by Marlene Goldman July 29, 1999. 2 pm. Even in the cool, air-conditioned rooms of downtown's Grady Hospital Emergency Care Center, signs of the heat and smog are everywhere: treatment rooms and hallways brimming with patients suffering from respiratory problems, one gasping into an oxygen mask, waiting for her asthmatic heaves to subside. In a nearby treatment room, physicians, residents, and nurses work swiftly to revive a patient in cardiac arrest. In the "holding" room, a sweating, heavyset man with an upper body tattoo broken only by the handcuffs that bind him to his chair is under another kind of arrest. A resident stitches up the long gash over his left eye as a burly officer stands close by. And there are the accident victims: this day, a family of five whose compact car was rammed from behind and thrown into oncoming traffic. All this, and rush hour has not even started. Meanwhile, in a very different part of town - Atlanta's financial center - a day trader has begun shooting everyone in sight. Within an hour, seven of the most critically wounded victims are on their way to the city's only Level 1 trauma center. Thirty-seven doctors and residents, 40 nurses, and scores of support staff are standing by. 3:55 pm. Grady Hospital is one of the last places that Charlie Williams ever thought he'd be going this hot summer day. Anytime, in fact. But the 55-year-old Marietta man with a bullet hole in his chest and another shattering his leg is being raced by ambulance from Buckhead toward downtown Atlanta. As they roll Williams into the Emergency Care Center door, the trauma team surrounds him. He is in surgery within minutes. Over the next five hours, a team of surgeons led by trauma chief Grace Rozycki and orthopaedic surgeon Toni McLaurin explore Williams' heart and left chest. They insert a rod in his femur up to his hip and two tubes in his chest to reinflate his collapsed lungs. A bullet had pierced his left side, torn within inches of his heart, then exited out the center of his chest. "I must have a good guardian angel," Williams says later. He still has a tangible reminder of his unlikely brush with death: a bullet remains embedded near his hip, so close to arteries and nerves that the surgeons decided to leave it in. Seven of the 13 victims of the Buckhead shooting were treated at Grady. All survived.

Charlie Williams credits Grady for saving his life. He was critically wounded last July in the worst mass shooting in Atlanta's history. Prepared for the rush: Empty gurneys are readied each afternoon near the ambulance bay. By early morning, more than 300 people usually turn to the city's busiest emergency department for treatment of everything from sore throats and high blood pressure to gunshot wounds and heart attacks.

