Linda Rosen

Dr. Linda Rosen has always juggled multiple functions as chief of the state’s Emergency Medical Services and Injury Prevention System Branch in the Department of Health. But in the last few months she’s added the role of traffic director to those functions, keeping an eye on how well Hawaii’s hospital network is managing its emergency-room workload.

What’s changed, of course, is the closure of the two Hawaii Medical Center hospitals, a subject that came up again this week in a state Senate informational briefing. There is hope of resolution — with the eventual reopening of HMC-West by a new owner, to serve the Ewa communities, and proposals to repurpose HMC-East in Liliha to address the state’s persistent deficit in long-term care facilities.

Besides coping with the current turbulence in the health care system, Rosen is focused on the continued development of a robust trauma-care system, with better coordination of specialists and hospitals on each island equipped as trauma centers.

The 60-year-old former pediatric emergency medicine specialist views the world through a multifaceted prism, with a family history in French Polynesia — her Marquesan mother married her American father — and with her own two children.

Still, Rosen said, trauma care can be hard, so in pairing EMS with injury prevention, the agency provides a kind of “antidote” to the strains of coping with emergency cases.

“I sometimes speak about ‘vicarious post-traumatic stress disorder,’ because when you’re in a field like EMS or in the emergency department, you really see sad things, tragic things,” she said.

“So I really think the hopefulness of working in injury prevention, and seeing what you can do to actually prevent some of those tragedies is gratifying, and it’s therapeutic to people in EMS.”

QUESTION: Where are we in the adjustment to the closure of the HMC hospitals?

ANSWER: Certainly there was sort of a shock initially. … I think everyone knew that it was possible that this could happen because the hospitals had been in trouble. But I think it was the abruptness of the announcement that really caught us off guard, that in a few days this could happen.

But there was a lot of proactive work done. The City and County of Honolulu actually put an ambulance in the parking lot (of HMC-West) the first few days, anticipating that there would be some people who wouldn’t have gotten the message. … Which was a good thing, because they did have some people driving up.

Q: So there was a paramedic crew there to do the intake?

A: Yeah. They even put an ambulance in with the lights on at night, and they had one of these vehicles that are for mass casualties.

Q: Wasn’t it hard for one crew to handle that situation?

A: Yeah; well, people didn’t come in all at once. But they also did deploy two additional units, one that was already planned by the City and County of Honolulu, stationed at Kuakini (Medical Center), to help with what has always been a difficult situation downtown. A lot of cases, each of those units carry a lot of cases every day. So one ambulance was at Kuakini, another at the airport; these were additional units.

Also, the supervisors who are in the area are able to initially respond; they have a little bit of equipment in their trucks. … So all of those measures were put into place very quickly, and it really helped to mitigate the situation. And we’ve been monitoring through our data system.

Q: How does that work?

A: My office contracts for all the 911 ambulance services statewide. And we also have an information system, which is for all of the records of those ambulance services, all the patient records and electronic medical record system we implemented in 2006. And it’s real-time. The field personnel are entering information about cases that they’re going to, and we have that information for analysis. …

At first there was a concern that there would be a lot more calls, because people would go, “There’s no more emergency room so I’m just going to call the ambulance.” And so we’ve been counting the number of calls, the response times.

So what’s turned out is the total number of calls hasn’t changed that much from West Oahu. … What it shows is that the other hospitals are picking up the slack, but on some days it’s a strain, such that they actually have to close to further ambulance arrivals. So we have had days when multiple hospitals have placed themselves on what’s called “closed status,” which is a signal to the ambulances that they’re full.

Q: That happens occasionally? Regularly?

A: Well, prior to the closure it happened only occasionally. And since the closure it happens more. The first few weeks of January were particularly bad, but it seems to have settled down now. And what I think has happened is that in the initial part … all that volume of patients went to the other hospitals. And so, of course, they got backed up. They got backed up in terms of having room to admit people. …

At the briefing, hospitals we’re talking about seeing 20 percent more patients in their emergency departments than the norm prior to the closure, at places like Pali Momi, Kaiser and Wahiawa. So they sometimes have closed, and there have been some periods of time when most hospitals have been closed. But, fortunately, they reopen, and we’ve been able to manage. But it is a concern.

I think what’s happened is they’ve made some adjustments. If you know you’re going to be getting more patients, you can add some more staff. Of course, it’s not easy to add physical space, but you can mitigate the numbers by having more staff and just trying to move people through a bit faster. … And so the hospitals are adjusting and that’s why we’re not seeing them go on “divert” quite as much.

Q: Aren’t there limits to what you can do in an ambulance to stabilize a patient’s condition?

A: Right. There are some time-sensitive conditions, and the transport time is one area where we see some fairly significant change in. What we found is our response times we’ve been able to maintain with those additional resources. … (Indicating figures on a graph) This is from leaving the scene to arriving at the hospital, and we have about a three-minute increase. … That extra three minutes is concerning, but there’s truly just a few cases where that would make the difference.

Q: For example, what kind of cases?

A: Well, again, the sooner the better, but to make the case that even in a trauma, three minutes would make a big difference, or in, let’s say, a heart attack.

The most important thing, really, is calling 911. Because at that point, although you can’t get everything from the ambulance that you can get from an emergency department — they can’t do surgery — but they definitely have a lot to offer that will help to stabilize the patient en route.

So we’d rather there wasn’t an extra three minutes, but we don’t think at this point that it really means worse outcomes for patients. And we hope that continues.

Q: Are there any models of this happening elsewhere to use as guidance?

A: Well, I think we’re so unique in the fact that we’re an island; we’re so dependent and we can’t really transport. For instance, if this happened, say, in some part of another state, they might be able even to transfer patients much further; there are more hospitals to work with in terms of one hospital closing. …

Q: How do you view proposals to convert the Liliha hospital to a long-term care facility?

A: Believe it or not, it affects emergency services because when you don’t have the long-term care beds, the whole system is affected. … The hospital takes a loss because they can’t admit a higher-revenue patient to that bed. And the patient doesn’t get really what they should in long-term care, not because hospitals aren’t good, but that’s not their mission; it’s acute care.

It is a problem. And we see it when we work with the neighbor island systems at the hospitals, because even they are affected. Not only at their facilities but if the Honolulu facilities are backed up, they can’t transfer their patients to Honolulu.

Q: What improvements are still needed in the state’s trauma system?

A: Our goal is to have a trauma center on each major island, so we want to get Maui verified as a trauma center. We also are working with North Hawaii Community Hospital. We’re hopeful that Tripler will come on board because we don’t have another trauma center on Oahu right now, just Queen’s. …

So we want to have this system and have everybody connected, so that if you’re at a center that doesn’t have the capabilities to take care of you, you will quickly be transferred to someplace that can.

Queen’s always took the severe traumas but the other issues that have been problematic for referring hospitals are not always major trauma. It might be an eye injury; it might be a bad dog bite, a plastic-surgery injury.

There are conditions for which they don’t have specialists on the neighbor islands. But before we had a system, they just had to, like, make phone calls, just ask people, shop around for a physician who would accept their patient. Once these hospitals are in a system, if one hospital has a resource that the other doesn’t, it’s pretty much automatic.

So if you’re Trauma Center X and you don’t have an orthopedic surgeon on call that evening, you could expeditiously get your patient to another trauma center that did. Because we have a system, it’s not every man for himself.