Trauma in the foothills
Part of the charm of the Sierra Nevada comes from the myriad opportunities for a good time the region offers.
But along with a rural lifestyle come the rigors of living “in the sticks.”
For victims of critical injuries suffered in car accidents or serious falls, or by gunshot, the need for vital emergency services becomes immediate in an area where treatments for some of the most basic medical needs aren’t immediately available.
For example, those with moderate head injuries suffered in a Nevada City car accident often bypass Sierra Nevada Memorial Hospital in favor of Sutter Roseville Medical Center, which has the neurological services SNMH lacks.
If accident victims are under 13, they must be airlifted to the University of California at Davis Medical Center in Sacramento, a trip that takes nearly 30 minutes.
The hospitals in Roseville and Sacramento are the closest trauma centers to western Nevada County.
“That’s part of the reason why we’re so busy,” said Wendy Nugent, a registered nurse and trauma program manager for UC Davis Medical Center, which counted 8,000 trauma visits in 2001, 3,000 of which lasted more than 24 hours.
“The vast majority of California doesn’t have an organized trauma system,” said Nugent, whose hospital is part of the Sierra-Sacramento Valley Emergency Medical Services Agency.
The Rocklin-based joint-powers agency sets trauma policy and disburses state-authorized trauma program funds for Nevada County, along with Placer, Yolo, Yuba and Sutter counties.
The region, according to statistics from the California Department of Finance, serves 648,241 people.
The 121-bed Sierra Nevada Memorial Hospital does not meet standards set by the agency to qualify as even a Level III center, which provides the most basic trauma services.
Those services include surgeons who specialize in emergency medicine, as well as orthopedic and neurosurgery specialties, either in-house or through a transfer agreement with another hospital.
Though SNMH has a fully staffed emergency department physician available 24 hours a day, seven days a week, hospital staff members say there simply isn’t the need for a full-fledged trauma center in western Nevada County. Establishing one would be impractical and exceedingly expensive to maintain, offering little return on the facility’s investment.
Though the hospital lacks traditional trauma services, it can play a key role in assuring a trauma patient’s survival, said Dot Mitchell, a registered nurse and clinical coordinator of the hospital’s emergency department.
“We can stabilize any patient,” she said. “Our initial level of care could run the gamut, from stabilizing their airway to checking their vital signs. You want to make sure they’re in the best situation before transferring them.”
The hospital has 10 emergency-room physicians who work eight-hour shifts, three during each shift. The hospital’s Quick Care service, which provides urgent care, is open 12 hours a day.
The majority of trauma patients who could be stabilized by the hospital are most often airlifted to either Davis or Roseville by on-scene paramedics who are first responders, said Dr. Darren Phelan, Sierra Nevada’s medical director for the emergency department.
There are times, however, when the local hospital pitches in to assist patients who would otherwise be immediately airlifted. Rick Senuty, one of the six individuals shot – allegedly by county mental patient Scott Thorpe – in a Jan. 10, 2001, rampage, was initially stabilized by SNMH doctors before being airlifted.
But the need for a trauma center, Phelan said, is minimal at this point.
“We can go days without seeing someone that requires those kinds of services,” he said. “Even if we had a facility, we could build it and we would not have the population to warrant (a trauma center).”
“Just the infrastructure expenses to staff a trauma center would be huge,” Mitchell said.
According to the Sierra-Sacramento Valley EMS agency that determines trauma center placement in the five-county region, only a dramatic population boom would warrant SNMH’s designation as a trauma center.
According to its guidelines, “No more than one Level I or II trauma center shall be designated for each 350,000 (people) within the service area.” Fewer than 95,000 people live in Nevada County.
However, Leonard Inch, executive director of SSV EMS, said the authority is always looking for hospitals willing to upgrade services to accommodate trauma patients.
“We’d be more than happy to talk to Sierra Nevada Memorial Hospital if they were interested in becoming a trauma center,” he said.
It’s a move that requires commitment of a large medical staff dedicated to treating the most seriously injured patients.
