Vital Signs

A night at Highline Medical Center’s $28 million emergency unit.

By James Ross Gardner July 11, 2010 Published in the August 2010 issue of Seattle Met

THE LUNG X-RAY on the vertical two-foot-by-three-foot monitor, like all lung X-rays, looked like a pair of black wings. But when the physician’s assistant called the doctor over to examine the image, she halted between the syllables of his name. “Gar,” she said, "cia.” The patient had checked in complaining of a cough. “She’s been a smoker for 20 years,” the PA explained, pointing at the screen. In the middle of the left lung appeared 
a white mass the size of a fingertip, an ethereal shape with uneven edges, brighter in some spots than in others, like in purported photographs of ghosts.

“Yeah,” Dr. Gregory Garcia said. The word hung in the room. Highline Medical Center’s chief of emergency services is not one to employ a pregnant pause to convey meaning. No, Garcia is all speech and motion, filling the air with anecdotes and acronyms, arms gesticulating madly. But staring at what could be a lung tumor, yeah was all the doctor had. Only when someone finally asked, “Will you guys mention the C-word to her?” did Garcia speak. “I think we have to. If we don’t at least mention the possibility of cancer, she might ignore the symptoms.”

And with that he grabbed his computer on wheels, his partner in vanquishing all that ails the human body, and rolled it down the hall. Before him lay Highline’s new $28 million emergency unit and four more hours of an eight-hour night shift.

The COW, as ER staff surreptitiously refers to the device (Garcia says they’re actually supposed to call them WOWs—workstation on wheels—“to avoid offending anyone who might think we’re saying they’re a cow”), displays a grid listing every patient in the unit, their name, age, room number, and chief complaint. Garcia no longer chases a maddening stack of papers around a cluttered office; he consults the mobile computer—connected to the hospital’s server—to retrieve patients’ medical records, and review X-ray, CT scan, and blood test results.

Chances are, five months ago, had life thrown an emergency your way—broken limb, heart attack, or mystery cough—Highline in Burien, 10 miles southwest of Seattle, would have been at the bottom of your list, even if you lived in the neighborhood.

The ER, built in 1958, had gone without an update for decades. Designed to accommodate 12,000 patients a year, the 19-bed unit served 50,000 annually, nearly all of whom languished in the waiting area for an hour or more only to be crammed into tiny exam rooms or, worse, a larger room shared with five other patients, just a thin curtain to separate them. An arcane traffic system ruled the cramped hallways, where staff members would flatten themselves against the sickly pink and green walls to yield to rolling hunks of medical equipment.

And the noise. The groans of arthritic octogenarians mixed with the wailing of flu-stricken toddlers. If someone vomited, you heard it. If an embarrassed patient proffered an explanation as to why he might have a rash there, you heard it. Meanwhile, nurses and physicians shouted their alphabet soup of industry acronyms over the whole nauseating din.

The ER was also the bane of ambulance crews. Only two vehicles could fit in the ambulance bay at a time, and drivers had to back down a curved ramp to reach it. Given the option, paramedics often took patients elsewhere.

Plans were in motion to upgrade the ER in the late ’90s, but the economy flatlined. As Seattle-area residents lost their jobs in the 2000s, Highline saw a decline in insured patients and an uptick in uninsured patients, which often meant that the hospital had to put bill collectors to work, stalling its cash flow. In 2009, money became so tight that the hospital laid off 85 employees.

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Code new Highline ER’s 64-slice CT scanner and one of the spacious, high-tech exam rooms.

Meanwhile, Highline’s competitors were upping their game. Valley Medical Center, nine miles away, announced plans to build a new state-of-the art, 55-room ER unit, complete with “soothing colors and bathed in natural light.” And Swedish Medical Center began planning small but nimble satellite emergency units in the suburbs nearby. The administrators of those hospitals knew what Highline CEO Mark Benedum knew: The ER is a hospital’s calling card, often the first point of entry for the public. “If patients have a good experience in the ER,” notes Benedum, “they’re more likely to return to the hospital for other things.”

Plagued by ledger books practically written in red ink, Benedum and his staff got creative. They raised enough money from donations to put up capital for a federally backed $60 million loan—$28 million for the ER, the rest for other hospital improvements—thanks in part to the U.S. Department of Housing and Urban Development. They hired one of the best medical architectural firms in the country and, two years ago, broke ground for the new ER.

The 27,000-square-foot unit opened in April. Three times larger than the old facility, it boasts 32 exam rooms and a nine-vehicle ambulance bay. More noticeable than the new size, however, is the sound. Or the lack of it. A quiet purr is punctuated only by the dim bleeps of medical monitors. A new CT scanner, blue-lit like a Star Trek prop, hums in a room attended by green-scrubbed technicians. The staff studies test results in the “fishbowl,” a window-walled office filled with diagnostic computer screens. And the doctors—two per eight-hour shift—speed-walk across the tile floor from exam room to exam room, spacious suites large enough to fit a patient’s family and a Zamboni-size X-ray machine at the same time.

