It was early evening when Oluchi McDonald, vomiting and writhing in pain, was wheeled into the packed emergency room at Martin Luther King Jr. General Hospital in Los Angeles County, Calif.
Through the long night ahead, McDonald's care would be neglected. Left alone with his pain, his heart rate soared and his blood pressure dropped. Eighteen hours later, the 20-year-old art student was found dead on the floor in a pool of his own vomit.
"It was a shock. It was totally unexpected," said his mother, Akilah Oliver, who lives in Boulder, Colo.
As surprising as McDonald's death in March 2003 was to his family, it fit a pattern of serious and sometimes fatal problems that have put a landmark medical center in jeopardy.
The circumstances leading to McDonald's death are detailed in one of two federal reports investigating claims of negligence and mismanagement at MLK Hospital, a community anchor built from the ashes of the 1965 Watts Riot and one of the most historically significant public hospitals in the nation.
The hospital's affiliated medical school, Charles R. Drew University of Medicine and Science, is one of four historically black medical schools in the nation.
Problems at the hospital and university, detailed in documents obtained by the Associated Press and interviews with dozens of doctors, nurses, students, health officials, patients and attorneys, now threaten King/Drew Medical Center's very future.
Negligence has been linked to five patient deaths in the last year. The hospital has twice narrowly missed losing $200 million in federal funding -- about half its annual budget -- and the university recently lost its ability to train aspiring surgeons and radiologists.
The teaching hospital also has an "unfavorable" rating from the Accreditation Council on Graduate Medical Education, meaning Drew can't reapply for accreditation in surgery and radiology.
One more "unfavorable" rating and the hospital would lose its ability to train all of Drew's 300 doctors-in-training, a move that would effectively shut down all residency programs.
The turmoil has scared away residents and nurses who had planned to make their careers treating the working class, mostly minority residents of South Los Angeles and could alienate promising new candidates at the medical school.
"To lose an institution like Drew would leave a deficit in the community that I'm not sure the other medical schools are ready to address," said Louis Sullivan, M.D., head of a national commission on minority healthcare and former U.S. Secretary of Health and Human Services.
The findings of the recent reports have added to a reputation of poor care that has been building for years. In South Los Angeles, where there are few other options for medical treatment, the hospital is known as "Killer King."
The crisis embroiling one of the nation's premiere minority medical institutions has prompted a round of finger-pointing as county, state and federal leaders scramble to salvage it.
In recent weeks, the county has moved to fire five top administrators at the hospital, saying they ignored obvious and growing problems at the institution. The county also blamed a nationwide health care funding crisis that has crippled public hospitals and a widespread nursing shortage that at one point left it with hundreds of vacancies.
But others, including key state and federal lawmakers and former managers, blamed the county for its lack of oversight. They said those at the top level repeatedly ignored desperate requests for more nurses and failed to intervene at critical moments.
And some, including past medical students, said the county failed to get involved because they were afraid of being mired in racial politics.
"Back in the 70s, this hospital was outstanding," said Derrell Sharp, 55, who recently waited nearly 30 hours in the hospital emergency room for treatment of leg pain. "The civil rights leader that this hospital is named after died so things could be equal and now look at it."
Filling a need
On Aug. 11, 1965, California Highway Patrol officers stopped a man on suspicion of drunken driving in the Watts section of Los Angeles, then predominantly black.
The traffic stop escalated into a confrontation after the man's mother and brother argued with officers from the CHP and LAPD, trying to block the arrest. A gathering crowd angered by the confrontation then grew violent, spitting at police and throwing rocks.
The resulting riot lasted six days, killed 34 people, injured more than 1,000 and caused $100 million in damage.
A state commission found that among the factors contributing to the community's anger was a lack of public medical facilities. Less than three years later, Los Angeles County broke ground on the Martin Luther King Jr. Hospital just south of Watts. It remains the only public hospital in South Los Angeles and serves about 1.5 million people in a 94-square-mile area.
Almost simultaneously, the Charles R. Drew Postgraduate Medical School was founded across the street. The school was named after a black physician who pioneered the concept of a blood bank during World War II.
