Short of Staff, Funds : Hospital: A Crisis in Critical Care

An 18-year-old girl was rushed to the hospital in December after a bullet fired from a passing car tore through her neck, pierced her jawbone, lacerated her tongue and blinded her in one eye.

But when she arrived at Martin Luther King Jr./Drew Medical Center in Watts, her ordeal was not over. In surgery, trauma doctors mistakenly slit her throat.

Both jugular veins were cut, causing a massive hemorrhage in what was described by one physician who later reviewed the case as a “botched” attempt to open a small airway for her to breathe.

‘Therapeutic Misadventure’

The girl eventually recovered--unlike another patient, Betty Jo Mack, 37, who entered the 430-bed, county-owned teaching hospital last winter for routine surgery to remove an ovarian cyst. Mack died on Feb. 1, after a series of surgical mistakes summed up by the Los Angeles County coroner as a “therapeutic misadventure.”

Records show that in surgery to remove the cyst, Mack’s colon was accidentally cut and improperly repaired, resulting in spillage of feces into the abdominal cavity. This caused a potentially fatal infection, necessitating a second--also unsuccessful--operation. Because the abdominal infection continued to rage, the patient developed breathing difficulties. During ensuing diagnostic tests, a major blood vessel and the apex of her heart were punctured.

“It was a chain of stupidity and incompetence the likes of which I’ve never seen,” said Dr. Elias Amador, chief of the department of pathology that performed the autopsy on Mack.

Dr. Harry Thadepali, chief of King’s division of infectious diseases, said, “I think this is the worst case I’ve ever seen. . . . That woman . . . really had no chance of getting out of this place alive. There were too many errors, too many mistakes.”

He added that he is so nervous about the number of “problem cases and . . . fundamental errors” by King physicians that he no longer refers patients for surgery at the hospital unless he knows specifically who is going to operate. “I want to make sure it’s done by a competent doctor,” he said.

King’s chief of obstetrics, Dr. Ezra Davidson, whose surgeons operated on Mack, declined to discuss the case. But he said, “The fact that death occurred does not mean something was wrong.”

To be sure, these cases are not daily occurrences. And clearly King’s medical staff has often

struggled valiantly to treat a staggering load of acutely ill patients.

But circumstances at King make quality medical care so difficult that even the hospital’s medical director, Dr. James Haughton III, publicly acknowledged a year ago: “We are doing some bad things to patients.”

Haughton cited a severe shortage of staff, modern equipment and critical-care beds that make it more difficult for doctors to care for a unique, acutely ill patient population.

Others say that despite the dedication of many King physicians, a lack of commitment and competence on the part of some doctors, as well as serious management problems at King, are also to blame for poor-quality medical care.

State health inspectors last fall, for example, found that the hospital had no documentation to show that quality controls were in place in the emergency department. The controls are supposed to ensure that obvious problem cases and most deaths are reviewed by hospital trouble-shooters.

For one reason or another--and sometimes a combination of factors--a disproportionate number of patients are dying at King, compared to the county’s two other major acute care public hospitals. One recent study of hospital deaths among elderly patients throughout the nation ranked King as among the worst 50 of 5,577 hospitals.

In recent months, county, state and federal officials have mounted separate studies and investigations of the medical center.

“The reputation of the hospital is that it’s a place where things just don’t get done,” said Dr. Marshall T. Morgan, chief of emergency medicine at UCLA Medical Center. “There are some devoted, competent people doing their best under the circumstances. But whether it’s at the level of the hospital or the (county Board of) Supervisors, obviously there is something wrong about the way the place is run.”

The problems at King are numerous and complex--and often beyond the control of the people who work there. Hospital officials say:

* The patients at King present a unique challenge. Typically deprived of basic, preventive health care, they often arrive at King with advanced illness and multiple complications. So many patients have been shot or knifed, either in gang warfare or other brutal assaults, that the hospital’s trauma director has likened medical training at the hospital to “combat duty.”

