24 hours in a Detroit ER: on the frontline of America’s healthcare debate

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Henry Ford hospital is one of the busiest in Michigan, and with many patients on Medicare and Medicaid it stands to be impacted greatly by an Obamacare repeal. As the debate rages, one doctor remains the calm at the center of the storm

Its Monday, generally the busiest day for any ER, but at Henry Ford hospital in Detroit, its biblical. Patients lie in beds lined up along soft hallways with harsh light, and the doctors have what they call a campfire going, a ring of moaning patients huddled in beds around a central dispatch area. An alarm sounds, and Dr Gerard Martin has two minutes to prepare. He doesnt yet know what tragedy will arrive by ambulance into the resuscitation bay, but he knows its a matter of life or death.

The doctor and the patient arrive at the recess room at the same time: Martin in a white lab coat with a rapid energy devoid of panic, and the patient naked and unresponsive. One of two resuscitation bays where the most severe cases are taken, the room is all stainless steel and focused dynamism. Fourteen medical professionals swirl the room, unwrapping plastic packages and holding needles while paramedics perform CPR. Two nurses ready a yellow and black machine that looks like a drill press with an oversized button where the chuck would be.

We call that the thumper, Martin winks before guiding a resident who is threading a needle into the flesh near the patients collarbone. The thumper is an automated CPR machine, manufactured in Michigan. A tech attaches it around the mans body. The piston compresses his chest with a pneumatic sound and a click, like one of the stamping machines in Detroits long-gone factories.

The patients belly fat roils, his ribs break. Five minutes. Another resident squirts blood into a pan. Ten minutes. The patients son is escorted from the room. Twenty minutes. The ambulance asks for its stretcher back.

Time of death: 7.26pm, heart attack.

Dr
Dr Gerald Martin asks questions of a patient who had complaints of chest pains and breathing problems. Photograph: Bryan Mitchell for the Guardian

Detroit is one of Americas most violent and impoverished cities, and Martin has spent nearly 30 years on the spear-tip of the health crisis in a violent and ill country.

From crack (not as big a problem now as in the 1980s) to gunshot wounds (fairly steady, worse when its hot) to heroin (currently at epidemic proportions), the challenges have varied. But Martin and the staff at Detroits last not-for-profit hospital have tackled them all. When other civic institutions were leaving Detroit, along with prosperity and civic order, Henry Ford hospital stayed to care for the sick.

Even in what may be the most desperate city in the US, if you have a heart attack, medicine has reached a level of sophistication where no fewer than 14 people will work to keep you alive if you reach the hospital, regardless of your ability to pay. As healthcare in the US continues to change, namely in the battle over government run and administered insurance, it makes sense to take a look at one of Americas most august and storied hospitals and their staff for insight and guidance.

One of the best things about Henry Ford is, if the guys homeless, and theyre having the same symptoms as the mayor, they get the same treatment, Martin said one evening, finishing an interrupted thought from the ER. To the people that do it, its not that remarkable. Its the way it should be done. In my opinion, everyone should have healthcare

Hes interrupted.

Another alarm, another patient, another life in his hands.

Slight and physically unimposing, Martin is an accomplished cyclist as well as a superbly talented doctor. He often rides his bicycle to work from his house in Grosse Pointe, an inner-ring suburb of Detroit. He has also ridden it clear across the country.

I rode from Oregon to New Hampshire, he says at dinner one night, characteristically humble about his accomplishments. It took him only 50 days.

Formerly the head of the ER department and now semi-retired, Martin has the particular characteristic of bowing his head and smiling sheepishly when someone praises his long list of accomplishments. He commands a staff of hundreds at the apex of a hierarchy resembling the military, yet when speaking with patients he says things like belly rather than stomach, and sick instead of injured.

As he speaks, he guides hospital beds through doors with the relaxed demeanor that comes after 30 years removing bullets, suturing knife wounds and watching people live or die on his watch. His countenance on the whole suggests a retired and beloved elementary school principal more than a man who has been up to the forearms inside a chest cavity due to axe wounds.

He has thousands of lives to his name, I hear as I make my way through the corridors of the dignified red-brick hospital.

He just walks on water.

I would follow him anywhere.

In the triage bay, Martin explains the workings of a sonography machine, while a woman in ripped jeans and an orange T-shirt yells at a rubber-gloved nurse. Each bed is separated by a curtain, but the woman in orange has ripped hers open. She entered the ER complaining of chest pains and is drunk. The patients shouts become insults and the nurse moves to restrain her.

Fuck you, you fucking faggot, the woman screams at man. I know my rights.

A scrum of police officers, EMTs and technicians move to help the struggling nurse, but the womans cries and insults only become louder and more full of pain, her struggles more ferocious. Martin stops his demonstration and steps into the middle of the crowd, waving everyones hands off the woman.

In less time than it takes to hand-wash a coffee cup, and with mysterious grace, Martin has defused the situation. As he checks the womans heart with a stethoscope, he explains exactly what is about to happen to her the nurses will hook her up to an EKG machine, among other procedures and gets the woman to lie down, still muttering at the original nurse but pliable.

