A Message from EPCH Physician-in-Chief Dr. Brad Fuhrman
ABC-7 is hearing from the El Paso Children’s Hospital’s Physician in Chief in an eight-page letter.
Dr. Brad Fuhrman fleshes out the hospital’s vision and what he calls it’s path to realization, a path that could be disrupted, he says, by focusing solely on finances as the hospital goes through this bankruptcy process.
“I think they’re so focused on finance right now that they’ve missed what {the hospital actually offers to children,” Fuhrman said.
County Commissioners have said Children’s will run out of money before the year ends, now that the bankruptcy judge has ordered it to pay $860,000 in monthly rent to UMC. Commissioners have said the hospital grew too fast, it was mismanaged and is now wasting hundreds of thousands of dollars on out-of-town consultants and attorneys.
Before Children’s was built, Furhman said El Paso didn’t have 24/7 in-house pediatric care, or access to cutting-edge cancer treatments or cancer specialists for kids. Children’s offers pediatric nephrologists, or kidney specialists, and gastroenterologists specifically trained to save the lives of infants and toddlers.
Fuhrman said these services could be compromised if Children’s is taken over by UMC and forced to share resources with its adult patients, which is the solution both UMC and county commissioners are pushing to get Children’s out of debt.
“What I’m hoping is that as the future of Children’s hospital gets sorted out,” Fuhrman said, “it’s not just determined on the basis of local finance, local elections, power structure within the city, and it’s instead determined by what the children of El Paso need.”
He ends the letter by saying that the hospital is still growing, and it has plans to develop a pediatric cardiovascular program, a pediatric neurosurgery program, and a higher level of neonatal intensive care.
He writes, “We are only a few feet from the start of the path.”
Read his letter below.
A Message from EPCH Physician-in-Chief
Brad Fuhrman, M.D.
Physician-in-Chief
El Paso Children’s Hospital
When El Pasoans voted to establish a “children’s hospital” they triggered a mission to bring this region excellent, full-service, if not comprehensive, healthcare for infants and children. This mission was adopted by the many subspecialists drawn here by the vision, and the mission has taken on a life of its own. I have heard this objective reduced to a vision of “4 floors just for children”, as though that were the essence of a children’s hospital. I would like to flesh out the vision and clarify our current location on the path to its realization.
Why a Children’s Hospital?
There are not as many children as adults, and children are mostly healthy. Hence fewer pediatric than adult subspecialists are trained. These relatively rare subspecialists are drawn to children’s hospitals, where they can find interdisciplinary collaboration, achieve critical mass and develop special pediatric services that focus on the special needs of children. Sick children often require the expertise of several different subspecialists, just like adults. Their care is best delivered where pediatric needs can all be satisfied under one roof. Absent a children’s hospital to provide that roof, pediatric subspecialists would not be attracted to El Paso, appropriate care would often be delayed and children would have to travel huge distances for subspecialty care, as was the case before El Paso Children’s Hospital opened.
There are costs associated with patient care programs. Hospitals prioritize their programmatic expenditures by profitability and by need. In a general hospital like UMC, or in a children’s hospital in the arms of an adult hospital like Providence, pediatric programs must compete for dollars with highly profitable adult programs, with programs that are needed by a larger adult population, and with programs that require investment to compete with other adult hospitals. Pediatric programs within a general hospital face constraints on growth and modernization because of this competition for resources. Allocation of resources rests on the shoulders of a hospital’s board of directors, and their independence is of paramount importance to prioritizing children’s needs.
Children’s hospitals develop special services with rare, child-focused and pediatric disease specific skills and programs. Examples include neonatal intensive care, pediatric cancer centers, and congenital cardiac surgery programs.
Children’s hospitals are fixated on advancing the state of the art in children’s healthcare. They bring together patients whose needs require new technology, pharmacology and healthcare systems, physicians who are rapid adopters, and researchers and educators committed to advancing their specialties. This purpose sets children’s hospitals apart from general hospitals that divide their attention between pediatric and adult populations.
Children’s hospitals not only provide novel, cutting-edge treatments, they are the proving grounds of advances in children’s care. El Paso Children’s has numerous review board approved research protocols and clinical trials. Novel pediatric treatments have been late reaching El Paso’s infants and children in the past for want of participation in nation-wide progress, research and development.
Where are we on the path?
