San Diego Magazine / October 2003 / Tackling Trauma

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Tackling Trauma

“Trauma” is one of those words that hits you in the stomach like a medicine ball. Gruesome car wrecks, gunshots, stabbings. Falls from ladders, dog bites, hands caught in machinery. Webster’s New World Dictionary defines trauma as “a bodily injury, wound or shock,” and it has always been human nature to squeeze the very worst out of words that make us cringe.

But to Dr. David Hoyt, “trauma” represents his life’s work. A charter member of San Diego’s trauma system, which came together in 1984, he’s now rightfully and righteously proud of what he and fellow San Diego surgeons—working with the county Health & Human Services Agency’s Emergency Medical Services unit (EMS)—have accomplished.

“We’re known internationally for not only having sustained a trauma system, with high-quality care, for 19 years, but also for contributing to and defining how care is delivered in this country through the quality of the system and ongoing research,” says Hoyt, professor and vice chairman of surgery and chief of trauma at UCSD Medical Center, one of the top trauma centers in the country.

“It’s a wonderful example of a public-private partnership,” says Dr. Brent Eastman, one of the key architects of San Diego’s trauma system. “And it’s an inclusive trauma system, designed to address the needs of a seriously injured person from the time of injury through rehabilitation.”

San Diego’s trauma system is a partnership among six of the county’s 21 hospitals and the county EMS, which oversees the fleet of ambulances and helicopters that transport trauma victims to the hospital. The network’s objective, Hoyt says, is to reduce mortality rates “through the initial identification of injured patients in the field and then transporting them to hospitals that are capable of caring for them.”

The six designated trauma centers—UCSD Medical Center and Scripps Mercy Hospital, both in Hillcrest; Sharp Memorial Hospital and Children’s Hospital, both in Kearny Mesa; Scripps Memorial Hospital in La Jolla; and Palomar Medical Center in Escondido—are all staffed with surgeons “who either sleep in the hospital or can get to the hospital within minutes of the patient’s arrival, and are trained to deal with trauma patients,” Hoyt says.

That’s a crucial, if not defining, characteristic of any successful trauma system, says Eastman, the N. Paul Whittier chair of trauma at Scripps Memorial Hospital and chief medical officer of the Scripps Health System.

“The fundamental principle of survival from major injury is dependent on minimizing the time from injury to definitive care, and I think we’ve done that successfully,” says Eastman, who also is a clinical professor of surgery at UCSD. “If you’re injured anywhere in San Diego, you’re ensured to be transported directly to a trauma center that has the resources to give you proper care.”

In a typical month, San Diego’s trauma system serves about 540 patients. The most common injuries are car crashes, followed by falls, gunshot wounds and stabbings. Since its formation nearly two decades ago, the network has cut the preventable-death mortality rate in San Diego from a high of 22 percent, where it stood before the trauma system was formed, to less than 2 percent, Eastman says.

Each year, the trauma center at Scripps Memorial stages a reunion for survivors. Of the hundreds of former patients Eastman has seen over the years, one stands out.

“A young man was working for the post office, delivering mail in one of those little trucks, and he was hit hard in a crash and was paralyzed from the waist down,” Eastman recalls. “I remember caring for him—along with his primary trauma surgeon—and seeing his young wife, who was pregnant at the time, at his bedside, facing the fact that he would be paralyzed.

“Well, he’s come to our reunions every year, and seeing him and his wife and that little girl who was born while he was still in the hospital and is now 10 years old, seeing her whip him around in his wheelchair, well, that’s just a wonderful sight. He could have died—he would have died—without immediate care.”

San Diego’s trauma system has become a model for trauma systems around the country. The local network’s medical audit committee, in particular, has been emulated by other trauma systems around the world, Eastman says.

The medical audit committee is made up of trauma directors and nurse managers from each of the six trauma centers, representatives from the county EMS, the county medical examiner and a cadre of medical specialists. Once a month, the committee meets to pore over all trauma cases handled in the preceding month, with special attention paid to autopsy reports.

“It’s a very exhaustive review process,” Hoyt says. “We sit down with everybody else and decide if there were any errors made. We literally review every patient who died to see if anything could have been done differently that would have saved a life.”

“It’s really an incredible thing,” adds Eastman. “You have all these medical care systems that are extremely competitive in all other areas, and yet here we all come together and really work as one.”

