A group of DASC (Doulas Association of Southern California) doulas are invited to tour the USC County Hospital on Marengo St. in Los Angeles. Our gracious host is legendary lactation guru Kittie Frantz, RN, CPNP-PC, Clinical Instructor in Pediatrics, University of Southern California Keck School of Medicine.
The doulas’ goal is to learn more about LAC-USC’s Labor and Delivery department, postpartum practices and to visit the NICU. Doulas are prepared with a lot of questions, and visiting a facility and meeting the staff is going to be a valuable learning experience for us. I can only assume that having fourteen doulas in the same room asking questions is probably a first for the staff at LAC-USC.
In the entry to the historic USC County Hospital which now sits abandoned and lonely on the back of the new facility, the builders carved into stone the following edict: “Erected by the citizens of the county of los angeles to provide hospital care for the acutely ill and suffering to whom the doctors of the attending staff give their services without charge in order that no citizen of the county shall be deprived of health or life for the lack of such care and services.”
In light of the new health care reform and all the talk we have heard about public health care and care for the uninsured, this gave me pause. Is there actually a hospital in town that would care for the uninsured (including yours truly,) and that is not plagued by long lines, huge crowds, untidiness, danger and maybe even a bit of chaos one associates with a free hospital? Here is what I discovered:
A bit of history:
LAC-USC Medical Center sits at the “hub” of the Department of Health Services for Los Angeles County, which is the most populous county of the state. It is not in a great neighborhood, but the building is impressive and new. I read that the medical center’s history is rich and extends to the pre-antibiotic era, the days of the iron lung. The medical center was born in the ‘30s from the social activism that was spawned by the great depression and, when it was built, it was the largest hospital in the United States (with close to 2000 in-patient beds). Kittie informed us that VBACs (vaginal births after cesarean) were first “invented here,” which is a good sign since there are very few doctors and/or hospitals who will even consider attempting this procedure.
Researching on the web, I learn that about thirty years ago this hospital became a Burn Center, a Level I Trauma Center, a Neonatal Critical Care Nursery, a Pediatric Critical Care Center, and hosted one of the busiest Obstetric Services in the country delivering 1 out of every 4 babies in California. William Mallon, MD - President of the California Chapter of the American College of Emergency Physicians writes that, “When I was an intern [at LAC-USC 1991] we–our team—delivered over 100 infants per 24-hour call.”
Unfortunately LAC-USC has had to reduce its services and the medical center shrunk in 2008 to host only 650 in-patient beds and Obstetrics now averages 2-4 deliveries in a 24-hour period. Of course this last detail brings a smile to my face as it only means that moms have a much greater chance to be cared for personally, find a bed when they reach the hospital in labor and have a comfortable room in postpartum. But I am getting ahead of myself.
When we meet in the in-patient tower we have to go through an airport security-like check point, which might seem strange but it gives one a sense of safety. The lobby is clean and pleasant and not too populated. Everyone gets a wrist band at the information booth up front and all fourteen doulas and Kittie are now ready for the tour. Before we begin, Kittie gives us the run down:
· LAC-USC is a teaching hospital which means that there are doctors and anesthesiologists [or an anesthesiologist] on the premises at all times. For the consumer this translates into the ability to have a VBAC, not having to wait for the attending doctor to arrive at the hospital before you are allowed to push (it has happened to my clients in those hospital who have no residents or midwives on premise) or to manage an emergency by an OBGYN vs. an emergency physician. It also means having anesthesia promptly available when you want it, and having a highly skilled neonatology staff on hand for emergencies with your baby. LAC-USC is one of the best facilities to handle any type of emergency.
· Medical students and residents who are chosen to work here are in the top three percentile in their academic performance nationwide.
· There are ten midwives on staff who work 24/7. These midwives manage and deliver patients but also are part of the teaching staff.
· Services are free to those women who have MediCAL . Delivery for the uninsured or those non-eligible to get MediCAl is only billed at $2,000 and, if you include prenatal care, the total bill will be only $2,500. The fixed rate for the uninsured has one qualification. The baby has to qualify for MediCAL.
