FLAWS RIDDLE STATE'S TRAUMA SYSTEM
MANY COUNTIES HAVE NO UNIT FOR TREATING BADLY INJURED PATIENTS.
Orlando Sentinel
w/Greg Groeller

Orlando Regional Medical Center shocked residents, politicians and emergency-services officials last month when it announced it would have to close Central Florida's only Level 1 trauma center.

But there were others across the state who weren't nearly as surprised.

According to some of those hospital officials and health-care experts, the scheduled shutdown of ORMC's trauma unit -- now on for May 1 -- simply exposed long-standing flaws in Florida's fragmented system of trauma care.

Four years ago, lawmakers ordered the Florida Department of Health to reshape the state's hodgepodge of trauma centers into a unified system that could provide lifesaving medical treatment for anyone at any time and anywhere.

But the department has made little, if any, progress toward improving a network that has actually dwindled in size and scope since its introduction two decades ago.

If ORMC's center is forced to close, metropolitan Orlando would be left without a single trauma unit. The nearest Level 1 center would be in Tampa; the nearest trauma unit of any kind would be in Daytona Beach -- itself facing a possible shutdown -- or Melbourne or Lakeland.

"The whole process needs to be totally revised," said Dr. Joseph Tepas, director of the University of Florida's regional trauma system, which oversees centers in Jacksonville and Melbourne.

"The leadership needs to come from the state," Tepas said. "It is the state government that is, by definition, the guardian of the welfare of the people."

NO LOCAL SUPERVISION

Unlike other life-saving organizations, such as police, fire and ambulance services, trauma centers are not operated or supervised by local or county governments, though some do receive local tax dollars.

Instead, Florida's trauma centers were established and are operated voluntarily by public and private hospitals. So while the state regulates who qualifies to run a trauma center, it can't prevent one from closing -- nor can it move quickly to secure a replacement.

Although the Legislature has divided Florida into 19 regions that each "should have at least one Level I or Level II trauma center," the law spelling this out has no teeth. Seven of the 19 service areas have no trauma center at all.

The only real solution, according to Tepas, is to establish a centralized, state-run commission. Such a group could encourage more hospitals to open trauma centers where needed, through financial aid and other incentives, and could work to ensure the financial stability of those already operating.

Florida lawmakers had the same idea in 1999, when they passed legislation placing "primary responsibility for the planning and establishment of a statewide inclusive trauma system" with the state Health Department.

Such a step was necessary because of "a lack of timely access to trauma care due to the state's fragmented trauma system," lawmakers wrote at the time.

The Health Department responded a year later by issuing a lengthy report that outlined plans to secure state money for the 20 existing trauma centers, to open trauma units in underserved parts of the state, and to work with other agencies in coordinating the "planning, operation and evaluation of the state trauma system."

STATE HAS NOT MET GOALS

The department promised to meet its goals by December 2005. But with less than three years to go before the deadline, it has not accomplished any of its primary objectives.

Susan McDevitt, executive community-health nursing director for the department's trauma program, blames the lack of progress on the terrorist attacks in September 2001.

"With 9-11, we've had to put some of our objectives on hold," said McDevitt, who worked on the department's 2000 report. "We've had to really work with our trauma centers in preparing for bioterrorism events."

McDevitt noted that the agency has implemented one of its "public information and education" goals: Florida will observe its first "Trauma Day" on May 20.

ORLANDO'S NEUROSURGEONS QUIT

The crisis at Orlando Regional began when about a dozen neurosurgeons told the hospital they would no longer accept on-call duty at the trauma unit.

Without neurosurgeons, a hospital cannot operate a trauma center under state law. When Orlando Regional first disclosed the problem in late February, it set an April 1 closing, but it was later able to work out a deal with eight neurosurgeons to continue working until May 1.

John Hillenmeyer, Orlando Regional's president, has asked Orange County for money that would enable him to hire a full-time team of neurosurgeons for the hospital's staff. He also said the state should pass legislation dedicating more money for Florida's trauma network.

Trauma centers already receive some money from the state -- about $15 million last year, according to the Florida Hospital Association -- but that's not much when spread across 20 units.

Orlando Regional isn't the only hospital with trauma-center problems:

In Daytona Beach, all six trauma surgeons at Halifax Medical Center have said they won't sign another contract to work in the Level 2 center there unless the Legislature, now in session, takes steps to reduce the fast-rising premiums that many doctors are paying for medical-malpractice insurance.

In Fort Myers, Lee Memorial Hospital has warned that its trauma unit is in jeopardy, now that Lee County residents have defeated a half-cent sales-tax increase that would have funded the center and an array of other health-care programs.

Despite the prospect of losing three of the state's 20 remaining trauma centers, lawmakers aren't planning any follow-ups to their 1999 legislation.

Instead, many of them are banking on passage of a doctor-friendly medical-malpractice bill to make the problem go away.

Insurance rates for hospitals and doctors -- particularly physicians in high-risk specialties such as neurosurgery and obstetrics -- have skyrocketed in recent years. Insurance companies say that larger and larger jury awards are forcing them to double and even triple premiums for some specialists.

As a result, hospitals have said it's difficult to recruit doctors to Florida, where such premiums are among the highest in the nation. The House already has passed a bill limiting noneconomic awards in malpractice cases to $250,000. But those same caps have met fierce resistance in the Senate.