In some cases, hospitals designated as trauma centers have decertified themselves because of cost, such as Truckee’s Tahoe Forest Hospital, which last month gave up its Level III designation.
“(Becoming a trauma center) can become quite political, and it takes a great deal of orchestration. It’s important to have everyone on board,” Inch said.
Trauma centers, Inch said, can cost millions but generate great revenues, like Sutter Roseville Medical Center. The Level II hospital is often the primary hospital for airlifts of car accident victims in SSV’s five-county service area – those more likely to pay medical bills than patients at UC Davis, which sees a higher incidence of penetrating wounds from victims less likely to have insurance.
“They have a lot more indigent-care patients, and it costs more to admit them,” Inch said of UC Davis’ trauma clientele.
In fact, according to “California’s Trauma Care in Crisis,” a report with statistics from the Centers for Disease Control and Prevention and compiled by Inch’s agency, trauma centers in California spent as much as $183 million in services for which they were not compensated in 2000.
That’s why many trauma centers and emergency departments are forced to close their doors, as Mercy American River Medical Center in Carmichael did about 18 months ago.
The state kicks in funds to help keep many of these trauma centers afloat. Last year, Gov. Gray Davis authorized $25 million for trauma services; hampered by budget shortfalls, Inch said he’s hoping to get $2.5 million this year.
“We’re in a fight to keep our funding levels the same,” he said.
It’s necessary, he said, because traumatic injuries are the leading cause of hospitalization for Californians under the age of 34.
At Sutter Roseville Medical Center, two trauma rooms with four beds and at least two trauma surgeons are available 24 hours a day, every day of the year.
It’s an expensive but necessary proposition in both a rural and rapidly growing area, said Cheri White, the hospital’s trauma program manager and a registered nurse.
The hospital saw 1,700 trauma patients in 2001, most of whom suffered blunt trauma – primarily concussions and broken bones, she said.
The hospital serves as a referral, or transfer center, for both Tahoe Forest and Sierra Nevada Memorial hospitals.
Patients from either come to Roseville “with regular frequency,” she said. “When you become a trauma center, you agree that’s a service you’ll provide.”
Though the trauma center is probably the most expensive part of Sutter Roseville’s operations, “patients probably spend the shortest amount of time of their hospital stay in the trauma room,” she said.
The rooms provide on-site X-ray capability, a CT scanner, volume infusers that can pump blood or vital fluids into the patient’s body; cardiac monitoring devices and digital radiography – two television monitors that allow physicians to see on-screen X-rays.
In addition to her duties as the medical center’s pre-hospital coordinator, registered nurse Susan Webb is responsible for directing radio traffic for incoming trauma flights from points as distant as Modesto and Reno. In fact, the hospital is in the process of adding a second helipad and increasing its emergency-room capabilities from 19 to 31 beds.
The 172-bed hospital must do this in part because of the rapid population growth east of Sacramento.
The helipad cuts down response times dramatically, she said, especially in some of the hospital’s undeveloped service areas, including Nevada County.
“It’s extremely important because of the community we serve. In our region, with twisty, windy roads, they can’t get (ambulances) there by ground in an hour, which is why we rely so much on the helipad,” she said. There are times now when the hospital must use a street in front of the complex if there are multiple airlifts arriving at Sutter Roseville.
“The majority of the time, we have no problem accepting whatever patients we can get,” Webb said.
That’s good news for people like Inch, who’s responsible not only for the health of trauma center patients, but for the health of the region’s trauma centers as a whole.
With insurance providers playing a greater role in a patient’s care, health care costs escalating and the state on uncertain financial footing, trauma centers are at a crossroads, he said.
“I think people are reasonable to expect good care, but the question is, will trauma services always be available?” he said.
“The trauma system is virtually on the verge of collapse, and it’s a statewide issue,” Inch said. “If you’re badly hurt and you go to a non-trauma center, there’s nothing guaranteeing you will get optimal care.”
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