· Child Birth Education classes are offered free of charge and baby care classes (4 of them taught by the residents themselves) are also free. My readers know I am not a huge proponent of hospital-taught classes, as most educators who work in a hospital have to tailor their presentation to the ‘hospital policies’ vs. the best ways to obtain a natural drug and intervention free birth. Nevertheless, free is a darn good price and education is better than ignorance.
· All nurses have been trained as lactation experts and even though there are no lactation consultant on staff, Kittie explains that “if all our nurses are lactation experts then moms who have questions at 2 AM don’t need to wait for the LC (lactation consultant) to arrive for her shift in the morning, or wait around for her availability.” And since Kittie is on call as well for all lactation questions I can confidently say that breastfeeding will not only be encouraged but closely followed for maximum success.
We are now jazzed and proceed on the tour. The corridors are clean and Kittie tells us that the administration sought artists to donate their work to embellish the walls and create a calming experience. After all the modern-art-museum-like hallways of Cedars Sinai and UCLA (which also are teaching hospitals that accept MediCAl) are tough acts to follow.
The L & D department is quiet and we are told there are only two women in labor at the moment. The residents are welcoming and we pile up in their room as an avalanche of questions is presented to them. Frankly, I could not share all the questions and answers or I would have to prepare a twenty page-paper, but suffice to say that all questions were answered, that the residents, who mostly manage critical care in this hospital (as all critical MediCAl patients, even those admitted at the emeritus UCLA or Cedars, are sent here,) were interested in what we have to say, but most importantly are open to witnessing a “natural childbirth,” and willing to make some concessions. We discuss Heplock (a small tube connected to a catheter in a vein in the arm for easy access, which many moms prefer for better freedom of movement and less risk of engorgements following the birth) vs. mandatory IV fluids, intermittent monitoring of mom and babe during labor, freedom of movement during labor, and we hear that all is possible within safety. Then Karen Grey, RN, CNM, a lovely and seasoned midwife takes us to see a laboring room. Clean, spacious and well equipped, it’s enough to host us all and once again the avalanche of questions comes pouring out. Karen skillfully and with great patience responds to all. She tells us that if all is well moms can take a shower during labor, (they would use a Doppler to monitor the baby intermittently,) that they have and are open to using a squat bar or allow mom to deliver on all fours if that’s her preference.
To our questions about induction and augmentation of labor, she tells us that they use Cervidil and Pitocin, one as a ripening agent during an induction and the other to augment labor, versus Cytotec, which is a very dangerous, yet widely used drug. This is good news. Unfortunately, the hospital policy is to induce at 41 weeks of gestation and not later; which is debatable but not unusual, as most hospitals and private doctors feel the same. Then again, I tell my clients that there are no induction patrols that will come to your house and force you to go to the hospital and be induced. If the baby is ok and there is enough fluid in the placenta, and it is safe to wait a little longer, one can always negotiate the scheduled induction with their provider.
On our way to visit the postpartum wing we meet with Dr. Jamie MacGregor, OB faculty in the University of Southern California Keck School of Medicine, who is also welcoming and speaks with passion about the critical “golden hour,” the first hour immediately following the birth where moms and babes bond and where successful breastfeeding starts. I like to call it the two golden hours as it usually takes the babe up to 45 minutes to even want to breastfeed, but this is a good sign, as unfortunately, few OBGYN will even consider immediate skin to skin, option for the nurses to admit and examine the child in the warmer before they give it back to mom.
The postpartum rooms are nice and comfortable, the nurses are very experienced (we ask how long they have been at this hospital and we hear “I have been here twenty-five years” “sixteen years for me,” loyalty to the place of work is a good sign) and as I mentioned before, all are trained in the art of breastfeeding by the guru herself. Then a quick stop to a very empty nursery, only one baby on the premises and Kittie explains that mom and babe room in and very few newborns make it to the nursery. Here we meet a lovely nurse Kelley Dantzler, RN who tells us that there is a huge diabetic population that comes to LAC-USC so babies are often checked for blood sugar and they feel comfortable with blood sugar levels at fifty (which is a bit higher than most hospital which consider forty or forty-five the minimum level before they intervene. Once again in a normal labor and delivery situation with a mother who is not diabetic, knowledge and asking questions can go a long way in having the right care.) We also learn that sugar water is not used in the nursery but that only formula is used in case of an emergency (i.e. low blood sugar.)