Martin seems unfazed and almost joyous through the ordeal. He leads with quiet slyness, kindness and confidence and 30 years of experience practicing those traits. When I was young, I thought: Im going to go to medical school, Im going to become a doctor, and Ill make enough money so that I can live in the woods in Vermont on a farm and Im going to work two days a week, he said one evening. I never in a million years pictured myself in the inner city, of any city, working in the situation I do.

Drs
Drs Manu Malhotra and Gerald Martin joke during a shift in the emergency room. Photograph: Bryan Mitchell for the Guardian

Henry Ford hospital has 877 beds, with 77 of them in the emergency room. Its intensive care unit holds more patients than any other in Michigan, and its emergency department is the third-busiest based on volume. More than 100,000 people visit the ER at Henry Ford every year.

The ER itself is split into four categories, numbered one through four, with category one holding the most acute patients. Martin is on this rotation today: a man who took too many seizure meds and is in a coma; a heavy user who shows up to ERs across the city multiple days a week because he is lonely or mentally ill; a woman who has been in an auto accident and is wearing a neck brace.

Martin touches each in turn, with ungloved hands. The physical proximity in the ER isnt exactly cramped, but it is close.

Ah, some residents always use gloves, but I dont really mind, he says matter-of-factly when washing his hands between patients. Next, he attends a woman with acute diabetes.

Oh, your hands are cold, winces the woman.

Cold hands, warm heart, the doctor replies.

She laughs, and Martin asks the woman about the nurse taking her blood.

She was great! She got [the needle] in on the first try!

We usually call her five-poke Sarah, Martin jokes.

They do not! the nurse laughs.

According to the hospital, statistically at least one of these patients is on Medicaid, the healthcare program run by both federal and state governments for low-income Americans. Of Henry Fords patients, 18% are on Medicaid or a Medicaid HMO, and another 43% are on Medicare, the federal program for seniors.

One of the cornerstones of the Republicans new American Health Care Act is a plan to begin rolling back the increased support that the Affordable Care Act gave states for Medicare expansion, starting in 2020.

Henry
Henry Ford hospital, one of Michigans busiest hospitals. Photograph: Bryan Mitchell for the Guardian

Im a big supporter of the Affordable Care Act for its principles and policies, Wright Lassiter III, the president and CEO of Henry Ford Health System, tells me in his office. Its less gaudy than I would have expected for the head of a $6bn organization, possibly owing to the hospitals not-for-profit nature. But its still spacious and stately.

I think our principle problem in society, with healthcare, is that as a society we havent decided yet, like every other industrialized country, that every citizen should have healthcare and that makes our society better.

He pauses for effect.

Now, how you pay for it or who provides it is it a tax credit or a block grant, or is it a government subsidy, or whatever we can debate that on political lines or on economic development lines or on social justice lines or on a number of fronts. But our fundamental problem is were still debating what most countries believe is a truism, which is: everyone should have healthcare insurance.

The Affordable Care Act (ACA), colloquially known as Obamacare, cut the number of uninsured people in America by about two-fifths. It increased the number of insured individuals by approximately 20 million, with 30 or so million left uninsured. In Michigan alone, more than 630,000 became insured through the laws Medicare expansion and another 345,000 or so via the healthcare exchanges. Its about one in every 10 people in Michigan.

What is less clear is what effect that has had on the overall health of the states population and the health of its urban hospitals. Nearly everyone interviewed for this story agreed that the ACA hadnt had time to reach equilibrium, as Manu Malhotra, associate chief medical officer, put it while sitting next to Martin in the ER.

Predicted drastic spikes in ER visits havent come to pass, but neither have drastically increased revenues for hospitals such as Henry Ford. The equation has now simply changed in complex ways, and hasnt had time to bear economic or medical fruit or fail to do so. There simply hasnt been enough time to tell.

Society at large, and people with the ability to pay, currently already shoulder the burden of providing the cost of healthcare coverage to the people who are unable to afford it and do that in the most expensive and inefficient way possible by providing care only in emergency situations, Malhotra said. Finding a better way to do that is essential, and the Affordable Care Act is the only cohesive effort that weve seen on the national level.

A
A hospital staff member holds up a bullet removed from a patient in the ER at Henry Ford hospital. Photograph: Bryan Mitchell for the Guardian

On a Wednesday, Malhotra and Martin are deciding whether to remove the bullets from a man who has been shot multiple times. Contrary to televisual opinion, bullets are generally left inside the body unless they actively present a danger to the patient or interfere with future medical procedures.

They decide one bullet will need to be removed, so a screening can be performed, while the others will stay. All the residents are out taking tests this day, so Martin will perform the procedure himself.

Get the metal pan! Martin jokes, aping the Hollywood convention of a gruff doctor dropping each slug into a brass surgical tray with a solid plink.

Martin pantomimes the motion, holing up his fingers dramatically, and Malhotra chimes in with a ding! when the phantom bullet falls. Everyone laughs.

