The Bronx Ink

On a November afternoon, a third year student at New York College of Osteopathic Medicine, showed up at St. Barnabas Hospital in her blue scrubs. Her mission was to treat the first trauma case in her career. The man on the stretcher had been shot in the jaw with a handgun and needed a surgical airway so he would not choke.

Marisa Wolff put on a pair of latex gloves, found the small hollow space that marks the airway on the patient’s neck and inserted a needle into the patient’s throat. A doctor instructed the 25-year-old to adjust the angle of her needle. Once corrected, she inserted a guide wire into the puncture hole and cut a horizontal incision on the man’s neck with a scalpel. Then she inserted a trachea into the incision until it reached the patient’s airway.

Success. The blockage inside his airway spurted out. Now the doctor-in-training had more time to deal with the man’s injuries without worrying about him suffocating. A second medical student attached an airbag to the new airway and kept pumping in even beats.

“Beautiful!” said Ann Marie McDonald, the trauma program coordinator at St. Barnabas Hospital.

Suddenly, a lab technician pulled the surgical airway out of the patient’s neck and tore off part of his skin. The patient’s red flesh and detailed anatomy was exposed. The technician calmly put another piece of skin on the patient’s neck and asked another student to start the process all over again.

The students were able to tear off his skin as many times as they wanted. They could even flip his skin up during the process to see whether the needle was in the right place. The man in trauma was a high-tech, ultra-realistic mannequin, an indispensable element in the evolving medical simulation education.

For years, the military and aviation industries have used simulation to select and train their personnel. Medicine, on the other hand, has adhered to the age-old practice of observing experienced doctors and learning from real patients, a practice that limits training possibilities.

In the past 10 years, as mannequin costs have fallen, and as a patient safety movement has emerged, simulation education has begun to take root in medical schools and hospitals across the country. According to the Society for Simulation in Healthcare, 120 hospitals in the U.S. currently have simulation labs. That estimate may be low, because some hospitals have small labs with one or two mannequins, and these did not become a member of the society.

At St. Barnabas Hospital in the East Tremont section of the Bronx, mannequins help doctors-in-training avoid causing unnecessary harm to patients, and help end some of the cruel practices used by some hospitals on animas in labs.

For medical educators, the mannequins provide a great opportunity for students to “practice the skills before seeing the patients,” said Dr. Anthony Errichetti, chief of virtual medicine at New York College of Osteopathic Medicine. “Medical education shifted from knowledge-based practice to competency-based practice.”

Skeptics point out that the mannequins are only rubber dolls, and they cannot simulate real situations. As of yet, there is no longitudinal study that examines whether students can recall the simulated scene and when faced with real life trauma.

This leads to the most debated question in simulation education to date: Do simulations actually produce better doctors? Simulation may provide a good indication of a student’s current skills. But does the training have lasting results later?

So far, the medical students at St. Barnabas Hospital are optimistic: “The simulation lab is effective in building confidence and skills that will be useful for when I’m a first year resident and actually performing those procedures on patients,” said Wolff.

Dr. Errichetti said he has seen a complete turn around in the acceptance of simulation in the past 10 years. He pointed out the problems in the health care system today are shorter hospital stays and inadequate insurance, so patients may not be around when a doctor wants to teach a particular class. Mannequins can give educators more opportunities to teach.

That is why McDonald was able to cram as many types of classes as she could into her tight teaching schedule. She did not need to check with the clinic to see what kinds of patient were available.

McDonald put “TraumaMan” on the gurney, and let Wolff try her best. The “TraumaMan” was made by the SimuLab Corporation, a major medical simulator producer based in Seattle, WA. The mannequin only resembles a man’s torso with replaceable skin. An air compressor is connected to the mannequin and a plastic lung inside breathes in and out. Wolff could practice trauma life support skills such as chest tube and diagnostic peritoneal lavage (DPL) on the mannequin.

Dr. Owen Kieran, a surgical resident at St. Barnabas Hospital, demonstrated DPL to the students. It is a common procedure in trauma care to treat intra-abdominal bleeding. When he cut a midline incision on the mannequin’s lower belly, it started to bleed. In fact, the blood came from a tube of red ink buried inside the mannequin.

