CEO of hospital called angry that I refused GI Bleed transfer.

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TulaneUnderdog

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I will do my best to keep this concise. I am a nocturnist working at a 150-bed hospital with services available but not all of them. We are a tertiary hospital to a much larger system within a 30-60 mile radius where there is a main hospital with trauma level 1 and all specialties actually on-site overnight; I plus an ER doctor are literally the only MDs on-site in this hospital. We have GI we can call in for any emergent procedures but we dont have IR. We have ICU but our intensivists are simply off-site teleconsults so its really us running the ICU and giving them a call for questions and orders. I have made mistakes accepting transfers “too sick” for our hospital and had to transfer out: such as a patient with hemo-thorax needing CT-surgery (which we have) but our CT surgery noted the patient needs an aorta repair and needs to be air lifted to another hospital. I also was pitched by the ED that a pregnant woman is having “appendicitis” but they dont have MRI to prove it so I accepted when we MRI’ed it was actually an ectopic and we also had to airtransport her out for Ob/Gyn because she rapidly was declining and entering shock.

In this case, I was called about a patient with ETOH abuse and hx of gastric varices s/p Banding found down for unknown period with blood on the ground and around his mouth likely as if he had hematemesis. The ED noted he was hypotensive, Hb of 5, obtunded, and cold clammy in clear shock so they did massive transfusion protocol, stabilized him, intubated and placed a central line and wanted me to accept him to our ICU for GI eval. That was their whole pitch and I told them let me chart check but of course they didnt tell me things that I had to discover for myself on the EMR that he also had acute renal failure, his Cr gone from 1 to 7 (but we do have HD, vascular and nephro support so no biggie) and although they trended a Lactate (which did improve); they never repeated the H/H and the only value we have is the pre-transfusion 5Hb. I also asked my ED doc why there was no scan. I felt he bought himself a CT and we still dont know what kind of bleed this is nor do I know the tempo, severity, or rate of blood loss. Overall I was quite frustrated and refused saying I appreciate them overall stabilizing him but with the limited information I have; he may have a more lifethreatening bleed that may require IR and more emergent intervention.

I never heard any flac since until the next day; the hospital administration and housing supervisor were furious and said the patient ended up going to a competitor hospital and all he had there was just GI: an EGD and banding and he was stable without needing IR. I said hindsight is 20/20 and argued we have GI but always need IR in case but then they argued that in that case we can send him to our main hospital (we are a feeder hospital to a larger system). I disagreed saying it was best for the patient to not make multiple pit stops while critically ill, actively bleeding, and in shock. Then they said it was obviously varices as he had it in history and was resolved with banding which we can offer but i said that is anchoring and they gave me limited information to clinically say this was vx in nature. Also my GI rotation was now a distant past but if I recalled anything from those attendings, I remember that artery embolization may not be first line but should be considered in the super unstable and although patients may not need it, its best to go to facilities with both GI and IR communicating together in case crap goes south; whether failed EGD or where a CT scan when actually done could reveal something more ominous.

Overall I am quite sure I felt I did what is best for patient but now I am second guessing myself. I’m trying to replay the scenario again because I always admit GI Bleeds for about 20% of my admits and I wonder if I am called and get pitched about this same exact presentation, would I change my response. But my answer to myself would be a No. I considered maybe saying “lets CT then call me back” or “call my on-call GI” but time is Blood for this patient and a GI doc overnight in his mansion miles away with his blonde wife and Porsche would wake up to this l biased story and say “sure” without chart checking and seeing how sick he really is. I think if replayed, my answer still remains firm no.
 
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First I recommend you delete this post since this can be used against you (see below).

Second I have literally lived this exact scenario once upon a time before I became an intensivist I was a nocturnist in a regional outlier hospital with just 2 MDs in house overnight and spotty subspecialty coverage. This behavior is indicative of financial distress, small hospital politics and you being an outsider since you work alone at nights and are not part of the 'in' crowd. It will only get worse--the hospital admin is looking for people to blame for their failures and have apparently chosen to micromanage you. This is going to turn in to a pattern that will get formalized as they will force their friends in the med exec committee to start scrutinizing everything you do, open files on you etc so they can show the board the actual reason they suck at their job is your fault. Look for another job asap.

To the point of your scenario--wtf is the tele intensivist doing? Make them weigh in on this. Make GI weigh in on this. Make the ER call both of them and get them to say yes they can manage the patient with the resources at this hospital. It is not crazy to think a TIPS may be needed in someone who rebled after a banding assuming the banding was fairly recent but the GI might feel that isn't needed. As an intensivist I would recommend hospice since an active drinker who keeps drinking with bleeding varices is going to die no matter what anyone does....
 
I will do my best to keep this concise. I am a nocturnist working at a 150-bed hospital with services available but not all of them. We are a tertiary hospital to a much larger system within a 30-60 mile radius where there is a main hospital with trauma level 1 and all specialties actually on-site overnight; I plus an ER doctor are literally the only MDs on-site in this hospital. We have GI we can call in for any emergent procedures but we dont have IR. We have ICU but our intensivists are simply off-site teleconsults so its really us running the ICU and giving them a call for questions and orders. I have made mistakes accepting transfers “too sick” for our hospital and had to transfer out: such as a patient with hemo-thorax needing CT-surgery (which we have) but our CT surgery noted the patient needs an aorta repair and needs to be air lifted to another hospital. I also was pitched by the ED that a pregnant woman is having “appendicitis” but they dont have MRI to prove it so I accepted when we MRI’ed it was actually an ectopic and we also had to airtransport her out for Ob/Gyn because she rapidly was declining and entering shock.

