Survey: Specialists for Trauma Cases Scarce, Rarely on Call

Crowded emergency rooms have long threatened access to quick medical care, but hospital officials say they are increasingly encountering another problem: not having a specialist available to treat trauma patients.

"Hand specialists, neurologists, some orthopedic specialties - there's just a general problem with getting them to agree to take on-call [cases], to be on call and to come in when there are emergencies," said Paul Cunningham, senior vice president of the Arkansas Hospital Association.

Doctors say the increasing amount of uninsured trauma care has translated into many unpaid overnight shifts. And a growing number of patients seeking elective procedures means some doctors simply don't need the emergencyroom work.

Getting physicians to be on call "didn't used to be a problem because a lot of times people would view that as a way to build their practice," said Dr. David Hall, senior vice president for medical affairs for the St. Vincent Health System. "They wanted emergency-room call. They wanted to see those patients. But it's not quite the plum that it used to be." Health groups are pushing for funding to develop a statewide trauma system that, some say, could begin to address the problem.

The shortage of on-call specialists isn't unique to Arkansas.

In a survey released earlier this year, the American College of Emergency Physicians found that 73 percent of emergency department directors reported inadequate coverage of on-call specialists in 2005, up from 67 percent a year earlier. Specialists were increasingly negotiating for fewer on-call duty hours, the survey found. The top five specialty shortages were in orthopedics, plastic surgery, neurosurgery, hand surgery and ear, nose and throat.

"Numerous other studies and surveys have investigated the shortage of on-call specialists, finding that the problem extends across many different specialties and all regions of the country," the Institute of Medicine wrote in a report on emergency care released in June, "and the problem appears to be worsening." For patients, the result can be delays in care as the staff at one hospital scrambles to find another hospital with the necessary oncall specialists.

A CASE IN POINT

Take for example the recent experience of Jake Bleed, a reporter for the Arkansas Democrat Gazette, who cut through the bone in his ring finger with a tile saw.

Only one surgeon in Arkansas reattaches fingers, but he wasn't on call that day. For about six hours, Bleed waited at Baptist Health Medical Center in North Little Rock while the medical staff called orthopedic surgeons in Little Rock and hospitals in Dallas and Memphis.

"I remember there being a point when it was like, well, if no one can take me, what does that mean for the finger," the 32-yearold North Little Rock resident said.

The staff at Baptist Health Medical Center finally found Bleed a surgeon in Louisville, Ky. But to get there he had to charter a private plane, spreading the $4,300 cost over two credit cards. Not knowing if his insurance would cover that expense, he considered whether having his finger was worth it.

In the end, Bleed decided it was, and in a surgery that began around 1:30 the next morning, a Louisville surgeon saved his finger.

Bleed was later surprised to learn that Arkansas has at least eight hand surgeons, including four in Little Rock, trained to reattach fingers. But at some point, those doctors decided not to include the procedure as part of their regular practice, said Dr. Randip Bindra, the sole Arkansas doctor who reattaches fingers.

SOME OPT OUT

"Some people make a choice for various reasons that they don't want to do it," Bindra said.

Many hand surgeons don't want to incorporate the unscheduled, often uncompensated trauma care in their practice, he said. An afternoon injury can mean an all-night surgery, a difficult proposition for a doctor when it's followed by a full day of scheduled surgeries.