A Matter of Life and Death
If you were shot in the heart and reached Parkland or Ben Taub Hospitals with visible life signs, you would almost certainly survive. Elsewhere in Texas, you would probably end up dead.
Tracy White, a Dallas contributor for Texas Monthly, was an auto-crash victim treated in Parkland Hospital’s Emergency Room several years ago. She remembers the experience well:
“We totaled our car in an eight-car collision on Stemmons Expressway. In shock, we were left with only our instincts and were totally dependent on the emergency care available. I remember arguing, while the ambulance attendants watched, over who was hurt the worst and who would get to lie down in the ambulance. Each of us saw only the other covered in blood. The ambulances were lined up in front of the red neon emergency sign at Parkland, like limousines before a brightly lit concert hall. I remember standing and waiting to be admitted, sitting and waiting for medical care. Everyone else there looked like they were dying—a man on a stretcher, his intestines hanging out; a child with a knife wound in the face; a black woman whose black lace evening gown had caught fire and had melted into her skin. I walked from one person in white to the next person in white, and I kept saying something simple and polite, competing to be part of the elite who would receive help. Three hours later we were stitched, bandaged, and sedated.”
The delayed ambulance service, the confusion of the emergency room where treatment came slowly while accident victims wandered in shock, were common experience in Texas emergency rooms (ER) before 1970. Since then, local medical societies and citizens have forced changes for the better in some Texas cities. Dallas—where Tracy White was a patient at Parkland in 1967—now provides the best emergency-medical care in the state, according to a six-month study by Texas Monthly of the major cities, their ambulance service, and the emergency rooms of their public, comprehensive-care hospitals.
There are a number of questions to ask when gauging the quality of an emergency-medical system: how many ambulances are available for how many people? Do those ambulances carry cardiac-care kits for heart-attack victims? Are those ambulances manned by emergency-medicine technicians (EMTs) or paramedics who can operate the cardiac kits? Are the technicians on the ambulance able to communicate with medical specialists at the waiting hospital? Are those specialists able to monitor the patient’s life signs via telemetry hook-ups between hospital and ambulance? And at the emergency room itself, is there a triage nurse who separates the critically ill or injured from the minor medical cases? Are there trauma or shock rooms available for treatment of heart attacks, head and chest injuries, burns, and gunshot wounds? Are the nurses trained in emergency medicine and do the physicians on duty include trauma or emergency medicine specialists? And how many people in how many counties is this small medical team responsible for?
The public ambulance service in Dallas holds the best average response time in the state—4.34 minutes; its ambulance equipment includes cardiac-care kits and telemetry; and it includes 121 paramedics among its 293 Emergency Medical Technicians. Parkland Hospital, recently reorganized and expanded, its ER into an Emergency Department, an impressive design of major, minor, surgical, burn, and other specialty rooms. Between Parkland and Baylor Hospital, more than 200,000 people were treated in 1974. Houston’s emergency-medicine system—backed by the resources of the state’s largest medical center—is close behind Dallas. San Antonio, with its year-old public ambulance service and the overworked but efficient Bexar County-Green hospitals, closes the ranks of the best in EM care in Texas. Elsewhere, in Austin, Corpus Christi, El Paso, and Fort Worth, the quality of emergency care is well below that offered in the major cities. People can die in these cities of injuries and traumas that might not be fatal in Dallas or Houston.
Our contributors were Martha Hume, Austin; Anne Cain, Corpus Christi; Tracy White, Dallas and Fort Worth; Wayne McClintock, El Paso; Phil Hevener, Houston; and Ron White, San Antonio. For a report on the quality of emergency medicine in rural Texas, our contributors were Robert J. Macdonald of The Lyndon B. Johnson School at the University of Texas in Austin and Moselle Boland, who interviewed Dr. Kenneth Mattox of Houston, a founder of the American Trauma Society.
Most people who are associated with health care in Austin believe that their city’s emergency-medical service is the worst in the state. The central problem is not a lack of dedicated people nor a lack of professional imagination; rather, Austin’s problems stem from lack of coordination between the city council, the medical profession, the hospitals, and private enterprise. In addition, the hard facts of general inflation and the low-profit yield of emergency-medical care systems don’t help.
