University of Chicago ER sends kid mauled by pit bull home

This is certainly a difficult situation, and I may be criticized for the following post. I am not saying that this child did not deserve necessary treatment, but I would like to throw in the following points:

• I think as usual, the Trib engineered the headline for maximum shock and reader value.
• The role of the ED in this case was to dispo, stabilize, and direct for the appropriate treatment. They did not "send the child home", but rather provided stabilizing treatment and directed them to a place where the appropriate competent care would be provided and paid for (the free county hospital).
• Certainly the ED could have just called down a GS/Plastics PGY-2 or 3 to do the repair, but depending on the complexity (proper lip repair can be an extremely complex chief-attending type case), at which point, compensation issues do indeed arise.
• The f/u one week vs. immediate transfer does seem questionable, however.
• The ED's judgment in this case was that this patient could be stabilized and receive the appropriate treatment at a different clinic, without undue financial burden incurred by both the patient and the UCMC. Adequate treatment and a good outcome were achieved, so I'd say the ED's actions were justified.
• I do understand that UCMC is a private entity that receives tax breaks for providing treatment to the uninsured, but that is not a blank check statement. The facility still operates under a budget, and is expected to adhere to that budget, as long as patient care and outcomes are not compromised.

and if it was your ten year old son with a mangled face? Must have been pretty bad to get a direct admit from county. Sounds like poor managememt if the kid ended up getting inpatient surgey that same night. Heads are gonna roll.

So far all we know is what was reported by the patient's mother to the Trib, who no doubt will probably be looking for a settlement. I'm not saying that there's more to the story, but I would like more information before ascertaining that UCMC is guilty of mismanagement. Was this patient seen by plastics before being released?

Doesn't appear the patient had a life threatening condition, so a screening exam is all that is obligated to be done.

If the child were insured, things might have been different. Another reason why everyone needs insurance. Specialists and hospitals often treat the uninsured as second rate citizens.

Moral of the story: get health insurance if you currently do not have it.

I wouldn't send the kid home, rather I would send him (by ambulance) to the county hospital for treatment and admission. You can't force a plastic surgeon to work for free, unless it's a life-threatening situation.

GeneralVeers said:

I wouldn't send the kid home, rather I would send him (by ambulance) to the county hospital for treatment and admission. You can't force a plastic surgeon to work for free, unless it's a life-threatening situation.

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Amen.

I know nothing about this particular situation but from what little I read on this thread it seems to be an extension of the "those damned specialists" mindset.

I think it's a stupid way to think about things because yes, EM is a litigious field but at the end of the day when we need Plastics/Ortho/ENT/Surg back-up we are essentially saying "I want you to come in an take this patient to the OR if necessary, you'll have to assume ALL the risk for this patient's future care. Who knows if you'll get paid."

Turn it around hypothetically: who in here would do a tendon repair, a non-emergent chest tube, a complicated facial lac, a suprapubic catheterization, or a non-emergent central line if they knew they had NO chance of being paid anything?

AmoryBlaine said:

Amen.

Turn it around hypothetically: who in here would do a tendon repair, a non-emergent chest tube, a complicated facial lac, a suprapubic catheterization, or a non-emergent central line if they knew they had NO chance of being paid anything?

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All of us do. Every day. 25-30% of the care I give is scott free. I do not manage pts differently based on their ability to pay, nor does anyone who practices emergency medicine, I'd wager. I'm blinded to my pt's insurance status but when the homeless guy comes in with a complex facial lac from a drunken brawl I've got a pretty good idea what my reimbursement will be...$0.
I'm okay with that.

As an EP are you paid a base salary and reimbursements from procedures?

Lumberg said:

All of us do. Every day. 25-30% of the care I give is scott free. I do not manage pts differently based on their ability to pay, nor does anyone who practices emergency medicine, I'd wager. I'm blinded to my pt's insurance status but when the homeless guy comes in with a complex facial lac from a drunken brawl I've got a pretty good idea what my reimbursement will be...$0.
I'm okay with that.

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ditto

and GV - how would sending this patient to county, assuming you have plastics available at your shop, not be a dump?