he Buckhead shooting and the Grady Emergency Center made national news. But Grady often has been in the spotlight. When an Atlantic Southeast Airlines flight crashed in a hay field near Carrollton in August 1995, eight of the most critically injured victims were taken to Grady. The trauma center cared for 35 victims of the Centennial Olympic Park bombing a year later. As in the case of the Heritage High School shooting in Conyers last year, the most critically injured were sped past city and suburban private hospitals to the place that ambulance drivers and law enforcement officers say they want to go if anything ever happens to them. But most of the time, to most Atlantans, Grady Memorial Hospital is like the nameless protagonist in Ralph Ellison's 1952 novel, Invisible Man. The black man leaves the South for New York City, where he hopes to become part of the American mainstream. He soon realizes that he is invisible "because people refuse to see me." Every day in Atlanta, thousands drive by Grady, a giant concrete monolith overlooking the I-75/85 connector. Few notice its sprawling, 16-story, two-block hulk -- except during a high-profile catastrophe or a funding crisis. Few understand Grady's critical role in the health care of metropolitan Atlantans or its contribution to the city's economy. Few know that there are no "Grady" docs per se -- that Emory's School of Medicine is responsible for more than 85% of the physician care at the hospital, with a growing involvement by Morehouse School of Medicine. Few know that the Emory physicians who work at Grady are the same faculty who teach, do research, and care for patients at Emory's clinics and hospitals. What most people do know is that Grady is the public hospital where the poor and disenfranchised go and where more than 50% of the patients are uninsured or self-pay. It is a place that Fulton and DeKalb county taxpayers love to hate. What most Atlantans, indeed many Emory faculty and staff as well as policy makers at all levels of government, don't know is that Grady's emergency center is but one of many centers of excellence at the 100-year old hospital. All created and headed by Emory and Morehouse physicians, these centers offer many unparalleled services to Atlantans and Georgians. For example, Emory doctors at Grady provide medical direction to the Georgia Poison Control Center. As one of the busiest and best such facilities in the country, it fields more than 107,000 calls each year. Most metro Atlanta patients with serious burns go to Grady -- the country's first major institution dedicated to specialized acute burn care and one of only two burn centers in the state. Premature babies as tiny as two pounds have a better chance of surviving at Grady than almost anywhere else in the country, even though 15% of the 4,200 deliveries at Grady are low-birthweight babies. Grady's Project Prevent has saved the state and federal government about $50 million by decreasing the number of drug-addicted babies and length of stay in neonatal intensive care. Grady is a pioneer in sickle cell research, screening, and acute care. It has some of the best surgical facilities in the state, overseen by six Emory surgeons, five of whom are board certified in two specialties. Grady is respected for its research in trauma prevention, cardiac care, and public health. Its community outreach is unparalleled in Atlanta, with a far-reaching agenda ranging from diabetes education to counseling teenage mothers. Grady's Diabetes Center takes referrals from all over the state, and its rate of amputation - a common complication of diabetes - is as much as 50% lower than that of services with patients who are not as sick. Grady's infectious disease service took over care of tuberculosis patients when the state closed its TB hospitals. And Emory and Grady oversee the largest single source of care for HIV-positive Georgians at the Ponce de Leon Center in Midtown. Few know that Grady attracts some of the country's brightest medical students, residents, and fellows to Emory's School of Medicine. Or that more than half of the physicians in The Emory Clinic also practice at Grady. That many, like world-class trauma surgeons Rozycki and Dave Feliciano, burn specialist Walt Ingram, and Atlanta police surgeon Jeff Salomone, eat, live, and sleep Grady. Most important, few people understand Emory and Grady's symbiotic relationship.

Good start for life: Premature babies born at Grady have a survival rate almost double the national average.

ebster's defines symbiosis as the living together or close union of two dissimilar organisms. It's an apt description of the mutually beneficial relationship between two very different Atlanta organizations: Grady, a publicly funded hospital established to provide care to the medically indigent, and Emory, a privately endowed academic medical center with a threefold mission of teaching, research, and patient care. They share a strong social commitment to treat the ill, more than half of whom can't pay for it. Grady gleans the economic benefit of having Emory and Morehouse residents and medical students to help treat the massive volume of patients who turn to Grady for health care. Emory needs Grady's spectrum of clinical cases that offer physicians in training unparalleled opportunities to learn how to become good doctors. The community needs Grady for the care it gives to people with no other resources and for the safety net that it provides the community at large. Georgians need Grady to train future doctors. And future generations need Grady and Emory for breakthrough research that will improve their quality of life. Grady itself is a study in paradox. A $318 million renovation and expansion project begun 12 years ago transformed a poorly maintained, aging facility into a state-of-the-art medical complex. But taxpayers often grumble that it's too nice. Now Grady's gleaming facade of green and white marble, soaring multistory atrium, advanced surgery and intensive care units, and new patient rooms belie the lingering image of the old Grady. In addition to more than 400,000 square feet of "new" space, dingy wings of the former hospital are being reclaimed piece by piece. Clinicians are staking out offices, and administrators are always looking for money to upgrade the old building to current standards and to supplement services as needs change. It's hard to attract Emory physicians and other staff to work at Grady. Many there often feel they are out of sight, out of mind. Most go there for the love of teaching but are stretched by clinical demands. Hours are long, patients are sicker, their numbers are overwhelming, and more resources - human, technological, and financial - are always in demand. Residents and medical students have mixed emotions too. They say their Grady rotations were by far the most difficult, least pleasant, most enlightening, and best experience of their medical education at Emory.