It’s doubtful, though, that Gregory Garcia had too much trouble moving through the old, cramped ER. Short but muscular, the 39-year-old moves fast. Pointing at a patient’s name on his monitor—a woman complaining of dizziness in room 10, say—he’ll dart off to greet her: “Hi! How are you tonight?”

Garcia hadn’t planned to be a doctor. His father owned a trucking business in Stockton, California, dispatching a fleet of produce-hauling rigs across the region. As a teenager Gregory changed truck tires, steam cleaned engines, and played gofer for the more experienced mechanics. “My dad worked me like a dog.” This is no way to make a living, he thought. So he started working for his father’s friend, a druggist, and afterward went to pharmacy school. He got a job at a Safeway in Portland. The grocery store expected one thing above all else: superb customer service. The brass sent secret shoppers to stump the pharmacist. Did you help the customer find the foot cream? Did you smile? “Safeway has this training video for new employees. It’s called ‘Where’s the pickle relish?’ In it you’re shown how to help the customer find an item. You’re supposed to walk them to it. And not be too overzealous.”

But dispensing pills and smiles wasn’t enough for Greg Garcia. The trucker’s son realized he wanted to use his hands after all. His wife had enrolled in medical school at Oregon Health and Science University. He wanted to attend, too, but was accepted at the University of Southern California instead, and moved to Los Angeles alone. There he did his rotations in an emergency room in one of the most active street gang areas in America. Shootings. Stabbings. Bludgeoned heads. He helped patch them all.

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He later joined his wife in Seattle, where he took up a residency at the University of Washington and pinged around among Harborview, UW Medical Center, and Madigan Army Medical Center. And when, in 2004, the time came to find a job, a fellow doctor at Madigan suggested a little community hospital in Burien. The people there are top notch, he said. “Greg, you should check it out.”

Six years later, on a warm weeknight in June, Garcia, now overseeing 21 other docs as Highline’s emergency medical director, spun into action at the sound of an old-fashioned telephone ring. He picked up the red phone in the fishbowl, the line that paramedics use to call the ER when they’re en route with a patient. “Garcia.” He nodded as he scribbled on a pad of paper. “Okay. Okay. All right. See you soon.” The incoming patient, he’d learned, was bleeding profusely from his rectum. Within five minutes the ambulance crew wheeled the patient in, his face cloaked under an oxygen mask. He has liver disease, the bald and burly paramedic explained, and he’s a heroin user.

The intravenous drug use had rendered the patient’s veins so useless that the nurses couldn’t take a blood sample. In order for the staff to administer medication and draw the patient’s blood, Garcia would have to insert a central line into the patient’s neck, tapping into an artery. He donned surgical gloves, mask, and gown, and pulled the exam room curtain shut. The patient began screaming. “It’s okay. It’s okay. I’m almost done,” the doctor said. Finally, he stepped back from the curtain. Blood covered his gown and gloves. “Poor guy,” he whispered, pulling his COW out of the room.

Highline Medical Center—just a few miles from Sea-Tac airport, SeaTac federal detention center, upscale Normandy Park, and the Somali and Ethiopian refugee strongholds of Tukwila and Burien—treats a diverse population: patients with top-of-the-line insurance, homeless people, illegal aliens, prison inmates (one came in toward the end of the night, flanked by four armed guards), and airline passengers.

During his shift, Garcia examined a woman who’d been kicked off a plane for intoxication and another who complained of chest pains but whose body fat rendered the X-ray nearly useless. (“That’s happening more and more,” he said. “Obesity is a big medical problem in America, even bigger than it was when I first started in medicine.”) He spotted a kidney stone in one man and determined that there was a chunk of broccoli lodged in the esophagus of another. Later he checked the vitals on a schizophrenic patient who paced the room and watched cartoons throughout the exam.

Garcia, a standout in the growing legion of customer-service-oriented docs, pays close attention to the amount of time patients have spent since setting foot in the unit. Jabbing a finger at his monitor, which tracks the time elapsed since the patient checked in, he said, “That lady’s been here too long,” then vanished down the hallway to her room.

Nationally, emergency patients wait about 40 minutes, on average, before seeing a doctor. But Highline’s expanded treatment space allows the hospital to usher patients out of the lobby within minutes of arrival. Check-in happens in the exam room. A Highline ER doc’s shift, then, simply becomes a matter of clearing the COW screen—by either discharging patients or admitting them to a hospital room.

The emphasis on patient satisfaction is working. In June, among nearly 500 hospitals nationwide, Highline’s ER scored in the 99th percentile in customer-satisfaction surveys, compared to 70th percentile a year earlier.

Those satisfied customers include patients who come in without any real symptoms—which happens way more than the public realizes, Garcia says. At least one patient that June night displayed, in layman’s terms, hypochondriac-like behavior. His chief medical complaint “a real awareness of my heartbeats.” Yet Garcia treated him with the same care and concern he treated a subsequent patient who was likely in the middle of a genuine heart attack.

“I want to make sure everything is okay before I send you away,” he told the anxious man. “Just so that we both feel better.”

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