Emergency rooms find on-call specialists rare

[gasnewby]

http://www.msnbc.msn.com/id/22335941/

check out how the plastics attending refused to see the patient.

i have to say- once i was consulted for a cold hand, during the day, and couldn't get any of the vascular surgeons to see him. i couldn't reach the on-call guy, and the person i did reach, who was not on call, didn't want to see him. i don't think he was in-house, so i can't really blame him. this was while rotating at a community hospital. i had to transfer him to my home institution. i really wanted to tell him "if you lose your hand..." we started him on a heparin gtt and he ended up being ok. but it took hours for the transfer and was a ridiculous situation. but this was the only problem i've ever had. what about you guys?

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[Celiac Plexus]

It's inevitable. That the public is starting to feel the crunch is not necessarily a bad thing from a systems standpoint. Major change in the way our system delivers care is patient-driven. But patients need to know what the problems are. That ERs have had coverage issues is not a new story. This has been going on for years. Only now the public is taking notice because the situation is worsening.

Perhaps it's my bias as a surgery resident, but I felt the article emphasized the notions that physicians were "unwilling" to cover ER call because of lifestyle and reimbursement issues. There was mention of malpractice liability fears but I felt that was underemphasized. We (physicians) have to be careful that this worsening problem doesn't get attributed to the whole benz-driving, greedy, physician stereotype.

 

[Castro Viejo]

We (physicians) have to be careful that this worsening problem doesn't get attributed to the whole benz-driving, greedy, physician stereotype.

Hard to break that when one of the most popular "medical shows" on television is about some ***** cosmetic surgeon and his (and partner's) lavish lifestyles.

What a schmuck he is... He's the reason I despise PRS a bit.

Anyway, while I think malpractice is an important issue to emphasize as well, I don't think we should be shy about discussing issues related to our lifestyle and reimbursement. It's bullcrap to pretend that any human being would want to work 130+ hours a week to get paid the same as the head cook in the hospital cafeteria. And to get sued to boot? Get the hell outta here.

If the public is unwilling to deal with the fact that physicians have feelings too, **** them. They don't seem to mind the CEO making hundreds of millions of dollars or savage Wall Street traders making tens of millions doing NOTHING MORE than gambling with other people's money.

 

[Playmakur42]

Just a med student here, but I've seen a frustrating case. A man came in to the local community hospital with an AAA that was apparently slowly leaking. The vascular surgeon in town was away, so they were unable to locate a surgeon to do the repair. There aren't any other vascular guys locally since the malpractice insurance costs have driven them to practice elsewhere. There were available general surgeons, but none of them would touch him due to fear of a malpractice suit. The guy died before he could be transported elsewhere.

Frustrating, but cases like this should be publicized to educate the public on the reality of the situation.

Would a GS who did some AAA repairs in residency, but doesn't do them in his practice have a decent shot at repairing this properly?
Is there any way to get a waiver that would allow a GS to perform the operation based on the dire circumstances & protect him from a malpractice suit (I'm guessing not)?

 

[Castro Viejo]

Would a GS who did some AAA repairs in residency, but doesn't do them in his practice have a decent shot at repairing this properly?
Is there any way to get a waiver that would allow a GS to perform the operation based on the dire circumstances & protect him from a malpractice suit (I'm guessing not)?

No, there's no waiver. If you cut, you're liable. So if you don't think you're qualified, don't cut. Then there are issues with whether or not your malpractice carrier is going to cover you... I dunno. Surgeons are billed by their malpractice carriers for operations they perform. So if a General Surgeon adds something like "AAA repair," then he's gonna pay a higher premium. I don't know exactly how this works out in the emergency setting, meaning as in the patient described, if the General Surgeon doesn't usually do these, and doesn't pay a premium that would allow him to, if he does it anyway, will he be covered?

A General or Vascular Surgeon would have a fairly decent shot at repairing the ruptured AAA but the mortality is 50% and no one's gonna think you're a hero even if the guy makes it out alive. 'Cause he'll probably have anoxic brain injury and be in a persistent vegetative state or have some other neurological sequelae, infarct his gut (requiring a laparotomy), and be a nursing home gome for years to come. Then they'll come back and sue you for making their dad, "who was in PERFECT health doc! I mean, yeah he's like 400 pounds, but that's mostly muscle!" a vegetable.

Nice world, huh?

 

[Tired]

What a schmuck he is... He's the reason I despise PRS a bit.

He did nothing wrong. Being on-call means being available to see and evaluate emergency cases. There is no responsibility to see every minor followup the ER decides to turf to you. This patient had a condition that the physician didn't want to treat, and that was absolutely his right. And who needs a Plastic Surgeon to treat a fricking leg wound anyway?

 

[Castro Viejo]

He did nothing wrong. Being on-call means being available to see and evaluate emergency cases. There is no responsibility to see every minor followup the ER decides to turf to you. This patient had a condition that the physician didn't want to treat, and that was absolutely his right. And who needs a Plastic Surgeon to treat a fricking leg wound anyway?

I was actually talking about Roberto Rey. The PRS in the article is A-OK with me.

 

[Tired]

I was actually talking about Roberto Rey. The PRS in the article is A-OK with me.

Oops, sorry, misunderstood you there.

As a side note, the article was a perfect example of why patients should never be allowed to refer themselves to specialists.

 

[Castro Viejo]

Oops, sorry, misunderstood you there.

