Lone trauma center works, keeps Tucsonans alive
System that sends 90% of cases to UMC called surprising success
By ANNE T. DENOGEAN
The teenager’s head was bleeding and his body bruised as the LifeNet helicopter landed at University Medical Center on a recent weekend.
In a flurry of activity over the next 35 minutes, a UMC trauma team of doctors, nurses and technicians examined the 18-year-old highway rollover victim from head to toe.
They inserted a breathing tube, put him on a ventilator, drew blood, inserted a urinary catheter, stapled the laceration on his head, did a quick abdominal sonogram and ran X-rays before sending him off for a CAT scan.
He was among the 4,915 people treated for traumatic injuries by UMC and other area hospitals during fiscal 2004 in what most hospital and emergency medical personnel say is a story of community cooperation and sometimes heroic effort.
UMC became the only remaining Level 1 trauma center in southern Arizona after Tucson Medical Center stopped operating as one a year ago today.
UMC handled 4,414, or 90 percent, of the trauma patients, including all of the most serious, close-to-death traumas, said Greg Pivirotto, UMC president and chief executive officer.
Other area hospitals saw 501 patients, 60 percent fewer than UMC projected they would take under the trauma protocol adopted last July.
Three years ago, southern Arizona was at risk of losing all Level 1 trauma care – the intensive level of care required by victims of shootings, stabbing, falls, car accidents and other events causing major injury. TMC had said it could no longer afford to offer the service, and UMC was unsure it could continue without its 18-year partner in trauma care.
A system emerged in which UMC would take all the trauma patients it could handle, but every other hospital would regularly accept some.
“From Kino to Northwest to El Dorado, every single hospital in this town has had to work outside of their comfort zone at one point or another in the last (12) months,” said Joe Gulotta, Tucson Fire Department’s deputy chief in charge of emergency medical services.
“They work very closely with UMC, and I think it’s made the community a safer place … It’s the only way the trauma center can remain open,” he said.
While the rural perspective is different, most local hospital and emergency personnel interviewed said the system is performing as well or better than they expected.
Dulton Nez, 20, was satisfied with care at UMC after suffering a ruptured collarbone in a car accident in Sells on Saturday.
“They’re doing a good job,” he said, resting in a trauma bay.
“They got everything done quick. He wasn’t sitting around waiting,” said his friend Leatrice Bernard, 20.
To gear up for its increased role, UMC spent $3 million in new state trauma funding to hire more emergency room doctors, trauma surgeons, neurosurgeons and orthopedic surgeons. The hospital also added about 300 staff members and opened a new intensive care unit, Pivirotto said.
UMC saw 47 percent more trauma patients this year than in fiscal 2003, he said.
UMC can put itself on “trauma caution” status when it’s approaching capacity on caring for trauma patients. That’s when other hospitals must take on lesser injured trauma patients to keep UMC open to the most critical patients. It was on that status 4,927 hours or 56 percent of the time, a hospital report said.
Dr. Herb McReynolds, chairman of the ED directors committee of the Southeastern Arizona Emergency Medical Services Region, said he hadn’t heard of any deaths caused by the inability to get someone to a trauma center.
McReynolds said St. Mary’s Hospital, where he is medical director of emergency services, and other hospitals remain uneasy about accepting trauma patients but “the system is working despite our discomfort.”
With a viewpoint that put him in the minority among those interviewed, Dr. Gary Figge, medical director of the ED for Northwest Medical Center, said the system has been “suboptimal” over the last year.
Trauma centers have the equipment, surgeons and specialists available that other hospitals don’t have at all times, he said. Northwest admitted patients who should have gone to UMC or sent them to Phoenix more often than was anticipated, he said.
“To my knowledge, nobody has truly suffered from this but people are rolling the dice, and it’s a gamble right now,” he said.
Ideally, he said, UMC would get sufficient public funding to handle all the trauma in this region.
Pivirotto said he doesn’t foresee a time when UMC will take all the trauma in the region and doesn’t believe it should. Having all the hospitals prepared keeps the trauma system flexible, as well as keeping everybody sharp, he said.
“Imagine if you had another 9/11, God forbid, in this city. You would want the hospitals to be ready to handle their share,” he said.
It isn’t clear how many people are being taken to Phoenix when Tucson’s trauma system is overloaded, and whether rural areas are adequately served.
UMC documented three instances of redirecting trauma patients to Phoenix since last July. But LifeNet, an air ambulance service, estimated it is making an 10 additional flights a month from southern Arizona to Maricopa County hospitals because UMC can’t take the patients, said Stacy Paisley, LifeNet’s director of program development. In most of the cases, the patients taken to Maricopa County wouldn’t have needed air transport if Pima County had available trauma care, she said.
For those patients, there is an added danger as their transport cuts into the “golden hour” that is considered optimal for getting a severely injured patient to a hospital. There also may be a financial burden to their families.
Arthur Maggs of Tucson was taken to Phoenix hospital by ambulance after he was injured in an Aug. 10 car accident. St. Mary’s doctors decided he needed trauma care for broken ribs and a punctured lung, but UMC was full, Maggs said.
His wife had to drive to Phoenix and stay in a hotel for four days. He was billed $1,700 for an ambulance drive to Phoenix, although he expects insurance to eventually pay the bill.
“It wasn’t a pleasant ride, I can tell you that. I had broken ribs and I felt the pain with the bumps in the road,” Maggs, 77, said.
Citizen Staff Writer Brad Branan contributed to this article.
Definition: What is trauma care?
A Level 1 trauma center cares for victims of car accidents, shootings, stabbings, falls and other traumatic injuries.
