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When Dr. Dominique Larrey came up with the idea in 1792 of using ambulances and field hospitals to more quickly treat soldiers critically wounded during the Napoleonic Wars, he transformed emergency medicine and trauma care by reducing the time between injury and surgical care.

Now 215 years later, as the only state with no trauma center or trauma network, Arkansas is still struggling with getting trauma patients the specialty care they need to survive in the minutes and hours after serious injury. A well-publicized trauma bill to establish such a system failed in the 2007 Arkansas legislative session, but a few healthcare activists have not yet given up their efforts to resuscitate it.

Sponsored by Rep. Denny Sumpter from West Memphis, the trauma bill proposed to establish a revolving trust fund to offset the costs of building trauma centers in the state and establish a network of trauma resources to coordinate care. Hospitals interested in building or upgrading facilities to establish a Level 1, 2, 3, or 4 trauma center could apply to the state for matching fund grants, and they would be reimbursed for the costs of providing trauma care to the uninsured. The bill failed when the House and the Senate could not agree on how to fund it; although it was introduced at the beginning of the session, the legislators ran out of time to come to a consensus.

"In Arkansas, we have a very serious problem with injury," said Dr. James Graham, chief of emergency medicine of Arkansas Children's Hospital and vice president of the Governor's Trauma Advisory Council, which he said worked on the trauma legislation for a year and a half before the session started. "Our serious injury rate is 40 percent higher than the national average, higher than some third-world countries. This really is a serious problem, and we don't have the right resources to take care of our people."

Myra Wood, director of Vital Link emergency transport in Batesville, agrees that trauma is a serious problem, especially in rural Arkansas where accidents are rampant, specialists are scarce and metropolitan-area ERs are often hours away. "In the rural areas, we have a fair amount of severe medical illness, but practically an epidemic of trauma," she said. "We have accidents on our lakes, motorcycle accidents, horseback-riding accidents, tons of motor vehicle accidents, four-wheeler accidents, farm accidents, you name it. And no trauma center of any level."

Numerous professional studies have shown that patients receive better care at trauma centers, Graham said, and that the resources of a Level 1 trauma center can increase survival by 10 to 30 percent. That means that between 211 and 633 of the 2,119 Arkansans who died from trauma in 2006 might have been saved had a Level 1 trauma center been available.

For these reasons, Graham said, every other state has a trauma center. "The system of trauma care we have in this state is truly inferior. And truly people are dying and becoming permanently disabled in our state, whereas if they were cared for somewhere else, they wouldn't be."

Rep. Sumpter got involved with the issue because of his district's proximity to the Elvis Presley Memorial Trauma Center at The Med (Regional Medical Center of Memphis) in Memphis, Tenn., a Level 1 trauma center that treats 12 to 14 million dollars worth of uninsured Arkansas trauma patients each year. Although Arkansas Medicaid reimburses The Med approximately $1 to 2 million a year, there is still "a big hole" there, Sumpter said. "They're $10 million in the red from last year because not only do we not have a center in the state to take care of our own, we don't have the money to reimburse them when they take care of our people for us."

The situation is leading to additional problems as Arkansas patients drain other trauma centers' resources. "They can't turn patients away," Sumpter said, "but they can say, 'Well, you can bring them over here and put them on our doorstep, then I guess we've got to take them. But we don't necessarily have to fly an hour into Arkansas and fly an hour back and absorb all that cost for what may be an indigent patient.'"

To make matters worse, aside from not having advanced trauma facilities, in Graham's opinion, the existing emergency system is eroding. Nationally, there are fewer emergency departments and emergency specialists, especially in rural areas, he said, and emergency department overcrowding is an increasingly serious problem. Then there's the added stress that an event like Hurricane Katrina or the Virginia Tech shootings can put on the system. "We can't even take care of the folks who come to our emergency departments when we don't have mass casualties," Graham said. "What are we going to do if we have a mass casualty event with serious traumas?"