Outsiders have taken note. Among them is Dr. Donald Trunkey, the past chair of the department of surgery at Oregon Health & Science University. His peers consider him the dean of trauma surgeons. Trunkey has high praise for San Diego’s trauma system.

“It’s an excellent system,” he says. “I think their quality improvement program [the medical audit committee] is the model for the rest of the United States. It’s really superb. They’ve got good hospitals, too, and good surgeons. They’ve done it right.”

San Diego’s trauma system was established in August 1984, at a time when similar partnerships between hospitals and regional governments were beginning to spring up throughout the country.

Locally, there was growing concern among members of San Diego’s medical community that certain trauma deaths could have been prevented had the right care been given at the right time. Among the cases that raised eyebrows was that of a surfer who had been injured in the water by an errant board. He had been sent home after a visit to an emergency room but later died of a ruptured intestine.

Eastman, who had come to San Diego in 1972, had previously practiced medicine in San Francisco, which already had a trauma system. In fact, San Francisco General Hospital, where he trained, had one of the country’s eight original trauma centers.

“My observation was that even though we had excellent hospitals and doctors, we did not have a system of care that could ensure that if you were injured, you would have all the proper resources available immediately,” recalls Eastman, then a trauma surgeon at Scripps Memorial. “If you were injured, you were taken to the nearest hospital, and in a sense, it was a bit of the luck of the draw that you would be taken to a hospital with the proper resources to care for you.”

Another surgeon who felt the same way was Dr. Richard Virgilio, director of trauma at Mercy Hospital. The two doctors rallied others to their cause, and in 1982, the Hospital Council of San Diego & Imperial Counties commissioned a study that took a long, hard look at preventable deaths. The findings were shocking.

“The report found that 22 percent of trauma deaths within San Diego County were potentially preventable,” says Gwen Jones, chief of the county’s EMS unit. “That caught the attention of the community, and the county Board of Supervisors immediately began to look at developing a trauma care plan for San Diego.”

In 1983, the board approved the formation of a trauma system modeled after the one in San Francisco. Requests for proposals were sent to local hospitals, inviting them to participate in such a system. In the end, six hospitals made the cut. The system was implemented in August 1984 and has remained essentially intact ever since, except that Grossmont Hospital was subsequently replaced by Palomar.

It hasn’t all been smooth sailing. In 2001, Palomar Medical Center threatened to withdraw from the trauma system, citing high expenses. A year later, orthopedic surgeons at Palomar called a strike over money and long working hours. The strike shut down trauma service in Escondido for two weeks while doctors haggled over terms.

The work stoppage prompted the county Board of Supervisors to commission a complete audit of the trauma system, at a cost of $300,000. The report, released in March, brought vindication. San Diegans “should be amply reassured that the network of prehospital providers and trauma centers provides high-quality, state-of-the-art care,” the report says. “The community should have confidence that the trauma system continues to provide a superior level of service to its residents.”

Still, there was room for improvement. More injuries are classified as traumas in San Diego than in any of California’s 18 other trauma systems, the report noted, taxing fragile hospital resources. Auditors said that while some studies recommend overestimating injuries in 35 percent of patients to ensure no trauma is overlooked, the rate at some San Diego trauma centers is as high as 48 percent.

Local trauma directors, however, took issue with that portion of the report, maintaining it’s better to be safe than sorry.

Trunkey, the nationally known trauma surgeon, isn’t surprised by this clashing of the minds. “Trauma systems around the country are under siege,” he says. “There are all kinds of problems. And they’re a microcosm of the problems facing healthcare in general.

“But one of the things that adversely affects trauma systems is high malpractice rates. Trauma centers, because they are the only means of getting excellent care after an injury, get a disproportionate number of injuries, so funding is a real problem.”

That’s not all. “It’s difficult to attract young surgeons into trauma surgery,” Trunkey says, “particularly in some of the specialty surgeries, like neurology and orthopedics. They can make more money doing things outside of a trauma center.

“We’re also under siege from accreditation committees and colleges. Now, residents can only work 80 hours a week. I’m not saying that’s bad, but what are we going to do about manpower?”

Trunkey urges San Diegans to look at the many positives in the report. “The citizens of San Diego County really have something to be proud of,” he says. “And they should sure as hell try to make it work.”