Hospital

by Julie Salamon

  He sighed again. “Teaching me patience.”

  Ramsay was a particular ER type, the swashbuckling hippie. He described his parents as “Grapes of Wrath folks,” Okies who moved to California, where Ramsay was raised. He trained in public hospitals in New York and then ran clinics in Grenada, in a part of the country even the Peace Corps forgot about. After that he secluded himself and his family in the middle of nowhere Oregon for thirteen years, running a free clinic for people without insurance, then returned to New York. He’d been brought to Maimonides a year earlier to help unstick a stuck system, including unclogging the route from the emergency room into hospital beds.

  Not the least of his problems were the sixty-seven languages that, out of practicality and social pressure as much as altruism, had become part of the hospital’s identity and pride. “We do a great job making sure we have the right interpreters downstairs, but it is incredibly challenging,” he said. “It is great training for your young residents to understand that when you walk up to a person from another country who speaks another language, that is a risk. Period. Period. It’s as much of a risk factor as diabetes or anything else, because you can make a mistake on them.”

  He elaborated: “If you had an internal point system to admit the patient, you should add twenty-five percent of risk on that just to make sure you’re not blowing something. It’s the old children’s game when you whisper in people’s ears. Having an interpreter doesn’t mean you are getting the right information. Immediately it should raise the red flag.”

  Ramsay met briefly with Carolyn and Chuck (Dr. Charles) Gregorius when they came to visit their son the first time. They liked Ramsay, but the emergency room itself made them feel, as Carolyn politely put it, “disheartened.” Actually, she said, “I was quite upset by the conditions, the nuttiness.” Before Davey went to Maimonides, his parents had never been to New York. “We’re west people,” Chuck explained. “We go west and into the mountains.”

  On the Internet, Carolyn had found a hotel that was about four blocks away from the hospital. When they got out of the taxi, they felt surrounded by Hasidic Jewish people. “They’re lovely people when they talk to you—you couldn’t ask for anything better,” said Chuck. “But because of their dress and everything, that was the first time in my life I ever felt like a sore thumb.”

  Carolyn added, “We were the only people who look like this.” Meaning like they’d stepped out of the pages of a Lands’ End catalog, ready for a game of tennis or a neighborly backyard barbecue.

  Chuck was an anesthesiologist at Bryan LGH Medical Center in Lincoln, Nebraska, a large modern hospital that had just undergone a $114 million renovation. He felt sucker-punched by the breathtaking volume he saw in the Maimonides ER. “The emergency room we have back in Lincoln is about twice as big as the hospital here in terms of space, and it sees perhaps twenty-seven, twenty-eight thousand visits a year,” he said during a visit to see his son. “The one here with half the space sees eighty to ninety thousand. And they’re sick. You don’t see coughs and colds and runny noses.”

  What amazed him more than the volume was the patient mix. “I work in a hospital where we see Vietnamese, occasional Russians, Hispanics of course, Ethiopians and Sudanese,” he said. “It’s a problem for us dealing with four or five languages on a fairly common basis, but to deal with that many, that truly boggles my mind. How they can deliver health care under those conditions.”

  Yet he had checked and was relieved to find that Maimonides had received good and even some excellent evaluations from outside observers, including the Joint Commission on Accreditation of Hospitals, the industry’s self-regulatory body, and an award for “clinical excellence” from HealthGrades, one of several private companies that profit from supplying insurers and the hospital industry with data.

  Carolyn, too, tried to see the bright side. “I have an analogy,” she said. “We’re from the Vietnam era, so many of our friends went through the military to pay for med school. The ones who said they had the best training are the ones who ended up in the field in Vietnam. They had nothing, no support; they just had to figure it out. This isn’t nearly as harsh, but in some ways it is comparable.”

  Her husband chimed in. “One day we were here and had just returned from dinner, around eight in the evening. David said, ‘You want to see the ER?’ I’d heard about these big ERs, big rooms with cubicles separated only by curtains, and he’d told me they’d be stacked as many as two or three and maybe five in each cubicle. You imagine that in your mind, but you’re not prepared for it. You walk in, and it was exactly as he had said. It was so busy that night both the residency program director and the emergency medical director [Marshall and Ramsay] were staffing, and David introduced us.

