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Life and death in the emergency room.


Ayoung black man, shot in a housing project on Chicago's West Side, lies moaning on a table in the trauma unit of Cook County Hospital. The bullet cut a ragged path through his right thigh, shearing the femoral artery. Like water from a half-open tap, blood runs from the wound until a surgical resident, Dr. Lipov, leans heavily on the entry wound with a handful of gauze. The victim isn't enjoying the procedure--"Ma leg, man, you got to lay off ma leg,' he pleads. But Lipov, well into his twenty-first consecutive hour on duty, is in no mood for complaints. At some point in his evening's adventure, the victim has fouled his trousers. The stench fills the air. Lipov considers what antibiotics he'll administer since the exit wound on the back of the thigh is awash in excrement.

At 4:30 in the morning on a Saturday in August, Cook County's trauma unit is no place for the faint-hearted. The bars have just closed, so it is a peak hour for gunshot wounds. The trauma team has treated about a dozen other seriously injured patients tonight; some of their blood still stains the floor. Though the staff is tired, this latest patient's condition is sufficiently urgent to give them a surge of adrenalin. They crowd around him, inspecting, probing, taking notes, voicing opinions. Then they draw blood, start I.V.s, clean what needs cleaning and determine that without prompt surgery, the man will lose his leg.

Though he probably doesn't know it, the patient is fortunate to have been brought to Cook County. The Dickensian grimness of this tax-supported institution--old gray walls, exposed pipes, crowds of poor people in the halls--doesn't inspire confidence. But ask a Chicago paramedic where he would want to be taken if he suffered a gunshot wound, and he'll probably say Cook County. Emergency medical personnel all over the country know of Cook County's excellent record. And the reasons for the hospital's success are simple.

Trauma is the umbrella term given to all forms of injury. The primary treatment for serious trauma is surgery. For this reason, the Cook County unit is set up to do immediate, often complicated operations. It has its own operating room and surgical specialists of every stripe available in the hospital ready to pitch in at any time. Wheel a seriously injured patient into most conventional operating rooms, and you usually get a Chinese fire drill: nurses dashing around looking for the right type blood and special equipment, interns trying to locate surgeons over the phone or rousting them from bed, bottlenecks in getting X-rays, CAT-scans, and lab work done. Such delays kill a surprising number of trauma patients who succumb to shock or a hemorrhage. Trauma surgeons speak of the "golden hour' immediately after the occurrence of an injury, when the statistical chances of saving a patient by sewing up his wounds are greatest. Wait much longer than an hour, and no matter how brilliant the surgery, the effects of shock will frequently kill the patient hours or perhaps days later.

The second reason for the success of the Cook County trauma unit is experience. The surgeons and staff handle thousands of gun and knife wounds each year--a volume which allows them to hone their skills and teaches them to attend to the subtle signs in a patient's condition which indicate hidden injuries.

Lethal delays

Unfortunately, Cook County is an island of competence within Chicago's emergency medical system. To begin with, numerous seriously injured patients don't end up at Cook County or the other area trauma centers. That's because paramedics aren't given rules--"field triage protocols,' as they're known in the trade--to determine what kinds of injuries go to which hospitals. Instead, local ordinances direct the paramedics to proceed to the nearest emergency room, unless the physician advising them on the radio--their "on-line medical director'--tells them otherwise. Since paramedics often can't or don't call their directors, and since these physicians, for various reasons, often won't direct the ambulances to a trauma center, too many patients die in emergency rooms that aren't prepared to handle them. In one notorious case last November, Ben Wilson, a 17-year-old high school basketball star, was shot twice in the abdomen on Chicago's South Side. Fire department paramedics brought him to St. Bernard's Hospital, which does not have a trauma unit, where he waited almost two hours before being taken to the operating room. He died shortly thereafter. Had St. Bernard's doctors transferred Wilson to a trauma center, or better yet, had he been taken to one directly, some physicians in Chicago believe he would have lived.

