EL SOBRANTE -- When emergency responders found a hardware store employee bleeding in a parking lot from multiple stab wounds Aug. 4, there was no question where they would take the man to try to save his life.
Although a fully staffed emergency room was two miles away in San Pablo, Daniel Stone was rushed halfway across the county to John Muir Medical Center in Walnut Creek, the site of Contra Costa County's lone trauma center. He was pronounced dead 104 minutes after arrival.
No one knows whether Stone's chances of survival would have been greater had he arrived at a trauma center sooner; details about the care he received are protected by privacy laws.
But Stone's case represents a challenging reality for treating stabbing and gunshot victims in Contra Costa County. While John Muir is in the center of the county, it is many miles from where most crime-related injuries occur, in West County and East County. In situations where every minute counts, it can sometimes take more than 20 minutes to get a victim by air or ambulance to John Muir.
The trauma center model of emergency care has been in place in the county for almost three decades, and health officials say it's an effective way to pool resources and surgical staff needed to save victims of life-threatening injuries such as falls and auto accidents, as well as those stemming from crimes, in a central facility. Trauma victims taken to John Muir, with its state-of-the-art emergency and surgical facilities, have a much better chance at survival than they would at other hospitals closer by, officials say.
Contra Costa County Supervisor John Gioia, of Richmond, said he explored several years ago the possibility of turning Doctors Medical Center in San Pablo into a trauma center, both to generate additional revenue for the long-struggling hospital and to better serve local trauma patients, but he became convinced it was impractical. The volume of trauma patients in the area is insufficient to support the robust network of physicians and specialists needed for a trauma center, health officials say.
"The hard realities of the health care system dictate where and how medical services are provided, and in our case they don't allow us to have trauma services in West County," he said. "Sometimes what you want is not what you get. You may want trauma services more local, but the hard realities make that impossible; they just don't allow that to happen."
In Stone's case, the ambulance ride to John Muir was 21 minutes and did not start for more than 20 minutes after he was stabbed -- allegedly by a man who walked into the store muttering deranged phrases -- because county sheriff's deputies had to secure the scene before paramedics and fire personnel could administer aid. Some witnesses complained about the time it took for paramedics to arrive at Stone's side. Foggy conditions that day prevented Stone from being flown by helicopter to the hospital.
According to county Emergency Medical Services policy, trauma patients in Contra Costa with penetrating trauma -- a category that includes gunshot and stabbing wounds -- should be taken to John Muir in most instances. Two major exceptions exist in which the patient would go to another, basic emergency room, such as Doctors, if it is closer, according to Dr. Joseph Barger, the county's EMS medical director.
One is a patient with an "unmanageable airway," meaning the patient is being deprived of oxygen, and the extra time needed to get to the trauma center could jeopardize the chance for survival.
The other is trauma arrest, in which the patient has already lost vital signs before transport, Barger said, adding: "In that situation, the survival rate is essentially nil unless the patient is relatively close to the trauma center, and in those situations, it is still only minimally improved -- and that is primarily seen in patients with penetrating trauma: gunshot or stab wounds."
County officials say that establishing another trauma center in West County or East County is neither practical nor desired.
"From a public policy perspective, it doesn't make sense," said Dawn Gideon, CEO of Doctors Medical Center. "It would be duplicative; we wouldn't treat the minimum volume of patients in West County to justify the additional resources."
The resources at John Muir far exceed those at any other hospital in the county: a trauma surgeon and surgical team in-house 24/7, with backups on-call within 30 minutes; a blood bank as well as dedicated trauma bays and surgical suites within the emergency department; a rooftop helipad and special elevators for quickly moving trauma patients; a dedicated trauma intensive-care unit; and a dedicated trauma step-down unit -- in other words, a unit with care one step less intensive than the ICU. Additionally, all the nurses at the trauma center have special trauma credentials.
"Taking the patient to Doctors (Medical Center) San Pablo or any nontrauma center where they may not have those surgical teams and facilities available is not in the best interest of the patient," said Kacey Hansen, executive director, Trauma and Regional Transfer Center Services at John Muir. "That's why trauma systems were developed."
Of the 1,636 trauma cases treated at John Muir last year, the majority were related to falls or auto-related accidents, according to hospital data; 370 stemmed from shootings, assaults or stabbings.
The American College of Surgeons recommends a minimum annual trauma inpatient volume of between 1,000 and 1,500 for trauma centers that offer the level of service provided at John Muir, according to hospital spokesman Ben Drew.
Although the majority of trauma injuries are not crime-related, the absence of a Contra Costa trauma center in areas prone to violence stands in contrast to Alameda County, which has two adult trauma centers, Highland Hospital in Oakland and Eden Medical Center in Castro Valley, as well as a pediatric trauma center, Children's Hospital Oakland, which also serves Contra Costa County.
The two counties are virtually equal in area -- Alameda County is 739 square miles; Contra Costa is 716 square miles -- but Alameda County had almost 1¿1/2 times the population of Contra Costa in the 2010 census: 1.51 million and 1.05 million, respectively.
The location of Contra Costa's trauma center is more the result of happenstance than design. In the 1980s, when Contra Costa sought to establish a trauma center, John Muir and Mt. Diablo hospitals, both in Central County, were the only bidders in a process that was open to all hospitals in the county, Barger said. Mt. Diablo withdrew, and in 1986, county supervisors designated John Muir a trauma center.
The American College of Surgeons sets national standards for trauma centers based on complex criteria related to population density, geography and quality and availability of pre-hospital care.
"It takes an incredible depth and breadth of physician and staff capability to do trauma care," said Pat Frost, director of Contra Costa County Emergency Medical Services. "Some counties can't sustain even one (trauma center)."