These centers have specialists in-house or on-call around the clock to take care of patients who may have multiple injuries involving more than one of the body’s systems.
A top-level trauma care center has a surgeon available at all times and can quickly call in doctors in such specialties as orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology and critical care. Other capabilities could include cardiac, hand, pediatric, microvascular surgery and hemodialysis.
If you’ve had the misfortune to visit an emergency room lately for nontrauma injury or illness, you may have experienced a longer-than-expected wait.
When doctors are busy with trauma cases that means they aren’t seeing you.
“We put through 60,000 patients a year in our ER,” said Dr. Gary Figge of Northwest Medical Center. “When all of sudden you’ve got a physician who was handling a number of people tied up in one room for an hour or two, somebody is waiting.”
UMC trauma patient load by acuity. Red is the most severe.
Year Red White Green Total
2004 580 947 2,887 4,414
2003 416 666 ,928 3,010
UMC accused of doing too little for rural trauma patients
By ANNE T. DENOGEAN
Because of an editing error, an article Thursday about trauma care in rural areas incorrectly attributed a remark to Dr. John Guisto of University Medical Center.
It was Ruth Kish, chief operating officer of Copper Queen Community Hospital in Bisbee, who said that trying to transfer trauma patients from the hospital over the past year has become an hours-long endeavor in frustration.
If the story of trauma care is a success in Tucson, it’s a story of fear and frustration in surrounding rural areas, officials at rural hospitals say.
“The ‘golden hour’ is gone here. It takes us two to three hours to move somebody now, even someone who is a legitimate trauma center patient,” said Ruth Kish, chief operating officer of Copper Queen Community Hospital in Bisbee.
University Medical Center, which collects trauma data, did not have figures on trauma patients treated by rural hospitals in southern Arizona over the past year.
On Saturday night, shortly after UMC accepted three car crash victims from Sells, UMC emergency physician John Guisto said, “For really major trauma cases, we almost never turn down a transfer from any hospital. That’s pretty rare.
“I don’t know that it’s possible to make everybody happy in a limited resources environment.”
Trying to transfer trauma patients has become an hourslong endeavor in frustration over the past year, Kish said.
Kish said UMC doesn’t outright refuse the patients but suggests it would better serve the patient if Copper Queen looked for a hospital that was less busy.
That leaves Copper Queen personnel shopping their patient to other hospitals in Tucson, Phoenix and even Yuma, she said.
One Copper Queen trauma case this year involved a woman who fell and had operable brain bleeding. The Bisbee hospital called UMC, Tucson Medical Center and hospitals in Scottsdale. UMC eventually accepted the woman, but it took 2 1/2 hours to make arrangements, Kish said. Ideally, the patient should have been out of Bisbee’s emergency room within an hour, she said.
Dr. Ross Luther, medical director for the ER at Holy Cross Hospital in Nogales, said UMC, as the only Level 1 trauma center in southern Arizona, has become much more “resistant to accept anything that isn’t really righteous Level 1 trauma.”
Luther said one trauma patient Holy Cross transferred to Phoenix while UMC was on “trauma caution” required insertion of a breathing tube to secure an airway, had multiple rib fractures and went to the operating room with a necrotic bowel, which means tissue was dying.
“It’s very unnerving to have a sick patient where you don’t have the capacity to handle and work up their problems,” Luther said.
UMC should give rural hospitals special consideration in taking even lower level trauma patients because rural hospitals lack the resources Tucson hospitals have in terms of surgeons, specialists, nurses and technicians, he said.
If a patient’s condition suddenly deteriorates, rural hospitals may not be able to provide needed care, Luther added.
Given the potential consequences, “you’ve got to give the guys in the rural areas the benefit of the doubt. It’s the humane, professional thing to do,” he said.
Dr. Everett Castle, an emergency room physician who works at El Dorado Hospital in Tucson and Sierra Vista Regional Heath Center, said UMC is providing adequate care in Tucson, “but they are not providing adequate service to the rural areas.”
Greg Pivirotto, UMC’s president and CEO, said it may be necessary for UMC personnel to visit rural hospitals this summer to see what can be done to better accommodate needs.
Kevin Craven, UMC’s director of emergency medical services, said the university plans to expand telemedicine services to offer real-time consultations between rural hospital staffs and UMC trauma surgeons.
The training of rural healthcare providers is a priority, said Dan Judkins, UMC trauma coordinator. LifeNet air ambulance service is providing $10,000 in scholarships so nurses can attend advanced trauma care training in Tucson, he said.
ILLUSTRATION: Southern Arizona trauma cases
(originating with the emergency medical system)
July 1, 2003, through present:
Seen by UMC: 4,414
(47 percent increase over previous year)
Seen by other hospitals: 501
Who got the 501 trauma cases:
St. Mary’s 110
St. Joseph’s 65
Tucson Heart 60
Kino Community 40
El Dorado 5
Benson Hospital 1
* Number of patients diverted to Phoenix or treated in rural hospitals is unknow. Also, the figures don’t include the small number of trauma patients who arrived on their own at other area hospitals and were never reported to UMC.
PHOTO CAPTIONS: FRANCISCO MEDINA/Tucson Citizen
Sherry Palmer, a nurse working in the telemetry room in the University Medical Center emergency room, stays in contact with city ambulances.
June 26, Kolb and Golf Links roads
Tucson firefighters remove two teens from a vehicle that was struck by a Waste Management truck.
XAVIER GALLEGOS/Tucson Citizen
University Medical Center ER
ER personnel spring into action to treat a man in his 50s who was thrown from his car after it rolled over.