The bleeding showed that the procedure was done correctly. Dr. Kieran then drained the blood through a tube connected to the incision.

Wolff was satisfied with her first trauma class. “It is not likely that I’d ever get the chance to place a chest tube or a trachea in a real patient as a third year student,” said Wolff, 25. “It is exciting to be in the simulation lab because as a student you are able to actually use the equipment and do the procedure on your own. The hands-on learning is much more effective and exciting than just watching.”

The lesson was videotaped by a lab manager, so doctors and students could critique her performance.

Sometimes if the curriculum allows, hired professional actors are hired to play distraught family members of the patient. Students practice as a team saving a person’s life and consoling loved ones. In this case, it is a hybrid simulation.

“It’s like driving a car,” said Lynn Kemp, the assistant vice president of surgical services at St. Barnabas Hospital who started the simulation lab with only one mannequin in 2006. “You could read a manual about driving a car, you could sit in a car, but when you actually drive a car, you don’t really know how to do things.”

But her inspiration came nearly 15 years ago, when she attended an air medical conference that trains flight nurses and paramedics in Salt Lake City, Ut. There a mobile simulation truck from the Alberta Shock Trauma Air Rescue Society (STARS) in Canada was on display, the first mobile simulation program in North America.

Kemp was led into the truck, and found herself inside a simulated helicopter, with a mannequin in trauma. The mobile simulation team debriefed them, telling them what they could improve. Even though Kemp was already an experienced flight nurse by that time, she was impressed. “That was a good way to teach me,” Kemp said years later. “It made an imprint on my mind.”

When Kemp arrived at St. Barnabas Hospital ten years ago as the trauma center manager, she was also involved in teaching classes for the American Heart Association at the hospital on advanced cardiac and pediatric life support, the two classes doctors need for their credentials.

“People would sit around and talk about things a lot, but they wouldn’t do it,” Kemp said about the classes. “That bothered me.”

So Kemp wrote a small grant to the Nurse’s Union and bought the first mannequin for $35,000 from Laerdal Company, a medical simulator producer based in Norway. In 2007, the New York College of Osteopathic Medicine began collaborating with St. Barnabas Hospital on the simulation lab, splitting the annual $550,000 costs.

Most hospitals cannot generate revenue from running simulation labs, but St. Barnabas Hospital is hoping to buck that trend by charging $35 for each of its cardiac and pediatric classes. Whatever is left is then spent on the lab.

Hospital employees believe the cost is well justified. “You don’t put a price tag on human life,” said Robert Scott Bostwick, the simulation lab manager with 30-year experience in emergency medicine.

More and more hospitals in the country are building new simulation labs; the New York City Health and Hospitals Corporation just built a 10,000 square-foot training facility at Jacobi Medical Center in the Bronx this year at a cost of $10 million. Banner Health, a nonprofit system, spent $12 million last year to build a 55,000-square-foot simulation training center in Arizona, the largest of its kind in the United States.

However, federal support is still lagging. A bill before the House to unlock $50 million in federal dollars for more medical simulation is still stalled in committee.

Simulation education may have its limitations, but it does help to solve some of the ethical dilemmas the medical profession faces.

In another trauma life support class at St. Barnabas Hospital, the mannequin was a 25-year-old backseat passenger who was ejected from a car in an accident. She lay on the gurney moaning, “I’m not feeling very well.” Every time she breathed there was a harsh vibrating noise. On the mannequin’s wrist and elbow there is a patch of extra soft plastic, so that students could feel the pulse or insert an intravenous drip.

McDonald explained the scenario to the students: “She wasn’t wearing the seat belt. Her heart rate is 130, and her blood pressure is 98/60.” The numerical indicators were shown on the monitor, but for the rest of the scene, the students had to use a little imagination. “She had multiple face lacerations and bruising on her abdomen. She had pain when we rocked her pelvis,” McDonald continued.

After learning the crisis, the trauma team had to decide quickly what should be done first. Remi Drozd, a visiting resident who was the team leader that day, recognized that the patient had to be intubated first.

Wolff held a laryngoscope in her hand and cracked open the patient’s jaw. She exerted a lot of force to push the laryngoscope so that she could open the patient’s throat wide enough and insert a tube.