As a side note, the article was a perfect example of why patients should never be allowed to refer themselves to specialists.

Or why ER docs shouldn't be allowed to call themselves "Doctor." "Triage Nurse" maybe but certainly not "Doctor."

 

[gasnewby]

i didn't get that she referred herself to a plastic surgeon. maybe i missed that.

and i think it IS the responsibility for the surgeon on call to see patients. this lady probably had thin skin and when she fell, maybe she had a lot of tissue loss. that's an appropriate consult, i think. maybe she needs a vac, maybe she needs a flap, who the hell knows. but difficult wounds that need coverage are more appropriately sent to plastics, not general surg.

 

[Tired]

i didn't get that she referred herself to a plastic surgeon. maybe i missed that.

and i think it IS the responsibility for the surgeon on call to see patients. this lady probably had thin skin and when she fell, maybe she had a lot of tissue loss. that's an appropriate consult, i think. maybe she needs a vac, maybe she needs a flap, who the hell knows. but difficult wounds that need coverage are more appropriately sent to plastics, not general surg.

Okay yeah, she didn't refer herself apparently.

But no, this doesn't need an initial Plastics consult, it needs General Surgery evaluation. If it needs a flap, it will need it down the road, not the night of (or even in the first few days after) injury. If there were exposed bone or tendon, or if the wound were really that bad, the patient would have been admitted, not sent home. Gen Surg is perfectly capable of managing a wound vac.

Also, methinks with his last post the reign of "Dr. Viejo - Advisor" is coming to an end.

 

[blotto geltaco]

Also, methinks with his last post the reign of "Dr. Viejo - Advisor" is coming to an end.

lol, the turtle has no fear. That comment is guaranteed to set off another round of whining from the EM folk how they are the whipping post of SDN.

 

[Tired]

lol, the turtle has no fear. That comment is guaranteed to set off another round of whining from the EM folk how they are the whipping post of SDN.

My next thread will be entitled:

"Nursing vs EM: Who's the bigger martyr?"

 

[Dr JPH]

"tearing large chunks of flesh from one leg"

Sounds like the family was embellishing just a bit, eh?

I wish we could have more faith in the ER. I got called for a surgical consult the other day for a 84 year old female with a "GI Bleed". Turns out she was heme Neg with a hemorrhoid. Nice physical exam by the ER "doctor." Despite my consult, he still contacted the hospitalist to have the patient admitted...which she was...and promptly discharged the next morning by the medicine attending.

Anyway, I cant imagine what sort of formal closure this lady might have needed, but I can bet you the ER waited several hours before bringing the lady in from triage...then a few more hours of sitting in the back...then they likely drew blood cultures (they love blood cultures)...then maybe the ER doc irrigated the wound before realizing the PA was too busy to suture...then he decided to call Plastics.

 

[ESU_MD]

the oncall crisis is largely due to the ER guys calling nonsense consults for things they should do themselves- like close lacs, set basic fractures, etc..
The lady in the article probably had a lac I would let my PA student close alone, but the ER guys talked her into wanting a plastic surgeon to lessen their workload

The ER guys are really the ones who want the "lifestyle" of coming in for a shift and never following anything up- like all those blood cultures.

Maybe specialists wouldn't mind coming to the ER if the providers there actually did a workup and werent looking to "dispo" patients.

 

[gasnewby]

Or why ER docs shouldn't be allowed to call themselves "Doctor." "Triage Nurse" maybe but certainly not "Doctor."

if the wound were really that bad, the patient would have been admitted, not sent home.

she went home? sorry, missed that.

 

[Castro Viejo]

lol, the turtle has no fear. That comment is guaranteed to set off another round of whining from the EM folk how they are the whipping post of SDN.

Whipping post? Please... Let's not insult the whipping posts.

They've got an IQ equivalent to a Pamela Anderson's left breast.

 

[sleeping]

Whipping post? Please... Let's not insult the whipping posts.

They've got an IQ equivalent to a Pamela Anderson's left breast.

Please lets not insult Pamela's left breast.

 

[thusell]

This thread's actual title should be: CRISIS IN MEDICINE, EMERGENCY ROOM PHYSICIANS DISCOVER THAT THEIR TELEPHONES CANNOT REACH REAL PHYSICIANS.

 

[DoctorMunchkin]

This thread's actual title should be: CRISIS IN MEDICINE, EMERGENCY ROOM PHYSICIANS DISCOVER THAT THEIR TELEPHONES CANNOT REACH REAL PHYSICIANS.

 

[gida]

c'mon people....let's call a Spade a Spade....

An "ER" doc is a glorified triage nurse. Really, it is.

 

[Kubed]

Please lets not insult Pamela's left breast.

 

[droliver]

This patient actually had a real & significant injury. She actually started a website documenting her experience and you can see pictures. Click here to see. Now it wasn't a Gustillo III open tib-fib fracture requiring a free-flap, but it wasn't something you'd get away with anything less then a skin graft.

I wrote about this on my blog Plastic Surgery 101

The doctor on call in this case makes the ridiculous argument that she, as a plastic surgeon, was unqualified to at least even evaluate the wound as she only practices cosmetic surgery. Her side of the story is quoted in an article in the AZ Star here and makes her come off even worseto me. If this doctor wants to maintain staff privileges at that hospital, she'll have to be able to start treatment for a straight forward wound like that in the ER. In an admitted patient she'd have the luxury of deferring the consult.

