A kitchen knife sliced through the skin, arteries, tendons and nerves of the second knuckle of the four fingers of Christian Dietrich's right hand.
An urgent care center near his Ahwatukee Foothills home sent him via ambulance to the nearest hospital with a hand surgeon available, Scottsdale Healthcare Osborn — 17 miles away.
Dietrich, 34, a salesman for Frito Lay, waited six hours before he went into surgery, lying on a gurney while emergency room staff called the Valley's hand surgeons, begging them to treat his hand, he said.
"It was a little nerve-racking," Dietrich said. "I didn't know if they were going to find anyone."
Some local experts say such scenarios are becoming more common: Patients in need of the intricate skills of a hand surgeon travel many miles and wait many hours for treatment. Even fewer hand surgeons are available for emergency care after Scottsdale Healthcare Shea hospital scrapped its hand surgeon call schedule May 1.
The problem is not a shortage of hand surgeons, most experts agree, but an ailing national health care system. Soaring malpractice insurance, high rates of uninsured patients and poor insurance reimbursement mean that neither hand surgeons nor the hospitals that staff them cannot afford to perform such procedures.
As a result, only a handful of Valley hand surgeons are willing to commit to being on call, and only two hospitals in the state have a hand surgeon call schedule, meaning at least one such specialist is available at all times to care for hand emergencies, said Dr. Todd Taylor, vice president of the Arizona College of Emergency Physicians.
Mayo Clinic Hospital in Phoenix is an anomaly. The hospital has no trauma center, and its emergency room hand call is manned by doctors employed by the hospital, not private practice physicians.
Dr. Marc Malek is one of four hand surgeons who take trauma calls at Scottsdale Healthcare Osborn hospital, and one of five who do at St. Joseph's Hospital and Medical Center in Phoenix.
Every other week the Scottsdale hand and plastic surgeon makes himself available for a seven-day, around-the-clock shift. During this time Malek said he performs between 25 and 35 hand procedures, from cleaning glass shards out of the hand of a drunken patient who punched a window to reattaching a severed arm.
Not only is he called to care for patients at the hospital for which he is on call, Malek receives calls from hospitals around the Valley and state that don't have hand surgeons on call.
Most of the emergency work Malek does is donated. Many hand surgery patients do not have insurance, but the attending physician must provide extensive follow-up office visits and paperwork, both of which interfere with his private practice.
Despite what he feels is an obligation to use his skills for public good, Malek is considering dropping being on call, especially when he knows that performing a face lift will earn him $10,000.
Hand surgeons have long petitioned hospitals to pay them for being on call for traumas, just as hospitals do for specialists such as orthopedic and ocular plastic surgeons. Hand surgeons asked St. Joseph's administrators 18 months ago for a call stipend, which they did not receive. Banner Good Samaritan Medical Center in Phoenix, which has a trauma center, is negotiating with insurers and specialists of all kinds to ensure doctors are getting reimbursed a fair amount, said Susan Edwards, president of Arizona region of Banner Health. And hand surgeons are currently negotiating with administrators at Scottsdale Healthcare for a stipend for being on call.
Dr. James Burke, Scottsdale Healthcare’s chief medical officer, said that paying hand surgeons to be on call takes money from other parts of the hospital.
Hospitals “have to balance some of the good reimbursement from some of not-so-good reimbursement,” Burke said. "It would be our hope that physicians in the community would take the same approach."
This argument won't persuade Dr. Douglas Bobb to return to hand trauma surgery. Several years ago, trauma cases made up 40 percent of his practice; today, they make up 5 percent.
When Bobb's malpractice insurance premiums soared from $25,000 to $175,000 in three years, he asked his insurance company what he could do to reduce his rates.
Bobb stopped being on call for hand trauma surgery and sticks to routine operations such as those for carpal tunnel syndrome and tendinitis. Today Bobb works strictly out of an outpatient surgery center and refuses most patients who could possibly be a high-risk case — and find a reason to sue him, he said.
"The general public is finally getting what they're asking for," Bobb said of the Valley's hand surgeon predicament. "If we can't get a perfect outcome, the public is disappointed and hires a lawyer."
Taylor said that hand surgery is just one example of how the free-market health care system is failing. Other specialists are in short supply.
"With hand surgery, it's inconvenient," Taylor said. "With neurosurgery it's a matter of life and death."