Austin’s emergency-medical care “system” is simple: one emergency room in city-operated Brackenridge Hospital and one ambulance company with nine ambulances handling Austin patients through a contract with the city council.
Brackenridge Hospital is the comprehensive-care emergency room for 500,000 people: Austin (population 250,000), Travis County (population 45,000), and a ten-county area which includes Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, Milam, and Williamson (total population 170,000). At present, Brackenridge ER treats 200 patients a day, an increase of 50 patients a day over the 55,000 cases treated in 1973. The Brackenridge ER is a fourteen-bed unit housed in cramped quarters on the first floor of the hospital and staffed by seven medical doctors from the Central Texas Medical Foundation (CTMF), twenty registered nurses, fifteen licensed vocational nurses, fifteen ward clerks, sixteen nursing assistants, one full-time social service worker, and one policeman. None of the CTMF physicians are emergency-medicine specialists, but all of them have had extensive ER experience, as have the nurses and the clerks. There are two “crash rooms” for trauma and coronary care, one obstetrics-gynecology room, and two isolation rooms. The minimum bill is $27, which includes a $12 hospital fee and a $15 physician’s fee.
Brackenridge’s emergency room will double in size when an expansion is completed in a new wing in 1977, but many Austin physicians are saying that the new facilities will be overcrowded when they open.
Ambulance service may change more quickly; the pressure for change is led by Dr. Maurice Hood, the chief of surgery at Brackenridge. An Ambulance Study Committee recommended to the city council that it create a public service, but failed to make specific recommendations on the “hows” of such a system. Presently Austin Ambulance Service, which charges $32 per Austin patient and makes an annual profit of seven per cent on its operation, holds the ambulance franchise with the City of Austin. Of its nine vehicles, four are Modulances, custom-designed vehicles that allow a number of people to be transported at once and a medical technician to treat them with special equipment. The city council authorized Austin Ambulance to purchase four more Modulances for $73,000. Council stipulated that the city can re-purchase the four vehicles if it decides to go to a public system in 1976, after its contract with Austin Ambulance expires. Austin Ambulance has 25 employees with nine on duty at all times; it handles more than 800 calls a month. The attendants have advanced Red Cross training, and later they enter emergency medical technician training given by the state health department.
RATING: In general, ER services range from adequate to nightmarish. As to the getting-there, the ambulance service rates “fair” to “poor.”
Dissatisfied citizens, hospital personnel, local physicians, and city officials combined to create a publicly operated ambulance service more than a year ago in Corpus Christi. The city now handles the operation of the ambulances and the Nueces County Medical Society directs the training of the Emergency Medicine Technicians—two on each of six fire-department ambulances.
The ambulances are fitted with light-rescue equipment but no cardiac-care equipment. The communications devices connect the ambulances with hospital emergency rooms, but do not include radio telemetry through which the emergency-room physicians can monitor the patient’s responses while he is on the ambulance. Of the two EMTs per ambulance, one attends the patient, the other drives.
Response time—the chief complaint about the old service—improved dramatically when the fire department took over. The response time now has an impressive average of 4.5 minutes. The ambulances serve a population of more than 200,000. Of the first year’s calls of 6800, 5000 were considered to be true emergencies. The cost of funding the public system averages $1 a year per citizen. The service charges $35 per call in the city, $45 in the county, and is responsible for billing and collecting.
Memorial Medical Center has the only fully equipped trauma center emergency room for residents of Nueces County and thirteen more counties in South Texas. The only other emergency room support in the area comes from Spohn Hospital, operated since 1905 by the Sisters of Charity of the Incarnate Word. Spohn is the only renal dialysis center and radiation therapy center in this area of Texas.
Memorial’s emergency room currently handles 800 cases a week. An increase of almost 4000 cases in 1974 was foreseen over the 37,749 cases treated in 1973. The hospital administration is currently planning to expand the emergency room. Five physicians under contract to Memorial provide 24-hour coverage in ER; members of Memorial’s medical staff are also on call. Other ER medical personnel include five registered nurses, seven licensed vocational nurses, a student vocational nurse, and an emergency-room technician.
