High Costs Mean Poor Prognosis for Trauma Centers in Big Cities : Medicine: The glory days are past. Now, uninsured patients force many hospitals into a life-and-death struggle with the bottom line.

MIAMI —  The helicopter appears as a point of light on the northern horizon, the brightest star in a dark blue sky.

Coming closer, it shoots a wide beam of light over the rooftop at Jackson Memorial Hospital and settles down with a shuddering blast of tropical air. Two men inside have been shot twice each with 9-millimeter bullets, and one is dying.

Dr. Jeff Vaughan, waiting on the landing pad, turns to a nurse. “You’re going to see blood now, sister,” he says.

But spilled blood is routine at Jackson Memorial’s trauma center. Already this evening, the trauma crew has treated a woman shot by her boyfriend, a man dumped 30 feet off a scaffold, a 10-year-old bicyclist hit by a car and a prison inmate stabbed with a homemade knife.

That roster accounts for every serious injury suffered in the Miami metropolitan area in the preceding six hours. If you are badly hurt in Dade County these days, the only place to go is Jackson Memorial.

That distinction puts Jackson Memorial, a publicly financed teaching hospital, at the forefront of a dismal national trend. It is one of a shrinking number of big-city hospitals offering special care for trauma, the medical name given to life-threatening injuries.

In Los Angeles, Chicago, Philadelphia and elsewhere, private hospitals have been shutting down trauma units, most of which opened in the mid-1980s, the specialty’s boom years.

The resulting squeeze threatens not only the quality of health care, but also the financial stability of the hospitals left carrying the load.

Gunfights, car crashes, the occasional industrial accident--these are the lifeblood of trauma-care centers. The American College of Surgeons estimates that 250 to 350 trauma centers operate around the country, ranging from such giants as New York’s Bellevue Hospital and Miami’s Jackson Memorial to the N.T. Enloe Hospital in Chico, Calif., and Easton Hospital in Easton, Pa.

Trauma units are usually affiliated with, but distinct from, ordinary emergency rooms. Emergency rooms handle broken legs, concussions, poisonings, the lesser varieties of mayhem. Trauma units take over in more serious cases of multiple injuries--when lives are on the line.

Trauma centers are staffed by surgeons, and major trauma hospitals keep full staffs of specialists on duty around the clock. If you need a neurosurgeon at 3 a.m., Jackson Memorial will have one.

In rural and suburban areas, trauma is almost always the result of auto accidents, and the drivers are usually insured. In these areas, trauma centers pay their way, even make profits.

But in inner cities, patients increasingly are members of what doctors caustically refer to as “the knife and gun club.” Club members have a couple of things in common: They are almost always involved in drugs and they are almost never insured.

At Jackson Memorial, which handles 6,000 trauma cases a year, about one-third of the patients are admitted for “penetrating trauma”--knife or bullet wounds. About one-third of the patients are uninsured.

These are expensive injuries, and “blunt trauma” injuries suffered in car crashes can be even costlier. It’s not unusual for trauma-care bills to mount into the tens or even hundreds of thousands of dollars.

“Even with the paying patient, trauma is going to cost more than the average treatment, more than what insurance will probably pay,” said Jeanne Eckes, a registered nurse who coordinates Jackson Memorial’s trauma service.

Jackson Memorial estimates that the trauma unit will lose at least $1.2 million this next fiscal year. In addition to direct losses, the hospital loses money when trauma patients “bump” regular patients out of operating rooms and intensive-care beds. That happens nearly every day.

Of four patients admitted to Jackson Memorial’s trauma center so far this evening, three have been sent to the operating room or intensive care. The lone exception is the luckless prison inmate, who has been treated for his stab wounds and sent back to prison.

It is already a grueling evening, filled with split-second, life-or-death decisions. Even the janitor is busy, mopping up blood from the floor of the trauma room.

During a break in the action, Vaughan and another doctor, Alan Rosenberg, wolf down dinner in the cafeteria. They are there when Air Rescue calls about 10 p.m.

Two men with gunshot wounds have shown up at a hospital eight miles away. They couldn’t be treated there--the hospital doesn’t handle trauma. They are being flown to Jackson Memorial.

On the elevator to the roof, Rosenberg and Vaughan turn goofy with excitement. They stretch out on the two gurneys and joke. They don’t get serious until the helicopter is down, and then, with the blades still turning overhead, they get serious in a hurry.

Vaughan is first into the elevator with the more seriously wounded man. Before the doors shut, he is frantically at work.

“He’s not moving any air, man,” he says, his voice tight with tension. He shoves a tube down the man’s nose and squeezes a bulbous green bag. A hole in the patient’s chest gurgles with blood.

When the elevator reaches the ground floor, Vaughan runs with the gurney to the trauma room. His patient is slipping away.

Patients like this are flown to Jackson Memorial every day. The hospital tallies more than 1,000 helicopter landings a year in what some doctors say is a legacy of the Vietnam War--the airborne rescue.

Some people say the entire modern system of trauma care grew out of the military’s medical experience in Vietnam; others say it evolved in large urban hospitals in the 1960s.

