Surgeon Tires of Effort to Plug Gap in Trauma Care : Hospitals: A doctor on call in emergency rooms says that disintegration of the network puts increasing stress on those who pick up the slack.

When it was created in 1983, the trauma care network in Los Angeles County was hailed as the finest emergency medical response system in the nation. Based on trauma care developed during the Vietnam War, 22 hospitals, strategically located throughout the county, were equipped with the best technology and staffed 24 hours a day to respond instantly to life-threatening injuries. Highly trained emergency room doctors, surgeons, anesthesiologists and other specialists stood ready to treat the victims of car crashes, industrial accidents and urban crime.

Now, by all accounts, that system has all but collapsed. Faced with increasing violence on city streets, a growing population of poor, uninsured patients, rising medical costs and, from the beginning, inadequate public funds to pay for indigent patients, nearly half of the hospitals have pulled out of the system, increasingly leaving the county’s other 80 hospitals with emergency rooms to deal with trauma cases.

Doctors are leaving emergency medicine in droves, but one who has hung on is Dr. Robert Pereyra, a 40-year-old vascular surgeon who was trained at Loma Linda Medical School, Childrens Hospital of Los Angeles and Cedars-Sinai Medical Center. Now in private practice in Glendale with a group of seven other surgeons, Pereyra does elective operations and is on call for emergency surgery at two private facilities: Glendale Adventist Medical Center and White Memorial Medical Center, where he is chief of surgery.

Although not technically part of the trauma-care network, the doctors who work--often without pay--in these hospitals are picking up some of the slack of the embattled public emergency care system. It is a job that for a number of years has brought Pereyra considerable professional satisfaction, but at a personal cost that is becoming increasingly hard to bear.

Q: What is your role in the trauma network? Do you consider yourself a trauma doctor?

A: My speciality is vascular surgery. . . . Forty or 50% of my cases involve fixing arteries on people with arteriosclerosis . . . 20 or 30% preparing (the veins of) patients who are about to undergo (kidney) dialysis. . . . The rest is emergency general surgery and trauma care. . . . I am not a trauma specialist. No one in our group is a trauma specialist, but the nature of our practice, working in inner-city hospitals, and the nature of our training, as surgeons, meant we were good at it to start with, and we have maintained competence in it because we end up doing a fair amount of it.

Q: Why do White Memorial and Glendale Adventist have trauma patients if they are not officially part of the trauma network?

A: It’s a matter of where they are located. At White Memorial, we’re in one of the poorest areas of the city . . . a lot of the residents are illegal aliens. . . . We have about four or five big freeway interchanges surrounding us. We get a lot of injuries from there. We’re very close to the Vernon-South Gate-South L. A. industrial area. We get a lot of stuff from there. And we’re unfortunately in the middle of a lot of urban warfare. . . . Everything that is wrong with trauma in L.A. is very clearly seen at White Memorial, just as it is at Big County (County-USC Medical Center), which is about six blocks away. . . .

In Glendale, the level of acuity (the severity of the injuries) may not be as great, but there are other problems. . . . Glendale Adventist serves Glendale, where there is a lot of civilian violence and also the Highland Park-Eagle Rock area, where there happen to be a lot of . . . people who don’t have insurance, and the ones who do are on Medi-Cal which means they have very little money and are prone to serious health problems.

Q: How do trauma patients get to you?

A: What happens is that we do a combination of trauma care and other emergencies that the county facilities simply can’t handle. . . . MAC (the county’s central telephone communication system, which directs ambulances to hospitals) will call and ask us if there is an OR (operating room) available . . . if there is a surgeon in house. They’ll ask, “Are you prepared to accept an ambulance run with a critical trauma victim because County (County-USC Medical Center) is overloaded.” Appendectomies and bowel obstructions will be stacked up at Big County in the hall. . . . I’ll also get a call directly from a resident who’ll say, “I’ve got this appy (a patient with appendicitis) who has been sitting in the hall for 16 hours, and he’s got insurance. Can you do anything?”

Q: Even though theoretically the county is supposed to send you only patients with insurance or guarantee payment for those patients who aren’t insured, you in fact aren’t always paid, are you?

A: I’d say, of the emergency surgery we do in my group, fewer than a fourth have some kind of insurance, whether it’s an emergency because of acute appendicitis or a bowel obstruction or a gunshot wound. Of the trauma patients we see, almost none has insurance, maybe 10 or at most 20%. . . . What happens is we attempt to transfer that patient to a hospital where there are salaried doctors on staff to treat indigent patients. We call the MAC center, but they’ll tell us, “All county beds are full. . . .” So you end up taking care of them and, if you are a private physician working in a private hospital, you take care of them for free. The hospital doesn’t pay us anything.

