Burn Victims Lose Options : A bed shortage has forced L.A. County to ship out indigent patients--but not to UCI Medical Center, which can only handle local cases.

A 3-year-old boy was taken to a downtown Los Angeles hospital several weeks ago after a street vending cart tipped over, drenching him with boiling water. The burns on his chest, genitals and hands were so severe he needed to be transferred immediately to a burn center for skin grafts and other special care.

But no beds were available in any of Los Angeles County’s three burn centers. Or in Orange County. Or San Diego County.

Seven hours after his accident, a burn center in Fresno finally agreed to take him, said Dr. Cheryl Lee, an emergency physician at White Memorial Medical Center who arranged the transfer. A helicopter took the boy away, leaving his parents behind because there was no room for them on board.

Los Angeles County’s three burn centers have a total of 12 intensive-care beds that are currently staffed, down from 34 two years ago, according to a tally by officials at the Hospital Council of Southern California.

Increasingly, all of these beds are occupied, forcing local burn victims to be flown to other counties or even out of the state for care.

By contrast, Orange County residents have no difficulty getting into the area’s only burn center, a highly regarded, eight-bed unit at UCI Medical Center in Orange, experts on emergency care said.

“We haven’t had any problems with our own patients. None whatsoever,” said Betty C. O’Rourke, an Orange County official who monitors emergency medical care. In a recent county study of 51 burn patients, all those with moderate or major burns were appropriately transferred to UCI, she said.

Barbara Patton, director of nursing at Fountain Valley Regional Hospital and Medical Center, agreed: “I haven’t heard of any problems getting beds. You just call and get a bed.”

But for years, the UCI burn unit has turned away Los Angeles County residents who lacked health insurance, said its director, Associate Professor of Surgery Bruce Achauer.

“We can handle the burn load” of insured and uninsured patients from Orange County, Achauer said.

Even though the ward is often full, the plastic surgeon said, he and his colleagues make space for a major burn victim by transferring a nearly healed patient from their intensive-care ward.

But “if we took all the people in Los Angeles County--a county of 8 million--and we started treating them at our burn unit, we’d be totally swamped,” Achauer said.

“Orange County can’t take care of all the indigent patients from Los Angeles. We get calls all the time, wanting to transfer indigent patients from Los Angeles County,” Achauer said.

If UCI were to admit them, he said, the hospital would probably double last year’s $11-million deficit, and “it would mean closing down our burn unit. It would be suicide.”

Achauer said, however, that he does accept transfers from Los Angeles County of privately insured patients. But after all, he said, in Los Angeles County, “there are probably plenty of beds for people with money and not enough beds for people without money.”

That problem--medical care for the rich and limited or no care for the poor--has fueled a debate here and around the nation.

A key issue, along with the question of national health insurance, has been how to better reimburse hospitals and doctors for indigent care.

In Orange County, three hospitals have dropped out of the state Medi-Cal system. UCI Medical Center, which cares for 65% of the county’s indigent, has threatened to do so, saying it may go bankrupt. Also, citing overcrowding and a flood of indigent patients from hospitals that discontinued Medi-Cal, UCI has limited admissions to its obstetrics unit since June.

Meanwhile, doctors elsewhere in California were incredulous that other Southern California hospitals cannot care for local burn victims.

“We’ve gotten a lot of calls from major institutions in Los Angeles to transfer very major burn cases,” said Dr. Steve Zumiga at Valley Medical Center’s burn unit in Fresno. “I find it unbelievable that the hospitals there can’t handle them.”

Dr. William D. Davies, founder of the burn center at Torrance Memorial Medical Center, said: “It’s a daily occurrence that people here in Los Angeles have trouble getting placed in a burn center in this county.”

UCI’s Achauer noted that there is no regional network for placing burn patients in Southern California.

Burn centers across the country are in financial trouble, mainly because the patients they treat tend to be poor and often lack health insurance. At the same time, medical advances have enabled doctors to save patients who only 10 years ago would have had no chance of survival. But such highly specialized treatment is costly.

Care for a “not very big, uncomplicated burn” can involve three weeks of hospitalization and cost $100,000, Achauer said, whereas care for a major burn can take four months of hospitalization and cost $500,000 to $1 million.

Achauer said UCI’s 22-year-old burn center can run well because it receives private patients from around Orange County. But “if someone were to open a private-only burn unit in Orange County, we would have to close,” he said, because that would upset the balance of privately funded and unfunded patients.

In Los Angeles County, however, that balance is already overturned. The number of uninsured residents--many newly arrived immigrants--is growing fast, while public funding for mental health, trauma care and other health services has been slashed.

In what threatens to make a bad situation worse, officials at Torrance Memorial are considering closing their burn unit because of financial losses from treating victims who do not have health insurance or who have inadequate coverage. These patients, hospital officials said, have put the unit in the red, costing the hospital about $200,000 during the first five months of this year.

Two years ago, another private hospital, Brotman Medical Center, closed its Michael Jackson Burn Center in Culver City because of financial problems. And this year, Los Angeles County-USC Medical Center, the county’s only public resource for indigent burn patients, drastically reduced service. Three of its seven intensive-care burn beds were shut down because of an unavailability of nurses.

In Los Angeles County, patients burned in car accidents, household injuries, assaults, or on the job increasingly cannot get a bed in a local burn center.

One family involved in a fiery traffic accident was split up when the husband was sent to County-USC for care, the wife was sent to Las Vegas and their 4-year-old child was sent to San Bernardino County.

