Major Surgery Needed for Region’s Hospitals : Neurosurgeon shortage complicates emergency-room crisis
Los Angeles County probably can cope with a shortage of emergency-room surgeons who deal with head injuries--at least for a time. But to do more than merely cope, what’s needed is basic and very expensive surgery on the network of trauma centers; anything less would be just a Band-Aid.
An examination of the most recent emergency for the county’s 89 emergency rooms shows how little hope exists for victims of violence and accident as long as the system is forced to lurch from crisis to crisis, reaching for solutions that often create entirely new problems.
LOCKED DOORS: As Times writer Claire Spiegel reported last week, the most recent affliction is a shortage of neurosurgeons available to respond to emergency-room calls to treat head or spinal injuries. Twenty-one of the 89 emergency rooms routinely send ambulances with such patients somewhere else. On average, half of all emergency rooms are chronically short of neurosurgeons.
Ironically, part of the problem is a federal law written in 1989 to prevent hospitals from sending ambulances to other emergency rooms--”dumping.”
In a sort of truth-in-trauma clause in an omnibus medical bill, Congress made hospitals that guarantee to provide certain kinds of emergency treatment subject to stiff fines if they refuse such treatment. Rather than face the fines, some hospitals that have trouble finding neurosurgeons simply remove head and spinal injuries from the list of emergency care they offer.
Another factor is the small number of neurosurgeons available in L.A. County. According to Dr. John Kusske of the state Neurological Society, there are only 120. At the 1990 rate of traumas involving emergency care for the head and spine, those 120 would have performed an average of 16 procedures every night.
FINANCIAL: Compensation for physician specialists is part of the equation, although it appears not to be central.
Neurosurgeons who work through the night to save an emergency patient are not likely to be at the top of their form to operate on patients of their own the next day. Many hospitals have to make up some or all of the loss of income just to get neurology specialists to be on call.
Many emergency cases stem from drug-related violence and involve people with no medical insurance. Risk of failure means high premiums for malpractice insurance.
Hospitals that guarantee emergency neurosurgical care need not only doctors on call but also diagnostic scanners, operating rooms, intensive care units and--above all--nurses and other assistants who can qualify as neurosurgical team members.
SOLUTIONS: The problem seems most severe in the Glendale area, where emergency rooms have sent so many cases to nearby Verdugo Hills Hospital that it is on the verge of losing its own overworked surgeons.
Hospitals, doctors and county health officials are talking about a plan to pool resources in regions so that one or two emergency rooms would be designated for neurological cases. Specialists at hospitals with too few neurosurgeons to support their own emergency services would sign up with the designated hospital.
A change in old habits might help. All urban areas are pressed to keep up with caseloads, but officials who monitor the anti-dumping laws say that Los Angeles seems particularly hard-hit. They say one reason may be that Los Angeles hospitals are less energetic than those in other cities about negotiating agreements with doctors. Under such agreements, common elsewhere, doctors promise to be on call for emergency rooms in return for using hospital services for private patients.
But the only real solution to the crisis is finding the public funds that are essential for restoring the tattered system to full strength.
