A Trauma Center to the Rescue

Los Angeles County’s newest trauma center in downtown Los Angeles has treated nearly twice as many patients as anticipated in the first three weeks of its operation and is expected to receive even more when the trauma unit at Martin Luther King Jr./Drew Medical Center closes Feb. 1.

The unit at California Hospital Medical Center on Grand Avenue has been bustling since it opened its doors Dec. 1, treating about 75 patients suffering from extreme injuries, including stabbing and gunshot wounds, and injuries suffered from falls and car accidents.

If the pace continues, California Hospital could treat about 1,250 patients a year -- far more than the 660 the county’s Emergency Medical Services Agency had expected.

Officials aren’t sure whether the numbers reflect a busy month or simply mean that there is an even greater need for trauma treatment in the central city area than they had thought. In any case, both the county and the hospital administrator are confident they can take on the extra patients. Despite the high numbers, the center has been able to treat all patients without filling up and without diverting ambulances.

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One of the most severely injured patients the new trauma center has handled was 24-year-old Tamara Ruiz, whose liver was split into three pieces during a car crash Dec. 9. Ruiz, who works as a parking attendant at Hollywood Presbyterian Medical Center, said she was driving to work from North Hills at 6:30 a.m. when a car blindsided her car. She was not bleeding and had just a bruise above her right eye.

Paramedics took her to California Hospital, where a body scan revealed a lacerated liver and a fractured clavicle.

“The doctor said, ‘Sign this paper,’ and then he will make surgery,” Ruiz said. “He said, ‘Do you want me to tell you what I’m going to do?’ I said, ‘No, just save me.’ ” Then nurses and others ran with her gurney to the operating room.

Surgeons had to perform two operations because Ruiz was so weak. In the first surgery, Ruiz and relatives said, doctors had to staunch the bleeding; in the second, they finished stitching together her liver.

Claudia Margana, 30, flew from San Francisco to be at her sister’s bedside. Ruiz flitted in an out of consciousness and seemed to have tubes all over her body. Margana said she kept asking for a pen and trying to write phone numbers, but Ruiz said she didn’t remember any of that.

“They told us she might not make it,” said Gabriela Sanchez, 28, who is married to Ruiz’s cousin. “I just kept telling her she was fine and I love her. We kept praying.”

On Friday night, a day and a half after the accident, Ruiz finally woke up and wondered what time it was, where she was and what had happened. By Saturday afternoon, doctors had removed the tubes and Ruiz could finally talk to her parents, who were anxiously waiting by the phone in El Salvador.

On Monday, she sat up, then walked a few tentative steps. She moved out of the intensive-care unit the next day and went home with Sanchez on Dec. 17. On Wednesday, she returned to the hospital for removal of a drain placed next to her liver to collect fluids.

“I just want to thank God for her and the doctors,” Margana said.

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At any given time, 16 people -- including a trauma surgeon, five nurses with different specialties, a respiratory therapist and trauma manager Steven Myles -- can immediately answer a “code trauma” call on the hospital’s loudspeaker. The hospital also keeps a list of on-call doctors and brings them in when the primary doctor becomes busy.

About a week after opening, the trauma center had to call on this reserve list, beckoning a second surgeon, then a third, as two patients came in who required immediate operations, Myles said. One patient, with complex internal injuries from a car crash, required two surgeons. The other patient was a man who had fallen off a bicycle and impaled himself.

So far, the four trauma beds, two in each of two rooms in the corner of the emergency room closest to the ambulance parking lot, have not filled up with critical injuries at the same time.

On a recent Monday, hospital officials were using the area for emergency patients who were not seriously ill. Those patients would be moved if a trauma patient arrived.

The trauma rooms look very similar to other emergency rooms, with ventilators and heart monitors. But next to the beds, there are also newly purchased ultrasound machines, machines that warm blood or saline for rapid infusion, and wheeled carts carrying trays of specialized equipment for creating airways quickly or opening skulls.

