Hospital’s Dropout Raises Questions

Many health authorities agree that the county has too many trauma centers already. The fewer the trauma centers, the more patients available to each center to keep its revenues and physician skills high.

So when San Diego County’s trauma care system began last spring, the county scrutinized prospective trauma centers closely and limited the number it would permit. In April, the board of supervisors designated six centers--at UC San Diego Medical Center and Grossmont, Mercy, Sharp, Children’s and Scripps Memorial-La Jolla hospitals.

And last month, after two North County hospitals waged a bitter fight to be allowed the prestige of operating a trauma center of their own, the board approved Palomar Hospital as a seventh trauma center. And Tri-City sued to become the eighth.

The county’s new trauma care system--under which severely injured patients are routed to trauma centers for top-flight emergency care instead of ordinary emergency rooms--was having its growing pains. But they peaked this week, when Grossmont--under fire because of a death related to its trauma center--abruptly quit the system.

A key cause of Grossmont’s withdrawal was its failure to speed up surgeons’ response time to emergency calls. The hospital was not willing to pay trauma surgeons extra money to stay for 24-hour shifts; county officials contended they must provide 24-hour coverage to meet county trauma center requirements.

In early December, county officials complained to Grossmont about its response. And then on Dec. 25, Nickey Trevino, a Navy petty officer, with a gunshot wound, died.

Trevino had waited in Grossmont’s trauma unit for 36 minutes while no trauma surgeon was available. He was “stabilized” at Grossmont and then transferred to UCSD Medical Center where, after surgery, he died. His death has led to investigations of Grossmont and its trauma unit by state and county health officials.

According to the hospital and county’s officials accounts, paramedics contacted the hospital at 12:13 p.m. from the scene in El Cajon where Trevino had been shot.

“Code Trauma” was declared at 12:22 p.m. based on information the paramedics transmitted. Two minutes later the emergency room doctor telephoned the trauma surgeon and told him Trevino’s condition. The trauma surgeon said he was unavailable and directed that Trevino be taken to UCSD Medical Center.

At 12:26, the emergency room doctor contacted the Life Flight helicopter at UCSD. The ambulance carrying Trevino from the shooting scene arrived at Grossmont at 12:29 p.m.

Investigation Triggered

The Life Flight helicopter landed at Grossmont at 12:40 p.m. and left for UCSD with the patient 25 minutes later. It arrived at UCSD at 1:12 p.m.--almost exactly an hour after the ambulance first arrived at the scene of the shooting scene. Trevino died at 2:44 p.m.

Trevino’s death triggered investigations by the state Department of Health Services and state Board of Medical Quality Assurance. The BMQA joined the investigation Thursday, according to the BMQA’s special investigator in San Diego, George Everard, cqwho declined to give details but confirmed that the targets of the investigation would be at least one Grossmont physician.

In the wake of the investigations, negative publicity about the Trevino death and the county’s continuing demand that Grossmont provide 24-hour service by trauma surgeons, Grossmont on Thursday abruptly withdrew from the trauma system.

It had been planning to do so anyway--but not until next Tuesday. On Dec. 18, the Grossmont board of directors had voted to leave the trauma system effective Jan. 8, in large part out of financial concerns. “The system was so expensive,” Ron Dahlgren, Grossmont Hospital administrator, explained last week. “It just was not financially feasible.”

But after Trevino’s death and a conversation Thursday between Dahlgren and county health services director James Forde, Grossmont withdrew early. Forde had told Dahlgren that a trauma surgeon had to be present 24 hours a day at the trauma center, in order to comply with county rules. Dahlgren said he couldn’t promise to do that and finally asked that his hospital be removed from the county trauma system by 4 p.m. Thursday.

The official order suspending Grossmont was issued by EMS director Gail Cooper. It is expected to be ratified by the Board of Supervisors Tuesday.

One reason Grossmont’s experience does not appear to have daunted other trauma centers, or would-be trauma centers around the county is that its trauma center was considerably different from other hospitals’ trauma centers.

Unlike the other trauma centers, Grossmont did not have trauma surgeons who serve 24-hour shifts “in-house”--that is, either in the hospital or within a few minutes’ walking distance. But the other trauma centers, except for Scripps, pay their doctors to serve overtime as in-house trauma surgeons.

In addition, Sharp Hospital has spared its doctors the boredom of sitting in an inactive trauma unit for hours by renting a condominium “within five minutes’ walking distance” of the trauma unit, hospital spokesman Ed Crawford said.

And Tri-City has bought and placed on the hospital grounds a four-bedroom “very plush” mobile home for its trauma surgeons while they’re on duty at the trauma center, said hospital spokesman Mart T. Havel.

“We’re not just sitting and reading,” Mercy trauma chief Dr. Dick Virgilio said in a prepared statement. “We have a variety of other activities such as making rounds on our other patients, doing (medical) charts . . . There’s an overwhelming amount of things to do.”

Although Dahlgren gave the word for Grossmont to drop out of the trauma system, getting out has been traumatic for some of the trauma center’s staff.

“It’s like being in a relationship that breaks up. We’re going through the grief process,” said Randi Herr Kroesch, director of emergency and ambulatory care at Grossmont. “We have an excellent (trauma) team. We give just as good care as any other trauma center.”

Some staffers may be dropped from the emergency room as a result of the withdrawal but the hospital will try to find new jobs for them at Grossmont or elsewhere, Dahlgren said.

Dr. Stephen Gormican said he was disappointed. Still, he defended his hospital’s practice of not supplying trauma surgeons full time as the county had required.

It wasn’t financially feasible to spend hundreds of thousands or millions of dollars paying trauma surgeons to serve in-house so they’d arrive several minutes earlier, Gormican said.

“Is that five-minute difference (in the surgeons’ arrival time) worth $5 million?” Gormican asked. “At Grossmont, if we had surgeons 24 hours a day, seven days a week, working in-house, they’d (each) do approximately one surgery a week.

“And it would probably be only one in 20 weeks where it (the surgery) would be done before 15 minutes (after the patient’s arrival), and maybe only one in 100 weeks where it would make a difference (as to the patient’s outcome).”

The money could be better spent elsewhere, Gormican argued. “I could throw $1 million at law enforcement or preventive medicine for drunk driving, and it would make a difference.”

Gormican believes the Trevino case has “become sensationalized . . . frankly he probably would have died anyway,” the trauma doctor said.