* The County of Los Angeles, which funds and operates King, has failed to provide adequate financial support. Much of the medical equipment, for example, is antiquated or broken, resulting last year in a $27-million backlog of unmet equipment needs.

* The hospital has had difficulty attracting top doctors because salaries are low, the neighborhood is dangerous, and the medical school affiliated with King has failed to provide doctors with supplemental economic and academic opportunities.

* Many full-time physicians at King have off-campus private practices that divert their energy and attention away from medical care at the hospital. In some instances, full-time doctors have worked far fewer hours at King than they have been paid for.

William Delgardo, King’s veteran administrator, said: “Under the circumstances, the staff has done a hell of a job and someday . . . someone is going to give them the credit for it. That isn’t to say we don’t have problems. We have problems like any other hospital. But I’m tired of people running this hospital down. . . .”

Dr. Brian Johnson, immediate past president of the Los Angeles Society of Emergency Physicians, described King as an “indispensable” part of the county’s health-care network. “The basic idea of (the hospital) is a good one,” he said. “The only problem is that it should be excellent, and it is not. In fact, I think it is an embarrassment. The community deserves better.”

After the Watts riots of 1965, King was built by the county to provide badly needed medical care for residents of some of Los Angeles’ poorest neighborhoods, while also serving as a training ground for mainly minority physicians.

Since the doors opened in 1972, King has evolved from a community hospital into a major trauma center and a linchpin in the county’s emergency-services network.

As private hospitals have closed their trauma centers or curtailed emergency services, King has been forced to pick up the slack. From as far away as the Westside and downtown Los Angeles now comes an unending stream of ambulances delivering bleeding and feverish patients: victims of accidents, assaults and acute illness.

The Times obtained the records of dozens of patients treated at King during a recent 2 1/2-year period. Some cases were gleaned from court records and hospital malpractice claims. Others were pointed out by frustrated medical personnel at King.

Medical experts outside Los Angeles agreed to review a dozen selected cases for The Times, at no charge. They concluded that there is cause for concern and said they were moved to publicly discuss their findings because of the overwhelming suggestion of serious malfunctioning at King.

Most of the cases they reviewed involved patients who entered the hospital through its busy emergency department--not by personal choice but because paramedics brought them there by ambulance.

In many cases, the patients lingered without adequate care and sometimes died. In other cases, they were subjected to questionable surgery.

Although the cases were not part of a comprehensive, scientifically random review of all patient care at King, the medical experts said the cases, individually, were egregious examples of bad medicine that seem to occur with enough regularity at King to cause worry.

Furthermore, they said, the cases in sum illustrate some fundamental systemic failures within the hospital, including lack of good management and supervision by qualified senior attending physicians.

Statistically, the gross patient death rate at King--2.4% of those admitted--is higher than at the county’s other two major teaching hospitals. Los Angeles County-USC Medical Center reported 1.5%, and Harbor General/UCLA reported 1.7% during 1987-88. During the previous two years, the gross death rate at King also was higher.

Excluded from the gross death rate are patients who die in a hospital’s emergency room. Statistics provided by hospital officials show that more patients died in King’s emergency room during 1987-88 than in the emergency rooms at County-USC and Harbor/General combined.

Among certain patients admitted to the hospital, such as heart attack victims, the death rate at King was considerably higher than at the other two county hospitals, according to gross mortality data collected by the state. Patients who underwent open heart surgery at King had one of the highest mortality rates in California until the hospital discontinued the service in 1986.

Furthermore, among elderly Medicare patients, King has one of the worst death rates in the nation as well as in the state, according to a recent national report.

Several investigations of patient care at King are under way. The Mack case, for example, was sent recently by the county coroner’s office to the Los Angeles district attorney and state Board of Medical Quality Assurance for investigation.

