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    Got Your Back

    Got Your Back
    by Chip Jacobs

    A fresh dish of chicken Parmesan whipped up by Alvaro Morfin bubbles with rich red sauce and even thicker symbolism. The skinny East L.A. homeboy cooked it as an assignment from his doctors, and nailed it, as he has other parts of his crash course on life as a paraplegic - life without the use of his legs.

    Parked in his wheelchair in a classroom-kitchen for the disabled, the young man wants to be clear: He can't envision a career under a poofy chef hat. His intellect is better grabbed by something like computer repairs. His life will be a horizontal one, to be sure, but, at 18 and a rookie patient at Rancho Los Amigos Medical Center, Morfin already knows what it means to beat the odds, and that helps him accept his present condition. He'd been the barrio kid who escaped, the Optimist High School Senior with honor-roll grades and a foster family that had insulated him from gangland temptations. That is, until one summer evening back home, when a rival's bullet found his spine before he found cover.

    "Me, cook?" he deadpans, his dark brown eyes swooping around to his visitors. "No, I'll get a girlfriend for that." Pretty soon, he says, "I plan to go home."

    His physician, Dr. Irene Gilgoff, gladly swallows this bit of chauvinism as if it were Morfin's gooey chicken. Over her career, she's seen 150 juveniles paralyzed by brutal and often random gang warfare that sent bullets and knives zinging their way. "There's a lot of hope for him," she says, smiling. "He recently went to the movies and noticed girls noticing him. That was big. Some go out and close themselves off. There's such rage."

    At Rancho, the L.A. County-run rehab hospital with a national reputation for its treatment of spinal-cord and traumatic brain injuries, the anger, depression, and denial that accompanies these life-changing injuries has to be treated as much as the physical wound. "Why me?" is a question that hangs over these wards.

    Dotted over 220 tranquil acres in the southern L.A. County town of Downey, the Spanish-style buildings here give way to ranks of sagging barracks and shady courtyards. The only modern structure is the tan-colored Jacquelin Perry neurotrauma rehab building. The hospital itself dates back to 1888, when a train offloaded the sick and Rancho operated a full-blown dairy to sustain itself. Back then, patient costs at the county's so-called "poor farm" were $31 a day.

    Now, however, hospital personnel, patients, and activists are fighting for Rancho's survival after the Board of Supervisors voted in January to shut the facility in order to save $60 million a year. The county's health department is sinking under a projected three-year, $709 million budget deficit with no last-minute federal bailouts on the horizon. Only an injunction by a federal judge in April kept the doors open. County executives want a nonprofit group to eventually buy it. Simply put, in a county with teeming emergency rooms and squeezed medical capacity, rehab itself is considered expendable.

    Should Rancho fold, spinal-cord patients would be referred to the four general county hospitals for treatment and rehab, though none of them specializes in this type of injury. Rancho's patients have little voice in the matter: 30 percent are uninsured indigents, the majority of others are on Medicare or Medi-Cal that won't fully cover the price of their treatment. The effects of wiping Rancho off the public-healthcare map are hard to exaggerate. People with devastating injuries and limited means would not only lose access to specialists and surgeons, they would also lose a well-regarded pediatric unit, a pharmacy, a walk-in clinic that sees about 75,000 people a year, a wheelchair-sports program, a bedsore ward, research studies, and therapists who teach everything from strength training to independent living skills.

    It's an ugly scenario. Don Knabe, Rancho's champion on the L.A. County Board of Supervisors, said some former patients would inevitably be "warehoused" in nursing homes or worse if the hospital were shuttered. He believes that any savings realized by the county would be sucked up later as patients fall prey to more complications taxpayers must finance later.

    "Nobody wants to close Rancho," said health department spokesman John Wallace. "We just have too many uninsured in L.A. County."

    Spending a day on this ward will make you rethink your own life.

    Outside the weight room, where wheelchair-hauling biceps are summoned from flab, an adolescent in Oakland Raiders, gear propels himself stomach-down on a gurney, smirking to himself. Or is he staring you down? Nearby, but a world away, a kindergarten-age little girl clutching her doll rolls around in an electric wheelchair with a nurse in tow. In another room, an affable mother with cornrows, unable to walk due to an undiagnosed disease attacking her spine, greets hospital staff with hardened dedication. Ethnically, it's pure L.A.: On the ward, a fireplug Middle Eastern-born surgeon trained in Europe treats kids born in L.A. and in Mexico.

    These rooms will change your definition of courage, revive hope, and embitter you toward the handgun. Here you'll find a new appreciation for the contours of a wheelchair and dampen your appetite for risk, even if it's just on the commute home.