Drew created a partnership with the University of California, Los Angeles, in the late 1970s to create a four-year undergraduate medical school in addition to its postgraduate program.
It joined other historically black medical schools -- Morehouse College of Medicine in Atlanta, Howard University College of Medicine in Washington, D.C., and the Meharry Medical College in Nashville -- that together train about 70% of minority physicians nationwide.
Between 1989 and 1999, 54% of Drew's graduates returned to minority communities. By contrast, 36% of minority graduates of UCLA did so. Nearly all graduates of the school's College of Allied Health, which trains physician assistants and medical technicians, take jobs in low-income or minority communities.
The hospital turned its location in a gang-infested neighborhood into an advantage of sorts, developing a reputation as a training ground for aspiring trauma surgeons. The trauma center treats more than 2,700 patients a year, including more gunshot victims than any other hospital in Los Angeles County. It trains one-quarter of U.S. armed forces surgeons.
Its flagship neonatal unit is named after civil rights leader Rosa Parks, who attended its dedication. In a community with above-average incidence of low birthweight babies and where 20% of mothers are drug-addicted, the complex saves nearly 95% of babies born under 2 pounds.
"It really is a national model," said Robert K. Ross, M.D., president of The California Endowment, a private health foundation.
"This is a university that is uniquely positioned to show the nation how the reduction of disparities of health care can occur."
A troubled hospital
The troubles highlighted in recent months illustrate King/Drew's other side, as a place to avoid.
In 1995, the district attorney's office found that "gross negligence" at the hospital contributed to the death of a wounded deputy who was given the wrong heart medication after surgery. The president of the Association of Los Angeles Deputy Sheriffs has said he blamed the death of a wounded deputy 12 years ago on negligence at King/Drew.
In recent months, the long-simmering erosion of trust came to a head, as a series of patient deaths and subsequent investigations exposed myriad problems.
A Jan. 8 report by the federal government's Center for Medicaid and Medicare Services, part of the U.S. Department of Health and Human Services, blasted the hospital for severe lapses in care due in part to a nursing shortage.
The report said nurses were instructed to downplay patients' conditions, left critically ill patients unattended for hours and failed to give doctor-prescribed medicine. The inquiry was prompted by a state report that found that two patients died in the summer of 2003 while connected to heart monitors.
Investigators also found that in nine of 11 cases reviewed, staff failed to assess patients' pain level as required by hospital policy. In one case, a patient with leg gangrene, kidney failure and a collapsed lung died in the emergency room after waiting 22 ? hours for treatment.
A March 3 federal report, prompted by a state complaint about the hospital pharmacy, found extensive problems with drug administration. It found that nurses repeatedly failed to give prescribed medicine to patients, gave the wrong medicine or gave medicines at the wrong times or dosage. Sometimes, federal surveyors intervened to get patients their medicines.
In one of the most egregious cases, 46-year-old William Watson was mistakenly given the potent cancer drug Gleevec for four days in February before staff realized the error. He had been admitted to the hospital for treatment of meningitis.
Watson's attorney, Roger Rosen, said Watson is now blind in his right eye, which he attributes to the Gleevec. He is contemplating a lawsuit, Rosen said.
Even after the pharmacy realized its mistake, records show, nurses still made 40 errors with Watson's medication, including with drugs for his swollen eye.
"I'm still afraid," Watson said in a telephone interview from his hospital room before being released. "I don't trust them because I don't know what they're giving me."
Critics say the crisis at King/Drew is a consequence of poor management.
Management problems were at the crux of a report on King/Drew commissioned by Los Angeles County and prepared by former U.S. Surgeon General David Satcher, M.D., former president of Meharry.
According to the Dec. 23 report, there was no "working partnership" between hospital administrators and the medical school. The report also blames an ineffective board of trustees and Drew leadership that "allowed the evolution and continuation of the present crisis."
Some go beyond the reports and say King/Drew overextended itself in an effort to create opportunities for minority physicians and low-income patients. The university's 300 residents train in specialties ranging from dermatology to otolaryngology, or head and neck surgery, but have only about 200 patients on which to practice their skills.