Then we enter the NICU, which is huge, and we meet with Dr. Rangasamy Ramanathan, also known as Dr. Ram, who is the head neonatologist in charge of the NICU and also Pediatric faculty for University of Southern California Keck School of Medicine. He graciously stops to answer our questions and give us information on this impressive facility. LAC-USC has one of the highest levels of critical care units in the city, about 10 percent of babies in the NICU are transported from other facilities.
We can see that parents are welcomed as we observe mom and dad caring for and feeding their little one just to the right of us. The middle of the room is crowded with chairs for potential visiting parents. Dr. Ram answers questions about kangaroo care, (Kangaroo care is a technique practiced on newborn, usually preterm, infants wherein the infant is held, skin-to-skin, with an adult) and Dr. Ram tells us that, Kangaroo care for a pre-term infants may be restricted to a few hours per day, but if they are medically stable that time may be extended.
He also tells us about a special room that has been set up for parents who, before taking their little one at home, can spend an overnight in the hospital rooming in with their child, in close proximity to the doctors and nurses available 24/7 to answer any question a new parent might have. It is called the transitional room, and I find this an amazing and unique service as I am sure many parents are afraid of their first night away from the hospital, especially if their little one has been in the NICU for long or have special needs.
Towards the end we discovered yet another pleasant surprise. Walking around the floor a lovely lady is available with her portable multimedia, multilingual translator in the guise of a laptop, on a trolley rigged with a camera. In case there is a question or need for instructions for a non-English speaking mom a live interpreter will be reached via computer used as a virtual video-phone. I believe there are nearly 25 language interpreters made available.
We end the visit in the very long corridor that conjoins the two towers of the medical center, as we meet an assistant nurse who stops by to steal a quick hug from Kittie and offers us a big smiling welcome and a little dance.
We leave the hospital after a very informative tour that lasted nearly three hours. I am personally impressed by what I’ve seen. Hoping to actually experience a birth there we all stop at the coffee shop just outside the in-patient tower entrance and enjoy an espresso and some delicious Porto’s pastries as we chat amongst ourselves.
Helpful hints for dealing with LAC-USC Hospital:
1. If you have insurance do NOT use this hospital as your insurance company will pay very little and you will be stuck with a huge bill.
2. Be proactive in your care. I can’t emphasize this enough. Know what you want, have a birth plan, find a doula (DASC is now working on a volunteer program for those who cannot afford a doula, visit DASCdoulas.org) and find a student doula who is looking for certification and will offer her services either free or at a very low cost.
3. Know what your rights are, visit the hospital, go to the classes, get names of the midwives and call or visit them in the clinic and ASK questions and tell them your birthing preferences.
4. Aside from Obstetrics the clinics are full and the wait is long. Emergency room is overcrowded, but you do not need to go to the emergency room if you are in labor, and that’s good news.
5. Ask questions and don’t stop until you get the answers you want.
6. It is a county facility so, yes, you will see prisoners handcuffed walking with security officers in the hallways, and some homeless too. Bless them and send love, they need it.
7. Don’t worry if you cannot pay. They have an “ATP” (ability to pay) program. If you qualify, you will be allowed to pay what you can. If that’s only $20 per month, then that’s what it is. ASK. They will help you fill out the forms.
8. Make friends with and get to know your nurses. They’re the ones who run the day-to-day operations and often are a little more informed than the doctors. Get the nurses on your side.
9. Have someone who can bring you food to eat. The hospital food, I hear, is not great. Art’s Coffee Shop across the street on Zonal makes a superior al pastor burrito and the best fish tacos, so I heard from a former patient. There is a coffee shop in the courtyard that serves good sandwiches and Porto’s pastries. There is also a Subway across the street.
10. They do have patient parking, and it is free. However it is very limited. There is street parking and meter parking, but it might take a long time to find one and meter might not be a good idea as things might take more then you expect. You may just have to suck it up and pay the $8 to one of the private lots.