Few neurosurgeons available on weekends

ANNA VELASCO
News staff writer
http://www.al.com

Jefferson and Shelby counties are home to 11 general, acute-care hospitals where about 30 neurosurgeons practice during the week. But on many weekends, the number of brain surgeons available to treat head traumas, hemorrhagic strokes and aneurysms drops to three or four.

The shortage of neurosurgeons on call during weekends is a problem not just for the more than 1 million people in the metropolitan area, but also for people statewide who rely on Birmingham’s medical services.

“It means that patients who need neurosurgery inundate those hospitals that have neurosurgical care,” said Joe Acker, executive director of Birmingham Regional Emergency Medical Services System, BREMSS. “As a result, some of the patients may not get care as quickly as they could, and their outcomes may be affected.”

Many parts of the state have no neurosurgeons. And others have neurosurgeons who no longer operate in emergency trauma settings because of the liability and the personal toll. Even in Montgomery and other similar cities with a neurosurgeon on call 24/7, patients can’t get surgery in their hometowns for aneurysms.

Some neurosurgeons who take weekend call in Birmingham said there are times when patients transferred from hospitals without a neurosurgeon arrive too late to be saved.

“There is a crisis pending with neurosurgical coverage in the community,” said Dr. Zen Hrynkiw, a neurosurgeon at Trinity Medical Center who has taken weekend call for years. “Birmingham has been a referral center for everything from all over the state.”

National issue:

The shortage of neurosurgeons taking night and weekend calls is a national problem, and parts of the country are in much worse shape than Birmingham.

The population is growing and aging, yet the number of neurosurgeons has not increased in 10 years, according to Betsy van Die, a spokeswoman for the American Association of Neurological Surgeons.

Many neurosurgeons are limiting their practices because of the rising cost of malpractice insurance. A 2006 survey by the association found that 38 percent had limited the kinds of surgery they do, including 13 percent who had stopped doing trauma cases and 11 percent who do only spinal operations and no longer do any brain surgeries.

“It may not be that there are fewer neurosurgeons, but fewer doing these procedures that are absolutely crucial,” van Die said.

An official with Baptist Health in Montgomery said the city’s neurosurgeons quit treating aneurysms several years ago because they didn’t have enough cases to stay proficient and provide the best results. Every fifth weekend in Montgomery, the neurosurgeon on call is someone who no longer does brain surgery.

Stretched thin:

BREMSS, the emergency coordination system for the six-county area around Birmingham, does not route head trauma and stroke patients to hospitals that do not have a neurosurgeon on call. Stroke patients are often cared for without surgery, but BREMSS’ hospital routing requires a neurosurgeon be available to operate if necessary.

Birmingham as a whole has a healthy number of practicing neurosurgeons. But many hospitals don’t have round-the-clock neurosurgical coverage because they have two or fewer of the specialists. Three in a specialty is generally considered the minimum for a hospital to provide complete coverage.

Medical Center East has not had a neurosurgeon since 2005, although the hospital paid specialists from other facilities to cover during part of last year. Those doctors, two from Trinity, quit taking the hospital’s call in October because they were already covering two hospitals.

UAB Hospital, Trinity (formerly Montclair Baptist Medical Center), Brookwood Medical Center and St. Vincent’s Hospital are the only hospitals in Jefferson and Shelby counties that have full-time neuorsurgical coverage. Even with those, the care is not automatic.

Slammed with cases:

UAB is often slammed with trauma and other cases, making its emergency department and critical-care unit go on diversion, which means patients have to be taken to other hospitals. The state hospital can’t take stroke patients through BREMSS, for example, if its emergency department is on divert.

St. Vincent’s is one of the hospitals that takes the most stroke patients in town but, unlike most other hospitals, it does not participate in BREMSS’ trauma program. That means the area’s emergency trauma system would not route a patient with a traumatic head injury to St. Vincent’s, even if UAB were overloaded with head traumas.

Some weekends and nights, one neurosurgeon is covering both Trinity and Brookwood. In September, Trinity stopped taking stroke and trauma patients from BREMSS at the urging of its three neurosurgeons, who said they were shouldering an unfair burden of after-hours calls. Patient request trumps all other factors when emergency workers decide where to take someone, so BREMSS has taken a few stroke patients to Trinity since then.

Monday through Friday:

Dr. William “Bud” Woodall, a neurosurgeon at Trinity, said common practice at hospitals without full-time coverage is for neurosurgeons to take their call shifts Monday through Friday, not on weekends. He said he didn’t think BREMSS could distribute the patients fairly on weekends because so few hospitals were available.

“It goes from a population of 30 during the work week down to three on the weekend,” Woodall said of the city’s neurosurgeons. “Of those three, there’s often only one available to work because UAB is full and unavailable and St. Vincent’s doesn’t do trauma.”

Officials with St. Vincent’s said the 338-bed Catholic hospital is too full with patients it has now, especially in the critical-care division, to add trauma services.

Dr. Loring Rue, the head trauma surgeon at UAB, said the public hospital takes care of all the patients it can, and then some. In 2006, the hospital handled more than 3,600 traumas.

“We are doing our share,” Rue said. “There’s just a lot of work to be done.”

But the overload of trauma has affected UAB’s ability to take other patients, such as stroke victims. St. Vincent’s, Brookwood, Trinity and Princeton Baptist Medical Center handled more stroke cases than UAB for the 12 months ended Dec. 11, 2006, according to BREMSS’ data.

What’s being done:

Last fall, BREMSS started a program within the six counties it covers to help hospitals without neurosurgical coverage to transfer patients quickly to a hospital with a neurosurgeon in emergency situations.

Medical Center East hopes to recruit a neurosurgeon this year, and Princeton is trying to recruit a third. The specialists are hard to come by. UAB has the state’s only neurosurgical residency and will produce one brain surgeon this year.

Trinity plans to get back into BREMSS accepting stroke patients Feb. 1 and trauma patients soon thereafter, said Vicki Briggs, the hospital’s CEO.

Briggs said the hospital also is considering recruiting a fourth neurosurgeon because her research shows the Birmingham market could use about four more.

But Acker said the issue here is not so much a shortage of neurosurgeons: “If all the patients got sick at convenient times of the week and day, we wouldn’t have this problem.”
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