“If they operated her then, she might have survived” – Hemorrhaging Hospitals II.

You are welcome - this is basically one of my specialities, even though my work focuses more on the prehospital fields.

Thank you, this will take some time to go through haha. I'll come back at you if I get the chance.

Sorry for the late reply.

Here are some leads - not all of these studies are truely "rockstars", but they will lead you into the right direction if you follow their citations.

**Myocardial Infarction:**

Searcy R, Patel R, Drossopoulos P, Arora S, Stouffer GA. Rural-urban disparity in survival and use of PCI in patients who develop STEMI while hospitalized for a non-cardiac condition. Curr Probl Cardiol. 2025 Mar;50(3):102979. doi: 10.1016/j.cpcardiol.2025.102979. Epub 2025 Jan 10. PMID: 39800089

Sasaki K, Koeda Y, Yoshizawa R, Ishikawa Y, Ishida M, Itoh T, Morino Y, Saitoh H, Onodera H, Nozaki T, Maegawa Y, Nishiyama O, Ozawa M, Osaki T, Nakamura A. Comparing In-Hospital Outcomes for Acute Myocardial Infarction Patients in High-Volume Hospitals Performing Primary Percutaneous Coronary Intervention vs. Regional General Hospitals. Circ J. 2023 Sep 25;87(10):1347-1355. doi: 10.1253/circj.CJ-23-0188. Epub 2023 Aug 10. PMID: 37558468.

**Stroke/Traumatic brain injury:**

Quantifying Improved Outcomes, Cost Savings, and Hospital Volume Changes From Optimized Emergency Stroke Transport. (2022). Stroke,53 (12), 3644–3651. https://doi.org/10.1161/strokeaha.122.039172

Tepas JJ 3rd, Pracht EE, Orban BL, Flint LM. High-volume trauma centers have better outcomes treating traumatic brain injury. J Trauma Acute Care Surg. 2013 Jan;74(1):143-7; discussion 147-8. doi: 10.1097/TA.0b013e3182788b5a. PMID: 23271089.

Saposnik G, Baibergenova A, O'Donnell M, Hill MD, Kapral MK, Hachinski V; Stroke Outcome Research Canada (SORCan) Working Group. Hospital volume and stroke outcome: does it matter? Neurology. 2007 Sep 11;69(11):1142-51. doi: 10.1212/01.wnl.0000268485.93349.58. Epub 2007 Jul 18. PMID: 17634420.

Tsai SHL, Goyal A, Alvi MA, Kerezoudis P, Yolcu YU, Wahood W, Habermann EB, Burns TC, Bydon M. Hospital volume-outcome relationship in severe traumatic brain injury: stratified analysis by level of trauma center. J Neurosurg. 2020 Mar 13;134(3):1303-1315. doi: 10.3171/2020.1.JNS192115. PMID: 32168482.

Trauma:

Tang A, Chehab M, Ditillo M, Asmar S, Khurrum M, Douglas M, Bible L, Kulvatunyou N, Joseph B. Regionalization of trauma care by operative experience: Does the volume of emergent laparotomy matter? J Trauma Acute Care Surg. 2021 Jan 1;90(1):11-20. doi: 10.1097/TA.0000000000002911. PMID: 32925573.

Nathens AB, Jurkovich GJ, Maier RV, Grossman DC, MacKenzie EJ, Moore M, Rivara FP. Relationship between trauma center volume and outcomes. JAMA. 2001 Mar 7;285(9):1164-71. doi: 10.1001/jama.285.9.1164. PMID: 11231745.

Let me know if you need more info on a specific field.

Currently at a conference, but will do. Remind me in two days if I forget it.

Hello fellow Black Forestian! (Neustadt? It has 150 beds, doesn't it? I hope you don't mean Oberndorf,Stockach or Wolfach..In these cases I have a lot of bad news for you...but they don't fit your description)

• Imaging: In cases like this, angiography is an imaging option to see which can be used (even though it's much rarer these days).Germany is also pretty much alone with it's common use of MRIs - these machines are expensive to run and are only that widespread because we use them far more than clinically indicated-this is why they are often outsourced to a radiology clinic(in Neustadt to a Freiburg one...their afterhour availability...is varying). Additionally even these machines often cannot perform all necessary imaging options (e.g. perfusion MRI for stroke)

• Blood means a blood bank. These cases need blood transfusions urgently. Currently none of the smaller Black Forest hospitals has more than a few emergency blood products. Everything else needs to be delivered - which is a problem if shit hits the fan

• Stroke is a nice example actually: We have a nice system of telestroke care,indeed. And medical development will kill it within the next few years. Because by now we have more and more evidence that thrombolysis (dissolves the blockage with a drug) has worse results than thrombectomy(removal of the cloth - in these cases with a catheter similar to a cardiac cath lab). And that even if it takes longer (lysis has a timeframe of 4.5 hours, cath can often be performed up to 24h after the incident) it shows better results. Even before that was it was a game of numbers as "bloody strokes" as in vascular damage strokes - the vessel is not blocked but ruptured- always couldn't be treated in telestroke units as fhey required neurosurgical intervention and we knew from the beginning that the telestroke concept did them more damage than good,but as they were rarer it was acceptable.

