Playing Dominoes with Malpractice Premiums, Part I

Medical malpractice premiums have clearly gotten out of hand. It’s estimated by the American Medical Association that 18 states face a true “malpractice crisis,” and we’ve all heard tales of physicians walking out on the job, leaving practice or moving out of high-risk areas of practice. It’s an ugly and scary issue.

As EMS providers, we should be concerned about any issue that affects the ability of our patients to receive care. However, the scope of prehospital work keeps us somewhat insulated from (and ignorant of) the problems of specialty and follow-up care. We only become concerned when the reluctance of physicians to provide emergency care impacts upon our own sensibilities like the temporary closure of the only trauma center in Nevada, forcing EMS to move severely injured patients to hospitals in other states.

Some weeks ago, I wrote a column on how the malpractice crisis was affecting the status of EMS medical directors in Florida. Since that time, the Sunshine State has been embroiled in further liability dispute with grave implications for EMS.

Here’s the nutshell version of what’s going on. Before the current state session, the medical community received an assurance from Governor Bush (yes, we’ve got one of them, too) that malpractice tort reform would be at the top of his agenda. Specifically, Florida physicians were looking for a $250,000 cap on non-economic damages, encompassing pain, suffering, and disability. (One thing that seems to have been lost in the debate is that economic damages, such as loss of income, would still be unlimited based on the plaintiff’s prior earning potential.)

About the same time, some of the neurosurgeons at Orlando Regional Medical Center (ORMC), Central Florida’s only level I trauma center, backed out of the trauma call schedule. One of the reasons cited was the high malpractice premiums required of facilities that care for trauma victims. ORMC began to tell other trauma centers in the region to prepare for a large increase in volume. As a result, the surgical group providing trauma services here in Daytona Beach (a level II center) declined to renew their contract with the hospital, citing an inability to handle the excess volume resulting from an ORMC closure, and concern over their own increased malpractice risk.

The implications of a trauma center shutdown are staggering for EMS. First and foremost, we face the dilemma of patient destination. I’ll use a Florida example, based on our current regional scenario.

Let’s say you’ve been called to care for a victim of a gunshot wound in central Orlando. On arrival, you find that the patient has a bullet hole in the chest. If there is no trauma center, you’ll find yourself in the unusual position of hoping the patient will be in a critical state. That way, you can transport to the closest hospital for stabilization, getting the patient out of your vehicle and into a place where the care should be more advanced than in the back of your rig.

What if you arrive on scene and the patient is stable? In that situation, you’ll be required, by custom and statute, to take the patient to the closest trauma center. The problem, of course, is that the closest trauma center is in Daytona Beach, a mere 50 miles away. So now you’re taking a ground unit out of service for more than two hours, or using all your air resources to transport out-of-area. You’ve diminished the level of care within the local area.

And where do you go if all three surrounding level II centers in Melbourne, Lakeland, and Daytona Beach go down (as they may due to increased patient load and unresolved malpractice issues)? Now you’re looking at an hour and a half to Tampa, or three hours to Jacksonville. Think anything can go wrong in a one-hour transport? How about a three-hour trip? Remember that the trimodal distribution of death in trauma has a peak at one to three hours after injury. In any scenario, the patient suffers.

Let’s go back for a moment to our critical patient. You’ve taken him to the closest hospital, and now he’s stable (or so you’re told). However, he can’t stay there, as the hospital is not capable of comprehensive trauma care. Now you’re looking at a delay in care while the present hospital arranges transport to a trauma receiving facility, and then you’re looking at a long-distance transport for the patient to benefit from definitive care.

A case report may help to better explain this theoretical scenario. Last week in our ED, a patient was flown to us following an automobile accident. He was hypotensive in the field, and complained of left hip pain and an inability to move his left leg. He was stabilized in the field with IV fluids, and transported to our level II facility. Within an hour, he became hypotensive once again and lost pulses in both lower extremities. Angiography revealed bilateral torn iliac arteries. In the absence of our trauma center, the patient would have traveled more than 70 miles to the next closest trauma facility once he was “stabilized” on the scene. He also would have lost both lower limbs.

If ORMC goes down as a trauma center, so will our hospital in Daytona. Our general surgeons have been covering trauma call without a formal contract for a month, and will do so for another thirty days pending the outcome of the Florida legislative session. If no resolution to the malpractice issue can be found, our trauma group stops work. Our trauma center closes, and if we go, rumor has it that general and orthopedic surgical groups in the next closest trauma centers will do the same.

I should mention that the closure of the other trauma centers is also not strictly a matter of liability; it’s also a matter of capacity. The hospital at which I work, already strained by a growing elderly population and a multitude of special events, simply cannot handle 700 more major trauma patients each year.

As of this writing, Orange County (encompassing the city of Orlando and ORMC) has come up with a tentative solution. They propose to put together nearly 6 million dollars to secure neurosurgical coverage until the fall of 2004. The County will pay a third of the costs, the hospital will kick in another third, and the four surrounding counties will divide the rest. But the political sparks are already flying. The surrounding areas contribute only 25 percent of the patients, and they can’t see why they should contribute 33 percent of the cost. And the hospital (a private institution) won’t open its books, so no one knows where the money comes from, or if there’s more to spare.

And … by the way … nobody asked the neurosurgeons how they feel about it. Meanwhile, in Tallahassee, our elected representatives in the state Senate defeated a cap on malpractice damages in committee by a 10-1 vote (in a legislature controlled by Republicans), and the state agency that regulates trauma services has told ORMC that they cannot “de-designate” themselves without a six-month notice to the state (if I understand the state on this one, you can be a trauma center even if your docs are not present to staff it. I wonder how that works).

Here at home, our surgeons continue to provide trauma services without a contract, wondering what relief the last-minute flurry at the end of the legislative session might bring. Stay tuned.

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