Grady at a Glance Patients: 750,000 per year Beds: 700 in operation (953 licensed) Physicians: 289 from Emory, 25 Morehouse Residents: 430 from Emory, 56 Morehouse Medical students: 100 from Emory, 35 Morehouse Allied health students: 21 Nursing students: 24 Kudos: Busiest Level 1 trauma center east of the Mississippi Best burn unit in state and among the nation's largest with 28 beds Most comprehensive AIDS program in the nation 1996, 1997 National Public Hospital Association First Place Safety Net Award for Grady Breast Health Initiative and Diabetes Detection and Control Center Regional Perinatal Center for high-risk mothers and babies Sickle Cell Center named NIH National Center of Excellence Nationally lauded TB control program Teen Center program to help teens postpone sexual involvement Georgia Poison Control Center open 24 hours; staffed by physicians, RNs, pharmacists, and certified poison information specialists Rape Crisis Center offers 24-hour hotline, examinations, medications, and counseling

rady Memorial Hospital was first established in the late 1800s after Henry W. Grady, editor of the Atlanta Constitution, decried the lack of health care for Atlanta's poor. The city council carried out Henry Grady's vision to erect a public hospital at the intersection of College and Butler streets in Atlanta. In May 1892, Grady Hospital opened with 100 charity beds and 10 paying patients. Almost from its beginning, Grady has been a vital part of Emory's commitment to Atlanta and Georgia. Emory's affiliation with Grady dates back to 1915 when Atlanta Medical College became Emory University School of Medicine. Many of those early physicians worked at Grady. In the 1930s, Emory and Grady formalized an agreement for Emory to provide doctors to Grady in return for the hospital's use as a teaching facility. Thousands of Emory students have trained at Grady since (or at the "Gradies" as the hospital was known before Emory helped integrate the black and white sections of the hospital in 1956). Under the first contract in 1951 between Emory and the Fulton-DeKalb Hospital Authority (Grady's governing body), Emory faculty, residents, and medical students were responsible for providing all medical care at Grady. That arrangement stood until 1978, when Emory provided substantial support for the creation of Morehouse School of Medicine, including overseeing clinical training at Grady for Morehouse students. Morehouse wanted to train family physicians to practice in the inner city and rural areas. When Morehouse graduated its first class in 1985, its physicians and students began to share medical responsibilities at Grady Hospital. In 1984, a new Emory-Grady contract continued Emory's teaching arrangement with Grady and gave Morehouse physicians and students responsibility for about a quarter of general surgery, medicine, pediatrics, and gynecology and obstetrics services at Grady. The contract extends until 2013. Today, the equivalent of 289 full-time Emory physicians, many world renowned for their expertise, spend some or all of their time at Grady, along with the equivalent of 25 Morehouse faculty. The number of Emory physicians at Grady has remained flat for three years, as has the total medical faculty on the university's campus. Patient volume also has remained level. Of the physicians supplied by Emory, 98 are at no cost to Grady or the counties. In addition, Emory underwrites costs of its physicians funded by Grady, doing so through charges collected from patients seen at Grady by Emory doctors and additional money from Emory's own resources. The massive volume of patient care at Grady - more than 750,000 patient visits and hospitalizations per year - is made possible physically and economically by the presence of 430 Emory and 56 Morehouse residents, who rotate through Grady under the supervision of more experienced physicians. These residents - pediatricians, neurosurgeons, the entire range of specialists - work long hours at salaries far less than the average for nurse practitioners in the state of Georgia. In addition, students from Emory's nursing, public health, theology, physician assistant, physical therapy, anesthesiology, and ophthalmic technology programs rotate through Grady each month. Today, the hospital is funded in part by reimbursements for uninsured health care to the Fulton-DeKalb Hospital Authority and by taxes from residents of those counties. Emory and Morehouse residents' services are largely free to Grady and to DeKalb and Fulton counties. Most of their salaries are paid through federal and state funds for graduate medical education. As a teaching hospital, Grady also receives indirect medical education support from the Health Care Financing Administration. Without residents, roughly $20 million of underwriting of care at Grady would simply vanish. Grady would have to hire an additional workforce to replace their efforts, says Emory radiology chair William Casarella, who also serves as interim senior vice president for medical affairs at Grady. In addition, medical students provide massive amounts of work at no cost to Grady or the counties. More than 100 third- and fourth-year Emory medical students and about 35 Morehouse medical students work at Grady every day, transporting patients, taking their histories, and providing other services. They are paid nothing. The schools and federal and state grants cover their costs.

