County’s Model Trauma System Showing Strain

The 8-year-old boy, hit by a car outside a major Orange County hospital, was alert as he was rushed into the emergency room. But not long after the doctor sewed up his cuts, the boy’s condition deteriorated before the eyes of the emergency room staff.

About an hour after the accident he had a seizure. Minutes later he went into cardiac arrest.

By the time a surgeon was called in and ready to operate, the boy was dead. A post-mortem examination revealed that the boy had a ruptured kidney and a belly full of blood. He simply had bled to death.

In September, 1973, most doctors involved considered the case a tragic fluke. But it was not so easily dismissed by John G. West, a surgeon fresh from training at San Francisco General Hospital’s nationally respected trauma center.

“It just kind of made me sick,” West said, recalling the boy’s death. “We should have been able to send him home. . . . They all said it was so rare, but I had this feeling it had to be happening elsewhere.”

It was, West found out.

The boy’s case launched West on a crusade that produced a 1979 study identifying 71 unnecessary deaths from traffic collisions, knifings, shooting, falls and other accidents out of 100 Orange County trauma cases he reviewed. The study is considered a landmark in the campaign for better trauma care nationwide.

It ruffled professional egos, prompted the county and the county medical association to conduct their own study--which substantiated West’s--and helped lead to the establishment of trauma centers in Orange County in 1980. Two years later a second study showed that by channeling the badly injured into a few specialized hospitals geared for trauma’s immediate needs, preventable deaths dropped to 9%.

Today Orange County’s medical turnabout is a compelling argument for trauma care advocates throughout the nation.

“Orange County is very important because of the way it was done. . . . The Orange County system broke new ground,” said Washington, D. C., trauma surgeon Howard Champion. “It documented that lives were actually being saved, and did so in more than an anecdotal fashion. It was a very important landmark in the process of getting trauma systems established throughout the country.”

“We’ve used the Orange County study to beat on the heads of county commissioners all over the nation,” added David Boyd, former chief of federal emergency medical services, who encouraged the establishment of trauma systems throughout the nation.

The Orange County system is a nationally known success story. But the medical and political opposition to the program that originally surfaced six years ago is, to some extent, still plaguing the network. The system’s evolution reflects the politicking and turmoil experienced by trauma programs across the nation.

In Orange County’s trauma system, severely injured people are rushed by paramedics past the nearest hospital to specially designated trauma centers. There, a trauma team led by a surgeon is ready to diagnose the injuries, perform tests to check for internal bleeding and, if necessary, take the patient immediately into surgery.

Since June, 1980, more than 7,000 people--about three-quarters of them victims of traffic accidents--have been treated at Orange County’s trauma centers, at UC Irvine Medical Center in Orange, Fountain Valley Regional Hospital, Western Medical Center in Santa Ana and Mission Community Hospital in Mission Viejo.

But there has been political fallout along the way.

Many of the crusaders who built Orange County’s system have left because of what they believe to be the county’s lukewarm support for trauma care. They have been replaced by officials whose dedication to the program, by comparison, is less evangelical.

Quarrels With County

Meanwhile, some doctors at trauma hospitals have quarreled with administrators in the county’s Emergency Medical Services office, whom they view as insufficiently loyal to the hard-fought-for system.

Topping the turmoil was the county’s damning review last summer of Fountain Valley Regional Hospital’s trauma center--the county’s busiest--which is run by doctors who have been openly critical of the county’s management. (A follow-up review restored the trauma center’s full certification earlier this month.)

And where Orange County was once a bellwether of trauma care for Southern California and even the nation, its trauma care system now falls behind systems in other communities, critics say.

Unlike Los Angeles County’s trauma centers, for example, Orange County’s centers are not required to have round-the-clock trauma surgeons, although three of the county’s four trauma centers have promised to do so anyway. Also, there is no regular review of trauma cases, as in San Diego County, where a committee representing the trauma centers meets monthly to study successes and failures.