The county recently announced plans to downgrade the hospital's neonatal unit, one of the few programs recognized as outstanding, because of low patient numbers, sending critically ill babies to another county hospital in another city within four hours of birth.
And the regionally recognized trauma unit now treats about 500 fewer people a year to relieve pressure on the hospital.
The county is moving to fire nursing director Rosemary Haggins and her top assistant, Barbara Bundage, for the lapses in nursing care.
During testimony in January before a state assembly committee hearing on King/Drew, Haggins defended her tenure, saying she had repeatedly asked county officials for permission to hire more nurses. She described herself as the county's "sacrificial lamb."
"I, as nursing director, reported to my superiors . . . the critical issues as I assessed them," she said. "And nothing -- well, I didn't get a response."
At the same hearing, county health director Thomas Garthwaite, M.D., said that in late 2003, county hospitals were about 1,000 nurses short of what was required to fully meet desired staffing ratios.
But he said the cash-strapped county couldn't compete with private hospitals, which lure nurses with higher wages, thousands of dollars in signing bonuses and gifts such as free cars.
Garthwaite said in the second half of 2003, the county was able to hire an additional 70 nurses systemwide -- something he felt was significant in light of the shortage.
Despite arguments over nursing shortages and funding problems, some observers said the county ignored problems at King/Drew to avoid racial politics. The administrations of both hospital and university are predominantly black.
At King/Drew, former surgical resident Anthony Charles, M.D., said nobody at the hospital took initiative except the residents, whose careers were in the balance.
"The type of leadership that was tolerated at King/Drew would never have been tolerated at other county hospitals," said Charles, who is black. "It was a politically charged environment because it was a minority institution."
Ross, with the California Endowment, agreed.
"What's critical is there appears to have been a tendency to dance around the substantive issues at King/Drew because of racial politics," he said. "It's the right time to be cognizant of it, but not be intimidated or awed by it, and cut through it."
Los Angeles County Supervisor Yvonne Burke, who is black, dismissed that idea. She attributes the lack of accountability to cronyism among doctors who began their careers together decades ago and protected each other.
"I think that there's been an awful lot of buddy-buddy things," she said. "Doctors are really good at that."
Prompted by threats to funding and state and federal inquiries, the county has begun implementing long-overdue changes at King/Drew.
Los Angeles County will renegotiate its $13.8 million contract with the medical school by September and is likely to scale back programs there, consolidating them with those at other county hospitals.
The university plans to reapply for accreditation in surgery and radiology, but can't do so until the hospital sheds its "unfavorable" rating.
The hospital has made adjustments to its pharmacy and its nursing, telemetry and emergency departments that officials hope will satisfy federal investigators. It also has named an interim CEO with a reputation for turning around troubled hospitals.
In an interview, Garthwaite said it's hard to keep a public hospital afloat in a region in which just 10% of patients have private health insurance.
"But I do think it's salvageable. We're working closely together (with King/Drew) and solving problems," he said.
Despite the hospital's well-documented problems, the black community has grown increasingly bitter about plans to downsize King/Drew, calling the proposals "an attack on our community."
More than 200 people rallied at a Watts church earlier this year, and doctors and nurses at the neonatal unit are furious about plans to downgrade it.
"My office was bombarded with doctors and community people who said they thought the hospital was being closed piece by piece and unit by unit," said U.S. Rep. Maxine Waters, D-Los Angeles.
The problems also have affected the hospital's aspiring doctors, 40 of whom have transferred elsewhere to finish their training.
Charles, a former resident who served on Satcher's commission, will finish his surgical training at Saint Joseph's Mercy Hospital in Ann Arbor, Mich., more than 2,200 miles from his wife.
He said he is disillusioned by what he saw at King/Drew and angry that leadership there squandered a chance to prove a minority hospital can succeed.
"They should have expected a higher standard, but that just wasn't the case," the 35-year-old said. "Maybe back in the 1970s that is what happened, but that's not what I saw."