“If you do that, you can just take out a checkbook and write a check,” Bostwick said, correcting the way Wolff was trying to intubate the patient. A laryngoscope, when used in the correct way, can open a patient’s throat for intubation without hurting him or her. But when used in the wrong way, it could damage the patient’s gum and teeth. Even though a basic procedure in emergency medicine, using the laryngoscope takes a lot of practice and muscle memory.

“If your arm doesn’t hurt from pulling the laryngoscope, you are probably not doing it right,” said Bostwick. “Your comfort is not important; your patient’s is.”

Mannequins provide an environment in which students can practice without worrying about the consequences. Once, a student broke five of the mannequin’s teeth while using the laryngoscope.

Before the mannequins came along, students learning pediatric life support had to practice surgical airways on cats, because a cat’s airway is the most similar to a baby’s.

Hospitals used to maintain animal labs to fulfill those needs. The animals were all anesthetized during the surgical procedures, but they all nonetheless suffered injuries. Now with SimBaby, a mannequin represents a newborn baby produced by Laerdal Company, hospitals no longer need cats to teach pediatric classes.

Right now mannequins range from anatomical models of a particular body part such as the brain and eyeball to full-scale SimMan that represents an adult male. When connected to computers, the doctor can adjust the SimMan’s heart rate and blood pressure to better simulate the real life situation in which the patient’s condition deteriorates.

Modern mannequin production in the world began in the 1960s, according to a paper published in the Quality and Safety in Health Care journal by Dr. Jeffrey B. Cooper, a professor of anesthesia at Harvard Medical School. But it was not until in 1999 when the Institute of Medicine, an independent group that advises the government on health issues, published a report about patient safety that hospitals began using mannequins widely.

The report, “To Err Is Human”, initiated a patient safety movement in the United States. According to the report, at least 44,000 people, and perhaps as many as 98,000 people, died in hospitals each year as a result of medical errors that could have been prevented. Even using the lower estimate, preventable medical errors in hospitals still exceed attributable deaths to such feared threats as motor vehicle accidents, breast cancer and AIDS.

According to Dr. Errichetti, the United States is now the world’s biggest mannequin user. Many of the European countries use mannequins as well. But for the rest of the world, mannequin use is sporadic. Some wealthy Middle Eastern countries may have the money to buy mannequins, but they lack the experienced faculty that could explain the scenario and teach how to tackle the unexpected.

“Every patient’s encounter is unique, you can’t recreate every single thing, because you don’t know how a patient is going to respond,” said McDonald. “But what we can do is to prepare our providers to be ready for that.”

Roberto Pareja waits for work on a chilly October morning. Photo: Yiting Sun

At 7:15 on a chilly October morning, a 33-year-old Mexican immigrant leaned against the shuttered door of Kennedy Fried Chicken, a worn-out backpack filled with wrenches and tape lay next to his feet.

Roberto Pareja positioned himself across the street from the Benjamin Moore paint store in East Tremont as he had done nearly every day for years, hoping one of the contractors leaving the store would hire him.

Two hours later it began to rain, and the father of two ducked under a deli storefront. None of the customers needed his help that day, nor the help of 20 other day laborers waiting with him. But he did not want to leave.

For Pareja, no work meant worrying about his $960 monthly rent, food for the six people in his family, and dolls for his young girls.

Pareja is one of almost 100 day laborers who have congregated for years on the corner of East 180th Street and Third Avenue. On a nice sunny day, almost all of them will gather, but on this rainy morning, only 20 tried their luck. The New York Immigration Coalition estimates there are about 10,000 day laborers in the city. Some of them have been in the underground labor pool for years. Others are newcomers driven here by the recession.

“There is less work this year than last year,” said Corinne Beth, an immigration lawyer that supports day laborers on behalf of the Westchester Hispanic Coalition, a not-for-profit organization. She added that with the group of day laborers she helps in Portchester, if five out of the 30 men get work in a given week, they are lucky.

Even though the National Bureau of Economic Research declared an official end to the recession in September, the day laborers’ predicament is far from over.