Before the opening of El Paso Children’s, outmigration of infants and children to other cities for health care was excessive. Even now, of the 30 largest US cities, El Paso (the 20th largest) is the only one that does not have availability of bone marrow/stem cell transplantation, solid organ transplant, extracorporeal membrane oxygenation (for bedside life support), open heart surgery, or pediatric non-trauma neurosurgery. El Pasoans travel for healthcare less than they did before EPCH, but they still travel. Distances from El Paso to nearest facilities with these special services are: 270 miles to Albuquerque, 432 miles to Phoenix, 547 miles to San Antonio, 574 miles to Austin, and 630 miles to Dallas. El Paso has the smallest children’s hospital (122 beds) of these 30 cities (range 122-589). El Paso Children’s is a work in progress. It is not over staffed with pediatric subspecialists; it is in an early growth phase. Yet it has been able to greatly reduce outmigration for care.
Until the opening of EPCH, no El Paso hospital offered 24/7 in-house pediatric attending coverage of NICU, PICU, or General Pediatrics. Until recently, El Paso was also the only city of the largest 30 not to have access to Children’s Oncology Group experimental protocols, many of which are rescue therapies for the child with cancer resistant to standard treatments. Now the children of El Paso can access protocols that are in place at St. Jude and other large pediatric cancer centers, because EPCH been granted membership in the Children’s Oncology Group.
Texas anticipates a worsening shortage of physicians. Prior to the opening of El Paso Children’s, the ratio of pediatricians to children in El Paso was 1: 3,532, far worse than Texas overall (1:2,421) or the US overall
(1: 1,769). El Paso also had a severe shortage of pediatric subspecialists. Children’s hospitals train 30% of all pediatricians and 50% of all pediatric subspecialists. We need a children’s hospital to train and attract the pediatricians of the future, and to avoid losing further ground as the shortage deepens.
What have we built in the past 3 years?
In Pediatric Hematology/Oncology, we have hired 4 full-time subspecialists, joined the Children’s Oncology Group and adopted numerous protocols for hard to treat and resistant cancers, the same protocols available at St. Jude’s, M. D. Anderson and Sloan Kettering.
Our Newborn ICU has grown to 6 faculty positions and 4 neonatal nurse practitioners. Unlike any other NICU in the region, a physician is present in the EPCH NICU all day and all night, every day of the year (24/7). The newborn team has introduced new nutritional tools to hasten the growth of premature babies. We have the only NIC-VIEW system of webcams in El Paso. Parents and relatives can log in from remote devices and see their infants in real-time, day or night. This has enabled servicemen in the Middle East (and other locations) to bond to their as yet-unseen newborn babies.
The Pediatric Endocrine Division has expanded from 1 to 3.5 physicians, which enables them to better-serve children with diabetes, growth failure and other endocrine conditions. This program is supported in part by an 1115 Waiver-funded initiative, the Delivery System Reform Incentive Payment (DSRIP) program, anchored for this region by UMC. Numbers of physicians recruited and milestones for the number of patients to be served were developed jointly with Texas Health and Human Services, so we have recruited the number of endocrinologists intended by Texas HHS. Though many of these doctors have only recently come to El Paso, their practice has grown rapidly and they have already met the benchmarks for patient volumes reported by MGMS. The demand was there, but unmet before this expansion of services.
We have recruited the first pediatric nephrologist to El Paso. This enhances patient opportunities for dialysis and management of pediatric kidney failure in this region.
Two pediatric gastroenterologists have been recruited. This has added immensely to the quality of pediatric Gl services available in El Paso.
We have recruited 6.5 pediatric hospitalists to provide 24/7 in-house coverage of general pediatric patients. Community physicians love this service. 98% of general pediatric admissions are placed on the hospitalist service. This team is the backbone of the EPCH rapid response and resuscitation teams, which are in-house at EPCH day and night, unlike other hospitals in this region.
The Pediatric ICU is supported by 4 and soon to be 5 intensivists. This team provides a 24/7 in house subspecialist presence in the PICU. It supports pediatric level I trauma and integrates care among all pediatric medical and surgical specialists for critically ill children.
The Pediatric ED at El Paso Children’s is now covered 24/7 by Pediatric Emergency Medicine trained physicians, with only rare instances of adult attending coverage.
El Paso Children’s has become the principal inpatient training site for the Texas Tech Pediatric Residency Program. This teaching relationship ensures the cutting-edge nature of physician care. This widely accepted paradigm, that a university presence improves care, is underscored by Thomason’s recent adoption of the name University Medical Center. El Paso Children’s has been awarded a HRSA grant to support Pediatric Resident training. This training program has been responsible for recruitment of newly trained pediatricians into El Paso practices. Last year UMC hired 3 of our graduates to work in their pediatric clinics.
