When Stacey Miller collapsed in a Beth Israel Medical Center bathroom on April 30th, her life was literally running out of her body.
A pounding headache had propelled her to call her best friend twice to take her to the hospital. Unable to wait, she finally took a cab across town, arriving at Beth Israel's emergency room at 16th Street and First Avenue a little after 11 p.m.
On an earlier occasion, when she had a broken ankle, Miller had gone to St. Vincent's Medical Center on 12th Street. But that option wasn't open this time. St. Vincent's, one subway stop south from Miller's apartment on 23rd Street and 7th avenue, had closed its emergency room on April 9, and had full shut down all other in patient functions by April 30—the same day Miller's headache sent her to the ER across town.
At Beth Israel, Miller's headache was diagnosed as a brain hemorrhage. Waiting for a CAT scan and an MRI, she excused herself to use the bathroom and vanished. The doctors found her shortly afterwards passed out in a pool of her own vomit.
The rest of the story is brief. Miller was rushed across town to St. Luke's-Roosevelt hospital, which has a Level 1 trauma center, because Beth Israel was not equipped to handle her critical neurological state. (Citing patient privacy laws, Beth Israel declined to comment; the details of Miller's story come from a friend.) Miller died two days later, on Sunday, May 2nd. She was 44.
And so the questions begin. Why did she wait so long to go to the hospital? Why was she taken to St. Luke's across town when Bellevue Hospital, which also has a Level 1 trauma center, is located at First Avenue and 25th Street? Most salient of all, if St. Vincent's hadn't shut its emergency room—which had a Level 1 center—on April 9, would Stacey Miller still be alive?
It’s impossible to say what, if anything, would have saved Stacey Miller. But one doctor, surveying the new landscape of life and death in New York hospitals after the closure of St. Vincent's, says, "It's like a car crash in slow motion."
Prior to the hospital's demise, there was speculation about what would happen if and when St. Vincent's closed. Now, six months since the hospital shut its doors, results are rolling in. And they don't look good.
'Off the board'
Ambulance transport time has increased by an average of three minutes and 15 seconds for all of downtown Manhattan. Triage patients are piling up as they wait for emergency care. Hospitals have expanded hours and pulled residents in to do the work of overtaxed doctors and nurses. Confusion is rampant as doctors try to recreate medical histories for St. Vincent's patients, who don't have access to their medical records. And ER violence has increased, as people in agonizing pain are forced to wait longer and longer for treatment.
Dr. Christopher McStay, Assistant Director of Emergency Medicine at Bellevue Hospital Center, has an expression for the influx of patients that has swamped the hospital—he calls it "off the board."
"The new norm means we're off the board," McStay says, referring to an actual white board posted in the emergency room that lists all the patients who are seen over a 24-hour period. The board, which used to have slots that ran from A to P, can now run to double F. About a month ago, McStay bought a new, larger tracking board.
Before St. Vincent's closed, Bellevue racked up 8,000 ER visits a month. Since May, that figure has been closer to 10,000 a month. Before St. Vincent's closed, the hospital had 2,000 ambulance runs a month; in the three months after it closed, ambulance runs jumped to 2,685 a month.
And the outpatient clinics are equally swamped. Combined, Bellevue's 90 outpatient clinics treat half a million patients a year. Depending on the clinic, patient load has increased anywhere from 5 to 19 percent—an increase Bellevue doctors attribute both to St. Vincent's closing and to the recession.
"I think we are in the middle of a crisis in the city," says Dr. Lewis Goldfrank, Chief of Emergency Medicine for Tisch Hospital at NYU Langone Medical Center and Bellevue, adding "the whole population of people at St. Vincent's had structured care and now they don't have it."
Hospitals struggling to cope
Since St. Vincent's closed, there has been a 25 to 30 percent increase in ER visits to Bellevue and an 18 percent increase in ER visits at Tisch Hospital. The pressure is being felt everywhere: in an overcrowded ER, in crowded clinics and on the hospital's floors, where 339 of Bellevue's 809 beds are assigned to psychiatric patients.
With St. Vincent's 80 psychiatric beds gone, more and more EDPs (emotionally disturbed persons) are being brought to Bellevue, where staff has had to scramble to find resources, putting an already strained system under even greater pressure. "It's an immense burden," says Goldfrank. "It has led to a level of violence in our ER that we haven't seen in a long time." At the same time, says Goldfrank, "it's also demoralizing for staff not to do the best job for people."
But it's not just Bellevue that's under pressure. All over lower Manhattan, hospitals have been scrambling to cope with the increase—doctors are calling it "the surge"—in patients since St. Vincent's closed. The hospital, $700 million in debt, the legacy of the 2005 collapse of its consortium of New York Catholic hospitals, struggled throughout 2009 and early 2010 to find a viable partner but was ultimately unsuccessful.
Critics of the New York State Department of Health blame both the hospital's board for mismanagement and inaction on the part of the DOH Commissioner Richard Daines for the hospital's collapse.
Responds Jeffery Hammond, a spokesperson for DOH, "DOH provided critical operational funding to allow St. Vincent's to explore merger opportunities with over 5 interested parties. After due diligence, none of these potential partners were interested in St Vincent's. It is clear that St. Vincent's did not have a business model to sustain itself nor did it have one that was attractive to any potential partner. It is very difficult to sustain a loss of $80 million in one year, which it did in 2009, and have an additional legacy debt of $700 million — and be a viable business."
