Violence overwhelms trauma center staff,costs millions

"HUP is the most frequently closed trauma center in the city," William Schwab, the center's director, said yesterday. "There are times when we get five, six, or seven victims in here at once and we can't take them all." Schwab said the closures are a direct result of the rising tide of drug-related violence, which is exhausting trauma center doctors and causing the center to lose millions of dollars each year. "A year ago we were admitting one gunshot wound patient a day," the director said. "Now we're admitting three a day." Because there are only two emergency trauma beds, doctors must turn away additional patients when two patients are being treated at once, Schwab said. The center is also often closed because the intensive care unit is full, the director added. When the center is closed, severely injured patients in West Philadelphia must be transported to one of the six other trauma centers in the area, costing precious minutes. But Schwab said the patients would be in greater danger if they had to wait for a bed at HUP. Last weekend the HUP trauma center treated eight separate gunshot victims. A week ago, three gunshot wound victims -- a drug dealer and two police officers -- were brought to the center at the same time, Schwab said, forcing it to close its doors to other patients for several hours. The dealer had shot at the two policemen, hitting both of them. The officers returned fire and hit the dealer 11 times. In addition to the closures due to the center's being full, the center closed on three occasions last month for a 24-hour period because the senior trauma surgeons were exhausted. The increasing number of victims of drug-related violence has also hurt the center's financial health because most victims of drug-related violence do not have private medical insurance to pay for their care. In 1989, the center lost approximately $3.9 million, or $5100 per patient. The center lost $1.3 million alone in caring for patients with handgun wounds. "You can't go on treating these people forever or you'll go out of business," Schwab said yesterday. The problems caused by increasing urban violence are not unique to the HUP trauma center. Across the country, many hospitals have been forced to dismantle their trauma centers, according to Alexander Walt, past president of the American College of Surgeons. In May, Walt told a Congressional subcommittee, which is considering a bill to provide extra federal funding to urban trauma centers, that in Los Angeles only nine of 23 trauma centers remain in a network set up in 1983, while Chicago has lost four of its 12 trauma centers since 1986. When trauma centers drop out of the system, Walt said, the remaining centers are forced to bear even heavier burdens. "If the drug dealers cause our trauma system to collapse, . . . our family members and friends who are the victims of automobile or bicycle accidents, falls, severe electric shocks, and the rest are at a real risk of suffering unnecessary disabilities or loss of life," Walt said. Schwab said that while the HUP trauma center will not be permanently shut down any time soon, something must be done on a city-wide level to handle the dramatic increase in injuries. "The whole system, Emergency Medical Services and the hospitals, have to get together and deal with this," Schwab said. Schwab suggested that the system could be better coordinated so that only patients who will die or lose a limb without immediate medical care -- the kind of patients the centers were designed to treat -- are brought to trauma centers. Currently, many patients who do not fit these qualifications end up at a trauma center, Schwab said. If violence continues to worsen, city hospitals with trauma centers will have to make a decision about whether to expand their money-losing centers to meet the rising demand, Schwab said. Schwab also testified before the Congressional committee. He called Philadelphia a war zone and compared the HUP trauma center to a M.A.S.H. unit, trying to save the war's casualties. "In addition to the handgun identified by the police, many wounded arrived in our trauma center sill armed with a second handgun, knives, explosive devices and even wearing bullet proof vests," Schwab told the committee. "At the operating room table, we routinely remove bullets known as hollow tips, wad cutters, and dum-dums, all of which are specific for one thing -- tissue destruction and human killing," Schwab continued. "Because of the destructive power of the weapons used, these patients require the same instantaneous type of surgical care as conventional mililtary warfare." Schwab reported that 66 percent of all the patients treated at the center last year tested postive for illegal drugs. Eighteen percent of all those admitted tested positive for two or more drugs. "Over 100 patients were so out of control, enraged or combative from substance abuse that they had to be anesthetized prior to receiving medical care," he said.

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