I would like to hear from some current residents on how this has affected their training so far. Also, it would be interesting to hear what they believe the implications are for the incoming class of residents. With rank lists due in under a week, this must be a topic of interest.

LastPolarBear said:

As an EP are you paid a base salary and reimbursements from procedures?

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Do a search. Reimbursement depends on your contract and shop. Academics ~> fixed salary. Some PP docs get a flat salary, some flat with production incentives, some FFS (and do a search for FFS ).

AB - Part of what I like about EM is that I wouldn't change my practice based on $$$, but I don't know if I could force others (surgical specialists) to make the same choice.

WilcoWorld said:

ditto

and GV - how would sending this patient to county, assuming you have plastics available at your shop, not be a dump?

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It would be a dump, but if your surgeons are anything like the ones at my facility their answer would be "have them call the office in the morning". When I refer the patient to the clinic, they typically tell the patient how much it will cost, and the patient doesn't follow up. As this is not a life-threatening case sending them to county would be reasonable if I couldn't sweet-talk the plastic surgeon to come in.

southerndoc said:

Doesn't appear the patient had a life threatening condition, so a screening exam is all that is obligated to be done.

If the child were insured, things might have been different. Another reason why everyone needs insurance. Specialists and hospitals often treat the uninsured as second rate citizens.

Moral of the story: get health insurance if you currently do not have it.

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Indeed.

This all boils down to medicine being run as a business. For profit hospitals (and some public like Denver Health) will continue to employ these tactics as long as the current system remains intact.

Sending somebody away with a cold is one thing, sending a kid home with "follow up instructions" after having his lip torn off is quite another. I agree you cannot force a surgeon to work for free but you should at least make the call to them and if they're unwilling to take the case, arrange for appropriate care...I guess we can debate the merits of what appropriate care would be.

You could always call and say I have this 20 year old beautiful model from Europe who fell during a show and has a complex facial lac and it needs to be repaired.
When he comes in and sees the kid with no insurance mauled by the dog with the complex facial lac you say oh I had 2 similar cases and must have been confused.
Why, would you treat them differently?

macdaddy23 said:

You could always call and say I have this 20 year old beautiful model from Europe who fell during a show and has a complex facial lac and it needs to be repaired.
When he comes in and sees the kid with no insurance mauled by the dog with the complex facial lac you say oh I had 2 similar cases and must have been confused.
Why, would you treat them differently?

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I think in this case, you'd be misleading the surgeon. Ethics aside (I'm not saying ethics aren't important, but just for the purpose of this discussion), if you're calling your facility's Asst. Prof. Plastics guys, that's one thing, but if you're calling up a private practice "eat-what-you-kill" surgeon knowing full well they may endup spending 4 hours in the OR doing a procedure they're probably not getting paid for, it just seems dishonest to me.

I'm not saying I have ever done that, I was just making a point. If someone is bad off enough to need plastics that night I don't think there should be a difference. I don't know the details of the case however.

At my hospital, the private plastics guys don't think anything is an emergency no matter who you are. Everything can be done later, which may be true too.

Alright, I may be completely misunderstanding how this works, but here's my thought (and please correct me if i'm wrong!):

Isn't this what residents are for? As in, if you have to consult someone (plastics or whomever), you page them down, and you get the consulting resident for that service? So, in this case, a plastics resident (or gen surg, depending) would come down, evaluate the patient, and then (under attending supervision? and this would be a salaried academic attending at the program) suture the kid up. So there wouldn't be an issue of who does/doesn't get paid.

The actual issue seems not to be about individual residents or attendings concerned about their salaries, but the hospital itself. If everyone is salaried, then their income is fixed regardless of who they treat, while the hospital only makes $ if they can bill patients or thier insurance companies. So I don't see why we're ragging on the surgeons - if they're at a residency program - and there IS one at U of C - then I don't think that's the issue.

I think that we need to look at some main facts:
1) nobody saw this kid, the paper and mothers version of "MAULED" is most likely VERY different than ours. Before we get our panties in a knot, lets see a picture of the kids lip/face.

2) I suspect that UofC has plenty of EP's who know when a surgeon needs to be called (forced) in, versus a f/u in clinic/office the next 24-48hrs, as we all do. I seriously doubt that a lip was "ripped off" and the EP just said "nothing to do here, go home".