Even before a near merger with Mt. Sinai collapsed in March, leading to the April 6 vote by St. Vincent's board to close the hospital, all Manhattan hospitals south of 59th street had been experiencing an increase in patients as rumors swirled about St. Vincent's seemingly imminent demise.
And the day after St. Vincent's shuttered its emergency room doors, officials at Beth Israel noticed an immediate effect. "St. Vincent's stopped receiving ambulances on April 9. We felt the impact on April 10thth," says Kathleen Ehrenberg, Associate Chair of Emergency Medicine. Prior to St. Vincent's closure, ambulance runs to Beth Israel hovered around the mid to high 50s, with approximately 250 patients in total seen daily in the ER.
Within a month of St. Vincent's closure, however, ambulance runs to Beth Israel were up to 75 a day and ER visits were up to 294 visits a day, a figure that has more or less held steady since, says Ehrenberg. "We are seeing more psych patients and more patients that have alcohol and substance abuse issues." She adds, "We absolutely know we are drawing from the St. Vincent's catchment area—we can tell by home addresses."
In many ways, Beth Israel got lucky. The hospital is finishing construction of a new emergency room this month and, along with hiring more doctors and credentialing those who used to work at St. Vincent's, the hospital has been able to hire an additional 400 employees, from nurses to radiologists and other technical staff. And the influx of patients, with private insurance or Medicaid or Medicare, means a boon to the hospital's bottom line, says Jim Mandler, a spokesperson for Continuum Health Partners, which includes Beth Israel Medical Center and St. Luke's-Roosevelt Hospital. "The increase in in-patient volume ultimately translates into more revenue and that revenue is used to provide for the overtime and additional staff," says Mandler.
As St. Vincent's was publicly floundering in the early part of 2010, Beth Israel was ramping up the renovation of its Emergency Department facilities, begun after the closure of Cabrini Hospital on East 19th Street in 2007, and opening the doors to a new, comprehensive psychiatric center.
At NYU, hospital administrators have responded to the increase in ER patients by extending shifts that used to end at midnight to 2 a.m., and hiring more doctors and nurses. At Bellevue, hospital administrators have been lobbying the New York City Health and Hospital Corporation, which oversees the city's public hospitals, for more money for nurses. In the interim, shifts have been added in the ER, five new nurse practitioners have been hired and third- and fourth-year residents are now running the hospital's urgent care center, whose hours of operation have been extended to midnight.
Still, it isn't enough. Doctors at NYU estimate that ambulance runs are averaging between 20 to 25 a day since St. Vincent's closed. According to FDNY, which tracks ambulance-related data, this is up from 16 runs a day before St. Vincent's closed. There's a longer wait-time to get a bed, but nowhere near the wait-time at Bellevue next door, where the door-to-floor time is an average of eight hours, up from six hours in 2009.
All this has only increased the frustration of hospital administrators at both NYU and Bellevue, the primary teaching hospital for NYU School of Medicine.
"If you are going to close a hospital, there has to be a plan," says Goldfrank, adding that Bellevue and NYU were overwhelmed in terms of demand for services when St. Vincent's closed. With rumors running amok and no clear information from either the Department of Health or HHC, doctors in Bellevue's ER finally pulled out a map, figured out where the ambulances that once went to St. Vincent's were likely to go, and estimated that they would be getting between 600 to 800 more runs a month. (They were pretty much spot on.)
As one doctor observed: "St. Vincent's didn't close in one day. The issue was that nobody wanted to bring in the resources and take this challenge head-on before the doors closed. And then the doors closed and all the patients showed up at our doorstep. Now we're trying to dig out. Six months later, after the rubble was poured all over us, we may finally be able to see daylight."
'Your life depends on traffic patterns'
Chui-Man Lai, a spokesperson for New York Downtown Hospital, confirms there has been an increase in ER visits since St. Vincent's closed, as well as ER wait times. The operating room (OR) has also "been pretty busy" and the hospital has plans to open up three new ORs, one before the end of the year and two more in 2011. Service hours at the hospital have been expanded during the week, from 3 p.m. to 8 p.m., but suspended on the weekend to allow for construction of the new operating rooms. "A lot of hospitals are going through this," Lai says of Downtown's efforts to deal with the new ER landscape. "You just have to accommodate."
Concerned about response and turnaround time in the wake of St. Vincent's closing, the Fire Department took over the five ambulance runs that formerly operated out of St. Vincent's, and authorized both St. Luke's and Beth Israel to each add one ambulance to the 911 system for 16 hours a day. Even with the increase in ambulances, transporting patients who would have gone to St. Vincent's to another hospital takes longer "because they have to travel further," says Chief John Peruggia, head of EMS for the Fire Department.
"Your life really depends on traffic patterns," echoes Rhona Chambers, a paramedic at New York Downtown Hospital and Long Island College Hospital and a former paramedic at St. Vincent's. "When you bring a patient in, there are already people on stretchers, in ambulances, waiting to get triaged before you."
In Stacey Miller's case, it's difficult to say what might've happened had she received immediate treatment at St. Vincent's. According to her friend Maryam Zadeh, Miller wasn't checked into St. Luke's until after 5 a.m. on May 1, six hours after her hemorrhage began. "By the time I tracked her down there, it was around noon, and she was on tubes," says Zadeh. "They said that she was 97 percent brain dead." Miller's doctors kept her alive until her mother and sister could fly in from Texas and say goodbye.