Where are we going?
This children’s hospital is in its infancy. The other 29 of the 30 largest cities in the United States have larger children’s hospitals, and all have the following available to them:
Open heart surgery for congenital heart disease… We anticipate the development of a joint cardiovascular program in the future, in collaboration with a premier surgical center. We have had several offers to discuss development of such a program whereby a surgical team would come to El Paso at intervals and repair lower acuity defects. More complex defects, for which outcome might be volume-dependent, would be referred to the partner. These patients would be accepted back to this hospital once stable after surgery.
We are the only one of the 30 largest cities not to have a pediatric cardiac catheterization laboratory at the Children’s Hospital. We should develop such a lab to facilitate trans-catheter procedures for congenital cardiac disease such as ductus closure, balloon dilation angioplasty, vessel stenting, ASD and VSD closure and embolization. These procedures are non-operative alternatives to cardiac surgery.
We should develop the capability of electrophysiologic analysis and treatment of arrhythmias. This requires some enhancement of catheterization lab facilities and recruitment of an electrophysiologist.
Pediatric Neurosurgery to include brain tumors, epilepsy surgery, shunts and other non-trauma procedures… There is a need for a pediatric neurosurgeon to provide these services, but it is anticipated that such a program would probably operate at a loss early in its development. Neuro-critical care capabilities do presently exist in this hospital.
Extracorporeal Life Support or Extracorporeal Membrane Oxygenation (ECMO)… Patients are referred from El Paso to other centers for reversible disease of the heart and/or lungs when death might occur before the opportunity for recovery. In patients dying of reversible disease who have failed other therapies, blood is continuously drained from the right atrium, oxygenated and cleared of carbon dioxide, and is then re-infused. This may be done for several days or for weeks, until recovery allows the patient to live without the heart lung bypass machine. This has become standard therapy for myocarditis, neonatal pulmonary hypertension, acute respiratory failure, sepsis and other conditions that are common, but usually not life threatening. Though not yet offered in El Paso, this technology is over 35 years old.
We do not have, but should develop, PET CT imaging capabilities. This technology allows the radiologist to superimpose anatomic images (CT) on top of PET (metabolic) images. This allows fine anatomic localization of cancers and brain seizure foci. This has become almost a standard component of pediatric cancer treatment and evaluation.
New cancer treatments make use of strategies to interfere with metabolism of cancer cells using agents that do not disrupt normal cell metabolism. This and immunotherapy may someday replace cell poisons in cancer treatment. The Children’s Oncology Group will fuel our transition to new modes of cancer treatment.
Bone marrow and/or stem cell transplant… This technology is available in virtually all of the 30 largest cities except El Paso. It is likely that we will develop these capabilities over time, but we certainly should be able to manage patients up to the point of transplantation and in follow-up.
Solid organ transplant… Much of the infrastructure for solid organ transplant has not been developed in this region. It is likely that we would seek a partner to perform such operations, but that we would need the organ system failure and transplant rejection expertise even if we choose not to develop the surgical option.
Neonatal Intensive Care is undergoing limited regionalization in Texas. This hospital needs to add various technologies to allow us to achieve the highest level of NICU designation and thereby enhance care and revenue generation (eg ECMO, cardiovascular surgery).
Several existing subspecialties will need expansion over the next several years based on volume growth and new technology development. Although we do not yet fully serve our expected entrapment region, virtually all of our subspecialties already meet MGMA benchmarks for patient volume. We expect increased demand in neonatology, pediatric cardiology, pediatric intensive care, pediatric hematology/oncology, pediatric gastroenterology, pediatric nephrology and perhaps pediatric endocrinology.
Fellowship programs should be developed in Neonatology, Gastroenterology, Endocrinology and Hematology/Oncology. Though we train pediatricians, we do not yet train subspecialists. Fellowship programs will expand the patient care capacity of existing programs and assure their longevity and succession planning, and may generate new subspecialists for this region.
There are other shortage areas in pediatrics which we must enhance. The only pediatric pulmonologist in El Paso may soon retire, and the hospital will continue to need pulmonology/bronchoscopy services. We have no depth in child development. We have minimal depth in genetics and dysmorphology (malformations). The region has no board certified specialist in child abuse.
So we have not overbuilt… we have just started. Without a children’s hospital, these advances will not occur. They were not part of the vision of the children’s hospitals within general hospitals at either UMC or Providence that preceded EPCH.
We are only a few feet from the start of the path.
Respectfully Yours,
Brad Fuhrman, M.D.
Physician-in-Chief
El Paso Children’s Hospital
