An old woman in a pale blue sweater slowly propels her wheelchair up and down the hall at D.C. General Hospital, past the painted animals still cavorting on the walls of what was once a children's lounge. She moans, to anyone who will listen, "I want to go home."
A stately woman sits down in the outpatient medical clinic next to a young man with a scarred face and twitching lips. She is Augustine Queen of Martin Luther King Avenue in Anacostia, and for the last 12 years she has been coming here for treatment of her diabetes. She pulls out hardboiled eggs and eats them slowly as the hours go by.
A shooting victim is rushed to the emergency room with barely a chance for life. There is no neurosurgeon, so the desperate surgical trainee, with the help of another young doctor, cuts a hole through the man's skull, an operation he has never performed. The patient probably was dead already, tests show later, but the memory haunts the resident for months.
For tens of thousands of people in the District of Columbia and nearby portions of Prince George's County, D.C. General is The Hospital. It is also the family doctor, the drug store and a home for many who have nowhere else to go.
Its legal mandate is to treat all District residents, whether or not they can pay. It thereby relieves Washington's private hospitals of the responsibility of treatiang those who have no health insurance. Thus, all over the city, private hospitals nudge alcoholics, abandoned elderly people and anyone else without medical coverage who can be moved into ambulances and even taxis to be shipped to D.C. General.
Half of the more than 200,000 patients treated there each year have no medical insurance, not even Medicare or Medicaid. Seventy-one percent if its patients live in Wards 7 and 8 east of the Anacostia River, the part of the city with the highest birth rate, the biggest families, the largest proportion of children and old people, and the lowest proportion of doctors.
One-third of the hospital's babies are delivered to mothers under 19. It has the highest infant mortality rate of any hospital in the District. Almost one-quarter of its beds are filled by old people waiting to get into a nursing home.
One whole ward is kept locked -- it is the only District hospital open to jail inmates or persons under arrest.
It has the city's busiest emergency room.
It has the best and the worst: some of the city's most dedicated doctors and some of its most cynical, some of its most determined nurses and some of its laziest.
It suffers from a chronic lack of money, shortages of nurses and technicians, problems of quality, training and motivation and a bureaucracy that frustrates ambition and stifles change -- all translating into long delays in treating patients.
D.C. General's typical patient is old, black, poor. His multiple illnesses work upon a body already damaged by high blood pressure and diabetes. iThose two diseases -- often present for decades and never treated -- produce bad circulation in so many D.C. General patients that the operation the hospital's surgeons do most frequently is amputation.
D.C. General's buildings cluster like red-brick mushrooms in the center of a 65-acre city-owned tract at 19th Street and Massachusetts Avenue in Southeast Washington. Flanking the hospital are the old and new D.C. jails, the office of the medical examiner, the city medical buildings housing Washington's tuberculosis-control program and a mental health facility.
Because ordinances prohibited D.C. General from rising taller than the Capitol, it grew sideways -- and its clump of buildings, some almost one-quarter mile apart, are linked by a network of underground tunnels so intricate and deserted that a man in a ski mask hid there several times last year, mugging passing patients and employes.
The central corridor of the hospital's core building is a linoleum highway crowded with bathrobe-clad patients shuffling to physical therapy, orderlies pushing wheelchairs, security guards, mothers leading toddlers, people in line to register for the out-patient clinics.
Blasts of hot or cold air -- depending on the season -- blow through as electric doors open for patients disgorged from ambulance and city van. The hammering of workmen busy on renovations provides a counterpoint to the twangy announcements of operators over the public address system. The walls are freshly painted, but the stream of patients carries grit that often defies jantiors' best efforts. No clock on any corridor has the right time.
D.C. General is owned by the District of Columbia government, and operatred by an 11-member commission of District of Columbia residents appointed by the mayor. Its operating budget for the year ending Sept. 30 is about $60 million, of which $31 million comes from a city appropriation.
Most of the remainder is paid by insurance programs -- primarily Medicare and Medicaid -- for care provided to insured patients. The city appropriation is supposed to reimburse the hospital for care given to D.C. patients who have no insurance.
Once thriving and gutsy in the best tradition of city hospitals, D.C. General has struggled over the years to stay healthy and alive. Since the early 1970s, it has survived a class-action lawsuit, the loss of its accreditation for three years and a dwindling demand for its beds.
Since 1978, D.C. General has again been accredited and has improved in many areas. Now, hospital administrators await the next, potentially most crucial accreditors' report, and face a federal judge's October deadline for demonstrating further improvements in nursing and medical record-keeping. And feelings about the performance and future of the public hospital of the nation's capital run as strong as ever.
