Can a hospitalist do an abscess I&D if there is no general surgeon?

[wrkndply]

if you admit a patient for a gluteal cellulitis and they form an abscess and you don't have gen Surg back up would a hospitalist be allowed to make a small knick and drain the abscess if they feel comfortable managing it?

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[DrMetal]

if you admit a patient for a gluteal cellulitis and they form an abscess and you don't have gen Surg back up would a hospitalist be allowed to make a small knick and drain the abscess if they feel comfortable managing it?

You can do any procedure if and only if you're credentialed by the hospital to do it.

If not, find somebody else (GS, IR, ER)

 

[dozitgetchahi]

You can do any procedure if and only if you're credentialed by the hospital to do it.

If not, find somebody else (GS, IR, ER)

Exactly.

On the other hand, out here in the sticks (where it sounds like OP is from given no GS available), hospitalists and FM docs can and do attempt to manage stuff like this themselves. Is it a good idea? Given the disastrous outcomes I’ve seen in these situations, I’d say no, but that never seems to keep anyone from trying it.

One thing I picked up from my surgery rotation as a medical student is that it can be hard to judge if a “simple abscess” is actually the tip of a massive iceberg of problems brewing under the surface. Proceed carefully.

 

[shouldigomd]

I wouldn't for several reasons. You / the hospital probably wont get reimbursed. You assume liability. It is outside your scope of practice. Nobody cares if you are trying to do the right thing.

 

[AlbinoHawk DO]

Exactly.

On the other hand, out here in the sticks (where it sounds like OP is from given no GS available), hospitalists and FM docs can and do attempt to manage stuff like this themselves. Is it a good idea? Given the disastrous outcomes I’ve seen in these situations, I’d say no, but that never seems to keep anyone from trying it.

One thing I picked up from my surgery rotation as a medical student is that it can be hard to judge if a “simple abscess” is actually the tip of a massive iceberg of problems brewing under the surface. Proceed carefully.

Yup, those damn sinus tracts. It can get crazy, I think the only abscess that might be reasonable to drain without backup is one where the patient comes to clinic with a small abscess accompanied by stable vitals and labs. The likelihood that it's superficial is high. In a hospitalized patient, you're likely asking for trouble

 

[chessknt]

If it is superficial and on an extremity absolutely. Gluteal where it can turn in to a surgical problem easily--absolutely not. Just transfer for access to a surgeon.

 

[Osteoth]

Came here and did not find what I expected lol.

 

[Make Or Break]

Personally, I don’t believe it would be wrong to drain a superficial abscess in an admitted patient for pain relief if the surgeon is already consulted and going to be doing an I&D anyways as long as it’s not midline to the spine or overlying some other delicate structure like the hand. Do I want to I&D an abscess the ER doc didn’t drain themselves for whatever reason and I’m 8 admits deep? Probably not.

 

[Osteoth]

Anyone work somewhere where the ED is staffed with mid levels?

 

[rokshana]

Anyone work somewhere where the ED is staffed with mid levels?

What ED doesn’t have midlevels?
Or do you mean exclusively midlevels? God I hope not!

 

[Make Or Break]

What ED doesn’t have midlevels?
Or do you mean exclusively midlevels? God I hope not!

They are out there in the more rural locations.

 

[Osteoth]

What ED doesn’t have midlevels?
Or do you mean exclusively midlevels? God I hope not!

Exclusively.

 

[DrMetal]

Personally, I don’t believe it would be wrong

It don't matta what you believe. It matters what you're credentialed to do.

 

[NewYorkDoctors]

It don't matta what you believe. It matters what you're credentialed to do.

agreed.

I&D is a procedure that is dictated by your hospital's delineation of privileges and that is dictated based on your malpractice insurance.

If you do anything outside of your malpractice insurance or delineation of privileges, then you can still bill for it and get paid. But if anything goes wrong, you have no defense for this.

Imaging these ten high priced lawyers at your court hearing (yes the GIF has 5 lawyers but im referring to another episode of the simpsons with 10 high priced lawyers - bonus points to anyone who can point out which episode I am referring to) :

"so Dr so and so... you are specialized in ... Internal Medicine? Not surgery right? Do you have the credentials and malpractice coverage to do this? why not? ladies and gentlemen of the jury. I submit to you a doctor who does NOT have the proper credentials to have done this procedure."

"but it was the right thing to do!"

"but did you have the proper backup in case something went wrong?"

"jury: i want to go home. guilty"

I do some I&D in my office for primary care patients now and then if its on the extremity or possibly another area. I do a point of care Ultrasound and confirm an actual abscess (rather than cellulitis cobblestone pattern or a lymph node - don't want to be lancing into those.... ) and not too deep first

but for a gluteal abscess? i'm not touching it. I will do more harm than good potentially. do I know how to follow up on it if it becomes a surgical issue? nope I do not.

ultimately lawyers and defensive medicine or not , just remember primum no nocere

 

[HemeOncHopeful19]

It don't matta what you believe. It matters what you're credentialed to do.

And interestingly as I have learned in the EM forums, if you are credentialed to do something, even if you never normally do it, then you can be called an EMTALA violation for refusing to do it.

As a side note I’m curious if you can even legally call yourself a hospital without at least one general surgeon?

 

[DrMetal]

And interestingly as I have learned in the EM forums,

You lurk around in the EM forums too? I stopped going there, got too depressing. All the talk about needing to "take back their specialty" from the mid-levels (of course, they talk a big talk on SDN).

 

[dozitgetchahi]

And interestingly as I have learned in the EM forums, if you are credentialed to do something, even if you never normally do it, then you can be called an EMTALA violation for refusing to do it.

As a side note I’m curious if you can even legally call yourself a hospital without at least one general surgeon?

It’s an interesting question. I have heard of tiny 30 bed “critical access hospitals” that didn’t have much aside from EM, a hospitalist and surgery, but I don’t know that I’ve heard of a hospital that doesn’t have a surgeon available. On the other hand, out here in flyover county, you’d be shocked at what institutions seem to get away with just because “that’s all we got and we can’t find anyone”.

 

[TooMuchResearch]

What's the hang-up here on stabbing butt abscesses? As long as it's not a peri-rectal abscess then we're just talking about normal old subcutaneous purulence, this is easy and the right thing to do if you're credentialed and know how to do it.

 

[InternistDO]

What's the hang-up here on stabbing butt abscesses? As long as it's not a peri-rectal abscess then we're just talking about normal old subcutaneous purulence, this is easy and the right thing to do if you're credentialed and know how to do it.

My feeling is that if a patient is getting admitted for an abscess, it's probably a fairly complex one or at least has the potential to be. I don't think anyone is saying you shouldn't I&D some small gluteal abscess in the ED or clinic and send the patient home.

 

[TooMuchResearch]

My feeling is that if a patient is getting admitted for an abscess, it's probably a fairly complex one or at least has the potential to be. I don't think anyone is saying you shouldn't I&D some small gluteal abscess in the ED or clinic and send the patient home.

I guess I assumed it wasn't the primary reason for admission otherwise they would be sent somewhere with a surgeon