One day earlier this year, a hospital technician at Bethesda's Suburban Hospital had just begun drawing blood from a patient's arm when the wall a few feet above his head shattered into a shower of plaster.
When the startled technician looked up through the gaping hole in the wall, he saw on the other side a construction worker busily blasting away on another of the hospital's expansion projects.
As minor and funny as the incident may seem, for many doctors and nurses at Suburban it is another symptom of what they consider a serious problem. The day-to-day needs of hospital care are being slighted at Suburban, they charge, while a hospital administration holding hefty cash surpluses is preoccupied with spending the money on expansion.
Nurses and doctoros complain that not enough of the excess cash is being used to upgrade medical services or hire desperately needed clinical testing personnel and more and better qualified nurses.
As a result, their claim, patients often must wait inordinate amounts, of time for help when they call for a nurse (one man lay in his urine-soaked bed for 20 minutes and finally rolled off to escape it before help arrived), wrong medicines have been administered by overworked nurses (one patient received the wrong intravenous solution for six hours before it was noticed), and routine tissue test results, which should take no longer than two days, take up to two weeks at Suburban.
Though no patients have apparently been harmed, these examples, as well as others, have prompted a number of doctors and nurses to file internal complaints, drawn a state regulatory agency into the controversy, and even resulted in several doctors forming a slate to challenge the hospital administration - unsuccessfully, as it turned out - in the annual elections for hospital board of administrators.
"I can't prove it in court, but I feel in my bones that health care has deteriorated at Suburban," said Dr. Robert F. Spicer, former Suburban chief of staff and one of the unsuccessful doctor candidates. "Those damned people won't spend money. They are just empire building."
Hospital administrators deny any such allegations. They point with pride to the fact that the daily room rate charge at Suburban, a non-profit hospital located at 3600 Old Georgetown Rd., is $75, the lowest in the Washington area and the second lowest for the entire state of Maryland.
As for patient care, Robert H. Myers, the president of the Suburban Hospital Association, said, "I disagree that care at Suburban isn't first-rate. It is. If it's so bad, why do doctors continue to send us their patients?"
"Physicians always speak up for their own specialities," he said, of the dissension at the hospital, "but we (the board) have to be concerned about providing service to all physicians. We have an overview of the situation. We can't be all things to all people."
At the center of the controversy is Suburban's new $15 million, six floor wing scheduled for completion in 1979. The wing will house a nuclear medicine department, medical library, an expanded psychiatric service, intersive and critical care units, operating and recovery rooms, and an additional 115 regular hospital beds.
Suburban had originally planned to begin building the wing in 1972 at an estimated $9 million, but delays caused by neighborhood civic association court challenges and lengthy state and local review board proceedings held up constrcution and drove up costs a spokesman said.
Suburban was founded as a wartime facility by the federal government in 1942 in an area that was then largely farmland. Today the hospital is a sophisticated health care complex located in the heart of one of the nation's wealthiest communities.
Last year at least 800 physicians admitted more than 14,000 patients to the hospital for treatment in the facility's 350 beds. During the same period, more than 42,000 persons were treated or seen in its 24-hour-a-day emergency room, considered one of the area's best.
The hospital's budget, which is currently, 123 million, has increased by more than 10 per cent annually for several years. The hospital regularly receives a full two-year accreditation from the Chicago-based Joint Commission for the Accreditation of Hospitals, which could withhold its approval if it found deficiencies anywhere in the hospital and its administration.
Suburban has been the object of some outside criticism, however. In 1974, for instance, a report by Ralph Nader's Health Research Center criticized, Suburban on a number of grounds, including what it claimed was the small size of its nursing staff.
The following year Suburban was given permission by the state regulatory agency that oversees hospital rates to raise its room rates so that more nurses could be hired. As a result, in the last two years Suburban has increased its nursing staff by 23 per cent and its 287-person nursing staff, now compares favorably in size with those at hospitals of similar size, figures show.
However, despite those staff gains, problems obviously persist. Hospital officials are at a loss to explain why 52 per cent of the nurses at Suburban - one out of every two - leave each year. Those are figures far above those at other Washington area hospitals of similar size, a suburban surbey shows.
Critics are quick to call the figures indicative of "poor morale" within the nursing staff. One nurse, who asked not to be identified, said she recently quit "because I was burning myself out" because of overwork and emotional drain. Another complained that one weekend evening shift with responsibility for the care of 29 patients was handled by two nurses when, she claimed, the hospital's own guidelines call for four.