Q: Despite what it costs you, does the system work for the patient?

A: Sometimes in private, non-trauma hospitals the patients get better care because they’ll have a regular surgeon, not a resident, working on them. But sometimes we get patients we simply aren’t prepared for.

Q: Can you think of an example?

A: The last night I was on call, I did a thoracotomy (a chest operation) for stab wounds to the chest. The guy died. I cut his chest open. He had a big hole in his heart. That depresses you because technologically we probably had the horsepower to save that guy, but we’re not a trauma center. . . . He was dropped off in the main lobby at White Memorial Hospital. If they had dropped him at the emergency room of County, he might have survived because they can mobilize a large group of people that we may or may not have. Here, the time of day dictates who is available and what can be done.

Q: Who was the patient? And why was he directed to White Memorial in the first place?

A: When I say dropped off, I mean somebody drove by and opened the door, threw him out and streaked. We got a lot of that. Dump and run. And they’re usually hurt in some gang-related thing or some drug-related thing. Lots of dump and run. Every week. . . . It turned out this particular guy was an illegal alien who got on the wrong end of a drug deal. I had already done an appy for free on an illegal alien earlier that night, which is why I was still in the hospital. If I hadn’t been in the hospital when that guy came in the front door, he would have been pronounced dead instantly. The ER docs simply couldn’t have dealt with him.

Q: What about the patients who survive? Are they thankful for what you do?

A: A lot of the patients are very grateful. But we also get a lot of difficult patients. They leave against advice, and they cuss at you as soon as the tube comes out of their mouth. We had one patient recently who I am sure would have died if a sub-specialist vascular surgeon hadn’t been immediately available. . . . The guy got slashed across the throat in a drug deal. . . . His carotid artery got chopped off. He was bleeding to death. The paramedics did a great job. They got him to us alive. . . . We fixed that artery. It was really an exciting case. It was really neat to do. . . . But the next day he pulled the tube out himself, realized he was OK, ripped out all of his equipment and just disappeared. Now that was probably $5,000 worth of service to him that was really expert service. . . . We didn’t even get the satisfaction of him saying, “Thanks, guys, you did a great job, and I appreciate it.”

Q: Given who many of your trauma patients are--drug dealers, gang members, illegal aliens-- why should taxpayers, who ultimately foot the bill, either through taxes or their own health insurance premiums, care whether the county’s trauma system works or not?

A: Because anyone at any time can become a trauma victim. There are basically three ways you come to be a trauma patient. You are in an industrial accident at work. . . . You are in an automobile accident or have a recreational accident, skiing, hiking in the woods, whatever. . . . Or you get caught in some civilian violence. That may be the Saturday night knife-and-gun club. But you also may be the innocent victim of a mugging. You may simply be in the wrong place at the wrong time, when some random shooting occurs. And that is increasingly happening all over.

Q: What can be done to rebuild the system--or at least to keep it from deteriorating further?

A: What is ironic about this is, L.A. County has in place the facilities and the people to have the best trauma program anywhere. . . . The problem is, it’s the only (county) in the U.S. where there aren’t major bucks being pumped in. . . . I don’t know whose fault it is. But I do know what the solution is. . . . If it was profitable to do trauma care, everybody would want to do it, and they would do it better. But it’s not profitable. We have made a social decision we’d rather not pay taxes to support trauma care. . . . As it was conceived, the L.A. County trauma system was super, but as it works out, it is a financial disaster. . . . Hospital after hospital has dropped out. . . . Doctors, who used to sue each other to get on emergency room panels because it was prestigious and because they could build a practice that way, are now resigning in droves simply because they aren’t being paid.

Q: What about you? If conditions stay as they are, will you move on with the rest of them?

A: I’ve certainly given it a lot of thought. . . . A lot of people are just opting out of inner-city practice. They are going to work for Kaiser. They are leaving L.A. and Southern California. They are limiting their practice to varicose veins. . . . There are fewer than 1,000 specialty certified vascular surgeons in this country, and there’s a lot of openings for them in private practice and in teaching programs. So it’s getting attractive to look elsewhere. . . . When I was a resident and didn’t have to make a living and I didn’t have kids, it was exciting. Now I’ve done all those things. I don’t need to learn how any more. It’s still interesting. It’s satisfying to save somebody’s life occasionally or to do something good for somebody, even for nothing. But then it cuts into your life so much. . . . You wonder if you should keep doing it. . . . And we’re seeing worse and worse types of accidents. We’re seeing a lot of drug-related stuff. We’re seeing a lot of HIV-positive patients. Anybody who is a drug abuser has a high-percentage chance to be HIV positive. All these things sort of get into it. It’s not viable financially. It’s less and less desirable socially. It’s just starting not to make sense.