The diagnosis was quick: stroke, brain hemorrhage, blood clot.
But it took 11 hours to find a specialist to try to save Mary Stone. Not a single neurosurgeon in Palm Beach County, or across South Florida for that matter, was willing or available to take her case.
The closest one found? A neurosurgeon at Shands at the University of Florida in Gainesville, nearly 260 miles away.
Stone, 52, had the surgery there but died 10 days later. “I think she’d be alive if they’d operated sooner,” said Sam Stone, 60, of Tequesta, who has a lawsuit pending against Jupiter Medical Center. “It was very frustrating. It just seemed it went on forever.”
Sam Stone blames hospital administrators for his wife’s death — for failing to address a critical absence of specialty surgeons in Palm Beach County emergency departments in recent years. Hospital officials declined comment, but their attorney denied all allegations in court documents.
Since Mary Stone’s death in October 2003, little has changed when patients need an on-call specialist, notably neurosurgeons and hand surgeons. These specialists, highly trained to perform some of the most complicated procedures, have shunned emergency surgeries. High malpractice premiums offering lower coverage have been the main deterrent.
The result, for patients, is uncertainty. On any given day, in one of the wealthiest counties in the state, there is no guarantee of an on-call specialist at every hospital.
The problem is at a crucial juncture: A cross-section of hospital CEOs and physicians appear poised to mend a system broken by the insurance crisis, low reimbursement for care and an increasing number of emergency patients. The Emergency Department Management Group — formed by the county’s medical society — is looking at the system broadly. Solutions range from coordinating specialists regionally to infusing money into emergency departments.
Just how deeply the group will impact such delicate issues as how private, for-profit hospitals pay specialists remains to be seen. Any new money, which some advocate in the form of a tax, would have to be carefully directed, said Dwight Chenette, chief executive officer of the Health Care District of Palm Beach County.
“It’s not going to be the writing of a single check and then it’s solved,” Chenette said.
INEFFICIENT SYSTEM
Finding a general surgeon or a vascular surgeon is never a problem for Dr. Michael Zappa, who runs the emergency department at Palms West Hospital in Loxahatchee. But a neurosurgeon, hand surgeon or ophthalmologist? That depends on the day.
The problem with delaying surgery, Zappa said, is “even in the best-case scenarios, there’s always the potential for deterioration.”
As an emergency specialist, Zappa’s job is to diagnose, treat and stabilize patients. But these days, his job also includes manning a telephone.
“We went from never having to worry about it to now, when a patient rolls through my door, care has to come to a grinding halt because I don’t have anyone to take over,” he said. “It starts a very frustrating series of phone calls.”
Cutting out the phone calls is crucial, said Dr. Steven Dutcher, a neurosurgeon with Palm Beach Neurosurgery in Atlantis. Dutcher said he and his partner are the only two neurosurgeons in the county who take emergency calls and operate on aneurysms. There are 14 neurosurgeons in the county, but most focus on the spine.
On average, Dutcher and Dr. Ramin Abdolvahabi get five to six transfers a week, from hospitals as far as Melbourne. But the system of transferring patients can be inefficient and prolonged, Dutcher said.
“It’s always a process,” he said. “Sometimes it can be quick, but you got to push them to get it done. Some facilities inherently take forever.”
Dutcher came to Florida five years ago just as medical malpractice insurance premiums swelled, pushing neurosurgeons out of ERs.
Doctors who have been sued in Florida are slapped with lawsuits on average once every five years. Nationwide, it’s once every 10 years, said Matt Gracey, a medical malpractice insurance agent in Delray Beach.
Insurances rates reflect the trend, making Florida less attractive for new doctors. At times, premiums cost more than their coverage. State legislators took aim at the issue in 2003, as doctors were leaving the state or closing their practices. But some physicians and medical experts say reforms that capped pain-and-suffering payouts didn’t go far enough.
Premiums are still high, though by some measures, they appear to be stabilizing or decreasing.
