FAYETTEVILLE -- Brooks Cartwright hit his head on concrete. He was airlifted 150 miles away to Mercy Hospital in Springfield, Mo.
Cartwright, who was 15 at the time of the injury in October, was transferred from Northwest Health-Springdale to Springfield because he needed neurosurgery unavailable to him in Northwest Arkansas, said Blair Cartwright, his father.
Hospitals in Northwest Arkansas treat most of the trauma patients they see. However, 132 people were airlifted from nine hospitals, most in Benton and Washington counties, for care elsewhere in 2018, said Greg Brown, trauma branch chief for the Arkansas Department of Health. The number airlifted includes patients from one hospital in Carroll County and one hospital in Boone County. The number also includes Mercy Hospital in Springfield, but Brown said few were from that hospital.
Doctors and hospital administrators say there are no quick fixes to allow them to treat more trauma patients instead of airlifting them to hospitals in other cities.
Tom Jenkins, governor's appointee to the state Trauma Advisory Council, has seen trauma care in Northwest Arkansas improve significantly in his 11 years as Rogers fire chief, but he said it has plateaued. Improving further isn't going to be easy, he said.
"It boils down to a financial investment. We are no longer six sleepy cities with suburbs. This is a metropolitan area," Jenkins said.
WHAT'S MISSING
Most patients are transferred because of head injuries, pelvic fractures, certain eye injuries and complex burns, Northwest Arkansas hospital officials said.
Washington Regional Medical Center in Fayetteville has four neurosurgeons, and it recently became the second hospital in the state to be certified as a comprehensive stroke center, meaning it can treat some of the most complex strokes. Mercy Hospital Northwest Arkansas in Rogers and Northwest Health have each added a neurosurgeon in recent years and have said they are trying to add more.
"Thankfully they have because there were a number of years when there was almost no neurosurgery, and our guys were it," said Dr. David Ratcliff, chief medical officer at Washington Regional. "You can imagine the amount of volume you receive when you're the only hospital in a 150-mile radius essentially that does spinal trauma or head trauma."
Children and teens are still sent away for neurosurgery.
The state Medical Board lists three pediatric neurosurgeons in the state, and all practice in Little Rock. Dr. Marcene McVay-Gillam, trauma medical director at Arkansas Children's Northwest in Springdale, said nonpediatric neurosurgeons generally don't operate on patients younger than 16, and children have a relatively high rate of head injuries compared to adults.
Children's Northwest, which opened about two years ago, doesn't have any neurosurgeons on staff. The hospital transferred 24 patients in 2019, mostly to Arkansas Children's Hospital in Little Rock and Mercy Hospital in Springfield, said Heather Kimbro, trauma program manager at Children's Northwest.
"If they need to be transferred, it's typically for neurosurgery," she said.
Surgeons in Northwest Arkansas can treat some burn patients, but not complex cases. Dr. Joe Olivi, for example, started at Northwest Health about two years ago and handles cases that previously would have been sent out of the region.
The only burn center in the state is at Children's Hospital in Little Rock, according to the American Burn Association. Burn centers offer specialized multidisciplinary programs dedicated to burn treatment and must have 24/7 surgical coverage among other requirements, according to the association.
The Children's Hospital burn center treats children and adults, according to its website.
Dr. Jeff Bell, trauma medical director at Washington Regional, said Northwest Arkansas' population of about 600,000 isn't large enough to support a burn center. Dallas has one burn center that serves an area of roughly 20 million, he said.
"Burn care is very, very specialized, and we just don't see the volume," Bell said.
Likewise, some pelvic fractures and eye injuries requiring highly specialized care usually have to be treated elsewhere, said hospital staff from each of the large hospitals in the region.
TRAUMA LEVELS
About 60 hospitals are part of the Arkansas Trauma System. The state Department of Health designates hospitals as either a Level I, II, III or IV trauma center, with Level I being the most comprehensive.
The department assigns the levels based on how equipped hospitals are to treat trauma patients and takes into account what specialties they offer and how much coverage they have in those specialties. For example, general surgery coverage is not required for a Level IV designation, but 24/7 general surgery coverage, neurosurgical coverage, orthopedic coverage and anesthesia services are required for a Level I designation.
