Trauma Center: Medicine Comes Ahead of Money

They waited in assigned positions--surgeons, nurses and technicians surrounding the white bed in Trauma Room A of UCI Medical Center. The bed was empty, but not for long.

Moments before, at 5:20 p.m., the red phone in the emergency department had rung. Paramedics were on their way. Throughout the hospital, beepers sounded, beckoning the trauma team to the stark and sterile room with its single bed.

They swiftly filed in, moving through the emergency department like players in a well-rehearsed drama. One taped the name John Doe 1,234 to the door. All of them donned blue gowns, masks and caps, readied equipment and instruments, and waited.

Soon they heard the familiar wail of a siren. It grew louder until, at 5:32 p.m., it stopped as the van screeched into the emergency department driveway. Seconds later, the paramedics wheeled John Doe 1,234 into Trauma Room A. Hands gently placed the moaning auto crash victim onto the bed.

Then the trauma team went to work.

For about 40,000 patients each year, the emergency room serves as the main entrance to UCIMedical Center.

On an average day, 120 people walk or are wheeled in, suffering from illnesses and injuries that range from stomach aches to heart attacks, sore throats to broken bones, minor cuts to major trauma.

Led to beds behind gold and orange curtains in the expansive and modern ward, they are comforted by a team of physician-professors, residents, interns, nurses and technicians 24 hours a day, seven days a week.

The take-all-comers role of the E.R. makes for exciting medicine, doctors say. But it also contributes to the hospital’s financial crisis.

UCI Medical Center is expected to be $12.5 million in debt by June 30, primarily because treatment for about 70% of its patients is paid by federal, state and county programs, which do not fully reimburse the hospital.

For a large segment of the county’s poor, the emergency room is their only doorway to health care.

And most of the medical center’s in-patients--again, about 70%--are emergency admissions, entering the hospital first through the emergency room, clinics or obstetrics ward.

Still, it is medicine, not economics, that is practiced first in UCI Medical Center’s emergency department.

On a recent day--a slow day, according to staff--the patients included a 12-year-old boy who fell from a tree and broke his arm, requiring surgery and a hospital stay. Soon after, an 11-year-old girl came in with a broken wrist from falling off a swing. An elderly man suffering chest pains came next, followed soon after by a burly man medicated on psychiatric drugs who fractured his right hand when he punched in a wall. He left a similar hole in an emergency room wall by the time he left the hospital.

A woman, previously diagnosed to have a brain tumor, walked into the emergency department after suffering three seizures that morning; she would undergo brain surgery the next day. A young woman suffering complications from an abortion performed at another hospital was examined and assured she would heal. A young woman with a cut finger was found to have a herpes virus infecting the wound. And there were two burn cases that day--a roofer who spilled a bucket of bubbling tar on his hands and a young man whose overheated radiator sprayed fluid over his bare chest and arms.

There was even a humorous moment when the muscular members of the staff had to be rounded up to lift an obese woman, with two sprained ankles, onto an examination bed.

“That’s what’s fun about emergency medicine . . . . It’s exciting and adventurous,” said Dr. Kym Salness, director of emergency medical services at UCI Medical Center.

“You never know what’s going to come in the front door. You make rapid decisions, rapid plans, and then you move on,” Salness said.

A former Anaheim High School football star and student body president who graduated from Temple University medical school in Philadelphia, Salness, 34, has been in charge of the emergency department for 2 1/2 years.

He has a standing offer to join his father, an Anaheim internist, in private practice, but Salness said he prefers the unpredictability of the E.R.

“There’s a great deal of variety. You can see a patient with asthma, then a patient with a heart attack, then next you see someone who just got creamed on the highway.” An emergency room doctor “skims off the interesting cases in all fields,” said Salness.

Most cases, the “bread and butter” of E.R.s, involve colds and flu. But two, sometimes three times a day, paramedics rush patients to the specially reserved rooms in the emergency center known as the “trauma center.”

Outwardly, John Doe did not look seriously injured when paramedics brought him in. The only evidence of injury was a trickle of blood that ran from the bridge of his nose. But the life-threatening injuries, sustained when a van broadsided his car and pushed it into a lamppost, were hidden.

