Florida emergency rooms can't find enough doctors

A statewide shortage of specialists sometimes delays patients' care.

By Lisa Greene, Times Staff Writer
Published February 29, 2008

Pediatric General Surgeon Dr. Richard Harmel, in center, performs surgery in the operating room at All Children's Hospital.
	[Dirk Shadd | Times]

ADVERTISEMENT Previous coverage Bayfront diverts trauma victims (Feb. 28) [Dirk Shadd | Times] Dr. Richard Harmel, pediatric surgeon at All Children's Hospital, works three or four days a week on call and logs 12-hour days. On weekends, he makes rounds to visit patients. The hospital has been trying to hire more surgeons.

When Bayfront Medical Center had to turn away trauma patients this week because the hospital didn't have enough neurosurgeons, it exposed an emergency system in crisis.

That crisis goes far beyond one hospital. Regional Medical Center Bayonet Point also has told state regulators it doesn't have neurosurgeons on call full time. Orlando and Palm Beach hospitals have had shortages.

And it isn't just brain surgery. Across Florida, hospitals lack enough specialists to cover emergencies.

If you sever your fingers in Florida, Tampa may be the only place to get them sewn back on.

If you're pregnant in Polk County, don't count on delivering in Bartow. The hospital had to close its obstetrics service.

"What we have here in Florida is a critical shortage of specialists who are willing to take call in emergency rooms," said Dr. Larry Hobbs, president of the Florida College of Emergency Physicians and emergency medical director of Southwest Florida Regional Medical Center.

Emergency doctors say the problem will only get worse.

Hospitals are shipping patients across the state, paying more to specialists to get them to work, lobbying for more legal protections, and desperately trying to hire more doctors.

* * *

Even now, seven months later, Naples resident Chuck Smith isn't sure how it happened. One minute, he was in his garage sawing wood for his new bathroom. The next he was trying to stop the bleeding.

Paramedics found his left hand 28 feet away, under a bush.

A helicopter flew Smith and his hand past three hospitals -- because Collier County has no trauma center -- and on to Lee Memorial Hospital.

Doctors there saved Smith's life but not his hand.

Three hours and 21 minutes after his accident, Smith, 59, arrived at Tampa General Hospital, where Dr. Al Hess, senior hand surgeon, was on call.

Over three days and 29 hours of surgery, Hess saved Smith's hand. But he still needs a lot of followup care. Because he lives so far away, every appointment in Tampa means a whole day off the job as a sheriff's detective.

But Smith is lucky. Some of Hess' patients come from so far away that their severed fingers or hands can't be saved. That's because Hess and three of his colleagues are among the only Florida surgeons willing and able to perform such delicate microsurgery in emergencies.

A single operation often takes two surgeons and 10 to 12 hours. Hess does it anyway. He's on call every third night.

"I don't do much else except family and work," he said.

When Hess was learning his craft, he was captivated by the idea of repairing nerves and tendons too tiny to see.

"It was like, 'Wow, microsurgery is so cool! I want to learn that,'" said Hess, 51. "Now nobody wants to do it, because of how much work it is."

As one of only seven Level I trauma centers in the state, Tampa General expects to see the most disastrous injuries from west-central Florida. But Hess and his colleagues see cases from all over the state -- once even from Georgia.

Hess and Dr. Roy Sanders, president of the Florida Orthopaedic Institute and orthopedics chief at Tampa General, say the hand surgeons reattach fingers about once a week. Every few days, they get calls about hand injuries, and Sanders sorts through whether they should take the patient.

As the crisis gets worse, Sanders said local hospitals are trying to send cases with less severe injuries to Tampa General.

"It's difficult to understand why a patient needs to come from a completely different region of the state by helicopter," Sanders said.

The crush of cases isn't because there aren't enough surgeons, the doctors said.

"If every hand surgeon in Florida took call, there wouldn't be a problem," Hess said.

Once, most doctors were willing to be on call for emergencies -- for free.

