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An Emergency Room’s Closure: A Community’s Betrayal

The views expressed are those of the author and are not necessarily those of Scientific American.


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View from St. Andrews' conference room. Note they have a dock and helipad, enabling access by land, sea, or air.

Although I’ve been busy traveling again, the struggle of the Boothbay peninsula communities to keep their hospital remains constantly on my mind. I’ve written two letters to the editor of the Boothbay Register*, which I am reproducing here to update my readers, as this is an example of broader David and Goliath healthcare struggles and a case study of a crisis in rural healthcare.

The proposed closure of the ER is scheduled for April, 2013. Lincoln County Healthcare and MaineHealth have, thus far, refused requests from the community’s citizens and elected representatives to delay this execution to have time to conduct a more thorough economic impact study or explore other options.

See Hospital merger déjà vu and Big Fish Eats Little Fish- Warning for Rural Hospitals for further background.

It is important to note that if the hospital ER is closed, St. Andrews also loses its accreditation as a hospital and its designation (and considerable funding) as a rural Critical Access Hospital.

Boothbay ER closure plans smell fishy

Trauma Bay at St. Andrews' ER

As I was leaving Boothbay Harbor, Dr. Timothy Fox [medical director at Miles Memorial Hospital and St. Andrews Hospital] was kind enough to show me St. Andrews’ ER and answer some of my questions. I was very impressed with both his knowledge and how well-equipped the ER is. In fact, it has more sophisticated equipment and capabilities than we had when I left the hospital I worked at in Cumberland, Md.

Dr. Fourre [Director of Emergency Services and a Trustee of the Board of Lincoln County Healthcare] had suggested the need to close St. Andrews was due to quality concerns, but I missed seeing that. After all, most of the physicians work at both Miles and St. Andrews and some even rotate up from MaineMed. Both ERs are staffed with one physician, except for a six-hour overlap shift at Miles.

Using Sue Mello’s numbers [Boothbay Register] regarding ER visits: 390-542 patients with true emergencies (Level 1-3, defined as needing care in less than 1 hour) would need to be transferred out annually, at night, just during hours the proposed urgent care center would be closed.

So patients with a heart attack or serious problem will now have a further delay in receiving care while they are being transferred first to Miles and then in the opposite direction to Portland or Brunswick, rather than being stabilized in town. Even during the day, urgent care is not intended to accept such seriously ill patients, nor authorized even to accept ambulances, so a total of ~1500 Level 1-3, or the most seriously ill patients, would have to be taken directly to Miles annually. How does this improve the quality of care?

So what’s a small town to do?

Many tiny Critical Access Hospitals throughout the country are turning to telemedicine. I spoke with Kristi Henderson, Director of Telehealth at University of Mississippi and Dr. Rafael Grossman, head of TeleTrauma at Eastern Maine Medical Center. Of Maine’s 15 CAH, 8 use TeleTrauma, with excellent results and cost savings for all parties. Maine hospitals use telemedicine for Cardiology, Neurology/Stroke care, Pediatrics, and more.

Miles uses telemed in their ICU and is exploring use for stroke care. So telemedicine is successful solution for all parties, except for those on the Boothbay Peninsula. Lincoln County Health Care says the technology, now no more cumbersome than an iPod or iPad, is not “developed” enough for us.

Interior of BRAS ambulance

And Lincoln County Healthcare’s Cindy Leavitt incorrectly describes ambulances as “traveling ICUs.” Though our EMTs are well trained, ambulances are far from that. But that is another post.  Frankly, the more I learn about the proposal to close the peninsula’s ER, the more irrational and inexplicable I find it. And when something like this plan makes such little sense, I’ve learned to follow the money.

[Would you rather get care in the well-equipped, relatively spacious St. Andrews ER or in this ambulance--which is more roomy than most--careening on curvy country roads to Damariscotta?]

Yesterday, Joe Gelarden, Executive Editor of the Boothbay Register, accurately reflected the community’s anger and mistrust of LCH: “They feel betrayed by Lincoln County Healthcare’s decision to close St. Andrews Hospital. They resent the way Lincoln County Healthcare’s brass hid behind closed doors to make their decision. And they have a very real fear that if something should happen to them, they would be denied adequate healthcare services.”

My just-submitted letter to the editor is an open letter to Jim Donovan, the CEO of  Lincoln County Healthcare. It was written in response to the shocking report of the preliminary estimates of the increased costs of the ambulance service (aka “BRAS) and Mr. Gelarden’s description of Donovan’s strategy as “Rope-a-Dope.”

