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Emergency Medicine News:
doi: 10.1097/01.EEM.0000452048.85666.38
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News: ‘Code Black’ is Health Care in Microcosm

Katz, Alissa

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What happens when the determination to heal meets the realities of a broken health care system?

A group of young residents at LAC+USC Medical Center — or LA County, as it is most often called — tried to find a solution on top of figuring out who they were supposed to be as emergency physicians. “Code Black” captures it all as it follows director Ryan McGarry, MD, and his colleagues through residency. It is an intense and moving glimpse into one of the nation's busiest emergency departments juxtaposed against the state of America's health care.

“Part of what we're trying to figure out now is who we are. What does it mean to be a doctor in these times in America,” Dr. McGarry said in his debut documentary. “When we started this, it seemed so simple. We were going to be doctors. We were going to help people.”

LA County is, as its name implies, sees every low-income, underprivileged, uninsured patient who doesn't otherwise have access to care. The doctors' journey begins in the hospital's former C-Booth where, at 20 square feet, more people have died than anywhere else in the United States. But more have been saved there than anywhere else, too. The residents who worked at LAC+USC with Dr. McGarry speak of their baptism-by-fire experiences in C-Booth with equal parts pride and adrenaline, describing it as a place where they not only proved themselves, but also provided the urgent, hands-on patient care that motivated them to become doctors.

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“I wanted to have the ability to help someone ... who needed it,” said senior resident Jamie Eng, MD, now an EMA administrative emergency medicine fellow in Los Angeles. “Being a doctor, I have the capability to relieve someone of their suffering.”

That reality changed, though, when they moved from their old ED to a state-of-the-art, billion-dollar facility because the old one failed to meet the earthquake code. Unfortunately, C-Booth was a victim of the new, modern design, making doctor-patient interaction less frequent, the doctors said. Waivers that previously exempted the staff from some burdensome paperwork also vanished, leaving residents and nurses complaining about spending more time filling out paperwork than actually seeing patients. The paperwork kills the passion of saving somebody's life, according to Dave Pomeranz, MD, a third-year resident. The charting, he explained in the documentary, is just a wall of bureaucracy. And when the ED is code black — when the waiting area is crammed full of patients — it slows the system to the point where “it feels like the place is going to blow up at the seams,” Dr. McGarry said.

The film details the professional and emotional experiences of the emergency physicians, and more often than not, it's difficult to separate the two. Residents called time of death several times within the 81-minute documentary, and by the looks on their faces, it didn't get any easier with practice.

“It wasn't a coincidence we did that,” said Dr. McGarry, now an assistant professor of emergency medicine at Weill Cornell Medical College and New York Presbyterian Medical Center in New York City. “The first time you experience something like that, it's obviously kind of arresting and intense, and there's a lot of disappointment that the whole place doesn't shut down and grieve for a moment. I think your expectation coming in is a naïve position that the whole place is going to stop. We notice that it actually doesn't, and as time goes on, you become more numb to that.”

Other patients who come into LAC's emergency department have just as much of an effect on the physicians, and one in particular who had an impact on Dr. McGarry was featured in one of the last scenes of the film. An attorney came to the county ED because she lost her health coverage after her law practice closed after being embezzled.

“I approached her to be a subject in the film not knowing any of her back story,” Dr. McGarry said. “It was this full-circle moment; the loop was definitely closed. I'm going, ‘Oh, my God. We couldn't have scripted this better.’ To have someone who is just one pink slip away from losing everything was effective, and is something we all realize but often maybe forget. You may not need a public hospital and you may not worry about your health insurance until, of course, you don't have it.”

The health care debate was one of the paramount components of the film, something that is as devoid of the physician voice as it is rife with a political one, according to Dr. McGarry. As an initial step to fixing the system, Dr. McGarry suggested taking the idea of profit off the table. When that's the case, as in public hospitals, it makes for a really different value system.

“People work at that institution for reasons of compassion, for reasons of service, for reasons that we feel are why we ultimately got into this business in the first place,” he said in an interview with EMN. “Is that a practical solution to be decapitalizing all health care? Probably not in America. But I do think it's an interesting starting point to say, ‘Hey, let's look at the public hospitals in this country. Let's look at what drives the value system there, and then let's see if we can institute that into our daily lives somehow.’”

That idealism is what gives the film its glimmer of hope. Unhappy with the loss of C-Booth and less patient interaction, the residents devised a plan to replace a handful of beds with chairs so they could keep an eye on the sickest patients. “This is just like C-Booth,” Dr. McGarry said. “It was incredible. Just a few weeks into it, the ER wait times started to drop.”

Even better, he said, was that what started as a 20-chair experiment renewed the physicians, all of them feeling that surge of adrenaline they were missing. “Suddenly we were practicing medicine for the reasons that we wanted to practice medicine in the first place: to serve, to help, to heal,” he said.

The problems at LAC+USC and the few remaining public hospitals in the country are legion, however. Understaffing, underfunding, and crowding continue to plague them in ways most EDs can't even imagine. “These people aren't seen as profitable, and the system will always find a way to still see them as not profitable,” Dr. McGarry said in the film. “So on the front line, the feeling is we need help. We need to be overfunded, we need to be overstaffed because we're this critical community resource, and right now we can't even run on all four cylinders.”

That's a sentiment echoed by all the residents and attendings at LAC where part of the ED had to be closed because no staff were available. “It hurts,” said Dr. Eng. “I came here to see patients, and to have a whole unit close ... it's heartbreaking. Soul-crushing, actually.”

Andrew Eads, MD, a third-year resident, perhaps summed it up best: “The doctors of this hospital believe we can do better, that it's not a failed system, that it can be fixed. You have to have people who believe first before you can actually make it happen.”

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Coming Soon to a Theater near You

“Code Black” is playing at the IFC Center in New York City and at the Landmark in Los Angeles. More theaters across the country will release the film as early as July 11. Find a theater showing the documentary in your area at http://codeblackmovie.com/screenings.

Wolters Kluwer Health | Lippincott Williams & Wilkins

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