Thread: Parkland brimming with babies

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Parkland brimming with babies

01:37 PM CDT on Sunday, June 11, 2006
By SHERRY JACOBSON / The Dallas Morning News


The baby was born healthy and crying, and his mother managed a faint smile before anyone realized that a routine C-section was going terribly wrong.

Suddenly, blood was everywhere in the operating room at Parkland Memorial Hospital, and a call went out to a third-year medical resident to get there "stat" and take over the surgery.

It was Dr. Lisa Remedios' job that day to grapple with any surgical complications that came up at the second-busiest maternity unit in America. In this case, she had to stop Fabiola Oviedo from hemorrhaging to death.

"I ran all the way to the operating room because I knew she'd be bleeding until I got there," the doctor recalled. "There was no screaming or yelling, but the situation was tense."

Doctors determined that the placenta that cradled Ms. Oviedo's baby had grown into the wall of her uterus, a potentially life-threatening condition that occurs once in every 2,500 deliveries. The 24-year-old Duncanville woman underwent an emergency hysterectomy and required the infusion of 10 units of blood – essentially replacing her blood supply.

Ms. Oviedo probably would have died at another hospital – but not at Parkland.

"The whole system is poised to take care of a patient like this," said Dr. Remedios, who was covered in blood by the end of Ms. Oviedo's successful surgery.

Doctors take page out of hospital's book

Parents, doctors fight for space in neonatal nurseries
It was a particularly hectic April day at Parkland, with 57 babies born, a third more than normal. Women were in labor in the hallways, doctors and nurses were too busy to break for lunch or dinner, and, suddenly, Ms. Oviedo's emergency cropped up.

Still, it wasn't too much to handle at Dallas County's public hospital, where delivering healthy babies has become a primary focus and a source of deep pride.

Last year, Parkland's doctors and nurse-midwives delivered 15,590 babies – a diaper-wearing contingent that was double the population of Highland Park.

Babies arrive at Parkland at an average rate of 42 infants per day. Feeding this birthing frenzy: the growing number of Hispanic immigrants using the hospital.

More than 80 percent of the women who gave birth at Parkland last year had Hispanic surnames. The hospital does not focus on whether these women are legal residents of the U.S. Federal law requires hospitals to care for any woman who shows up in labor.

"We are the safety net hospital for Dallas County, and these folks are residents of our county," said Dr. Ron Anderson, president and chief executive officer of Parkland.

The hospital spent almost $71 million to deliver the babies born there in 2004, with Dallas County taxpayers covering about 40 percent of the cost and federal and state funds making up the difference – and then some. The maternity program ended the year with a surplus of almost $8 million.

The magnitude of the annual baby boom tends to overshadow Parkland's highly successful method for delivering babies and the way it can quickly respond when anything goes awry.

It's called "The Parkland Way," and Dallas County's charity hospital is famous for inventing it.

"People at Parkland respond very quickly and effectively to situations like this," said Dr. George Wendel, the obstetrician-gynecologist who oversaw Ms. Oviedo's life-saving surgery. "They go back to what they were taught, and, in general, things work out."

Later in the recovery room, Ms. Oviedo was grateful to the doctors who saved her life. Pushing aside her oxygen mask, she whispered through an interpreter, "They knew what they were doing."



Standard for care

A pregnant woman who makes it to Parkland – or one of its nine prenatal clinics – does not step onto a conveyor belt that carries her through an impersonal birthing factory. But, she does turn herself over to doctors and nurses who have created a massive delivery system that standardizes nearly every facet of care.

Each woman gets the same number of prenatal visits, the same tests, the same vitamins and, virtually, the same medical care – as long as her pregnancy is normal.

She doesn't get a sonogram unless there is a medical reason for one. She might not see a doctor unless there are complications. Nurse practitioners routinely oversee routine prenatal care, and nurse-midwives handle thousands of uncomplicated deliveries.

The key: No one does anything on a whim.

"One of the reasons we do things so well is that we have these algorithms set up to make it work," said Kim Brinkman, a registered nurse at Parkland for nine years. "It's a step-by-step approach to how we take care of our patients and handle certain emergencies."

If there is a code word that describes Parkland's approach to obstetrics care, it is algorithm, a mathematical rule or complex recipe that directs every aspect of patient care.

Although some experts criticize Parkland for taking a "cookbook" approach, the hospital's nurses and doctors endorse it as the only way to cope with the overwhelming number of deliveries.

"You go through a series of questions and answers to figure out what needs to be done for the patient. It's the way we've all been trained to think," said Miriam Sibley, a registered nurse and Parkland's senior vice president of Women and Infants' Specialty Health.

The approach is so well-regarded that Parkland's doctors are the primary authors of the nation's premier maternity textbook, Williams Obstetrics, which is used to train most U.S. obstetricians.

