Review Panel to Probe Fatal Trauma Case

Saying that a thorough investigation is needed to ensure confidence in the county’s trauma network, Los Angeles County’s health director announced Thursday that a special review panel will examine the case of Torin Comeaux--a gunshot victim who died after spending six hours in the Martin Luther King Jr./Drew Medical Center’s emergency room awaiting a vascular surgeon who could not be found.

Comeaux, 31, was taken to the King/Drew trauma unit the afternoon of April 12 with a gunshot wound in his knee. He ultimately was airlifted to the trauma unit at County-USC Medical Center near midnight. Comeaux died at County-USC after more than six hours of surgery.

Comeaux’s sister and mother told The Times that doctors at King/Drew said he had bled to death--a suspicion shared by at least one emergency room surgeon from the hospital.

Mark Finucane, director of the county Department of Health Services, said Comeaux’s case has raised a host of potentially troubling issues--from treatment of individual patients, to management of a hospital emergency room and its surgeons, to how well the entire emergency management network is working.

Finucane’s department oversees the county’s trauma centers and hospitals.

“There are enough unfortunate coincidences and lapses [in this case] to cause me to want to take a good thorough look with a very high-level group of senior clinicians and managers to see what happened, why it happened and to make sure it doesn’t happen again, where humanly possible,” Finucane said. “This was a highly unusual case, in that from a common sense point of view people would think this was preventable.

“There are a variety of things that have come right to the fore that you want to look into; a number of issues indicating a need to take a very broad view of what the implications are for the system,” Finucane said.

“Some of it has to do with management at one institution [King/Drew].”

Finucane said the review panel will pore over the findings of his team of investigators, who are already probing the case, and inquiries are already underway by both hospitals and the Emergency Medical Services Agency.

But he will also bring in at least one outside surgical specialist to ensure an objective review, and assign one of his top aides, Dr. Donald C. Thomas, to pursue additional avenues of investigation.

Officials at the South-Central Los Angeles medical center also moved quickly Thursday to address controversies involving the Comeaux case.

At a packed staff meeting, hospital Administrator Randall Foster told concerned doctors, nurses and staffers that various reviews of the case are underway. “We’ll be looking at the specifics, and at our policies and procedures to see if we can improve, and how we can improve,” Foster told the crowd.

Finucane said he was particularly troubled by King/Drew’s apparent violations of county policy.

Because the hospital is one of the top trauma centers in the county, regulations require that at least one vascular surgeon be no more than 30 minutes from the emergency room at all times to operate on gunshot victims and others requiring life-saving surgery on damaged veins and arteries.

Sources also say that King/Drew officials never notified the county Emergency Medical Services Agency that they did not have a vascular surgeon ready to operate so patients could be rerouted to other trauma centers.