In the last several years, additional medical cases have come under review by the district attorney’s office, although no conclusions have been reached. In May of 1987, the district attorney’s office received from a King physician a list of cases said to demonstrate “gross negligence and medical malpractice occurring in the departments of surgery and emergency medicine” at King. The physician charged that the cases “testify to the lack of medical supervision in these two clinical departments and to the lack of competence of the house staff who are being ‘trained.’ ”

The county Board of Supervisors was also alerted to substandard medical care at King in a lengthy report prepared by Legal Aid attorneys two years ago. And audits and management reviews of the hospital have repeatedly pointed out serious operational weaknesses at King that threaten the hospital’s accreditation and jeopardize patient care.

“Pervasive problems” in medical record keeping, for example, resulted in such a high incidence of lost, misfiled and incomplete patient charts that the “existing deficiencies are sufficient to jeopardize the quality of patient care and, potentially, the medical center’s licensing,” according to auditors.

Auditors also cited a high incidence of hospital-borne infections attacking patients at King and noted fundamental inadequacies in the hospital’s infection-control program.

In addition, billing foul-ups have cost the hospital millions of lost dollars, according to auditors. And lax controls have permitted doctors to hold outside jobs without authorization and to collect their paychecks at King based on blank time cards they signed, auditors reported.

Earlier this year, federal officials ordered state health investigators to conduct a thorough review of all facets of medical care at King. The inquiry was prompted by a recent national study that compared death rates among Medicare patients at 5,577 hospitals across the country.

King ranked 35th from the bottom. Its score was worse than at any other public hospital in California except Riverside General Hospital. Both County-USC and Harbor/UCLA scored considerably better.

The study reported that King’s “risk-adjusted mortality was substantially higher--31%--than the average for California’s county and municipal hospitals” during both 1986 and 1987. King’s patients were sicker than average, but “the difference (in severity) was not statistically significant,” according to Dr. Michael Pine, president of the Chicago health-care consulting firm that prepared the analysis based on mortality data collected by the federal government.

Delgardo, King’s administrator, dismissed the study as unreliable and blamed King’s high death rate on the nature of the hospital’s patient population, rather than on any shortcomings in the hospital’s medical care. He said patients tend to arrive at King sicker than usual and are therefore harder to save.

Much of the criticism of King, however, is coming from within the hospital itself. In June, top doctors and nurses signed declarations protesting proposed county funding cutbacks (now on hold) and pointing out problems with the hospital’s medical care.

Physicians stated, for example, that patients sick with tuberculosis, other infectious diseases and heart ailments must wait more than a month for an appointment at the hospital’s jammed outpatient clinics.

A nurse said that the emergency room is so crowded that patients sometimes are forced to lie on backboards on the floor awaiting care. “Some patients have died in the emergency room, because they did not receive the close monitoring that they would have if they would have been admitted in an intensive care unit where they belonged,” said nurse Walter Smith in one of the declarations.

Thadepali, chief of King’s division of infectious diseases, complained of a serious shortage of beds and equipment at the hospital, premature discharge of very sick patients, and acute staff shortages that threaten the hospital’s accreditation.

“It is sad to say,” he concluded in his declaration, “but I believe we provided better quality medical services 13 years ago than we do today. In comparison to private hospitals and some other county hospitals in the country, the facilities at MLK (King) hospital are very poor and need to be improved.”

The emergency department at King is the hospital’s hub. It is the point of entry, doctors said, for 78% of all patient admissions, compared to about 70% at County-USC; 80% at Harbor/UCLA; and a statewide hospital average of about 20%.

At times, it seems that emergency and trauma cases virtually overwhelm the hospital. “It’s sort of like . . . the whole hospital is an emergency room,” said Dr. Arthur Fleming, King’s chief of trauma and surgery.

Trauma cases typically crowd elective surgery off the day’s schedule. Patients get bumped from their critical-care beds into wards to make way for even sicker patients, and the emergency room becomes clogged with patients on ventilators and monitors needing intensive care.

“The emergency room is the front line,” declared Dr. Sam Keim, a recent graduate of the emergency medicine residency program who described his tour of duty at King as a “nightmare.”