Rep. Frank Farkas, R-St. Petersburg, chairman of the House's Health Care Committee, said a cap on medical-malpractice awards would make it easier for hospitals such as Orlando Regional to recruit.

"It's a manpower issue with the trauma centers," Farkas said. "The med-mal bill takes care of that."

Farkas said there has been some talk of giving more state money to hospitals with specialized services such as pediatrics and trauma. But he acknowledged that's going to be difficult in a year when lawmakers are scraping to find enough funds for basic health services such as Medicaid.

Trauma centers began appearing in Florida and throughout the country in the early 1980s, as advances in medical technology and procedures made it possible to save more of the most seriously injured accident and crime victims -- patients that just a decade or so earlier probably would have died.

Under state law, hospitals had the choice of opening Level 1 or Level 2 trauma units. Level 1 operations were considered the cream of the crop -- they had the largest and most-specialized staffs and, as a result, were able to handle larger numbers of patients. Level 2 units also could handle critically injured patients, but they had smaller staffs and faced less stringent regulations.

HOSPITALS EAGER FOR CENTERS

At first, many hospitals eagerly opened trauma centers, hoping to increase business and revenue. But many were unprepared for the high costs and complexities of running a trauma center, leading to an industrywide shakeout. Since 1985, about 30 trauma units have closed in Florida. In 1983, for example, there were eight centers in Jacksonville; today, there is just one -- Shands Jacksonville's.

"A lot of hospitals felt that, if you had a sign that said 'trauma center,' it would give you access to more patients," Tepas, who oversees Shands Jacksonville's Level 1 unit, said. "As they began to realize that being a trauma center was not a guarantee of increased community prestige or market share or fiscal stability, they said, 'I can't make any money at this, so I'm out of here.' "

LARGE AREAS HAVE NO COVERAGE

That retreat has left large areas of Florida without trauma coverage. Emergency-services workers in those areas often have little choice but to transport patients dozens of extra miles to reach a trauma center.

That requires precious minutes those patients often don't have. Orlando Regional, which serves as many as 22 counties in the middle portion of the state, has acknowledged that closing its Level 1 center will lead to more deaths because of the added time needed to get patients to Daytona, Melbourne or Lakeland.

TIME SAVES LIVES

After breaking his neck in a surfing accident at Cape Canaveral in September, Kent Shoemaker of Winter Park was flown by helicopter to Orlando Regional, even though his accident took place closer to the Level 2 units in Daytona Beach and Melbourne.

Dr. Steven Bailey -- one of the neurosurgeons who subsequently resigned from Orlando Regional -- inserted two titanium plates and bone tissue from a cadaver into Shoemaker's neck. Shoemaker, who was initially rendered a quadriplegic from the accident, has since regained nearly full use of his arms and legs.

"It's a frightening thought to me that I might have broken my neck after the [ORMC] trauma center closed, instead of six months ago," he said.

Shoemaker said he thinks that frivolous lawsuits are at the root of the trauma center's problems and that capping jury awards is the only solution. But not all former trauma patients are as supportive.

Bobby Lloyd of Altamonte Springs was transported to Orlando Regional in 1998 after being hit by a truck while riding his motorcycle.

He credits the trauma unit with saving his life. But the next year, Lloyd said, surgeons at Orlando Regional left a sponge in his stomach while performing follow-up, reconstructive surgery. He said it took doctors nearly two years to discover their mistake, which Lloyd said left him with an abscess in his stomach and continual bowel problems.

Lloyd, who is suing the hospital and the doctors who performed the second procedure, said caps would only protect bad doctors.

"That's not going to solve the problem," Lloyd said. "We need to weed out these doctors that don't know what they are doing."

'NO RELIABLE SOURCE OF FUNDING'

Hospital officials argue that capping jury awards and improving state funding for trauma centers are the only ways to save the system.

"Hospitals have always been totally on their own to do this," said Carol Gormley, the Florida Hospital Association's government affairs director. "There is no reliable, sustainable source of funding for trauma centers."

Four of Florida's six remaining Level 1 trauma centers receive at least some money from surrounding communities or are affiliated with state universities; as a result, they are better able to fend for themselves, Gormley and other experts said.

Officials at those hospitals are clearly confident their trauma centers won't end up like Orlando Regional Medical Center's.

"It's not conceivable," said Dr. Stephen Cohn, medical director of Ryder Trauma Center at Jackson Memorial Hospital in Miami. Ryder was built with $28 million in private funds but now operates with the aid of a half-cent sales tax. Cohn said Ryder won't close as long as it has the county sales-tax revenue. Southeast Florida's two other Level 1 trauma centers -- Broward GeneralMedical Center and Memorial Regional Hospital in Hollywood -- both draw on tax dollars that originate within the county.

Shands Jacksonville gets no local or county funds for its Level 1 trauma center, but it is helped in part by its affiliation with the University of Florida.

Orlando Regional and Tampa General Hospital -- the only Level 1 trauma units that don't receive taxpayer dollars or benefit from a state-school affiliation -- are more susceptible, experts said, to outside pressures such as reductions in government and private insurance reimbursements, increases in malpractice-insurance premiums, the rising cost of treating uninsured patients, and a nationwide shortage of skilled surgeons.

Even internal problems, such as squabbles between management and staff, can take on a greater significance. "If the hospital had a good relationship with the doctors, you could make it work," said Dr. George Ellis, an Orlando urologist who is secretary of the Orange County Medical Society.