Falling Behind

Data gathering has faltered in Orange County because of understaffing. Up-to-date information about trauma patients--where they were sent, how many survived, whether deaths were inevitable or preventable--is imperative to determine the system’s success or problems, advocates agree.

“What you see when you look at Orange County and San Francisco County are places that were far ahead of their time in implementing regional trauma centers. And certainly Orange County was a model for a long time. But EMS (emergency medical services) has progressed and Orange County has stood still, not because the EMS agency hasn’t wanted to move on but because the political jurisdiction there hasn’t provided the staff and funding,” said Gail Cooper, emergency medical services chief for San Diego County.

Perhaps the most visible sign of change has been the exodus of the vocal pioneers who helped establish the Orange County network--and alienated many medical leaders.

Mike Williams, former emergency services chief, left in 1980 to start a private firm that advises communities and hospitals nationwide about trauma systems. Dr. Richard Cales, Orange County’s former emergency medical services director, left because of policy differences. West was dropped as the county’s trauma adviser.

‘Misled the Public’

Betty O’Rourke, who succeeded Williams, is quick to deflate what she sees as trauma center hype.

“I think trauma centers are absolutely necessary. They are quality if they are set up right,” she said. But “I think we’ve really misled the public in a sense . . . that we’ve glorified trauma center to mean this hospital is all things to all people,” she said.

“I think the community is so misled by the trauma center designation,” O’Rourke continued. “It’s no different than a burn center or a spinal cord center. . . . You have these kinds of centers, and they have to have the expertise, and should have the expertise, within that (medical) area. But that doesn’t mean the whole hospital is God’s gift to all patients,” O’Rourke said.

She also discounts West’s studies on Orange County trauma deaths that have been heralded nationwide.

“Let’s say that the trauma system got in place, and that was good,” O’Rourke said. “(But) until we have good, statistically valid studies coming out, I’m not going to feel comfortable.”

Still, she reprinted West’s work in a 1981 booklet she prepared summarizing Orange County’s trauma system “because there was no other data available.”

Critics Not Impressed

Recently, new staff and a computer program were acquired to help O’Rourke’s office handle its workload.

Critics have not been impressed with her stewardship.

Many of Orange County’s trauma care leaders say O’Rourke is too sympathetic to the interests of non-trauma centers, and they look with admiration to outspoken emergency services chiefs shaping strong trauma systems elsewhere. “That’s what our EMS office should be doing,” said Dr. Alan B. Gazzaniga, UC Irvine Medical Center’s trauma director.

Orange County’s system began to suffer “when they got everybody who was supposedly biased (in favor of trauma centers) out of the program,” said Fountain Valley Regional’s trauma chief, Dr. William Thompson. “The people running the program at the county level are in many ways anti-trauma center.”

O’Rourke answers her critics by saying that when she sat through a trauma systems seminar conducted by West earlier this year, “he went down the list of how to set up a trauma system and make it work right. And he went down the list of everything I’ve done . . . and saying it’s the perfect way.”

Still, the Orange County trauma system has had to shake out several problems.

Anaheim Drops Out

Originally, there was a fifth trauma hospital, and a turf war to go along with it. Both Anaheim Memorial and St. Jude Hospital in Fullerton vied for the north county trauma center designation in 1980. Anaheim Memorial won, and St. Jude was awarded the radio “base station” that decided whether paramedics should deliver their patients to Anaheim’s trauma center.

But three years later, Anaheim Memorial officials dropped out of the trauma system, saying they were not receiving enough patients. St. Jude took over, but it, too, closed within a few months after losing money.

Despite the dropout of the north county hospitals, trauma care has not suffered, officials said. While it may be faster for paramedics to rush victims to the nearest hospital, the minutes saved on the road are lost if the patient ends up in a non-trauma center where “it just happens that all the ORs (operating rooms) are busy or it just happens that a surgeon can’t be reached,” said Gazzaniga.