“It’s one of the heaviest trauma situations in the world,” he said. “It’s face-to-face with Watts, face-to-face with the community. It’s a battlefront. There’s no buffer.”

The hospital treated about 2,420 trauma patients in 1988 and received an average of 1,200 emergency ambulance runs a month, county health officials said. About 70% of the time, the hospital’s resources were stretched so thin that the emergency department had to be closed to all but walk-in patients.

“No matter where you’ve been, King’s a shock,” said Dr. Kevin Ferguson, another recent graduate of King’s emergency medicine residency program.

Dr. Charles Whiteman, who graduated last year with top honors as chief resident in emergency medicine, asserted that patients in King’s emergency room receive “very minimal, substandard care.”

He said that he and other residents gave up filing formal reports of “screw-ups and substandard care” because the incidents were so frequent and the reports drew no reply from hospital administrators.

As for quality-assurance controls in the emergency room, he said, “I didn’t see any evidence of it.”

Part of the problem, he suggested, stems from a lack of leadership at the top. The department of emergency medicine has been without a permanent chairman for more than seven years--something that Haughton, the medical director, acknowledged is “just crazy.”

Because of this leadership void, Haughton has said that he personally gets called at 3 a.m. and on weekends “when things go wrong” in the emergency room.

Hospital statistics show that 867 patients died in King’s emergency room during the last two fiscal years.

The other two county hospitals could not provide comparable data for the fiscal year ending in June of 1989. But a comparison for fiscal 1988 showed that King had 457 emergency room deaths; Harbor/UCLA reported 142 deaths, and County-USC reported 242 deaths. County health officials could not provide comparable figures for the total number of emergency room visits at each hospital.

Various explanations were offered for why more patients died in King’s emergency room, even though it handles far fewer patients than County-USC, for example.

Outside medical experts who reviewed selected cases of patient care for The Times said it appears that young doctors in King’s emergency room at times are not properly supervised and that the hospital, overall, is not always able to respond quickly to patients with life-threatening emergencies.

Dr. Richard H. Cales, chief of emergency medicine at San Francisco General Hospital and a recognized expert in the field, said that judging from the seven cases he reviewed, King appears to be “paralyzed” at times in responding to acute medical and surgical emergencies, forcing patients to undergo “unacceptable delays in diagnosis and treatment leading to avoidable death and disability.”

Cales said it appears that “certain (medical) services are simply unavailable, specifically neurosurgical. . . . Other services, which are apparently available, cannot respond because the hospital system is paralyzed. So, the patients are basically up against two problems, either one of which can adversely affect their care. They come requiring a service that isn’t available or they come requiring a service that is supposedly available but not in a timely manner.”

Delgardo, King’s administrator, said: “I’m not even going to respond to that kind of trash.”

But several senior physicians strongly defended King’s patient care. Fleming, chief of trauma and surgery, said that staff shortages, antiquated equipment, and an overwhelming patient load all make it much harder to save lives at King than at other hospitals.

“If you weigh the number of emergency cases, I marvel at our ability to keep going,” he said. “We do the best we can given the circumstances.”

Dr. Theodore Schlater, acting chief of the department of emergency medicine, said he believes that the vast majority of deaths in the emergency room involve patients who were not medically “salvageable” upon arrival at the hospital.

“If it looks like extraordinary numbers (of deaths) in comparison to our colleagues (at the county’s other medical centers), I don’t know why,” Schlater said. But he said it probably reflects “the population we serve and what’s happening in the streets,” rather than any problems with the hospital’s medical care.

During the month of December, for example, there were 53 deaths in the emergency room, and Schlater said he initially thought: “Oh, my God! What’s happening down here?”

But he said that after looking at each case, he concluded that most patients had died because they were too sick to save.

It is hard to assess whether King’s patients are actually sicker and harder to save than those who are taken to other public hospitals.