    For the spinal-cord patients, the challenge is to come to love parts of themselves that have become numb to the touch and, sometimes, dead to everything else. They will become adept at manipulating catheters and monitoring kidney infections, and work on legs and butts they can't feel to prevent pressure sores - the common cold of the wheelchair crowd - and learn all about living life in L.A. from the seat of their pants. Rancho is their home and school during a harried adjustment phase, after they are released from trauma units but before the shock of a life diverted wears off.

    The spinal cord - which transmits the brain's lightning-like instructions to breathe, walk, reach, procreate, release waste, and myriad other functions - is still mysterious. It's also not forgiving of abuse.

    Despite the promise of "cures" offered by stem-cell research and other neuro-biological avenues, and the hoopla generated by Christopher Reeve's promise to shake off his quadriplegia (inability to use all four limbs), the central nervous system is proving more complex than some scientists originally thought.

    Spinal-cord injuries afflict 450,000 people in the U.S. today. Of the thousands in Southern California, anyone who doesn't have private insurance is coming to one of the 207 beds here. Should you misjudge your dive, catch a bullet, jack-knife your motorcycle, get thrown from a horse, trip off a roof, blow your acrobatic landing or develop a compromised spinal canal in any other fashion, there's a good bet the rest of your life starts here. On your back.

    Rancho is a place of both healing and reflection, and its legend stands taller than its buildings. Doctors here have trailblazed polio treatments, back-fusion surgeries, and the "halo" traction device that is the gold standard around the world. (One of only 18 designated regional spinal-cord centers in the U.S., Rancho is part of a national study for paraplegics relearning stepping motions via treadmills.) Hospital alumni have achieved seemingly impossible things, too, from quadriplegic skydiving to exquisite mouth-brushed Expressionist art that fetches top dollar.

    As a mirror on the population they serve, the wards here also reflect something less noble: the implacable "drive-by" culture of L.A.'s urban warfare. All over the U.S., the No. 1 cause of spinal injury is car accidents, but not at Rancho. Here it is gunshot wounds.

    Growing up in East L.A., Alvaro Morfin was raised by his mother after she and his dad, a taxi driver, separated. He didn't join a gang for sheer mayhem: He joined it, he said, because, "you don't have nothing else." He was busted on a pot charge and sent to live with a foster family for two years. During that time, he said, he earned straight As. He excelled in history. Cleaned himself up.

    Back home this summer, his willpower wilted. His friend stole $1,000 and persuaded him to come party with the money. The two took off on bikes. They rode to the home of a third friend, and that's when they spotted a car carrying a rival gang. It cruised by menacingly, and Morfin expected a fistfight. Within seconds, someone started firing indiscriminately. He hotfooted it out of there, but a bullet caught him as he scaled a wall. The lead clipped him in the side, hit his spine, and exited from his ribcage. He took a few steps and dropped.

    L.A. County General was the nearest emergency room. He hated it there, unaccustomed to being sick, nervous about being probed, wondering why it took two hours to get pain medication. At Rancho, however, he says he's connected with everybody, janitors included, and he's learned skills he never considered before.

    "I have to push my [old friends] to the side. I can't walk like them. I came to realize that my family members are my real friends," he says, a little choked up. "Now they are letting their feelings out. This probably happened for a reason. I had a lot of chances before, and my luck ran out."

    When he does leave Rancho, luck won't have much to do with it. On a typical Rancho day, he showers, attends occupational therapy, then physical therapy, rests for an hour, attends class, eats lunch, hits weightlifting, practices wheelchair transfers, and then relaxes. To unwind, he fancies PlayStation (Grand Theft Auto is his favorite videogame) and watching the Angels, which he seems to know more about than their skipper, Mike Sciossia.

    Image-conscious administrators discourage talk of Bloods and Crips, of Eastside gangs and "busting caps" inside their wards. Past media coverage of that, they say, has sensationalized that angle, sullying Rancho's mission in the process.

    Physicians are more vocal about it. It's budgetary politics they'd rather not touch. Just like the firefighter who tore his spine in two falling from an all-terrain vehicle in the desert, irony and heartbreak infuse every chart they review, they say.

    Doctors have occasionally treated a gang member left a paraplegic after one shooting, only to see him return to Rancho as a quadriplegic after a second incident.