RATING: The Nueces County Medical Society says both ambulance and emergency room service are Very Good. Citizens and media sources rate Memorial’s ER service Good and the new firemen/EMTs a little better.
Before 1972 many Dallas ambulance drivers were apprentice morticians making $40 a month plus room and board. Their training was basic first aid; because of high job turnover some had no training. The funeral home operators of the ambulances were under contract to the city to maintain an average response time of fifteen minutes. A computer check by the city revealed that in one week 66 out of 482 calls took sixteen minutes and one call took more than an hour. Public dissatisfaction and medical criticism forced the creation of the fire department-operated system in November, 1972. The first change was dramatic—a cut in response time from the contracted fifteen minutes to an average of 4.34 minutes.
There are currently 293 Emergency Medical Technicians, enough to staff ambulances and accompany Dallas firemen on their calls. The ambulance dispatcher is also a trained EMT. The Dallas attendants complete the required 81 hours of study plus 96 hours of duty in Dallas hospitals, under the guidance of The University of Texas Health and Science Center (formerly Southwestern Medical School). Within the EMT ranks, Dallas has 121 trained paramedics who have completed 120 hours of classroom work and 280 hours of hospital duty, in addition to 177 hours of EMT training. They are trained in the use of intravenous fluids, electrocardiogram reading and monitoring, electrical shock treatment for heart cases, and administration of drugs.
A changeover also came in ambulance equipment: sixteen Modulances are designed so the attendant can work standing up; five extra beds can be installed. Telemetry equipment financed with federal revenue-sharing funds is in working order, linking the ambulances with the emergency room at Parkland, the county-owned charity hospital.
Parkland is the emergency-room destination for most Dallasites, a testimony to the hospital’s reputation. Parkland’s Emergency Department, the largest trauma center in the country, treats more than 160,000 cases a year. As the teaching hospital for the UT Health and Science Center, it draws on the school’s specialists. In 1973, Parkland opened an emergency-room suite which includes five divisions each open 24 hours, each with its own medical staff and equipment, each division in contact with the ambulances, with three divisions having telemetry contact. There are 52 registered nurses in the program.
A triage nurse sorts and directs patients to the appropriate division—Major Medical with 21 treatment and two cardiac resuscitation rooms; Minor Medical; Surgery with six trauma, rooms; Obstetrics and Gynecology; Pediatrics; and Psychiatry. Triage has removed much of the air of confusion that filled the old ER at Parkland; ambulatory patients no longer wait on benches beside newly arrived victims on stretchers.
The other major Dallas center capable of trauma and cardiac care is Baylor University Medical Center. Baylor ER treated 40,000 cases in 1973. Although a private hospital, Baylor reportedly accepts all comers regardless of ability to pay. The Baylor ER includes six trauma resuscitation rooms and an operating room and has a staff of two physicians, one-private emergency physician, one intern, and fifteen nurses.
RATING: Dallas is the best city in Texas to be in when an ambulance and the skills and immediacy of trauma medicine are required. Its service is a model for emergency care. However, such praise would not have been deserved before the Seventies.
El Paso seems content to provide only bare-bones emergency medical care. There is little or no civic or medical clamor for better care. In the city’s central emergency room, 100 patients a day wait in crowded and hectic conditions for medical aid.
Bert Williams promoted a public ambulance service in 1972 when he was mayor, but he couldn’t raise operating funds.
Recently members of the El Paso County Medical Society backed another ambulance service over the longtime franchise-holder El Paso Ambulance and Rescue, Inc., but city council members supported the existing service. That company serves a city population of 350,000, and another 30,000 in the county, with eight ambulances, each one carrying oxygen, resuscitator, aspirator, and one Emergency Medical Technician. The ambulances made almost 14,000 runs last year.
El Paso may, however, be within reach of telemetry equipment and more sophisticated training for its EMTs. There is no direct communication between hospital emergency rooms and ambulances, but a federal grant for $1.25 million-worth of communications equipment has been approved. EPA&R is also sponsoring a physician-directed paramedic course for its eighteen EMTs, which would give their minimum 81 hours of training a professional boost.
