Shock Trauma Aftershocks: A Fight for Control

THE BALTIMORE SUN

On a chilly day two weeks ago, the halls of the Maryland Shock Trauma Center were humming with news that the brief reign of Dr. Kimball I. Maull was about to end in what amounted to a coup from above.

He had offended many of the center's doctors as he tried, in a style notably lacking in finesse, to topple the fiefdoms and end the turf battles that had characterized the center for years.

Now, it appeared he had offended his bosses, too, and the result was that he was about to become a former director, relegated, as he later put it, to pondering a new future while hanging towel racks at home.

With a bittersweet grin, a doctor dressed in baby-blue scrubs said he and his colleagues had gotten exactly what they wanted -- Dr. Maull's ouster -- and now they were really in trouble. He noted that the staff was losing its chief protec- tion against what it feared most: attempts by governor, legislators and officials of the University of Maryland Medical System to carve up Shock Trauma and the emergency medical network.

The worst possibility, in the doctor's view, was that the University of Maryland Medical System would win full control over the Shock Trauma Center. Always a part of the medical system, Shock Trauma had been run like an autonomous state. This gave it an air of separateness, a sense that the staff was engaged in a heroic mission that only its members could appreciate and preserve.

And a sense that Shock Trauma was clearly superior to the university hospital next door.

"Sure they want this place," he said. "It's the diamond of the system. The concern is that they're trying to build an empire and they want to steal it from the citizens of Maryland. Just imagine what would happen if we were taken over by them.

"We would become just like them."

In the aftermath of Dr. Maull's forced resignation, attention has turned to the General Assembly, where legislators are considering two bills that would dramatically alter the complex relationships linking Shock Trauma, the university medical system, the university itself, other hospitals, a glitzy Medevac fleet, Gov. Wil- Jonathan Bor covers medicine for The Baltimore Sun.

liam Donald Schaefer and the citizens of Maryland.

At stake is the care given to thousands of sick and injured Marylanders across the state, including almost 3,000 who are taken by ambulance and helicopter to the Shock Trauma Center itself.

Often, it seems each party in the debate claims the others are con- cerned solely with power and money, while it alone cares about patients. And one doesn't have to take sides to notice the intense and often vicious rivalries.

"I've been involved in church politics, union politics and electoral politics, but academic politics is by far the worst I've ever seen in my life," said Del. Lawrence A. LaMotte, sponsor of a bill about the Shock Trauma system, who once served as assistant to the chancellor at the University of Maryland Baltimore County.

"The egos are the most vicious on all sides. It's the nature of the beast."

The organizational chart is so Byzantine that officials with the state medical society got it all wrong when they testified last fall before a gubernatorial commission that was considering Shock Trauma's future. So it's not surprising that any attempt at restructuring will prove equally confusing.

"It's like putting your hand into a mess of wire and trying to follow the blue one," said Dr. James D'Orta, a personal friend of Gov. William Donald Schaefer who led the commission.

An emergency physician at Franklin Square Hospital, Dr. D'Orta popped up in news stories over the years as a doctor who frequently joined disaster relief teams, such as the ones that aided earthquake victims in Armenia and Mexico City. Suddenly, his evolving friendship with the governor placed him in a far different type of mess.

The current system puts an entity known as the Maryland Institute for Emergency Medical Services Systems (MIEMSS) at the center of emergency medicine in Maryland. Its director controls Shock Trauma, a research center and the statewide network of rescue personnel, ambulances and helicopters that whisk patients from accident scenes to emergency rooms across the state.

The system was carved out two decades ago by Dr. R Adams Cowley, the charis-matic Shock Trauma founder who thought it made sense to place the premier trauma hospital at the hub of the emergency medical network. Under him, MIEMSS became what one observer called "the Taj Mahal of emergency medicine."

But critics said the scheme gave Shock Trauma the power to determine where injured patients were taken. And this, they felt, meant he could ensure that the highest-paying patients (suburban accident victims) went there, while lower-paying patients (inner-city gunshot victims) went to other hospitals.

So while the arrangement had an appealing logic, it presented at least the appearance of a conflict of interest while inciting jealousies among doctors and nurses working at eight other major trauma centers statewide.

It also gave the MIEMSS director two bosses: the chief executive of the University of Maryland Medical System, a private corporation, and the president of the University of Maryland at Baltimore, a public institution. Dr. Cowley held them at bay because he was perceived as untouchable. But his successors weren't so skillful.

Shock Trauma, built with $35 million in state money and subsidized to the tune of $3 million a year, was made part of the private hospital corporation while the statewide emergency network remained a public institution.

The commission's bill, backed by Governor Schaefer, seeks to end the confusion by splitting MIEMSS in two. Shock Trauma would become wholly a part of the private medical system. Meanwhile, the emergency medical system and research center would have a separate boss overseen by a board reporting to the governor.

Dr. D'Orta said this makes Shock Trauma an equal partner in a statewide network where all trauma centers are treated the same. Rescue operations would be governed by a public board that would ensure that all hospitals are treated fairly.

"The way it is now, the system is too lopsided," he said.

He hopes the arrangement will also inject a healthy dose of reality into the emergency system that has grown heady with images of daring rescues and helicopter landings. With Shock Trauma at the helm, he said, little attention has been paid to medical emergencies such as heart attacks that kill far more people than do car accidents.

Sounds great so far, but the proposal has hardly any supporters inside Shock Trauma. There, doctors, nurses and laboratory workers fear they are about to be "swallowed up" by a medical system that will use Shock Trauma's financial success to improve the bottom line of the larger medical complex.

Dr. Morton I. Rapoport, chief executive of the university medical system, denies any such intention. But doctors note that he has already merged the university hospital's trauma department into Shock Trauma, and consolidated the respiratory therapy programs of the two institutions. They wonder what's next.

"By this time next year, the sixth floor of Shock Trauma may become a cardiac unit," Dr. Maull, now an outsider, said in a recent interview. "The fear," said one doctor, "is that he [Dr. Rapoport] will come here and let this whole building be wasted."

The second bill, sponsored by Del. LaMotte, seeks to put those fears to rest by placing Shock Trauma, field operations and the study center under a single boss. That boss, the MIEMSS director, would report to a governing board reporting to Governor Schaefer.

The university medical system would retain its ownership of the 10-story Shock Trauma building -- but not the power to set policies. Mr. LaMotte said that should put a quick end to a consolidation trend he finds disturbing.

"My concern is that Shock Trauma is being diluted and diminished with bringing in inappropriate patients who do not require the highest level of trauma care," Mr. LaMotte said. "The whole Shock Trauma was created by public funds and has a public mission. UMMS does not have that same statewide focus."

Each proposal has its internal logic, and its possible flaws.

The LaMotte proposal, which has won an enthusiastic following among Shock Trauma staff, could leave undisturbed the perceived conflict between the trauma center and the helicopters and ambulances that deliver patients. The safeguard both Shock Trauma and the emergency network would be directly responsible to the governor.

Meanwhile, Dr. D'Orta concedes that he is "torn up" by criticism that his bill could make Shock Trauma the pawn of a greedy medical system.

He argues that the bill has safeguards, too, such as a provision that gives the MIEMSS director control over how a $3 million annual taxpayer subsidy is used. But he admits the proposal could have unintended consequences. And he worries whether he will even recognize the bill once it emerges from committee.

In what seemed a frank admission of how strange things have become, he said: "If it comes out in a bizarre fashion and in a way that's going to hurt the emergency medical system, I would

then urge the governor to veto it."

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