“The recession hits day laborers harder than it does people with full-time work,” said Lynn Svensson, director of the Day Laborer Research Institute. Of the estimated 260,000 individuals working as day laborers in the United States, approximately 75 percent are undocumented immigrants, according to “On the Corner,” a study by the University of California at Los Angeles in 2006. The study found that their immigration status and the lack of English skills are the biggest impediments in finding more stable work.

Since the recession began in December 2007, the number of day laborers at this spot has increased, said Bob Ascat, the paint store manager who has seen them for the last decade. Local contractors drive by the corner looking for workers to assist in construction work. For a worker who does not have a business relationship with a contractor, he relies on customers from the paint store who have home projects to complete.

But the work available for them has decreased as more people compete for a shrinking pie. In 2009, the Pew Hispanic Center, a nonpartisan research organization, reported that the unemployment rate for foreign-born Hispanics in the fourth quarter of 2008 was 8 percent, a 3-point increase from the same period in 2007.

Although immigration status was not recorded for the report, the center estimates that undocumented immigrants account for about five percent of the U.S. labor force. In certain industries such as construction, which is the primary industry for day laborers, undocumented immigrants account for 12 percent of employment. Most undocumented immigrants are from Latin American countries, with 55 percent coming from Mexico.

“Life is difficult,” said Pareja, who emigrated to the United States from Mexico eight years ago. “There are times when you don’t find work, and even more now that things have gotten harder.”

His family is still suffering from the recession’s consequences. A month ago his wife started selling Mexican tamales by the dozen to acquaintances with the hope of earning the family an additional $150 a week.

When there is no work, Pareja supports his family with savings and relies on his father-in-law, who assists him in some projects, to pick up half of the rent when necessary. Every single workday counts for him because coworkers may learn of his skills and recommend him for contract jobs.

A week after that chilly Monday morning, Pareja found a contract job with the help of a friend he met through work. He would earn $450 a week for six weeks remodeling apartments on 1st Ave near 60th St in Manhattan.

But work comes sporadically for Pareja, who may have a week with only two to three days of work, other weeks nothing. “No one can survive on that,” said Svensson. “ Bosses are paying less now, their wages have actually gone down.”

There are also day laborers in the underground economy who may not get paid for days and even weeks of work when contractors use a person’s immigration status as an excuse to withhold payment.

“They threaten you with sending immigration, and you can’t turn somewhere else for help,” he said.

“Day laborers are often the targets of exploitation,” Svensson added. “They are often paid less than they were promised, or not paid at all for their work, and told by employers that if they call the police that they will be turned in to immigration.”

What makes the situation worse is day laborers often do not know enough about their rights. “They have no sense of empowerment,” said Beth.

Other day laborers in this Bronx intersection have also been cheated out of money by dishonest contractors. According to the UCLA study, 54 percent of day laborers in the Eastern United States have not been paid for their work.

In a more recent study released this past summer, the Seton Hall University School of Law surveyed 26 day laborers (approximately half of the workers) at the corner of Stockton Street and Wilson Avenue in Newark. Ninety-six percent of day laborers at this East Ward intersection, located less than 40 minutes from the Bronx, reported instances of nonpayment or underpayment from contractors.  These regional and local reports exceed the 48 percent reported nationally for day laborers who have lost wages, and in Newark the majority of them have lost $800 or more.

“They have accepted wage theft as a cost of doing business,” said Bryan Lonagan, a Seton Hall law professor who oversaw the Newark study. “There really isn’t an effective avenue for them right now to bring a wage complaint.”

Bronx day laborer Jose Balquiera understands the frustration of losing $800 of wages.  After only a few months in New York City, the 28-year-old lost two weeks and $1,000 when a contractor did not pay him for remodeling an apartment. The person who hired him dismissed any discussion of payment from the beginning, simply saying he would pay him on Saturday, then telling him another day.

“Sometimes they don’t show their face,” Balquiera said, scanning the street for cars pulling up. “They give you their numbers but they don’t answer to not pay you.”

The Toluca, Mexico native has been in the United States for a year, and feels overwhelmed by the language barrier, which often causes day laborers even more fear to enforce their rights. “It feels really bad,” said Balquiera in Spanish of not being able to defend himself when he encounters contractors that do not want to pay. “Imagine, they talk to you in English and you don’t understand.”

