MIAMI -- Omar Bickel forgot to look both ways when crossing the street the other day, and he never saw the van coming. The 6-year-old boy was rushed by ambulance, bleeding and in agony, to the nearest hospital, a block from his house in North Miami Beach.
But when paramedics wheeled the boy into the emergency room, they were turned away -- no doctors were there to treat him. The ambulance was forced to travel another 35 minutes -- past at least seven other hospitals -- to get him to Jackson Memorial Hospital, the only place in Dade County now accepting trauma victims.
"This time the kid is going to live," said Lt. John Romano, one of the paramedics. "But will the next one be as lucky? I don't really know who to blame, but if this crisis doesn't end soon, it's going to start killing people."
Already besieged by malpractice insurance costs that are among the highest in the nation, many doctors in the Miami area have decided they can no longer accept the burden of the insurance premiums or the risk of malpractice suits for performing emergency room surgery. Since July 1 when the St. Paul Fire and Marine Insurance Co., the largest insurer of Florida doctors, raised rates 43 percent in Dade and Broward counties, more than 1,000 specialists have refused to work in emergency rooms in the two counties, according to Richard Glatzer, president of the Dade County Medical Association. The shortage has forced most of the region's 57 hospitals to shut their doors to emergency patients.
As huge jury awards become more frequent and malpractice suits turn into a common part of medical life, soaring malpractice insurance premiums -- particularly in high-risk specialties such as obstetrics and neurosurgery -- have become a major issue in medicine. Led by California, several states have limited the amount of damages that juries can award.
But in Florida, with a surplus of both doctors and lawyers, the crisis has resisted every attempt at resolution. Last year, the state Supreme Court ruled unconstitutional a law limiting jury awards for pain and suffering to $450,000.
"The lawyers and doctors are out of control, and so is the legislature," said William G. Stafford, executive vice president of the Broward County Medical Association, where only three of 17 emergency rooms are taking all patients. "This is a situation that has been getting worse for years. We have a couple of places serving the needs of 3 1/2 million people. We are in line for some serious trouble."
Few in the Miami area would disagree with his assessment. A growing number of doctors simply "go bare" -- they refuse to carry insurance that costs up to $200,000 a year. Public officials have asked that people drive only if they have to. Gov. Bob Martinez has called a special session of the legislature for September. But so far, the rhetoric seems to have drowned out any attempt at a sensible solution.
Doctors blame the problem on greedy lawyers who are "suit happy." Lawyers say they are only after incompetent doctors who destroy lives. And almost everyone blames the insurance companies, who are either pulling out of the state or raising rates to cope with the surge in claims.
"The policies ought to be X-rated, because the premiums are obscene," said state Rep. Art Simon, who has led the search for a legislative solution to Florida's malpractice problems. "But this whole thing is really a bottom-line issue. Everybody tries to cloak their monetary concerns with sanctimonious talk about the public. Well, the public is the biggest loser by far."
Glatzer called the problem "a total catastrophe -- and it will get worse. So far, people have been largely inconvenienced, but we have been lucky. The hospitals that are working can't handle their usual loads." During the July 4th weekend, two people died after taking long ambulance trips to hospitals, but state medical officials said the delays in obtaining treatment were not factors in their deaths.
Million-dollar malpractice judgments have become common in southern Florida, and the average jury award in Dade County last year was almost $250,000. According to the Dade County Medical Association, 86 percent of the state's neurosurgeons were sued in 1986. It is difficult to watch television here for more than 30 minutes without seeing at least one lawyer reminding potential customers of their rights to sue doctors.
"There is an element of blackmail with lawyers trying to shake down doctors," said J.B. Spence, a prominent Miami attorney whose walls are covered with newspaper stories about his many million-dollar victories. "But we also have some very bad doctors, and I absolutely love to sue them. They are arrogant and they are selfish."
Fed up with the whole mess, the St. Paul insurance company has announced it will leave Florida completely at the end of the year. Company officials say they are receiving 32 claims for every 100 insured doctors in Dade and Broward counties, nearly twice the national average, and they say they can no longer make money in the market.
Doctors say they do not oppose damages for real malpractice. They add, however, that many physicians are sued for complications over which they had no control and that insurance companies settle rather than risk confronting a jury.
"It's gotten to the point where I get the jitters when I go into surgery, because I know that even if a patient turns out well, there is going to be a lawyer looking at the chart the next day," said Dr. Frederick Gottlieb, a urologist at Broward's Memorial Hospital.
Beyond the hyperbole and fear, many say the crisis has been caused by the changing nature of medicine and the unique demographics of the region.
Many physicians in the area mostly serve Medicare patients, and the federal government strictly regulates what they can charge. Doctors, like others in business, try to pass on increased costs to customers, but in Florida, with so many Medicare patients, they are prohibitted from passing on the rising costs of insurance.
"The focus of medical care has moved away from the patient," said Dr. Bernard Elser, director of emergency services at Jackson Memorial Hospital, Dade County's largest hospital and one of the busiest in the country. "They come and they go and nobody knows a thing about them."
He and others suggested it is easier for patients to sue a doctor they don't know than one with which they have an established relationship. And medical technology has raised expectations to heights that some feel are unreasonable.
"It's getting to the point where if you have a baby and he doesn't have an IQ of 140, you want to sue the doctor for malpractice," said Dr. Richard Dellerson, chief of emergency services for southern Broward County. Many officials have suggested that the state force all doctors to carry insurance, thus creating a larger pool. But the Florida Medical Association opposes any pool concept because it would mean that low risk doctors from most of the state's 67 counties would subsidize a minority of surgeons in big cities.
"Florida has finally come to the ultimate truth on malpractice," said the legislature's Simon. "Everyone agrees we need to help doctors work without fear of losing their savings. Well, we can do it two ways: We can dramatically limit the cost of damages, or we can share the risk over a much broader pool in society. So far, nobody seems really willing to do either."