The accident victim moaned in agony as doctors examined the tire marks that stretched across his burly chest. Witnesses said he had been drinking. They saw him backing his truck up on a Pacoima street when, somehow, he fell out and the truck rolled over him.
He had suffered massive injuries to his ribs and lungs, and, on this recent Friday night, the late-night emergency crew at the Holy Cross Medical Center trauma unit in Mission Hills was trying to find out if there was any internal bleeding.
The Los Angeles County trauma care system, like the patients it tries to save, is in critical condition.
In 1983 the system was launched with eight hospitals. By 1985 there were 23 hospitals in the system, but today only 13 are left. Both St. Joseph Medical Center in Burbank and Whittier Presbyterian Hospital have closed their units in recent months. And now Holy Cross, whose trauma center lost $1.5 million last year and expects similar losses this year, could be the next casualty.
Diane New, director of emergency and trauma services at Holy Cross, said that since the beginning of 1989, the hospital has evaluated the trauma center monthly instead of every six months and while there are no immediate plans to shut it down, "I can't tell you it will definitely be here in a few months."
That would mean the end of a service that has on the premises a surgeon, anesthesiologist and operating team 24 hours a day. Unlike the old days of emergency care, where a surgeon and the assisting team had to be rounded up, sometimes causing fatal delays, a trauma victim can be on the operating table in minutes.
And it would mean that the San Fernando Valley would have only one trauma facility--Northridge Hospital Medical Center.
"We'd be going back to the dark ages of emergency medical care services," said Virginia Price Hastings, head of paramedic and trauma hospital programs for the county Department of Health Services.
Hastings said hospitals have been dropping out of the system primarily because of losses incurred from uninsured patients; 55% of all county trauma patients are uninsured. In addition, the average cost for a surgeon and anesthesiologist in a 24-hour shift is $1,500 each. Some facilities--such as Holy Cross--have subsidized their trauma centers with profits from other departments.
Hastings is counting on help from the state Legislature, which may as early as next month vote to allocate money raised by last year's Proposition 99 tobacco tax for medical services.
"Without some funding from the state, the situation is going to get worse," Hastings said. "I'm absolutely convinced we will lose a few more before the year is out.
"They went into this with the clear understanding of being self-supportive," she said. "But the method for reimbursing for health care has changed, and the cost has been passed on to the hospitals. We all expected more people to be insured."
Although Holy Cross has not received as many additional trauma patients as originally expected with the closure of the St. Joseph unit, the team admits that it feels the extra pressure.
"We'll just do it," said Melanie Kelham, an emergency nurse. "We know exactly what we have to do."
The accident victim, 41, mumbled in Spanish. He was in shock. Larry Andersen, an emergency technician, told him to remain calm as doctors inserted tubes to analyze his urine and checked his vital signs. Once the patient was stabilized, Dr. Peter Hong, the surgeon on duty, called for a chest X-ray. Other tests showed that there was blood in the man's abdomen. The patient was on the operating table in 10 minutes.
"We intervene," said Dr. Michael Sarti, an emergency room physician. "This is a way station. We stabilize the patient and move him toward the operating room as quickly as possible."
Members of the trauma center staff believe in the "Golden Hour" rule: If they can begin administering care to a trauma patient within one hour of an accident, chances are the person will survive.
Of the 645 trauma cases that Holy Cross had last year, 96%, or 621 patients, survived initial treatment and subsequent recovery periods. A similar percentage lived through their operations and treatment at Northridge Hospital Medical Center.
A trauma is generally defined as penetrating injuries to the chest and abdomen, which usually mean knife or gunshot wounds; falls greater than 15 feet; head injuries with a loss of consciousness; vehicle accidents in which someone has been ejected; severe burns, and injuries where life or limb is immediately threatened.
Most of the cases at Holy Cross involve vehicles, although about 11% to 15% result from stab or gunshot wounds.
"It makes the trauma center crisis a major problem for every single person in this country," Hastings said. "An accident can happen to anyone."
Whatever the injury, to the emergency staff, survival doesn't necessarily spell success. Although they may survive the original treatment, many patients spend months and even years in intensive care.