Wage theft in New York City amounts to an estimated $1 billion across all low-wage industries, according to the National Employment Law Project. Passed last month in legislature, the New York Wage Theft Prevention Act calls for stricter penalties and the enforcement of laws meant to protect workers.

Although this provides an added resource for workers, the Newark study suggests day laborers are vulnerable to wage theft because they have limited English skills and they fear complaining to the authorities due to their immigration status.

“Most of them expressed fear of the police reporting them to immigration and customs enforcement for possible removal,” Lonagan said of the lack of police involvement.

Lonagan added that if a day laborer submitted a dispute through small claims court, it could take almost a year before the claim was just recognized. The day laborers choose then to seek work to make up the lost money instead of spending days in the process.

Although Bronx day laborers may not seek formal assistance in cases of labor abuse, these workers look out for each other even as they compete for jobs. Demaso Genis said he makes an effort to point out crooked contractors who have stiffed him in the past when they return to the intersection. He wants to make sure others are not exploited and left at construction sites without payment.

“There’s no way to reclaim that money,” he said. “No one is interested in lending us a hand.”

The day laborers support each other in whatever possible ways. Photo: Yiting Sun

Genis said even when contractors actually do pay, every day there is someone different who promises a specific salary only to actually pay less.

The 47-year-old left his wife and two children in Morelos, Mexico more than a decade ago. He said even when the recession might have ended for others, supporting the family is still a struggle for him.

“There are weeks that you can’t even send $50,” he said of this variable work that pays him an average of $80 a day when there’s work.

Remittances to Mexico dropped 20.4 percent from February 2008 to February 2010, according to BBVA Research, a global finance company. After 17 consecutive months of falling remittances, April offered an increase of less then a percentage point. Although remittances continued to increase at a small rate, the improvement slowed in September, and it’s not expected to reach more than two points based on the outlook of the United States economy.

As a result, these day laborers live on as little as possible to send as much money as they can to families in their native countries. Balquiera lives with 11 other men in a four-bedroom apartment, where his portion of the monthly rent is $120.

“When I do find work, I send money; when I don’t…” he stopped and shrugged off the rest of the answer. “It’s difficult here.”

Before the recession hit, day laborers had less competition and more work. With more money to send home, their families invested the money they received in education, businesses and new houses.

After almost 20 years of sending money to his wife and six children in his native Acapulco, Mexico, Cornelio Hernandez, 63, now has his own house in Mexico and is currently putting his youngest daughter through college.

“Everything is done with sacrifice,” he said of not seeing his family for almost two decades. “We come to this country to suffer, to become something.”

Hernandez’s time in New York City has paid off. He is solicited by contractors throughout the city because of the reputation of his work. For the past few summers, a real estate agent has hired Hernandez to work in City Island for the upward sum of $110 a day to remodel apartments. His tired eyes light up and his smile widens when he talks about his children’s professional pursuits.

This winter Hernandez is prepared for more than the harsh winter. According to Svensson, there is less work for day laborers from November to the end of February. Contractors focus mostly on indoor projects such as painting and installing floors.

Pareja said his current contract job is helping him save for those winter months. He still hopes this job could lead to the next so he does not have to spend hours waiting for work in the snow. “We try to do things as best as possible,” he said with his one-year-old daughter on his lap in his home. “If your boss likes your work, he can give you more work.”

A Bronx teen preparing for college was shot and killed in front of his home Saturday over a dustup that started the day before, police and family said. (NY Daily News)

Dozens of Bronx residents are in emergency housing after the city ordered their building evacuated Saturday. (NY1)

The Syracuse Orangemen are coming to town for the first Bronx bowl game in almost five decades. (NY1)

A baby aardvark born in the Bronx was nearly doomed by a neglectful mother – and saved by determined zookeepers who nursed him around the clock. (NY Daily News)

Progress is finally coming to a small street in the Riverdale section of the Bronx – if you consider sidewalks progress.

The city is demanding that homeowners on a little-used, dead-end street make expensive improvements, CBS 2′s John Slattery reports. (CBS)

Parishoners at a Bronx Catholic church could lose their school – and possibly their place of worship.

St. Augustine School in Morrisania is one of six Bronx parochial schools facing closure by the New York Archdiocese because of dwindling enrollment and mounting deficits. (NY Daily News)