We have 50 of those pans in the back, he says to me, clearly kidding, but the joke belies the typical gallows humor used as a coping method of those cops, firefighters, soldiers who work with death daily.

The children are the most difficult, Martin tells me later, shaking his head. I like joking around, but when someones sick its no time for joking. You need to buckle down and know what to do and take care of the patient. Put the patient first.

A woman sits with her elderly mother, who wears a breathing mask. She has a degenerative nervous system disease and will one day stop breathing, her mind fully alert, because her brain can no longer tell her diaphragm to contract.

The same day, another family, in the corner and speaking a foreign language, huddles around a matriarch quite literally kept alive by machines. Although this person they love cannot communicate with them, they cannot in turn let her go.

A scared teenager has a dislocated shoulder. A hilarious elder gentleman tells anyone within earshot his historic life story as he lies in bed with chest pains. A professional woman is terrified by a mysterious rash. Martin inspects them all with the care of a good dad scrutinizing scrapes and bruises on a calming child.

The national healthcare battle seems to be waged largely with swords of political ideology and money rather than bodies and souls, and the man lying with bullets lodged inside his frame can seem an afterthought. They say a single death is a tragedy and a million is a statistic. Some of those statistics, the faces and the names and the bodies behind the giant numbers thrown around by politicians, are sitting in the ER today.

I can feel the bullet in the skin right here, Martin tells the gunshot victim. (As with every other patient in this story, US law protects the privacy of medical information and thus prohibits providing identifying details of patients or their situations.) Im going clean it off, numb it up and pull the bullet out.

As he cleans the wound on the mans forearm, a circular bruise about the size of a basketball with a small slit in the center, the aural landscape in the ER is lush. Beeps and blips and alarms and dozens of voices are overpowered only by the heart monitor tracking the mans pulse, a steady ding, ding, ding.

The procedure takes about two minutes. The blips from the heart monitor become faster as the doctor places a needle loaded with numbing drugs inside the mans forearm DING DING DING and faster still when the doctor expertly digs around in his body for the bullet DINGDINGDINGDINGDINGDING.

Is it out? the patient asks.

Martin drops the bullet in a plastic pan with a hollow thud. The bullet appears to be .45 caliber, with bits of flesh and blood attached, jagged and mushroomed from the impact. If not for the rifling inscribed on the body, it might look like a moon rock or a miniature bonsai tree. Almost all bullets, regardless of provenance, go to the police.

Can they reuse it? Martin jokes, as he whisks on to the next person.

The man in bed is apparently relieved the procedure is over, the hands of the doctor having preformed their work perfectly. His heart rate has slowed back to a steady, plodding rhythm.

The American Health Care Act keeps certain popular provisions of the ACA, such as guaranteed coverage for those with pre-existing conditions and allowing children to stay on their parents plans until theyre 26 years old.

It does away with others, including the individual mandate, or forced enrollment, and many of the taxes levied on the wealthy to pay for the program. Starting in 2020, the bill proposes to reduce the planned Medicaid expansion and, over time, in effect eliminate it.

Roundly criticized from nearly every corner of the political spectrum, the bill will undoubtedly go though many revisions, and the House speaker, Paul Ryan, has promised that this is only the first step in a Republican overhaul of healthcare. What does seem clear is that the bill will do little to further reduce the number of Americans without health insurance approximately 30 million and will probably reduce the number currently insured.

The nonpartisan Congressional Budget Office has put the number at 24 million fewer people insured by 2026. And although the figure is notoriously difficult to predict with scientific rigor, as creating control groups in giant healthcare studies of this nature would be unethical, two Harvard Medical School professors put the number of deaths directly due to an ACA repeal at 43,000 people each year.

As the Republican healthcare bill and, more generally, healthcare in the US is debated, the broader question outside of the minutiae of individual bills and policies is: how, as a society, do we define success in healthcare reform?

Is it measured by how many individuals receive healthcare? Or how comprehensive the coverage is? Is it how much money is saved on the national level, or how many people no longer have to declare bankruptcy because of medical bills?

Is it about the patient with the blonde braids laying before Martin on the operating table? She has been dropped off by a good Samaritan who found her unresponsive and lying in a gutter. Rushed into the recess room by nurses, the patient is nearly catatonic and slipping further into herself, barely able to answer questions, finally drifting completely out. One of the residents lifts her hands and they stay as they were placed, stiff, like when a dog lies on its back. Doctors yell to her. Nothing.

Watch this, Martin tells me.

A resident loads clear fluid into a needle and injects it into the woman.

Fifteen seconds, nothing.

Thirty seconds.

Nothing.

Sixty seconds.

The woman snaps out of bed and opens her eyes, absurdly conscious and alive, wonderfully lucid. Shes just received a dose of Narcan, a drug to reverse heroin overdoses. The result is stunning and immediate, as if shes arisen from the dead.

Where am I? she asks.

Youre in a hospital, the doctor replies.

Read more: www.theguardian.com

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