  “I was about five occupied gurneys away from a wall where I saw an Ambu bag [a lightweight, self-inflating disposable resuscitator], and I said, ‘What would you do if you needed that Ambu bag to get to a patient on the other side of the room?’ Dr. Ramsay said, ‘I’d crawl over those five patients.’ That just boggled my mind in the year 2006.”

  Chuck said he wasn’t worried about his son. “David is ten times the student I ever was,” he said proudly. “He really likes to learn. And the cultural diversity he is experiencing and the sheer volume—there probably isn’t anything he’s going to see for the rest of his life that he doesn’t see here.”

  Carolyn nodded but looked worried. “I hope he comes out without an ulcer,” she said.

  Two

  Pooh-Bah

  In June 2003, Stanley Brezenoff, the president and chief executive officer of Maimonides Medical Center, announced that he was leaving the hospital. The news didn’t come as a surprise to the administrators who ran the place. Many of them regarded Brezenoff as a larger-than-life figure who was destined for greater things. Brezenoff was an imposing man, maybe not larger than life but certainly big—tall, broad and confident, a Brooklyn boy who had successfully crossed the river to the big league of Manhattan. He’d been a deputy mayor under Ed Koch and the head of the Port Authority. Brezenoff was a galvanizer, shrewd and quick, adept at getting people to do what he wanted them to do while allowing them to think it was their idea.

  Still, when the news of his impending departure came, neither the board nor the administrative staff expressed alarm. The hospital was prospering, and Pamela Brier had been chief operating officer, a capable number two, from almost the beginning of Brezenoff ’s tenure. It was understood that she would eventually take charge.

  They were considered to be a well-oiled team—he was the master planner, she was a meticulous detail person. She may not have been as politic as he, but she relished political maneuvering and liked being in charge. By the time Brezenoff told her he was leaving to run Continuum Health Partners, a giant consortium of five major New York City hospitals, she was ready to be the boss.

  Brier elicited a more complex set of reactions than did Brezenoff. He could be gruff, even fearsome, and his brilliance was intimidating, but he was thought to be straightforward and easy to read. Brier was harder to categorize. Few would deny that she was smart and capable, but she was also eccentric and unpredictable.

  Brezenoff was scheduled to begin his new job in July. Brier had been working nonstop in preparation. Her husband, Peter Aschkenasy, whom she had married six years earlier, had also been on a work jag. A restaurateur who dabbled in Democratic politics, Aschkenasy owned Concert Foods, which ran the food and drink concessions for Central Park’s Delacorte Theater and Summerstage, and he had just opened the park’s Sheep Meadow Café. Summer was Aschkenasy’s peak season, as he coped with the crowds drawn to the park by free Shakespeare and numerous concerts.

  This power couple could barely remember the last time they had been to their country house in Columbia County, a few hours’ drive north of the city. Late Wednesday evening, July 2, Aschkenasy called Brier and convinced her they should take advantage of the extended holiday weekend. He was a little weary, but they decided it w
ould be worth the tiring drive that night for the luxury of sleeping in the next morning.

  At 2:00 A.M. they were just a couple of miles from their destination when Brier noticed that Aschkenasy looked really exhausted. She remembered asking him if he wanted to stop and rest, though they were almost home.

  When Steven Brier, Pam Brier’s first husband, looked at the photographs their daughter, Jenny, took of the car after the accident, for insurance inquiries, he said to her and her partner, Kat, “It is a fucking miracle they’re alive.”

  He had been asleep in his country house on Long Island when Jenny called and asked him to drive upstate to meet her at Albany Medical Center. She told him that her mother and Peter had been in a disastrous accident and their survival was uncertain.

  Their Audi station wagon had hit a two-hundred-year-old oak tree with enough force to push the engine back into the passenger seat. The car’s air bags had inflated, protecting Pam and Peter from the waist up; from the waist down, they were two sacks of broken bones. As if to underscore the fine line between disaster and miracle, misfortune and luck, health and infirmity, the dog riding in the backseat—a good-natured Chesapeake Bay retriever named Charlie—suffered no physical harm. (But it would turn out to be a bad day for Charlie, too. He was a big dog, and after the accident his owners would be too frail to care for him. They gave him away.)