    About 10 years ago, a young Hispanic paralyzed by a gunshot wound and treated at Rancho was selected to appear on an ABC-TV roundtable special about adolescent violence called Kids in the Crossfire. The show was televised at a Washington, D.C. high school and was attended by about 30 kids and various dignitaries, including Attorney General Janet Reno and actor Chuck Norris. After the program, the former patient promised he wouldn't return to his old gang habits. Nobody told the members of an opposing faction. Within a year of the program, they ran him down on the street and shot him to make sure he was dead.

    "It was a tragic statement about society," said a Rancho doctor, who asked that his name not be used. "It's happened on too numerous an occasion. As a physician, you do the best you can. You encourage your patient to change their life, and you don't let it sour you."

    Over the years, Rancho's safeguards against in-hospital violence have become institutions themselves. Some gang patients are assigned aliases. No tribal colors or paraphernalia are permitted on site. Guards are stationed around the buildings, though a P.R. person said it's mainly to dispense directions. Nonetheless, staffers here know that Saturday is the busiest day for spinal gunshot wounds, and summer is their busiest season.

    "When I came here 20 years ago, there were a few patients with gunshot wounds," Dr. Gilgoff said. "Today we get quite a few. Now there can be multiple paraplegics in the same gang. I've had patients with five, six bullet wounds, and you realize it's because semiautomatic weapons are in play."

    Interestingly, one of Rancho's best innovations actually comes from the street - in the form of sports. Young men from ragged environs, where gang camaraderie is often more comfort than family, need a vent now and then, a way to reconnect with the street. The hospital has an extensive wheelchair athletics program, and a bursting trophy case to prove it.

    There is basketball, baseball, tennis, and hockey, where getting knocked out of your chair can be a badge of honor, and a magazine - Sports N' Spokes - to chronicle it. The athletics, sponsored by a Rancho support group, have two non-negotiable stipulations: to participate, patients must be in school and clean from drugs. "They've gotten more out of sports than anything," Dr. Gilgoff said. "Of the 150 gunshot victims I've treated, only about four of them, I thought, should have been incarcerated. The other 146 were young men in the wrong situation. With the right assistance, they do really well."

    Dr. Michael Scott, a soft-spoken, 40-year-old specialist for the disabled with a Zen-like calm and a Stanford pedigree, is hearing the lowdown during morning rounds from a female medical resident.

    His first patient is a 27-year-old man with multiple gunshot wounds, one that damaged the middle section of his spine. He'd been shot before, but odds are this time he won't amble away from his injury. Originally treated at Martin Luther King Hospital emergency room, he is feverish, glum about his prognosis, and still carrying the bullets that laid him out.

    The next patient, a 35-year-old Hispanic man, was shot three times in June. Unlike his ward-mate, he is expected to walk again. Still, he has problems - heart problems, hepatitis problems, mood problems, and drug problems. The intricate tattoos adorning his chest gyrate as he writhes in bed, where he complains about pain and circulation-aiding socks that have given him rashes.

    Dr. Scott predicts the man will be returning to the same "difficult condition" that put him here once he's well enough to leave. It's a common problem for gunshot victims, one muddled by family issues and lack of money, and not helped by a combatant's new fragility. "They're more vulnerable in a chair," Dr. Scott says. "They're not going back to Beverly Hills."

    Neither is the outlook always so bleak. A smiling, gap-toothed African American man who appears to be in his mid-50s wheels up to the white-coats as they make their way down the squeaky-clean hall. He is wearing a loud blue plaid Fedora and matching shorts, and wants a nail clipper. "My toenails look like tiger claws," he says merrily. Dr. Scott tells him he'll fix him up. "They're great docs," offers the man. "I love them. But the therapists! They're trying to kill me." With that, he rolls off.

    A Latina mother of four is one of the last visited. She was ejected from her van during a May accident because she wasn't wearing a seatbelt. The impact dislocated the most sensitive part of the back - the cervical spine. Upright in a wheelchair, looking content as can be, she reports in Spanish she has nothing negative to report. "She never complains," says resident Sheila Patel. "If there are any problems, I have to find out through my sneaky ways."

    There is nothing sneaky about Rancho's adult physical therapy room, a cavernous, well-lit space with electrical outlets that dangle from the ceiling over a mishmash of low-tech gizmos that attack forlorn muscles and lost coordination. It feels like a gym and sounds like one, too. A patient grunts, and a young female therapist exhorts "Good job!" Sweat beads and repetition grinds on. What a split-second mishap took from many of these people, this room may take months, if ever, to restore.