There are plenty of vermillion border lacs w/through/through in multiple places that we put together in our ED. We do not have plastics residency, and they are very hard to get in, but it is VERY common for us to clean, wash, suture, and have follow up in the next few days. Parents ask for plastics, we say no, they get mad and "want one RIGHT NOW", and "we want to be admitted"....people (regardless of location), don't like to be told no and I suspect this is more of the case.

I'm sure that there will be a lot more to do with the story than the paper has published

The fly in the soup is that Dr. Mark Grevious, a well known Plastics faculty in these parts, did the repair emergently and claimed that this procedure should not have been put off. So it appears to be a case of UCMC's judgment vs. that of Dr. Grevious. If UCMC's ED dispo'd the kid without getting UCMC Plastics on board, they'll likely be found in the wrong. If UCMC Plastics was on board (and preferably an attending saw this patient), it'll probably be between the aforementioned physician's judgment and that of Dr. Grevious.

LastPolarBear said:

As an EP are you paid a base salary and reimbursements from procedures?

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Nope, I'm fee for service. I only get paid what I collect, so free care is just that.
I agree you can't force another physician to begin a doctor-pt relationship against their will but if these docs are on call to that hospital they are almost certainly getting paid a salary to be available for that call period. I feel it is our responsibility as pt advocates to demand that the on-call doc come in and see pt/admit/arrange transfer/dispo. Also that's better medicolegally for us as EM docs. Otherwise if they refuse to see pt and your transfer is questioned the on-call doc at your facility has an out..."I wasn't told the severity of the situation otherwise I naturally would have come in."

Dimoak said:

The fly in the soup is that Dr. Mark Grevious, a well known Plastics faculty in these parts, did the repair emergently and claimed that this procedure should not have been put off. So it appears to be a case of UCMC's judgment vs. that of Dr. Grevious. If UCMC's ED dispo'd the kid without getting UCMC Plastics on board, they'll likely be found in the wrong. If UCMC Plastics was on board (and preferably an attending saw this patient), it'll probably be between the aforementioned physician's judgment and that of Dr. Grevious.

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"Plastics attending come in to see the patient"???? What are you smoking?... The attending only comes in to operate...

http://www.chicagotribune.com/business/chi-biz-university-of-chicago-emergency-room-feb19,0,2937923.story

ACEP does not appear to be a fan of the U of C's actions....

The "facts" as we know them are this...

A 12 year was attacked by a pit bull and definitive care was not provided at the ED he showed up at.

He was then taken to another hospital, by family, where an attending plastic surgeon was concerned enough to admit him for immediate surgery.

No matter how you want to break that down, it doesn't look good for U of C.

Dimoak said:

If UCMC's ED dispo'd the kid without getting UCMC Plastics on board, they'll likely be found in the wrong. If UCMC Plastics was on board (and preferably an attending saw this patient), it'll probably be between the aforementioned physician's judgment and that of Dr. Grevious.

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In our society, if you don't bend over and cater to the patient, then you're held liable.

Dimoak said:

This is certainly a difficult situation, and I may be criticized for the following post. I am not saying that this child did not deserve necessary treatment, but I would like to throw in the following points:

• I think as usual, the Trib engineered the headline for maximum shock and reader value.
• The role of the ED in this case was to dispo, stabilize, and direct for the appropriate treatment. They did not "send the child home", but rather provided stabilizing treatment and directed them to a place where the appropriate competent care would be provided and paid for (the free county hospital).

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• 
  
  Read the ****ing article. They asked the kid to go to Cook County after 1 week, not the same night. Where will the kid stay for a week? At his home, your home or some other hospital?
  
  

  Dimoak said:

  [*]Certainly the ED could have just called down a GS/Plastics PGY-2 or 3 to do the repair, but depending on the complexity (proper lip repair can be an extremely complex chief-attending type case), at which point, compensation issues do indeed arise.

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  What part of "emergency" do you not understand?
  
  

  Dimoak said:

  [*]The f/u one week vs. immediate transfer does seem questionable, however.

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  Thank you for answering your own question above. The source of the information seems to be a hospital employee.
  