At a rapid-fire pace, the trauma team inserted IVs and performed a battery of tests, X-rays and examinations, looking for the source of the man’s agony but finding his breathing passage clear and his malady uncertain.

So they stood back, watching and waiting for the patient, in trauma room parlance, to “declare himself”: either get better, indicating that the injuries were minor, or get worse, exhibiting specific symptoms that signal internal bleeding and guide the trauma team to the source of the distress. John Doe 1,234 got worse.

Tell-Tale Signs

Suddenly, his blood pressure dropped, his chest puffed up, his pulse raced and his breathing became more labored. Doctors, who had suspected that the patient had a punctured lung and was losing blood into his chest, were certain now.

The team rapidly poured disinfectant on his torso and draped the right side of his chest. A tray of surgical instruments appeared at the elbow of trauma surgeon Dr. Ken Waxman, who quickly sliced through the skin, the muscle and finally the lung. Waxman took a length of clear plastic tube, about the width of a person’s little finger, and with effort pushed it through the incision and into the lung, all to the chorus of the patient’s howls, despite the local anesthesia.

The suction machine on the other end of the tube gurgled to life, and soon drops of blood flowed through the plastic.

X-rays, taken in the first minutes of the patient’s arrival, came back and showed the damage to his chest. His right lung appeared badly bruised and punctured by a broken rib.

His nose was broken, doctors determined, and an analysis of his urine showed traces of blood, indicating a possible kidney injury.

Most Pressing Injury

But those injuries were not as pressing as the battered lung, which continued to drain blood. Doctors decided to put yet another tube into the patient, this one down his trachea, so that a ventilator could help him breathe.

A badly bruised lung “can get so stiff, it cannot expand,” said Dr. Carl Schultz, an emergency room physician.

Another complication arose. The patient, who had been moaning and loudly protesting the probing and jabbing, became quiet--a bad sign. The trauma team called for a radiologist to crank up the CAT scanner, a sophisticated X-ray machine that gives detailed pictures, to determine whether there was brain damage.

The trauma team grabbed the bed and swiftly wheeled John Doe out of Trauma Room A down the hallway to the CAT scanner room.

Victims of stabbing, shootings, car crashes and other accidents are a specialty of the UCI Medical Center trauma center, one of four in the county. Two rooms are reserved for trauma patients only. Surgeons, anesthesiologists and other specially trained doctors are in the hospital around the clock to handle trauma victims.

But although it is the most famous function of the medical center’s emergency department, trauma care represents less than 2% of its cases.

Actually, most emergency room business consists of treating non-urgent ailments, Salness said. And many of the patients suffering from these aches and pains who seek help at the emergency department are poor, he said.

One irony is that although private patients shun the former county hospital, the care there is of top quality. The poor are treated by enthusiastic residents who draw on the expertise of specialists and researchers versed in the latest medical advances.

Patients ‘Dumped’

Many of these patients are “dumped” there--referred by other hospitals or medical offices because the patients have no private insurance or are on government medical plans that don’t fully pay the way.

UCI Medical Center refuses to accept patient transfers from other hospitals unless the special services of the medical center, such as its renowned burn ward, are needed.

For example, on a recent day Salness approved the transfer of the roofer who spilled tar on his hands. “His funding looks uncertain, but, oh well . . . , “ he said. An hour later, he received a phone call from another hospital seeking to transfer a patient injured on the job, but whose employer was denying him workmen’s compensation.

“Gee, why would they want to send him to us,” Salness said, in mock wonder.

Because many patients are Latino, a Spanish-speaking technician is always available to assist at the reception desk. And off to the side of the waiting room is a bank of desks where employees, 24 hours a day, determine whether non-insured patients are eligible for Medi-Cal or county-sponsored health programs.

Extreme Cases Common

For many patients, poverty exacerbates their medical problems. Many do not have family physicians, and when they become ill, they tend to wait until their symptoms are aggravated and complicated before going to the emergency room, doctors said. They walk in with pneumonia, infections or advanced stages of cancer, they said.

