Trauma Care on the Critical List

By John Langone

Of all the rules of thumb that govern emergency medicine, one of the most basic is to get the patient to the nearest hospital -- and fast. More and more, however, that precept, designed to save lives, has gone awry. In medical centers and hospitals across the country, disorganized, underfunded and understaffed emergency services are on the critical list. In Chicago not long ago, a fire-department rescue team rushed a 19-year-old gunshot victim to a nearby hospital emergency room unfamiliar with such cases. Within hours the patient, who had been alert and in satisfactory condition, began to fail. The hospital staff, unable to respond adequately, belatedly asked the Cook County Hospital trauma unit to take the patient. On his arrival at the facility, some five hours after first receiving medical aid, the youth was dead.

Beset by high costs and poor patients, often ignored by paramedics and abandoned by doctors who fear malpractice suits, the nation's trauma centers -- specialized 24-hour emergency rooms -- have been especially hard hit. Last week the Journal of the American Medical Association published a survey of U.S. regional trauma systems that came up with a disturbing diagnosis. Twenty- two years after the National Academy of Sciences declared that trauma was the "neglected disease of modern society," only two states, Maryland and Virginia, have set up acceptable statewide systems. Nineteen states and the District of Columbia either have incomplete coverage or lack essential components; the remaining 29 states have not yet set up formal systems. Says Dr. John West of the University of California at Irvine, an author of the J.A.M.A. report: "If you drive across the U.S. and get into an accident, you have maybe a 1-in-50 chance of getting the proper treatment."

Those odds also apply to affluent areas. In Northern California a bicyclist whose legs were severely damaged in an accident lay for several hours in a local emergency room waiting for special surgeons. The patient was eventually transferred to a trauma unit in San Francisco, where doctors had to amputate one of his legs. A more tragic case occurred at a Nevada hospital that claimed to specialize in trauma care. A skier with a ruptured spleen died while waiting for a CAT scan ordered by a surgeon who believed the patient's injuries were not immediately life threatening.

Traumatic injuries -- including violent accidents, shootings and stabbings -- are the leading cause of death among Americans between the ages of one and 44. The bleeding and shock that frequently ensue demand a degree of speed and precision not often available in most hospital emergency rooms. Experts believe that of the more than 140,000 Americans who are killed by traumatic injuries each year, at least 25,000 die needlessly because they do not receive the proper care in time.

In the 1970s trauma-care networks sprang up in a number of American cities, inspired by MASH units -- mobile army surgical hospitals -- widely used in the Viet Nam War. Twenty-three Los Angeles hospitals signed up to participate in a county trauma network that was launched in 1983, although experts warned that there would not be enough patients to go around and urged that only eight centrally located units be designated. It soon became evident that 30% to 35% of the trauma victims were uninsured and unable to pay their bills. Today seven of the Los Angeles trauma centers have closed their doors, citing huge costs run up by indigent patients.

The centers that remain in the L.A. network are swamped. At the Los Angeles County-University of Southern California Medical Center, officials occasionally have been forced to stop accepting trauma victims from other hospitals. Says David Langness, of the Hospital Council of Southern California: "It doesn't matter whether you drive a Pinto or a Rolls-Royce. You still can't get trauma care."

Southern Florida faces similar problems. Six of the eight hospitals in Dade County's trauma network have dropped out. An especially ugly factor in the closings has been their abandonment by doctors: surgeons, outraged at malpractice-insurance premiums that can exceed $200,000 a year, have begun "riding bare," dropping their coverage and refusing to treat gravely injured patients.

For most physicians, the risk of a less-than-perfect outcome -- and a lawsuit -- is just too high. Last June a pregnant woman with a broken neck lay in the emergency room for 4 1/2 hours as officials at AMI Palm Beach Gardens Medical Center begged one neurosurgeon after another to treat her. The first five refused. Finally, an orthopedic surgeon agreed -- on condition that a neurosurgeon assist him.

To ease the crisis, Florida lawmakers approved a bill in February that would limit pain-and-suffering awards in arbitration cases to $250,000 and make "wanton disregard" the only grounds for liability in the emergency room. In the U.S. Senate, Democrat Alan Cranston of California is sponsoring a bill that would provide matching grants to states for regional trauma-care systems. That measure and a similar one in the House have drawn strong backing. Declares Dr. Howard Champion, chief of trauma services at the Washington Hospital Center in Washington, D.C.: "Why the hell should the hospital dish out $50,000 for the care of a patient if there's no way of getting it back?"

In the J.A.M.A. report, West recommends an aggressive approach for improving trauma care: development of comprehensive regional plans that would care for patients "from the field to complete rehabilitation," and better identification of trauma victims at risk for life-threatening injuries. He even proposes a national trauma-care network. Areas without many uninsured people, which would include most of the system, says West, would more than pay for themselves; other regions, he believes, should require federal or state reimbursement.

With reporting by Beth Austin/Chicago and Scott Brown/Los Angeles