 

[labst]

I'm reading the article now. First of all, the ER physician quoted is hilarious. Some good quotes: "...the system is broken ...You can no longer rely on the ER to save your life." LOL. "Our job, as ER doctors, is to keep you alive long enough to get you to the specialty care you need." How thrilling. It then goes on to state that it's so bad that ER physicians are being forced to "treat patients I had no business treating." Yeah, but who does the ER have any business treating? Almost nobody who is actually ill. So what's the point? Triage. But if you say that, then it's a grave insult. Finally, the fact that most plastic surgeons in that area are only doing cosmetic procedures is no shock. I'm not a plastic surgeon, but I'm fairly certain that plastics -- although difficult to get established in -- is a cash cow once you have done so. Why are people shocked that physicians are going to do what pays? Also, why is this wealthy, well-insured woman having trouble finding any care for a "grave injury"? If someone has an open fracture in Arizona they just die or something?

 

[Tired]

This patient actually had a real & significant injury. She actually started a website documenting her experience and you can see pictures. Click here to see. Now it wasn't a Gustillo III open tib-fib fracture requiring a free-flap, but it wasn't something you'd get away with anything less then a skin graft.

So what? Lots of people have "real and significant" injuries, but that doesn't mean that they require initial specialty treatment in an emergency room. Any jacka$$ ED doc can put on a dressing (or more likely ask a nurse to do it). The patient can follow up. This was not an emergency requiring urgent intervention by a specialist.

The fact that the ED doc 'really really wanted to arrange followup' does not mean that the on-call person was required to see her in clinic. It's called the Yellow Pages, let the patient's fingers do the walking.

 

[labst]

The article is pretty funny. This particular physician says that she didn't feel qualified to deal with the wound, she had devoted her practice to cosmetic surgery, she didn't want to "own" the wound, and that most such wounds are in indigent (and in AZ, illegal) people who are uninsured and pay poorly. And YET, the conclusion is that she should have seen the patient anyways? Why? Those sound like pretty good reasons to me. Like I said, if you don't want to pay people to do stuff like this, then how can you be shocked that they won't do it? Are they supposed to do it for "the common good"? Why? Do other people do their jobs for the common good? I'm just as satisfied with this case as I am with the case where there was no tort reform, so all the trauma surgeons left town. Suddenly, there was tort reform! (It was in Las Vegas, I believe.)

 

[labst]

I like how the plastic surgeon, at the end, "guiltily admits that 'we're wasting the time of the ER physicians'." And then the ER physicians go, "AMEN." Um, what? What happened, you got too used to residency, where you can just make a phone call and everyone has to run downstairs or get in trouble? Not used to people saying "no" to you? Now you're going to cry because you have to "call other people"? Wow.

 

[toofache32]

Since when does a plastic surgeon have to treat this wound? The general surgeons at my institution do most of the skin grafting and they would be all over it.

 

[droliver]

So what? Lots of people have "real and significant" injuries, but that doesn't mean that they require initial specialty treatment in an emergency room. Any jacka$$ ED doc can put on a dressing (or more likely ask a nurse to do it). The patient can follow up. This was not an emergency requiring urgent intervention by a specialist.

A few things:

1) by having staff privileges, the Doctor in question has likely agreed to be available for this under the privledges and duties that go along with Plastic Surgery under the bylaws of that institution. Refusing to see the patient (if asked by an ED physician) is an EMTLA violation which carries significant potential fines for the doctor and hospital.

2) This patient's avulsed skin flap needed to be assessed for salvage. In fairness to this surgeon, it's possible the wound may not have been described accurately by the ED. (I had a scenario like this last week that I was asked to see BTW.)

3) I'm no apologist for the ER, but this was a fumble that's brought with it a lot of negative attention to both that hospital and the plastic surgeon involved. I appreciate the dilemma of the doctor on call, but she should have seen this patient for this particular problem.

4) This was an entirely appropriate urgent consult by the ED for a Plastic Surgeon, Orthopedist, or general surgeon

 

[SLUser11]

Or why ER docs shouldn't be allowed to call themselves "Doctor." "Triage Nurse" maybe but certainly not "Doctor."

My next thread will be entitled:

"Nursing vs EM: Who's the bigger martyr?"

the oncall crisis is largely due to the ER guys calling nonsense consults for things they should do themselves- like close lacs, set basic fractures, etc..
The lady in the article probably had a lac I would let my PA student close alone, but the ER guys talked her into wanting a plastic surgeon to lessen their workload

The ER guys are really the ones who want the "lifestyle" of coming in for a shift and never following anything up- like all those blood cultures.

Maybe specialists wouldn't mind coming to the ER if the providers there actually did a workup and werent looking to "dispo" patients.

Whipping post? Please... Let's not insult the whipping posts.

They've got an IQ equivalent to a Pamela Anderson's left breast.

c'mon people....let's call a Spade a Spade....

An "ER" doc is a glorified triage nurse. Really, it is.

I like how the plastic surgeon, at the end, "guiltily admits that 'we're wasting the time of the ER physicians'." And then the ER physicians go, "AMEN." Um, what? What happened, you got too used to residency, where you can just make a phone call and everyone has to run downstairs or get in trouble? Not used to people saying "no" to you? Now you're going to cry because you have to "call other people"? Wow.

