Spaces of Urban Emergency Care in Code Black

The American documentary Code Black (U.S.A. 2013) centres on the emergency room – the ER – of the Los Angeles County hospital which is located in central L.A. The film was shot between 2008 and 2012 – the year when President Barack Obama’s healthcare reform, known as Obamacare, became law in the United States.[1] The specific emergency department in the documentary has negotiated the question of hands-on medical care in its city, county, and even nation, since the inception of American emergency medicine fifty years ago.[2] Code Black opens up perspectives for thinking about bodily illness in relation to the ills of both urban space and the U.S. healthcare system.
Picture

When we think about the body, health, and the city, a common association is the metaphor which modernist architectural thinkers such as Le Corbusier promoted. As architectural historian Eva Eylers points out, they compared the city itself to a dynamic living body. They used medical language of health and sickness to qualify the efficiency of that urban body.[3] In this conceptual framework, the inner-city ER can operate as an essential organ of the city, helping to keep the urban body alive and healthy, although such a terminology might be offensive to people experiencing pain and even loss in the emergency room. The language reappearing in the film and the academic literature is that of the ER or the hospital as an urban safety net.[4]

Code Black represents the Los Angeles ER as a safety net because this is a county hospital. As such, it is one of very few hospitals in the country that does not reject any patients, regardless of whether they possess health insurance or not. In the film, many poor, working-class, and uninsured people have no other option to obtain even non-emergency treatment than by coming to the emergency department. Statistical data confirms that most patients who are treated in this hospital are poverty-stricken and have no health insurance. The majority are Latino and were not born in the United States.[5] One of the film’s doctors contends that their clientele is related to the hospital’s location within the city. In the hospital’s neighbourhood, the district of Boyle Heights, more than 90 per cent of the population is Latino while the average income and higher-education rates are below that of L.A. as a whole.[6] A survey of the primary food purchasers in East L.A. and Boyle Heights’ households revealed that 40 per cent of them had no health insurance.[7] Prognoses for Obamacare suggest that significantly more legal immigrants will have access to health insurance while the situation for illegal immigrants will remain unchanged.[8] Yet unlike the majority of its patients, the doctors speaking in the film are White, Asian, or Arabic. Merely one Hispanic nurse is interviewed. This suggests that there is not only a dividing line between insured and uninsured patients but also between who can be a doctor and who is a patient in this city.

The documentary shows how the ER represents the agglomerated detriment of the underprivileged population in the city of L.A.. The title Code Black epitomizes this challenge of an immense influx of patients with emergency and non-emergency needs into a confined space. As one doctor puts it, Code Black signals the state when so many patients pour in “that it feels like the place is going to blow up at the seams.” The L.A. County ER spends half its time in Code Black when the safety net is at breaking point.

The film’s representation also evokes the frontline of a war zone, doubling the language of Public Health Scholars John McDonough, Michael Cousineau, and Robert Tranquada.[9] Code Black shows a chaotic space full of people suffering and bleeding. People are in pain elsewhere in the city but in the ER everything can become a matter of life and death. The practitioners are at war with mortality and time. Even if it is not an immediately life-threatening condition, emergency specialists have to diagnose it in time and to refer the patient to the right hospital area before it does become life-threatening.[10] The ER embodies urgency, if not franticness. The documentary’s look at the ER as a frontline thus offers an intensified representation of the city as a whole: of its pain and its rush.

