How trauma center designation happened in Colorado

Annie Johnson (a pseudo name) had just won the title of Roundup Rodeo Queen for 1993, and had just been crowned Homecoming Queen at her high school.   She was embarking on one of the most exciting times of her life; she’d earned it all.  Annie was a senior, a good student, active in 4-H and volley ball; actively participated in rodeo competition, and community activities making sure she always did her part.  Everyone in her community, young and old, knew her because she was so full of life; they all loved her.   Those who knew Annie described her as, “a very determined person, always willing to go that extra mile; she was no cream puff queen, but a real person.”  At 14 years of age, Annie could drive a trailer loaded with cattle to help make her family’s ranch work.  Even covered with manure from head to toe, she was still the prettiest, most delightful one around.

                In the fall of 1992, Annie and her boyfriend, set out for a birthday celebration.  After a few hours of great fun, they were traveling back to their rural home on highway 285 around 7:30 p.m.  The young man was at the wheel driving about 45 mph on a dark night with blinding cars coming his way.  In attempt to try to be safe, he decided to pull off to the side of the road into the emergency lane.  When he did, he plowed right into a huge van parked in that same lane.  Neither of them had been able to see the van before he exited; they were not wearing seat belts.  Not much time passed before, they were discovered by some classmates.  Immediately, they realized Annie was seriously injured; the boyfriend had only minor injuries.  The helpers went to a friend’s house to call for help, and to notify Annie’s family.  A 911 emergency number is not in place in this area.  Annie was taken to a community hospital in rural Colorado.  Annie was examined and x-rayed at the same hospital, and found to be more than they could adequately handle.  Life threatening lung and heart bruises were suspected.  Possibly, there was an aortic rupture; this would mean open heart surgery.  “Where would you like to have her taken?” the doctor asked.  Of course, the parents had no idea what would be best for Annie, but were relieved by the possibility that she could be air lifted to Denver.

                The physician summoned a helicopter and conveyed his suspicions to the receiving hospital’s pulmonary and cardiac specialists.  In this instance, this helicopter service had a greater ETA (estimated time of arrival to a rural Colorado hospital and back to take the victim to their hospital base.  While this same hospital has an emergency room, it was not certified to treat trauma victims.  A better option would have to summon a closer helicopter service and have Annie flown to a geographically closer trauma center either in Colorado Springs or Grand Junction. 

                At the time of this incident, physicians in Colorado decided on a case by case basis how they would handle accident victims.  Had a state-wide trauma system with a non-partisan communications network been in place, information about Annie’s injuries would have been fed into a computer.  When and where Annie’s care would have taken place would have been dictated by law.  The victim would not have been flown past hospitals better qualified to treat her critical injuries.  A helicopter with a closer ETA would have been employed.  Annie was transferred to a Denver hospital around midnight where she was taken to an ICU (intensive care unit) where she was met by two resident pediatricians.  While these physicians were probably adept in their own specialties, they were not trauma specialists.  According to medical personnel who saw Annie, she was alert, and talking; she underwent some tests and treatment.  Annie was then put to bed in the ICU without full evaluation of her catastrophic injuries. Around 6-6:30 a.m. Annie’s parents signed for blood to draw out of Annie’s back.  A reliable source close to the case said the same thoracic  surgeon alerted hospital staff that night to the severity of Annie’s injuries and volunteered his services noting that –rays showed her chest was full of blood.  This same surgeon went to the ICU three ties offering to help, and was told, “Everything is under control.”

                On the order of an admitting physician, Annie was examined for internal bleeding.  The same physician was quoted as saying, “Put a needle in her chest and see if there is blood.  If it is, call me.”  The procedure was conducted; a liter of blood was removed from the chest cavity, but the physician was not notified.  Eight hours later, Annie went into severe shock; doctors performed emergency surgery taking Annie’s lung out, but they were too late.  Annie Johnson died the next day at 12:30 p.m.  Later the hospital conceded that Annie was, “An apparent victim of miscommunication. Annie’s death would be reviewed as part of the hospital’s quality management program.  The hospital allowed that it handles ‘a wide variety of trauma cases referred to its doctors.  A medical source close to the case said the failure to diagnose Johnson’s key injury –a ruptured thoracic aorta, was ‘inexcusable, indefensible, reprehensible.”  There are those who would argue that Annie’s death was “preventable.”  She would have had a very good chance of surviving had her injuries been correctly diagnosed and open-heart surgery been performed in a timely manner instead putting her to bed for several hours as she bled to death.

                According to Dr. Ernest “Gene” Moore, Chief of Trauma surgery at Denver General Hospital, a torn aorta is the most common cause of death in traffic accidents.    About 85 percent of victims with ruptured aortas die at the scene.  Of those who make to a hospital, 75 percent survive, if their condition is identified and treated within six hours.  Denver General’s Trauma Center has a survival rate of 88 percent in such cases.  Hospitals are to report unusual deaths to the Colorado Health Department within 24 hours; however, this did not happen until the story was disclosed in The Denver Post.  Failure to report the death violated state law.  The Denver Coroner’s Office then requested The Colorado Board of Examiners to investigate Annie’s death because “of the allegation she had not been properly cared for.”   The Johnson family did not learn of disturbing events surrounding their daughter’s death until they were contacted by The Denver Post.  A reporter called and said, “I’d like to come down and talk to you before we print this story.”

The Johnsons were shocked at the inhuman treatment of their daughter.  Later, they said, “It was an unfair question to ask us where Annie should be taken.  We did not know anything about trauma injury.  We had never heard of a trauma system.  We thought everything possible had been done to save her life; we would have been none the wiser if this had not come out in the paper.  Ewe just wish the cardiac physician had trusted his instincts and gone in there to so something to save our daughter.  Annie was referred to the Denver hospital by a physician who knew the hospital was not certified to treat trauma victims; the system let us down.  We don’t think hospitals should have a helicopter program if they are not attached to trauma centers.”

 Lawmaker urged trauma system

                State Senator Dottie Wham introduced trauma bills to the legislature in 1987; she withdrew the bill in face of “extraordinary objection to it from it seemed like everyone.  In 1989, Wham tried again.  The bill was revamped; it made it to the Senate, but died in the House Committee.  Primary opponents of change came from the medical community.  Senator Wham said, “Annie Johnson’s death is a tragic example of the need for a state-wide trauma system.  I felt particularly bad; maybe if I had worked harder, the system would have been in place and this wouldn’t have happened.”

                After this incident, Senator Wham again introduced Trauma Bill 86 to the legislature early in 1993.  In effect, this bill, “Shall develop an integrated sate-wide trauma system which shall, at minimum, provide or promote access to and standards for pre-hospital care, hospital care, rehabilitation care, preventive care, disaster medical care, education, research, communications and costs of trauma care in a manner consistent with recognized national standards for EMS systems.  Such a system shall involve all appropriate health care agencies, institutions, facilities, and providers on the national, state, and local level.”

                When public hearing were held early in 1993, Mr. and Mrs. Johnson were able to testify to the effect that the system had failed them in the treatment of their daughter.  No one opposed the bill; it was accepted. 

                In the gallery of the legislative hearings, Joe Butterfield M.D. of Children’s Hospital in Denver, commented, “It has taken 20 years to get to this point.  There just isn’t any cooperation; it’s a matter of egonomics.  Everyone wants to do their own thing.  We really do need regional care to save lives.” 

                Linda Dodge of the Colorado Trauma Institute said, “We can’t walk away from the fact that half of our trauma patients are dying.  Similar cases happen in other hospitals, not only in Colorado, but all over the country.  We need to get the right patient to the right place at the right time for the right care.”