‘Biggest Tragedy’

“Isn’t that an awful way to have to deal with the biggest tragedy in a family’s life?” asked Audrey Bahr, chief of the contract program office of the Los Angeles Department of Health Services. “How would you like to be Grandmother trying to figure out who to visit?”

During the first six months of this year, Los Angeles County health officials said there was no room at local burn centers for 13% of patients seeking care. They had to be treated either at non-burn centers or at hospitals outside Los Angeles County.

Most hospitals routinely treat burns, but only specially equipped burn centers are capable of performing the skin grafts and surgery to treat the most severe injuries. In Los Angeles County, it can take up to 10 hours, with phone calls to more than six hospitals, before a patient is placed, according to county health emergency care official Darlene Isbell.

David Langness, vice president of the Hospital Council of Southern California, called it “a crime that a county like Los Angeles” has so few intensive care burn beds that patients have to be sent as far away as Dallas for treatment.

“It is indicative of a problem when we are shipping hospital patients to Dallas, Las Vegas, San Francisco instead of to Orange County,” he said.

Unlike Los Angeles, other major metropolitan areas usually have enough beds to treat local burn victims.

“New York City seems to be pretty well served by the available burn beds,” said Dr. Cleon W. Goodwin, director of the burn center at New York Hospital-Cornell University Medical Center in Manhattan. Rather than flying patients out of town for care, he said, patients are often flown into New York for treatment at one of the three burn centers.

In Miami, the city’s single burn center at Jackson Memorial Hospital is big enough to accommodate the vast majority of Dade County’s burn victims, said Dr. Charles G. Ward, director of the hospital’s burn center and immediate past president of the American Burn Assn., a national network of about 120 burn centers that sprung up during the late 1960s and early 1970s.

Despite sharply rising costs, his group is not collapsing, Ward said: “Everyone has the same problem: funding. But we haven’t seen any collapse yet.”

Obligation to Community

New York’s Goodwin said: “Most burn centers . . . are aware that you aren’t going to balance the books by taking care of burn patients. . . . They continue the care as part of their obligation to serve the community.”

Many of the country’s biggest burn centers, especially in large urban areas, are in teaching institutions or public hospitals where patient care is subsidized. In Miami and New York City, for example, all the critical burn care is provided by such institutions.

But in Los Angeles, the burn center at County-USC has lost beds as the number of patients seeking care there has grown.

“We’re moving backwards,” said Dr. Bruce Zawocki, director of the County-USC burn center, which is plagued by a shortage of critical-care nurses.

Generally, County-USC concentrates on providing care for the county’s poorest burn victims, allowing the county’s two privately operated burn centers to care for those who have insurance.

But when County-USC is full, the private hospitals are called upon to accept indigents, as well as privately insured patients.

“We shudder when we get a call,” said Ray Alan Rahn, senior vice president at Torrance Memorial Medical Center, a nonprofit community hospital in the South Bay, with five staffed burn beds for intensive care patients. “Every time we get a call, it could be a half-million-dollar exposure for us. It’s really frightening.”

Nine of the 31 patients treated at Torrance Memorial’s burn center during the first five months of 1989, he said, were sent there because County-USC was full. The cost of caring for them--about $200,000--wiped out the burn center’s overall profit, provoking serious consideration of closing the unit down, he said.

In prior years, Rahn said, the burn center has by and large broken even. But this year, it has been hit by increasing numbers of patients with no insurance or inadequate coverage.

He listed 10 instances during 1988 in which the hospital wrote off $18,000 to $200,000 in medical charges incurred by patients with no medical insurance or limited coverage through Medi-Cal or Medicare.

Most of them lived in parts of the county outside of the hospital’s general service area, Rahn said.

One woman lived in Tacoma, Wash. She was driving on a freeway near Bakersfield when she was hit by a truck, severely burned and taken by helicopter to Torrance Memorial. Before she died, Rahn said, she spent 22 days in the hospital and ran up a bill of $134,000. She had no health insurance.

Patients insured through Medi-Cal and Medicare also leave behind staggering unpaid bills, Rahn said. Torrance Memorial is reimbursed about $900 a day for Medi-Cal patients.

“That formula is a disaster for us,” Rahn said, because the hospital charges $4,300 a day for care.

Hospital officials are lobbying state health officials for a raise, which Rahn described as critical to the burn center’s survival.

Bahr, at the Los Angeles County health department, said that losing Torrance Memorial’s burn center would be a “big blow.”

“It would bring us down to seven intensive care burn beds countywide,” said Langness of the Hospital Council of Southern California.

“If Torrance Memorial pulls out,” he said, “we’d be left with a situation in which burn victims in Los Angeles County would be sentenced to a slow and painful death.”

BURN CENTERS Rising medical costs and an increase in uninsured patients have led to cutbacks in care at special burn centers. Los Angeles County officials say the number of staffed intensive care unit beds in the county’s three burn centers has dropped to 12. Orange County’s burn center has 8 beds. There are 11 other burn centers in the state, as well as one in Las Vegas. Three staffed, intensive-care-unit beds for burn patients are located in Los Angeles County. L.A. COUNTY CENTERS 1. Sherman Oaks Community Hospital: 3 beds 2. County-USC Medical Center: 4 beds 3. Torrance Memoria Medical Center: 5 beds

ORANGE COUNTY CENTER UC Irvine Medical Center: 8 beds