  

  Dimoak said:

  [*]The ED's judgment in this case was that this patient could be stabilized and receive the appropriate treatment at a different clinic, without undue financial burden incurred by both the patient and the UCMC. Adequate treatment and a good outcome were achieved, so I'd say the ED's actions were justified.

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  No, they just want some other hospital's ER to suck up the financial burden. Even though a badly torn upper lip may not be life threatening, we all know that it's an emergency.
  
  

  Dimoak said:

  [*]I do understand that UCMC is a private entity that receives tax breaks for providing treatment to the uninsured, but that is not a blank check statement. The facility still operates under a budget, and is expected to adhere to that budget, as long as patient care and outcomes are not compromised.

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The patient outcome WILL be compromised if you do not repair a torn upper lip for one week.

Seeing that I manage as much on my own as a possibly can and generally try to watch the back of my subspecialty colleagues as much as possible by referring to them as an outpatient as opposed to requesting a direct consult, I do not lose any sleep over asking someone to come in and help when they are truly needed. Furthermore, I think someone whose primary consideration regarding providing emergency care to the acutely ill/injured is whether or not they will get paid has some serious soul searching to do about why they even went into medicine in the first place.

The bit about asking about insurance status is a bit melodramatic, because it is necessary info. People always act offended when I have to ask about their insurance status (makes no difference to me...I'm already in the room). But when I explain to them that it will be the difference between prescribing something which will cost $4 vs $250 or sending them to a subspecialist who is going to ask $500 to even let them walk in the door vs going to a sliding scale fee-based clinic, they start to get the picture.

AmoryBlaine said:

I think it's a stupid way to think about things because yes, EM is a litigious field but at the end of the day when we need Plastics/Ortho/ENT/Surg back-up we are essentially saying "I want you to come in an take this patient to the OR if necessary, you'll have to assume ALL the risk for this patient's future care. Who knows if you'll get paid."

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Dimoak said:

The fly in the soup is that Dr. Mark Grevious, a well known Plastics faculty in these parts, did the repair emergently and claimed that this procedure should not have been put off. So it appears to be a case of UCMC's judgment vs. that of Dr. Grevious. If UCMC's ED dispo'd the kid without getting UCMC Plastics on board, they'll likely be found in the wrong. If UCMC Plastics was on board (and preferably an attending saw this patient), it'll probably be between the aforementioned physician's judgment and that of Dr. Grevious.

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I would point out that the receiving facility now has a vested interest in making this out to be as bad as possible in an effort to end the deferral of care. I imagine that the public hospitals in the area have been hoping for something that would turn into an EMTALA violation as they think it will end the policy.

docB said:

I would point out that the receiving facility now has a vested interest in making this out to be as bad as possible in an effort to end the deferral of care. I imagine that the public hospitals in the area have been hoping for something that would turn into an EMTALA violation as they think it will end the policy.

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As I mentioned earlier, this situation will likely be fought out in the court of public opinion. But given Grevious' statements on the matter, it'll be quite difficult for UCMC to prove they did nothing wrong (at least in the eyes of the public and politicians).

waterski232002 said:

"Plastics attending come in to see the patient"???? What are you smoking?... The attending only comes in to operate...

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Why, do you want some?
What I was trying to get at was that if the patient was seen by Plastics in the ED, it likely was not an attending, and so it would be hard for the validity of their decision to send the patient home to hold up (at least in a court of public opinion) against that of a Plastics attending who felt the case was severe enough for emergent surgery.

Ninja, please read the thread before posting such responses.

docB said:

I would point out that the receiving facility now has a vested interest in making this out to be as bad as possible in an effort to end the deferral of care. I imagine that the public hospitals in the area have been hoping for something that would turn into an EMTALA violation as they think it will end the policy.

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As far as I can tell there was no EMTALA violation. Our duty is to provide a medical screening examination to determine if there is an emergent condition. Does a torn upper lip count as emergent? No, if by emergent you mean immediate threat to life and limb. I would definitely say it's an urgent complaint that requires medical care, but transfer to the appropriate facility is not an EMTALA violation.