"The book is important to many people because it's based on experiences at Parkland hospital. There's been a long history of evidence-based medicine here over the years, and we've codified how we do things," said Dr. Kenneth Leveno, chief of obstetrics at Parkland and a co-author of the 22nd edition of the 1,441-page book.

Dr. I. Murphy Goodwin, professor of obstetrics and gynecology at the University of Southern California, said Parkland's delivery system has kept pace with medical developments.

"Parkland has a signature way of doing things – and it's constantly improving it," he said. "If doctors across the country don't know the name of Parkland hospital, they are still affected by it."

Parkland doctors, who also are affiliated with UT Southwestern Medical School, have been refining their maternity protocols since the 1950s to accommodate more and more births as well as assure quality care.

"What's really remarkable about this place is that these things work," said Dr. Leveno, who also is the vice chairman of maternal-fetal medicine at UT Southwestern. "The patients can go through the system with rather consistent health care based on our experiences. Our computer system has been set up since 1982 to measure their outcomes."

In 2002, Parkland's neonatal mortality rates – deaths that occur within the first 28 days of life – were far lower than the national average, which stood at 4.7 deaths per 1,000 U.S. births. At Parkland, the mortality rate for newborns whose mothers received prenatal care was 2.7 per 1,000 births.

For black babies, the hospital's mortality rate was about half the national average, and for Hispanic babies, the rate was a third better than the rest of the nation.


Seeing mothers early on

The path to Parkland's successful deliveries nearly always starts in the hospital's prenatal clinics. Studies have suggested that for every dollar spent on prenatal care, hospitals save several dollars on delivery and postpartum care because fewer babies are underweight at birth or suffering unexpected complications.

"It's a public health program predicated on the assumption that by the time a woman gets to delivery, it is too late to change the course of the outcome," Dr. Leveno said. "You need to get to her first in the community to affect the outcome of the delivery."

More than 90 percent of women who deliver at Parkland receive care at the hospital's prenatal clinics scattered throughout low-income areas in Dallas County.

Word-of-mouth generally spurs pregnant women to call Parkland when they first suspect they're pregnant, noted William Lodriguez, a nurse practitioner, who formerly supervised the Maple Plaza Prenatal Clinic.

"The hospital's goal is to give a woman an appointment within two weeks of that first call," he said. "We overbook, but it's not a problem."

About 20,000 women annually seek prenatal care in the county hospital system, although 5,000 of them eventually choose to have their babies at other hospitals.

Losing patients to other hospitals doesn't alleviate Parkland's heavy load. It has relied heavily on those medical formulas to move an ever-increasing number of pregnant women through a facility that officials say is half the size needed to accommodate them.

The main hospital building was completed in 1954, when 3,596 women delivered babies there, less than a quarter of the 2005 baby boom.

"We're 200 percent undersized for the current patient population," Dr. Anderson said. "We know that renovation costs would exceed replacement costs. The question becomes, What will we do with overcrowding if the number of births continues to rise?"

Parkland supporters have tried to inspire community backing to build a new facility to house women and infants' services as well as meet government safety and patient-privacy standards.

As recently as 2002, the hospital's board of managers unanimously endorsed a $300 million construction plan for a new birthing center. But the proposal quickly evaporated in favor of a larger, but ill-fated, facility that would replace the entire hospital at an estimated cost of $1.6 billion.

"There was sticker shock when the plan came out, and we never got a chance to take it to the public," Dr. Anderson said. "Next time, we have to bring the idea along more openly so that everyone understands the need to build it."

A blue ribbon panel has endorsed the idea of replacing all of Parkland, possibly with several smaller facilities throughout the county. A final recommendation is expected later this year.


Spilling into the halls

Friday is usually the busiest and most overcrowded delivery day at Parkland because patients nearing their due dates – as well as those who are overdue – attend a weekly clinic at the hospital, said Becky Scasta, former associate unit manager. These women are placed briefly on fetal monitors before they can leave the building.

"They want to make sure the patients are OK before they send them home for the weekend," Ms. Scasta said. "The patients come here to rule out problems. They may have blood pressure issues but it's too early for delivery. Some get to go home. Some don't."

Often, the patients end up in beds lining the corridors of Parkland's three labor and delivery units. An eerie background noise of fetal heartbeats fills the air.

One patient, Lizbeth Sosa, 19, highlighted the hazards of being relegated to a hallway bed. Thirty-seven weeks pregnant and suffering from high blood pressure, she was required to lie still for two hours to see whether medication would bring down the rate.

To give her a physical exam, the staff outlined her hallway bed with six blue screens, from which a rusty rod jutted into the narrow aisle alongside her bed. Through the space between the panels, anyone nearby could see what was happening behind the screen.

Asked later how she felt lying in the hallway bed, Ms. Sosa said she didn't mind the lack of privacy because she'd given birth three years earlier at Parkland, and everything worked out fine that time.

The women receiving Parkland's special brand of obstetrics care do not always understand the basis for it.