Nor was Ben Wilson an isolated case. Nurses, physicians and paramedics say delays like this kill patients in Chicago hospitals regularly. Studies conducted by Cook County Hospital show that patients with serious head injuries who were first taken to the nearest hospital and then transferred to Cook County were twice as likely to die as patients taken directly to Cook County.

Another problem is that not all trauma centers are as proficient as the one at Cook County. The state of Illinois designated certain hospitals as trauma centers 15 years ago; since then there has been no serious review to see if these hospitals are doing the job. An emergency room nurse with 20 years experience told me of a young woman suffering multiple injuries from an auto accident who was brought to a "level II' trauma center in a suburb near Chicago. The surgeon on duty arrived in the emergency room within 30 minutes of the woman's arrival. Three hours later, still in the emergency room, she died. When the nurse asked the department director why the woman was never operated on, he replied that "the surgeon was afraid about what he was going to find when he opened the gal's chest, because he knew he didn't have the equipment to handle it.' Why, then, asked the nurse, wasn't she immediately transferred to the "level I' trauma center five minutes down the road, where they would have the proper equipment? The director replied that the surgeon wouldn't allow it, claiming the woman was "too unstable to transfer.'

The ultimate catch-22: a patient too badly injured for the surgeon to handle but too unstable to transfer to a hospital where she might have been saved. "I reviewed the records on this case,' the nurse said. "I know this was a preventable death.'

Fortunately, there are now trauma physicians and city officials calling for changes in Chicago's emergency medical system--changes that have saved lives in other cities. First, they want to redesignate trauma centers and begin inspecting and auditing their performance. Then, they want to institute triage protocols to get seriously injured patients to those centers. John Barrett, chief trauma surgeon at Cook County Hospital, estimates that these simple changes could save as many as 200 lives a year.

Chicago's trauma system is typical of systems throughout America. There are much better ones--for instance, in Maryland, parts of California, and Seattle--though advances in monitoring are showing that even these systems aren't saving a large number of patients with treatable injuries. Other areas of the country, such as southern Florida and many rural areas, have almost no trauma centers at all. Most urban and suburban America has trauma care like that in Chicago: half-organized, unassessed, slipshod.

"Safe in the arms of Jesus'

200 lives--just in Chicago. The figure gives some idea of the magnitude of the problems regarding the treatment of trauma. At least 140,000 Americans die each year of traumatic injuries; three times that figure sustain permanent disabilities. According to a National Academy of Science (NAS) report issued last spring, injury is "the principle public health problem in America today.' Trauma is the leading cause of death among Americans under the age of 44 and causes the loss of more working years than cancer and heart disease combined--at a cost to society estimated by the NAS to be in the tens of billions of dollars each year. Advances in the treatment of heart disease and cancer come slowly and at a tremendous cost. Great improvements in the treatment of trauma victims are available now; indeed, they've been around for years.

If you're dubious about these numbers and you've never heard of the "trauma crisis' before, you're in good company. Many doctors don't believe it either. Most of us don't see injury as a preventable, treatable "disease' but rather as a matter of fate, an act of God. It's easy to believe the emergency room doctor who tells you that "nothing could be done' for the friend who dies from injuries suffered in a car crash. Yet study after study demonstrates that most emergency rooms simply aren't set up to save the most seriously threatened trauma patients. "Most people who wind up in ERs think they're safe in the arms of Jesus,' observes John Otten, a trauma surgeon in Peoria, Illinois, "and that's often true in about 10 minutes.'

The best way to save trauma victims is still through prevention--seat belt use and air bags in cars, gun control and so on. But the secret to saving lives once injuries occur is quick and effective surgery. The major cause of death in cases of trauma is simply the loss of blood. Surgery won't save most trauma victims, since more than half die so suddenly that even if the injury occurred in the operating room, the surgeons probably couldn't do a thing. But of the roughly 40 percent of trauma deaths that occur in hospitals, a large percentage could be saved using existing surgical techniques. How big a percentage is open to debate. But studies from all over the country have found that in places where there is no complete system of trauma care, which is most of the U.S., 20 to 50 percent of those who die in hospitals from trauma could have been saved. In other words, 10,000 to 30,000 people die each year because an effective system of care hasn't been established.

