One April evening two years ago, 9-year-old Justin Davis dashed into a busy Jacksonville street, headed to a convenience store for snacks.
When paramedics arrived minutes later, they found the boy lying on the road, unconscious. The impact of a car had fractured his skull and his brain was swelling and bleeding.
Paramedics knew they had to act fast.
Instead of taking Justin to the pediatric trauma center 13 miles away — the only place in Jacksonville equipped to handle his injuries — they drove him in the opposite direction, to a new adult trauma center a few miles closer.
If they thought they were saving time, they were wrong.
Doctors there couldn't treat Justin's brain injuries. They called for a helicopter to take the boy back across town to the pediatric trauma center.
It wound up taking more than 80 minutes to get the boy to specialists who had been less than 20 minutes from the scene of his accident.
Justin never woke up.
Under Florida guidelines, children who suffer traumatic injuries are supposed to go straight to a trauma center that specializes in pediatric care. Studies show that gives them the best chance of survival.
But dozens of children each year aren't getting that chance, a Tampa Bay Times investigation has found. Instead, paramedics are taking them to adult trauma centers that may be closer but aren't equipped to help them.
This is an unintended consequence of the recent expansion of Florida's trauma system.
Starting in 2009, state officials approved six new trauma centers owned by Hospital Corporation of America that compete with existing pediatric trauma centers.
Well-intentioned paramedics started taking severely injured children to some of these new centers, which could do little to treat them. Local EMS officials and state regulators failed to monitor the impact of these new adult trauma centers on children.
The Times analyzed thousands of hospital billing records for children who were taken to Florida trauma centers over the past four years. Among the findings:
• More than 100 patients under 16 wound up at HCA's new trauma centers even though none of those hospitals are designated by the state to treat children. More than 60 had to be transferred to another hospital for treatment.
• Transfers meant delays of hours, not minutes. In one case, a 13-year-old girl with a concussion and a broken forearm waited more than four hours before she was transferred to another hospital.
• At least three children died after they were first taken to an HCA trauma center for adults despite meeting state criteria to go to a pediatric center. Those children then had to be transferred to get the care they needed. Their injuries may have proven fatal regardless of where they went. But in each case, time would have been saved if the child had been taken directly to a pediatric trauma center.
• Ultimately, paramedics decide where to take an injured child. But the HCA hospitals have a say too. Paramedics contact the hospitals in advance and staff could direct them to a pediatric trauma center.
• The cost can be high, even for children with relatively minor injuries. HCA charged as much as $33,000 last year to patients just for showing up at their trauma centers, even if they can't be treated and are shipped to another hospital within minutes.
Kids need special care
Florida has designated 13 hospitals as pediatric trauma centers. Most of these centers treat adults too, but are required by the state to have surgeons experienced at operating on an infant's brain or repairing a 5-year-old's fractured pelvis.
The Times interviewed more than two dozen emergency room physicians and EMS officials. All agreed that children with severe trauma injuries should be taken to a children's trauma center — even if an adult center is closer.
Though there are no hard and fast rules, in general, trauma experts consider 50 miles a reasonable distance to fly a severely injured patient to reach appropriate care. In some states, pediatric trauma centers draw children from hours away.
The only exception is when a child is in cardiac arrest or when paramedics have some other reason to believe the child will not survive the longer trip.
But state officials have done little to make sure young trauma patients wind up at the right hospital.
In fact, Department of Health spokesman Nathan Dunn said his agency — which certifies trauma centers — does not examine how children fare when they are taken to adult centers.
Paramedics always have the discretion to head first to the closer hospital, he said, even if the child needs to be transferred later.
"There would be no reason to automatically investigate such transfers," Dunn said.
Paramedics, meanwhile, rarely learn whether they made the right decision because they don't routinely get feedback on patients who are transferred elsewhere for treatment.
A spokeswoman for HCA's trauma center in Ocala said paramedics, not the hospital, decide where to take an injured child.
"We're not going to second-guess the life-saving decisions first responders make on the spot every day," said Suzanne Santangelo.