"The care (the hospital) delivers can compare quite favorably with most of the city hospitals in the United States," said Dr. Milton Corn, associate chief of medicine at Georgetown University, who spent 10 years at D.C. General.
"The quality of care is better than I'd say more than half of the hospitals in the District," said Dr. Stanford Roman, medical director of the hospital for the last two years.
But some of Roman's colleagues don't agree.
"These people get the worst that money can buy," said Dr. Michael Boyars, a respiratory specialist at the hospital.
"If people really understood what a quality facility was, they'd burn this place to the ground," said Kenneth Ball, who resigned as assistant comptroller on Feb. 1.
No one questions that D.C. General is doing a job that has to be done -- and it isn't an easy one. Consider the problems seen by a team of Howard University medical school surgeons on their rounds one recent morning.
The day started before sunrise in the room of a 31-year-old mother of seven who had been stabbed by her best friend in a fight over a man. One of her roommates was a frightened middle-aged woman with a bloody discharge coming from her breast, a symptom of cancer that probably had spread. The other two patients were moaning elderly women, waiting for spots to open up in nursing homes.
In the next room, one old woman had a devastating neurological disease and another had lost both of her legs because of poor circulation. She had been waiting for a nursing home bed for 1 1/2 years.
The third roommate, an elderly mental patient who refused to move or eat, was being fed through a tube in her nose. She chanted, "Oh Lordy Jesus man" over and over as the resident tenderly turned her to check her bedsores. The fourth patient -- the only one who was able to carry on a conversation -- was waiting to be operated on that day for a large intestinal cancer.
The Howard doctors -- nine or 10 in all, counting residents, interns, medical students and two professors -- moved from room to room, undressing and inspecting wounds, checking temperature charts, bantering with patients who could talk, gently examining those who could not.
Lewis Kurtz, the soft-spoken doctor who runs the Howard programs with an iron hand, listed each patient's diseases: gangrene, arthritis, high blood pressure.
Kurtz said he tells medical students who balk at caring for indigent old people that he has seen three doctors die as paupers at D.C. General.
"Any of us can come upon hard times," he said. If you look at it like that, it's a little easier to take care of patients."
The surgical team entered a 12-bed men's ward, one of several wards still in use at the hospital because the city hasn't provided the money to subdivide them.
Cartoons blared from a television set at the far end of the room. The doctors checked a healing abscess on the leg of a man with severe diabetes, tended to the bedsores of a man paralyzed from advanced syphilis, then complimented a young burn patient who was painstakingly changing his bandages himself.
They paused for the longest time at the bedside of a pale, emaciated 52-year-old man who had been admitted the night before with a swelling in his groin that had been growing for six months. He had had most of his stomach removed six years before and had lost 150 pounds since then. The doctors fingered the huge, hot swelling and debated whether it was cancer, an abcess or tuberculosis infection.The patient was so malnourished and anemic that Kurtz estimated it would be at least a week before they could operate to find out.
Caring for the advanced illnesses of patients who have sought health care too seldom or too late is a job that D.C. General shares with other public hospitals -- a mandate now being reexamined in many cities. At one time, a public hospital was every city's solution to the problem of who should treat "charity" cases. But with the establishment of the federal Medicare and Medicaid programs, many "charity" patients received insurance coverage and began to be accepted by private hospitals.
As a result, the need for public hospitals has decreased over the last two decades, and most have shrunk in size. In 1964 D.C. General had 1,400 beds; it now has 557. In some cities, such as Philadelphia, the public hospital has closed. Yet, in Washington and other cities, there are still thousands of people without health insurance who rely on public hospitals for all their medical care.
And those public hospitals, once judged differently from private hospitals, are now being forced to compete with them for patients and for approval by the agencies that evaluate care and disburse funds.
But D.C. General, besides sharing these overall problems, has others all its own: fickle relationships with the Howard and Georgetown University medical schools; a budget that is subject to the whims of Congress; a civil service system that can paralyze the hiring and firing process; and beds choked by a critical nursing home shortage in the District.
Important nursery and obstetric equipment breaks down frequently, and despite the high infant mortality only this year did the hospital start teaching nurses who work in the nursery how to resuscitate infants.
Its emergency room physicians frequently handle shootings, stabbings and head injuries. But D.C. Generalhas no radiologist after midnight to read X-rays, and no staff neurosurgeon to do emergency brain operations.
Not everyone can work with problems like these, or live with the hospital's bureaucracy and its often confused priorities. Dr. Robert F. Donahoe, who resigned last October as chief of the respiratory department, said he left because he could not persuade the administration to buy equipment he considered essential to good patient care.
"There are members of that medical staff that do not speak for patients." "I do not think they are being heard."