In this case, I was called about a patient with ETOH abuse and hx of gastric varices s/p Banding found down for unknown period with blood on the ground and around his mouth likely as if he had hematemesis. The ED noted he was hypotensive, Hb of 5, obtunded, and cold clammy in clear shock so they did massive transfusion protocol, stabilized him, intubated and placed a central line and wanted me to accept him to our ICU for GI eval. That was their whole pitch and I told them let me chart check but of course they didnt tell me things that I had to discover for myself on the EMR that he also had acute renal failure, his Cr gone from 1 to 7 (but we do have HD, vascular and nephro support so no biggie) and although they trended a Lactate (which did improve); they never repeated the H/H and the only value we have is the pre-transfusion 5Hb. I also asked my ED doc why there was no scan. I felt he bought himself a CT and we still dont know what kind of bleed this is nor do I know the tempo, severity, or rate of blood loss. Overall I was quite frustrated and refused saying I appreciate them overall stabilizing him but with the limited information I have; he may have a more lifethreatening bleed that may require IR and more emergent intervention.

I never heard any flac since until the next day; the hospital administration and housing supervisor were furious and said the patient ended up going to a competitor hospital and all he had there was just GI: an EGD and banding and he was stable without needing IR. I said hindsight is 20/20 and argued we have GI but always need IR in case but then they argued that in that case we can send him to our main hospital (we are a feeder hospital to a larger system). I disagreed saying it was best for the patient to not make multiple pit stops while critically ill, actively bleeding, and in shock. Then they said it was obviously varices as he had it in history and was resolved with banding which we can offer but i said that is anchoring and they gave me limited information to clinically say this was vx in nature. Also my GI rotation was now a distant past but if I recalled anything from those attendings, I remember that artery embolization may not be first line but should be considered in the super unstable and although patients may not need it, its best to go to facilities with both GI and IR communicating together in case crap goes south; whether failed EGD or where a CT scan when actually done could reveal something more ominous.

Overall I am quite sure I felt I did what is best for patient but now I am second guessing myself. I’m trying to replay the scenario again because I always admit GI Bleeds for about 20% of my admits and I wonder if I am called and get pitched about this same exact presentation, would I change my response. But my answer to myself would be a No. I considered maybe saying “lets CT then call me back” or “call my on-call GI” but time is Blood for this patient and a GI doc overnight in his mansion miles away with his blonde wife and Porsche would wake up to this l biased story and say “sure” without chart checking and seeing how sick he really is. I think if replayed, my answer still remains firm no.
Why are you taking on so much as a nocturnist? Why not call the intensivist? I'm a pulm crit fellow now and I've realized that it's best to let IR and GI fight out about who needs endoscopic intervention vs IR procedure. If you're in a situation like this, you can share the burden and ask GI to weigh in. Or get CTA, see if there's active contrast extravasation and call IR/transfer out. Or say the patient is too unstable for floor and needs ICU. I also worked as a nocturnist and been in the same predicament. Nights are hard and sometimes you have to make decisions on the fly. But also, just ask the transfer line to rope in more people to make the decision easier. Did you admin guys have a better way to deal with situations like these?
 
Ty for the insight. Luckily as far as the politics go, our hospitalists dont directly work for the hospital but I’m part of a group contracted for that hospital. But ya, I have noticed a string of resignations as we have been pressured to accept all transfers as its been a big bulk of the admissions for our tiny hospital. We are definitely not the in crowd for sure
 
Ty for the insight. Luckily as far as the politics go, our hospitalists dont directly work for the hospital but I’m part of a group contracted for that hospital. But ya, I have noticed a string of resignations as we have been pressured to accept all transfers as its been a big bulk of the admissions for our tiny hospital. We are definitely not the in crowd for sure
The issue is the administrators there are incompetent, otherwise they wouldn't be personally micromanaging each transfer by yelling at you instead of figuring out what is driving that behavior and fixing that. This degree of administrative malfeasance is going to potentially result in reportable actions if they keep pushing it. I saw the writing on the wall and already had a pre-planned exit at my job so didn't care much when it started to happen and peaced out. You can of course try to stick it out but as a nocturnist you should be able to find work almost anywhere so I would tell them you are going to transfer yourself out of their ****ty hospital as well.
 
The only person looking out for that potentially transferring patient's best interest at your hospital is YOU.
The only person looking out for your medical liability interest when things go bad, is YOU.

Let others yell all they want. Leave or get fired with your potential patient and your integrity intact.
You act on the best information you have available to you at the moment.
 
Ty for the insight. Luckily as far as the politics go, our hospitalists dont directly work for the hospital but I’m part of a group contracted for that hospital. But ya, I have noticed a string of resignations as we have been pressured to accept all transfers as its been a big bulk of the admissions for our tiny hospital. We are definitely not the in crowd for sure

Admin will always want you to accept everything.

Full census=$$$

They have no skin in the game so they can eat $h!t.

If there is any bad outcome, you will be sued (and if damages are high enough, your personal assets are at risk) and/or your medical license is on the line with the state board.

I have yet to hear any hospital CEO or dummy hospital administrator ever get named in a lawsuit. So of course they don't care. The hospital itself is a faceless entity with deep pockets that will absorb any lawsuit while shielding admin.

Look out for the patient and yourself. That's it.
 
Admin will always want you to accept everything.

Full census=$$$

They have no skin in the game so they can eat $h!t.

If there is any bad outcome, you will be sued (and if damages are high enough, your personal assets are at risk) and/or your medical license is on the line with the state board.

I have yet to hear any hospital CEO or dummy hospital administrator ever get named in a lawsuit. So of course they don't care. The hospital itself is a faceless entity with deep pockets that will absorb any lawsuit while shielding admin.

Look out for the patient and yourself. That's it.
Similar corporate pressure can happen with for profit hospices.

Only the medical director has the substantial risk as they are the ones that attest to eligibility.
 
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