Lack of a nearby trauma center imperils Las Vegans

By Steve Kanigher

Saturday, July 13, 2002 | 11:29 a.m.

It is virtually impossible to find anyone who doesn't believe that a trauma center is a necessary and integral part of a big city.

When a trauma center closes, which happens occasionally, usually for financial reasons, there is a great deal of anxiety expressed by physicians, politicians and the public at large that lives will be needlessly lost.

That is because of the widespread belief that having a team of specialists available around the clock to deal with life-threatening injuries is preferable to relying only on emergency rooms.

The anxiety has been especially heightened in Las Vegas, whose only trauma center closed July 3 after 57 orthopedic surgeons resigned. They said rising medical malpractice insurance rates made it too costly for them to treat high-risk trauma patients.

Most other communities have other trauma centers nearby if one closes, but that is not the case in Southern Nevada, where the closest trauma facilities are outside the state.

The trauma center at University Medical Center reopened Saturday morning when orthopedic surgeons agreed to return for at least 45 days.

A leading proponent of trauma centers is Sonny Oztas, spokesman for the American Trauma Society in Upper Marlboro, Md. The nonprofit society advocates trauma prevention and improvements in trauma care.

"The emergency room staff can have general doctors who can deal with broken fingers and legs, but when you have a patient losing a massive amount of blood, time matters," Oztas said. "With an emergency room you're leaving it to luck. If a doctor there happens to specialize in that injury, you're lucky. At level one trauma centers those specialists are on hand at all times.

"Having the nearest trauma center hundreds of miles away is a tragedy."

When county-run UMC closed its trauma center, the Las Vegas Valley was the largest metropolitan community in the nation without such a facility. That is a distinction spokesmen for mayors in other large cities said they would like to avoid.

Andrew Hudson, spokesman for Denver Mayor Wellington Webb, said trauma centers can be expected to play a critical role in community health care, particularly in the aftermath of the Sept. 11 terrorist attacks.

"Without a trauma center we'd have a lot more dead citizens," Hudson said. "I can't tell you how many lives have been saved because of it but I can't imagine our city without one. We have some of the most highly trained physicians available whose jobs are saving lives in very extreme circumstances."

Taxpayers in Seattle consistently have supported exapnsion of Harborview Medical Center and its trauma center, Casey Corr, spokesman for Mayor Greg Nickels, said.

"For anything from an earthquake to a terrorist attack you need trained staff to be able to handle those problems," Corr said. "If we didn't have a trauma center, I think we would have a lower level of preparedness for natural and man-made disasters. We would have more people die for lack of immediate advanced care."

San Diego Mayor Dick Murphy said through his spokesman: "I believe trauma units are critical to the quality of life of our city. I cannot imagine existing without one."

As Nevada's only level one trauma center, the highest of four levels recognized by the American College of Surgeons, UMC's facility includes trauma surgeons, emergency physicians, neurosurgeons, orthopedic surgeons, anesthesiologists and other on-call specialists available around the clock.

Mike Tymczyn, marketing director for Valley Health System, which includes Valley, Summerlin and Desert Springs hospitals, said establishing a trauma center is a huge ordeal involving major financing, staffing additions and physical expansion of the hospital itself.

Large endeavor

"We only have one trauma center here because for a facility to go from an emergency room to a trauma center is a very large endeavor," Tymczyn said. "It's having big enough space. It's having physicians on-call 24 hours a day.

"It's not only a huge investment monetarily but a fundamental change in the way a hospital does business. If a Valley Health System hospital wanted to be a trauma center, we would have to make substantial changes in emergency room staffing and in the physical plant. There would also have to be a huge investment in technology and equipment."

Before UMC established its trauma center in 1989, trauma patients were taken to the nearest hospital. But Ann Lynch, spokeswoman for Sunrise Hospital and Medical Center, said having a trauma center has improved the treatment of such patients because everyone who works at the center specializes in trauma care.

Lynch said the Las Vegas Valley has only one trauma center because trauma surgeons, who are full-time employees, are hard to come by.

"There aren't that many people who are trauma surgeons," Lynch said. "It would be very difficult for a community this size to find enough trauma surgeons to staff more than one trauma center.

"In order to have a trauma center you need to have trauma surgeons round the clock. It's very expensive. If you look at trauma, it doesn't happen every day. So you have to be standing by, waiting for the most urgent cases. It's cost-prohibitive for most hospitals to do that."

When a trauma center closes the biggest losers are young people, according to statistics compiled by the National Trauma Data Bank. In a nationwide survey of 67 trauma centers from 1994 to 1999, the data bank found that individuals aged 16 to 22 represented the greatest number of patients admitted to those facilities. After about age 40, the percentage of older trauma patients decreased dramatically with the exception of a slight upward swing around age 80.