Ball, who quit as acting comptroller Feb. 1, said he was frustrated by his coworkers' low expectations. "If we were at an inch and we made it to two inches, our progress had doubled," he said.
Dr. Louis Diamond, acting chief of Georgetown University's medical training program at D.C. General, said many staff doctors take too little responsibility for patients. Instead, they carry on private practices at private hospitals, leaving most of the care of D.C. General's patients to the residents -- doctors in training.
Like the country's other major public hospitals, D.C. General was once a little city unto itself, modeled on the hospitals of Europe founded in the Middle Ages to care for the homeless, the sick, the dying. In the 1960s, Georgetown's Corn says, it had a "101st Airborne feeling" -- a sense among employes that they were giving crack medical care to the sickest patients in the city. Medical students clamored to train there. Funds were always tight, but the place had heart.
By the end of the decade, as health technology took off and costs soared, city hospitals everywhere were falling behind private hospitals in what they could offer patients.And at about that time, the growing District government took control of personnel, purchasing and maintenance from hospital administrators and moved that control downtown under the Department of Human Resources.
Funds got tighter. Hospital workers were "borrowed" to do jobs in other city agencies. Buildings deteriorated. The pharmacy ran out of life-saving drugs. According to Corn, sometimes when a patient's heart had stopped a doctor would shout for adrenalin and there would be none available.
Corn said the hospital had so few nurses that the ones working sometimes didn't have time to give patients their medications. Employes recalled watching a new executive director arrive every few months. Each was appointed by the Department of Human Resources -- but none was given any new power to change the situation.
In 1971, lawyers at Washington's Center for Law and Social Policy filed a class-action suit on behalf of several patient and senior citizens' groups, charging that the city had failed to provide good care at the hospital. The suit culminated in a 1975 trial in which D.C. General doctors, nurses and technicians testified that patients had been harmed by understaffing and scant resources.
U.S. District Judge Barrington Parker ordered immediate and long-term improvements in the emergency room, the intensive-care units and nursing, medical records and other departments. To this day, hospital administrators must file monthly reports with the court.
Also in 1975 -- perhaps partly because of the suit -- the Joint Commission for the Accreditation of Hospitals, a national inspection agency, refused to accredit D.C. General. Corn, who was at D.C. General then, said building code violations and deficiencies in staffing and documentation were the main reasons why accreditation was denied. But the public read it as a wholesale condemnation of the hospital and its care.
D.C. General remained unaccredited until May of 1978. The consequences were enormous. The U.S. Department of Health, Education and Welfare threatened not to reimburse the hospital for Medicare and Medicaid patients. Staff morale plummeted. Several training programs closed because their directors were unable to recruit enough young doctors to fill them. Others, like the medical residency which Georgetown University operates at the hospital, no longer attracted applications from American medical school graduates, and became filled by foreign doctors.
Since 1978, the hospital has received provisional accreditations each year -- that is, the accreditations are for one year rather than the usual two. yIn April, the accreditors visited the hospital again. Robert Johnson, the hospital's executive director, said he expects another one-year accreditation -- potentially the last the hospital can receive -- because renovations to eliminate life-safety code are not complete and because of a few remaining problems in two laboratories.
The hospital's setbacks persuaded the D.C. City Council in 1977 to cut the hospital loose from the Department of Human Resources and establish a commission, appointed by the mayor, to run the hospital.
All officials acknowledge that much remains to be done, although the hospital has achieved a good deal since then. Among the achievements:
The hospital has begun an $18 million project to bring its outdated buildings in line with modern life-safety codes -- installing stairways, fire exits and other needed additions. A renovated obstetrics building and emergency room were formally opened by Rosalynn Carter on May 15.
The hospital acquired Johnson as executive director and Roman as medical director. Staff members say both men are providing better leadership than D.C. General has had in a decade.
The hospital has recruited young administrators to revamp the hospital's financial management and outpatient services.
It has improved the ratio of patients to registered nurses by 25 percent since 1975 and upgraded the qualifications of nurses who work in the intensive-care unit.
Billing procedures have been computerized, and financial officers have doubled collections within two years. In 1975, according to a budget officer, D.C. General collected "virtually nothing;" in 1980 it is expected to collect $32 million.
The pharmacy and medical records departments have been vastly improved.
The hospital has received federal and foundation grants to extend medical care to the underserved population of Southeast Washington.
"The hospital has reached a point where it doesn't need an asterisk after its name any more," said Gilbert Hahn Jr., chairman of the hospital commission. "The things that the hospital was forced to do out of that suit were good for everybody. Now I think it's time to let the commission run the hospital."