Sadly, ‘familiarity breeds contempt’ with Adirondack Health

At the May 1 meeting in Lake Placid, the board chairman, CEO and chief medical officer of Adirondack Health presented the case for converting the Lake Placid Emergency Department to an urgent care center. As revenues to Adirondack Health diminish from improved outpatient services and decreasing reimbursement by government-sponsored insurance, the cost of the LPED, which has a very low nighttime census, may no longer be justified. This conversion could save $950,000 annually. Members of the medical staff have supported this move based upon a belief by some that the finances make sense, critically ill patients should not be delaying definitive treatment by going to the LPED, and EMS services are of good quality, providing safe transport to Adirondack Medical Center in Saranac Lake.

I wish to comment on several points raised by participants at the meeting.

The financial wisdom of building a Wound and Hyperbaric Treatment Center was raised. The implication of the question was that, had Adirondack Health not embarked on this project, there would be sufficient funds for the LPED. As someone who was involved at the project’s inception, I wish to clarify that there was a clinical need for such a center given a high incidence of diabetic wounds in particular and the inability of practitioners, myself included, to devote the time required to care for these wounds appropriately. Furthermore, the board had decided to invest resources in the center after an exhaustive financial analysis, which had predicted the center would generate revenue, which, in fact, it has done. Finally, the center’s building was also designed to accommodate additional physicians’ offices unrelated to wound care. In summary, erecting the building for medical offices and establishing the wound center were sound clinical and financial decisions, with the latter, in fact, creating jobs.

It was stated that trauma patients should not be transported to AMC in Saranac Lake but rather to Fletcher Allen Health Care or to the Champlain Valley Physicians Hospital. As an instructor of Advanced Trauma Life Support and a surgeon who has managed trauma at AMC and CVPH, I need to correct this misconception. A basic principle of trauma care is to render the appropriate care as rapidly as possible. Most trauma patients are best served by transport to AMC in Saranac Lake, where there are general surgeons, a thoracic surgeon and a vascular surgeon supported by appropriate ancillary services.

It is the responsibility of the emergency department staff and surgeon to determine whether a patient is best served by being treated locally or whether there are injuries which require a Level I trauma center (FAHC). The decision to transfer is based on clear and internationally recognized guidelines (ATLS), which we follow. Examples of injuries best treated at AMC are splenic injuries or penetrating trauma, in which case delay could be fatal. Over the years, AMC has successfully managed some highly complex trauma cases.

It was also claimed that stroke victims should bypass AMC, another misconception. Stroke victims are treated by protocol, which emphasizes rapid diagnosis and treatment with clot-busting agents when appropriate. This is done under the supervision of a neurologist via telemedicine available 24/7. Certainly, if the patient has a brain bleed and requires neurosurgical expertise, then transport to FAHC is appropriate. This is the rare patient, who still needs AMC for the initial radiographic diagnosis. Finally, AMC has a vascular surgeon, this writer, who can provide surgery in cases of stroke due to plaque in the carotid artery.

Excellent and thought-provoking points were made by some audience members. For example, the concern regarding the anticipated stress on the EMS system deserves careful consideration. However, I was, frankly, appalled by the general tone of the audience and by the implication that the administration and board may not be acting in the best interest of the institution and the entire population served. The board, which volunteers countless (and, based upon the meeting’s tone, thankless) hours, and the administration have a fiduciary responsibility to do what is best for the common good while fulfilling the institution’s mission statement.

I accept that some decisions made by the board and administration may be incorrect and know that many will be exceedingly difficult. For example, purchasing the nursing homes was morally correct but retrospectively was a bad business decision, based in part on promised but undelivered state funds. Despite the slanderous suggestion to the contrary, neither board nor administration is deriving any personal gain from making these hard decisions.

In the end, every American needs to realize the runaway costs of health care must be reduced and that we will all – whether patients, administrators, or physicians – feel the effect of this. We as a community must adapt to the new realities of national budgetary constraints and be respectful of those who are in good faith trying to find ways to provide high-quality care in the context of these new economic realities. In the end, as the board chairman stated, if the board does not take its fiduciary responsibility seriously today, there may be no hospital at all tomorrow. Based upon the multiple hospital closures in New York state, that statement is not fanciful.

Having observed the strengths and weaknesses of hospitals from Britain to Haiti, and having learned the delivery of health care is variable, it distresses me that the adage “familiarity breeds contempt” manifested itself during the meeting. Adirondack Health, which does not belong to any specific town but rather to all individuals served, is an unusually well equipped and staffed facility. I brought my mother from Westchester County to AMC for major surgery recently. I know what the superb nurses and physicians of Adirondack Health do every day. I urge my friends and neighbors not to take what we have for granted.

I trust that the next public meeting on May 8 will be a civil discourse better informed of the weighty issues of concern to both sides of the issue.

Claude Roland, MD, FACS, is a member of the departments of surgery at Adirondack Medical Center and Champlain Valley Physicians Hospital in Plattsburgh, and is medical director of Adirondack Health’s Wound and Hyperbaric Treatment Center in Saranac Lake.