The amount of ER hate in here is ridiculous. We even have the GI fellow joining in.

I did a month of ER as a fourth year med student, by which time I'd already had a full 14 months of hearing from all specialties how incompetent and lazy the ER docs were, and how most of their consults were B.S., so I was getting ready to do the same. During that month, I saw almost no true B.S. consults, but plenty of whiney consultants.

How many of you have done some time working in the ER? I'm sure some of you have, but not all. I think it should be a med school requirement, as it provides some much-needed perspective for soon-to-be doctors. When someone comes in with chest pain and it's your @ss if they go home and die of an MI, you might be dragging some residents out of bed at 3am to admit what appears to the partially-trained resident eye as a bulls@#t consult.

As for closing lacs, etc....a lot of ER docs look forward to these, as they dreamed in med school of a career with a controlled lifestyle and still some procedures......but the VOLUME of patients they see often prohibits this, and they're forced to triage away things they'd rather do themselves.

Whining about the ER is fine, and is somewhat related to the severity of your vaginitis, but calling them nurses is ridiculous and near-sighted. They aren't specialists, and don't know how to treat lots of diseases, but THAT'S NOT THEIR JOB! They are there to find out what the patient doesn't have (things that can kill you immediately), and leave it to the inpatient doctors to discover what the patient does have and treat it.

ER docs are a first line of defense, much like PCPs, and deserve a little more respect than we give them.

 

[labst]

by having staff privileges, the Doctor in question has likely agreed to be available for this under the privledges and duties that go along with Plastic Surgery under the bylaws of that institution.

Possibly, but not necessarily. Also, all this mentality will do is drive surgeons to those stand-alone Surgi-centers where they can just operate electively. That's the thing: some people try really hard to force people to do what they don't want to do (take care of people for no pay) and end up shooting themselves in the foot (as evidenced by this case). Makes you think, huh?

This patient's avulsed skin flap could have potentially been salvageable with prompt treatment.

That's true. So since that is the case, suddenly people have to do something they don't want to do? And you can drill this one surgeon all you want, but if you believe the account of the patient, NOBODY wanted to take care of her. Even her friends who were physicians. Apparently, hardly anyone in the entire state wanted in on her, a wealthy, well-insured person. Don't you even stop to ask yourself why? Or are you too busy being outraged?

I'm no apologist for the ER, but this was a fumble that's brought with it a lot of negative attention to both that hospital and the plastic surgeon involved.

Sure, and look at the set up. The ER looks great because, although they don't provide any care themselves, they're always the ones "looking" for care. It's like how nurses always look better than doctors because the nurses are always asking people if something's wrong and then "getting someone to take care of it." Meanwhile, the plastic surgeon is a mean ol' lady because she's evil and greedy. Lame.

 

[labst]

They aren't specialists, and don't know how to treat lots of diseases, but THAT'S NOT THEIR JOB!

It's great that you say that we're all "whining" and have "vaginitis," however your defense of them underlines the exact problem with the specialty that we are all irritated about. The fact that they don't know how to do much. And that their job is to move people around, rather than treat them. Which involves calling other people to be physicians. The only difference between us and you is that you are magnanimously saying that this doesn't bother you, which is great. You're a wonderful person, OK? Sheesh.

 

[droliver]

Possibly, but not necessarily. Also, all this mentality will do is drive surgeons to those stand-alone Surgi-centers where they can just operate electively.

That's fine and it happens. However, when you do agree to take staff call at a hospital you've made an obligation to the ER to be available for a defined set of privledges. This patient would fall within those privledges at any hospital. I you don't want those resposibilities, resign your privledges. That's what a lot of us do for hospitals where the call becomes burdensome relative to how much we value our practice at that hospital.

So since that is the case, suddenly people have to do something they don't want to do? .... .Don't you even stop to ask yourself why? Or are you too busy being outraged?

It is a completely ridiculous claim (as this surgeon made) that you can perform complex flap based surgeries at that hospital (like tummy tucks, breast lifts, and face lifts) but be unqualified to even evaluate a soft tissue injury. It's not that I'm "outraged", it's just that I'm pointing out the fallacy of her defence for dodging this ER consult.

 

[labst]

I you don't want those resposibilities, resign your privledges.

I'm not sure how feasible it is currently to operate out of a Surgi-center, since I believe you basically have to lease out time. In other words, right now as a surgeon you practically have to have hospital privileges somewhere. However, in theory, I agree with you.

It is a completely ridiculous claim (as this surgeon made) that you can perform complex flap based surgeries at that hospital (like tummy tucks, breast lifts, and face lifts) but be unqualified to even evaluate a soft tissue injury. It's not that I'm "outraged", it's just that I'm pointing out the fallacy of her defence for dodging this ER consult.

Strictly speaking, a traumatic injury is different from an elective, controlled procedure. There are different complications and morbidities. It's one thing to do an operation electively, especially when you are the one creating the flaps. Working with traumatized tissue is quite a bit more challenging in many regards. In addition, she was quite up-front that she wasn't interested in performing non-cosmetic surgery. Although I'm not a fan of cosmetic plastic surgeons, I at least find it refreshing that she was so honest. I'd have a lot less problem with a lot more people if they were equally honest.

