This story has been edited for the print edition of Modern Healthcare. Read the full special series "The Other Victims of Gun Violence."
'In my experience, Miami was busier than Afghanistan'
MIAMI—The man on the table at Ryder Trauma Center in Jackson Memorial Hospital has been shot four times, in the forearm, chest, flank and thigh. Dr. George Garcia spends two hours operating on him, removing bullet fragments, closing blood vessels and repairing tissue. By the time he's tied the last suture it's 2 a.m. Garcia tosses his blood-stained gloves in the trash and goes out to tell the victim's father his son will be fine.
Then Garcia's pager signals that an ambulance is on its way with another shooting victim. And so, he heads to the observation bays to greet his next patient.
There is no “typical” when dealing with blood spilling out of a body and scared families waiting for news. But this night is not unusual.
During a recent eight-hour shift, Garcia worked on four gunshot victims from different parts of Miami (in addition to two stabbings and a machete attack). As soon as staff stabilized and moved one patient to the operating room, another would come through the door.
“It was like a war zone,” recalls one nurse.
Miami so often resembles a war zone that the U.S. Army chose Ryder Trauma as its training center for all surgical teams that will treat soldiers in battle zones.
That's how Garcia, an Army veteran, ended up at Ryder, where he trained before being stationed in Afghanistan.
“In my own personal experience, Miami was busier than Afghanistan,” says the 47-year-old, who still keeps his hair brush cut. “I can't imagine doing anything other than this.”
Ryder's selection as a military training site is a dubious honor, of course. It speaks to the professionalism of the place, but it also underscores this urban area's constant mayhem.
Over the past five years, Ryder's medical teams have treated 2,753 gunshot victims, an average of 550 a year, or more than one patient a day, every day of the year.
The demographic stays pretty constant—mostly young men, mostly poor, often people of color without any way to pay for lifesaving surgery. Of those 2,753 victims, 45% were uninsured, according to Jackson, a public not-for-profit hospital. Many more were on Medicare or Medicaid. That means the hospital has to swallow the cost of many of the treatments.
Jackson officials declined to estimate how much the shootings cost the hospital every year, saying there are too many variables. In general, it is difficult to estimate the actual medical costs of a trauma visit for a gunshot wound. No national studies have been done.
Further complicating the scenario, Florida's Republican governor, Rick Scott, and the state Legislature declined to expand Medicaid under the Affordable Care Act. That put Jackson Memorial in a bind, because federal low-income pool funding, used to defray the costs for treating the uninsured and underinsured, is being phased out precisely because the feds anticipated Medicaid coverage would be expanded. State legislators have cobbled together a solution, but Jackson meanwhile lost about $15 million in funding for treating the poor in fiscal 2016.
That's a shame because Ryder, which is part of the public Jackson Health System, is the only Level 1 adult, pediatric and burn trauma center in Miami-Dade County. It has its own helipad, through which about 40% of its patients arrive. This is where virtually all of the county's gunshot victims were brought until two other hospitals opened trauma units in the past three years. If you've been seriously injured in the Miami area then you want to go to Ryder, which is one of only nine Level 1 trauma centers among the state's 31 trauma centers.
But Garcia doesn't spend too much time pondering the politics, funding issues or social problems that spawn urban violence. He just wants to do his job.
“There are people whose job is to worry about those things,” he says. “Until we solve all the problems that bring disenfranchised youth in here, I see us as the vanguard. We're just ready to take care of them.”
His job is not to worry. Worrying doesn't save patients.
Garcia's stoicism is practically in his DNA. His father was a career Marine who served three tours of duty in Vietnam. His uncle flew in bombers during World War II. His brother and late sister-in-law served in the Army. Another uncle was a Green Beret in Vietnam. So it was not entirely surprising when Garcia announced plans to attend the military's medical school after graduating from the University of California at Irvine.
“My mom was fairly distraught when I told her,” he recalls. “She had envisioned another life for me.” Something in the civilian world, away from danger.
Garcia served in Army medical facilities in Hawaii, North Carolina and Kentucky and did a trauma fellowship in Miami at Ryder. Then in January 2008, he shipped out to Afghanistan with the 126th Forward Surgical Team. He flew on a C-5 from Fort Hood, Texas, to Bagram Airfield, in Afghanistan. He worked in a forward operating base in the mountains of northeast Afghanistan.
The helicopter flew in at night. “They don't like to fly during the day,” Garcia says. “Easier to shoot at.” Garcia was excited. “It was what I signed up for. If you take that route, Army surgery, the purpose is to deploy and take care of soldiers.”