It is impossible to determine whether there are enough nurses at Suburban simply because there are no established national standards for optimum nurse-to-patient staffing ratios. National experts on hospitals in both government and private industry say in effect that whatever staffing ratio works at a hospital is the right one.
One national expert believes that the frustration expressed by many nurse at Suburban is the precursor of things to come at hospitals throughout the country.
"A nurse is no longer a bedpan carrier," said Harold L. Hirsh, the expert who is both a doctor and a lawyer and lectures extensively. "The old-fashioned nurse just wanted to follow the doctor's orders, which was fine with the old-fashioned doctor. The new breed of nurse is far more highly trained, knows she sees more of the patient than anyone else, and wants to share her insights with the physician. When she can't do that, she complains."
"Every hospital will go through what Suburban is going through," he predicted.
Nontheless, in April the hospital's head nurse, Mary B. McCann, resigned after numerous conflicts over "management procedures" with Suburban's administrator, Robin H. Hagaman. McCann, who is married to De. Spicer, had been hired specifically to upgrade nursing care at the hospital, and hospital officials contend she accomplished just that.
The patient care committee at the hospitals, which consists of doctors, later voiced concern that the resignation had been "forced" because of what sources say were her decisions to hire more nursing supervisors and coordinators than some administration officials believed were necessary, and her attempts to get certain operating rooms closed because she felt there were not enough staff members to handle their operations.
Shortly after McCann's resignation, on May 10 Dr. Josiah Sacks, former chairman of Suburban's gynecology department, bitterly complained in a letter to a hospital supervisor about the "chaos" that resulted when two temporary nurses were sent in to assist him in an operation.
Sacks alleged that the two nurses were so unfamiliar with the hospital and its procedures that their presence transformed what should have been a relatively routine operation into a more complex one and put the patient in unnecessary danger.
The nurses had been hired by administrator Hagaman rather than by nursing staff supervisors, according to a complaint filed later with the state Board of Examiners of Nurses by the Maryland Nurses Association. The association claimed that a state law required all nurses to be hired by nursing supervisors.
Hagaman declined to comment on the complaint because he had not yet been formally notified of its filing. He noted, however, that all nurses at all times are supervised by senior nursing staff.
"Patient care at Suburban has deteriorated enormously in recent years," Sacks later told a reporter. "I don't know why. I now send my patients to Holy Cross."
Senior hospital officials suggested that Sack's remarks to the press may have been prompted in part because he "had an ax to grind" because the hospital's obstetrics department, in which he had worked, had been phased out.
The six doctors on the ill-fated slate of candidates that challenged the administration in April's board elections said they did so because more doctor input was needed at the decision-making level of the hospital. The one doctor who represents the medical staff on the board was not enough, they said.
In addition, they said they pledged to hire 30 more nurses, fill the long-vacant seat of head of the pathology department by speeding up search efforts, and to improve communication between physicians and the administration.
While the challengers were easily defeated, what was already a festering discontent was exacerbated, doctors claim, when Suburban Association president Myers sent out a letter to voting members of the association before the election that labeled the doctor slate as "dissidents."
"This is an exceptionally bad time for this type of activity to develop," Myers wrote, since he claimed it could jeopardize the issuance of tax exempt bonds needed for the construction of the new hospital wing.
Myers said in an interview his letter was meant to express his concern that adverse publicity about the situation at Suburban might have caused state regulators to increase the amount of interest the hospital would have to pay to holders of the bonds.
Many of the complaints against the hospital center on its financial success. For years the nonprofit hospital has regularly piled up $1 million and $2 million in annual revenue surpluses, money that was always stored away in the hospital building fund rather than spent on increased hiring or medical service improvements doctors claim were needed. That fund currently totals $12 million.
One senior hospital official, William D. McLean, contends that the banking of the $12 million has enabled them to save patients $15 to $20 a day in additional room charges. He said that much more would have to be charged today if the hospital were to have to borrow the $12 million for its construction projects.
In addition, Hagaman said that the hospital spent $731, 291 on new equipment and that virtually every request for new equipment purchases was approved.
"In my 15 years of professional experience," said Hagaman, "including work at three major hospitals, I've encountered these complaints before (elsewhere). There's nothing unusual about them, and the care at Suburban is more than excellent."
Dr. Spicer, despite his concerns, says he continues to send his patients to Suburban because "its a good hospital. That's the damned problem. We just want to make it a better one." CAPTION: Picture, This construction of a $15 million wing to Suburban Hospital is, some observers feel, less needed than improvement of staff and services. By Charles Del Vecchio - The Washington Post