Official cites doctor 'crisis' in death

By Phil Galewitz

Palm Beach Post Staff Writer

Donna Casasnovas understood the consequences of a shortage of emergency room specialists months before the Palm Beach County Medical Society released the results of its study earlier this week.

She might not have known that the 14 area hospitals have struggled for years to find enough surgeons for their ERs, or that new trends were emerging in the county’s crisis that would be detailed in the report.

What the Royal Palm Beach mother knows is that her four children no longer have a father. Her husband, Enrique Casasnovas, 39, had begun vomiting blood in the middle of the night Dec. 23 and was rushed to the hospital.

But on Dec. 23, Palms West Hospital didn’t have a gastroenterologist – a doctor specializing in the digestive system – who could treat his internal bleeding. Neither did any other hospital in the county.

Hours later, Casasnovas was transferred via ambulance to a hospital in Broward County, where, upon arrival, he had a heart attack.

“This is a health-care delivery crisis,” said Dr. Jean Malecki, director of the Palm Beach County Health Department. “It’s totally inexcusable.”

The problem is not a new one, but the medical group’s report sheds light on its breadth. The Palm Beach Post exposed the ER doctor shortage in 2004, when a Lake Worth woman died after being unable to find a neurosurgeon in the county willing to treat her stroke.

Still, area hospitals continue to struggle to find enough neurosurgeons, hand surgeons, orthopedic surgeons and other specialists to work in the ER.

Regulators cite violation

The latest twist, detailed in Monday’s report, is that despite an abundance of gastroenterologists in Palm Beach County, most don’t take ER calls. Just 12 of 92 of the specialists operating in the county took emergency calls last fall, when the study was conducted.

That glaring detail isn’t lost on Donna Casasnovas. She said Enrique was still alert when paramedics arrived that December night and specifically instructed them to take him to Palms West in Loxahatchee because he believed he would get quicker care there.

But later, he was shuttled to North Broward Medical Center in Deerfield Beach. The heart attack was likely the result of uncontrolled bleeding. He died on Jan. 11. State regulators say the treatment of her husband, a cook, is a violation of Florida’s “patient dumping” laws.

Palms West CEO Ron Lavater said he could not comment directly on the Casasnovas case, citing confidentiality laws. He said the hospital has enough gastroenterologists to handle patients three weeks a month and has transfer agreements for the other days. It is trying to recruit more gastroenterologists. “When we have a sign out front that says ‘Emergency,’ we have an obligation to make sure we have that coverage, and we are working hard to do that,” Lavater said.

But the medical society’s report predicts that the current shortage of ER specialists will worsen during the next few years, and that has local health-care officials concerned about the potential for more cases such as Casasnovas’.

For example, according to the report, Palm Beach County will have about half as many general surgeons and family physicians as it needs by 2011.

Ironically, the overall doctor shortage is not to blame for the crisis with gastroenterologists. The county actually has about twice as many gastroenterologists as it needs, according to the report. Its just that most of them don’t take emergency calls.

Gastroenterologists quit hospital

No hospital has felt that the burden of that fact more than Palms West. In late January, 13 of its 16 gastroenterologists quit the hospital rather than be forced to handle emergencies. The doctors would stay only if the hospital paid $1,000 a day for one of them to be on call. The hospital refused.

To address the countywide issue, a group of doctors, hospital executives and county health district officials has been meeting for three years with few results. The Emergency Department Management Group, tasked and funded to come up with solutions, ended up handing the problem off to the Health Care District of Palm Beach County in January.

The district is devising a solution. But any plan would take at least a year to implement because it would need state and federal approval and the agreement of area doctors and hospitals.

Meanwhile, the problem continues to grow. To be sure, doctors nationwide have either stopped or reduced working in hospital ERs, citing higher malpractice risk and higher numbers of uninsured patients. But observers say the problem appears to be more acute in Palm Beach County.

The two main reasons for that are the cost of medical malpractice insurance, which is higher than average here, and the lack of a major public hospital that provides doctors immunity from lawsuits. The first has led more county doctors to “go bare” – operate without malpractice insurance. Without coverage, doctors are less inclined to want to work in the ER because they believe that makes them more vulnerable to lawsuits. The second reason, the lack of a large public hospital, means there’s no major safety-net hospital that is fully staffed with different specialists.

Weeks before the medical society report came out, County Commissioner Jess R. Santamaria said the problem of hospitals lacking emergency specialists of all kinds was worsening. Santamaria, who has served on the boards of both Palms West Hospital and Wellington Regional Medical Center, noted that anyone experiencing an emergency is vulnerable. “It could happen to me next,” he said.

Malecki takes it a step further in calling for political leaders to take action.

“I think someone needs to take a leadership role in this, and we are doing that at the district,” said Malecki, who’s a district commissioner. “Health care should be a right, not a privilege, and this issue should be on the front burner of every policymaker.”

But no one expects state lawmakers to take action anytime soon.

Gayle Harrell, R-Stuart, who chairs the House Health Care General Committee, said she’s aware of the problem. But “right now this is not a high priority of the legislature,” she said.
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