Dr. Paco Arrascue, a nephrologist, or kidney specialist, who is part of the task force, had a $1.3 million policy five years ago. Today, he can get coverage for only $250,000.
“We have liability and just have to deal with that,” he said. “You expect to have the doctor waiting for you in the emergency department. That’s going to cost money and it’s going to need a system that guarantees that.”
Arrascue sees a new tax as part of the answer. Just as taxpayers fund fire-rescue and police departments, they also should pay for the emergency care they count on. But having taxpayers fund private, for-profit hospitals could be problematic, said Chenette, of the Health Care District.
Some hospitals, such as Boca Community Hospital, pay their on-call staff. The Boca Raton hospital competes in the Broward County market, where on-call physicians also are paid. In most of Palm Beach County’s 13 hospitals, specialists called in for an uninsured patient don’t get paid unless the hospital chooses to compensate them.
Chenette said he anticipates the Health Care District — which has a $216 million budget — would contribute money to the problem.
The solution, though, will take more than money, task force members agree. In the meantime, the task force recently launched a physician census to count and track the number of specialists in the county. Another idea, a Web-based on-call schedule, would end the cold calls that emergency department doctors now make. The census and on-call schedule should be ready by the end of summer, said Rick Cameron, a consultant hired as task force project manager.
The Emergency Department Management Group has been meeting for about a year and is optimistic it can overhaul the system.
Other ideas include creating a countywide database to track patient access to specialists, supporting more community health centers to take the burden off emergency departments treating non-emergency cases, like the Caridad Center west of Boynton Beach, encouraging niche physicians who run clinics to accept indigent care and evaluating malpractice alternatives.
“We’ve been able to bring these hospitals together to work on a problem and put aside their individual interests,” said Tenna Wiles, executive director of the Palm Beach County Medical Society.
The Health Care District, largely funded by taxpayers, may take over the task force, which could eliminate anti-trust concerns from the Department of Justice. Because several hospitals are participating, the government warned against changes that undermine competition.
It could take a year or more for the task force’s most transformative changes to take place. In the meantime, “We’ll do the best we can,” said Dr. Zappa, of Palms West.
“It’s hanging on by a thread.”
Patty Pensa can be reached at or 561-243-6609.
COMPLAINTS ABOUT CARE
Since 2004, 72 complaints have been filed against Palm Beach County hospitals for violating the federal Emergency Medical Treatment and Active Labor Act, a law designed to prevent hospitals from refusing to treat patients or transferring them to “charity” or public hospitals. Thirty-five of the complaints were confirmed. The most were at Palm West Hospital in Loxahatchee (9) and St. Mary’s Medical Center in West Palm Beach (5). Here is a sampling:
April 6: A patient who went to the Palms West emergency department after falling from an ATV was diagnosed with an open fracture to his leg. The orthopedist on call said he was not doing general orthopedics and refused to see the patient.
May 7, 2005: A patient with facial trauma, cuts and bruises was transferred to Palms West for oral maxillofacial surgery. Emergency room doctors called the surgeon’s answering service six times in about two hours. The patient was sent to a hospital 70 miles away instead.
Feb. 2, 2004: An aneurysm patient waited more than four hours to be transferred to another hospital after the on-call neurosurgeon at Palms West said he could not treat the condition. The surgeon later said, “I don’t do aneurysms. There’s no reason for me to come in to see the patient.”
Nov. 11, 2004: The on-call ophthalmologist at St. Mary’s refused to accept a patient with a nail gun injury to the eye. The doctor said the hospital did not have the equipment required for surgery. The patient was referred to the Bascom Palmer Eye Institute at the University of Miami. The director of surgery at St. Mary’s later said they could have done the procedure.
Oct. 14, 2003: The emergency department physician at St. Mary’s needed a neurosurgeon for a patient who had a previous head injury and arrived unresponsive. The hospital had seven neurosurgeons on staff but none was on call for consultation or treatment. Two who were called refused to see the patient. Orlando Regional Medical Center ultimately accepted the patient.
— SOURCE: FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION
