Will the Bronx have no pediatric trauma center?

October 11, 2017

Sean Petty, a pediatric emergency room nurse, reports on New York City's reckless proposal to eliminate the borough's only trauma center for children.

SENIOR MANAGEMENT in New York City Health & Hospitals (NYCHH), the country's largest public health care system, are planning to dismantle the only pediatric trauma center in the Bronx.

Unless they are stopped, sometime after the first of the year, the New York State Department of Health will de-designate Jacobi Medical Center's Pediatric Emergency Room, a place I've worked for the last 10 years, as a trauma center.

If that happens, a borough that is home to almost 400,000 children--and that contains the poorest congressional district in the country--will have to contend with the horrific uncertainty of whether there will continue to be skilled health care workers able to care for child victims of car accidents, gunshot wounds, falls and other forms of violence to the human body.

This decision would be catastrophic at any time. But it is especially cruel given that the island of Puerto Rico has suffered catastrophic devastation following two hurricanes. The Bronx is home to approximately 160,000 people of Puerto Rican decent--almost triple that of any other borough in New York City, and more than any other city in the country.

The Jacobi Medical Center in the Bronx
The Jacobi Medical Center in the Bronx (Zoirusha | Wikimedia Commons)

Tens of thousands of people from the island will be seeking much-needed refuge with their families in the coming months, and they will be desperately in need of wraparound social services.

In addition, the latest mass shooting last week in Las Vegas is a stark reminder of both the public health crisis of gun violence and the need for health care systems to be optimally prepared.

This past July, a former employee of Bronx-Lebanon hospital--several miles west of Jacobi in the Bronx--opened fire on patients and health care workers. And just a month later, a former employee of Montefiore Medical Center--a couple miles north of Jacobi--jumped off the roof after having tried to purchase a rifle earlier that day.

Any sensible assessment of public health needs in the Bronx would conclude that we need more trauma centers, not less.

WHAT WILL happen in the short term if Jacobi loses its pediatric trauma center is that child trauma victims will continue to be transported to the most qualified emergency room that the medics think the patient can make it to--but those medics will face much tougher decisions to make, and their chance of being wrong will increase.

For instance, if a child is in a bad car accident near a non-trauma center and that child has significant injuries, a wrong call by medics can lead to the patient being taken to a place with less qualified staff who may not have the skills to save the child. Or that patient could deteriorate on the longer trip to a designated trauma center.

Jacobi, like other hospitals, will still receive trauma patients if they are the nearest to the victim and that victim needs immediate attention. Those patients will be treated with a fairly high level of care--again, in the short term--but then will have to be transferred to another borough, leaving families having to travel miles through the city's notoriously deteriorating public transit system to visit and help care for their critically ill children.

Even worse, whenever these patients are transferred, there will be increased risk for increasing the severity of the injury. During transport, spinal injuries can worsen and intubated patients' breathing tubes can get dislodged, all while only a skeleton crew of health care providers is monitoring the patient during the trip.

In the medium term, Jacobi will begin to rapidly lose doctors, nurse practitioners and nurses who work there explicitly because of its trauma center.

Jacobi has arguably the highest level of pediatric trauma care in the greater New York City metropolitan area. It has a nationally known Pediatric Emergency Fellowship program. Its attending physicians have sacrificed salary and career opportunities to work here. The nursing staff has over 250 years of combined experience in pediatric trauma care, and several individuals have well over 20 years of experience themselves.

In the medium to long term, as our inpatient census in both our Pediatric Intensive Care Unit and Pediatric Inpatient Unit declines, NYCHH management will have more of an excuse to reduce or eliminate these services, further escalating a decrease in access to quality pediatric care in the Bronx.

TO ADD insult to injury, this change was not officially communicated to the medical or nursing staff. Some staff members were notified by e-mail and individual conversations, but most got confirmation only after management was asked directly about it at a hospital-wide town hall meeting.

Similarly, details as to why this decision was made have not been made explicit. However, management has referenced the public hospital system's budget crisis as possibly being a factor.

We have also confirmed that it is not just Jacobi that has been denied continued designation as pediatric trauma center. The applications from Harlem Hospital, Kings County Hospital in Brooklyn and Elmhurst Hospital in Queens have been rescinded as well. While some of these facilities are closer to already existing pediatric trauma centers, none are closer than several miles.

It is true that the system does face severe budget crisis. But this is itself the making of state and federal policies that have intentionally undermined the public system.

New York's Democratic Gov. Andrew Cuomo has systematically cut Medicaid reimbursements to health care facilities during his tenure, while Barack Obama's Affordable Care Act undermined public hospital funding in two critical ways: by phasing out the Disproportional Share Hospital funding for hospitals that take care of poor and uninsured patients and by decreasing the rate of federal Medicare reimbursement.

The overwhelming majority of Jacobi patients are uninsured or on Medicaid. Most of the rest have Medicare, while only a sliver have private insurance. This has created an increasing structural deficit, which has ballooned to $1.8 billion this year. Under Mayor Bill de Blasio, New York City has increased its subsidy of NYCHH, but is essentially demanding service reductions in exchange.

Meanwhile, both the city and state have significant budget surpluses and are home to a sizable number of undertaxed millionaires and billionaires.

While Trump's ongoing assault on federal health care funding continues to loom large over our entire health care system, there exists more than enough resources to provide these basics of health care for the children of New York City.

It's not economics but politics that is getting in the way of preventing needless death and injury to some of the city's most vulnerable residents.

Encouragingly, resistance against this decision has already begun to emerge. As community members and health care workers have become aware of this situation, immediate outrage and willingness to organize have been the overwhelming responses.

If NYCHH officials continue with their decision over the next few weeks, they are going to have a serious fight on their hands.

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