Collaborators: William Casarella, interim senior vice president for medical affairs at Grady, and Robert Brown, chairman of the Fulton-DeKalb Hospital Authority, stress that Grady is a community resource, not a liability.

September 23, 1999. Gasping for breath, a 49-year-old man drives from Lithonia to Grady, where he's been treated for lupus and heart disease for the past five years. The team of residents and medical students overseen by an Emory faculty member find that the patient's immune system has been compromised by the lupus. He needs two heart valve replacements because he has developed infective endocarditis. After surgery, they put him on a blood thinner. Less than a day after discharge, he's back in the emergency center, close to bleeding to death after being punched by his brother during a playful scuffle. Patients with multiple conditions make the Grady learning experience unique, says Joel Felner, associate dean for clinical education at Grady. Residents and medical students on rotation at Grady quickly realize that working up one patient at Grady is often like working up five patients. In this case, they learned not only about lupus but also about the immune system, heart disease, and infection, as well as the importance of patients' understanding how medications like blood thinners can affect them. Grady is the keystone to clinical training for Emory medical students and residents and turns them into doctors. Medical students receive more than 60% of their clinical training at Grady, with the rest divided among Emory University Hospital, Crawford Long, and the Veteran Affairs Medical Center. All third- and fourth-year medical students do rotations at Grady in internal medicine, pediatrics, obstetrics, surgery, and psychiatry. Most residents spend at least half of their first, second, and third postgraduate years at Grady. While students are there to learn, they play an important role in the patient's experience. On the wards, medical students are the first to see patients in the morning. "We talk to the patients more because we have more time, and sometimes we pick up on things because of that," says fourth-year medical student Monique Welsh. "We find out about the social and financial complications in their lives. Sometimes it can be frustrating to try to teach patients how to take care of themselves, while they're trying to decide whether to eat this week or buy medication for high blood pressure." Residents play a more prominent role in patient care at a public hospital like Grady than at private institutions, says Robert Mondschein, chief resident in medicine. Outpatients assigned to him in his intern year as part of a "continuity clinic" left the most lasting impression. Mondschein saw those clinic patients every two or three months, just as he might in private practice. "You get to know these patients and almost become part of their families," he says. His patients developed similar attachments. One elderly woman who suffered from hypertension, diabetes, and congestive heart failure did not miss an appointment for three years. "She had serious problems, but we stayed on top of them and kept her out of the hospital," says Mondschein. On completing his residency, he not only received a cardiology fellowship from Emory to continue his studies but also a cake baked by the grateful 75-year-old. Grady's interim associate dean for clinical affairs and former chief of pediatrics, Bill Sexson, came to Atlanta from Ohio, where he dealt with a middle-class patient population that was virtually 100% insured. All babies had prenatal care, mothers knew their pediatricians, and none of his patients abused drugs or had sexually transmitted diseases. That's a very different picture from what medical students and residents encounter at Grady. "If it weren't for Grady, our residency program would not offer anywhere near the breadth and depth of experience that it does," Sexson says. "Indigent patients bring more significant health problems that go without treatment because they don't access care as easily. Residents at Grady see a large number of patients with both common and unusual diseases, and that prepares them to practice." Grady also has enabled Emory as a research institution to look at the problems that disproportionately affect minorities and the indigent, such as stroke, hypertension, diabetes, sickle cell, and AIDS, and to translate those advances into clinical care.

