|Second-year resident Dr. John Hunter reassures auto accident victim Dawn Bender shortly after her arrival at the trauma center. X-ray technician Chris Vineyard observes while waiting to perform part of the initial exam.|
Of course, that's if it can stay in business. A step back from the doctor-swarmed gurney stands Ashley Book, her starched aqua scrubs bunched at the ankles. Book's clipboard records every procedure: every suture, injection, and IV bag. Book, 24, is a physician's assistant studying at nearby University of Texas Health Science Center; right now University Hospital System's trauma center is her classroom. Tonight's lesson is in ER care, and financial survival.
Trauma services are never fully reimbursed by insurance providers, but the financial shortfall grows when doctors and nurses don't record each procedure during the hectic treatment. So Book is assuring financial accountability. She learns what it means to treat trauma, as the hospital continues its lesson in working for each dime.
EC Tech Mike Dodd stabilizes a patient's head as a surgeon works to stop the bleeding from a serious head injury.
NICKLED AND DIMED
In 1991, the Texas Department of Health, attempting to provide better trauma coverage across the state, split Texas into "trauma areas." It designated Bexar County the center of Trauma Area P. University Hospital serves 22 counties, but is paid by only one Bexar. Out-of-county residents and uninsured patients are the primary reasons for UHS' money problems. Of the 13,000 patients treated in the trauma center from September 1999 to August 2000 at a cost of $29 million nearly 4,000 lived outside Bexar County, and an additional 4,000 were uninsured.
Yet UHS often accepts patients from outside its 22-county range; in 1999-2000, it treated patients from 104 counties and lost $13.7 million in unreimbursed treatment costs. In 2001, unreimbursed treatment costs had decreased to $12.5 million.
As South Texas' population increases, the strain on the trauma center grows. One in three Texans will require a trip to a trauma center at least once in his or her lifetime, hospital officials say.
"We're all at risk for not having care if we have an emergency condition," says Dr. Ronald Stewart, the center's director of trauma. Critics charge that UHS should quit treating non-Bexar residents to save money. Stewart, a 9-year veteran of the ER retorts: "You ever travel outside the borders of Bexar County? You ever head south and hit the coast? So when you're in your car crash out there we're supposed to say, 'Nope, we're not taking care of you. You're from outside of Bexar County.' Do we ever say that? No, that's illogical."
|Nurse Chris Esparza, center, places a mask and eye shield on third-year surgery resident Dr. John Bini, as the trauma team works to repair a head wound. Team members. EC Tech Mike Dodd (right) and surgical resident Dr. Kevin Hundenko (2nd from the left) assist.|
Inside the tinted glass doors that lead from the ambulance bay to the inner maze of the trauma center, three patients lie on gurneys that are parked to the side of the hallway. The patients idle in this busy thoroughfare because there are no beds elsewhere in the hospital. A passing nurse notices that one person's allergic reaction to an unknown substance is getting worse; she sticks her with a syringe filled with epinephrine. These three could be worse off: UHS turned away other ailing people what is called a diversion before they even made it to Medical Drive.
It seems odd that the patients are left in a hallway while a floor above the ER, in room 1062, a quiet bed is stacked with only office chairs.
"We don't have enough nurses to staff all the beds," says Dr. Osbert Blow, the hospital's head of pediatrics. When the hospital runs out of beds, it starts turning away all but the most severely injured. Sometimes it has to turn away everyone. April 2001 saw the worst shortage. Since then, the hospital has offered more incentives to attract nurses, such as a shorter work week and higher salaries. Tonight 20 out of a possible 26 beds are staffed. Earlier in the week only 17 beds were.
|Trauma surgeon and head of University Hospital's trauma services, Dr. Ronald Stewart (center), prepares to administer pain medication to an auto accident victim in the hospital's trauma center.|
"There is a crisis and it's manifest in emergency health care. But at its root, there's a money problem. I can tell you that if all these patients were fully funded, driving around in these ambulances, there would be no bed crisis, and there would be no diversion. And there would be competition for getting those patients," Stewart claims. "The problem is there's not money to `increase bed capacity`. Hospital administrators have to make a decision. In some ways it goes like this: you want to be responsible and a good steward of your institution and the public, so do you expand your bed capacity and lose money at a faster rate? That's really what it is. If you increase your bed capacity, what it amounts to is, you go broke quicker."