 

[labst]

P.S. She did not say she was "unqualified to even evaluate a soft tissue injury." If she evaluates the patient she then establishes a patient-doctor relationship and becomes responsible for the patient until a new relationship is formed. That's the law. Therefore, she is not inappropriate in not evaluating the patient if she does not want a relationship. I'm sure you know this, but if you don't there it is.</p>

 

[gasnewby]

dr oliver, i agree with you that she should have been seen in a more timely fashion, and that by taking call, you are responsible for these types of consults, in line with your privileges. i'm going to PM you b/c i'm sure this will go to court, and we shouldn't be giving the lawyers more ammo.

 

[droliver]

I'm not sure how feasible it is currently to operate out of a Surgi-center, since I believe you basically have to lease out time. In other words, right now as a surgeon you practically have to have hospital privileges somewhere. However, in theory, I agree with you.

There are lots of Plastic Surgeons who have office OR's and who do not have active staff credentials at hospitals. However, if your active staff you usually have to take some amount of call within your specialty. Most people who do bigger cosmetic cases where you might need to admit patients post-op try to do these at facilities that won't bring excess amount of ER call.

Strictly speaking, a traumatic injury is different from an elective, controlled procedure. There are different complications and morbidities. It's one thing to do an operation electively, especially when you are the one creating the flaps. Working with traumatized tissue is quite a bit more challenging in many regards.

That's a weak defense for not seeing a patient that is intellectually dishonest IMO. It's the kind of line I'd hear during residency where oral surgeons from around the state of Kentucky would send unfunded mandible fractures to the UofL Plastic Surgery resident clinic because "they're the experts" (in uninsured drunks or meth-heads with broken jaws I presume)

In addition, she was quite up-front that she wasn't interested in performing non-cosmetic surgery. Although I'm not a fan of cosmetic plastic surgeons, I at least find it refreshing that she was so honest. I'd have a lot less problem with a lot more people if they were equally honest.

Irrespective of her fessing up to the fact she wants to do only fee-for-service cosmetic surgery, she was "in the box" for ER call for something clearly not beyond the scope of her expertise to at least evaluate. She's got no out just because she didn't want to establish a treating relationship with this patient. Yeah EMTLA sucks and it's obligations are unreasonable at times, but it's the environment we work in. You will get bent over the barrel by the feds on EMTLA violations for things much less then this. I'm sure there's been endless memos at that hospital over this, particularly as it's been publicized world-wide.

 

[Castro Viejo]

I did a month of ER as a fourth year med student, by which time I'd already had a full 14 months of hearing from all specialties how incompetent and lazy the ER docs were, and how most of their consults were B.S., so I was getting ready to do the same. During that month, I saw almost no true B.S. consults, but plenty of whiney consultants.

Whoa, slow down there junior... A whole month-long rotation in the ED as a fourth-year medical student? Why, your opinion must trump that of the "partially trained" resident you describe below, huh? If I remember correctly, you're an R2 in General Surgery, which means you've probably only begun seeing consults called by the ED staff. It's really great to play consultant when you first start out, but come back and tell me in a few years just what you think of them.

How many of you have done some time working in the ER? I'm sure some of you have, but not all. I think it should be a med school requirement, as it provides some much-needed perspective for soon-to-be doctors. When someone comes in with chest pain and it's your @ss if they go home and die of an MI, you might be dragging some residents out of bed at 3am to admit what appears to the partially-trained resident eye as a bulls@#t consult.

My medical school required a four week clinical clerkship in Emergency Medicine. On top of that, to kill some time and to hang with the Trauma Team (since we were limited to no more than eight weeks of elective time in any one discipline), I did an ED rotation for another four weeks. That's eight clinical weeks at one of the nation's busiest EDs. My General Surgery program also requires us to be ED General Surgery consultants Q3 for two straight years. So I've had my taste of EDs and their inner workings.

As for closing lacs, etc....a lot of ER docs look forward to these, as they dreamed in med school of a career with a controlled lifestyle and still some procedures......but the VOLUME of patients they see often prohibits this, and they're forced to triage away things they'd rather do themselves.

Unless their shift is about up... Funny how those wonderful lacs they all supposedly wanna sew up get dumped around 7PM or 11PM at my institution? Might it have something to do with SHIFT change? Or how, as 11PM rolls around, my General Surgery consult pagers goes off with -- SURPRISE! -- eight consults who "just all walked in, doc." Yeah right... So what's the story?

Patient No. 1 -- Abdominal pain. CT scan pending.

Patient No. 2 -- Abdominal pain. CT scan pending.

Patient No. 3 -- Abdominal pain. Drinking for the scan.

Patient No. 4... You get the idea.

Oh, yeah, and Patient No. 8 -- Vaginal bleeding. Wait a minute. What's the General Surgery issue there? "Well, she's got abdominal pain too. Oh, and OB/GYN is busy with a C/section upstairs."

There's a lot of partial workups to be followed and, lookie here in the chart, now who wrote, "General Surgery notified" all over it?

They are there to find out what the patient doesn't have (things that can kill you immediately), and leave it to the inpatient doctors to discover what the patient does have and treat it.

Uh, isn't that triage? So what makes them "Doctors?"

ER docs are a first line of defense, much like PCPs, and deserve a little more respect than we give them.

Like tampons.

 

[Faebinder]

Sorry, I disagree with everyone.... Plastic surgery should have the right to refuse to see this patient. It's not an emergency and she should not be able to invoke EMTALA. If she wants her leg fixed then she should offer the plastic surgeon her payment up front... that oughta make her more cooperative.

