When he thinks about it, Dr. Andrew Freese of Brandywine Hospital gets an uneasy feeling driving through Chester County to work before sunrise.
If he got in a crash, it could take more than an hour to get to the nearest trauma center. "It's almost sinful, in my opinion, not to have a level-one or level-two trauma center in Chester County," Freese said.
Chester County, with about 485,000 residents, is the largest county in Pennsylvania without a trauma center, but that may change. A group of local hospital executives, doctors and public officials called the Chester County Trauma Services Task Force is trying to reopen a top-of-the-line trauma center here.
If they succeed, though, it likely will take several years to acquire funding, recruit staff, and obtain accreditation and will also require some money from county taxpayers.
Brandywine, in Coatesville, and the Chester County Hospital in West Chester have been identified as potential sites because of their central locations.
Freese is the county's first full-time neurosurgeon since Brandywine Hospital shuttered its trauma center in 2002, largely because of high malpractice costs.
Trauma centers handle the most severe and life-threatening injuries, including penetrating wounds to the head, neck and torso; burns; and abdominal injury during the third trimester pregnancy.
Emergency rooms, in contrast, usually deal with urgent but less severe conditions, including broken bones, chest pain, asthma attacks, seizures, loss of consciousness, and deep cuts and lacerations.
The hiring of Freese at Brandywine could move the hospital closer to resurrecting its trauma center, said Brandywine Hospital Chief Executive Officer Mark A. Benz, who brought in Freese earlier this year to open a certified stroke center.
"Neurosurgeons are the cornerstone of a trauma center," Benz said.
The demand on emergency services will continue to rise as 100 families move into the county each month, said Benz. A higher population also means more traffic congestion, further delaying transport.
It can take trauma victims in Chester County as much as 73 minutes to get to an operating room, according to the 2007 Chester County Trauma Center study, spearheaded by U.S. Rep. Jim Gerlach (R., Pa.). That's well above the "Golden Hour," the window of 60 minutes after a trauma during which medical and surgical attention increases the survival rate. In 2001, victims reached the Brandywine trauma center in 61 minutes.
Delayed care puts patients at greater risk for death, infection, intestinal injuries, brain damage and internal bleeding.
Trauma deaths from accidents originating in Chester County have risen since the closure of Brandywine's trauma center. In 2006, 6.3 percent - or 31 - of 490 people admitted for trauma injuries died. By comparison, 4.7 percent - or 25 - of trauma patients out of 530 died in 2001.
Longer transport times out of the county has factored into the rising death rate, said Andrew Wigglesworth, a member of the county trauma task force. Wigglesworth is a partner at TRG Healthcare LLC and former chief executive officer of the Delaware Valley Healthcare Council
The most common trauma cases in the county are from auto accidents and falls, said Wigglesworth. Paramedics decide at the scene whether victims need trauma care and to which hospital to transport them. Many trauma victims must be airlifted to Philadelphia's Hahnemann University Hospital or the hospitals of the University of Pennsylvania or Temple University.
Others are sent to Abington, Crozier-Chester or Reading. The number of emergency medical flights has increased fivefold over the years, from 120 flights in 2001 to 660 in 2006.
Funding presents the biggest barrier for the two hospitals under consideration for the trauma center. The hospitals would require an additional $6 million to $8 million a year to sustain a trauma program, according to preliminary estimates. County residents might be asked to foot part of the bill on their property taxes. Supporters say it would cost $10 per person a year to run the trauma center.
The state will provide $500,000 to $1 million a year, and insurance companies pay hospital trauma centers a 15 percent surcharge for treating crash victims with trauma injuries, said Wigglesworth.
The task force will make formal recommendations to the county commissioners by the fall, said Wigglesworth.
Chester County Hospital would have higher costs initially. In order to meet The Pennsylvania Trauma Systems Foundation's accreditation guidelines, Chester County Hospital would need to make $2.5 million in changes, including moving its helipad closer to the trauma bay, Wigglesworth said.
While both are touting the advantages of locating there, Chester County Hospital chief H.L. Perry Pepper said it's not competitive.
"We're interested in making sure an objective decision is made," Pepper said. He listed the hospital's alliances with the Hospital of the University of Pennsylvania and Children's Hospital of Philadelphia, a $98 million expansion, and community support as advantages for opening a trauma center.
Among the advantages of locating at Brandywine Hospital, Benz said, is that much of the systems, staff and equipment already are in place from the previous trauma center. The hospital also is ramping up its emergency services, including recently purchasing a $4 million helicopter and hiring seven additional orthopedic surgeons.
Benz said Brandywine hospital officials started talking about reopening the trauma center two years ago, when malpractice rates began moderating. In fact, the hiring of Freese reflects an important shift in the malpractice climate.
Freese has degrees from Harvard and the Massachusetts Institute of Technology. He practiced in Philadelphia for 14 years with The University of Pennsylvania and Thomas Jefferson University Hospital.
During this time, his insurance rates climbed to just under $300,000.
"I had never lost or settled a suit," Dr. Freese said. "I couldn't afford to practice in Philadelphia."
So in 2004, he moved his wife and four children to Minnesota, where he paid $27,000 for liability insurance. Now he pays $130,000.
As Freese aims to recruit four more neurosurgeons to Brandywine Hospital, he said one of the first questions candidates ask is the cost of malpractice insurance.
Malpractice insurance rates have started to moderate, largely because of more carriers, said Dr. James Tayoun, founder of the Patients and Physicians Alliance. But no reforms are in place to keep the rates from taking off again if the carriers leave, Tayoun warned.
Changes in state laws, such as one that requires plaintiff's attorneys to prove that medical procedures fall outside of acceptable standards, have also helped. The number of malpractice cases in Chester County has fallen from 42 in 2001 to 35 in 2007.
Over the next several months, the trauma task force will develop detailed cost projections, which include malpractice and liability insurance expenses, and develop a public awareness campaign.
We have to get the word out there isn't a trauma center, said state Rep. Carole Rubley (R., Chester), who heads the task force.
The task force is hiring a public relations firm to create educational pamphlets and to poll residents about their willingness to pay for a trauma center. Unlike, say, the public library or school, the trauma center may be used by only 1,000 people a year at most - some of whom may be commuters who do not live in Chester County.