GeneralVeers said:

As far as I can tell there was no EMTALA violation. Our duty is to provide a medical screening examination to determine if there is an emergent condition. Does a torn upper lip count as emergent? No, if by emergent you mean immediate threat to life and limb. I would definitely say it's an urgent complaint that requires medical care, but transfer to the appropriate facility is not an EMTALA violation.

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Doesn't appear that they transferred him. Just shoved him out the door.

BKN said:

Doesn't appear that they transferred him. Just shoved him out the door.

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EMTALA doesn't state what you are required to do once we've established that there is no emergent medical condition.

What I would do would depend on the facts. Is it just a small lip lac, and the hysterical mother was demanding a plastics repair? If she refused to let me do it, I'd shove them both out the door with instructions on whom to follow up with.

Was it a big lac and the lip was half hanging off that required plastics repair? I'd probably arrange ER to ER transfer to a county facility with plastics on call.

I agree with GV that it does depend on the severity of injury. Life, limb, or vision threatening are (relatively) easy decisions, but the face... let's just say disfigurement is a relative term. A 60 yo drunk with a forehead lac is different then a 12 yo female with a gaping, irregular, through & through lip lac. The effect on quality of life will be dramatic in the latter, but probably not the former. With the info I have I can't confidently categorize the above case.

I make the motion that we add "permanent disfigurement" to the "transferable list" of life, limb or vision threatening.

I don't train at either facility nor do I know the individuals involved, so please don't accuse me of taking one side or the other.

I remember seeing this article in the paper last week and sat down to read it. There was a picture of the kid, which I'm assuming is 4 months post-op, since this happened in August, and I remember studying the picture and trying to figure out where the injury was. I would encourage anyone who reads this post to read the article as well. The OP posted the beginning of the article, but that makes up about the first 5th. The rest of the article talks about U of C and how they plan on seeing less public aid patients, and how they rank last in Chicago already in this, blah blah blah. That's a whole other discussion.

Anyway, my point is this. This article easily could have read "U of C ED discharges patient bitten on lip by dog and recieves differing 2nd opinion at different facility by specialist" Like all media content, information is going to be presented in a way that is intended to achieve a desireable endpoint. In this case, it seems the author wanted to use the case to bring to light the larger percieved plans of U of C in general.

Now, without the facts, I can only guess, but the child was probably seen in the ED, sutured by the physician/resident/student/midlevel (who knows), and the mother was unhappy because he was going to have a scar on his face. Like many patients we see in the ED, insured or not, they don't all leave happy. Some, and I'm sure you've seen it, come in and say "I was just at hospital X, but they ______________, and I still don't feel better, so I'm here". Being uninsured, im sure she knew what a day at a clinic is like, and what it's like to get an appointment, and did what she did. Only the people involved at both facilities really know what happened.

Read the wording of the article. The surgeon is quoted saying this was an urgent matter, but when? Before, or after the U of C ED visit. Arrived at Stroger after an hour long bus ride at 5 am. When did the child get bitten? What was he doing up so late in the first place around a pit bull? He was admitted for surgery, but was it really emergent? Did he go right to the OR, or was he an add on later that day? And I'm sure any plastic surgeon at least thinks he/she can suture better than an EP (Just kidding, im sure they all can, but hey, that's what they do). This just seems like someone who recieved the necessary care, a mother who felt that her son was ENTITLED to more, and the media getting wind of it and putting it's own spin on it to achieve their own goals.

Why didn't the original EP just try to repair the lac as best as he could before sending the patient out? Even if the plastics guy has to take your your sutures later, at least the gaping wound isn't open.

I've had a few where I've repaired (usually the face) and I've referred them to outpatient plastics follow-up. I tell patients that the surgeon may want to revise the scar once it heals to reduce the cosmetic impact.

I'm pretty sure they did, but I think the article I read was the same one the OP posted.

Also, Cook county and Stroger are the same hospital, and most likely were referred to the same Plastics attending. The difference was simply that she went to the ED to see him urgently rather than wait to see him in clinic.

"Adams said she demanded that the medical staff admit Dontae but that they refused. The emergency room staff gave Dontae a tetanus shot, a dose of morphine, prescriptions for antibiotics and Tylenol 3, and told Adams to "follow up with Cook County" in one week, according to medical center documents."

