Palomar Hospital Faces Loss of Trauma Care Status : Medicine: The facility has been idled by a walkout of surgeons. S.D. County may make the closure permanent.

The San Diego County health department is prepared to strip Palomar Medical Center in Escondido of its trauma care credentials--an unprecedented action that would deprive North County of its only trauma center.

“My position is very clear-cut: If they do not come into compliance, they must get a termination notice,” Dr. William Cox, director of the county Department of Health Services, said in an interview Wednesday.

Health officials met with the County Board of Supervisors in closed session earlier this week to discuss sending out a letter informing Palomar that it would no longer be allowed to participate in the county trauma network. Officials are taking the unusual action because a strike by orthopedic surgeons has idled Palomar’s trauma center since Dec. 23.

Unless Palomar shows substantial progress in finding enough of the surgeons to staff the center, a letter of termination will be sent out within days, Cox said. County officials have never before terminated a hospital in the county’s five-site trauma system, he said. Grossmont Hospital resigned from the program several years ago.

The letter gives Palomar officials 60 days to solve its doctor shortage or lose the profitable trauma center--one of the few in the nation to earn money.

“We’re concerned,” said Linda Fahey, assistant administrator at Palomar. “We feel Palomar Medical Center has a mission to serve the community, and we feel it is very important that we remain a trauma center in North County. It is our full intention to do so, and we are optimistic that these problems will be solved.”

But these are harrowing days at Palomar. A $60,000 search for orthopedic surgeons, launched in January, has yielded four possible candidates but no signed contracts. Since the next crop of new doctors in residency won’t be available until June or July, Palomar officials have expressed concern that they may not get additional physicians until this summer.

Hospital officials are also trying to woo back their seven striking orthopedic surgeons. Though Palomar officials tout success in those negotiations, there is little concrete evidence of it: None of the surgeons has yet agreed to resume on-call duties at the trauma center.

“Our hope is Palomar will work it out so they will be able to operate the trauma center,” said County Supervisor Susan Golding, who declined to discuss the details of this week’s closed meeting.

Some of the orthopedic surgeons, however, are not optimistic.

“I see no progress--nobody really likes what they (hospital administrators) are coming up with,” said one of them, Dr. Paul Milling, an orthopedic surgeon who is also former chairman of Palomar’s department of orthopedic surgery. “I don’t think there will be any progress until the hospital gets that letter.”

Milling said he also believes that the county has dallied in sending out a letter of termination, leaning over backward to accommodate the struggling hospital.

“They are giving Palomar an excessive amount of time to solve the problem Palomar’s way, which will not cost the county any money but will cost the working people and the businesses of our area inflated, excessive trauma bills,” Milling said. “The entire system needs to be changed. . . . I’m afraid, however, there are too many self-interest groups that will lose a lot of money if the system changes.”

Indeed, shutting the facility itself has proven costly. Palomar officials estimate that the hospital loses at least $35,000 each month the trauma center remains closed.

Since December, more than 50 patients have been diverted from Palomar to the county’s four other adult trauma centers, Fahey said.

This is the second time Palomar has been forced to assume bypass status and dispatch its patients elsewhere. Last fall, county officials shut the facility for 12 hours after its orthopedic surgeons threatened to strike. Then, too, county officials sent a letter threatening termination if a resolution to the labor dispute was not found, Cox said. But Palomar, under much pressure, came up with a solution to placate the county, and its orthopedic surgeons went back to work.

It turned out to be a quick fix that didn’t hold, and the surgeons walked out again in December.

Palomar and its orthopedic surgeons have been battling since June, when the doctors’ contracts expired. Doctors say the on-call stipend of $520 a day, or a 5% increase over the previous stipend, is inadequate compensation for the burnout and rigors of working a 24-hour shift in which many patients have no insurance and cannot pay their bills.

The problems faced by Palomar are common to trauma centers across the nation. In September, neurosurgeons at Scripps Memorial Hospital went on strike. In August, 21 hospitals in Los Angeles County refused to treat head-injury cases because there weren’t enough neurosurgeons willing to work on-call duty.

In one way, however, Palomar is different: Its trauma center makes money. A recent nationwide study of 35 trauma centers showed that Palomar made a profit in 1989--one of only two surveyed to do so. While the others had an average deficit of $2.1 million, Palomar pulled in $511,000.

The same study showed that the county’s four other adult centers had a deficit of more than $1 million.

Prompted by actions at Palomar and concerned by what she regards as a mounting problem, Golding has called for a special task force to review the trauma system. The task force would report to the board by June 30, Golding said in a memo to the county’s chief administrative officer, Norm Hickey, and Supervisor Leon Williams.

The task force would analyze how the county trauma system could operate more efficiently. It would be made up of officials from hospitals within as well as without trauma centers, law enforcement agencies, fire departments, community groups, the county’s emergency medical systems and other experts.

The county health department also plans to convene its own task force to rethink the trauma system. This group, which will not include any local hospital officials, will consist mostly of outside experts, Cox said. The panel is expected to deliberate for several months, he said.

“We need to revisit what we did in 1983 and 1984 when we set up the trauma network,” said Cox. “Is it still appropriate? Should it be modified? How much?”