Physical therapy: Grady's burn unit last year treated 264 patients in intensive care and 432 in its stepdown unit. Sickle cell: James Eckman directs the Sickle Cell Center at Grady, where patients benefit from pioneering research. Well prepared: Leon Haley, Grady's chief of emergency medicine, says Grady could have handled more than double the number of victims of the Buckhead shooting, but thankfully didn't have to. All seven victims taken to Grady survived.

nfortunately medical heroics and research breakthroughs often don't make as big headlines as money shortages, cutbacks, and management crises -- controversies that Grady has endured often since its founding. But many of Grady's financial worries are not of the hospital's making, says Casarella. Since coming to Emory 18 years ago, he's watched health care costs double, reimbursement rates drop, and the number of uninsured and underinsured patients grow rapidly. More than 40% of the patients now seen at Grady have no insurance. At the same time, government and private insurance alike continue to reduce how much they reimburse for care. Support to Grady from Fulton and DeKalb counties has plummeted over recent years, as has state Medicaid and federal support. The successful welfare-to-work program is getting more and more Atlantans off welfare, and therefore off Medicaid. Many take jobs without insurance, and Grady is left holding the tab. Georgia ranks sixth in the nation in terms of population with no insurance at all. Most of the uninsured live in Fulton and DeKalb counties, which also have the highest rates in the state of trauma, AIDS, TB, and many other high-cost illnesses. In the old days, hospitals could shift some of the money received for care of insured patients to help cover the costs of caring for patients who had no insurance. Both private and federal payers keep cutting the amount they will reimburse for care, and there is no "float" left for such shifting. Furthermore, more people are losing coverage as private employers cut back and as the government tightens guidelines for assistance. Medical cost inflation since 1993 has run about 4.5% per year, yet the public funds continue to dry up. "At a time when Fulton and DeKalb counties' budgets are going up and Atlanta is blessed with prosperity, why is community support so much less for this irreplaceable community resource?" Casarella asks. In 1999, the two counties provided Grady $22 million less than they did in 1993. In dollars adjusted for inflation, that represents a $44 million decrease in funding over the past six years. (Ironically, a 1993 management study found that, contrary to public perceptions of waste and mismanagement, Grady ran a highly cost-effective ship relative to its peer institutions. Grady spent 40% less in operating expenses per admission than similar providers, and its public subsidy was 48% lower. Grady cost less to operate than two thirds of the hospitals in Atlanta.) Grady also provides care that no one else wants to do, care that is inherently costly. "Medical education is expensive," Casarella says. "Trauma, burns, HIV/AIDS, tuberculosis, neonatal intensive care, and teaching are not profitable ventures." Like other teaching hospitals, Grady is bleeding profusely from sizeable cuts in Medicare reimbursements -- a result of the Balanced Budget Act (BBA) of 1997, which sought to trim health care costs. Teaching hospitals were hardest hit since part of Medicare is earmarked for graduate medical education. Under the BBA, Georgia's teaching hospitals were expected to lose $1.9 billion over five years. While Congress recently modified the act to provide some relief to teaching hospitals, they will still lose. The repercussions of those cuts cannot be taken lightly. Teaching hospitals train 75% of the nation's future physicians and provide a significant portion of hospital care to the uninsured. Medicare cuts have come at the worst possible time. Besides more patients without insurance and shrinking reimbursement from managed care and government payers, Grady faces rising costs of drugs and health care in general. The population is aging, and the number of Georgians with high-cost illnesses is growing. While Grady's financial picture sometimes seems bleak, Emory has historically done its share to pick up the load. In addition to the 98 Emory physicians provided at no cost to the hospital, the presence of hard-working residents and medical students has had major implications on care. Emory physicians provided $24 million last year alone in patient care for which they received little or no compensation. Over the past decade, Emory has provided more than $190 million in uncompensated care. Emory also plows money back into its programs at Grady and its buildings. "I think that Emory has done an extremely good job," says Robert Brown, chairman of the Fulton-DeKalb Hospital Authority. "We've been partners for a long time, and Emory tries very hard to live up to its contract and deliver health care. For the most part, patients are very pleased with the quality of health care they receive at Grady, and I would hate to see where we'd be without having those docs there."

