Imagine, for a moment, that Hosam Maher Husein Smadi got it right.

On a brisk late September morning, the sort of crisp, cloudless day that marks the transition from summer to fall, the 19-year-old Jordanian native parked a moving truck at the corner of Ross Avenue and Field Street, directly in front of Fountain Place, and unobtrusive to the downtown office workers finishing their commutes. In the truck’s cargo: 3,500 pounds of explosives, a mix of ammonium nitrate, liquid nitromethane, and Tovex, the same mixture Timothy McVeigh used when he bombed the Alfred P. Murrah Federal Building in Oklahoma City on April 19, 1995. Since then, those ingredients have become hard, but not impossible, to come by, so Smadi’s bomb was about half the size of McVeigh’s.

That was more than enough. At 8:22 am, the truck exploded with such force that it knocked people over six blocks away and shook cars on Central Expressway. A 20-foot-wide, 5-foot-deep crater opened up where the truck once stood. Forty-nine people (many of them employees of Wells Fargo Bank and the Region 6 headquarters of the U.S. Environmental Protection Agency) died in the blast, which destroyed almost a third of the 60-story office tower and rained shards of glass over a swath of the downtown area. 

Those 49 never would have made it. They were gone before anyone even realized a bomb had detonated. The other 23 who died later and many of the 237 injured in the explosion—Smadi couldn’t claim full responsibility for them. He may not have realized it, but Smadi picked the perfect city to maximize the human cost, a place with trauma care facilities that could barely withstand the strain of a big wreck on Stemmons Freeway, let alone an attack like this. No one was ready, and, worse than that, they knew they weren’t ready. And so patients died in traffic, on the way to one of the few area facilities that could handle an incident of this magnitude. Others died near the fountains that give the building its name, because there weren’t ambulances to transport them. Minor smoke inhalation injuries became major. It was much worse than it had to be. Instead of spending $1 million on a mobile trailer that could treat as many as 100 patients on site, the county spent twice that much in wrongful death lawsuits.

Dallas residents probably don’t think much about this worst-case scenario. You might work downtown at the Crescent Center or in the Plaza of the Americas or at the Legacy Town Center in Plano. You might wake up, listen to KERA’s Morning Edition, and think about traffic on North Central Expressway. Maybe you are getting dressed for lunch at the NM Fashion Cafe at NorthPark.

But you probably don’t think about what would have happened if Smadi, who was arrested in September 2009 for placing an inactive car bomb near Fountain Place, had actually succeeded. (The casualty and injury numbers suggested here are an educated guess, using McVeigh’s Oklahoma City attack and the 1993 World Trade Center bombing as reference points.) If Dallas were hit by terrorist attack or a natural disaster (like the tornado that came perilously close to whipping through downtown in September), the area’s trauma centers in its three big emergency rooms probably wouldn’t be able to handle the situation. If you were injured in these or any other big event, there is a good chance that you would have no place to go, no way to get there, and no one to help you once you arrived.

It is not that the city doesn’t have response procedures in place if it were challenged by a natural disaster or terrorist attack. But North Texas trauma care—the facilities themselves—are just scraping by, trying to meet the challenges they face on a normal day of business. If the region were challenged by a calamity that caused mass casualties, highly unlikely though not impossible, the hospitals would overflow with injured people who couldn’t get medical attention.

“If something significant happens, I would question if the Dallas County community would be prepared to handle the onslaught,” says Jorie Klein, registered nurse and director of Parkland Memorial Hospital trauma center.

Hospital directors and advocacy groups have been lobbying to help the North Texas trauma system expand its reach and abilities. But so far the groups haven’t received sufficient state and federal aid. The result is that Dallas residents are at risk if a disaster hits.

In March 2009, the Legacy Center for Public Policy, a Dallas-based think tank, drafted a paper addressing Dallas’ need for additional trauma resources. “Trauma and burn treatment care in North Texas is in critical condition,” the paper says. “Failure to address the problem has 6.7 million Texans in 19 counties at risk of catastrophic health care failure and the collapse of our emergency room trauma and burn care capabilities.”

Texans are at a disadvantage when it comes to emergencies. Level one trauma centers, those that handle the most acute burns and other injuries, are built according to demand and population in an area. But Texas is tricky because the population density varies greatly among counties in the state. Dallas County is 25,000 times as dense as Loving County, according to a May study released by the American College of Surgeons Committee on Trauma. This dynamic makes it more challenging to accommodate patients because the hospitals are forced to account for people in poorer rural communities as well as urban areas that may have high traffic or crime. Emergency response resources and funds can become strained, even without a surge in demand caused by a disaster.

Though the estimate varies, the American College of Surgeons says, “One frequently mentioned estimate is to have one level one trauma center per 1 million population served.” North Texas is starting to lag by this crude measure. There are only four facilities to serve more than 6 million people. The number could quickly look worse as the population grows. JPS Health Network serves all of Tarrant County. Dallas has only two hospitals for adults—Parkland Memorial Hospital and Baylor University Medical Center—and one pediatric level one trauma center at Children’s Medical Center of Dallas.

