Crisis in the Trauma Center

The trauma center at Queen’s saves hundreds of lives every year. What happens if it closes?

Most of us expect that, if we get seriously hurt, we’ll be taken care of. Listen to the news enough, and you notice that most victims in major car crashes are either “rushed to Queen’s” or “medevacced to Queen’s.” Last year alone, The Queen’s Medical Center received about 45,000 people in its emergency room, 1,500 of whom were trauma patients—those who suffered life-threatening injuries due to collisions, falls or violence.

These are people like Irma May Baptiste. In 1998, she was driving through an intersection in Kaneohe when another driver ran a red light at 80 miles per hour, broadsiding her car.

Emergency technicians pulled Baptiste from the wreck and transported her to Queen’s trauma center. Baptiste’s back was broken in three places, one of her hips in two. One of her kidneys had to be removed. Her liver had to be stitched back together. In the process, Baptiste needed eight blood transfusions.

“I was in a coma for five days, and my mom was told that I might not make it,” says Baptiste, now 28. But she did. After a month-long hospital stay and a year of intense physical therapy, Baptiste fully recovered. “If it weren’t for Queen’s trauma center,” Baptiste says, “my accident could have been devastating.”

As the leading trauma center in the state, Queen’s treats practically all of Hawaii’s major trauma patients, including many transferred from other hospitals on Oahu and the Neighbor Islands. But for all its importance to the people of Hawaii, Queen’s is facing an alarming shortage of doctors in its trauma center. For financial and personal reasons, fewer and fewer physicians are willing to take emergency patients, crippling the hospital’s ability to care for critically injured patients in the Islands.

As the only trauma center in Hawaii certified by the American College of Surgeons, Queen’s must have surgeons, an anesthesiologist and various medical staff in-house 24 hours a day, as well as keep doctors in at least 15 other specialties on call at all times, ready to respond at a moment’s notice.

With each passing year, Queen’s is having a tougher time providing that safety net. Neurosurgeons, for example, perform one of the most crucial aspects of trauma care, but there are only four neurosurgeons at Queen’s willing to take emergency calls—down from eight just a few years ago.

“The four neurosurgeons, including myself, take calls five days a month, more or less, but that means there are some days when there are no neurosurgeons on call,” says chief of neurosurgery Michon Morita. “There were five days in January when there was no neurosurgeon on call. There was one day in February. Up until the past six months, that hadn’t happened in 10 years.”

What does that mean for patients who arrive in the ER in need of neurosurgery? They have to wait. That can mean crucial minutes lost when a patient needs immediate attention. And it isn’t just neurosurgeons in short supply. Queen’s Trauma Center struggles to find specialists such as gastroenterologists and anesthesiologists to respond to emergencies.

“The ER doctor will start calling neurosurgeons around town, and we’ll eventually find one,” Morita says. “But it’s uncomfortable to not have someone on call who has already cleared his schedule and promised to be available.”

Where have all the doctors gone? Many have been chased out by the higher cost of practicing medicine in the state, thanks to ever-increasing medical liability insurance premiums. These days, more doctors prefer to avoid emergency cases, in which the chances of lawsuits are higher.

“Hawaii is heading toward a crisis,” says former Hawaii health director Dr. Jack Lewin, who now serves as CEO and executive vice president of the California Medical Association. “The first places that high insurance premiums affect are emergency and on-call services. It’s those doctors who take the riskiest cases that have the highest malpractice premiums.”

Medical Insurance Exchange of California (MIEC), the largest of only three medical liability insurers in the state, raised its rates an average of 17.4 percent last year and an average of 26.2 percent the year prior, according to the state insurance commission. Another insurer, The Doctors Company, increased premiums an average of 26.9 percent last year and an average of 28 percent in 2003.

“My medical malpractice insurance premiums doubled from $25,000 to $50,000 over the past three years, without a single suit,” says cardiologist Raymond Itagaki, Queen’s vice chief of staff. “In 25 years, I’ve had three lawsuits, all thrown out. But my insurance keeps rising. But unlike other products or services, I can’t charge any more for what I do, because fees are regulated by the state.”

Doctors blame medical malpractice lawsuits for the steep insurance hikes. Liability insurers cover not only the cost of jury awards and settlements, which can run in the millions, but also the cost of defending physicians and hospitals. Trial attorneys, however, blame insurance companies for unnecessarily bleeding doctors with seemingly exorbitant premiums.