In Chicago, trauma physicians and others have argued strongly for the changes, but so far without success. The roadblock isn't an immovable bureaucracy or corrupt politicians. Instead, the opposition comes from within the medical community--specifically from doctors and administrators at some Chicago hospitals that do not have trauma centers. Stan Zidlow, head of emergency medicine at Northwest Community Hospital, says that the doctors who sit on key advisory committees of Chicago's Emergency Medical Services Commission and oppose these changes, seldom say so; they just gum up the works. "After each new proposal came before the commission,' he explains, "the medical community would put it back to the committee, have terms redefined, wouldn't designate people to watch for abuses in the system and so on. Every one of these proposals never came to fruition, and no agreement was reached.'

Why oppose such sensible improvements? Two reasons, say trauma care reformers, are ego and ignorance. Physicians and hospital administrators refuse to believe that a lack of understanding and commitment on their part is killing people. The other big reason is money. The seriously injured often represent sizable revenues for doctors and hospitals. They require numerous procedures, close attention and, for those who live, long convalescences in expensive wards. By giving each Chicago hospital a share in the lucrative victims market, the current system pleases the largest number of local hospitals--at the annual expense of those 200.

With the city and county governments paralyzed by the medical community's obstinance, the people of Cook County must look to the state if they want their emergency medical system reformed. But the state has its own problems. Since the mid-seventies the staff of the state's Emergency Medical Services (EMS) agency has shrunk from 50 people to 19. The reason for the drop, one EMS official says, is a decrease in federal funding and the perception among state public health administrators that emergency service is not a very high priority.

Fear and favor

The man behind that federal EMS grant program also happens to be the man who designed the EMS system for the state of Illinois: Dr. David Boyd. In the early seventies, boyd, then chief resident at Cook County Hospital's trauma unit, helped persuade Governor Richard Ogilvie to institute the nation's first coordinated, statewide system of emergency medical care. The program, interestingly, was financed with seed money that Boyd--like Ogilvie, a Republican-- requested from the Nixon administration. Boyd's "systems approach' to emergency care--which involves paramedic training, regional radio communications, a network of state-designated trauma centers, and a trauma "registry' for monitoring and evaluating hospital performance--is still considered one of the great innovations in the field. As Illinois's first EMS director, Boyd soon gained widespread attention and testified before Congress on the need for a nationwide system of emergency care. From 1974 to 1981 he headed a new federal EMS program at the Department of Health, Education and Welfare. During those years Boyd allocated some $300 million in federal grants to states and localities to set up EMS systems.

Boyd failed, however, to convince Illinois officials to adopt triage protocols, probably the most important aspect of the systems approach. Without these guidelines, paramedics cannot route trauma victims to the right hospital with enough speed, leaving Chicago's emergency system a vast, sophisticated machine that is never switched on.

One reason the EMS office hasn't followed Boyd's lead is fear. Doctors, administrators, and trustees at Illinois hospitals who oppose reform have the power to pull strings at City Hall and in the state capital. Health officials in Illinois and in other states say that colleagues who have pushed for reforms, such as trauma center designation and triage protocols, have found themselves looking for work. "If I do my job the way you and I think I ought to do my job,' one Illinois EMS official confides, "I don't have a job.'

Boyd's grant money gave EMS advocates a much-needed push. So in 1981, when the Reagan administration folded the federal program into less well defined preventive medicine block grants, much of the cause's momentum disappeared. What has happened in Illinois seems typical of what has happened across the country. In many areas, trauma care has stopped improving; elsewhere it's actually getting worse. Says Mike Williams, former EMS director for Orange County, California: "I've seen some good systems that with federal money were on the verge of designating trauma centers decompose, and others that have just gone into a silent mode.' Since no one gathers data on this subject, no one can say if individual impressions such as this are generally true. But one GAO study last year found that after the Reagan administration pulled the plug on Boyd's program in 1981, funding for EMS dropped in ten out of eleven states surveyed. The states, it seems, have not picked up the ball.

