Originally posted at California Healthline.
By Leslie Griffy.

In rural California, traumatic injuries often happen hours away from medical services.

Rescuers scramble helicopters or ground ambulances to rush victims of car crashes, major accidents or violence to hospitals outside of the region. Occasionally, those expensive trips to life saving aid are waylaid by weather or traffic.

It can take as long as three hours to get the injured to a trauma center, even by air. Access to centers along the north and central coasts and the East Sierra is most limited.

Over the past two years, communities long without trauma centers began to fill the void – designating regional hospitals as resources for those suffering from traumatic injuries.

In 2012, San Luis Obispo County officials picked Sierra Vista Regional Medical Center to be a level-three trauma center. Late last year, Monterey County followed suit, beginning negotiations with its own hospital, Natividad Medical Center, to change staffing in order to qualify as a level-two trauma center.

“I think there are going to many profound benefits to Monterey County and perhaps other counties, too,” county Supervisor Jane Parker said as officials opened talks with Natividad last year.

Still, there are six counties in the state without trauma centers. San Mateo and Merced counties have quick and easy access to nearby trauma centers. Yolo county trauma patients are sent to UC Davis

Traditionally, San Luis Obispo, Monterey, San Benito, Santa Cruz and Tuolumne counties faced the biggest obstacles, said the California’s EMS Authority’s Bonnie Sinz.

These areas “may have transport problems due to weather because if ground transport is too long, patients are air lifted to trauma centers outside their area,” Sinz said.

All counties must plan where to take trauma patients. That plan is approved by the state’s Emergency Medical Services Agency.

Local EMS agencies and county officials designate hospitals as trauma centers, if nearby hospitals are willing to take on the cost of extra staffing. Those centers must meet standards set by the American College of Surgeons. There are a variety of levels of trauma designations. Lower level trauma centers have fewer staffing requirements and can stabilize patients before sending them on to other hospitals for care. Higher-level certification requires round the clock access to surgeons and others.

Before San Luis Obispo County designated Sierra Vista as a level-three trauma center, allowing it to accept trauma patients and stabilizing some of them before sending them on for more intensive care, it may have been one of the most isolated counties in the state without a trauma center, Sinz said

“Ground transport was in most cases too far and even air transport was long and in some cases difficult due to weather,” Sinz said, “…To quote the American College of Surgeons ‘organized systems of care have been shown to save lives after injury.’”

But adding a designated trauma center created new concerns.

It can be hard, for example, to explain to a person injured in the north of the county why an ambulance bypasses nearby hospitals as it heads to the trauma center, said EMS division director Steve Lieberman.

“It’s going to be a process of public education,” he said. It’s also requiring learning for the EMS teams, as they track where patients are going and how they categorize patients as having traumatic injuries or not.

But in an area with an aging population and many fall-related injuries, having a trauma center equipped with CT scans is important, Lieberman said.

The Monterey County Civil Grand Jury twice raised concerns about the lack of trauma care in the area, noting that the first hour after trauma is often the window for life saving care.

According to a state Emergency Medical Systems Authority report, an estimated 20 to 40 percent of injury-related deaths could be avoided if a patient can quickly receive adequate help.

While waiting for its trauma center, the county largely depends on helicopter services to rush injured patients to out-of-county emergency rooms.

Thirty-three times in a single year weather forced emergency ambulance crews to seek alternate transportation for the injured, according to the grand jury report.

Not only can the flights be delayed, they are often expensive, costing as much as $30,000. Insurance covers about 80 percent of the cost. Medi-Cal pays for about 12 percent. The rest of the bill is either sent to the patients or written off by the nonprofit that provides the service.

Add to that the cost of travel for the family of the victim, which may have to drive an hour one-way to visit or help care for the injured.

Despite all of the compelling reasons to establish local trauma centers, the expense of required staffing for trauma center designation can be prohibitive.

“Nobody builds a trauma center for financial benefit,” said Harry Wardwell, board member of the other Monterey County hospital that vied for the trauma center designation, Salinas Valley Memorial Hospital.

The cost is in part why Monterey County didn’t establish a trauma center the first time the grand jury raised concerns about the lack of care in the area back in 2007.

At that time, Natividad Medical Center, a county-run hospital, faced crippling debt and Salinas Valley Memorial was helping to bail Natividad out. There simply wasn’t the money to increase staff.

But better fiscal conditions led both hospitals to compete for the designation in 2012.

Natividad is expected to fill the second trauma-center black hole on the central coast by January 2015.

Still, trauma centers remain far away for populations in other areas of the state.

“In the rural areas of the state, we could agree that trauma center access is difficult,” Sinz, with the state’s emergency medical agency, said.

Some lower-level trauma centers exist in these areas, but only act as a stopping off point for the seriously injured, Sinz said. But without the population to support a trauma center, it’s a situation unlikely to change.

“There are few hospitals in those areas that have the resources available to commit to a higher level of trauma center designation,” Sinz noted.