But one gauge is to look at how many people are admitted from the emergency room to the hospital for treatment. During 1988, about 18% of the patients treated in the emergency rooms at both King and at Harbor/UCLA were were admitted to the hospital, compared to 24% at County-USC.

As Dr. Gerald Whelan, associate director of emergency medicine at County-USC Medical Center, put it: “They have pretty sick patients, and we have pretty sick patients.”

One enormous obstacle in providing top-quality patient care at King is the shortage of modern equipment.

“The equipment that is in this hospital . . . is the same equipment that was in the hospital when it opened in 1972,” said Haughton, King’s medical director.

“The hospital is starved for resources,” said Morgan at UCLA Medical Center.

Doctors at King pointed out that until late last year there was but a single defibrillator for all emergency heart patients. And women with gynecological emergencies during the night had to wait until morning for an ultrasound examination.

It typically takes four to six hours to get laboratory results because the system is not computerized, residents said. And CT-Scans (computerized axial tomography) to pinpoint internal injuries such as hemorrhages and tumors often take even longer.

The hospital has only a dozen critical-care beds equipped with special monitors and staffed by special nurses to care for critically ill patients. Usually, between two and four of the beds cannot be used because of the shortage of nurses, doctors said.

Because of the bed shortage, Fleming said that physicians at King are forced to discharge sick trauma patients who at any other hospital would be admitted for observation and care.

If they are clearly too sick to discharge, the patients are held in the emergency room until a bed becomes free. Doctors said patients have been forced to wait in the emergency room as long as five or six days--despite an unwritten rule of emergency medicine that patients should be moved out in no more than about four hours.

Asked if patients had died because they were stuck in the emergency room awaiting proper placement, Haughton said, “I think so, yes. I don’t think there’s any doubt that there are patients that if we could have gotten them to the intensive care unit . . . they would have had a better chance for survival.”

“The emergency room is like a funnel with a cork at the bottom,” summed up Dr. Ron Melendez, who graduated in June from King’s emergency medicine residency program. “There are patients coming from every angle. You can’t get X-rays back. Patients are sitting here and there. Paramedics keep coming, and we can’t get patients moved out” into hospital beds for specialized care.

Help may be on the way. King is planning a multimillion-dollar expansion of the trauma center, to be financed through a county bond issue. In the meantime, to relieve some of the stress on the emergency room, an “emergi-center” was set up in May to treat patients with non-life-threatening problems. Furthermore, much of the antiquated and broken equipment is now being replaced, thanks to an appropriation of $6.5 million by the county supervisors last year.

But money alone is not the solution to all of King’s problems.

A review of individual trauma and emergency cases pointed out problems of management and supervision.

“There’s certainly a consistent suggestion . . . that there isn’t good supervision, and there is an inordinate amount of time before people get to the operating room or to definitive diagnosis,” said Dr. Michael L. Callaham, chief of emergency medicine at the University of California’s Moffitt-Long Hospital in San Francisco.

Cales, at San Francisco General Hospital, said: “There is a common thread: supervision. The mistakes that were made . . . can be minimized or avoided thorough review and participation by qualified attending (physicians).”

Both doctors, for example, faulted the handling of a patient who was rushed to King in February of 1987 suffering from a gunshot wound in the chest.

In the apparently mistaken belief that the patient was unconscious and about to die, trauma surgeons tried to stick a breathing tube down his throat and perform emergency surgery, cutting deep into the patient’s chest cavity through the muscle and between the ribs--all without giving him any anesthesia.

In agony, the patient--described in records as “awake and somewhat alert”--nearly leaped from the operating table.

“I sat up and I said, ‘Doc, don’t let her cut me again because I’m not out!” recalled the patient, who is now fully recovered and asked that his name be withheld. “Never will I forget it. . . . I could feel my skin ripping from the knife.”

With his chest open, the patient was rushed to the operating room and sedated for surgery.

Fleming, King’s trauma chief, defended the surgeons’ “judgment call” in performing the emergency operation, called a thoracotomy.