What kinda of example is this? A damaged breast does not equal free boob job via EMTALA. A damaged breast equals stabilized breast and if you want to make it look nice again then pay on the side since the plastic surgeon doesnt want the pitful amount paid by the insurance for fixing that. The surgeon in this story seems more interested in pay-for-service rather than cosmitc service only, which is fine and frankly admirable considering the status of the non-pay style of our system.

My 2 cents.

 

[SLUser11]

Whoa, slow down there junior... A whole month-long rotation in the ED as a fourth-year medical student? Why, your opinion must trump that of the "partially trained" resident you describe below, huh? If I remember correctly, you're an R2 in General Surgery, which means you've probably only begun seeing consults called by the ED staff. It's really great to play consultant when you first start out, but come back and tell me in a few years just what you think of them.

It doesn't take five years of residency to see who the whiney b@tches are.

Oh, yeah, and Patient No. 8 -- Vaginal bleeding. Wait a minute. What's the General Surgery issue there? "Well, she's got abdominal pain too. Oh, and OB/GYN is busy with a C/section upstairs."

There's a lot of partial workups to be followed and, lookie here in the chart, now who wrote, "General Surgery notified" all over it?.

It sounds like the ER docs at your institution in New York suck. I've heard a lot of things about the way your hospital works, including the nursing, that is way less than ideal. This has led to frustration and crappy attitudes like yours, but this is not, however, something that you can then apply universally, and say that all ER docs are triage nurses. There are plenty I've interacted with that are excellent physicians. Maybe you should practice in the midwest.....of course, you'd have a lot less to cry about.

Uh, isn't that triage? So what makes them "Doctors?"

The fact that they went to medical school. Their work is more flowsheet/grunt work, without as many glorious moments as we get in surgery, but I don't think it's much different than the family practice doc triaging a patient with pneumonia to the hospitalist, or a patient with abdominal pain after 5pm to the ER, etc.

 

[Castro Viejo]

It doesn't take five years of residency to see who the whiney b@tches are.

True. Most anyone in a hospital figures out it's the ED and its "doctors" within a month of starting internship. Why has it taken you so long to figure it out?

It sounds like the ER docs at your institution in New York suck. I've heard a lot of things about the way your hospital works, including the nursing, that is way less than ideal. This has led to frustration and crappy attitudes like yours, but this is not, however, something that you can then apply universally, and say that all ER docs are triage nurses. There are plenty I've interacted with that are excellent physicians. Maybe you should practice in the midwest.....of course, you'd have a lot less to cry about.

Have you read the posts on this thread? Or the opinions of other surgeons/surgical residents on SDN who have had run-ins with the ED staff? I'm just about the only active poster who's from New York! Yet there are plenty of complaints about the ED and its "doctors'" inherent laziness, all the way from Pennsylvania to Georgia to Kentucky. Perhaps at whatever midwestern institution you train in the ED is great. I'm sure the guys at Shock think their ED is great as well, but perhaps it is you who are experiencing the anomaly in the way ED "physicians" run things?

In about 158 days I'll be training in the midwest. Chicago to be exact. We'll see what the EDs are like there, but I've got no hope. I'd rather not set myself up for a big disappointment. My friends out in California think their EDs suck too. Big surprise!

I give all services a fair shake wherever I am. I've rotated through eight or nine different hospitals as a medical student and surgical resident, and I can tell you that academic or community, urban or suburban, rich or poor, ED physicians are the same the world over. You can call it a "New York thing" all you want, but if other's posts are any indication, it's not exclusive to New York at all. Shoot, I've even had to deal with the ED staff at a "US News & World Report Honor Roll" hospital in New York. They sucked too.

The fact that they went to medical school. Their work is more flowsheet/grunt work, without as many glorious moments as we get in surgery, but I don't think it's much different than the family practice doc triaging a patient with pneumonia to the hospitalist, or a patient with abdominal pain after 5pm to the ER, etc.

Nothing is as glorious to me as surgery. That's just a damn fact.

But the ED isn't just about flowsheets and grunt work. It'd be great if they actually took care of people every once in a while! It's about turfing. Plain, old, House of God style turfing. They buff their patients with mysterious complaints, do half-assed workups, order CT scans on everything that walks in through the door, and then comes the INEVITABLE consult or admission to Medicine. And why is this? Because they practice a "Cover Your Ass" form of medicine and need to "load the boat" constantly to protect themselves from malpractice lawyers. Hey, it's understood. I don't blame the ED for doing what they do -- they're not really trained in anything after all.

But to go ahead and tell me that they serve an important role in the institution? Sorry, no. They really don't. They don't direct traffic since they let everyone in. They don't utilize resources efficiently since the CT scanners are usually tied up with their nonsense. They don't take the burden of initial workup off the primary teams since their workups are usually bullcrap to begin with. If anything some of the things they do just cause more problems for the services who eventually take care of the patient.

I agree. They're physicians by virtue of the fact they attended medical school and graduated and that even the guy who's last in his class is called "Doctor," but they lost it somewhere along the way. Perhaps it was the whole, "I need to work my three 12-hour shifts a week and that's all I give a damn about" attitude that drew them into being EM docs to begin with, but they're just not physicians in my estimation. If you don't like my calling them "nurses," fine, they're "triage coordinators."

