TALLAHASSEE — After a gunman opened fire inside the Pulse nightclub last summer, the most seriously injured victims were rushed a half-mile to Orlando Regional Medical Center.
There, doctors and nurses in Florida's busiest trauma center sprang into action, treating nearly four dozen patients from the nation's deadliest mass shooting. They had practiced repeatedly for such an occasion.
"Trauma care is something that you don't really pay attention to until you need it," said Dr. Michael Cheatham, a surgeon who was working in the hospital that morning.
Politicians in Tallahassee are paying attention. Republicans are pushing to make it easier for more trauma centers to open, particularly in rural areas, by lifting caps on their number in each part of the state.
They say they want to make the highest level of care available to more Florida residents.
"The bottom line is we need more trauma centers," said state Rep. Jay Trumbull, R-Panama City. "Really what we are trying to focus on is to make sure that we have greater access for people."
But many trauma doctors, including some who treated the Pulse shooting victims, say that's a bad idea. They say caps on the number of trauma centers ensure each is filled with highly trained specialists, in densely populated areas where they get plenty of practice treating everything from bullet wounds to car crash injuries.
Critical lawmakers say Republicans are trying to fix something that already works.
"Our system is well-regarded across the nation," said state Rep. Nick Duran, D-Miami. "So it is difficult for me to understand the reason why we need to bulldoze it."
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State law caps the number of trauma centers at 44. The Department of Health decides how many each community needs based on factors including population and the number of trauma cases each year.
Ten are designated Level One, such as the ones at Orlando Regional, Tampa General Hospital and Miami's Jackson Memorial Hospital. They are located in mostly major cities and equipped to handle the toughest cases and biggest disasters.
Legislation filed by Trumbull (HB 1077) to end the caps is gaining steam in the Florida House. It instead would allow the state to designate trauma centers at hospitals that have been certified by national organizations such as the American College of Surgeons.
The bill is set for a vote by the chamber's health care budget subcommittee today, though a similar measure in the Senate has not had a single hearing.
Trumbull's proposal does have support from Gov. Rick Scott, a former hospital executive, who in January identified deregulating trauma centers as one of his top health care priorities for the year.
"I want to get rid of the cap on trauma centers," he said. "I want to let the private sector figure out what we should do there."
This is part of a broader push to make health care more like a free market and represents an unusual agreement between the often-feuding Scott and House Speaker Richard Corcoran, R-Land O'Lakes.
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Trauma center doctors argue that trauma care does not work like the free market. People who have suffered a serious injury don't have time to shop around. They need high-quality treatment and they need it quickly, generally within one hour of being injured.
Central to meeting both of those goals is ensuring trauma doctors treat a large number of patients each year, said Dr. Gary Parrish, who also was working at Orlando Regional Medical Center the night of the Pulse shooting.
The more frequently doctors do something, the better they get at it, said Parrish, who has visited Tallahassee with Cheatham and other trauma doctors to lobby lawmakers against the bill.
"What happens if you or I is involved in a motor vehicle crash and we get taken to a hospital that doesn't have the experience?" Cheatham said. "Our survival will drop because we're not receiving the care that we need."
Further, it is expensive to fully staff a trauma center 24 hours every day. The hard math means they rely financially on treating a steady stream of patients, which is generally possible in larger cities.
"If (Pulse) had occurred next to a smaller hospital that doesn't do trauma, perhaps even one or two gunshot wounds would've totally overwhelmed the emergency room," Cheatham said. "They're not prepared, they're not trained, they're not equipped, they're not staffed."
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Because trauma centers are so expensive, Trumbull says he doesn't worry about too many of them opening up "on every single corner in somebody's neighborhood."
But he does think the state needs to find ways to encourage more of them to open.
"Here's the reality," he said. "We have not done anything significant to this law since the early '90s, and the state looks totally different than it did then."
When hospitals try to open new trauma centers, they often end up delayed or blocked by lawsuits from existing centers.
As a contrast, Trumbull points to New York City, which at a third of the population has nine Level One trauma centers to Florida's 10.
"We are doing Floridians a disservice by not looking at this law and trying to figure out a way to increase access to care," he said.
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At Orlando Regional, the staff does drills to prepare for the worst tragedies that could fill its halls with patients. They simulate mass shootings, major car accidents, acts of terrorism, violent hurricanes.
Pulse didn't even scratch the surface of what they're capable of treating, Cheatham said. They prepare for incidents with hundreds of victims.
Instead of allowing for new trauma centers, particularly in areas that already have them, he thinks the state should focus on ensuring existing ones are as good as they could possibly be and are fully staffed with high-quality doctors.
"It just makes more sense to use our health care dollars efficiently and have trauma focused in places that are going to be able to not only have the appropriate resources and be financially viable, but at the same time be able to provide a high quality of care," Cheatham said.
Contact Michael Auslen at firstname.lastname@example.org. Follow @MichaelAuslen.