Like a snapshot in time, the emergency room displays the acute sufferings of a city’s population. In a single space, it makes the city’s emergency needs palpable. The ER collapses aching bodies in time and space, more than a filmic montage of different people across the city ever could. The ER resembles an overcrowded public plaza full of people in life-threatening conditions. They lie exposed or are separated by curtains at best. There is more at stake behind these curtains than in the other spots of urban semi-privacy, such as department stores or cinemas. In the ER, the velocity of city life, much-invoked by writers such as sociologist Georg Simmel, is not about gaining time, money, or entertainment but your life.[11] As one staff member summarises the temporality of this urban hotspot: “[N]o matter how many times you’ve […] done a chest tube under casual circumstances, it’s very different from placing a chest tube that needs to be placed in thirty seconds.”
Picture

If we return to the modernist language of the city as a living body, the question arises: what about the hospital building’s own skin and skeleton? Is the ER architecturally “healthy” or ailing? Code Black witnesses the hospital staff’s transition from the old building established in 1933 to a new adjacent construction. The former was built to cope with the increase in the city’s size. Back then, its Art-Deco design was categorised as “step-back modern monumental.” A reinforced concrete exterior covers a steel skeleton. The hospital’s massive body and surface were intended to communicate strength.[12] An earthquake in 1994 caused severe damage to it and propelled plans for a new site.[13] In the case of human casualties in a future earthquake, the ER would be key for helping the injured, and yet it has itself become a casualty of natural disaster. Ideas for the building’s residential or commercial repurposing circulate,[14] yet it is no longer safe for curing patients.
Picture

Why does it matter to study this emergency room through the lens of film? Medicine and controversy about it have long been mediated to people through television and the press.[15] The media shape our ideas of what medical care does and where it happens. In the 1970s when emergency care gained momentum, the TV fiction series Emergency! engaged with the newly established ambulances and doctors in L.A.[16] The façade of the old L.A. County building has served as the exterior appearance of the TV show General Hospital.[17] The documentary Code Black has received its own television drama spin-off with an eponymous title. The TV Code Black, however, is set in a fictitious hospital rather than the real L.A. County facility.[18] No comparable policy debate in America has seen media coverage as widespread as Obamacare, the political context of the documentary Code Black.[19] The film participates in the tradition of opinion-shaping through the media at a critical point in medical history.

Frederick Wiseman is the key name in the field of documentaries about institutions of care, especially medical care.[20] His film Titicut Follies (1967), about the Bridgewater State Prison for the Criminally Insane in Massachusetts, is the most famous but Wiseman also shot a film simply called Hospital (1970). Code Black raises the same ethical question of whether the camera is a further form of the violation of patients that are not only hurt but also vulnerable to exposure in their sensitive state..[21] Yet this documentary differs from Wiseman’s work in that it is not a third-party filmmaker who seeks to observe what happens in the institution without interviews or voice-over narration..[22] Code Black is made by one of the doctors themselves and takes on the perspective of the ER staff. According to the film publicity, the documentary is intended as a “first-person reflection” on working at the L.A. County Hospital..[23]

This approach puts the doctors in a position of power. They address the audience directly in the interviews about their motivations. Their actions organise the film. In the old building, the viewers face a site of seeming chaos. Only the doctors know how to give structure to this space. The viewers become students of these specialists as much as the trainees huddling to observe this bustle in the emergency room from above. Their gaze turns the life-saving activities in America’s biggest teaching hospital into a performance.[24] After the move to the new ER, the dissatisfied doctors reorganise its design, moving bed and waiting sections around. The doctors’ self-portrayal sometimes aggrandizes their roles, mirroring the murals in the old hospital lobby. The frescos by Hugo Ballin depict ancient Greek scientists and medical demigods.[25] According to historian Caroline Luce, the murals unmistakably link the awe-inspiring Greek healers to the practitioners at L.A. County, underlining the latter’s significance.[26] Yet the importance of medical staff is also stressed in architectural praxis: The request of more staff participation in the design of emergency spaces has been part of debates about improving ER efficiency.[27] The documentary, then, evokes the struggle of emergency medicine specialists. While their depiction is sometimes controversial, they work to relieve the Code Black that national and urban conditions cause.
Picture

