Urgent care center opens

PRINCEVILLE — A new urgent care clinic has opened in Princeville, bringing medical resources to the North Shore that community leaders have sought for nearly a decade to counter the risks and inconvenience of long drives to the hospital or calling 911 for an ambulance that might not arrive for 30 to 60 minutes.

The clinic also models an approach to urgent care service delivery never before attempted in the United States and intended to join the resources of a sophisticated, university-affiliated emergency medicine and trauma center with the needs of a rural island community in the middle of the Pacific Ocean.

The affiliated Mainland medical center is at the University of Utah in Salt Lake City, and has recruited a team of at least 15 experienced emergency physicians and more than 20 nurses, nurse practitioners and other support personnel. They will fly to Kauai for periods of two to three weeks, during which they’ll staff the new Makana North Shore Urgent Care center on an around-the-clock basis.

The medical staff will be housed in two condo-like apartments on the second floor of the newly constructed clinic building in Princeville at the intersection of Kuhio Highway and Hanalei Plantation Road. It is just behind the existing joint station housing the Kauai Police Department and Kauai Fire Department — a location chosen to round out the public safety services already located there.

The clinic, which is organized as a nonprofit corporation and accepts charitable gifts and grants, also constructed a house a couple of blocks away. Between them, the two locations will provide lodging for enough doctors and nurses to cover the clinic round the clock, though service during nighttime hours will require patients to activate a doorbell so one of the medical personnel staying at the clinic can respond quickly to provide care.

The new facility can offer immediate treatment of illness and minor injuries and will be able to stabilize patients with more serious problems before sending them to Lihue by ambulance. It is equipped with X-ray and laboratory facilities not found elsewhere on the island north of Kapaa. A Kilauea-based pharmacy will open a second location inside the new clinic.

“This is the single most important achievement on Kauai’s North Shore since we have lived here, for nearly 10 years,” said Ken Rosenthal, a Princeville resident who is a board member of the Kauai North Shore Community Foundation (KNSCF) and chairs its annual Ohana FitFest, a family-oriented health promotion event that will take place on the WaiKoa Loop Trail on Oct. 6.

“The need for 24/7 urgent care was so dramatic because of the thousands of people who visit the North Shore daily, as well as local residents,” he said.

Mary Paterson, another board member of KNSCF — which helped raise money to construct the urgent care center — called the development “amazing.”

“There has been a huge need for urgent care for many years,” she said.

Hanalei resident Makaala Kaaumoana, executive director of the Hanalei Watershed Hui and a founding board member of the new urgent care center, said “Makana offers specific emergent care experience and doctors with trauma expertise. It’s a level of care that we haven’t had on the North Shore.”

The new clinic is operating under a concept originated by Dr. Edward Kimball, a University of Utah Medical Center associate professor of surgery and emergency medicine who is also co-director of the university’s surgical intensive care unit. The arrangement grew out of the fact that Kimball and his family have been vacation visitors to Kauai at least twice a year for nearly 44 years, he said. Kimball is the Makana facility’s medical director.

The challenge any rural, isolated community faces in attracting high-quality, urgent-care services is that the island’s small population and limited hospital resources make it difficult for doctors most qualified to deliver such services to reside and work on island full time.

Kimball’s motivation was at least in part personal.

“I almost drowned once in Hanalei Bay,” he recalled.

And when he was 14, he had a close call with a tiger shark off Hanalei. Even at that age, he said, he concluded that “urgent care was just not available up here.”

More than five years ago, Kimball said, a group of North Shore residents asked him to help resolve the problem of urgent care availability. The concept of such a clinic in the Princeville area had been considered often, but deeper financial analysis had questioned its business viability.

That’s where Kimball and the community foundation hit upon the nonprofit model relying on medical professionals willing to come to Kauai for two or three weeks at a time — with their families if they want. This doesn’t mean these doctors and medical professionals will be on vacation, but they will be able to enjoy island attractions in their off hours. They will receive fees far lower than if they were in their home communities.

Jenny Colarusso, a trauma care nurse who also runs emergency tele-medicine services for rural communities in Utah and elsewhere, came over for the clinic’s first weeks of operations. She brought two teenage sons who apparently did not need to be convinced to come to Kauai.