Those findings were similar to the experience at UMC, where 45 percent of the trauma patients last year were 17 to 34 years old. Only 17 percent were 55 or older.

Among other data bank findings:

Leading cause

At UMC last year, 41 percent of the patients admitted to the trauma center were victims of motor vehicle crashes, making it the leading cause of injury. Close behind, at 39 percent, were patients with other blunt injuries. The remaining 20 percent of the patients were admitted because of gunshot or stab wounds.

Trauma care was first commonly practiced by the military during the Korean and Vietnam wars. The hit motion picture and television comedy M*A*S*H showed wounded soldiers being transported by helicopter to a Mobile Army Surgical Hospital.

Many inner city hospitals developed trauma units in the 1970s. But by the 1980s, dozens of centers shut down nationwide because they were losing money and hospitals could no longer afford to keep them.

The number of trauma centers nationwide rose from 881 in 1995 to 1,352 in 2000, according to the American Hospital Association. Included was an increase in level one centers from 193 to 254. But the financial pressures that led to closures in the 1980s exist to this day.

Much of that has to do with the fact that many trauma patients are uninsured or under-insured, which makes it difficult for hospitals to be fully reimbursed for that care. Trauma centers commonly are subsidized through profits from other departments within the hospital or from state revenues, such as taxes on tobacco or alcohol.

UMC's trauma center has been in good shape financially and contributed "positively" to the hospital's bottom line, UMC spokesman Rick Plummer said. Detailed revenues and expenses were not available for the trauma center because it is not logged as a separate line item in the budget.

But Plummer said the reason hospital officials believe the trauma center is a money-maker is that the vast majority of its patients are covered by insurance, which makes it different from many other trauma units.

"Some larger cities have more than one trauma center and some of these trauma centers care for larger numbers of trauma patients with gunshot and stab wounds who are traditionally uninsured," Plummer said.

"About 80 percent of the trauma patients brought to UMC were victims of blunt trauma. The majority of blunt traumas are caused by motor vehicle accidents. Automobile insurance is mandatory in Nevada."

In neighboring Arizona, the Legislature met in special session last fall to approve a $4.3 million state-funded bailout to keep two level one trauma centers open in Tucson, Ariz., for another year. The money was needed to help pay for trauma physicians, Mike Letson, spokesman for Tucson Medical Center, said.

"The issue we were looking to fund was the readiness," Letson said. "With a level one center you need people standing by to spring into action whether or not cases arrive. It's a community-wide service to have people ready, much like police and fire service. You fund a fire department even when they're not fighting fires.

"One problem at hospitals all over the country is that the ability to support money-losing programs is becoming more difficult. There's no margin left. Everything has been squeezed out of the system. Trauma centers are not designed to be profit makers."

Another reason trauma centers close is because they cannot retain enough of a particular specialty. That's what happened in May at Carraway Methodist Medical Center's level one facility in Birmingham, Ala., which lost many of its nurse anesthetists to rival hospitals.

When two neurosurgeons retired earlier this year in Hagerstown, Md., the stress placed on the three remaining brain surgeons became so overwhelming that Washington County Hospital last month suspended operation of its level two trauma center. The closest trauma centers, in Baltimore, are about an hour away by ambulance.

Washington County Hospital spokeswoman Maureen Theriault said the remaining neurosurgeons became concerned about the lack of personal time available to them.

"When you're up all night it's tough to come back to your private practice in the morning and be at your best," Theriault said.

Looking at options

"We are determining what type of options are open to us. One option is to become a level three trauma center, which means trauma specialists would have to be within 30 minutes of the hospital."

It is rare for a trauma center to close because of skyrocketing medical malpractice insurance rates, as was the case when UMC lost all but one of its 58 orthopedic surgeons. The doctors left initially because they said they could no longer afford the risk of working at the trauma center.

Some of them came back Saturday to help reopen the trauma center after the state attorney general's office stated it would be legal for UMC to extend its $50,000 liability cap to the surgeons for 45 days. The doctors are hoping for a more permanent solution when the state Legislature meets in special session later this month.

The only other trauma center closing linked to malpractice insurance rates occurred when Brandywine Hospital in Coatesville, Pa., closed its level two center on June 10. The hospital had a contract with 10 surgeons from the University of Pennsylvania to provide trauma care, but skyrocketing medical liability rates in that state discouraged them from renewing their agreement with the hospital.

The Pennsylvania Legislature passed insurance reform this year but it did little to appease doctors because the legislation did not include caps on damages for pain and suffering, Brandywine spokeswoman Evelyn Walker said. Area trauma patients are now transported about 35 miles away to hospitals in Philadelphia and Lancaster, Pa.