Trauma care grew rapidly after research in the late 1970s proved that trauma centers routinely saved lives that would be lost with ordinary emergency care.

By the early to mid-1980s, trauma had become hot business. In search of prestige and profits, hospitals jumped at the opportunity to treat trauma victims despite the expense of maintaining a 24-hour staff of surgical specialists.

Some cities established trauma networks to ensure that patients were sent to the closest trauma hospital. Miami’s network, established in 1985, ultimately consisted of six private hospitals and the public Jackson Memorial.

B. Boyd Benjamin, the blunt-talking, gravel-voiced chairman of the board of the Dade County Public Health Trust, recalls what happened then.

“It was wonderful,” he said. “Big committees met, everything was fine. And the first thing that happened, I guess, was (someone) got run over and didn’t have a penny and he ends up at one of these for-profit hospitals. And they want to ask: ‘Where’s your insurance?’ ‘I don’t have any insurance.’ . . . They found out very quickly that this was going to be a loser.”

In the space of six months in 1987, all six private hospitals dropped out of the network, leaving Jackson Memorial the only metropolitan-area hospital willing to accept adult trauma patients. (Miami Children’s Hospital accepts injured children.)

A similar winnowing process has taken place in other big cities as hospitals discover their expected profits are elusive.

“They see it as fiscally irresponsible,” said Dr. Gerald O. Strauch, director of the Trauma Department at the American College of Surgeons in Chicago. “We all know that hospitals have become big business, and they’re managed like a big business.”

In Los Angeles County, a regional trauma network with 23 hospitals has shrunk to 13--and will drop to 12 on May 1, when another hospital’s unit closes. Chicago had 10 adult trauma hospitals two years ago; the loss of another hospital in February reduced the number to six.

Houston is down to just one Level I trauma center, capable of handling the most serious cases. One of Philadelphia’s major trauma centers, Temple University Hospital, recently announced that it was leaving a regional trauma system.

The hospitals that remain are increasingly overwhelmed, their trauma centers resembling nothing so much as military MASH units in the heat of battle. Indeed, the military sends its physicians to inner-city trauma centers to prepare them for combat.

The consolidation of trauma care raises some daunting questions. What happens to the patient who is in a serious auto accident and has to be taken 25 miles to a hospital instead of five? Worse, what happens when a plane crashes?

“It’s gotten to the point where, no matter who you are, if you’re injured in a city, your chances of getting to a trauma center that has everything it needs are getting slimmer,” said Dr. Jeff Augenstein, one of the attending surgeons in charge at Jackson Memorial.

Jackson Memorial’s administrators believe they have found a solution. Having accepted their hospital’s role as the city’s only trauma-care center, they intend to capitalize on it. They are trying to raise $25 million for what Benjamin, the public-health trust’s board chairman, calls a “state-of-the-art, world-class, self-contained, free-standing shock-trauma center.”

The idea is to get trauma patients out of the main hospital, leaving more room there for regular, paying patients. “Our projections show that we will at least break even,” Benjamin said.

Hospital officials hope that the new center will become a magnet for research dollars and talented staff. In the meantime, doctors at Jackson Memorial insist that they can handle anything that comes their way.

It is 10:14 p.m. when Jeff Vaughan wheels the gurney into the trauma room. Half a dozen people jump into action. One slips an oxygen mask over the patient’s face, another takes blood. Vaughan examines the body. It is young and strong and has bullet holes in the chest and shoulder. Two police officers stand to the side, watching.

“Where’s X-ray?” Vaughan hollers. “C’mon, Hector, let’s get a quick film.”

At 10:18 p.m., Vaughan inserts a tube nearly the width of a garden hose into the left side of the man’s chest. It begins pumping hemorrhaging blood out of the chest cavity and into intravenous tubes for transfusion. Vaughan’s rubber gloves and gown are covered with blood; red dots shine on his eyeglass lenses.

“What’s his pressure?” someone shouts.

“Very, very low,” Vaughan yells back. “He’s got serious problems in his chest.”

He goes to the other side and inserts another tube. “We’ve got blood on this side too, guys, and lots of it.”

Within minutes, the crisis ebbs. The patient’s systolic blood pressure, about 50 when he entered the trauma room, is up to 110. His pulse is strong. He breathes with the aid of the oxygen mask.

The gurney is pushed out the door and up to the operating room.

“He’s a long way from being OK, but he’s got a chance,” Vaughan says.

Bloody footprints mark the path down the hall.

It has been a remarkable display of grace under pressure, but it isn’t enough this time. The patient dies 10 minutes into surgery.

His buddy survives, and not for the first time. Medical records show that he has been treated at Jackson Memorial before for gunshot wounds--six times.

“Hey, man, you gonna get some frequent-flier miles if you keep coming in here,” Vaughan tells him.

Police say the two men claimed to have been attacked on the street for no reason; the cops’ tone suggests disbelief.

Vaughan drifts into an employee lounge for a Dr Pepper and a smoke. He is about 18 hours into a 24-hour shift, and it is beginning to show. He speaks bitterly about the strains of the job and patients who “would just as soon kill us as look at us.”

“It’s a war zone,” he says. “And it’s like this in every major city.”