The operation is supposed to be reserved as a last-ditch measure to save an unconscious patient in imminent danger of death. With the chest open, doctors can reach vital internal organs to perform heart massage, for example, or to control a hemorrhage.

But in his review of this case, Callaham pointed out that the patient “really did not need” the emergency operation because he was conscious with an acceptable blood pressure.

“It’s not a mistake that should be committed by an experienced physician,” Callaham said. “And people in training should be supervised by somebody . . . who would be there to say, ‘No, this is not somebody whose chest you should be opening right now.’ ”

Another “astounding” example of bad medicine that might well have been avoided by better supervision, Callaham said, is the case of 18-year-old Temeka Williams, who was shot in the head in a gang drive-by shooting on Dec. 2.

Upon her arrival at King, trauma surgeons attempted to perform a cricothyroidotomy to open a small airway in her throat. But in the process, they cut both her jugular veins, triggering a massive hemorrhage.

“You’re supposed to make a little incision about an inch to an inch-and-a-half,” said Callaham in describing the procedure. “To get the anterior jugulars . . . you have to be working at decapitating. . . . You’re so far away from where you’re supposed to be!”

Dr. John G. West, an Orange County trauma surgeon who also reviewed the case, agreed that the operation was “botched.” And Cales said after his review, “Somebody overreacted and got in there and started slashing. . . . The complications in this case are serious and fall into the category of who is minding the store?”

Fleming described the case as a difficult one, with the patient struggling and the situation becoming “rather chaotic.”

“While one could blame the lack of an adequate amount of local anesthesia or an inadequate time for the anesthesia to work, the clinical decision about the urgency of such procedures cannot be dictated, but is a judgment call,” Fleming said.

One troubling aspect of King’s emergency and trauma care is the scarcity of neurosurgeons to care for a very heavy load of patients with spinal and head injuries.

Health officials said that hospitals countywide have had trouble finding neurosurgeons willing to treat patients in their emergency rooms and trauma centers, because private practice is so much more lucrative and the hours are regular.

Nevertheless, as a Level I trauma center, Los Angeles County regulations require King to have a neurosurgeon on the premises or available within 20 minutes.

But there are instances where patients needing immediate neurosurgical attention have languished for hours in King’s emergency room and sometimes died before being seen by a qualified neurosurgeon.

“Unless the trauma (patient) comes in between 9 a.m. and 3 p.m.,” said Keim, a recent King graduate, “the attending neurosurgeon is not going to see them.”

Whiteman, another recent graduate, concurred: “No matter what time they (patients with head or spinal injuries) come in at night, the neurosurgery attendings won’t come in (to see them) until 7 a.m.”

Dr. George Locke, chairman of the department of neuroscience, acknowledged a serious shortage of neurosurgeons at the hospital, mainly due to low salaries. In December, the department lost one of its most devoted, hard-working neurosurgeons, leaving only two full-time neurosurgeons to care for as many as 40 patients a day and perform about 300 operations a year, Locke said.

Also, the hospital has no specially trained neurosurgery resident doctors to assist with the heavy workload. Instead, the neurosurgeons must rely for help upon a corps of unlicensed medical generalists with no training in neurosurgery.

These aides cannot perform operations, for example. Mostly, they accompany patients to the CT-Scan machine and keep in touch by phone with the attending neurosurgeon on duty.

Locke said that he has been called to make decisions when he was as far away as Boston.

“People know where to find me,” he said. “(At night) I’m always at home. . . . I can give telephone instructions to do this and that, and then give me the results, and I’ll make the decision whether to come in.”

Two or three times a month, he said, he goes into the hospital during the middle of the night to treat patients.

But the situation is far from satisfactory.

In a June memorandum, Haughton, the medical director, complained: “At the moment, Dr. Locke is practically alone in staffing the department. This is having a very adverse effect on the operation of the hospital.”

Doctors said patients have died as a result.

