The Trauma Center Trauma

A map in the Trauma Hospital Program office of the Los Angeles County Department of Health Services charts the deterioration of the trauma network, with areas of crosshatching marking the regions no longer within 20 minutes by ambulance from a trauma center. The deprived areas in Eastern San Gabriel Valley and around the Los Angeles International Airport soon will spread to Eastern San Fernando Valley. With the closing June 19 of the trauma center at St. Joseph Medical Center in Burbank, the county will have lost nine of the 23 trauma centers established in 1983.

“Money is the answer,” according to Dr. Donald J. Gaspard, medical director of the trauma center at Huntington Memorial Hospital in Pasadena. “The problem is, where is it coming from?”

Indeed, it is a money issue, part of a broader problem of an unraveling health-safety net that goes beyond trauma centers and includes the whole issue of uncompensated and undercompensated hospital and medical care, and the 5.2 million Californians and 37 million Americans who have no health insurance. But the trauma network deterioration has a special meaning, because it affects the safety of everyone, rich and poor, who travel the freeways and highways of the region: 65% of the trauma cases are traffic-related. “The majority of the patients are people like you and me, driving a freeway,” said Dr. John McConnellogue, medical director of the trauma operation at the Northridge Hospital Medical Center.

St. Joseph estimates that it lost almost $2 million last year as a result of the trauma operation. Each of the three trauma centers that will be affected by the closing--Northridge, Holy Cross Medical Center in Mission Hills and Huntington in Pasadena--already are sustaining annual trauma-generated losses of $1 million to $1.8 million. All of them have under regular review their ability to continue. Furthermore, both Northridge and Huntington have recently had more periods when they could accept no additional trauma patients because of saturation in their intensive-care units. The Huntington intensive care units were at saturation seven times in January.

Trauma centers have high direct costs, because they must maintain trauma surgeons and anesthesiologists on duty at all times. It is the instant availability and schooled teamwork of those staffs that set trauma centers apart from emergency rooms. But the standby specialists, including neurosurgeons and orthopedic surgeons, who initially volunteered, also are part of the cost. Understandably, they are now insisting on compensation for standing by. Hospitals also must pay the high cost of malpractice insurance for the trauma doctors. And the costs do not stop at the trauma center. Probably most of the intensive-care unit and acute-care hospital costs for trauma patients go unpaid, adding to the burden of private hospitals for indigent patients they cannot transfer to a county facility.

Furthermore, the hospitals are required to pay the county a $35,000 fee to cover costs of a computer information network that analyzes trauma services and costs. Hospital budgets already are heavily affected by their Medi-Cal contracts, which pay less than 70% of the actual costs of treatment. At the Huntington, for example, 15% of all patients are Medi-Cal.

The response from public officials has not been helpful. St. Joseph made clear in its announcement that abandonment of the trauma network was accelerated by Gov. George Deukmejian’s effort to take new tobacco tax money, intended to supplement health-care funding and increase help for uncompensated care, and use that money to replace general tax revenues. A fund created last year to help finance emergency-care physicians and hospitals pays so little and is so complex that some doctors do not bother to apply. An emergency fund to keep inner-city trauma centers going in Los Angeles County expired Jan. 1.

“Perhaps there will not be an adequate response until a disaster involving some prominent person dramatizes the impact of allowing the trauma network to fall apart,” said one medical official.

There are alternatives. In Sacramento, serious efforts to fill the gaps in the health-safety net are being made. It is there that the first steps must be taken. Combined with recent proposals in Washington to broaden Medicaid, which operates as Medi-Cal in California, these state proposals could rescue the system. At least they recognize that no solution short of a broad reform of the health system will be effective.