Jasmine James, 25, was a week overdue and expecting to have her delivery induced on a busy Friday afternoon. The Hurricane Katrina evacuee said she was surprised to find herself lying in a hallway, waiting to be examined.

She had given birth five years earlier in New Orleans and had a private labor and delivery room. "I know back home, I wouldn't be in a hallway," she said.

Three hours later, Ms. James was sent home to await a spontaneous delivery in the belief it would reduce her risk of having an unnecessary Caesarean delivery. But she was unaware of medical studies supporting this approach.

"I didn't think I'd be waiting at 41 weeks," she said as she trudged toward the elevator. "I guess this is a Texas thing."

Patient communication can be a problem at Parkland, particularly because so many of its maternity patients speak only Spanish.

Although many hospital staffers have picked up limited Spanish, including basic conversational phrases and words for medical procedures, interpreters often must be called to help explain medical options to the patients.

Pam Krywalski, a longtime obstetrics nurse who is fluent in Spanish, takes it upon herself to help the resident physicians learn Spanish. She even developed a "cheat sheet" of basic terms to get them started.

"It's a tremendous help to be able to speak Spanish to these women," she said. "By the time they're out of residency, the doctors can get through an admission or delivery in Spanish."


A place to learn

Parkland is a giant educational institution for doctors. For annual salaries that start at $40,000, resident physicians who want to learn medical specialties are the main providers of health care to Dallas County's indigent and uninsured patients.

"It's great training," said Dr. Shana Wingo, who is finishing her fourth year of obstetrics/gynecology training. "At the end of the day, some of us are probably overtrained because you won't see all this intensity in private practice. We work hard here, but I wouldn't trade it for the world."

The 72 doctors training to become obstetrician-gynecologists are handling about 60 percent of Parkland's deliveries – mainly the complicated ones. They work in groups headed by an attending physician, who also is a UT Southwestern faculty member.

"During your residency, you're not doing anything alone. There's always an upper-level resident or a nurse around," said Dr. Stephan Shivvers, an attending physician who specializes in maternal-fetal medicine.

"During a nine-month pregnancy, a lot of things can go wrong," he said. "Anything that can go wrong, you will find us dealing with here on top of a pregnancy. But when things go bad, they can go really bad."

Unless complications arise, however, nurse-midwives deliver about 40 percent of the total annual births.

It was Dr. Leveno's suggestion that Parkland add midwives in the 1980s, when births at the hospital topped 13,000. He had toured Great Britain hospitals in 1985 and seen how credentialed midwives were a key part of the birthing network.

"That was a good idea, given the situation at Parkland," he said. "The physicians were too busy to spend time with the patients. We had medical students delivering babies without supervision."

Parkland employs about 45 nurse-midwives, who follow "very strict protocols," said nurse-midwife Nancy Thamel, "because there's so many levels of education and so many people who work here. We all have to practice the same or it would be chaos."

Many of Parkland's low-risk patients have come to prefer the midwife care.

Patient Cristina Orendain compared a midwife delivery and a doctor delivery when she gave birth to her son, Manuel Eduardo, at Parkland in December. A doctor at St. Paul's hospital had delivered her daughter three years ago.

"The midwife was more involved than the doctor in checking on you," she said. "With the doctor, it was the nurse who checked."

But Parkland will never be mistaken for a private facility, given the overcrowding and the lack of amenities in the aging hospital. Most of the patient bathrooms, for example, do not have showers.

"It's not like a private world where they fluff your pillow, rub your back and refill your ice," said charge nurse April Malone, who must oversee two to six women in labor simultaneously.


Still, staff members such as Ms. Malone are choosing to have their babies at Parkland, rather than a private hospital. She gave birth to a daughter in a Parkland birthing room in January, and three months later was back at work.

"I like all of the drama, all of the running up and down the halls," she said. "It's like a giant chess game where you're trying to make all the pieces fit every day. I just love it."

E-mail sjacobson@dallasnews.com


About this series
Today: Delivering healthy babies has become a primary focus and a source of deep pride at Parkland Memorial Hospital, where nearly 16,000 babies were born last year. How does Dallas County's charity hospital handle such a birthing frenzy? It's called "The Parkland Way," and the hospital is famous for inventing it.

Monday: A recent survey of patients indicated that 70 percent of the women who gave birth at Parkland in the first three months of 2006 were illegal immigrants. These women weren't drawing much attention until the recent debate over immigration.

That hospital is hell on earth. I've been there. Police everywhere, escorting gang members in handcuffs. The shape of things to come...

"More than 80 percent of the women who gave birth at Parkland last year had Hispanic surnames. The hospital does not focus on whether these women are legal residents of the U.S. Federal law requires hospitals to care for any woman who shows up in labor."

And the hospital takes it in the shorts and tries to pass on the unrecovered costs to all the paying and insurance patients. What an intelligent set-up.