Debate Continues on Future of Besieged Trauma System

When the Los Angeles County trauma system was set up in 1983, private hospitals battled hard and even sued to be included in the prestigious network, regarded as the crown jewel of the county’s emergency services program.

This month, the 10th trauma center of the original 23 permanently bowed out of the system. On busy nights, half a dozen of the remaining ones are full and temporarily closed. As a result, millions of people living in wide swaths of the county are served by no trauma center at all or by one that may well have no space when they need care.

Like trauma systems in many other parts of the country, the one here--what is left of it--is fighting for its life.

Several more hospitals may yet bail out. Temporary closures due to overload are way up over last year--”more than 1,000%” at Cedars-Sinai Medical Center, for example, according to statistics compiled by Alan Cowen, chief of paramedics for the Los Angeles Fire Department.

Some critics say that now is the time to evaluate the efficiency and effectiveness of the local trauma network before allocating more money to revive it. Some favor redrawing the boundaries for hospital trauma service areas or setting new medical criteria for which patients are taken to the centers.

But the chairman of the Los Angeles County Emergency Medical Services Commission, Dr. Stephen L. Michel, warned that any tinkering “is fraught with danger and may gut the whole system.” He and many others maintain that the trauma system’s only salvation lies in increased public funding. The commission is expected to present its recommendations today to the county Board of Supervisors.

In the meantime, growing numbers of trauma patients are not getting to a trauma center at all. Or they are making it just in the nick of time due to increased used of helicopters or because “paramedics are busting their little wheels to make it all the way across town to an open trauma center,” said Virginia Price-Hastings, the county health official in charge of emergency services.

2 Children Hit by Car

For example, when two children were mowed down by a drunk driver in South-Central Los Angeles one day last month, the trauma center less than 10 minutes away was already full and closed to new patients. After waiting 15 minutes for an ambulance, the children--one with tire marks across his chest and plummeting blood pressure--had to wait again for a helicopter to be summoned to fly them to a pediatric trauma center at Childrens Hospital in Hollywood, recounted Los Angeles city paramedic Becky Hegwar.

“They probably made it within the hour, but barely,” Hegwar said.

Dr. Brian Johnston, an emergency physician at White Memorial Medical Center in East Los Angeles, pointed to the case of a young motorcyclist who had crashed into an automobile at a speed upward of 100 m.p.h. It was a classic trauma case, he said, but for lack of a nearby trauma bed, the patient was brought to White’s emergency room where, fortunately, a surgeon was on hand to quickly operate, saving the patient.

Unlike a trauma center, emergency rooms are not required to have a surgeon and anesthesiologist on the premises ready to operate, as well as a battery of other specialists like orthopedists and neurosurgeons available within 20 minutes.

This special staffing requirement at trauma centers is designed to ensure quick surgical capability for those patients who are bleeding from injuries to their vital organs like the brain, lungs, heart and the accompanying vascular system.

Overall, about 60% of the county’s serious trauma injuries are caused by traffic accidents, health officials say. The rest stem from violent crimes such as stab or gunshot wounds or from work-related injuries such as falls from great heights on construction sites or entanglements with factory machinery.

“Unfortunately, trauma patients bleed. They bleed into their heads, into their chests, into their abdomens,” according to Paula Woo, former trauma coordinator for Presbyterian InterCommunity Hospital in Whittier which closed its trauma center Aug. 7.

“The emergency department can provide high-tech equipment, specialized emergency physicians, qualified nurses who can figure out what the problem probably is,” she continued. But, “they can’t fix it.” Trauma centers are designed to do that.

When the trauma system was established in Los Angeles County, it was designed so that no point in the county would be more than 20 minutes’ distance from one of 23 trauma centers.

The system was very popular. As Price-Hastings from the county Health Service Department pointed out: “People that drive Jaguars bleed at the same rate as people that walk. So, it is a health care impact on every single one of us.”

Hospital officials leaped at what they thought would be a prime opportunity.

“Everybody wanted to be a trauma center for the same reason everybody wants to do everything else--money,” Dr. Mike Vitullo, chief of emergency room physicians at Midway Hospital Medical Center, recently recalled during testimony before the county Emergency Medical Services Commission. “Everybody thought it was going to be a lot of money coming into the hospital. All these paid patients.”

But as it turned out, most trauma centers lost money at a time when hospitals were increasingly unwilling to absorb the losses because they were being squeezed by new government and insurance health care cost controls. Worse, many surgeons and other specialists who staffed the trauma centers revolted when they discovered that so many patients could not pay their doctor bills.

“Now, nobody wants to be a trauma center,” Vitullo concluded.

With all the holes in the network, Los Angles County no longer has an integrated trauma system, Price-Hastings said.

Not Served by Centers

Most of the San Gabriel Valley, a large section of the East San Fernando Valley and the beach cities and inland area surrounding Los Angeles International Airport are no longer served by trauma centers.