It doesn't say they sutured his lip. That's really awful reporting if they left that out.

Yes, but it also doesn't say "Did not suture his lip", so we don't know, unless of course we were involved. Judging from what it seems like the article is trying to accomplish, it may have been a "convenient" omission.

Any decent reporter would not omit that.

I just came across this:

http://www.uchospitals.edu/pdf/uch_018837.pdf

Interesting...

WakeMedHeel said:

Interesting...

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Not really. It said nothing. Just bureaucratic double-speak.

As a resident in a hospital within the NYCHHC network (basically city / community hospital), we get dumped on all the time. Every single day. We frequently get re-routes from a private hospital that is only 4 blocks away. Not a situation as bad as the pit bull maul, but more than once, we have gotten psych patients bleeding profusely from lacerations sustained during psychotic breaks who were picked up DIRECTLY IN FRONT OF THE PRIVATE HOSPITAL'S ER DOORS. On one occasion, there was a serious arterial bleed requiring transfusion and then MICU for AMS in addition to the psychotic episode. These are serious situations and although not technically EMTALA violations, I personally believe that many of them ARE EMTALA violations as lack of correct "screening" causes grave potential harm to the patient. Who is left to pick up the tab? often underfunded, under-resourced community hospitals.

EBKame asked if this affects the training of residents. I believe it does.

Not only does the general field of EM require seeing the worst of society / social circumstances on a daily basis, insult to injury is done when residents who are already serving an overflowing underprivileged population (meaning many primary care-type cases) are dumped on by other hospitals, leading to too many "minor" cases and not enough training in Emergency / Trauma. Especially in NYC when there are only a couple designated trauma hospitals.

Then, when serious cases do come in like that described above, the feeling of being "left to clean up other people's messes," plus being dumped on, plus anger that other programs could treat patients (whatever their social standing or appeal) with that kind of callousness leads to a festering resentment that makes an already stressed ER even more stressed. This increases fatigue, decreases performance and leads to low morale among residents, all house staff and nursing staff alike.

two points:
1) always be careful about what, if anything, you say to the media about cases, especially when they involve other institutions/docs. you see here that Mark Grevious probably got the entire UofC institution in hot water and had to issue what was basically a retraction in that memo.

2) agree with Leorl, the bigger issue--uninsured patients are a burden on whatever hospital they go to. Bottom line is hospitals have to make money to stay open. Until the government starts reimbursing more for Medicaid and increases subsidizes for non-reimbursed care, private hospitals will be re-routing patients to county/city hospitals, and EMTALA only stops them (or tries to) from being dangerous about it. End result--ERs close down. This has happened in California (lowest ER doctor to population ratio, among the longest wait times) and we're seeing it happening in Manhattan and the borroughs here--ERs are not viable, they close down, all patients who went there are re-routed to city hospitals, long wait times become even longer. City hospitals become crazy places where youwait forever and no insured pt wants to go to. what's the solution? i dont know.

.

abbaroodle said:

I wish I believed the problem was limited to U of C and not an omen of the future of emergency medicine.

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It's definitely not limited to Chicago nor is it anything new. It's been around for a while and has been talked about on SDN for several years (see link). It is likely to be the future indeed.


http://forums.studentdoctor.net/showthread.php?t=167548

Did anyone see the ACEP news release on this, pretty interesting. I also posted the UC's response.

http://acep.org/pressroom.aspx?id=44294

http://www.uchospitals.edu/news/highlight12.html

Wow, pretty strong stance from ACEP. Even if the ACEP Pres did not try to verify facts (which should have been done), two big players at UChicago resigning? Something must be going on.

leorl said:

Wow, pretty strong stance from ACEP. Even if the ACEP Pres did not try to verify facts (which should have been done), two big players at UChicago resigning? Something must be going on.

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What's going on is that the EM/IM residency programs are sending a message to the administration that they're committed to caring for Chicago's southside population. You have to separate the clinicians from the financial board when analyzing the U of C situation. The vision is not a shared one. Don't think for one moment that the ER residents purposely sent a severely mauled kid out the door. When your subspecialty services refuse to accept consults on underinsured patients (b/c of the policy set by the admins) where are these patients supposed to follow-up ----> Cook County Hospital