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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.
Between groans, the driver of the wrecked car asks where her passenger is, while a technician slices the jeans and blouse from her body. Her snapped wrist bulges beneath the skin of her forearm, and her stomach aches from the impact of the crash, but Dawn Bender, 38, is lucky to be here. Paramedics took the less-injured friend to a downtown hospital, but brought her to University Hospital because the Level 1 trauma center is able to deal with the most severely hurt — like Bender — 24 hours a day, seven days a week.

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.

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EC Tech Mike Dodd stabilizes a patient's head as a surgeon works to stop the bleeding from a serious head injury.
Since 1999, the trauma center has operated at a loss nearly every year. It is in good company — other metropolitan hospitals also are suffering a near-catastrophic money crunch. Yet San Antonio's situation is unique in that several factors have converged to affect not only the city's poor and uninsured, but every person living in south Texas: a state-mandated increase in UHS' service area, a lack of funds, and what hospital officials say is community apathy. If University's trauma center doesn't receive financial help soon, each of us in the region it serves — from El Paso to Brownsville and all points between — could be without it when we need it most.

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.

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The trauma center's re-sus room, where the most serious traumas are examined and treated, is abuzz with activity after receiving four trauma cases in 10 minutes.

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."

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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.
Since trauma is trauma — the hospital's mandate is to serve anybody in need who comes through the door — the insured and uninsured both could be turned away if the center runs out of beds or funds. As the hospital's executive vice president says, "People need to know that this is a middle class problem, too."

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.

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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.
"The focus that we bring on this is indigent care and trauma. But I think it's much broader than caring for those 350,000 people that don't have insurance," says Dr. Stewart. "I can guarantee you that you may have Blue Cross and Blue Shield and the world's best insurance plan, but if you happen to keel over right across the street, and we're on diversion and Wilford Hall's on diversion and it's 5 p.m., you're going to BAMC — and it's going to take a while.

"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.

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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."

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No money to increase bed capacity
University Hospital administrators say they are doing what they can to stem the trauma center's money bleed, in part by hiring more nurses and improving the billing process. A new, permanent funding source is needed to maintain the facility's current services. Officials are moving away from a property tax hike — which they say would be only a bandage — and talking about levying a sales tax.

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.

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Pediactric surgeon Dr. Osbert Blow discusses X-ray results with Dr. Dan French, a second-year urology resident.
This session, Hernandez is meeting with groups such as the Texas Association of Public and Non-profit Hospitals, the Texas Hospital Association, and Houston's Save Our ERs to craft what he calls a "comprehensive solution."

"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."

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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.
So far, no cuts have been made to UHS services in Bexar County. "One of the reasons that we went to the legislature last time is that we recognize that this is a very fragile situation that we're in. It's not just money, it's a problem with people not wanting to spend their lives doing what `Trauma Director` Dr. Stewart does," says Jeff Turner, CEO of UHS.

"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."

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"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.
Bender, the car crash victim, got lucky. In addition to re-setting her broken arm, Dr. Stewart suspected that the pain in her stomach was her colon, ruptured by the seat belt during the crash — a fairly common injury in car wrecks. An exploratory surgery at 1 a.m. proved him right. If overlooked, the small blow-out could have killed Bender within days.

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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