Hospital

by Julie Salamon

  Davidson had recently hired a nursing manager, a position that had been vacant for two years. He considered himself lucky to get anyone who was qualified. With a national nursing shortage, candidates were not knocking down the door to take over an emergency room jammed with acutely sick patients speaking numerous languages. Davidson said he thought Ann Marie Ceriale had “some great leadership chops.” When he tried to intimidate her, she didn’t let him. “She got red as a beet and pushed back,” he said. Guts she would need, he said. It would be rough for her, especially because, with Sommer gone from the department, he had no one to train her.

  “We are at a very important transition time for nursing in the emergency department,” said Davidson. “There is a large cadre of staff who has an intimate relationship with Barbara Sommer, built over many, many years. They know each other’s families, the way each other thinks, their failures and heartbreaks. At the same time, there’s a new, young, eager nurse manager who will be quite challenging for the staff, and the staff is going to be quite challenging for her. And the most important mentor for her, a nursing director, is nowhere to be seen.”

  In December, Davidson thought he had finally found someone willing to take Sommer’s place, someone who could train Ceriale, among a million other things. The candidate was a nurse director at another big Brooklyn hospital’s ER. Sommer interviewed her and thought she could handle the job. When questioned as to what she knew about Hatzolah, the woman said no problem, she and Hatzolah got along well.

  Davidson decided to hire her. But when he told Douglas Jablon, Jablon told Davidson he should call Bernie Gips, one of the coordinators of the Borough Park Hatzolah. Gips would later say—with sharp-pronged tact— he felt she wasn’t the right choice. “She’s a very nice person, competent, but two and two doesn’t always add up to four,” he said elliptically. He felt he had conveyed his message to Davidson, and nothing more needed to be said.

  This courtesy call, as Davidson thought of it, became the opening volley in a round of accusations and counteraccusations that wound up with Davidson withdrawing the job offer and eating a large piece of humble pie, washed down with a big gulp of scotch.

  Douglas Jablon was furious because Davidson hadn’t consulted him about the delicate diplomacy required to approach Hatzolah. Bernie Gips was insulted that Davidson hadn’t listened to him about the nursing-director position. Davidson thought he had fulfilled his obligation by putting in a call to Gips.

  When the contretemps blew up to the executive offices, Brier was not pleased.

  “Stupidity,” she said. “These ER people really don’t get it. Well, they get it, but they don’t get it. This has been true since Stanley was there. Steve Davidson will tell you the day I sat him down after I took over and said, ‘You are not doing X and Y and Z. If you don’t do that plus ABC, you are not going to make it here.’ He said, ‘Stanley never told me that.’”

  In her view, Davidson needed remedial training in community management. She recounted the story.

  “Whereupon I called Mark McDougle and said, ‘Mark, Douglas is in meltdown. Can you call Douglas and calm him down?’ So he did. Meanwhile, I talked to Steve and said, ‘Steve, Douglas is very upset.’ ‘Why?’ he said. ‘I love Douglas!’ I said, ‘Steve, you went and chose the ambulance person after Douglas told you Bernie didn’t like her,’ and Steve said, ‘I guess the lesson is, I should just take matters into my own hands.’ I said, ‘No, actually, the message is just the reverse. You’ve got to make Douglas feel like the player that he is, because he’s working his little heart out to smooth things over and make things good, and to the extent you don’t go through him, you make him look bad. He found out about the supervisor-person hire from them! That’s bad. He shouldn’t. Could you just call him?’”

  She concluded, “When I talked to Douglas a while later, I asked, ‘Did Steve call you?’ He said, ‘I didn’t return his call.’ I said, ‘You must return his call. You must let him apologize.’”

  Jablon felt betrayed by Davidson, but his sense of betrayal paled next to his fear of Brier. “In front of both of my bosses, he let them believe I didn’t take care of the situation, which I did. I would never treat anybody like that,” Jablon told me. “But then Pam said [he paused] Steve apologized [another pause], and I kissed him [long pause], and that’s that.’”