    It's the visuals that stick. Off in the corner, near the plastic mini American flags, is a burn victim with a bandaged stub where a hand used to be. There is the sheepish-looking car-accident survivor with a chest brace and deep scars seared into his face. He doesn't walk so much as waddle on the beige-and-white floor, but his real problem is his arms. Hyperextension injuries like his jam the nerves controlling the arms, which may never regain full strength and range. A paradox of the limbs results: Some patients post-accident are nimble enough to dribble hackeysacks with their feet yet are unable to wash their face.

    The spine can be mysterious. People can break one of their vertebrae without suffering neurological damage and be fine. Unfortunately, the reverse can be true as well. The worst-off sustain nerve death. The higher up the spine it occurs, the more devastating the result in terms of lost movement, breathing ability, bowel control, and sexual function. Sometimes, only the myelin, the insulation-type coating around the nerve, is damaged, and it - unlike the nerve itself - can mend itself.

    Generally speaking, whatever sensation returns after nine months from the time it was lost is the best it will get.

    "It's a life-changing injury," Dr. Scott says. "They've lost the person they used to be. Everybody handles it differently."

    Some of the most heroic figures at Rancho are children. Nelly Benarbashian, an eight-year-old patient in Rancho's pediatric ward, is sitting under a "SpongeBob SquarePants" blanket as she wolfs down Taco Bell burritos and does coordination-building puzzles with gusto.

    Nelly's journey to Rancho began when she went to the school nurse at Hazelton Elementary in the Valley, complaining of a sore throat. Hours later, at her bus stop, she collapsed into her mother's arms. At an emergency room in Northridge, she labored to breathe, unable to feel her limbs and gasping, "Mommy, I'm dying."

    Doctors concluded she had "transverse myelitis," a puzzling condition where the spinal cord swells up. They stabilized her - inserting a ventilator and getting her situated in a wheelchair - and then transferred her to Rancho because they lacked the expertise to rehab someone in her shape.

    "When she first got here, she had a trachea tube and a [feeding tube]," said Nelly's mom, Maral. "Her left foot could only wiggle. I was scared, but I could see she was in good hands. The therapists got her walking. Without Rancho, I don't know what I would do."

    Nelly can walk. Most who come here won't. To lead them back to a civilization not always as accommodating as those blue handicapped parking spaces, Rancho has set up a "model home" that looks as if it were thought up, in part, by Aldous Huxley. There are gadgets that robotically turn pages, rotate plates, and operate spoons. Counters move up and down on a lift, and showers and sinks are wheelchair-friendly. Patients are brought here to mull their options, even if they can't afford all of them.

    Sam Morris, a blond, guitar-playing paraplegic who traveled to L.A. from Maine, opted for Rancho when a local private hospital twice bungled efforts to heal a nagging pressure wound. These bedsores are caused by the weight of the body rubbing sores into the skin that the patient can't even feel. They can go from a small bruise to open sores the size of a softball.

    Dr. Salah Rubayi, an Iraqi-born surgeon with a rapid-fire tongue, makes it his life's work dealing with these wounds. To him, the idea that a county general hospital would handle these sores is absurd. It can take 12 weeks to recover from an $80,000 bedsore surgery. In typical cases, the wounds are covered with muscle flaps exported from the same area as the wound.

    Morris is in the minority of patients here with private insurance. A friend told him that Dr. Rubayi was "the best in the business," and had trained other doctors how to do the flap surgery.

    "In hindsight, the whole experience at the other hospital was ridiculous," said Morris, 27. "My [first surgeon] confused confidence with arrogance."

    Like the wounds it treats, Rancho is not a place that leaves the system easily. Walk out of here and pray you never wind up with a patient ID on a tingling wrist. But, wind up this way and pray you end up here, if it's still here.

    Doctors must often simultaneously play healer, psychologist, social worker, and hope salesperson. Aspiring MDs are drilled to look beyond garden-variety complications such as embolisms, kidney infections, skin lesions, and spastic limbs that can toss people from their chairs and into combat with the psyche. The patient's past often dictates his coping calculus. People with tight-knit families and established roles as breadwinners, parents, etc. tend to fare better. So do folks with a strong faith in a creator-with-a-gameplan, Another thumbnail rule: The younger the victim, the quicker the acceptance

    Some patients demand their prognosis immediately. Others say hold off. A-type personalities with kinetic determination to reclaim their legs can flame out emotionally. Oddly enough, a quadriplegic on a ventilator can be more at peace than a paraplegic.

    "We've had a few dramatic cases where people with no movement in their legs walk out of here," Dr. Scott explained. "Even for those with a poor prognosis, hope means different things. I've had some [gang] patients say: 'This is the best thing that could have happened to me. If I weren't paralyzed, I'd be dead.'"

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