Northwest Arkansas doesn't have a Level I trauma center. UAMS Medical Center and Children's Hospital, both in Little Rock, are the only Level I trauma centers in the state. Four out-of-state Level I trauma centers are a part of the Arkansas Trauma System, meaning Arkansas patients may be transferred there. They are Regional One Health and Le Bonheur Children's Hospital in Memphis and Cox Health and Mercy Hospital in Springfield, Mo.
Airlifting critically injured patients is an added risk to those patients, Jenkins said. He said it's frustrating to see patients airlifted to Springfield, which has a smaller metropolitan-area population than Northwest Arkansas.
"We need a Level I trauma center," he said.
Washington Regional is one of three Level II trauma centers in the state. The hospital transferred 63 of 1,097, or about 6%, of its trauma patients in 2019. That compares with 142 of 1,153 patients, or about 12%, in 2017, said spokeswoman Natalie Hardin.
The only other Level II trauma centers in the state are Baptist Health Medical Center in Little Rock and CHI St. Vincent Hospital in Hot Springs.
Mercy and both Northwest Health hospitals in Northwest Arkansas are Level III trauma centers.
Arkansas Children's Northwest recently received a Level IV designation, according to the Health Department. The hospital pursued the Level IV designation because it doesn't have an intensive care unit, McVay-Gillam said.
Children's Northwest has an emergency department with physicians who specialize in pediatric emergency medicine, but it doesn't have the inpatient capacity to keep the more critically ill patients, she said.
TRAUMA TRANSFERS
Before the trauma system was established 10 years ago, ground ambulances took patients to the nearest hospital regardless of whether that hospital could treat them, Brown said.
If the hospital was unable to treat the patient, then the staff would transfer the person to another hospital. Now, paramedics with patients who are diagnosed in major or moderate trauma categories are required to call the Arkansas Trauma Communications Center for guidance on where to take them.
"In trauma, time is the most important thing," Brown said.
The trauma system has cut down on unnecessary patient transfers and helped decrease the state's preventable mortality rate, he said. The purpose of the system is to get patients to the most appropriate hospital as quickly as possible, either by ground or by air.
Other than faster travel, the only significant difference between a ground ambulance and an air ambulance is that the latter is required to have a registered nurse on board in addition to an emergency medical technician and a paramedic, Brown said.
The air ambulance system can be patchy and expensive for patients, said Dr. Joe Thompson of the Arkansas Center for Health Improvement.
Air ambulances are regulated by the Federal Aviation Administration and are usually privately owned, Thompson said. They are aircraft first and ambulances second. The Health Department has no authority to regulate air ambulance prices.
Air ambulances are most often used in the rural parts of the state, Thompson said. He said airlifts out of Northwest Arkansas are almost exclusively for highly specialized surgeries.
Air ambulance bills can vary greatly, and no "hard and fast rules" exist as to who pays what portion, Thompson said.
The bill often becomes a negotiation between a patient, a vehicle insurance company, a health insurance company and an air ambulance company when the trauma resulted from a wreck, he said. Some air ambulance companies have sold what is essentially insurance to people in case the company ever airlifts them, but those fees are useless if a helicopter affiliated with another company transports the patient.
Of his son's bill, Blair Cartwright said, "I figured it'd be high, but I didn't expect it to be that much." The bill was originally $55,000. Insurance will cover $25,000, leaving $30,000 to be paid out of pocket, Cartwright said.
IN THE MEANTIME
Some hospitals have taken a preventive approach to trauma by working with emergency medical technicians and educating the general public, who are often first on the scene during a traumatic event such as a shooting or car accident.
Capt. Leon Lieutard of the Bella Vista Fire Department said hospitals send representatives to department meetings to make sure first responders are up to date on best practices for treating patients before they get to the hospital.
Dr. Velvet Reed-Shoults of Northwest Health said a fire department may request that she and other doctors teach them about updated standards for burn treatment, for example.
"How we treat something now is very different than how we did five years ago, so together, we're trying to keep up on those standards," she said.
Reed-Shoults said it's beneficial to patients when first responders and hospital staff members work together because first responders learn what information is helpful for the hospital, and the hospital staff has a better understanding of what first responders are dealing with during a traumatic event.
"Our response is only as good as their information," she said.
Metro on 03/16/2020