A local resident, Tom Hagan, questioned how LCH could make a sound decision to close St. Andrews without even having done the arithmetic, saying, “The headline should have been ‘St. Andrews Closing Decided Without Cost Data From Ambulance Service.’” One might say the same about the lack of an economic impact study. These lapses appear totally irresponsible.

LCH Plays Shell Game

Dear Mr. Donovan,

Please tell me again how closing St. Andrews’ ER will result in a significant cost savings for the citizens of the Boothbay peninsula and improve their quality of care, and otherwise create the best of all possible medical worlds? On the other hand, moving towards telemedicine, as is increasingly being done in rural communities throughout Maine (including Miles) and the rest of the country, has been cost-effective. So why not offer this at St. Andrews?

The delays in patients receiving care due to the transport time to Miles will certainly not improve the quality of care—(certainly not for those patients who die en route to Miles.)

And now we learn that the shift will increase the Towns’ subsidy of BRAS from:

$34,205 to $187,676.13 or an increase of 549% for Boothbay

$38,215 to $223,549.39 or an increase of 585% for Boothbay Harbor

$8,044 to $48,529 or an increase of 603% for Southport.

And that’s just for the next fiscal year. Costs are likely to continue to increase in the future due to the added costs for salaried EMTs (including health insurance), training, equipment. Would Mr. Donovan like to cover the town’s subsidies that will result?

 

"The Conjurer," painted by Hieronymus Bosch. The painting accurately displays a performer doing the cups and balls routine, which has been practiced since Egyptian times. The shell game does have some origins in this old trick. The real trick of this painting is the pickpocket who is working for the conjurer. The pickpocket is robbing the spectator who is bent over.

By closing St. Andrews’ ED, LCHC is playing a shell game here, as many cost savings LCHC realizes will simply be shifted to the taxpayers of the affected communities in higher taxes for increased ambulance service subsidies, and increased morbidity [illness] and mortality [death] for the Boothbay peninsula’s residents due to the additional travel time and ED wait times at Miles.

 

Is the ultimate plan to claim, 2 or 3 years down the road, that Urgent Care is not financially viable, and turn the entire valuable St. Andrews waterfront property into a casino or condos to subsidize local residents’ care? If this move is not a shell game, what would you call it? Aren’t shell games illegal?

*The first letter was published last week; the second has been submitted but not yet published.

P.S. to Mr. Donovan. You recently said, “I’m writing today to support the St. Andrews Task Force in its efforts to understand the demographic, clinical and patient volume trends that are significantly changing the way we (and providers everywhere) are delivering healthcare.” If this were true, you would not be rigid about an April, 2013 closure date, but would grant a stay of execution so that more thorough impact study could be done.

Credits:

Molecules to Medicine banner © Michelle Banks

Images of St. Andrews and BRAS ambulance by Judy Stone

Bosch’s “The Conjurer”/Wikipedia

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Judy Stone About the Author: Judy Stone, MD is an infectious disease specialist, experienced in conducting clinical research. She is the author of Conducting Clinical Research, the essential guide to the topic. She survived 25 years in solo practice in rural Cumberland, Maryland, and is now broadening her horizons. She particularly loves writing about ethical issues, and tilting at windmills in her advocacy for social justice. As part of her overall desire to save the world when she grows up, she has become especially interested in neglected tropical diseases. When not slaving over hot patients, she can be found playing with photography, friends’ dogs, or in her garden. Follow on Twitter @drjudystone or on her website. Follow on Twitter @drjudystone.

The views expressed are those of the author and are not necessarily those of Scientific American.





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  1. 1. aidel 9:49 am 10/26/2012

    Dr.Stone, I admire your willingness to keep fighting for justice. The decade of new MDs that I raised simply don’t do this. Are they indifferent or afraid to buck the system?

    Link to this
  2. 2. Derick in TO 10:55 am 10/26/2012

    Health care can be “for profit” or “for patients”, but not both. You can only serve one master, and if “profit” is your master than “patients” are your currency, not your concern.

    So which is better for the country – universal access to quality medical care or health care corporations that line their pockets at the expense of public health?

    Link to this
  3. 3. hanmeng 11:17 pm 10/26/2012

    @Derick in TO–

    Sooner or later even the government will find it can’t pay for every medical expense and will start looking for ways to cut costs.

    Link to this

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