  People who saw newspaper photographs of the car marveled that anyone had walked out alive. No one did walk out. The couple had to be extricated from the wreckage by the Jaws of Life, a hydraulic cutting tool developed for auto racing that could slice metal without rocking the crushed vehicle and harming those trapped inside.

  Their memories were fragmented. “I remember the accident, asking Pam if she was all right, someone coming down the road going, ‘Oh my God, oh my God, let me get you help,’” Aschkenasy would recall. “I remember the fire department showing up and cutting me out of the car. I remember . . . being loaded onto the helicopter, the helicopter taking off, and thinking, ‘God, it’s freezing,’ and then I remember nothing for two months.”

  His injuries were devastating; the prognosis was uncertain. When Lillian Fraidkin, the chief of staff at Maimonides, saw him at the hospital in Albany, she had to look away. “The man was so bruised, so bloated, so . . . It wasn’t his face,” she said. “Oh, I tell you, he was not Peter. He was just blown up— you could not identify him. If that man was in a morgue and they asked me was that Peter . . . I don’t know.”

  Fraidkin could not talk about that moment without becoming tearyeyed, uncharacteristically losing her cool. “I was a basket case,” she said. “Pam looked like a little doll. She at least was recognizable. Still bruised, bruises on her face. She had a collapsed lung. It was an absolute mess. I was a basket case. I was just standing there, holding her hand and talking to her.”

  After that, Fraidkin anointed herself Brier’s health-care advocate. “She’s very dear to me, even when she’s driving me friggin’ crazy,” Fraidkin confessed one day. “She comes into my office and starts moving all my stuff. She kills my plants. She tells me, ‘Get rid of that painting, it’s hideous!’ but I can tell her, ‘Pam, go do something presidential and stop meddling in my things.’ And she does.”

  Brier remembered little from the immediate aftermath, though she had been reminded, on prompting from Jenny, that on seeing her daughter she first asked for her pocketbook and how Charlie the dog was doing. She began issuing commands for her hospital, for Maimonides. Only later did she ask about her husband.

  The injuries were horrific. Aschkenasy was on life support for several days. When he and Brier recounted what he had broken, it began to seem easier to itemize what hadn’t been injured. The breakage included both hips, an elbow, his left leg, collarbone, ribs. His left ankle was shattered, a lung collapsed. One doctor said that twenty-eight bones had been broken. More gruesome was the loss of skin and flesh from his legs; his right ankle, foot, and lower leg had been almost stripped of tissue. The damage was so significant that the doctors came very close to amputating the leg.

  Brier’s injuries were not as devastating, but only by comparison. Hers were merely terrible. Her right leg was broken in two places; the lower part was nearly severed. She broke her hip in two places, had a collapsed lung and broken ribs. Like her husband, she lost significant stretches of skin and flesh on both legs and on her right hand and wrist.

  Jenny Brier found it difficult to talk about the accident, even years afterward. At least for the moment, and possibly forever, the power balance had shifted. As the child of two working parents, Jenny had always been encouraged to be self-sufficient, but her mother had always loomed large (contrary to appearances). Theirs was a storytelling family, and on one of Jenny’s birthdays she heard another emblematic tale: of how, as Pam was going into labor with Jenny, she finished typing a grant application for a child-care center, ate a piece of pound cake that her mother, about to become Jenny’s grandmother, had made for her, because Pam wanted to appear appreciative, and dropped off the grant application on the way to the hospital.

  Now Pam Brier was immobilized, and her only child had to run the show. Jenny Brier literally held her mother’s well-being in her hands, in the form of a health-care proxy. Peter’s belonged to his son, Paul.

  New York is one of many states that allow people to appoint a family member or close friend to make health-care decisions for them if they can no longer make such decisions for themselves. As a hospital president, Brier knew, such consent could be vital when doctors dealt with patients on the verge of death. But, like most people, even those in their fifties, she and Aschkenasy had not gotten around to a formal discussion of the health-care proxy with their children.At some point, however, they had mentioned to Jenny and Paul that they would be in charge of their parents’ health, envisioning some distant moment. The car crash had sped up the timetable, dropping Jenny and her stepbrother into a dreaded narrative, the pivotal juncture in a child’s life that too often takes place exactly this way—in a crisis.

