There has been much discussion in
the media regarding the need for an additional trauma center on Chicago’s south
side. The level of gun violence in the city is indeed alarming – according to
statistics from the Chicago Police Department, during the period from 1999 to
2009 the city saw between 450 and 650 homicides per year, the majority of which
were due to firearms. Furthermore, the southeast side, including the
neighbourhoods of Englewood and Woodlawn, see some of the highest rates of gun
violence in the city. Victims of penetrating trauma in this area are taken to
the closest level I trauma center – generally either Northwestern Memorial
Hospital in Streeterville or Christ Advocate hospital in Oak Lawn.
On the surface, it would seem that
having a trauma center in the area capable of caring for these critically
injured patients would be beneficial and potentially save lives. The public has
certainly latched onto this idea – multiple protests have been staged at
hospitals on the southeast side. The public outcry gained significant momentum
in 2010, when a local youth advocate was shot within walking distance of a
major south side medical center, but was taken across the city to the nearest
trauma center and died. Would the patient have lived if the appropriate
resources were more closely available to him? A recent paper in the American
Journal of Public Health suggests just that. According to the study, set in
Chicago, patients suffering gunshot wounds more than 5 miles from a trauma
center are 23% more likely to die. This study has been used as ammunition for those
arguing for an additional trauma center to be placed in this troubled
neighbourhood. However, there are both medical and economic factors to be
considered.
A crude financial analysis included
in the distance-mortality paper suggests that, in fact, a new trauma center
would provide the community with a much needed financial surplus. However, a
closer look at the data reveals a different story. Trauma medicine is
extraordinarily expensive, often caring for young and uninsured patients who are
unable to pay. Moreover, trauma surgery can often take precedence over elective
surgical cases, from which hospitals derive enormous financial gain. Even in
the unlikely case the hospital were to “break even” on the patients it sees,
these hidden sources of lost revenue could prove extremely costly.
But if lives are saved, could this
justify the increased economic burden? The authors of the paper estimate that
6.3 lives could be saved each year, based on the mortality advantage of more
patients being within 5 miles of a trauma center. The study looked at a sample
of approximately 12000 GSW victims per year. This makes the number needed to
treat 120 (i.e. the number of GSW patients needed to be treated in order to
save one life). But, a trauma center does not limit itself to GSWs. In order to
see all of those patients, the center would be required to treat all patients
fitting level I criteria (and likely many who do not). Thus, the number needed
to treat is actually much higher – greater than 8000. The busiest trauma center
in the city sees approximately 5000-6000 traumas per year. If the proposed new
south side trauma center were to see 1000 patients yearly, then one life could
be saved approximately every 8 years.
Another factor not accounted for is
the nature of the specific injuries of the trauma patients being brought in.
For example, patients with GS injuries to the great vessels or heart will have
an extraordinarily high mortality, regardless of whether they present to the
trauma center within one minute or twenty. Patients are self-selected in a way;
those who survive the trip to the trauma center are more likely to have
survivable injuries, while others will die en route.
The bottom line is that things are
not always as simple as they seem on the surface. Common sense would suggest
that having a trauma center close to the violence would result in better
outcomes and more lives saved. However, this may not be the case at all, and
the data do not support this assertion. The economic burden on the very
community in question must be considered, however crude it may seem in the
context of human life. Most importantly though, it is likely that little to no
impact will be seen on the survivability of gun violence. The efforts of those
calling for a trauma center are well intentioned, but misdirected. Only by
stopping the violence in the first place can the people of the south side of Chicago
heal, and move forward towards a safer community.
from Dr. Jordan Stern
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