 

[tri]

ok I thought I'd chime in with my two cents even though i may regret it. I feel like i should since i'll be a prs fellow in a few short months.

ED Docs: They can range. I did my med school in chicago and basically the ER attendings/residents were pretty pro-active in diagnosing things and really calling consultants when they were legit and admitting for legit stuff. However, I'm in the southwest right now and some ED docs here won't even examine the patient when they hear "belly pain" so I don't think all ED docs are bad. I think most of us, as residents, instinctively get mad/annoyed when we look at our pager and see one of the many memorized ER extensions. And most likely, we remember the ER docs that call us with crap and don't remember the good ER docs cuz a) they don't call us that often cuz they handle their s#1t b) when they call us, it's straight forward, no discussion needed, and c) we spend more time yelling at the bad ER doc and ridiculing them later amongst our peers.

Plastics coverage in the ER: I read the article. They leave a lot of details out. I am not sure why they called that particular plastic surgeon in particular. Was she on call for the ER? I find it hard to believe that a plastic surgeon who only does cosmetics would ever sign up for ER call cuz nothing that comes in through the ER is going to be something she wants (cosmetic). As a trauma resident, my hospital didnt' have plastic surgeons on call either so i had to beg, plead, sell my body and various other unspeakables to try to get plastics to see trauma patients. For that reason, most basic recontruction (skin grafts, etc) were performed by trauma. In fact, very rarely would plastics ever consider admitting a patient as primary service. Given the little info i gathered from that fluff article, what would seem the most reasonable would to have gen surg or trauma evaluate the patient and control any bleeding and initiate wound care and then have a plastic surgeon be consulted later on after initial evaluation. Who knows, maybe the wound was not as bad as that newspaper reporter with no med background portrayed it to be. I wouldn't put it over the newspaper to exaggerate the wound which may have been only 3cm or something. It's like the brand new 100% mortality microbe called MRSA that the media thinks was just discovered. I mean, ****, i've fart out a billion MRSA particles everyday for the last 7 years since the first time i stepped into a VA during med school.

Practically speaking, most plastic surgeons don't want/need to take ER call. Why would they? Long surgeries (free flaps for wounds), low re-imbursements (medicaid), high liability, and opportunity cost that takes away from their free cash flow cosmetics schedule. There are plastics guys who do take ER call here, but most of them are newly trained and are trying to set up their practices, and the hospital usually has to pay them a stipend (ie $10,000/week) just to be on call to make it worth their while, which isn't unreasonable to guarantee prs coverage

I'll be honest, if i was a senior plastics guy with a thriving cosmetics practice, not taking ER call, and the ER called me with the above described patient, ... I'd turn it down too.

 

[labst]

The fact that they went to medical school. Their work is more flowsheet/grunt work, without as many glorious moments as we get in surgery, but I don't think it's much different than the family practice doc triaging a patient with pneumonia to the hospitalist, or a patient with abdominal pain after 5pm to the ER, etc.

Sorry, junior, but you're wrong. The fact that someone goes to medical school makes them a doctor in name, but it is quite apparent it didn't make them physicians. Like I've said before, being a doctor doesn't just mean having some lame initials after your name or a degree to frame. How the hell does one call themselves a physician if they don't diagnose or treat? They "manage"? WTF is "managing"? Don't they get a little embarrassed when they don't know the history or haven't done a physical? They know a little bit about everything, not much about anything. Ever listened to an EM sign-out? Do it some day and you're going to be embarrassed you're even at the same hospital. "Bed 7, being seen by surgery, they're going to accept. Bed 8, waiting to be seen by medicine. Bed 9, in X-ray, call surgery."

The fact is that their work IS gruntwork. And you know what? That's fine, but don't try to convince me it's intelligent. EM gets great hours and great pay. Unfortunately, it gets ZERO RESPECT. And there are reasons for all three of those things. They go into the specialty because they love the great hours and great pay. Then they get all upset and whiny because they don't get respect for doing nothing. SORRY. OUR BAD. It happens. We get sucky hours, moderately good pay, and great respect (even if people hate our personalities, lol). Guess what? Life ain't perfect, son. Deal with it.

 

[labst]

Given the little info i gathered from that fluff article, what would seem the most reasonable would to have gen surg or trauma evaluate the patient and control any bleeding and initiate wound care and then have a plastic surgeon be consulted later on after initial evaluation.

Wow, a Plastics guy who wants General Surgery to take the patient and then be on consult. This is an amazing turn of events. Seriously, dude, look at the pictures of the injury. What "trauma" issues are there? You want us to maintain the airway of her tibia or something? That thing is ALL YOURS, ENJOY.

 

[Castro Viejo]

ED Docs: They can range. I did my med school in chicago and basically the ER attendings/residents were pretty pro-active in diagnosing things and really calling consultants when they were legit and admitting for legit stuff.

I hope it's as you described your Chicago ED when I show up in the Windy City in just a little over 6 months!

 

[Castro Viejo]

They "manage"? WTF is "managing"? Don't they get a little embarrassed when they don't know the history or haven't done a physical?

"Manage" is what the ED staff calls it. Upstairs we call it "triage."

I don't think they're embarassed at all. In fact, I think they've accepted the idea that they don't do much of anything at all except for paging consults and admitting everything in sight. It helps the institution generate much-needed cash and it gets the patient off their hands. They should be just called "buffers and turfers," but I think we'd be insulting the art of a good buff and turf. What they do is just blatant fudging lazy crap.