It wasn’t Kauai that attracted her, though, Colarusso said. It was the opportunity for professionals with some of the most up-to-date training in the country to apply their skills in a rural setting.

“We will be using cutting-edge protocols,” Colarusso said in a brief interview before she went off to find her sons so she could return to the clinic and work the night shift.

Kimball recruited other doctors, nurses and health workers and began a protracted process of getting the zoning and other approvals necessary, and finding the funding. Eventually, the U.S. Department of Agriculture made a low-interest loan to the clinic on the grounds that it is intended to serve people in a rural, agricultural area.

The community foundation and other private donors made up the difference.

While community members in Hanalei, Princeville and Kilauea said they welcome the new center, the clinic has raised concerns from a family medicine group practice, the Kauai Community Health Alliance, which operates as Hale Lea Medicine and Urgent Care. Its medical staff includes three physicians, two allied health support professionals and a physical therapist.

Hale Lea’s website lists family medicine and urgent care services between 8 a.m. and 7 p.m. Monday through Friday and from 9 a.m. to 5 p.m. on Saturday and Sunday. Patients arriving without an appointment are seen based on their medical conditions and when openings occur in the clinic’s normal schedule. It is not open during nighttime hours and, while it has automated laboratory equipment, it lacks the capability to do X-rays. Without that, determining whether an ankle is sprained or fractured might be difficult and X-rays on the spot can often rule out unnecessary trips to a hospital emergency room.

On the North Shore, ambulance dispatch delays are common and the drive to Wilcox Medical Center can take more than an hour. If a patient resides in Wainiha or Haena, the time can be far longer. Some patients, Kimball said, are so disheartened by the travel time that they stay home and risk having their conditions worsen.

The Kilauea clinic’s resistance has been strong. One of the staff suggested that the new Makana facility will engage in “patient stealing” and that its services are unneeded and threaten the livelihoods of existing medical practices on the North Shore.

Assessing Hale Lea Medicine’s vulnerability to competition from the new clinic is difficult. The Hale Lea operation is also operated by a nonprofit organization and, accordingly, is required to file tax returns that are public record. The tax returns showed the clinic had total revenue of just over $2 million in 2016, up from just below $1.7 million in 2015.

The Kauai Community Health Alliance — the 501(c)3 organization that runs Hale Lea Medicine — paid James Winkler, a physician’s assistant who serves as its president, more than $285,000 in 2016, and nearly $262,000 to Dr. James Rogoff, a family practitioner who also works part time at an emergency room on Molokai. Winkler leveled the charge that the new Makana clinic would engage in the equivalent of “patient stealing.”

In an interview, Winkler said the doctors’ opposition was not simply economic.

“It’s really about the community,” he said, “and what is best for this community.”

He said the development of the new clinic “was done very disingenuously.” He said his clinic has “always offered urgent care,” but that such care is not always effective in dire emergencies that require immediate hospitalization and might suffer from delays in ambulance dispatching.

“We’ve never had a bad outcome in 25 years,” he said. “Because we’re here in the community, we’ve always left holes in our schedules for walk-in urgent patients. But now, this knight on a white horse comes walking in.”

He said he and his colleagues objected, in particular, to a zoning variance that allowed for construction of the two apartments on the top floor of the clinic, arguing they provide the Makana clinic with an unfair financial advantage.

He contended that his clinic’s urgent care operation doesn’t have an X-ray machine because he said it isn’t needed. However, the American Academy of Urgent Care Medicine lists on-site radiology capability as an essential ingredient of any urgent care facility.

Several long-time Kilauea residents said that, though they know the doctors at the Hale Lea clinic, the community is largely unaware there is a controversy over the new Makana operation.

Nationally recognized emergency medicine experts did not agree with Winkler’s analysis.

Dr. Mark Reiter, a University of Tennessee medical professor and past president of the American Academy of Emergency Medicine, said that while he wasn’t aware of Kimball’s approach of flying in experienced emergency personnel for brief periods, he found it intriguing.

“Emergency medicine training offers an excellent background for urgent care,” Reiter said. “Emergency physicians are adept at identifying those patients who are significantly sicker than they appear. They are comfortable caring for patients of all ages, with medical and surgical complaints, OB/GYN issues, and performing procedures that are often required.”

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Allan Parachini is a journalist and a former public relations executive. He is a Kilauea resident.