  Later I asked Bernie Gips and Elliot “Lazer” Rosman, the Borough Park Hatzolah coordinators, about the incident. Rosman, a gray-haired, intense man, was director of disabled students at Queensborough Community College; Gips, who tucked his side curls behind his ears, was president of a commercial air-conditioning business. (They both exuded the excitability that once led me to ask a Hatzolah volunteer why the Orthodox always seemed so nervous. Without hesitation he replied—grinning, “Because God gave us nerves!”) Jablon was the liaison for our meeting. He invited us to use his office, made introductions, left, and then returned briefly to deposit a box of cookies on the table.

  “In the same breath I’m criticizing, I want to defend,” said Gips, who spoke so rapidly he wheezed as though he were running, not sitting. “They have a very good computerized system. But you have to have the doctors to go on the computer and check it. What good is it if the doctor doesn’t enter the order in the computer, the nurse doesn’t read the orders, and then the patient doesn’t get the right medications? The system is overwhelmed.”

  How would he fix the emergency room?

  Gips hesitated, just for an instant. “Couple of things,” he said. “I would change certain personnel.”

  Who?

  “You’re putting me on the spot. Certain personnel.”

  Who?

  “You know what they say?” asked Gips. “The fish stinks from the head. Let me just say that.”

  Rosman chimed in. “That person, for example, he has certain expertise. He is a computer genius, and this makes him look good. This is very nice for patient information, but it doesn’t relate to what we call in Yiddish nisht mayn a’khaver [‘not my friend’].”

  What was this, a Harry Potter story, talking about Lord Voldemort, “He Who Must Not Be Named”?

  Neither of them corrected me when I asked if either of them had told Davidson directly that they didn’t approve of the nursing director Davidson wanted to hire.

  “Not me personally, but someone let him know there might be a problem,” said Gips, whose face was flushed; he had a reputation as a hothead. “I want to ask you a question. Anyone trying to work with the community—and we bring five hundred patients a month, four hundred patients, which turns into big dollars—is it worth it to take on a fight? Is there only one person to take her place?”

  Gips shook his head. “He talks to us without respect.”

  When Brier called McDougle to deal with the situation, he once again was reminded that Maimonides was not like other places he’d been. “Everybody knows everything about everybody,” he said. “It’s very bizarre.”

  “I’ll never forget Bernie’s first comment to me,” he recalled. “He said, I’m going to be a pain in the ass.’”

  Gips fulfilled his promise, but McDougle didn’t really mind. He admired Hatzolah. “Other ambulance drivers come, it’s their job,” he said. “Hatzolah are volunteers, and they are like advocates for the people they bring. It’s like everyone comes with an advocate. ‘Why is the doctor taking so long? Why are the lab techs taking so long? Why is the medication not being given? Why is the radiology exam not done?’ They stay there. It’s the difference between being not just an ambulance person but an advocate. And they felt that this person [the nursing-director candidate] hadn’t been sufficiently sensitive.”

  But he was also sympathetic to the pressures in the ER. “I do believe that everybody who works there is part saint,” he said. “When things don’t go perfect, there’s a lot of blaming. So not only do these people have to deal with sick patients, old patients, not enough space, too much noise, they have people running around blaming everybody for why
it’s that way.”

  “Bernie said Steve didn’t call, and Steve said Bernie didn’t return my call,” said McDougle. “They don’t like each other, so they don’t communicate and they blame each other. Who’s right? I don’t know who’s right. There are times you have to draw the line, and this didn’t seem to be one of those times. So now we’re back to square one with trying to hire a nurse director.”

  McDougle looked at me poker-faced. “But square one is better than negative three.”

  I sent Davey Gregorius a note asking him what he thought about Hatzolah.