R. E. Thomason General Hospital is the county’s trauma and cardiac care emergency center. Through its affiliation with the Texas Tech University School of Medicine, it can call on specialists in a variety of surgical fields, internal medicine, cardiology, family medicine, and obstetrics. Thomason opens its own Emergency Medicine Program this year.
Yet, while present and future sound good for Thomason patients, El Paso ambulance drivers report that the majority of emergency patients are requesting, not Thomason ER, but the emergency room at Providence Memorial, a private hospital. At Thomason Central ER, a triage nurse sorting and directing patients is needed. Thomason carries a big load—100 patients a day, 700 a week, 36,500 a year. While Thomason regularly staffs its ER with two residents and a backup resident, Providence is staffed with a 5 p.m. to 7 a.m. emergency-room physician who cannot admit patients to the hospital but sees to “saving life, limb, or prevent great suffering” before he contacts a personal physician for the patient.
It is to Providence Memorial that the helicopters of Military Assistance to Safety and Traffic (MAST) on medical emergencies within a 100- mile radius deliver patients. The crews from William Beaumont Array Medical Center include two pilots, one crew chief, and one medical corpsman, all EMTs. They receive their orders from Thomason and then fly the patients to the heliport at Providence. (Thomason lacks the ground area or the proper roof for a heliport.) Emergency-room support also comes from the Beaumont Medical Center at Fort Bliss. Its staff and capabilities are impressive—a 24-hour cardiac emergency team, trauma facilities, a minimum of two physicians, two nurses, two corpsmen, and ambulance drivers who are EMTs, all of which is available for civilian emergencies.
RATING: The ambulance service rates a Good. El Pasoans should see an improvement over minimum emergency equipment sometime in 1975. For now El Pasoans are content with less than other Texans. Thomason ER rates Excellent on the basis of its dedicated and skilled medical work.
Emergency-medical service in Fort Worth is supported by eight ambulances answering 66 calls a day, calls that are increasing twenty per cent each year. At John Peter Smith Hospital, the city-county trauma center, 6000 patients are treated each month in crowded, outdated facilities. The only improvements proposed by area leaders are more than a year away.
The Tarrant County Hospital Association has proposed a plan to the Department of Health, Education, and Welfare that would put 75 paramedics, 150 Emergency Medicine Technicians, 350 emergency-care attendants, and three levels of roving community emergency-medicine vehicles into Tarrant and eight other counties by mid-1976. It calls for a $5 million federal grant to be matched by local funds. Currently eight Modulances operated by Ray Crowder Ambulance Company serve the population within the city limits. It is not unusual for a Tarrant County resident to be delivered in one ambulance to the city border and then transferred to a Crowder ambulance for the rest of the ride to Smith or another Fort Worth hospital. Smith, meanwhile, serves the city and county.
Crowder meets the city’s requirements: 75 per cent of its attendants (38) have completed the 81-hour emergency-medicine course, and one EMT is aboard each ambulance run. There is no radio telemetry equipment or cardiac-care equipment aboard. Crowder’s average response time is a respectable 5.8 minutes.
John Peter Smith Hospital is a teaching arm of The University of Texas Health and Science Center in Dallas and draws on the center’s specialists and its interns and residents. They work in an emergency department years overdue for improvements and expansion. More than 72,000 emergency patients were treated at Smith in 1974.
The wait at Smith ER is a long one. A triage nurse separates the major medical cases from the rest; those with minor medical problems are sent to the emergency department annex if they are at Smith between 3 p.m. and 11 p.m. Those in need of surgery are admitted to the main hospital and sent to operating teams on duty 24 hours a day. Smith’s emergency department is divided into four trauma rooms, and special areas like orthopedics, obstetrics, and gynecology.
The regular medical staff consists of one resident and two interns during the day shift and one resident and one intern at night, and only one intern from 2 a.m. until 7 a.m. There are also fifteen registered nurses, twenty-two licensed vocational nurses, and twenty nursing assistants.
RATING: The medical service at Smith rates a Good; the physical conditions under which medicine labors and patients wait rate a Very Poor. The ambulance service rates a Good under the conditions the city has set for it; however, the Modulances themselves are not always maintained in top-notch condition.
