In February, Yakima (Wash.) Valley Memorial Hospital started paying on-call specialists to pick up extra shifts each month, and Yakima Regional Medical and Cardiac Center began sending some emergency orthopedic patients to a surgeon in Toppenish, Wash., 21 miles away.
It's a scenario that may threaten the stability of emergency medical care across Washington state.
Yakima, a city of 74,000, has seven orthopedic surgeons, the only two neurosurgeons in the county and two ear, nose and throat specialists eligible to be on call for emergency room work at the city's two hospitals.
Hospitals are required to have specific numbers of specialists on call for emergencies, in accordance with each hospital's trauma designation. Physicians under age 62 have to work on-call shifts to earn the right to admit private patients to the hospitals.
Increasingly, however, surgeons are complaining that those shifts eat up too much of their free time, taking them away from their private practices and cutting too deeply into their pocketbooks.
Yakima's orthopedic surgeons -- among the most highly demanded specialists in an emergency room -- recently made similar claims.
Fear of losing them and not being able to find replacements sent area hospitals scrambling. Two years ago, there were 13 orthopedic surgeons in Yakima. Each had to take about two on-call shifts a month. Due to retirements and relocations, seven surgeons remain.
"They were busy and could never catch up. They needed some relief from that," said Roger Vielbig, M.D., chief of Yakima's medical staff members who work at Memorial and Yakima Regional.
An executive committee responsible for the physicians decided to bring the days orthopedic surgeons are on call down to two per month. That meant there would be an orthopedic surgeon on call in Yakima only 14 days a month.
"I'd rather have them two days a month than no days a month," Vielbig said. "I'd rather have them here daily seeing patients in their offices."
The situation posed a threat to both hospitals' trauma ratings, which could have forced patients in most emergencies to be transferred to other hospitals in Wenatchee (115 miles away), the Tri-Cities (84 miles) or even Seattle (143 miles).
A facility with a trauma rating of Level One is qualified to treat the most complex of injuries. Level Five is the lowest rating, where the bulk of emergency patients are stabilized and transferred to a higher-rated facility.
Yakima's hospitals share a Level Three rating and alternate daily being the designated trauma center for the area.
In order to keep that designation, state law requires that an orthopedic surgeon, whose specialty is working on bones, muscles and joints, be available for patient consultation or management.
With the cutback in on call shifts, Yakima's hospitals no longer met that requirement.
It's not a predicament unique to Yakima. A lack of available surgeons forced two Eastern Washington hospitals -- in Walla Walla and Sunnyside -- to reduce their trauma-level ratings last year. Walla Walla dropped from a Level Two to a Level Three and Sunnyside dropped from Level Three to Level Four.
Yakima surgeons worked out a separate compromise with each of the city's hospitals.
Memorial Hospital brought in an orthopedic surgeon from Bremerton, Wash., to cover eight to 10 on-call shifts a month, and agreed to pay at least one local orthopedic surgeon to work the remaining uncovered shifts.
Rick Linneweh, Memorial's chief operating officer, predicts he'll soon have to consider similar steps to cover shortages in neurosurgery and in ear, nose and throat care.
An orthopedic surgeon in Toppenish agreed to take Yakima Regional's emergency orthopedic patients when no one else is available. Additionally, the hospital made an agreement with the Yakima orthopedic surgeons to use them only as consultants for physicians, instead of calling them into the hospital in the middle of the night.
Tim Trottier, Yakima Regional's chief executive officer, said the new plan is working so far. Before, if an orthopedic surgeon was operating on a patient and a second patient came in needing a surgeon, the second patient would have to be transferred to Harborview Medical Center in Seattle, the state's only Level One trauma center.
Now, the second patient is seen by a general family physician, who later will consult with the surgeon. The new method has cut back on the surgeons' caseloads and reduced the number of patients being transferred, Trottier said.
The only permanent solution, however, is recruiting more doctors, Linneweh and Trottier agreed.
Recruiting to a high-poverty and rural area like the Yakima Valley can prove challenging.
As long as they work to recruit more surgeons, the hospitals' trauma rating is safe, said Kathy Schmitt, section manager for trauma designation registry and quality improvements for the Department of Health.
"It doesn't really serve anyone well to take away a designation or lower a designation when a hospital is really making a sincere effort to recruit," she said.
Dropping a designation would shift more work to rated trauma centers such as Seattle's Harborview. That hospital's mission is to provide emergency care to King County and referral care on major traumas for the rest of Washington.
However, due to a lack of specialists, hospitals from all over the state are sending patients to Harborview who normally wouldn't be sent there. The increase has come largely in the form of simple injuries, such as hand injuries and bone fractures -- injuries that a specialist, if available, would be able to handle, Chief Operating Officer Johnese Spisso said. Since July, visits have increased by 8%, she said.
"It's a strain on our staff and our medical staff," Spisso said. "We know our mission. We know our commitment is to the underserved, and we value our role as the safety-net hospital, but we can't be the safety net for the entire state."
Yakima's medical professionals haven't given up hope. With the hospitals and doctors combining their efforts to bring more surgeons to the area, it's likely only a matter of time before the area is staffed again, Vielbig said.
"Maybe by the summer of 2005, we'll have a full complement back" of orthopedic surgeons, he said.
Rayburn Lewis, M.D., a member of the Washington State Medical Association's board of trustees, is familiar with the plight.
"This is a major issue," he said. "Yakima should not feel alone."