It was part of a code: Doctors got the "privilege" of being on staff at the hospital. In return, they gave their time in the emergency room. Often, they benefited by gaining new patients.

But the code has broken. Fewer doctors want to work 100 hours a week. They don't want to practice in the ER, where they say they're less likely to be paid by uninsured patients and more likely to be sued by strangers. Working emergencies often means they actually lose money, because they have to cancel paying patients.

Even doctors who do work emergencies have become more specialized and often are more reluctant than they used to be to perform an operation on a child, or out of their subspecialty.

In Tampa Bay, hospitals have resorted to paying doctors to be on call. The money adds up. It costs All Children's Hospital in St. Petersburg about $6-million a year to be a trauma center, said Gary Carnes, the hospital's president and CEO.

But money isn't enough.

For some specialties no amount of pay is worth it to them, including eye and plastic surgeons, said Mark Vaaler, vice president of medical affairs for St. Joseph's Baptist Healthcare. "It's a huge headache, but we've been able to Band-Aid it. I am very, very concerned about what's going to happen in the next several years."

State medical leaders are asking legislators to give doctors more protection from malpractice lawsuits when they're treating emergency patients.

* * *

Outside Orlando, Dr. Vidor Friedman frantically worked the phones one recent afternoon, trying to care for a common illness: The 13-year-old boy had appendicitis. Friedman, director of emergency services for Florida Hospital Celebration, didn't have a pediatric surgeon available.

After two hours, the boy's father asked whether it would be faster to just put him in the car and drive to Georgia.

Friedman finally got the boy to another hospital for surgery. But the incident still rankles.

"We work really hard to get patients taken care of, but sometimes it takes an hour or two on the phone, trying to find a specialist," said Friedman.

What specialties are the worst? "Any pediatric specialty at all. Ob-gyns. Most surgical subspecialties -- orthopedics, thoracic, gastroenterology, urology. There aren't enough interventional cardiologists."

Really, he says, there's not enough of anybody.

Friedman has no orthopedists to work on hip injuries. He's sent people with severed fingers out of state, and children who have swallowed coins to Tampa.

Every emergency doctor seems to have a story. For Hobbs, the emergency doctor group's president, it's the little girl who was hurt in a carjacking a few years ago. Her foot became tangled in a car seat strap, and as she was dragged along, her head hit the ground. It took Hobbs more than six hours to find care for the girl at All Children's, which had no beds, but took her case anyway.

"If she was bleeding or the pressure had been building in her brain, she would have died," he said.

At All Children's, Dr. Richard Harmel, the medical director of pediatric trauma, is one of those surgeons who tackles the cases that nobody else can.

He is on emergency call three to four days a week, as well as seeing other patients. His 12-hour workdays run to 7 p.m., unless he comes back for a night emergency. On weekends, he makes rounds to check on patients and typically handles a few emergencies.

Harmel describes this stoically, as only "kind of exhausting."

"I do work a lot of call," he said. "But there's a strong commitment on the part of most pediatric surgeons to provide trauma care. I'm happy to do that."

All Children's has three such trauma surgeons. Carnes has been working on hiring more since July.

When Smith, of Naples, had his accident, he had no idea that specialty care was such a problem. Despite the long drives for treatment, he's just glad that he still has the use of his hand.

"Dr. Hess and his people, they are fantastic," he said. "I wish there were more doctors like him."

Lisa Greene can be reached at greene@sptimes.com or at (813) 226-3322.

Update: Bayfront takes traumas
Bayfront Medical Center began accepting trauma patients again Thursday. But until the hospital signs up more neurosurgeons, it will likely have to divert trauma patients again. Two of the hospital's neurosurgeons recently stopped taking emergency calls, dropping its on-call staff to two. The hospital has had to suspend its status as a trauma center three times this month. During that time, it has remained open for regular emergencies.

About this series
In coming months, the Times will look at changing forces affecting doctors, medical students and the practice of medicine, and how the decisions doctors make about their careers will affect patients' care.

[Last modified February 28, 2008, 23:45:06]