Scripps Sets Goal for Microsurgery : Wants to Become Center; Other Hospitals Fear Loss of Quality

Scripps Memorial Hospital here has begun a drive to become the leading microsurgery center in southernmost California.

An important use of microsurgery is reattachment of severed limbs, and Scripps’ move has raised concerns that too many San Diego-area hospitals may be getting into that field.

But Dr. Stephen M. Krant, a plastic surgeon who heads the new Scripps unit, has a different view. “We are not creating a new science at Scripps,” he said. “We are creating the availability of the microsurgeons. People will know that, if you have an accident or fire, you call 911; if you have an amputation, the first thing you think about is Scripps Memorial Hospital-La Jolla Microsurgery and Replantation Center.”

However, critics of the proliferation of such high-profile programs as microsurgery worry that having too many of them will dilute their efforts and might lower the quality of overall care. Furthermore, it would limit the ability of UC San Diego Medical Center to train surgeons in the microscopic intricacies of reattaching severed limbs, some doctors say.

“What you’re dealing with is a lot of administrators trying to play one-upmanship on the next hospital down the street,” Dr. Jonathan Jones said of the boom in new programs. A plastic surgeon, Jones heads the Mercy Hospital & Medical Center replantation team.

Microsurgeons, viewing the field of surgery through a microscope and using sutures so fine that they can float in the air, are able to sew tiny blood vessels together and restore circulation to newly connected tissue.

Microsurgery is useful in a variety of specialty operations, including breast reconstruction after a mastectomy and transplanting tissue from one part of the body to another to repair birth defects, cancer damage or chronic wounds.

Some of the technique’s more dramatic results come in emergencies when it is used to reattach fingers, hands or limbs and make them functional again. Such operations are done by teams of rotating doctors, and can take more than 24 hours.

San Diego County’s first limb-reattachment unit was at the UC San Diego Medical Center, which began performing the operations in 1977. By the early 1980s about 60 a year were being performed at the center. When the unit was too busy to handle a case, it was usually referred to surgeons in the Los Angeles area.

The number of amputation cases in San Diego County has fallen, microsurgeons say, apparently because of safer equipment in industry and home shops. Nevertheless, replantation programs have proliferated.

Three years ago Mercy Hospital set up a replantation unit that Jones said was intended to handle UC San Diego’s overflow. Then, a year ago, a surgeon trained at UC San Diego began setting up a program at Grossmont Hospital. It is gearing up for a major marketing push to industrial employers in eastern San Diego County and, possibly, Baja California.

Together, those two hospitals handle about two dozen major replantation cases a year, and the UC San Diego total has dropped to about 30, doctors there say.

In that competitive milieu, Scripps is using a San Francisco hospital as a model for what it would like to become: the private hospital that draws patients from a wide region because of its medical reputation and no-nonsense efficiency.

“Even though microsurgery has been done in San Diego for a while, this whole unified concept hasn’t been done,” Krant said. “It is an all-inclusive program because we are organizing a complete team approach with social service, psychologists, rehabilitation, occupational therapy--because all of that is really involved with these patients that are injured.”

‘Willing and Committed’

Even as UC San Diego Medical Center and other hospitals in the county back away from drawing in no-pay patients, Krant said, the Scripps program won’t set up financial roadblocks to replantations.

“We are willing and committed to taking all comers--insurance, no insurance, whatever,” said Krant, who has a private plastic surgery practice in La Jolla.

He hopes this policy will help Scripps become the best-known replantation center in both San Diego and Imperial counties, which would then draw in more paying replant operations as well as non-emergency microsurgeries.

Allen Yearick, associate administrator at Scripps, said the unit is a logical extension of reconstructive microsurgical work the hospital’s doctors already are doing related to cancer surgeries, birth defects and the trauma unit. It also will offer an opportunity to educate the public about what to do when an accident at home severs fingers or limbs.

The Scripps model for its unit is Davies Medical Center in San Francisco, a private hospital where microsurgery pioneer Dr. Harry J. Buncke leads a team that does 150 replantations and 200 other microsurgeries a year.

That is despite the fact that there are competing centers at UC San Francisco, Stanford University and UC Davis. Scripps’ replant team has consulted with UC Davis and sent nurses there for training, Krant said.

“A lot of the industry workers’ compensation cases don’t go to UCSF. They go to Buncke because they know from the time you make that phone call there’s no hassle,” Krant said.