Jon Swanson, executive director of Metropolitan Emergency Medical Services (MEMS), the publicly owned nonprofit that provides emergency transport services for 12 Central Arkansas hospitals, said that MEMS daily sets new records for numbers of transports, but that he has full confidence in the quality of emergency services in his area. "My sense in Little Rock is that a trauma center would certainly be an improvement, but they already have great capacity, they already have tremendous facilities, there are already great hospitals," he said. "It's not so much a matter of going from black to white, as going to a lighter shade of gray."

From his EMS perspective, Swanson said, "The overloads and pressures on each facility vary minute to minute, hour to hour, day to day." Even with the guarantee of specialist coverage that comes with a trauma center, he said, "I don't see how trauma centers necessarily change that. They may make more of a difference in rural areas, but then, the bill wasn't exactly planning to put a trauma center in every area of the state."

Wood, who is also president of the Arkansas Ambulance Association, said the establishment of even one trauma center in the state, and the accompanying preventive measures, additional job training, resource networking and additional compensation for treating indigent patients the legislation would have supplied would undoubtedly have been a great boon to the ability to save critically injured rural Arkansans. "It's not about whether we need it," she said. "It's how to do it. Every legislator we talked to said, 'I know we need a system. I know we need a Level 1 trauma center in Arkansas.' The problem is coming up with a solid funding stream."

"There's no doubt that a trauma system is expensive," Graham said, "but it's our current system that's the 'money pit,'" he said, referring to the widely reported characterization of trauma centers by Rep. Daryl Pace of Siloam Springs during the session's debate. Graham, Woods and Sumpter agreed trauma systems make economic sense when the hidden costs of the current system — liability, disability, higher insurance premiums and life insurance payouts, tax revenue, etc. — are considered, not even counting intangibles like the inherent value of human life and the immeasurable lost potential of a young trauma victim. "It becomes clear that in some ways," Graham said, "having an organized trauma system is akin to having immunizations and other preventive measures where there could be tremendous cost savings."

Sumpter said the advocates' best hope now is that Governor Mike Beebe will agree to call a special session to make a trauma bill work, or at least include the issue if he calls a special session. There are two more years until the next scheduled session, Sumpter said, and every year without this capability means another 200-600 Arkansans may die unnecessarily.

"The governor's expressed that he would like to see how we're going to pay for it," Sumpter said. "Since we could not come to an agreement in the session with a $900 million surplus already there, I don't know what the likelihood is that we'll come to an agreement now on raising any new revenue, especially now that we've spent the surplus. And everyone's in the mood not to raise any tax for any purpose, no matter how good it might be."

Sumpter, who would like to see the project funded through the existing general revenue stream, said he regretted that the legislature prioritized $40 million of the surplus for general improvement projects above the same amount for the trauma bill. "All of those may be important requests for rural areas, including most definitely my own," he said, "But are those projects more important than the 2,000 lives lost to trauma each year, when we might have potentially saved some of those? It's hard to make that case. We could have done away with the local rodeo."

If the governor does not call a special session, Sumpter said the bill's backers are considering a general referendum to the Arkansas voters, which would require collection of 65,000 signatures to get on the ballot. Graham said he's skeptical whether the referendum is feasible, since some estimates indicate that the petition drive could cost a minimum of $250,000, but Sumpter is hopeful that support within the medical community would help sustain it.

"If every Arkansan who worked in a hospital, not counting all the other healthcare workers or general public, signed the petition, we'd be about two-thirds of the way there," Sumpter said. "I would urge physicians to get involved, donate to the campaign, help us collect signatures, talk to your representatives."

Woods said if the medical community were to rally around the issue, they would be "a real force to be reckoned with. Together, physicians have substantial power and influence," she said.

Despite the bill's failure, Graham said proponents were able to get a good amount of momentum, but that the issue needs to stay current and relevant before the lawmakers. "A lot of the physicians I talk to share my opinion that our emergency care system is overcrowded, is overburdened, is at the point of breaking," Graham said. "Lawmakers need to know that, and physicians need to communicate that to them."

Sumpter said he'll continue fighting for the trauma system. "It's easy to get caught up in these political debates in a theoretical sense," he said. "But somewhere out there, there's someone who had a car wreck today, and they died. And with a trauma system, maybe we could have saved their life."


June 2007

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