"It's phenomenal that doctors and other medical practitioners can't get through to legislators how critical this is," Walker said. "I believe lawyers have a better ability to lobby. Hospitals and doctors are not as diligent when it comes to lobbying."

Physicians said that when UMC closed its trauma unit it increased the likelihood that Southern Nevada patients would die within an hour of their injuries.

What they couldn't predict was the extent to which patient survival would have fallen below the 96.6 percent success rate recorded by UMC's trauma center last year.

Now that the trauma center has reopened the issue of patient survival has become moot, but only temporarily. That's because the hospital faces the prospect that it will have to close its trauma center once again if doctors fail to convince the state Legislature to adopt the medical malpractice insurance reforms they seek.

Up until the announced reopening, physicians such as Dr. David Hoyt, medical director of trauma for the American College of Surgeons, and Dr. Donald Palmisano, president-elect of the American Medical Association, were calling the UMC situation a tragedy. The college sets standards for trauma care.

Borrowed time

"You're living on borrowed time right now," Hoyt said earlier this week. "At some point the services that hospital provided will overwhelm the other hospitals."

Hoyt, who is also chief of trauma at the University of California at San Diego Medical Center, cited a study that found the lack of trauma care can decrease the likelihood of survival by as much as 10 percent. If the survival rate of trauma patients taken to other Las Vegas Valley hospitals was reduced to 86.6 percent from 96.6 percent, the 121 fatalities recorded by UMC's trauma unit last year would have increased to 479 deaths over the next year.

One factor working against Las Vegas is that it is hundreds of miles away from the nearest trauma centers in Arizona and California. That's what set the UMC closure apart from most other trauma centers that have been shut down nationwide over the past 20 years. In most cases, there was another trauma center within an hour's drive by ambulance or sooner by helicopter.

When Birmingham's Carraway Methodist closed its trauma center, patients simply were diverted to the city's other trauma center run by the University of Alabama at Birmingham.

"That's one of the things we looked at when we decided to suspend our services, the impact it would have on the community," Carraway spokesman Cullen Clark said. "We knew there would still be a trauma center available."

That luxury was not available in the Las Vegas Valley. Instead, it was determined that trauma patients would be taken to the closest hospital.

"We believe this jeopardizes the care of thousands of Las Vegans and vacationers," Palmisano said earlier this week. "This also increases the burden on emergency rooms, which aren't set up to handle these patients. What the AMA is concerned about is that there will be a lack of access to care for patients."

The closest trauma centers by air from Las Vegas are 75 minutes to Palm Springs, Calif., 80 minutes to Loma Linda, Calif., 90 minutes to Flagstaff, Ariz., and 100 minutes to Los Angeles. Within the first week of UMC's closure, Mercy Air transferred only one trauma patient, a 12-year-old girl, out of state. The girl, transferred from UMC to Children's Hospital in Los Angeles on July 7, survived.

But Mike Griffiths, regional business director and flight nurse for Mercy Air, said Southern Nevada simply was lucky.

"You're going to have patients who will survive whether there's a trauma center or not," Griffiths said. "But in general it's just a matter of time that there are patients who are going to die."

'The Golden Hour'

The lack of a trauma center puts a damper on what is known in the medical community as "the golden hour." Those first 60 minutes represent the period of time considered most critical in saving the lives of patients after they have suffered life-threatening injuries.

If emergency rooms have to transfer trauma patients to other medical facilities with specialized care, it can cut into that golden hour.

"The longer the patient is in shock the greater the chance the patient will have increased complications or face the risk of death," Palmisano, a New Orleans surgeon, said. "So speed is essential.

"The longer you have feces in the abdomen the greater the chance there will be an invasion of germs into the bloodstream. If you have a blood clot on the brain, the longer you wait the greater the chance of permanent damage."

Hoyt said it's guesswork to predict the ability of hospitals without trauma centers to save the lives of trauma patients.

"You'd really have to measure that based on how many patients you thought died because they didn't get care quickly enough," Hoyt said.

While some emergency rooms have equipment similar to that found in trauma centers, the question is whether they can assemble the surgical and nursing specialties necessary to work on patients with multiple injuries. An example is a patient who has suffered a blood clot on the brain as well as severe chest injuries and fractures to lower extremities.

"Car accidents can result in that, especially if someone didn't have his seat belt on," Palmisano said. "That person is more likely to have multiple injuries when he is tossed around."

One of Palmisano's fears is that other trauma centers will close because of high medical malpractice insurance rates.

"I'm afraid this isn't going to stop with Las Vegas, unfortunately," he said.