The Houston Fire Department directs the oldest public ambulance services in the state and responded to more than 51,653 emergency calls in 1974. Eighteen private ambulance companies handle non-emergency calls. From the view of L. O. Martin, head of the public service, there never was a place for the pulling and shuffling of competition between public and private service. There is more than enough business for both, and the line is almost indelibly drawn at emergency, the bailiwick of the fire department, its 23 specially equipped ambulance, and 210 paramedics. Each paramedic has more than 400 hours of advanced medical training. Besides ordinary medical supplies like portable oxygen systems, eye packs, and splints, each ambulance includes a cardiac-care unit, with which EMTs record the patient’s heart functions. Telemetry equipment connects the EMTs and the patient in the ambulance with the doctors at Ben Taub General Hospital, the city-county trauma center. The cost of an ambulance ride is $25 and billing is through the city tax office.
In all likelihood, the ambulance carrying a critical case or a person unable to pay at a private hospital will go to Ben Taub’s emergency room. The hospital treated 87,000 people in 1974. Taub’s ER area includes three trauma or shock rooms, plus areas for burns, obstetrics and gynecology, pediatrics, and other specialties.
It is the training hospital for Baylor Medical School and that staff of teaching doctors is on daily emergency call. The Ben Taub ER staff is headed by two senior residents, one a medical, the other a surgical specialist. They oversee about six interns and medical students on duty in ER, more than a dozen residents on call, and a varying number of nurses trained in emergency medicine.
Patients are triaged at a front desk; the wait has long had a reputation for being a lengthy one for those with minor medical problems. The waiting room is very clean, and the patients are handled quickly, but quite impressively, with gentleness and even cordiality, within a generally hectic and tense atmosphere.
Hermann Hospital, the teaching arm of the new University of Texas Medical Center in Houston, is the second comprehensive-care emergency room in the city. “The Hermann emergency center runs hot and cold,” says a Houston physician. “Their facilities are fine but their personnel are not always of the same caliber.” Hermann’s ER handles about 2000 cases a month, but not as many trauma cases as handled by Taub. The goal for Hermann is to provide trauma and cardiac care like Taub does, only for people who can pay.
RATING: The Houston ambulance service and the emergency rooms at Ben Taub and Hermann hospitals rate Excellent.
San Antonio will soon complete its first year with a publicly run ambulance service. The predictions were that the city firemen in eleven Modulances would answer at least 30,000 calls the first twelve months, but response has been slightly more than predicted. In the first ten months nearly 26,000 calls were answered. Under the private service, getting a patient to a hospital seemed more a competitive sport like pro football than a medical specialty. Competition between private companies ran high; stories of one ambulance blocking the route of the one with the patient, and of drivers following a patient into a hospital demanding immediate payment were not unusual. The Bexar County Medical Society was the primary source behind the change, and the result at $35 a ride is considered a bargain.
The Modulances cost the city $15,000 each; they are equipped with telemetry and two-way radios to most of the city’s major emergency rooms. San Antonio’s 90 EMTs have more than 400 hours, of emergency medical training; they expect soon to be handling a system with the ERs that will monitor five cardiac cases simultaneously. Bexar County Hospital has the only comprehensive-care emergency room except for Brooke Army General and Wilford Hall Air Force hospitals in the San Antonio area. Bexar is the teaching hospital for The University of Texas Health and Science Center and draws on its 300-plus residents and physician-teachers for emergencies.
Robert B. Green Hospital, in downtown San Antonio, operates under Bexar County Hospital; it has a walk-in clinic open 24 hours and handles the majority of minor medical problems with an emphasis on pediatrics. More than 100,000 people were treated at Green in 1974. Bexar County Hospital itself handled more than 38,000 cases in 1974 with a staff of eleven registered nurses, four licensed vocational nurses, and thirteen medical attendants on duty per shift. All have completed special emergency-room training. One surgeon and one internist complete the staff.
The atmosphere in the waiting room at Bexar County is almost always hectic. Patients are triaged; the minor medical problems wait and wait their turn. There are three trauma rooms, five medical treatment rooms, and burn facilities (but no special burn treatment room) available. A specially trained staff on duty 24 hours a day oversees Bexar’s coronary-care unit.
RATING: The San Antonio public ambulance service rates a Very Good. The Bexar County emergency-room, system rates a Good.