Hawaii physicians worry about another kind of insurance, too—patients’ health insurance, or lack thereof. That’s because emergency rooms often serve uninsured patients or those only partly covered by Medicare and Medicaid programs. Doctors, therefore, are much less likely to get paid for their emergency services than for the patients they see in their regular practices.

“Even though the Queen’s trauma center is the busiest in the state, we won’t turn anyone away, regardless of their ability to pay or what kind of insurance they have,” says Dr. Richard Friedman, Queen’s vice president of medical affairs. “We can’t turn anyone away.”

Doctors opt out of emergency cases for personal reasons, too. They know what it’s like to pull all-nighters in the ER, only to have to see full slates of their regular patients the next day. Younger doctors, especially those with families, seem less willing to work the kinds of hours their predecessors have.

“When you’re on call, you don’t have a life,” says Itagaki, who, at his busiest, responded to emergency calls about two nights a week. “It’s an imposition—you can’t travel, you can’t even have a glass of wine.”

No matter what the reason, the cost of handling medical emergencies in Hawaii is pushing our local hospitals into a crisis. And because of the nature of the work performed by Queen’s trauma center, its plight demands the most immediate attention.

Historically, doctors volunteered to take emergency calls. But emergency-staff shortages have forced hospitals to pay physicians stipends of about $1,000 per night to do so. That’s on top of the fees the physicians charge for their services, if they are actually called in to an emergency.

“Doctors have traditionally taken emergency calls for free out of a sense of duty, to provide services to the public,” says Paula Arcena, executive director of the Hawaii Medical Association. “But now there are more disincentives than incentives for them to be on call. Doctors are at a point where they’ve absorbed as much of the blow as they can.”

The cost of paying for on-call services has taken a hefty toll on local hospitals. Queen’s spends more than $32 million on its trauma center each year, with losses of $4.6 million. Earlier this year, Queen’s asked for an emergency $6.9 million appropriation from the state Legislature to help cover those costs—the first time it had ever done so.

North Hawaii Community Hos-pital on the Big Island now spends nearly $1 million annually to cover stipends for on-call doctors—an exp-ense it didn’t have to pay just four years ago. Like many Big Island hospitals, North Hawaii often doesn’t

have orthopedic surgeons on call during weekends and holidays. In those cases, the hospital must send patients with even minor fractures to Queen’s, further straining the overburdened trauma center.

“If there are no orthopedic surgeons available on the island, we have no other place to send them but Queen’s, because they have to be cared for,” says North Hawaii’s CEO, Stan Berry. “But by commissioning a helicopter, I may have just doubled the cost of caring for a broken hip versus taking care of the patient here. The families are incredulous. They don’t understand why there’s no doctor here to take care of the patient.”

Honolulu residents could end up going without doctors, too. If you think it can’t happen here, consider Las Vegas, whose only trauma center shut down for 10 days in 2002, when its remaining doctors walked out. In Florida, more than half of the state’s original 50 trauma centers have closed in recent years, jeopardizing emergency care in the state’s rural areas. Florida reports the highest medical liability in the nation, with even its OB/GYNs paying an average of $143,000 to $203,000 in insurance premiums annually.

This year, Hawaii’s Legislature is taking a hard look at proposals to curb the financial burden on local hospitals and doctors. Last month, local doctors turned out in force to testify in favor for a tort-reform bill, which they insist will keep their liability premiums down. The bill is modeled after a California law enacted in the late ’70s—capping noneconomic damages in medical malpractice lawsuits to $250,000; ensuring that the bulk of the awards or settlements go to plaintiffs, not their attorneys; and placing a three-year statute of limitations on filing medical lawsuits.

Local hospitals continue to look for more funding sources for on-call services and to spread out the trauma caseload among hospitals, hopefully easing the burden on Queen’s. Your life could depend on what kind of solutions Hawaii comes up with.

“Any one of us could get into a trauma situation, getting into a car accident or having a serious fall,” Friedman says. “If we didn’t have a trauma center here in Hawaii, we’d really be in trouble. It’s not just a physicians’ or hospitals’ problem. This crisis is scary, because it affects all of us in Hawaii.”