“By the time you finish with the ‘just happens,’ the patient is dead,” he said. “I can’t think of one case where transportation from north Orange County has been a problem. The extra 5, 10, 15 minutes in transit are absolutely made up for by the hours saved here.”

Still, some trauma patients were indeed dying at non-trauma hospitals during the first three years of Orange County’s system. Advocates say the county’s triage rules--used by paramedics in the field to decide who is and is not a trauma patient--were overly restrictive.

From 1980 to 1983, only patients with visibly serious injuries were dispatched to trauma centers, while others with internal and less apparent--but life-threatening--injuries were sent to non-trauma hospitals, studies showed.

“That prevailed for over three years . . . despite the fact that we knew from day one that those standards were inadequate,” said former county emergency services medical director Cales, who had lobbied for tougher triage rules.

“The physicians in non-trauma hospitals were concerned they would lose patient volume if those standards were changed. I found it very disturbing. We had solid proof within six months that the standards were totally inadequate. . . . I am saddened by the fact that politics had a negative impact on the quality of care for three years.”

“It was an inexcusable delay,” added Fountain Valley’s Thompson. “The triage criteria we started the program with were literally bringing in the dead and the dying.”

Criteria Broadened

Two years ago, the triage criteria were broadened to include “mechanism of injury,” which allows paramedics to assess particulars of an accident--the speed of the vehicle, how badly it was damaged, how far the victim fell. The new category has enabled them to identify victims who might appear unhurt but who have suffered internal injuries.

In effect, the paramedics are now “triaging Volkswagens,” O’Rourke said. But it is necessary because “. . . the patient who is seen within 10 minutes of injury and transferred in another 15 hasn’t had time to go into shock” and suffer the symptoms that indicate internal bleeding, she said.

The latest turmoil in the Orange County system involved the recent evaluation of the four trauma centers. Fountain Valley was rated most harshly and given only a 120-day recertification last summer. UC Irvine Medical Center, ranking a close second in trauma caseload, was given a one-year renewal. Western Medical Center and Mission Community received full two-year certifications. A recent reevaluation of Fountain Valley extended its certificate for 20 months, bringing it in line with Western Medical Center and Mission Community.

Transfer Criticism

The first reviewers, who studied patient charts from 1983 and 1984, criticized Fountain Valley for using too many diagnostic techniques. The survey also criticized Fountain Valley for failing to transfer trauma patients to other facilities when its emergency room was overflowing. At UC Irvine, the reviewers knocked the trauma team for not doing enough intravenous kidney X-rays, doctors said.

Doctors at Fountain Valley and UC Irvine countered that the evaluations of the four trauma hospitals were uneven, with the most critical member of the review team involved in the audit of UC Irvine and Fountain Valley but not Western Medical Center and Mission Community.

Tom Uram, county Health Care Agency director, responded that there is “no validity” to grumblings that the trauma center reviews were unfair. He said there was no intent to assign a particular reviewer to the two hospitals, adding that every hospital had an opportunity to challenge the membership of the review team and none did. Surveys by outside consultants “have taught us a lot. We are getting better all the time,” he said.

Still, Fountain Valley doctors were stunned by the report. For a second opinion, the hospital brought in two physicians from renowned trauma centers in Chicago and Maryland to study the same case records that the review team had examined.

Skill and Art

“I was quite impressed,” said Dr. John Barrett, director of the Cook County Hospital trauma service in Chicago. He said the first reviewers knocked Fountain Valley for using techniques that they did not like but that were not necessarily wrong.

“There’s a degree of skill and art to trauma care. . . . Some methods are grossly inappropriate, others are clearly appropriate, but there’s a vast gray area” for individual doctor preference, he said. There are many ways to manage a trauma patient “and there’s no right answer,” he said.

Until last summer’s critical evaluation, trauma had been one of the best things ever to hit Fountain Valley Regional Hospital and Medical Center. Once a small community hospital, the facility since its designation has added operating rooms, increased its baby deliveries threefold, developed a sports medicine clinic and even changed its name--dropping “Community,” substituting “Regional”--thanks in part to the heightened visibility and status that comes with being a regional trauma center.