“We see cases that are further along,” said Dr. Robert Realmuto, a senior resident in internal medicine. “We’d never see this caseload at a private hospital.”

The high cost of treating an abundance of complicated medical conditions adds to the hospital’s financial burden. At the same time, though, such cases provide a valuable educational laboratory for the teaching hospital’s medical students, interns and residents.

On a recent day, for example, a Mexican laborer in his early 20s sat on one of the emergency department beds, silently suffering the pain of a rare form of cancer of the arm.

Three years ago a doctor in Mexico told the man the arm would have to come off, but the patient could not accept that and fled to the United States, Salness said. He eventually came to the medical center where a biopsy had been taken several days earlier. UCI doctors, too, decided the arm had to be amputated and scheduled surgery for the following week.

‘Wants It Off Now’

“But he is in so much pain, he wants it off now,” Salness said, glancing at the man clutching his right arm. The patient was on Medi-Cal, which would not pay for an emergency amputation, “although for that kid, I can guarantee you, it’s an emergency.”

The patient, Salness said, presented “a wonderful teaching case. Not often do you do amputations. But it’s an awful case for that individual. His problems are not over yet. He’s right-handed. I don’t know what this guy’s going to do.”

The medical staff cannot turn a poor patient away, simply because the symptoms don’t appear to warrant emergency treatment, Salness said.

“The person who comes in with symptoms of the flu might actually have TB or pneumonia. You don’t know until you examine him. You can’t sort them out at the front door,” he said. Beside, that would establish two standards of care, one for the poor and the other for paying patients, he said.

Added another emergency room doctor: “It becomes an ethical problem. Do you see them on the basis of pain or finances?”

Changes at Facility

Salness has seen many changes at the hospital, formerly known as Orange County Medical Center. In 1976 he was a resident at the medical center, which at that time had just been turned over to UC Irvine by the county.

The emergency room then was “a cubicle, a pit in the basement of an old building . . . small, cramped, hot and noisy. A classic television E.R.,” Salness said.

Since the university took over, a new emergency room has been built, erasing all trappings of the stereotypical charity hospital.

Plants, posters and maroon and mauve couches decorate the waiting room. In the main ward of the emergency department 10 beds are within the view of the nurses’ station. Down the hall is an orthopedic room for patients with broken bones, a gynecology examination room and a lavage (stomach pump) room which, when not used for its intended purpose, is employed to confine unruly patients or sequester jail inmates from public view.

Competition Cited

Farther down the hall is a bank of small examination rooms called “Quick Care,” reserved for patients with the non-urgent symptoms of sniffles, sneezes and coughs. It was set up to combat “Doc in the Boxes,” the disparaging term hospital physicians have for the storefront emergency centers that are siphoning off the paying emergency room customers.

But the paying and the indigent are treated equally, regardless of income.

“No matter what the patient mix is, I have been insisting on a level of professionalism that any patient would be comfortable with,” Salness said.

The medical center’s financial crunch has caused some cutbacks in the emergency department, “and we’re still able to provide adequate care,” he said. “But we can’t predict how busy we’re going to be, so we always have to be geared up for a busy day.”

And even a slow day is transformed into a busy one when a trauma case is wheeled in.

An hour after John Doe 1,234 had arrived, Trauma Room A was empty again. The floor was mopped, blood-soaked gauze was gone, gauges and equipment were back in their places, and fresh linen was on the bed. It was ready for another trauma run.

Later than night, the trauma patient was admitted to UCI Medical Center’s intensive care unit. A brain scan showed he had suffered a concussion.

He remained on the respirator for three days, and a week or so later he went home. Fortunately for the hospital, the patient had private insurance, although that was not known until after he had been admitted.

“There’s no question he would have died if he had not been treated,” said an emergency room physician the night the patient came in.

Watching his doctors, nurses and technicians work on the trauma patient, Salness reflected on his job.

“It’s like a general orchestrating a war,” Salness said. “What’s coming in that front door is trying to overwhelm your resources.

“And it’s a real good feeling when you win.”

Next: UC Irvine Medical Center is looking to the private sector for possible solutions to its financial troubles.