"Success is a person leaving with a decent quality of life," said Tom George, a respiratory technician. "I don't consider someone who becomes a vegetable a success. But in trauma, we have some successes. To see the terrible accident victim leave the hospital is so rewarding."
On the other hand, some members of the trauma staff don't hide the excitement they feel when a patient arrives.
"You have to like a certain pace to work down here," said Jim Glazier, a medical technician. "Upstairs on the floors, it's the same thing night after night. Here, people enjoy the challenge. If they didn't, it would kill them."
Hong made a long incision in the victim's abdomen. There was massive internal bleeding stemming from a severely ruptured liver. The victim's survival depended on whether Hong could stop the bleeding. One white rag after another was used to control the flood, but it would not stop.
Suddenly, a nurse informed Hong that another trauma case was about to arrive at the hospital. He continued to operate.
"Sometimes it's so quiet that you wonder if the world is still out there," Glazier said. "And then there are days where we are lucky to get anything to eat in 12 hours, and we don't get a chance to go to the bathroom."
On one recent weekend, Friday and Saturday nights produced no trauma cases. The only visitors to the emergency room were young children who bumped their heads and drunks who got into fights. (Normally, the unit will receive about two or three trauma cases a night.) But the following weekend, in just two hours, the trauma unit received three cases.
When the center is quiet, the staff usually helps out on minor emergency room cases or relaxes in the lounge. They work 12-hour shifts and know how to pace themselves. Favorite topics are the quality of the night's coffee and why the refrigerator is never stocked with anything appetizing.
"It's like sailing," said Dr. Richard Benedon, a trauma physician. "It's either boring or terrifying. The rate at which it goes from calm to chaos is amazing. All we need is to hear a few things on that radio and we'll scatter in no time."
As Hong continued to operate on the man with a ruptured liver, Joe Altshule, the clerk, announced the imminent arrival of the next patient: "This guy's real bad."
The "guy," 22, was driving southbound on the Antelope Valley Freeway, just north of the Golden State Freeway, when his jeep struck the center divider. He had been drinking, lost control of the jeep and was ejected. His passenger and girlfriend, 19, was thrown from the vehicle. Neither had been wearing a seat belt. A third passenger, sitting in the back seat, was wearing a belt and wasn't hurt.
The injured couple were wheeled in by paramedics. The girl had suffered multiple scrapes and a broken collarbone. She was conscious. Her boyfriend was not.
They gave him a CAT-scan to determine the extent of his massive head injuries. Within minutes, they discovered that he had a sub-dural hematoma--bleeding in the lining of the brain. The prognosis offered almost no hope. A brain surgeon, summoned from home when the call came in, was unsure that surgery would make a difference.
The injured man's family had already arrived and was in shock. The girl kept asking about her boyfriend. She was released from the hospital.
Scattered along the wall in the emergency room corridor are dozens of photos taken by the trauma staff, including the backside of a drunken female who evidently did not realize that her gown was open.
"Yeah, I guess humor is our release," said nurse Marty Peters.
The staff draws close to the patients. Some visit them regularly in intensive care even when it is not part of their medical duties. They ask each other constantly about the status of former trauma patients. Details from previous years are hard to forget.
Staffers recall a patient whose head injuries from a motorcycle accident were so severe that he could not be transferred to another hospital. For nearly two years, until his death in 1987, he barely hung on to life.
"We used to ring up his bill all the time," said Mary Wolf, a nurse. "He cost the hospital a lot of money. It was overwhelming."
It was actually about $500,000, according to Holy Cross officials, who cite that sum as an example of the financial burden the hospital must face in treating patients who are uninsured or under-insured.
The man with the ruptured liver was moved to intensive care. He died shortly after 7 the next morning.
"No matter how fast that guy went into surgery, it wouldn't matter," Hong said. "There was just too much damage to the liver."
The young accident victim underwent surgery to relieve the pressure in his brain. After several hours, he was moved to intensive care.
He died four days later.
"Most of us are pretty critical of ourselves," Glazier said. "You talk about what didn't go as clean as it should have or what we could have done better. But we know we can't save everyone. But at least we are there to try every time."