The University of Texas Health Science Center, the major "feeder school" for UHS, has also been operating in a deficit for the past few years as much as $12 million in 2000. UTHSC, like other national medical schools, hasn't been able to graduate enough students to keep University's trauma center staffed with trauma surgeons and neurosurgeons. In July, UHS' trauma center refused to accept patients with suspected head injuries because it didn't have enough neurosurgeons on staff. Without these specialists, the trauma center must rely more heavily on fully staffed military hospitals whose ability to take patients is also uncertain.
|Former fighter pilot Dr. Greg York, a fourth-year surgical resident manipulates the delicate thread as he sutures the colon of a stabbing victim.|
The Level 1 military trauma centers at Brooks Army Medical Center and Wilford Hall serve as back-up to University, but treat only one-fifth of the number of patients as the civilian ER. Neither BAMC or Wilford Hall is required to treat the public: These centers admit civilians to prepare Army surgeons for war casualties. If bloodied soldiers fill the bases' trauma centers, they can close to outsiders
Unless a person has an object sticking into him, protruding from him, or his body is bruised blue, the less-injured (broken bones, cuts, smashed hands) land in the ER's midlands: the waiting room. A fuzzy TV picture sends blue flickers over the agonized people here, where not even the "Out of Order" snack machines offer solace. In one corner, two bed pans hold vomit. Nearby a heavy-set man paces as his friend, with his hand wrapped in bloody towels, waits for treatment. The two drove 114 miles from Victoria because the hospital there wasn't equipped to operate on the badly broken fingers.
George Hernandez Jr., UHS' executive vice president, says this type of trip is common: "Even if those counties wanted to take care of their own trauma, they could not do it. It is a labor intensive, high-tech industry. So we're in it together, for better or worse."
|No money to increase bed capacity|
Last year Hernandez worked with state legislators to introduce Senate Bill 1459, which would have levied a Bexar County sales tax of 1/4 cent. The bill made it through committee in the Senate but got stuck in the House. It still would have left Bexar County footing most of the bill: Hernandez estimates it would have generated $3 million for University's trauma center in out-of-county visitors and nearly 10 times that amount from within Bexar.
Also last legislative session, District 40 State Rep. Juan Hinojosa (D-Hidalgo County) acted independently of UHS lobbyists to introduce House Bill 893: The measure, which made it out of committees in both the House and Senate, was never put to a larger vote. It would have added $10 to vehicle registration costs and alleviated some of the state's trauma center woes. Hinojosa based the new fee on the hospital stats showing that 60 percent of trauma in the state result from motor vehicle accidents.
|Pediactric surgeon Dr. Osbert Blow discusses X-ray results with Dr. Dan French, a second-year urology resident.|
"I'm of the opinion that the problem has gotten so acute that we all have to work together," he says. "Part of the solution is regional. We are a regional service. From here to Brownsville, from here out to El Paso, we're exploring ways of getting a revenue stream for the expense. It's something that Harris County, Dallas County, El Paso County, and Lubbock are all struggling with.
"It's going to have to be across the state: Houston, Dallas, Ft. Worth, Lubbock. And that's what we're working on right now. Do we have a solution? No, we don't have a solution."
|Tim Ford, R.N., records EMS treatment data from San Antonio Fire Department paramedic Ralph Sifuentes. Although paramedics enter their reports electronically, in the trauma center it is done by hand.|
"In terms of the future of San Antonio, (where the medical industry is the largest sector of the economy) how are we going to compete with Dallas, Houston, Atlanta?" adds Chairman of the UHS board Roberto Jimenez. "What else do we have? Tamales? Mariachis? I mean, give me a break."
|"Take it slow and easy," Dr. Osbert Blow instructs surgical resident Dr. Sandkeep Khandahar as he prepares to insert a chest tube into a critically ill patient.|
The cost to the hospital for treating her, whether a loss or a gain, hasn't been settled yet. For the healthy citizens, policy makers, and everyone else living within a helicopter ride of Bexar County, hopefully that expense won't mean another unstaffed bed at University Hospital, or another patient waiting in a hallway. The bed that's not available might ultimately be the one you need.
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