  His reply:

  I mostly have had good experiences with Hatzolah. it is unfortunate that they sort of get a “bad rap” from the other EMS/Ambulance crews. i think they got bad reputation 1. some people infer that they only run Jewish patients (which i do not think is true . . . . but certainly 95% of the people they bring in are Jewish). so i think it’s a sort of counter-discrimination. 2. (i am told) they respond faster than any city-wide (private or government) EMS “company”. not sure of the exact times, but i was told something to the effect of average response time for Hatzolah was like 3-4min vs. 8-9 minutes when calling 911 . . . . so if this is true, i can see why FDNY and Maimonides EMS workers would be “jealous”

  you’d have to ask some people a little more close to the program than i

  one thing i do recall is that they usually gave a very professional presentation of the patient they brought into the Resus [Resuscitation] room

  and 3. the other thing was they were notorious for “Hatzolah-fications”, which is a unnecessary “notification” called in by Hatzolah. a notification is when the ambulance crew (regardless of company) calls ahead to the ER to warn of a life-threatening condition (stroke, heart attack, bleed, etc), and thus all Notifications were immediately triaged to the Resus room, instead of waiting in that line at triage and then waiting however long to be seen. the general consensus is that Hatzolah calls in some Notifications that did not need to be notifications. that the Hatzolah members would call in a Notification for an elderly Jewish patient that they just wanted to get seen faster instead of waiting 1-2 hours, although they really were not sick enough to require “jumping the line”, if you will . . . . i think overall, Hatzolah is great and if i was injured or having a heart attack, i’d call Hatzolah. also i wouldn’t want to piss anyone off. Ha

  January 8, 2006

  Daily Log—J.S.

  A couple of months ago, Steve Davidson told me about Ann Marie Ceriale, a youngish nurse he’d hired to be a nurse manager in the ER. The nurse manager’s main job is handling discharges, organizing the floor nurses to make sure each patient has been seen, diagnosed, and then sent home or to a hospital bed. Nice and orderly job description in the abstract. Davidson hadn’t been able to find anyone willing to take the position for the past two years. Before that the department regularly ran through nurse managers at a rate of one a year or so. Ann Marie sounded like someone I should hang around with, to see if she survives.

  Davidson agreed but asked me to wait until January. “Yeah, January sounds good,” he said, looking worried. “Barbara Sommer, who’s been in the ER twenty years plus, is becoming associate VP of nursing as of January 2, and I won’t have a nursing director, just this new nurse manager. She’s a nifty young woman. She’s been a charge nurse on the cardiac-cath recovery unit and worked a couple of ER’s in Westchester. She’s got some great leadership chops—she wouldn’t let me intimidate her. I like her. She pushed back.”

  The other day I reminded him about introducing me to Ceriale, and he said he would see how she felt about having me tag along with her. “I don’t want her to feel too much on the spot,” he said. “She might . . . I don’t know how I feel about it. Her success is pretty important to me, I don’t want her to pull her punches.” Then he shrugged. “She’s a grown-up, you should talk to her.”

  I called Ann Marie. “Sure,” she said, “you can follow me around. Just don’t go into shock.”

  On January 9, Ann Marie Ceriale came to fetch me at 9:00 A.M. in the pleasant-enough waiting room at the walk-in entrance to the emergency department. She was thirty-four, had long brown hair and big dark eyes, pretty, Italian-American, a little chubby, assertive. She told me she lived in Yonkers, four blocks from her parents, and that she’s lost more weight in the six weeks of this job than on any diet, including the twenty pounds she’d dropped on Jenny Craig. In the hallway leading to her office, I read the advisory posters on the wall and felt a mild panic at the implications in these instructions on what to do in case of stroke, chemical terrorism, smallpox.

  On the way we passed through the emergency room, which appeared calm, with patients neatly deposited behind curtains and doctors and nurses walking rather than careening. I noticed a woman doctor with the unlikely but momentarily appropriate name of Placid Bone.

  “Just wait,” said Ceriale. “Two o’clock. You can set your watch.”

  “What?” I said.

  “Chaos,” she said. “You can set your watch by it.”

  Ceriale stopped to snap at a nurse who was reading the newspaper. “There’s no time for this,” she muttered.