One such tray held instruments for a thoracotomy, the opening of the chest. Among the 33 items inside this special metal box are bone shears, a saw for the sternum and a device that spreads ribs.

California Hospital had been seriously considering creation of a trauma center for 14 months. The hospital had put together a panel of specialists, including neurosurgeons and orthopedic surgeons, and had found radiology technicians who could be on call at night. Hospital managers had reserved two operating rooms for trauma patients and made sure they were heated to 72 degrees, warmer than operating rooms for other surgeries.

They set aside an eight-room wing of the intensive-care unit and arranged for extra beds in other intensive-care areas. They enlarged the curtained-off areas around four beds in the emergency room to allow a larger number of doctors, nurses and technicians to gather around patients.

They were ready to open in July, but last-minute concerns about whether California would get enough patients to cover its cost scuttled the plan. The county’s proposal in September to close King/Drew’s trauma center, located 10 miles south, helped to restart negotiations between the hospital and the county. On Nov. 16, the Board of Supervisors approved a seven-month contract with California Hospital that would pay a maximum of $3.98 million for about 1,000 patients. On Nov. 23, the board voted to close King/Drew’s trauma center.

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The first call for “code trauma” over California’s loudspeakers -- also transmitted by pager to trauma team members -- came about 10 a.m. Dec. 1.

Los Angeles city paramedics were bringing in a man who had fallen on a sidewalk at the intersection of 5th and Hill streets. Witnesses told firefighter-paramedic Douglas Nuttman that the man had possibly been hit by a car or suffered a stroke. Because the man was not fully conscious and suffered multiple cuts, Nuttman decided this was a possible trauma case and headed to the nearest trauma center: California.

“There was an overwhelming response,” Nuttman said recently. “They had a bed open and waiting. There were security guards available to us. There was a full trauma team in the ER. There were several well-wishers and onlookers.”

“A normal trauma team is eight to nine people -- doctors, nurses, ER technicians,” he said. At California, “there were probably 20 to 25 people in the room.”

Some hospital administrators approached him after he transferred the patient from the ambulance’s backboard to the hospital bed.

“They all wanted to know where we came from, how we knew they were open, what criteria the person had met, that kind of thing,” Nuttman said. “They were really excited.”

More cases followed in unpredictable clusters, Myles, the trauma manager, said. One Friday, the hospital saw six stab wounds, then no trauma patients for days. Then, three victims came in with gunshot wounds, one right after the other.

In the first 14 days, the hospital treated three “hangman’s fractures,” a rare break in certain neck bones that might happen when, for instance, a person is not wearing a seat belt and hits his or her chin on the dashboard of a car.

Many of California Hospital’s new trauma patients come from the northern part of the area served by King/Drew, health officials said.

King/Drew’s trauma center, which saw about 1,800 patients this year, is handling an average of only about three patients a day, half of its former load, said John Wallace, a spokesman for the county’s Department of Health Services. Most of the other patients are now being taken to California, he said. (The emergency room at King/Drew remains open, and the trauma unit will treat patients until Feb. 1, 2005.)

King/Drew, which is in Willowbrook, just south of Watts, has been under intense scrutiny by federal regulators and national accreditors after medical lapses contributed to several patient deaths. The L.A. County Board of Supervisors hired an outside consulting company to identify problems and begin making changes over the next year and voted to close the trauma center in a last-ditch effort to relieve pressure on the troubled hospital.

Many local activists and politicians, saying they hold the trauma center in high regard, have protested the closure. They worry that the added time to transport gunshot or stabbing victims to the next closest facility could lead to deaths.

The county intends to review California’s performance in mid-January and then decide how to proceed.

“We’re talking a lot of what-ifs, and we’re only talking three weeks,” said Carol Meyer, director of the county’s Emergency Medical Services Agency. “From everything I’ve heard, they’re doing a good job.”