Beware the lobbyists

To get a picture of problems at the state level, it's worth taking a look at Pennsylvania. Approximately 50 hospitals in the state advertise themselves as trauma centers, but, according to officials, about six actually have the specialized staff and facilities that meet generally accepted standards such as those of the American College of Surgeons. Nor are there any state guidelines to insure that seriously injured patients get taken quickly to hospitals capable of treating them. As a result, the state's health department estimates that 1,300 injury victims die whose lives could be saved.

Trauma care advocates have been trying to do something about this for years, but the state's medical community hasn't let them get very far. David Boyd charges that millions of dollars provided by the federal government during the seventies were squandered on various unproductive committees. When EMS advocates attempted to publish an evaluation of hospitals in southwest Pennsylvania, an essential first step toward systematizing trauma care, the hospitals blocked the move. In 1981, the state health secretary, Dr. Arnold Muller, tried to institute the kind of state-wide, state-enforced systems Boyd and others had advocated; he gave up the next year, thwarted by lobbyists from the Pennsylvania Medical Society (PMS) and the Hospital Association of Pennsylvania (HAP). PMS and HAP, by the way, ranked fourth and fifth respectively on the list of PAC contributors to Pennsylvania politicians that year. To make matters worse, several hospitals threatened to sue, charging--if you can believe it--restraint of trade. Only one hospital, Lehigh Valley Medical Center in Allentown, managed to get the state's official trauma center designation before the program was terminated. When the state compared preventable trauma death rates in Allentown before and after the designation, it found a 33 percent drop.

In 1983, members of the state legislature proposed a bill to develop in the rest of the state the same system that saved lives in Allentown. But after months of fighting, the sponsors threw in the towel and let lobbyists for the hospitals and physicians association gut the legislation. "I talked to my committee chairman and others,' Rep. James Greenwood, the bill's House sponsor, told Andrew Schneider of The Pittsburgh Press, "and I finally realized the reality was that, unless this bill was blessed by the HAP, it would never get out of committee. There is a long record of that happening.' The bill's Senate sponsor, Roy Wilt, chairman of the Senate Public Health and Welfare Committee, agrees: "The political realities were that we'd never be able to move the bill into law. HAP and PMS are very persuasive.'

The law Governor Richard Thornburgh finally signed gives the state no power to designate, monitor or enforce the trauma center system. Instead, it leaves responsibility for setting "private, voluntary' standards for and maintaining the trauma "system' to an independent organization, the Pennsylvania Trauma Systems Foundation. The foundation is staffed primarily by members of the HAP and PMS. "We don't want the government involved,' says the HAP's chief lobbyist, Jack Wicks. "We want the free enterprise, competitive approach.'

The free market strategy

Pennsylvanians who want to see what a little free enterprise looks like in emergency medical care can take a look a thousand miles to the south at Florida. Like Pennsylvania, Florida took several million dollars worth of federal EMS grants in the seventies and began to designate trauma centers but failed to come up with a comprehensive state-wide plan. After the federal money ran out, Florida embarked on a new course. One jealous hospital that wasn't going to be designated a trauma center challenged in court the state's right to designate hospitals as such. Rather than meeting the challenge with a law empowering the state to designate selectively, the legislature mollified the hospitals in 1982 with a law allowing any hospital to call itself a trauma center. All the hospital had to do was file a long application promising to fulfill minimum manpower and equipment standards and then pay a small fee to cover the costs of state inspections.

Problems surfaced almost immediately. Most of the hospitals that applied were those competing in areas that already had enough trauma treatment facilities. Jacksonville, for instance, was well-served by the University of Florida Medical Center. Today, the city has eight trauma centers. Since the university hospital is tax-supported, the patients it now receives--about half of the total--are predominately those who can't pay, and these account for the lion's share of the gunshot and stabbing victims. The other seven hospitals are all private, and their patients are typically car accident victims who can pay their bills, thanks to car insurance. This skimming off of the profitable trauma victims, revolting as it may be, is probably less harmful in the long run than the shortage of cases that the surgeons and staff have at these seven hospitals. Without that volume, these practitioners simply won't be as effective at saving lives.