Rivalry for trauma patients is still a sensitive topic in the west Orange County area, which Fountain Valley serves. Hoag Memorial Hospital had sought the trauma center designation, but officials wanted to treat patients from only their Newport Beach area. County officials said being a trauma center meant taking patients from throughout the county, and Hoag officials decided they did not have enough beds to do that, Hoag vice president Jim Haden said.

Stabbing Near Hoag

Today, Hoag officials watch patients who are injured near their hospital taken to Fountain Valley’s trauma center. One such case was especially memorable.

Several years ago, the son of a hospital board member was stabbed near Hoag. He was taken to Fountain Valley’s trauma center, where he died.

“I can’t tell you that he would have lived if he had been taken to our hospital instead,” Haden said. “But a lot of people here wanted to take care of that patient, who was next door.”

Dr. Edwin Amyes, a neurosurgeon affiliated with Hoag, was more certain.

“We think we could have saved him if he came to Hoag. Why did he require 20 minutes in an ambulance . . . when he needed five minutes to get right into our hospital? . . . Why not treat people in their own backyard and near where they live?” Amyes said. “Hoag could have provided the same care. As it turned out, any good community hospital with a good emergency room (could have).”

By shuttling too many patients to trauma centers, the skills of other hospital staffs can decline, he said. “If you want good community hospitals, they have to be able to take care of all major things. If you can’t take care of major injuries, eventually you aren’t going to have surgeons or new equipment or the nursing staff,” he said.

Opinions Differ

Despite mumblings of discontent, county emergency medical services chief O’Rourke says she thinks resistance to the trauma system is dying. “I don’t have the political pressure now. I don’t see or hear the arguments that used to be, . . . that they’re stealing our patients. You don’t hear that anymore. I think it’s very accepted.”

Doctors at the trauma centers are not so sure.

“There’s always an effort to erode it,” said UC Irvine’s Gazzaniga.

Doctors at non-trauma centers still are unconvinced of trauma centers’ worth, said Fountain Valley’s Thompson. “They made up their mind a long time ago that trauma centers don’t do anything. That attitude still pervades this county,” he said.

Neurosurgeon Michael Sukoff, an early critic of John West’s efforts, grades Orange County’s trauma care “a good system. It could be better. . . . There’s still an awful lot of nonsense and politics and unnecessary activities, but that’s life.”

Sukoff still rankles at the mention of West’s well-known studies, charging that West produced inaccurate data based on unreliable autopsy reports.

Won’t Congratulate West

“It would be foolhardy for me to totally criticize John West because the end result is a successful trauma unit in Orange County, and that speaks for itself. His methods, I don’t think, however, were appropriate and I think we probably could have gotten there faster other ways,” Sukoff said. “But it’s done and we’re there and maybe he’s to be congratulated for doing it any which way. But I’m not going to congratulate him.”

West, these days, has tempered his criticism of the county administration.

“Maybe what we’re seeing is an evolution. Maybe it was unrealistic for us to expect EMS to be an advocate of the trauma system because of the pressures within the county . . . and we (should) just orient ourselves to making the trauma centers the best possible,” he said. “The system has weathered a few storms, and it’s still working pretty well.”

While maintaining a private practice in Orange, West serves on the American College of Surgeons’ national committee on trauma and travels around the country campaigning for regionalized trauma care.

And West has taken on another role: novelist. “Trauma,” which he co-wrote with Long Beach Press-Telegram journalist John J. Fried, tells the story of a young surgeon who, dismayed by needless deaths in a big city emergency room, goes on to compile autopsy records, ruffle the medical physicians’ egos, battle devious hospital administrators and risk his career as he fights for a lifesaving trauma system.

“People who read the book assume that much of it is just fiction. But I keep telling them that it’s real--that it’s based on real-life people and situations,” West said. “It’s a pretty honest depiction of what actually goes on in hospitals all over the country today.”