Dispute Led to Lapses in County-USC Trauma Care : Medicine: Inspectors attribute ‘preventable’ deaths to physician-surgeon feud. Remedies have been instituted.

A turf war between two key medical specialties has led to serious lapses in care, including “preventable” deaths, at County-USC Medical Center, according to a review team of the American College of Surgeons, which sets the standard for trauma care in the United States.

The ACS review team blamed the situation on time-wasting disputes between emergency medicine doctors and surgeons over who is in charge of major trauma cases.

Both specialties play important roles when a critically injured patient is rushed through the emergency room doors. Emergency medicine doctors often make the first judgments on the degree of injury and the need for lifesaving measures. But national guidelines for trauma care require surgeons to be present at the arrival of seriously injured patients and to have the final say on their treatment.

That has not been the policy at County-USC, the reviewers found. In some cases, the reviewers said, surgeons have not been summoned to the emergency room and in other cases have had difficulty wresting patients in need of prompt surgery from the jurisdiction of the emergency medicine doctors, leading to life-threatening delays.

These problems are exacerbated by inadequate patient records, the reviewers said in a confidential report to the Los Angeles County Department of Health Services, a copy of which was obtained by The Times.

Based on these findings, the ACS committee on trauma concluded that the hospital failed to meet national standards for regional trauma centers, which is its designation in Los Angeles County. The finding has no formal effect on this designation, but the Health Services Department, which runs the county’s trauma system, has adopted ACS standards in its contracts with trauma hospitals.

In interviews with The Times, senior medical officials at County-USC vigorously defended the hospital’s care of trauma patients and denied that patients have died as a result of physicians’ turf battles. Nevertheless, since the report was issued last April, they have assigned a surgeon to the emergency department to be present for all major trauma cases.

Dr. Sol Bernstein, chief of County-USC’s medical staff and associate dean of medicine at USC, also cited repeated funding cuts to the county-run hospital that he said have hampered the medical staff’s ability to maintain patient records and perform quality reviews in accordance with national standards.

The chief of emergency medicine, Dr. Gail V. Anderson, responded to the ACS team’s report with one of his own. In it, he charged the reviewers--both nationally renowned trauma surgeons--with bias against his specialty and with having outdated notions about the qualifications of emergency physicians to handle the initial treatment of seriously injured patients.

In response to the ACS report, the county Department of Health Services obtained from County-USC a “plan of correction,” which is being reviewed, said Virginia Hastings, chief of paramedic and trauma hospital programs for the county. She would not disclose the plan’s content and declined further comment except to say that the department’s goal is to have County-USC in line with national trauma standards.

Reducing the role of County-USC in Los Angeles’ overburdened trauma system is not an option, Hastings said. “The reality is . . . County-USC is too important a resource for us,” she said.

With more than 73,000 admissions per year, there is no busier hospital in the nation than County-USC. Of these patients, 90% enter through the emergency room and almost 4,000 are classified as major trauma cases.

The review last February was routinely commissioned by the Department of Health Services as part of its quality assurance program. The ACS trauma committee provides this service nationally.

The reviewers were Dr. Frank L. Mitchell, chairman of the ACS committee on trauma and professor of surgery at the University of Missouri, and Dr. Kenneth L. Mattox, chief of surgery at Ben Taub General Hospital in Houston and professor of surgery at Baylor College of Medicine.

The doctors assessed several other hospitals in Los Angeles County’s trauma network, and other teams dispatched by ACS evaluated other hospitals. Mitchell and Mattox would not comment on the other hospitals they inspected, nor would the Health Services Department release their reports to The Times. The documents are considered by the department and the hospitals to be confidential.

In an interview, Mattox expanded upon criticisms contained in the report on County-USC. He said he considered the power balance between emergency medicine doctors and surgeons at the hospital to be out of line with their respective skills in major trauma cases.

As a USC teaching hospital, County-USC has one of the nation’s largest training programs for specialists in emergency medicine. Seventy residents are enrolled in the four-year course, compared to 41 residents in the department of surgery.

County-USC’s emergency medicine department, with Anderson at the helm, also has earned a national reputation for pioneering work in the young but growing specialty. Founded in the early 1970s, emergency medicine was recognized with its own specialty board examinations just a year ago.

“Many of the foundations of academic emergency medicine are built on concepts from this hospital,” the reviewers acknowledged in their report. “However, the hospital and its staff have NOT continued to evolve . . . with the rest of the country.” The areas where this lag was most apparent, according to the report, was in the division of responsibilities among doctors tending to trauma patients.

According to Mattox, the tug of war between emergency medicine and surgery on trauma management is a longstanding problem at County-USC and well known in medical circles.

“That has been a criticism of (the hospital) since well before we reviewed them,” Mattox said. “It has been an internal criticism in that institution for the last 10 or 15 years. I’ve listened to surgeons complain about that at conferences.”

During the review, Mattox said, emergency room doctors asserted that they summoned surgeons whenever patients needed their expertise. But patient records did not reflect this, he said.

“We said, ‘Show us a chart that demonstrates to us that the surgeon was there,’ ” Mattox said. “And the charts that they showed us showed the surgeon wasn’t there in some cases until several hours later.”

Mitchell declined to comment on the actual report, citing its confidential nature. But he said he was surprised by the uneasy relationship at County-USC between emergency medicine and surgery. Similar turf arguments once existed at a national level, but were largely resolved about five years ago, according to nationally prominent experts in both fields.

“We have reviewed for verification now over 100 hospitals and this is really not an issue in most other places,” Mitchell said.

His counterpart at the American College of Emergency Physicians, Dr. Thom A. Mayer, agreed.