Jacksonville, though, has the distinct advantage of having trauma centers. In southern Florida, where there were none before the 1982 law, only a few applied after its passage. One reason hospitals held back was the fear that indigent patients, such as those from the large population of illegal aliens in the area, would be dumped on the first hospital to step forward. Another was the unwillingness of the local surgeons to make the commitment in time and effort to meet the state guidelines, one of which is to have at least some surgeons in the hospital at all times. In response, EMS officials purposely watered down the commitment statements to require only that the surgeons get to the hospital as quickly as possible--all in the hope of persuading more surgeons to take trauma care seriously. The changes were made despite the well known need for prompt action in cases of traumatic injury.

If the more lenient guidelines were meant to get more hospitals and surgeons involved, the effort didn't work too well. In Dade County, hospitals feared that if only a few institutions sought designation as trauma centers, they would be stuck with caring for most of the poor patients and those without insurance. To avoid the problem, the hospitals conspired to seek the designation en masse, effectively defeating the idea of having certain hospitals that specialize in emergency medicine. Elsewhere in southern Florida, hospitals didn't even make this gesture. Outside of Dade County, there isn't a single trauma center in the southern third of the state.

In other respects, Florida much resembles Pennsylvania. The same sort of legislative battle was fought just this year with hospital associations leading the successful counter-offensive against reform. Next year another bill is expected to come before the legislature, with the full support of the hospital associations, and it will aim at simply preserving the status quo. Dr. Ray Alexander, chief trauma surgeon at Jacksonville's University Medical Center and a state EMS advisor, observes that Florida has tried the marketplace: "Look what happened. It gave us trauma centers of questionable quality, distributed geographically in the worst possible way.'

As if all this weren't enough, the fees paid by those hospitals that did apply to be trauma centers were insufficient to pay state inspectors to do on-site investigations. "The way it works now,' says Alexander, "you send your application to the state, and they send you your official trauma center certificate in the mail. If my staff, say, can't meet some of the commitments, well, I can just turn my head and the state's never going to know.' Don't kid yourself into thinking no hospital would ever cut corners. John Pekkanen reported in The Washingtonian that Maryland inspectors made a surprise visit to a small hospital the day after an official inspection only to find a large quantity of expensive emergency room equipment being loaded onto trucks. The hospital, it seems, was eager enough to win designation as a trauma center to rent the equipment just for the inspection.

The price of delay

The Florida and Pennsylvania trauma center bills aren't wholly without merit. The debate surrounding them has raised public awareness and helped convince some doctors and legislators that there really is a "trauma problem' out there. The bills also call for field triage protocols and the drafting of hospital monitoring programs. Whether officials will have the will or the money to act on these plans is another question. But if they do, both states systems will be "switched on' (as Chicago's never was), and analysts will be able to compare the effectiveness of these free market trauma systems with that of government designated systems, such as the one in Orange County, California (see "One Doctor's Fight for Emergency Care,' p. 26).

The doctors and hospital administrators aren't all heartless. Many truly believe their free market approach can save as many lives, perhaps more, than the government designation strategy. Of course, if numerous hospitals and doctors sincerely gear up for trauma, many lives will be saved. But in this contest, the burden of proof is now on the free market doctors and hospitals. The people who devised the government designation program spent several years studying the problem of trauma and have numbers to prove that their approach works. Most free market advocates spent those same years denying there was a problem; now they want us to believe they will solve it. Given the thousands of needless deaths that continue to occur because we don't have adequate trauma systems in place, you have to wonder if the contest is worth the price.
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Title Annotation:part 1; includes article on Dr. John West
Author:Glastris, Paul
Publication:Washington Monthly
Date:Nov 1, 1985
Previous Article:How to stop libel suits and still protect individual reputation.
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