  For six weeks she’d been trying to connect Dr. Davidson’s continuous quality improvement model to reality. But almost every day of the six weeks she’d been in the ER, Ceriale had been short of nurses. She usually spent the first couple of hours at work trying to find subs. She had six open positions, all on nights, and depended on the staff she had to do overtime. One of her jobs was to solve the staffing problem. She was thinking of using more travelers, who worked on contract. She had been a traveler and loved it. She’d seen California that way, Sonoma County. If you don’t show up, you don’t get paid, while the Maimonides nurses were unionized. “Call in sick and you get paid,” she said, adding quickly, “I one hundred percent support the union.”

  When she first walked in from the street to the ER, her impression was that it was a “complete disaster.” She said, “I thought, ‘I would never want to be a patient here nor would I want to work as a nurse,’ and now I’m a nurse manager.”

  But she came to see there was both method and madness. “There’s actually a very organized and systematic way we’re doing business here, but from the outside it looks like a complete disaster,” she said. By then we were in her small office, decorated only with a photograph of a sunset taken by Ceriale at Club Med in Mexico.

  “We’ll get a massive amount of discharges today, because it’s Monday and a lot of beds open up on the floors, because doctors don’t do a normal amount of discharges on Saturdays and Sundays,” she said. “Meanwhile, the ER is backing up throughout the day, so by the time we get the beds available, we have a flow list of fifty or sixty and one or two transporters.”

  She said it was ironic that she took this job, because what she loved about nursing was the clean slate at the end of the day. No matter how grim or hard or tense, her duties were finite. “At the end of the day, it was the end of the day,” she said. “At the end of the day, you handed off patient care to someone else. Now there’s no end of the day.”

  The ceaseless demands, the unending pile of loose ends, reminded her of the seven years she spent working at an insurance company. “I had files of injury cases I had started at the beginning, and when I left seven years later, I had the same files,” she said. “Instead of taking up one single file folder, they were taking up a drawer in litigation. They had a life of their own. There was never a time I could say my desk was completely cleared off. This is very similar. My desk is never going to be clean. The end of my day is never going to be a fresh start or the end of the day. Your days off are not your days off.”

  At 11:00 A.M. we went to a management meeting led by Carl Ramsay, the medical director, Dr. Ponytail. The head of the ambulance service said the fire department’s new computer terminals with GPS tracking weren’t working and screwed up the entire system over the weekend. Lab problems, staffing problems, a stab wound in
pediatrics. Ramsay told the group that the new nurse director hadn’t worked out, though he didn’t mention the Hatzolah veto. “We’ll do fine so long as we are talking to each other, respecting each other,” he said wearily.

  Next time Ceriale and I walked through the ER, the earlier calm had evaporated. I checked the clock. As Ceriale had predicted: It was 2:00 P.M. Chaos time.

  We walked by an Orthodox man on a gurney surrounded by women praying. A blond young man on a stretcher in the hall complained he’d been waiting too long. Dr. Huang and one of the cancer fellows swooped in to press the belly of an African-American woman. I saw Dave Gregorius bee-lining it for the “resus,” or resuscitation room, reserved for possibly about-to-die patients needing swift attention.

  Back in Ceriale’s office, she showed me the tracking board on her computer. She was starting to get the hang of it, using this snapshot to find hang-ups in the system. She could see that at 2:28 P.M. there were seventy-three patients in the ER, none of them in pediatrics. A sixty-seven-year-old female with complaint of chest pain had spent eleven minutes with a nurse and was now with an attending physician. A report was given to the doctor on the floor, patient admitted to telemetry. Team One. They’d requested a telemetry bed. Here on the cardiac monitor, her EKG. Lab orders. Blood work, vital signs, history.

  But between “patient admitted” and “they’d requested” lay the gap between “continuous” and “quality improvement.” Minutes could quickly become hours. “It’s a very busy emergency room,” said Ceriale.

  Her beeper went off. She stared at it. “The beeper, the beeper, the beeper,” she moaned. “I already had my first dream of the beeper going off. I got up Saturday at five in the morning searching for the beeper, which was right next to my bed.”