ome teaching hospitals are buckling under the economic pressures of 1990s-style health care, in some cases closing services and even their facilities. Leaders from Emory, Morehouse, and Grady want to ensure that doesn't happen here and have spearheaded aggressive initiatives in recent months to counter public misperceptions and tightening finances. Grady itself has instituted reforms expected to save about $20 million a year, including reducing its workforce by 10%. A new $14 million computer system is expected to address the hospital's billing problems and cut costs by automating tasks such as the pulling of 3,000 patient charts each day to prepare for clinic visits. A one-time, $52.5 million payment to Grady in additional state Medicaid funds will be used for more computer upgrades and to help balance Grady's budget. The unexpected boost to Grady's coffers, however, is a temporary fix, believes Brown. Funding crises will not go away. Emory leadership is working with Grady and Morehouse to find local solutions to the challenges facing the public hospital and to launch an information blitz about Grady successes. They have traveled from county courthouses to the state house and the White House to tell citizens' groups and officials about the economic and social pressures on Grady and other teaching hospitals. In the spirit of collaboration, Grady CEO Edward Renford, Morehouse President Louis Sullivan, Emory Executive Vice President for Health Affairs Michael Johns, and Medical School Dean Thomas Lawley have joined forces to emphasize their continuing strong commitment to keeping Grady healthy. About 50 Emory faculty from all departments in the medical school have spent months on committees examining Grady issues and have developed a strategic plan regarding faculty, clinical services, teaching, research, and government relations for Emory programs based at Grady. Recommendations were recently submitted to Dean Lawley. Certain to be on that list is building more community support for Grady. As chair of the clinical services subcommittee, Casarella is working with Grady to find ways to help guarantee the survival of its programs. "We need more access to philanthropy and support at the state level," he says, noting that some services, such as poison control, burns, and trauma draw patients from all over the state. At least one of 12 patients seen at Grady comes from outside Fulton and DeKalb counties. Atlanta area hospitals should be supporting Grady as well, Casarella says. "For example, Piedmont doesn't have a Level 1 trauma center or a burn center because we have one at Grady. If there were no Grady, patients with no insurance or the underinsured would have to go somewhere else. "Grady is a community resource, not a government liability," he adds. "It's in everyone's best interest to support Grady. Without it, we would have a big hole in health care in this community. Those services are in trouble, and something has to give. Are we going to limit services or provide services? It all comes down to money." Cardiologist Joel Felner chairs the teaching subcommittee of the Grady strategic planning group, which recommended more faculty, more space and computers, and more amenities for students. He would like to develop a teaching fund that could supplement income and encourage more faculty to teach at Grady. On the national level, Congress has restored some funding to teaching hospitals and is looking at new ways to fund medical education, including pulling managed care organizations and insurance companies into the loop. Closer to home, Brown would like to see Grady, Emory, and Morehouse plan strategically together for Grady's future. "Each partner needed to do its own strategic planning first to understand how it could survive and thrive. We all need money, and we're all concerned where the resources will come from. It's time to see how we fit and together come up with a road map to follow. "My view is what's good for the partners is good for Grady," Brown says. "We all have a vested interest. That's why Grady works so well for our patients and for the medical schools. If we didn't have the medical schools, it would cost us far more for high-quality care, and it would be difficult to carry out our mission. But in any relationship, it's good to step back and see if we're still on the right track. Someone once told me that change is certain, but progress is not. You've got to work at it."

From the Director  /  Letters The Grady Crunch The Healing Fields Getting into the Act Moving Forward  /  Noteworthy Grady's Crisis is America's Dig It!

here probably will always be challenging patients at Grady or some political stew boiling there -- because it is a public facility and many taxpayers resent having to pay for it. On the other hand, former Grady residents will continue to garner respect wherever their careers take them -- because they interned at one of the best residency programs in the country. Still, the Grady of today is very different from the Grady of even five or 10 years ago. Faculty, some of whom have spent their careers at Grady, note tremendous progress in terms of physician personnel and facilities. Patients are the beneficiaries. Buckhead shooting victim Charlie Williams can only speak from his own experience. "I wouldn't be alive today if it weren't for the people at Grady," he says, his voice trembling. "They saved my life, and I will be eternally grateful." Marlene Goldman is editor of Momentum.