Pact Highlights Troubles Facing Trauma Centers : Hospitals: The five hospitals with trauma centers sign a six-month contract with the country rather than usual three-year accord. Uninsured patients are at heart of problem.


The five hospitals participating in the San Diego's trauma program signed a six-month contract that began Jan. 1, instead of the customary three-year one, an action that will give county officials time to rejigger the ailing system.

Meanwhile, county officials Thursday turned down Palomar Medical Center's proposal to operate its still-shut trauma center part-time--a move that would enable hospital administrators to hammer out a contract with its orthopedic surgeons.

"The citizens of North County deserve better than part-time trauma care," said Paul Simms, the county's deputy director of physical health services. Simms acknowledged that he had not yet seen Palomar's proposal, which was reviewed by his staff.

"It's conceptually difficult to figure out how we would organize a system such that on one day, we managed patients one way, and another day, we managed in some alternate fashion," Simms said. "Palomar has played an important role as a trauma hospital, and I'd want to do everything within our ability to keep Palomar in the trauma system, but I will not create a separate standard of care for patients in North County."

Palomar, North San Diego County's only trauma center, began Dec. 23 to refuse trauma patients, after not settling a longstanding dispute with its orthopedic surgeons. Since then, 25 patients have been dispatched to the county's four other adult trauma centers. Of those trauma patients, 18 required a Life Flight to Sharp Memorial or Scripps Hospital in La Jolla--facilities that are about a 25-minute ride by ambulance from Palomar.

The county's response to Palomar's proposal of a part-time trauma center sends hospital officials back to the drawing board in search of a quick fix.

"Oh well, one more solution down the drain," said Linda Fahey, an assistant administrator.

"We intend to get back to full operating status as soon as possible," said Palomar's administrator Tom Spindler, who acknowledged that shutting the trauma center costs the hospital about $35,000 a month.

But the problem of manning the trauma center has rocked Palomar since last spring. The hospital's seven orthopedic surgeons have worked without a contract since June. Doctors say the on-call stipend of $520 a day, or a 5% increase over the previous stipend, is insufficient compensation for the burnout associated with working the 24-hour shift on patients who frequently have no insurance and require follow-up care.

The problem for doctors at Palomar has been echoed by physicians at other facilities here and across the state as administrators try to offer care to a growing population of uninsured and underinsured patients.

In September, neurosurgeons at Scripps Memorial Hospital went on strike, citing concerns similar to those voiced now by Palomar doctors. In August, 21 hospitals in Los Angeles County refused to treat head injury cases because there weren't enough neurosurgeons willing to work the on-call duty.

Hoping to get ahead of what appears to be a growing problem, county officials will use the next six months to devise a new trauma system, soliciting opinions from local doctors and hospital officials, as well as from those around the nation.

"This will allow us to explore policy questions," Simms said. "The county is redesigning the trauma system. . . calling for a complete system review."

The key issue is how to cope with the problem of uncompensated medical care, especially during a time when the county is already scraping the barrel to fund existing programs. At Palomar, for instance, 40% of the trauma patients are uninsured.

"If I knew in 1983 (when the system was created) what I know now, we would have created an indigent care fund associated with trauma," Simms said. "You can't unscramble an egg, but perhaps we can do better with the current decade."

A thorny part of that redesign will be having enough specialists, like the orthopedic surgeons, to man the trauma centers, Simms said. There are now scarcely enough specialists willing to handle the 24-hour on-call duty, a stint that can require a doctor to cancel his normally scheduled patients so he can tend a patient who might be unable to pay for his care.

At Palomar, this problem is aggravated because only seven orthopedic surgeons work at the trauma center. This means each one pulls a 24-hour on-call duty once a week, a rigorous schedule that wears them out, the doctors say.

When county officials re-examine the trauma system, they will also ask basic questions, including whether to keep five centers or decrease the number, Simms said.

Experts in the medical community, however, believe the crucial answers might lie in easing the burden on hospitals that participate in the trauma network. One solution might be the creation of a stratified trauma system, where facilities are geared up to handle cases of varying degrees of seriousness, said Jim Lott, president of the Hospital Council of San Diego and Imperial Counties.

Another solution would be to streamline the existing system. Now, 20% of all trauma patients require the care of a neurosurgeon, Lott said. "We might consider not having the requirement that neurosurgeons be on call at all trauma centers but maybe every other one."

In any case, the solution will have to be creative, Lott said. "It's a Cadillac system, we'd like to make it a Buick or Oldsmobile and still provide the same quality service."

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