– Elisa Jochum – May 2016

Notes

[1] The act, officially titled “Patient Protection and Affordable Care Act,” will be fully in effect by 2022 (Obamacare Facts. http://obamacarefacts.com).
[2] Robert E. Suter. “Emergency Medicine in the United States: A Systemic Review.” World Journal of Emergency Medicine, 3(1), 5-10.
[3] Eva Eylers. 2011. Hygiene and Health in Modern Urban Planning: The Sanatorium and its Role within the Modernist Movement. PhD Thesis. Architectural Association, London. “Conclusion,” Section 5.4.
[4] Michael R. Cousineau and Robert Tranquada. “150 Years of Service by Los Angeles County Hospitals.” American Journal of Public Health, 97(4), 606-615 (606); John E. McDonough. 2011. Inside National Health Reform. Berkeley and Los Angeles: University of California Press, 24, 164.
[5] Cousineau and Tranquada, “150 Years,” 606.
[6] “Mapping L.A.” Los Angeles Times. http://maps.latimes.com/neighborhoods/.
[7] Héctor E. Alcalá et al. 2016. “Access to and Use of Health Care Services Among Latinos in East Los Angeles and Boyle Heights.” Family & Community Health, 39(1), 62-71 (66).
[8] McDonough, Reform, 134. The film, sometimes problematically, emphasizes that low-paid, non-immigrant patients equally seek help in the ER.
[9] See n. 4 in this paper.
[10] Suter, “Review,” 6.
[11] Georg Simmel. “The Metropolis and Mental Life.” In The Blackwell City Reader, edited by Gary
Bridge and Sophie Watson. Oxford: Blackwell, 2002.

[12] PCR Services Corporation. October 2008. “Intensive Historic Resources Survey: Adelante Eastside Redevelopment Area, Los Angeles, California,” 85-86, 102. https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=10&cad=rja&uact=8&ved=0ahUKEwi7ytHHmc3JAhVFoQ4KHb4xBpMQFghlMAk&url=http%3A%2F%2Fwww.preservation.lacity.org%2Ffiles%2FAdelante%2520Draft%2520Report%2520revised%2520FINAL_print_0.pdf&usg=AFQjCNF8pjMahnYfnKrThH6uPl7Zlp6M7A&bvm=bv.109332125,d.dmo.

[13] Cousineau and Tranquada, “150 Years,” 614.
[14] John Hisserich. “County General Hospital’s Building Deserves New Life.” LA Times, 1 May 2004. http://articles.latimes.com/2004/may/01/news/vo-hisserich1.
[15] See also Suter, “Review,” 8.
[16] Suter, “Review,” 7. The show ran from 1972 to 1979.
[17] Hisserich, “New Life.”
[18] Jack O’Keeffe. “Is Angels Memorial A Real Hospital? ‘Code Black’ Has Multiple Sources of Inspiration.” Bustle.com, 30 September 2015. http://www.bustle.com/articles/113492-is-angels-memorial-a-real-hospital-code-black-has-multiple-sources-of-inspiration.
[19] McDonough, Reform, 306-7.
[20] Barry Keith Grant. 2006. Five Films by Frederick Wiseman. Berkeley and London: University of California Press, 3-15.
[21] For ethics in Wiseman, see Therese Jones. 2015. “another kind of dnr.” In The Picture of Health: Medical Ethics and the Movies, edited by Henri Colt, Silvia Quadrelli, and Friedman Lester. New York: Oxford University Press, 90-95.
[22] For Wiseman’s technique, see Grant, Five Films, 3-5.
[24] HOK. “A New Vision for Providing Healthcare in Public Hospitals.” http://www.hok.com/design/type/healthcare/los-angeles-county-university-of-southern-california-medical-center/.
[25] L.A. County Arts. “County Collection: LAC+USC Medical Center General Hospital.” http://www.lacountyarts.org/civicart/projectdetails/id/113.
[26] Caroline Luce. “Hugo Ballin’s Los Angeles.” Scalar, 22 August 2014. http://scalar.usc.edu/hc/hugo-ballins-los-angeles/reluctant-modernist.
[27] Huddy, Jon. 2002. Emergency Department Design: A Practical Guide to Planning for the Future. American College of Emergency Physicians, xiii.