Vital Signs Unstable at Palomar Trauma Center : Health care: Six weeks after a walkout by orthopedic surgeons, the facility sits idle, with no recovery in sight.

North County’s only trauma center, idle for the past six weeks, is nowhere near reopening, as the county’s trauma system approaches its busy season.

“The trauma center is dead. I’m not negotiating with them and we’re not talking with them as a group,” said Dr. Paul Milling, one of the seven orthopedic surgeons who walked away from the facility at Palomar Medical Center in Escondido shortly before Christmas.

The hospital’s emergency room still treats unstable patients, and, in some cases, people who previously would have been labeled “trauma” patients have been given the lesser designation of “emergency.”

In some ways, this has meant a boon in terms of lower prices for North County emergency patients. Like designer jeans, labels carry costs. In the case of hospital care, having an “emergency” label could mean paying only a third as much as for a trauma case.

In the meantime, Life Flight, the emergency-airlift company, is considering adding a third helicopter to its North County operation and moving its base farther east. In addition, San Diego County’s remaining trauma hospitals are bracing for an influx of North County patients in the spring, typically the busy months for trauma units.

Trauma systems throughout California have been collapsing because of high costs and low reimbursement rates. Ironically, Palomar had one of the few units turning a profit. Now, however, it can’t find enough orthopedic surgeons to work there.

The rift between Palomar and the so-called “orthopods” began as an argument over money, but the surgeons have since decided that being on call 24 hours, the middle-of-the-night operations and the risks involved just aren’t worth it.

“Basically, we got to the point where we burned out. Traumas occurred at night and on weekends, and we have our own private practices,” said Milling, who has been part of the Palomar trauma team since its inception in 1983, on 24-hour call once a week.

Milling stopped short of saying he would never go back to work for a trauma center, but said that “chances are slim to none. It’s nothing I relish doing.”

With plenty of other orthopedic surgeons in Palomar’s service area--52 in all--the difficulty the hospital is having in finding replacements underscores how unattractive the job really is, Milling said.

Tony Noronha, acting chief executive officer of the Palomar Pomerado Health System, the governing organization of Palomar Medical Center and Pomerado Hospital in Poway, said he isn’t sure when or where the hospital will be able to find surgeons to replace the ones who left.

On Jan. 13, the board of directors of the health system approved spending $60,000 to hire a headhunter to conduct the search. Even so, Noronha said, finding replacements to reactivate the center could take until June or July, when the next crop of medical students can begin residency.

Noronha said the hospital has reached agreement with some of the seven orthopedic surgeons for their return, but still needs “three or four more.”

The closure of Palomar’s trauma center has had a minimal effect on neighboring hospitals, said Dr. Brent Eastman, director of the trauma center at Scripps Memorial Hospital in La Jolla.

“The actual impact as we have assessed it has been only in the range of (a) one- or two-patients-a-day increase,” Eastman said, attributing that to “the strength of our system, the fact that we are able to adjust to this one center being on bypass.”

The key to the success of a trauma system without Palomar or any other such facility in North County will hinge on how quickly patients can be taken to other nearby centers, Eastman said.

As of Wednesday, six weeks after the walkout by the orthopedic surgeons, 50 patients have been diverted from Palomar to either Sharp Memorial Hospital in San Diego or Scripps Memorial, far below last year’s average of 85 trauma patients a month.

“Trauma, especially in the last two to three weeks, has been very slow,” said Linda Fahey, an administrative nursing assistant at Palomar.

While the center’s closure has resulted in only a slight increase in the number of helicopter flights, Life Flight officials predict a significant increase in April and May, which traditionally bring a heavier trauma load than January.

“The real impact that you will see is a couple months down the road. The main impact will be seen during motorcycle season,” said Dr. Kevin Hutton, medical director of Life Flight.

The company had been considering moving its helicopter at Palomar Airport in Carlsbad to a location farther east, and those plans have been given more consideration since the closure of the trauma center, Hutton said.

Life Flight might also activate a third helicopter, he said. The company makes about 150 flights a month to hospitals, about 30 of them to Palomar, Hutton said.

The walkout at Palomar brought the trauma center to a standstill. The unit has all of the equipment of an emergency room plus several X-ray machines--all of it now sitting virtually unused. Members of the hospital staff say using the equipment would be tantamount to admitting the center is closed forever.

“We have lots of really good equipment in here, and it’s just a shame,” said Gail Tomsky, the emergency unit nursing director at Palomar. The hospital has 21 other emergency rooms at its disposal. “Right now, it’s just a very expensive X-ray room.”

Tomsky and others hope for a break in the impasse that has brought the closure. Until then, the center will remain idle, and the hospital will continue to pay out more than $2,000 a day in salaries to medical personnel who remain part of the trauma program.

The extra costs for a trauma center stem in part from the need to keep on hand at all times an entire team of medical workers, including two nurses, a trauma surgeon, an emergency medic, a pharmacist, a radiology technician, a laboratory technician and a pulmonary technician, Fahey said. Exacerbating the situation is the fact that 40% of trauma patients have no health insurance.

Because the staff costs are continuing but the hospital cannot charge trauma prices, the center will show a deficit for the first time since 1987, when red ink ran in the multimillion-dollar range.

But maintaining Palomar’s trauma staff without the orthopedic surgeons still allows the hospital to respond to emergency situations in which a patient might need lifesaving stabilization and cannot afford the precious minutes required to get to the next trauma center, Palomar administrators say.

“Having or not having an orthopedist doesn’t matter in most unstable patients,” Fahey said.

Milling agreed that orthopedic injuries, usually fractured bones, tend not to be life-threatening situations.

A study being done by Palomar and the county takes a close look at whether some so-called trauma patients can be cared for without a trauma team, Fahey said.

The study, which began Jan. 10, could help in developing a permanent system that would provide trauma care without the exorbitant costs, Fahey said.

As of Wednesday, more than a dozen patients, most of whom would probably have been labeled trauma patients, have been part of the study. All were treated at Palomar, Fahey said.

Their treatment without the trauma label meant dramatically reduced costs.

Finding new surgeons for a trauma center is a difficult task in the best of circumstances, with the working conditions and relatively poor reimbursement being the main disincentives, said Scripps Memorial’s Eastman.

Palomar in July offered its orthopedic surgeons a $520 stipend for each 24-hour on-call shift, a 5% increase. Noronha said the hospital has since developed a plan in which orthopedic surgeons would be guaranteed a percentage of the trauma billings, although it is unclear how much that would be.

A nationwide study of 35 trauma centers released by the U.S. General Accounting Office last May showed that Palomar made a profit in 1989, one of only two in the survey to do so. According to the report, while Palomar’s trauma center made $511,000 that year, the other trauma centers surveyed had an average deficit of $2.1 million.

The same study showed that San Diego County’s other four trauma centers ran an average deficit of more than $1 million in 1989.

Palomar had estimated that the trauma center would make a nominal $8,000 profit before the orthopedic surgeons walked out. The hospital doesn’t know what the cost of shutting off the trauma center will be, Noronha said.