“A couple of cases . . . have wound up in fatalities to young people who with more rapid neurosurgical intervention may have survived or done well,” said Dr. Melendez.

He pointed to the death of a 27-year-old woman he described as “probably the most tragic case I’ve had since I’ve been here.”

Delirious and in critical condition, the woman arrived at King shortly before midnight on March 29, 1988, her medical records show. She was diagnosed as suffering from meningitis or hydrocephalus--a swelling of the brain.

A CT-Scan indicated at 2 a.m. that she needed an operation, called a ventriculostomy, to relieve internal pressure in the head and prevent the brain from rupturing.

But she languished for hours without surgery and was brain-dead by the time an attending neurosurgeon finally came to examine her in the morning.

“From the time she had the CT-Scan until the time she herniated, as I remember, (there was) . . . plenty of time for something to be done,” Melendez said. “After she herniated about 5 a.m., the game was over. The attending (neurosurgeon) came in an hour or two later, like on morning rounds, about 7 a.m., and at that point she was considered inoperative.”

After reviewing the patient’s charts, Callaham concluded, “Nothing happens until, of course, all of a sudden the attending (physician) comes in in the morning and recognizes the disaster, but it’s too late.”

If the patient had been operated on promptly, Callaham said, “she probably would have come out neurologically normal.”

The attending neurosurgeon at King who examined the patient said he remembered little about the case. But, asked if quicker action might have saved her, he said, “Possibly.”

Cales, at San Francisco General Hospital, said, “If you can’t get a neurosurgeon in within . . . at most within 30 minutes, then they shouldn’t be receiving such patients,” he said. “There should be a sign up saying that’s not a real emergency department . . . or trauma center and they shouldn’t be directing patients there because they’re not going to get the care they need.”

WHO THE EXPERTS ARE Dr. Richard H. Cales: Since 1987, he has served as chief of emergency services at San Francisco General Hospital and associate professor of the departments of medicine and surgery at the UC San Francisco School of Medicine. He previously served as the medical director of Orange County’s office of emergency medical services and as chairman of the trauma committee of the American College of Emergency Physicians. He earned his medical degree from Loma Linda University and completed his residency in emergency medicine at Los Angeles County/USC Medical Center. He has edited or contributed to six books on trauma and emergency care and has served on the editorial boards of six academic journals. He is a member of the board of directors of the American Trauma Society.

Dr. Michael L. Callaham: He is a professor of medicine at UC San Francisco and has served since 1982 as chief of the division of emergency medicine at the university’s Moffitt-Long Hospital. Before that, he served as medical director of Alameda County’s emergency medical services. He earned his medical degree from the UC San Francisco School of Medicine and completed his residency in emergency medicine at Los Angeles County/USC Medical Center. He is an associate editor of the academic journal, Annals of Emergency Medicine. He has written three textbooks on emergency medicine and contributed chapters to 20 other books. He serves as president of the San Francisco Emergency Physicians’ Assn.

Dr. James R. Macho: Since 1986, he has served as assistant professor of surgery at the UC San Francisco School of Medicine and as attending surgeon and associate director of the medical/surgical intensive care unit at San Francisco General Hospital. He earned his medical degree from Harvard Medical School and completed his surgery residency at the UC San Francisco School of Medicine, where he was appointed chief resident. He has written six articles in medical publications and is a member of the Assn. for Academic Surgery and the Society of Critical Care Medicine.

Dr. John G. West: Since 1984, he has served as assistant clinical professor of surgery at UC Irvine. He is a founder of the Orange County Trauma Society and has served for the last decade as the trauma consultant to Orange County’s emergency medical services. He earned his medical degree from the UC San Francisco School of Medicine, where he also completed his residency and fellowship in surgery. He is on the editorial board of Emergency Care Quarterly and has published 13 books or articles on trauma. He is a member of the trauma committee of the American College of Surgeons and also serves on the board of directors of the American Trauma Society.