At most times of the day, Price-Hastings said, there is no hope-- barring a helicopter--that these people will be able to get one of the remaining trauma centers within the county-mandated 20-minute transport time.

“Naturally, if it is 2 o’clock in the morning--if you can plan your trauma--you will be able to get there,” she said.

It is not that the system needs all 23 trauma centers to be effective, Price-Hastings added. In fact, she said it is generally agreed that Los Angeles County designated too many trauma centers in the first place.

Thirteen would be enough, she said, if they were properly distributed. But as it stands, she said, they are in the “wrong places.”

Cowen of the city Fire Department said the trauma system might actually be better off without the private hospitals, which, he said, continually hold the county “hostage” to their demands by threatening to pull out. He suggested relying upon the county’s four public hospitals and UCLA Medical Center for all trauma care and using helicopters much more extensively for patient transportation.

The president of the United Paramedics of Los Angeles, Fred Hurtado, has urged that the county review its medical guidelines that dictate what symptoms require trauma treatment. He said the guidelines are so loose that they have allowed the public to use scarce ambulances as a “taxi service” in non-emergencies.

Dr. Joseph Morales, an emergency physician at County-USC Medical Center, has challenged the fundamental idea that trauma centers are more effective than well-equipped emergency rooms in saving lives. He has co-authored a report that studied automobile accident death rates statewide and concluded that trauma centers in Los Angeles, Orange and San Diego counties do not appear to have reduced motor vehicle mortality, compared to the rest of the state where there are no trauma systems.

“We had expected our death rates in these three counties would be lower, coincident with the trauma centers,” he said. He questioned whether trauma centers are not built on a foundation of “fluff” and pointed out that Los Angeles County has done no outcome studies to assess the effectiveness of the local trauma system to date.

‘Let’s Get Some Data’

“I think it’s time to say, ‘Whoa, let’s get some data,’ ” Morales said.

Price-Hastings acknowledged that there have been no trauma outcome studies done in Los Angeles so far but that attempts are under way.

Orange and San Diego counties have conducted comprehensive outcome studies showing trauma centers there have substantially reduced deaths, according to a nationwide review of trauma centers in 1988 by the Dade County Trauma Task Force in Miami.

Dr. Howard Champion, a leading proponent of trauma care and chief of trauma services at Washington Center Hospital in the nation’s capital, said that in San Diego and elsewhere across the country, good data has been collected documenting how trauma centers have dramatically reduced the number of patients who, before the advent of trauma centers, died as a result of delayed or inappropriate care.

However, despite this “strong documentation” and the fact that trauma is the leading cause of death for people under the age of 38, Champion said “trauma systems are in trouble” across the country.

“Trauma tends to claim as its victims a young, (medically) uninsured population, and nobody is picking up the bill,” he said.

One health care economist, Greg Bishop with the Trauma Resource Project in Irvine, has pointed out that in California a major part of the financial dilemma for trauma centers is that while automobile accidents are responsible for about two-thirds of all patients sent to trauma centers, less than 10% of trauma center costs are reimbursed by automobile insurance companies.

Unlike many other states, he said there is no requirement in California that a motorist carry medical insurance as part of his auto policy. New York requires motorists to carry a minimum $50,000 in medical insurance and Colorado requires $135,000, Bishop said.

Automobile Insurance Changes

Bishop said he is hopeful that changes in automobile insurance under way in Sacramento will ultimately provide a greater source of funding to the state’s trauma centers.

Public subsidies of the trauma network would probably provide the quickest salvation, but in California there is fierce competition among health care programs for money.

Earlier this summer, Gov. George Deukmejian blue-penciled $100 million earmarked in the Legislature’s budget for trauma and emergency services statewide. Health officials are hopeful that money raised through the recent passage of Proposition 99, which boosted taxes on tobacco products, will eventually be released to the counties.

But even so, there are many other health care programs, including local mental health services, that can be expected to stake a claim to the money. David Langness, vice president of the Hospital Council of Southern California, said he expects that there will be no subsidies for private trauma centers without a big battle.

A survey by the council of about 10 hospitals in 1987 showed the average loss per trauma patient was $4,386 among those classified as having no insurance.

Los Angeles County’s Trauma Centers More than 1 million county residents live farther than 20 minutes from a trauma center, according to county health officials. The gray shaded area in the map shows these parts of the county. 1. Henry Mayo Newhall Memorial Hospital 2. Holy Cross Medical Center 3. Northridge Hospital Medical Center 4. Westlake Community Hospital 5. Cedars-Sinai Medical Center 6. UCLA Medical Center 7. Huntington Memorial Hospital 8. Los Angeles County-USC Medical Center 9. Martin Luther King Jr./Drew Medical Center 10. Harbor/UCLA Medical Center 11. Memorial Medical Center of Long Beach 12. St. Mary Medical Center * not shown-Children’s Hospital of Los Angeles --pediatric trauma only