Prognosis Gloomy for Trauma Network : Health care: Some say the strapped system can be saved by sending most gun and knife injuries to county facilities.

The deterioration of the county’s emergency health-care system may mean a return to what paramedics call the “Wild West days” before the trauma system existed, and that means many more people would die, according to trauma surgeons, other physicians and hospital officials.

Now that Huntington Memorial Hospital in Pasadena has pulled out of Los Angeles County’s once-sprawling trauma network, it is starkly clear that a significant number of county residents no longer will have speedy access to a trauma center. Victims of drunk drivers near Los Angeles International Airport or gang victims in the East San Gabriel Valley likely will end up in two- or three-room emergency departments at tiny community hospitals with no surgeon readily available.

Already, 25,000 people injured across the nation die each year after they reach hospitals. Last year, Los Angeles County trauma centers treated more than 14,000 patients--a number that continues to rise while the number of trauma units declines.

The trauma system has crumbled primarily because of the large financial losses incurred by the hospitals, some of which sued to be designated as trauma centers, believing that it would bring in millions of dollars and much-valued prestige. Instead, they lost millions, in part because of new government and health insurance cost controls, but mostly because of the large numbers of indigent patients that entered their doors. Some of those patients ended up staying at the hospitals for months recovering from their injuries, running up sky-high medical bills.

Since the county’s trauma network opened seven years ago, 11 of the original 23 member hospitals have pulled out of the system and others have threatened to do so unless the operation is revamped.

The rapidly failing health of the trauma network is so troubling to emergency service officials that they are considering sweeping changes to salvage what is left of the system, thought to be the nation’s finest when it opened in 1983.

Unless they make those changes, the officials say, the gaping holes in the trauma net will foster a return to the pre-trauma times when emergency surgeons had little status and there was little organization over how and where critically injured patients should be transported.

Topping the list of proposed changes is a radical, two-tier system in which nearly all “penetrating” trauma victims--most of them gang members suffering from bullet wounds--would be taken to county trauma centers, and nearly all “blunt” trauma victims would be treated at private hospitals. The gaping wounds caused by knives and bullets, and usually associated with gang warfare, make up the vast majority of the penetrating trauma cases, while the blunt injuries are usually caused by falls and car accidents.

The idea recognizes the fact that gang members almost never carry medical insurance and don’t pay for their medical care. And doctors at private hospitals such as Huntington Memorial in Pasadena have said that they pulled out in part because of the “criminal element” that injured gang victims brought to their community.

The new system, if approved, would allow most of the private hospitals to treat trauma patients who carry medical insurance while the county hospitals would be left with the brunt of the non-paying gang victims.

The proposal has been criticized by physicians and hospital administrators who believe that it would further segregate indigent patients and create a privileged trauma-care system for those with medical insurance.

In addition, they say, it would eventually force city and county paramedics to use more helicopter transport for critically injured patients, an expensive and logistically difficult endeavor on the crowded streets of Los Angeles.

The proposal “would be my last choice, because frankly I don’t think it would be safe, but it may be the only choice left to save the trauma network,” said Virginia Price-Hastings, head of the county trauma program. “We’re going to have to look at ways of changing the system or somehow create a whole new system that will work in this county. But I have difficulty favoring any idea that would change the system for social, and not medical, reasons.”

However, supporters of the idea say that to keep the status quo would be akin to placing the critical-care network on life support.

The idea was among those discussed by a special group of trauma network officials that met in a closed-door session with Sen. Alan Cranston (D-Calif.) in Los Angeles on Monday to talk about ways to save the network from collapsing in Los Angeles and other cities throughout the state.

“I think separating blunt and penetrating trauma cases is an interesting, even creative, possibility for salvaging the trauma system,” said David Langness, vice president of the Hospital Council of Southern California. “Yes, it might ghettoize knife and gun club victims, and that’s unfortunate. But our county hospitals are the best at treating those type of combat-type injuries, so why not give them a chance to save them all?

“In the end, the purpose is to save the trauma system, so the risk of creating a two-tiered system might be worth it if it saves the system itself.”

When Huntington Memorial announced in February that it was pulling out of the trauma system, officials predicted that the move would have a domino effect on the remaining medical centers, further taxing their finances and their trauma physicians.

Huntington’s action was deemed crucial since it was one of the largest private hospitals remaining in the network, and trauma physicians feared that cases from the San Gabriel and East San Fernando valleys would overwhelm Cedars-Sinai Medical Center, which was already reeling from huge financial losses.

To stop further defections from the network, county officials quickly ordered all paramedics and ambulance crews to restrict the transport of patients so that the remaining private trauma hospitals wouldn’t be overwhelmed. Price-Hastings said that plan has temporarily stabilized the system, but admits that a long-term solution is needed.

The tattered state of the trauma system in Los Angeles has prompted some physicians to suggest that county emergency officials design a new trauma network from scratch. Dr. A. Brent Eastman, chief of trauma services at Scripp’s Memorial Hospital in San Diego, said one of the main problems with the Los Angeles trauma network was that it was one of the first large-scale systems set up in the nation.

“Los Angeles has always had some disadvantages in being a very populous city with some severe logistical problems,” said Eastman, chairman of the American College of Surgeons’ Committee on Trauma. “And since they were one of the trailblazers, there were some problems that no one had foreseen.”

Among them is the size of the trauma network, which county emergency officials now acknowledge was much larger than necessary. Eastman and others believe that the county would be much better served with fewer hospitals covering wider areas, as long as the boundaries could be drawn so that no hospital is faced with an inordinate share of indigent patients.

“That may be a problem in the central city, but the bottom line is that a trauma system in Los Angeles should not be defeated by the sheer size of it,” Eastman said. “But a failed trauma system is probably worse than no system at all.”

County trauma officials cling to the hope that they might be able to lure a few hospitals back into the trauma network with Proposition 99 tobacco tax funds. Trauma and emergency health care officials in California also hope to receive up to $250 million in alcohol tax funds next year if enough signatures can be gathered to place an initiative on the November ballot.

“The biggest issue is resources,” said Dr. Stanley Klein, director of trauma services at Harbor/UCLA Medical Center. “There’s not enough people or (money). If you took all the penetrating trauma victims to the county hospitals it would break their back. But if the money was there, you might be able to develop a system predicated on that basis.”

However, Dr. Allen W. Mathies, president and chief executive officer at Huntington, said that it will take more than money to save the trauma network.

“It seems to me that you cannot even call it a system at the moment because of the geographic disparity” of the remaining hospitals, he said. “In the beginning, there was a general lack of recognition for what the costs would be, the need for long-term care for many of the patients and the potential liability of the physicians.

“But it’s like in those Gallup polls where when the question is asked, 90% of the people believe that access to health care is a basic right. But when asked whether they would raise their own taxes to pay for it, 80% of them say no. Without that basic commitment to a trauma system, it becomes very difficult.”