At the turn of the 20th century, the Sacramento River Delta was prone to flooding in wet years, while the southern San Joaquin languished in drought more often than not. This unpredictability of water supply led the 1930’s California legislature to authorize a bond issue for the construction of a series of canals and dams to control and stabilize the flow of water for the entire Central Valley: $170 million was raised in short order, and the State and Central Valley Water Projects were born.
Unfortunately, owing to the Great Depression, the state soon ran out of money to proceed with the projects, and the federal government and Army Corps of Engineers stepped in to assist. The result of their joint efforts is abundantly evident today. These public works enable the sun and soil to produce fully 7% of California’s GDP. It was the resilience, persistence and sweat of the original ranchers and farmers who worked the land, coupled with the investment of state and federal dollars, which turned this area into the “Cadillac Desert,” described in a piece by Marc Reisner on environmental history.[i] Similarly, it is the energy and commitment of physicians in the Central Valley, paired with federal and state cash flow that has built a network of district hospitals, clinics, and teaching institutions that help care for almost 3 million residents.
The Friant-Kern Canal: Fresno to Bakersfield
This canal takes its origin from the outflow of Friant Dam in Fresno County and meanders to its terminus over 100 miles away near Bakersfield. Water from Friant-Kern sustains the citrus and fruit ranches along the foothills of the Sierra Nevada. In a similar vein, the flow of federal, state and county dollars sustains the teaching hospitals that lie due west of its course: Community Regional Medical Center-Fresno (CRMC) and Kern Medical Center in Bakersfield (KMC).
CRMC is a 626 bed teaching affiliate of UC San Francisco and is a Level 1 trauma and burn center. Some say it used to be the flagship hospital in Fresno decades ago, when it was known as Community Hospital of Central California. However, since it now resides in a part of town that has seen better days. Some of the more affluent (and commercially insured) patients have fled north to newer, shinier businesses and homes, and they typically stay up north for their medical services. Nonetheless, it would appear that CRMC continues to not only survive, but expand the services it offers to its medically indigent and non-indigent patients. How do they do it? The yearly subsidy Fresno County gives to CRMC to the tune of $17 million to defray the cost of caring for the county’s uninsured and jail populations helps, no doubt. And the Graduate Medical Education (DGME) dollars CMS disburses to defray the cost of educating residents who staff most major medical specialties at CRMC helps too. The hospital’s reimbursement is further enriched by Disproportionate Share (DSH) funds from the federal government’s Center for Medicare and Medicaid Services (CMS). In essence, eligibility for DSH reimbursement is determined by a complex formula that takes into account the percentage of a hospital’s revenues that derive from Medicare and MediCal beneficiaries who live in poverty (SSI recipients), or from the percentage of patients at a hospital who are medically indigent and thus completely uninsured. Both KMC and CRMC get DGME funds and amply qualify for DSH subsidy as well. In contrast to CRMC, Kern Medical Center is a teaching affiliate of UCLA and UC Irvine. It too is a trauma center, albeit Level 2, to CRMC’s Level 1 designation.
The anesthesia department staffing arrangements at both teaching hospitals have changed a number of times during the past decade. Neither has an anesthesiology residency. A physician who was present during the tumultuous time of one of those changeovers, long before the current two managing groups were in charge at Kern and CRMC was interviewed, stating, “It was a stressful time for the anesthesiologists in the group that was taking over the department, because the CRNAs already at the hospital had a long history of what was, de facto, independent nurse anesthesia practice. They weren’t accustomed to having physicians involved at all, except to sign paperwork when necessary, and maybe to be another pair of hands on a really bad case.” So this situation led to significant tension between the physicians in the incoming group, who were mandated to practice in the Anesthesia Care Team (ACT) mode, and the CRNAs who strongly believed that they had been practicing just fine for years without significant physician involvement. “They were, by and large, a very competent and seasoned group of CRNAs, so they considered our insistence on being involved in every single case to be unnecessary.”
In the opinion of several present at that time, this atmosphere of tension and conflicting practice expectations may have led to at least one “near miss,” during which a patient almost died. Just before this particular incident, the anesthesiologist performed the pre-op evaluation as is customary in ACT practice. Apparently, the patient had a history of asthma and was morbidly obese. On physical exam, the airway was assessed as Mallampati grade 4, with significant adiposity around the neck. The patient was terrified about being put to sleep for the operation, so the anesthesiologist departed with these reassuring words, "Don't worry, I’ll be in the room with you when the nurse anesthetist puts you to sleep.” Famous last words…
The next time the anesthesiologist saw the patient was upon being summoned to a “code blue” in the operating room. The nurse anesthetist had taken the patient to the OR, unbeknownst to the supervising physician, and induced general anesthesia. “When I got to the room, there was no end-tidal CO2, the heart rate was in the 30's, and the Sat was in the toilet. I grabbed the blade and took a look. Pink bloody tissue everywhere. So we started transtracheal jet ventilation.” Fortunately, this bought enough time for a formal tracheotomy to be performed by a general surgeon who happened to be passing by. This disturbing vignette highlights some of the risks that may be present in the period surrounding the “non-friendly takeover” of a department or in a practice where all the stakeholders have not explicitly agreed on how they will collaborate in a new practice. Such was apparently the case at that time, in that hospital. This story illustrates the fact that in the midst of changing practice patterns, the combination of hubris and poor communication may put patients at risk for injury or even death.
Which brings us back to the original query, “What Would Happen if They Cut Off the Water?” This is not an entirely theoretical question, because in the Central Valley the water supply has been severely restricted in the past. During drought years, or due to enforcement of environmental policy, irrigation water has been rationed or turned off entirely, to large swaths of the valley. In that case, ground sits fallow, farmers go out of business and small family farms are gobbled up by large industrial farming operations. What if a similar “drought” were to strike local, state and federal funding that helps sustain much of the medical infrastructure in the valley? Government policies change, administrations come and go and revenues decline. If a funding “drought” occurred, how would we respond as a profession? Would some anesthesia groups go out of business or be merged into larger regional or national entities? Would practice patterns change in the face of dire economic constraints?”
And what about our patients? In the relative chaos that often accompanies change, would we allow turf battles and power struggles with other physicians, hospital administrators and mid-level practitioners to distract us from that which is non-negotiable?
One would like to believe that as physicians, no matter what pressures are brought to bear, we will continue to place the greatest emphasis upon insuring the safety of our patients, as we have in this state and in our profession for the past century.