But in at least one case, paramedics waited on the scene for officials at an HCA hospital to tell them where to take a toddler with a brain injury, Marion County Fire Rescue records show.
The hospital's response: Bring him in.
Within minutes of arriving, doctors decided he needed to be transferred to a pediatric trauma center. He later died.
From 5 to 57
For years in Florida, it was relatively rare for an adult trauma center to accept critically injured children.
It happened most often in places where the nearest pediatric trauma center was more than 50 miles away.
Among them: Lee Memorial in Fort Myers and Tallahassee Memorial Hospital, both 100 miles or more from the closest pediatric trauma center.
Halifax Health Medical Center also regularly treats young trauma patients even though it is not a designated pediatric center. The Daytona Beach hospital is slightly more than 50 miles from the closest pediatric hospital.
In areas closer to pediatric centers, few children wound up at adult centers until HCA entered the market.
In 2010, only five seriously injured children were taken to non-HCA adult trauma centers within 50 miles of a pediatric center.
In 2012, after HCA's expansion, 57 children were taken to adult centers.
The increase has come largely in three counties — Marion, Clay and Pasco — with new HCA centers, none of which have a pediatric trauma designation. Those centers benefited from the new business; they can charge tens of thousands of dollars in trauma activation fees to each patient.
Local officials welcomed the new centers because they gave residents faster access to trauma care and saved paramedics time. They also saved departments money on overtime pay and vehicle wear-and-tear from driving patients out of the county.
In Marion County, the fire department sent representatives to state hearings to boast about the benefits of adding a trauma center to Ocala Regional.
But no one was focusing on children, who make up a small percentage of trauma patients.
Since Ocala Regional's trauma center opened in December 2012, paramedics have taken at least 19 seriously injured children there instead of to UF Health Shands in Gainesville, 34 miles north by helicopter.
Shands and other pediatric trauma centers unsuccessfully sued to stop HCA's expansion, saying the new centers added costs and diluted quality. Surgeons at Shands were particularly concerned about the impact on pediatric trauma patients.
In a May court hearing, one of them criticized Ocala Regional for attempting to treat children, then handing them off to his hospital when things went wrong.
"Some of these kids may never have survived," Dr. Fred Moore said. "But they certainly didn't get the advantage of landing at Gainesville (first) and having all the forces that we have to come to bear."
Marion County's medical director, Dr. Frank Fraunfelter, said his paramedics are still told to take injured children to Shands unless they would not survive the trip.
But in a fire department report provided to the Times, paramedics noted that only six of the 19 children taken to Ocala Regional were in cardiac arrest or had breathing issues.
The Times asked county officials whether there were specific medical issues not noted in the report for the remaining children or if air transport had been unavailable in those cases.
"In each of the 19 incidents where pediatric patients were transported to Ocala Regional Medical Center there are documented reasons for doing so, which abide by policies established by all counties in the North Central Florida Trauma Agency and are supported by the medical community," Marion County Fire Rescue spokeswoman Jessica Greene said.
She would not provide those reasons.
The Marion County numbers are a stark contrast to those in Polk County to the south. Polk County is home to an adult trauma center, nonprofit Lakeland Regional Medical Center. It takes about as long to get to the nearest pediatric center — in Tampa — as it does in Marion County.
Yet paramedics in Polk County rarely take children to the Lakeland trauma center.
Even though Polk County is bigger than Marion, and home to twice as many people, its fire rescue delivered no traumatically injured children to the adult trauma center last year.
"If you're a kid hurt really bad," said Mike Linkins, deputy chief of Polk County Fire Rescue, "you're not staying in Polk County."
Bring him in
Taking a child to a pediatric center that's farther away can be the fastest way to get him help.
Consider the case of 2-year-old Kayne Williams.
At 8:35 p.m. in early January, Marion County paramedics found Kayne unconscious, his arms and legs stiff and extended, his pulse dangerously low.
Paramedics were told the boy hurt his head when he fell in the tub. But they suspected abuse and noted it in their report, which became public as part of a criminal case.