He contrasts this with what he characterized as bureaucratic roadblocks, based on financial issues, that an employer with an injured worker faces at a university hospital such as UC Davis or UC San Diego. Already, the Scripps replant team has drawn one such case from El Centro, he said.

Gearing Up for 2 Months

For the patient, the difference between a replant operation at a public university and one at a private hospital is “the difference between a bed and breakfast and the Hyatt Regency,” said Michelle O’Hara, coordinator of the Davies replant center.

As the Scripps team was gearing up over the last two months, it did three replantation operations, about the same rate as Mercy and Grossmont. Krant said he hopes the center will do 10 to 15 replants a year and an additional 40 to 60 elective surgeries involving microvascular techniques.

If that goal is met, it should be enough to keep Scripps’ four plastic and reconstructive surgeons in good enough training through elective surgeries to assure they have good results with the emergencies, Mercy’s Jones said. As in any complicated surgery, the more practice a surgeon gets, the better the outcome.

But Jones and others worry that too many programs might mean too few elective cases at any one hospital to keep the doctors in good training--leading to unsuccessful reattachments of fingers and limbs.

“The tragedy of it will be that, if Grossmont gets their big program going and all their PR, and Scripps has theirs, and Mercy and University, you’re going to find that each hospital with their well-advertised program does two cases a year, and they may not be successful,” he said.

Whether that becomes a problem will depend on how many non-emergency microvascular surgeries the hospitals attract, Jones said.

“If the person doing them does free tissue transfers and regularly does microsurgery procedures then this is just a spinoff from that, and then it can be successful in all the centers,” he said.

Dr. Ephraim Zinberg, chief of the Hand and Microvascular Surgery Service at UC San Diego Medical Center, said UCSD used to be the only hand and limb replantation center in the county “and, as far as we’re concerned, we’re still the only one.”

He questioned whether a replantation program should consider its doctors qualified to do replantations if they have not done one-year fellowships in hand surgery to gain experience in the complicated surgical and follow-up care such cases need. Zinberg has done so, and UC San Diego also trains two hand fellows annually.

Zinberg noted that the American Society for Surgery of the Hand appears likely to establish the one-year training program as a requirement for eligibility to take a new board-certification exam in the specialty.

Of the private microvascular centers, only Grossmont’s has a surgeon who has done a one-year hand fellowship. He is Dr. Ronald Vandell, who was trained at UC San Diego.

At Scripps, Krant’s training included a three-month hand fellowship in a community hospital while he was a resident at Yale University, plus many microsurgeries at Yale. His three plastic surgeon colleagues on the Scripps team have not done one-year hand fellowships, but they have extensive experience in complicated microsurgeries.

For instance, Dr. Ned Garrigues started the microsurgery program at San Diego Naval Hospital in 1982 and had a six-month specialty training in skull and face reconstruction in Paris.

“There are a lot of people that are excellent hand surgeons who are not going to take those boards and have not had a special fellowship,” Krant said.

Worries About Training

Some doctors also worry about UC San Diego’s ability to train hand fellows if the number of replantations there falls because patients are being drawn by private hospitals.

“When you begin to have it all over the place, things get fragmented. When I started practice here, having trained at UC San Diego, I took all my replants to University Hospital . . . because my concern was that that is a training program,” Vandell said. “If these injuries are now going to be taken care of in the private hospitals, then that significantly injures the training program.”

Despite his involvement in the Grossmont program that will compete with UC San Diego for patients, Vandell continues to be involved in the university’s efforts as a hand surgery teacher at the UC San Diego Medical Center and the VA Hospital.

One solution to the potential dearth of patients at UC San Diego would be cooperation among the various centers to train doctors in microsurgery. UC San Diego and Grossmont recently announced a joint training program to teach microvascular surgical techniques to doctors in the community. Beginning in September, the program will offer a five-day course.

Krant said he would be interested in cooperative programs between Scripps and the university too, but said the option has not yet been explored.

In the end, whether there are too many microvascular/replantation programs in San Diego County may be settled Darwinian style, with the survival of the fittest.

“I don’t think UCSD’s our competitor,” Krant said, but added: “I think we can blow them out of the water in terms of quality of care.”

“It’s the same as in any specialty or sub-specialty,” he said. “Those guys who do good (heart operations) are going to be very, very busy. And those who don’t do good hearts and don’t have good services are not going to be very busy.”