And despite being far from a modern hospital, in a place where ambushes and mortar attacks were routine, Garcia says he felt ready. “Because of the training in Miami, I was as confident as I could be that I could do what I needed to do.” Urban violence had prepared him for war.
Grim as it is to say, trauma surgery has benefited from our wars in Afghanistan and Iraq, Garcia says. One example is that medical professionals figured out that patients do better if they are given a 1-to-1-to-1 ratio of platelets, blood cells and plasma.
Garcia has used a lot of these skills in both environments. He returned to the States more inspired than ever to continue in trauma surgery. After a brief stint in Washington, D.C., he was assigned to run the Army Trauma Training Center at Jackson Memorial. After his commission ended, he joined the hospital as a trauma surgeon, which comes with a faculty position at the University of Miami's Miller School of Medicine.
“I like the chaos,” he says about his decision to stay in trauma. “I like not knowing what the next case is. I'm around the pressure, but I don't feel the pressure.”
And his time spent in the mountains of Afghanistan influenced his practice in interesting ways. They operated in tents, without a lot of high-tech equipment, like CT scanners.
“Not having a lot of stuff streamlines your thinking,” he says. “Today, I'm comfortable taking action. I tend to see things in a straightforward line. I don't see the technology as a necessity, but as a luxury.”
Garcia's devotion to this type of medicine is not unique to the healthcare teams in the trauma wards. Many of the nurses in Ryder spend entire careers there. One weekend shift, charge nurse Robert Tudor—who has been at Ryder for 27 years, even before it was a free-standing unit—ends his shift just as nurse Natalee Wrisk, 25 years in the unit, and Anne Higgins, 18 years in the unit, are starting theirs.
“You need to be a little crazy to work here, but in a good way,” says Victoria Franco, also starting her shift. She's been a nurse in the trauma center for only three years, but you can hear her passion for the place when she talks. “You know you're coming to work to see the worst. There is no happy day at work.”
Because of the inherent unpredictability of trauma and emergency units, hospitals must staff doctors and nurses of varying skills and abilities. Franco lists the requirements for a nurse to work there, including a bachelor's degree and certifications in burn treatments and pediatric life support. They ride with EMTs in ambulances and helicopters.
“Once they're here, they stay here. They die here,” Franco says, ribbing her colleagues, many of whom, studies have shown, choose emergency department appointments because it's one of the few schedules with flexibility, a draw for millennial doctors.
In a sense, they're masking ways to say they love their job, which could sound insensitive if taken out of context. But when a patient arrives, it's easy to see how exhilarating the work is.
The process is a ballet of efficiency. As soon as the call comes in, the observation bay is prepped; IVs are readied for fluids and a blood infusion machine is prepped with universal blood (O positive and O negative). The thoracotomy tray is brought out—scalpels, suture clamp and the “adult rib spreader” for opening a chest cavity to massage the heart by hand in the most dire cases. Defibrillators are charged. When the victim is wheeled in, clothes are cut away and mobile X-rays are taken. When they are done, and the patient is either stabilized or moved to an operating room, the floor is heaped with discarded pads, packaging, plastic wraps and gloves.
If you're a medical professional in trauma, there is no greater sense of fulfillment than using the available minutes, even seconds, to save someone's life like this. But when the shift is over? What kind of toll does this work take? A 2012 survey of 133 trauma surgeons, using a secondary stress trauma scale, found evidence of post traumatic stress disorder in two-thirds of respondents.
There have been a dozen times when a child or teenager has come in, and Garcia, who is divorced, has gone back to his office after surgery to call his two sons, 13 and 11. “Anytime a kid comes in it's like that. I'll call them; I just need to hear their voice,” he says. “It's probably part of our coping mechanism.”
Most of the staff need some way to decompress after work. Some do yoga or meditate. Others immerse themselves in family life. “Some just sit inside their car for 20 minutes before going inside their home,” Franco says.
“I think you're either naturally good, or you become good, at compartmentalizing,” Garcia adds.
A friend once tried to get Garcia into yoga. “It wasn't for me,” he says.
Instead, he exercises—relentlessly. Garcia likes to compete in triathlons. To train he takes long runs in his leafy north Miami neighborhood. He rides his bike on Key Biscayne. He swims laps in his gym's pool at 5 a.m. Working out is his therapy. The more miles he can put on his shoes or tires, the further away last night's shift—and the woman whose pelvis was smashed by a bullet while she was sitting in a car with her boyfriend—drifts from memory.
Until the beeper goes off again.
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