The cath-based thrombectomy has one major downside, though - it is an extremely advanced (both skill and equipment wise)and delicate process. In the black forest region only Freiburg Uniklinik, Villingen (rather recently) and Basel currently are able to do so.

• A myocardial infarction is another very good example. The state-of-the-art treatment for an MI is a catheter intervention. Period. Anything else is not even remotely as good. We also know, that interventionists need a certain quantity of interventions to do so reliably,fast and with a good quality. This already makes it hard to impossible for a small hospital to provide good outcomes. Even medium sized hospitals like Tuttlingen(450 beds )fail to provide these, especially in urgent cases. There is already an abundance (fucking Waldshut has one but does not provide urgent care 24/7)of cath labs in Germany - which by a "euros needed to treat" perspective is a total waste of money but as cath interventions are a good way to make money for a hospital it is acceptable for some reason. Most other countries in the world cannot afford this luxury (and we can't either, tbh)

Anyway. In your case the MI wouldn't even be transported to the small hospital right now. The ambulance service does a 12 lead. If this confirms a STEMI (MI with urgent cath lab need-the most urgent one) it will be transported to a cathlab right away(currently Villingen,Krozingen, Freiburg Uni and Josefshaus, Freudenstadt, Singen, Basel,sometimes Waldshut, sadly Lörrach).

And no, we don't measure outcomes just for the cases which arrive at the hospital alive - all major studies factor in transport times and even then the results are absolutely staggering in favour of a concentration of facilities. (And even if we would follow international standards and remove the Cath labs from Waldshut, Lörrach and Tuttlingen the patients would benefit). There is only one very small subgroup of patients this doesn't apply to: Patients who either already have an cardiac arrest at the time the ambulance arrives or within the first 10min of treatment and in theory could be catheterised with ongoing CPR - but these are rare, even then have a horrible outcome and the evidence even in an urban setting simply is inconclusive.

Don't get me wrong, I do agree with you on some points:

• Our secretary of health is..a dimwit. As a Bavarian reingeschmeckter here I really really feel ashamed. We didn't want him and then he became a secretary of health here. (And I've met him personally. The only good thing I can say about him: He is not as bad as Karl Lauterbach or Jens Spahn)

• The uni hospital fucked up,yes. But at the moment of "shit hit the fan" the patients survivability would have been better in a uni hospital - even considering the driving distance. (Hungary has an excellent ambulance system that surpasses ours in some areas)

And don't get me wrong: The way we "concentrate" hospitals in Germany is a scam. We actually simply close hospitals without extending the amount of beds and capabilities in the centres.

Which then of course leads to overcrowding, etc.

From a healthcare economist's perspective you would need to build up 1.2 beds in a centre per bed closed as people normally would need to stay a bit longer there due to various reasons. Only then it works properly.

There is also the option to retain some beds in a step down approach, with primary and urgent care being delivered in the centre and the patient later being transferred to the "smaller" facility but treatment is still being controlled by the centre, as well as using the smaller facility as an urgent care clinic, e.g. in partnership with external medical offices. As it is done in the UK,Australia, Hungary (sic!), Italy,Australia, etc.

But for the later we would need a centralised healthcare management and not a rag rug of different providers.

What do you mean with blood to imaging.

Even my small 120 bed hospital in the black forest has a CT, and an MRI.

They also have their own laboratory for blood analysis, and can teleconsult specialists in the University Hospital 24/7 if a Stroke Patient should be transferred to them

Also in this case the University Hospital fucked up the case too.

So yes, bigger hospitals have better outcomes in certain areas, this is not a good example for this point.

And it's also convenient to be better in stats with care concentrated on bigger hospitals when you measure outcomes only starting at the hospital door

If you need 1-2 hours to reach the hospital in Denmark with an acute myocardial infarction (it's an example our previous health minister loved), then the cases still alive when reaching it might be not the worst ones, because they died already on the way there

We have a mountain of evidence, that small hospitals are providing far worse outcomes, even if you factor in transport times to larger facilities.

Do you per chance have interesting sources you recommend? I feel this must very much depend on the distance.

Oh damn. Here we go again.

We have a mountain of evidence, that small hospitals are providing far worse outcomes, even if you factor in transport times to larger facilities.

They don't have the equipment(from blood, to imaging, interventional radiology, etc.), the qualification(you won't find a interdisciplinary surgical team like you find in a larger centre)and the experience(you need to have a certain case load to keep your skills up) to handle cases with higher severity.

Of course people feel like the "good old hospital" close by would "save their life", but the times where a small surgeon saves a life are long gone. (And realistically they fucked up more than enough cases back then as well. We have started to gather evidence about that since the 50ies).

In that case multiple people fucked up. There is zero evidence that the uterus rupture wouldn't have happened if she was an inpatient - or that she would have survived if she was an inpatient in that small hospital.