Instead of heading straight to the pediatric trauma center in Gainesville, 39 miles away, paramedics called Ocala Regional, just 7 miles down the road, for advice, the documents show.
Their report says there was a delay at the scene before an Ocala doctor told them to bring the boy in. They loaded him in their ambulance at 8:50 p.m.
They arrived at Ocala Regional at 9:04 p.m., where doctors slid a breathing tube down the boy's throat and X-rayed his chest.
By 9:15 p.m., however, the trauma surgeon was on the phone to Shands to arrange a transfer, noting on a form that it was necessary to "obtain a level of care/service unavailable at this facility."
At 10:54 p.m., Kayne arrived by helicopter at Gainesville.
More than two hours had passed since paramedics first put the boy in their truck.
If paramedics had bypassed Ocala Regional and headed straight to Shands, they could have gotten Kayne there by ground in about 40 minutes; by helicopter, in about half that time.
Surgeons say time is of the essence, particularly with head injuries.
"In trauma, we talk about the 'golden hour' during which potentially fatal injuries can be reversed," said Dr. Barbara Gaines, director of pediatric surgery at the Children's Hospital of Pittsburgh. "If you have a traumatic brain injury, the sooner the patient can get to some place that's comfortable treating them, whether with a surgical procedure or intensive medical therapy, you assume the outcomes will be better."
At Shands, surgeons operated on Kayne's brain but could not save him. He was taken off life support 12 days later.
Four veteran paramedics who reviewed Kayne's EMS report questioned why rescuers who spent 15 minutes on the scene waited for a response from Ocala Regional. Most of them believed the boy should have been taken directly to Gainesville and that Ocala Regional erred in not redirecting them there.
"If Ocala did not have the ability to do immediate surgery, they should have directed paramedics straight to Shands," said Guy Haskell, a veteran paramedic and expert witness in Indiana who also is editor of EMS continuing education for Gannett Healthcare.
"It's clear he had a head injury and needed to go to a place where they could deal with that."
Marion County Fire Rescue declined to comment on the case, though its records say the child was taken to Ocala Regional with the hospital's "consultation and approval."
Department of Health officials say they reviewed Ocala Regional's pediatric trauma protocol and "relevant medical records" as part of a regular inspection in May and found "no deficiencies."
The spokeswoman for Ocala Regional says it has five trauma surgeons on staff who meet state criteria to provide immediate care for children, and can call in pediatric specialists as needed.
But state data show that from December 2012 through the end of 2013, the Ocala trauma center's surgeons had operated on only one young child with traumatic injuries.
That child, an infant who had been shot, died.
Delays begin the moment injured children arrive at a hospital that can't treat their injuries.
As a matter of course, trauma patients are put through a battery of tests to diagnose their injuries.
Even if surgeons quickly realize they can't treat a patient, a pediatric specialist at the next trauma center has to be informed of the child's status. An ambulance or helicopter has to be arranged.
A Times review of state hospital data from 2010 through 2013 shows that young trauma patients spent an average of two hours — and in a few cases as long as five — at HCA's new trauma centers before being transferred for treatment. That doesn't include the time it took to drive or fly patients to two facilities.
Among the children whose treatment was delayed was a 6-year-old with an open head wound who spent more than three hours at Ocala Regional and a 5-year-old with a concussion who spent more than two hours at Lawnwood Regional Medical Center in Fort Pierce. Both children had to be transferred to have their injuries treated.
There's no way of knowing how children who experienced delays in care fared at the next hospital. State data do not include patient names, so patients cannot be tracked from one hospital to the next.
Interviews with officials at pediatric hospitals suggest that most children survive the delays caused by transfers.
Dr. Paul Danielson, head of pediatric surgery at All Children's Hospital Johns Hopkins Medicine in St. Petersburg, which partners with Bayfront Health to provide trauma services to children, said there is always room for improvement.
"More kids could come here directly and more kids could come here faster," he said.
