clinic on the Palmer-Wasilla Highway. They were also two of the founders of Arctic Insta Care, the practice that Valley Hospital purchased in 1989 and renamed AIC Urgent Care.

Manning said Lakes Medical Clinic gets most of its business by keeping patients and families that he and Layman have been serving during the years. The two learned from their experience with Arctic Insta Care about the challenge of simultaneously promoting urgent care services and educating the marketplace about what an urgent care facility can -- or can't -- provide.

The double-edged sword is so unavoidable that it even comes up when Manning is queried about his clinic's market share.

"We're probably more firmly grounded in family practice and our urgent care service is mostly to patients that we already have. Of course, we don't mind seeing new patients, but we don't want to give the appearance to anyone that this is a modified emergency room," Manning said.

Lakes Medical Clinic is closed on Thanksgiving Day and five other major holidays each year. It's also closed on Sundays. Wasilla Medical Clinic is also closed on major holidays and Sundays. Manning said Lakes was open Sundays once, but found it difficult to let Valley residents know that they were open.

"Nobody ever showed up. We tried that for a whole year and no more than six people ever showed up on a Sunday," Manning said. "Which is a shame because we could have taken some of the burden off of the ER."

Valley Hospital Association provided statistics that show patient flow between AIC Urgent Care and Valley Hospital in Palmer and the four hospitals in Anchorage.

In 2001, AIC served 30,094 patients while the emergency room in Palmer served 17,104. Of the patients who checked in at AIC, 192 were transferred to area hospitals. One hundred fifty-nine went to Valley, 17 went to Providence Alaska Medical Center, eight went to the Alaska Native Medical Center, six went to Alaska Regional Hospital and two went to the 3rd Medical Group Hospital on Elmendorf Air Force Base. VHA was not able to provide information on which of those patients were transported by ambulance or how often AIC workers dialed 911 last year.

Last fall, VHA's members voted to proceed with

negotiations for a joint venture agreement with the for-profit company Triad Hospitals Inc. The plan is for the new joint venture company to build a new hospital to replace the one in Palmer. If it's built, the new hospital would have an urgent care facility co-located with its emergency room, according to VHA spokesperson Elizabeth Ripley. The co-located urgent care clinic will lighten emergency room traffic and can provide lower-cost services to patients who don't require an emergency room.

"If you co-locate the two then your triage nurse can sort [the patients] out right there," Ripley said, "It mainly affects your billing," she said.

No place to put them

Under federal law, Valley Hospital is required to care for any patient who arrives with an emergency condition or who is in active labor. If the Valley-Triad joint venture goes through, the new joint venture company will be for-profit, but Valley CEO George Larson said that won't change the rules of emergency care.

"It doesn't matter if you are for profit or nonprofit. Anybody that shows themselves to us in an emergency situation, we have to accept them. We have to care for them and we have to stabilize them … The law is written in such a manner that every hospital has to take care of any emergency or active labor situation."

The replacement hospital is planned to have 75 beds; the current hospital has 39 beds, four of which are intensive care unit beds. VHA officials still don't know how many ICU beds will be included in the 75-bed mix at the new hospital, it's one of a myriad of design issues that are being worked on with Triad even as the two companies work out financial details of the joint venture.

But Alter and the other emergency room physicians have been supportive of the plan to build a new hospital. One reason is that although the emergency room isn't always full, Valley's four ICU beds often are. Alter often has patients in the emergency room longer than he would like to and has to use the beds that he has available carefully. Alter gave the example of an

elderly man coming into the ER with the symptoms of vomiting and diarrhea.

"If he was younger it would be a no-brainer, but since he was 90 years old and he lived alone, we admitted him to the hospital," he said.

The Palmer ER keeps track of available beds at the four other Anchorage hospitals. The information is posted on a dry-erase board by ward clerks who keep track of patient files and the flow of information in the ER. On the board there are also cells for each of the 11 emergency room beds and one cell that's labeled "hall" in case a 12th patient is being treated.

When Valley runs short on ICU beds, doctors taking patients from the ER must admit them to a different hospital.

"When we are at 75 percent of our ICU beds [or three out of four full] that means that the emergency room can admit one patient per shift," Larson said. The situation gets more difficult when the other four hospitals run short of beds.

"We have held patients in the emergency room, sometimes, for up to 48 hours," Larson said.

About two years ago, the four hospitals in Anchorage got together to create standards for "divert status," according to Providence spokesperson Karina Jennings. Providence's ICU beds are full about 90 percent of the time, according to Jennings. Divert status applies to ambulances only, according to Jennings who said all emergency rooms are required to take in patients that arrive at their door.

"A couple of years ago, diversions started increasing," Jennings said. "The hospitals talk to each other a lot," Jennings said adding that a citywide team that includes the city's ambulance service meets to set standards and discuss issues involving the divert status. The plan also calls for an immediate level ground if all four hospitals claim divert status at the same time.

"When that happens, then all of the hospitals immediately go off of divert status and hospitals take patients on a rotation basis," Jennings said.

85 mph into Anchorage

Once Terry Bettis was checked into Valley's ICU, Alter hoped his patient would stabilize and be able to make a trip to Anchorage to a cardiac catheterization lab at Providence.

Cardiac catheterization is a procedure in which a long, thin catheter is placed in a blood vessel and then guided to the heart. The cardiac catheterization lab is a service Valley doesn't provide. The lab is equipped with real-time imaging equipment so cardiologists can see the procedure on a screen as they perform it. Alter said most often the procedure takes place a day or two after recovering from a first heart attack.

That didn't happen with Bettis. His condition didn't stabilize in the Palmer ICU, so the doctors called for transportation to Anchorage.

"As soon as they found out that I wasn't going to remain stable they sent me in," Bettis said. There was no helicopter available. An ambulance took Bettis to Anchorage with his wife riding in the front passenger seat.

"The driver took me aside and said, 'I want you to understand before we get in that we are going to be driving very, very fast,'" Diane said. "It was a really good trip because the roads weren't slick or anything, it was just a weird trip."

In the cardiac catheterization lab, a stint was placed in Terry's circumflex coronary artery, one of the arteries that feeds blood to his heart muscles. He was discharged from Providence on Monday, Dec., 2, just four days after the initial cardiac arrest in Valley's emergency room. Bettis expects to go back to work in the first week of January. Last week he was exercising lightly on a stationary bicycle in his living room.

"I'm going to have another check up here in about three weeks. I'll have my cholesterol checked and blood work-up," he said.

Larson said it's too early to tell if a catheterization lab will be included in the plans for a new hospital. VHA -- with help from Triad -- is still trying to determine what new features will be financially viable for the new hospital.

"It would be one of the major expenditures that we could include," Larson said, adding that a small "cath lab" could cost $1.5 million to $2 million.