They know a little bit about everything, not much about anything. Ever listened to an EM sign-out? Do it some day and you're going to be embarrassed you're even at the same hospital. "Bed 7, being seen by surgery, they're going to accept. Bed 8, waiting to be seen by medicine. Bed 9, in X-ray, call surgery."

That's all they care about. Dispo, dispo, dispo. They'll call you once the patient hits the door, "Hey Surgery, we have an abdominal pain for you."

General Surgery Consult: "Great. What's the story?"

ED Staff (Attending/Resident/PA -- they're all the same): "Uh... Dunno... Lemme see. Well the triage nurse wrote..."

General Surgery Consult: "Look. I'm in the middle of a ton of real consults. Call me back when you've actually seen the patient."

No call back AT ALL. And finally the General Surgery consult makes it down to the ED to see the patient, picks up the chart and reads, "General Surgery consult notified," and it's timed with whenever the heck the consult resident was paged. Nice. That's messed up. All they've done is have the nurse draw some bloods, start an IV (always heplocked), and has the patient drinking for a CT scan. What the hell are we scanning? "The belly." Why? "'Cause the patient's got pain."

I really what the hell is in those EM textbooks. Maybe it's got like all the secret direct numbers to every consultant in every hospital in North America. I dunno.

The fact is that their work IS gruntwork. And you know what? That's fine, but don't try to convince me it's intelligent. EM gets great hours and great pay. Unfortunately, it gets ZERO RESPECT.

I suppose it would be "great pay" if you considered they get paid way more than their nursing bretheren.

Nice.

 

[Celiac Plexus]

It doesn't take five years of residency to see who the whiney b@tches are..

Wow.

It sounds like the ER docs at your institution in New York suck.

Huh.

The fact that they went to medical school. Their work is more flowsheet/grunt work, without as many glorious moments as we get in surgery, but I don't think it's much different than the family practice doc triaging a patient with pneumonia to the hospitalist, or a patient with abdominal pain after 5pm to the ER, etc.

I think you've just insulted the tens of thousands of hard-working primary care doctors out there.

SLUser, you may think that only your view of ER physicians is valid, and that everyone else is wrong. That's ok, since everyone's opinion is equally worthless. However, I find it bizarre that you feel comfortable calling everyone "whiney b@tches" with "vaginitis" who has a different opinion than you. I don't agree with 100% of the ER bashing in here, and I do find it unprofessional at times. However, try to maintain a higher level of discourse here, and refrain from the "vaginitis", and "whiney b@tches" insults. Thanks. Have a nice day.

 

[Tired]

A few things:

1) by having staff privileges, the Doctor in question has likely agreed to be available for this under the privledges and duties that go along with Plastic Surgery under the bylaws of that institution. Refusing to see the patient (if asked by an ED physician) is an EMTLA violation which carries significant potential fines for the doctor and hospital.

2) This patient's avulsed skin flap needed to be assessed for salvage. In fairness to this surgeon, it's possible the wound may not have been described accurately by the ED. (I had a scenario like this last week that I was asked to see BTW.)

3) I'm no apologist for the ER, but this was a fumble that's brought with it a lot of negative attention to both that hospital and the plastic surgeon involved. I appreciate the dilemma of the doctor on call, but she should have seen this patient for this particular problem.

4) This was an entirely appropriate urgent consult by the ED for a Plastic Surgeon, Orthopedist, or general surgeon

You make a lot of sense except for one glaring detail that you conviently ignore.

The patient was sent home by the ER doc.

If this were as serious as you are pretending it is, then the patient would have been admitted, or the ER doc would have called the Orthopod or General Surgeon you mention. He did not. This was not an emergency, and if it warranted the "immediate evaluation" you think it did, then they would have either called in someone else or admitted the patient.

The ER doc felt this wound was not serious enough to warrant even one more phone call to another specialist before discharge. That ought to tell you everything you need to know about this case.

 

[VFTW]

Wow. You manage to offend 99% of the posters in here in one sentence. Impressive.

Hmm, I think it's Castro Viejo who is being as offensive as possible about his ED colleagues, not SLUser.

I just want to know, from all you smart, brilliant, perfect surgeons, what your solution is to staffing the Emergency Department if you think that ED physicians are so worthless.

 

[Faebinder]

I'm down here in Florida and our ER works exactly as Castro describes. Heck they take it a step further... they will call the attending and tell them they are admitting this patient to his service cause the last time the patient was here, she/he was under "his" service. I get so mad at that... Pt "known" to us. #$#!@#!@ So whenever a crohn pt comes to the ER you automatically call Colorectal Surgery?!

- Sir, I got Crohn and just had a round of diarrhea. Sure wait a second.. lets call colorectal surgery?!

- Sir, I got Crohn and just got a fever. Sure wait a second.. lets call colorectal surgery?!

- Sir, I got Crohn and my belly hurts. Sure wait a second.. lets call colorectal surgery?!

The worst part is when they call at 3 am for this BS. Couldn't you wait till the morning? How hard is it to give him some morphine, that's what they usually want anyway. God forbid you actually give someone their usual lopressor for tachycardia (even though they tell you they have not been taking it or any medication for that matter cause of the pain).


Grand Triage Nurses is correct... sorry... lost respect to them right after the first few night oncalls.