“If there is anything sad about the situation, it is that this problem has already been addressed in most places around the country,” Mayer said. “The real issue is what is the best thing to do for the patient. And that is where trauma physicians and surgeons (elsewhere) have come together saying, ‘Let’s not look at this as a turf battle and focus on the patient.’ ”

As is customary in such assessments, Mitchell and Mattox picked patient charts at random to test how the hospital’s systems worked in individual trauma cases. Some of the report’s sharpest language describes what they found in 12 of these charts.

One case involved a young woman brought in after a car accident who eventually bled to death. The investigators found that although a chest X-ray was taken in the emergency room, there was “no evidence in multiple doctors notes that (the X-ray) was ever seen.” Her blood pressure was unusually low and she received nine units of replacement blood during her stay in the emergency room. But despite this evidence of internal bleeding, a surgeon was not involved in her care until 20 minutes after she arrived, according to the report.

More than an hour later, during exploratory surgery to discover the source of the blood loss, doctors found that the body’s major artery, the aorta, was ripped open--something the chest X-ray might have indicated.

“Missed injury,” the report says. “Never suspected by any notes in chart. Possibly preventable death.”

Another case involved a child who was having trouble breathing after an accident. The emergency room physicians had difficulty inserting a tube in the child’s windpipe, and so gave paralyzing drugs to make the procedure easier. “Surgery, anesthesia never called to assist emergency physician. Child died. . . . Preventable death.”

Three of the 12 cases summarized in the report met with the reviewers’ unconditional approval; the others elicited varying degrees of criticism. The investigators’ overall conclusions highlighted what they found to be a consistent pattern of delay in summoning surgeons.

“From this chart review it is obvious that the surgeons are not present in the (emergency department) on arrival of the seriously traumatized patients,” the report says. “This is not only poor trauma patient care but also is a significant malpractice issue if (County-USC) is to call itself a trauma center.”

The dispute’s origins lie in the fact that surgeons and emergency medicine doctors are trained for different tasks.

Surgeons typically spend five years in hospital-based training programs. In the trauma setting, they are experts at determining a patient’s need for lifesaving surgery, and when it must be done. Some of the factors they evaluate are the degree of internal injury or uncontrolled bleeding and damage to vital organs.

Emergency medicine physicians are trained to evaluate and rank the needs of patients as they arrive in the emergency room. The caseload of these doctors ranges from minor cuts and sore throats to multiple gunshot wounds, bone fractures, severe head injuries and other life-threatening conditions. As members of the team responding to major trauma cases, they are experts at resuscitation, stabilizing treatments for patients in shock and diagnostic procedures to identify the extent of injuries.

“The emergency medicine physician is part of the trauma team, but he cannot be the head of it because the head of it has to see past the emergency room requirements to the full continuum of care,” Mitchell said. The patients that illustrate this principle best are grievously injured and near death.

“In many cases, the only way that patient is going to be saved is by getting them immediately to the operating room,” Mitchell said. “Only a surgeon can make that judgment call.”

Hence the ACS standard: In the crowd of medical specialists that typically swarm over a critically injured patient, the surgeon is to be in charge. Delay of even a few minutes--to call a specialist or resolve a jurisdictional dispute--can be the difference between life and death, full recovery and lifelong handicaps, trauma experts say.

But at County-USC, this model has not been followed, the report said. The emergency room doctor has been in charge, handing off to the surgeon only if he or she deemed it necessary, or when the patient was on the way to the operating room, the reviewers said. Surgeons often were not in the emergency area when the patient arrived and had to wait to be called.

Because of this practice, the committee said that County-USC not only fails to meet standards for a regional, or Level 1, trauma center, it falls short of requirements for Level 2, or community, trauma centers.

Although the Department of Health Services refused The Times’ request for reports on the county’s other 12 trauma centers, some of the directors of those centers said in random interviews that they follow ACS guidelines. The directors also said that surgeons and emergency medicine doctors at their hospitals worked cooperatively and in a complementary fashion.

The ACS report triggered a high-level meeting last spring of senior physicians in surgery and emergency medicine at County-USC, said Dr. Thomas H. Berne, the hospital’s director of trauma. Out of that meeting came the decision to assign a third-year surgery resident full time to the emergency room. In major trauma cases, this surgeon now calls the shots, Anderson said.

Berne believes the change has “lowered the tension a little bit” between emergency medicine physicians and surgeons. Bernstein agrees.

The hospital also is addressing the review team’s criticism of its patient records and data collection. Hospitals rely on so-called quality assurance data--death rates, treatment choices, infection rates, length of hospitalization, complication rates--to find out if they are doing a good job and to pinpoint problem areas.

The ACS team said the data at County-USC was being collected in a manner that, from a quality assurance standpoint, was useless to the medical staff.

Anderson, Bernstein and Berne blamed many of the chart problems on a shortage of emergency room nurses.

“When you have limited time and limited resources, is it better to stop the bleeding and save the life” or make detailed notations in a chart? Bernstein asked with some exasperation during an interview.

Bernstein’s view is held by many at County-USC who believe the hospital’s resources have been stretched desperately thin, even as the patient load increases.

Yet the hospital’s budget was cut last August, part of $7.6 million in cuts to health care facilities countywide. The action by the Los Angeles County Board of Supervisors followed cuts in state aid to the counties. Last Wednesday, a Superior Court judge unexpectedly ordered the supervisors to give the money back to the financially strapped hospitals. But it is too soon to tell how or if these developments will affect County-USC’s trauma services.

In any case, the $7.6 million cut was only the most recent example of a pattern of funding shortfalls for health care in Los Angeles County. A year ago, for example, County-USC sought $1.6 million from the Department of Health Services to bolster its medical quality assurance and data collection, calling the program “a critical unmet need.” The hospital did not get it.

“The basic bottom-line problem is funding,” Berne said. “We are as low as we can get and still survive.”