While experts question the benefit children get from being taken to adult trauma centers, the financial benefit to the hospitals is clear.
The Times analyzed 2013 hospital data for all children who were charged for the activation of a trauma team but were not admitted to the hospital.
Among this group, children taken to HCA trauma centers had the highest average bills in the state.
Topping the list was Regional Medical Center Bayonet Point in Hudson, whose five child trauma patients last year were charged an average of $60,000 each. One died. Two were sent home shortly after. Two were transferred to other hospitals within hours.
Though hospitals don't collect every dollar they charge, they often are reimbursed a percentage of the trauma bill by insurers. So the higher the bill, the higher the reimbursement.
One big component of the HCA bill is the for-profit hospital chain's trauma response fee, the price of activating a team of specialists to await a patient's arrival. HCA's response fees, levied on top of the cost of every medical procedure, are the highest in the state. Over the past four years, an average fee of $27,700 was tacked on to the bills of nearly 60 children who had to be transferred elsewhere for treatment.
The bills at HCA's trauma centers are also boosted when doctors order multiple CT scans before moving the child to the next hospital or sending them home.
HCA's spokeswoman said such scans are done to "help trauma surgeons decide if patients with internal bleeding need immediate surgery or can be transported."
But the vast majority of children who had CT scans at HCA trauma centers in Florida were not operated on by HCA surgeons, state data show. Most had to be sent elsewhere for treatment. Among the dozens of children scanned but never admitted to the hospital was a 1-year-old boy with a fractured femur who could not be treated at Lawnwood Regional. During his two-hour stay, the hospital gave him five CT scans and a $70,000 bill.
Some states, including Pennsylvania, recommend hospitals avoid scanning children if they're going to be transferred. The procedures, experts say, do little but cause delays, cost money and expose children to unnecessary radiation.
"The minute you recognize the child's needs exceed your capability and capacity, you should be packaging that kid and putting him in an ambulance," said Dr. R. Todd Maxson, trauma medical director for Arkansas Children's Hospital. "No other tests are required unless you are going to act on the data provided."
In February 2013, less than a year after doctors declared Justin Davis brain dead, the HCA trauma center that first tried to treat him was closed by Florida's Department of Health.
Orange Park Medical Center can accept regular patients, but it is no longer allowed to treat either adults or children with severe trauma injuries.
Health department officials refuse to say why, citing a state law that allows them to keep inspections of trauma centers secret.
In their report, Jacksonville Fire Rescue paramedics said they took the boy to Orange Park on April 24, 2012, because it was the "closest facility." It was 5 miles closer than the children's center at UF Health.
Michael Braddock, captain of Jacksonville Fire Rescue, said the department does not have records showing how many injured children were taken to Orange Park while it was certified as a trauma center.
Citing patient confidentiality, he would not say whether his agency reviewed Justin's case to see if paramedics made mistakes. But Braddock defended their decision.
Patrick Shepler, a retired Clearwater Fire Rescue lieutenant who has taught paramedic courses at St. Petersburg College, reviewed Justin's EMS report. He commended rescuers for spending less than six minutes on the scene before departing. But he thinks they headed in the wrong direction.
"I don't see any reason they didn't take him to the pediatric trauma center since the difference in distance was pretty insignificant," said Shepler, who is now a paramedic north of Seattle. "It's not so much my opinion. It's the criteria."
Justin's mom, Sonya Coleman, still remembers that day like a bad dream — begging her son to wake up, wanting to scoop him into her arms and hold him, but believing it best to leave him to the expert hands of paramedics.
"I'm always trying to take control of a situation, but I let my guard down," she said. "I thought they knew what they were doing."
She recently saw a story about a car wreck near the site of Justin's accident. Paramedics took the victims straight to UF Health.
Why, she can't help but wonder, did they not do that for her son?
Times computer-assisted reporting specialist Connie Humburg and Times researcher Caryn Baird contributed to this report. Contact Kris Hundley at firstname.lastname@example.org or (727) 892-2996. Contact Alexandra Zayas at email@example.com or (727) 893-8413.