  The accident was a defining moment for the Brier and Aschkenasy families, but it also carried profound institutional significance. Two months earlier the hospital had had the equivalent of two chiefs; Brezenoff was still there, and Brier was preparing to take over. Now, two weeks after Brier’s official promotion to president and Brezenoff ’s departure, Maimonides had no one at the top. For Marty Payson, the board chairman, the accident provided the kind of fraught situation that had been his specialty when he was general counsel at Warner Communications and then vice chairman at Time Warner after the merger. He was a natural troubleshooter: mild-mannered, imperturbable, perceptive, and deeply loyal. He set out for Albany.

  The chairman was part of a platoon of people from Maimonides who made the 150-mile drive upstate. Joseph Cunningham arrived first—with Lili Fraidkin, who insisted on going with him. Brier could drive her crazy, but Fraidkin couldn’t bear the thought of her dying.

  Dr. Joseph N. Cunningham Jr. was head of strategic initiatives, chair of surgery, and a significant force in the hospital. He was also chief of cardiothoracic surgery. Twenty-one years earlier, in 1982, he had left a promising career at New York University Hospital to go to Brooklyn, where he helped bring national prominence to the Maimonides cardiac surgery department. He remained striking at sixty-three, tall and still sexy, though his frame was slightly stooped and his shock of hair was gray and white. Smooth and courtly, he had star power, though he was in danger of self-parody, wearing cowboy boots to surgery and—senior citizenship be damned!—still generating rumors because he liked the company of attractive nurses.

  In Brooklyn he was a novelty, with his accent doused in the syrup of his southern boyhood and his apparent identification with the Swamp Fox, Brigadier General Francis Marion, the daring Revolutionary War commander. The connection? Cunningham grew up in Marion, Alabama, and admired rugged men. A print of Ernest Hemingway hung on his wall, standing beside a boat called the Swamp Fox. Cunningha
m, too, liked to deep-sea fish in dangerous waters and named all his boats Swamp Fox. Even the mugs in his office carried the “Swamp Fox” logo.

  In Steve Brier’s recollection, though, it was Douglas Jablon who dominated. Jablon was conspicuous wherever he was: six feet two inches tall and broad, a yarmulke always perched on his head, looking like an Orthodox fullback who had softened into middle age. He always dressed the same way, ready for a funeral, in a black suit and white shirt. His official title was “special assistant to the president,” but Steve Brier called him the “Mitzvah Man” (mitzvah means “good deed” in Hebrew). Jablon ran the patient-representative department at the hospital, meaning he took care of the VIPs—the Very Important Patients—a category that for Jablon encompassed anyone who asked him for help. Jablon managed to be simultaneously unflappable and on the verge of hysterics. He was in Albany because he loved (and feared) Brier and because his job—he would say—was to handle tsuris (“troubles”). If the situation in Albany didn’t represent tsuris, what did?

  Sondra Olendorf, head of nursing and hospital operations, went to the upstate hospital and so did a contingent of physicians besides Cunningham, including the chairs of plastic surgery, obstetrics, and orthopedics. Some were there to oversee the medical care; others went simply to provide support. Brier’s assistant, Annette Cruz, accompanied a Hatzolah ambulance driver when it came time to bring Brier home; Aschkenasy would again be airlifted by helicopter, to New York University Medical Center.

  Thinking about who could manage Maimonides right then, Payson turned to Fraidkin, hospital chief of staff, a nurse by training who had become personal manager for the hospital’s physicians and who had been a favorite of Brezenoff. Fraidkin had been at Maimonides for more than twenty years and had everyone’s respect. (No one would dare to disrespect her; Fraidkin knew where all the bodies were buried.) Still fabulous at sixty-something, she was known for her ability to get things done, her toughness, her streetwise swagger, her love of riding Harley-Davidsons in leather chaps, her cadre of loyal physicians.