The three area adult hospitals are nearly at capacity handling daily shooting and car accident victims. Say you have to go Parkland. On an average day, it is already running at 90 percent capacity, and it has only 62 intensive care beds. In an emergency, Parkland could open up only 100 extra beds, far fewer than the thousands that would be injured in a significant event. JPS in Fort Worth is at 93 percent capacity on a typical day. Baylor is at full capacity, too. And the pediatric trauma center might have trouble serving adults, given its equipment. Though Parkland is opening a new hospital in 2014, it will only replace the old facility.

Logistics in North Texas cause problems, too, especially when hundreds of people need to be transported quickly. Because the trauma centers are downtown, suburban victims are out of luck. It takes about 35 minutes—or more than an hour in traffic—to get to Baylor hospital from Legacy Town Center in Plano. The trauma centers have only a handful of helicopters to medevac patients. So you’d likely have to hitch a ride with an ambulance or a friend and fight traffic to reach help.

Other Texas cities might not have the capacity to help much either. Houston doesn’t have sufficient hospitals to handle its own daily demands, according to the American College of Surgeons. Galveston is still rebuilding after having had to shut its doors following Hurricane Ike.

The Legacy Center’s paper asked for coordination between, and incentives for, hospital staff, among other things. After the group published the paper, it proposed a bill to Texas Legislature that was intended to form a new trauma care group to organize infrastructure and coordinate resources. This group would have the ability to lobby Congress for money to help fortify the trauma centers.

“There needs to be a plan and a greater plan than just the city of Dallas,” says Warren Rutherford, one of the authors of the paper. “It needs to have an authoritative relationship for those that they need to serve.”

The bill fell flat, though, partly because the state is already broken up into 22 regions with individual advisory groups, called Regional Advisory Councils, meant to organize trauma centers in case of an emergency.

Carrie Hecht is chairman of the North Central Texas Trauma Regional Advisory Council and director of trauma at JPS. “We have done an excellent job at building the system,” she says. “ But North Texas needs to [continue] to mature and develop our trauma system—and that means all of us.”

The Regional Advisory Council has tried to coordinate emergency response, hospitals, police, and fire systems in case a 9/11 or Hurricane Katrina-type event happens in North Texas. And the overall Regional Advisory Council system in Texas is better than in other states. But its abilities are somewhat limited. Though it coordinates hospitals, it isn’t responsible for staffing them. It can deliver extra supplies in an emergency and set up a central command station to communicate. But it cannot lobby Congress for more money to help its cause.

So the hospitals themselves are left to ensure that their own trauma centers are funded and ready. Since they struggle to pay their bills every year, it is hard to find extra money to put toward the one-off chance of a terrorist attack.

Still, North Texas could do quite a lot to boost its emergency resources without taking on the huge cost of building a new hospital. It could pay more doctors in the area to stay on call. That could run upwards of $6 million a year—not peanuts, but it might be a small price to keep a bigger network of doctors at Dallas’ fingertips. For just $1 million, the hospitals could purchase trailers that could be driven to the site of an emergency and tend to 100 patients at a time. Parkland has considered buying some of these trailers, but the hospital had to spend the money elsewhere.

So far, the federal government has provided little financial aid to Dallas hospitals for large-scale disasters. Despite the vast funds set aside for trauma over the past decade, Parkland has received about $600,000 in federal funds since 9/11, with just $9,000 coming last year. That’s only enough to keep current resources up to date and offer some additional training, according to Klein.

The state has set aside money for trauma facilities in one of the more comprehensive initiatives in the country. In 2003, it passed the Driver Responsibility Program law that tacked on a surcharge to traffic offenses. More serious violations, such as a DWI, carry more punitive charges. A chunk of these fines goes into a pot to pay out to trauma centers.

The idea had some logic. A large number of emergency room visits are a result of drunken driving accidents. The program was meant to penalize the perpetrators who were stressing the trauma care system. But the bill hasn’t worked. Some of the money has been difficult to collect because people aren’t paying their fines. And with the massive budget deficit the state is currently running, some of that money has been spent elsewhere.

Senator Florence Shapiro of Plano recognizes the need to keep trauma a priority, but she doesn’t expect cash to flow to it anytime soon. “Everybody knows we are in very difficult times,” she says. “I am not sure trauma centers are going to be at the top of the list for more funding or more ways of funding. I think we are going to have to do more with less.”

Hospital emergency rooms have received about $300 million since 2004 from various sources, according to Shapiro. But trauma care advocates say that the state is holding onto money that was meant for hospitals. Dinah Welsh is chief executive officer of Texas EMS Trauma & Acute Care Foundation, a nonprofit group seeking to raise awareness of trauma in Texas. She says that by August 2011, the state will have a $300 million IOU to trauma care from the Driver Responsibility Program account.

“There are dollars out there, but they are sitting in a big state pot in the sky,” Welsh says. “I guess I was pretty naïve to think that when we formed this account in the state treasury that those dollars would go to trauma.”

Shapiro says that after 9/11 the state worked hard with the Regional Advisory Council in Dallas, as well as the 21 other Regional Advisory Councils throughout the state, to be sure the proper procedures are in place when masses in Texas are hit. But others think more can be done.

“No one is saying that if there is an event we need to be sure Texas is shining,” Parkland’s Klein says. “We want to be ready.”

Write to lauren.silva@gmail.com .