Consultants Cherry Picking Patients

[DissocativFugue]

For all you seasoned docs out there, what have you done in the past if you have a specialist on cal who balks when you call them. For instance, someone having a mycotic abdominal aneurysm (6.7 cm with free fluid and contained rupture!) and we have CT surgery on call. They stated they wouldn't be comfortable with the case and recommended transfer to the local academic center. They stuck to their guns even after mentioning EMTALA. I called ad sup who bumped it up admin and in parallel got transfer center involved. Patient was accepted by the other facility prior to resolution in house. Luckily, BP was stable.

I've also run into this with ORS stating they are not comfortable with this or that fracture and recommending transfer, but those are within our large system of hospitals making EMTALA an unlikely scenario but still concerning. It always feels like they are doing a wallet biopsy before denying or accepting care. How far do you question their practice recommendations? Who do you get involved to help with these conundrums. Our other docs just go by what their rec is for the most part even though they think it is sketch too. While I don't want to ruffle feathers unnecessarily, I feel they are acting a little chicken **** and being paid on call to do so.


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[UKEMdoc]

Do your surgeons get ranked by raw mortality?

(Allegedly) this is an issue with UK cardiothoracics

 

[em1234]

On these weak transfer requests, I always ask the consultant what SPECIFICALLY they need that we don't have at our hospital. If they can't give me a specific thing or they give me some BS thing like "I'm not comfortable", I tell the consultant that I will start the transfer, but should the receiving specialist give me a bunch of heat about it or really wants to know why it isn't being handled locally, I will forward the call to our specialist's cell, so he/she can plead their own case for the transfer. Works great.
I have successfully taken myself out of the middle of some BS urology, NSGY and ortho transfers with that move. They have a specialist to specialist discussion and I get a call back from the transfer center with an acceptance or my consultant calls back and takes the patient. Either way it works for me.

 

[WilcoWorld]

On these weak transfer requests, I always ask the consultant what SPECIFICALLY they need that we don't have at our hospital. If they can't give me a specific thing or they give me some BS thing like "I'm not comfortable", I tell the consultant that I will start the transfer, but should the receiving specialist give me a bunch of heat about it or really wants to know why it isn't being handled locally, I will forward the call to our specialist's cell, so he/she can plead their own case for the transfer. Works great.
I have successfully taken myself out of the middle of some BS urology, NSGY and ortho transfers with that move. They have a specialist to specialist discussion and I get a call back from the transfer center with an acceptance or my consultant calls back and takes the patient. Either way it works for me.

I think that having the consultant speak with the recipient is a good idea. Another option is to make the consultant come see the patient in the ED prior to transfer, but that introduces a lot of difficulties.

 

[gutonc]

I think that having the consultant speak with the recipient is a good idea. Another option is to make the consultant come see the patient in the ED prior to transfer, but that introduces a lot of difficulties.

As the consultant occasionally in situations like this, I will call the receiving place myself as soon as I get off the phone with you guys. I explain why it can't (or shouldn't) be handled where the patient currently is (of the 7 hospitals where I have privileges, only 2 or 3 of them can handle acute leukemics which is about 90% of my transfer requests) and rarely, if ever, get any pushback.

If I'm not going to take care of it, I want to make it as easy as possible for everybody else.

 

[Psai]

Please get your specialists to come in and see the patient. The number of patients transferred from outside hospitals that get seen by our specialists and then dumped onto medicine after being deemed "nonoperative" is mindboggling.

 

[erdoc00]

As the consultant occasionally in situations like this, I will call the receiving place myself as soon as I get off the phone with you guys. I explain why it can't (or shouldn't) be handled where the patient currently is (of the 7 hospitals where I have privileges, only 2 or 3 of them can handle acute leukemics which is about 90% of my transfer requests) and rarely, if ever, get any pushback.

If I'm not going to take care of it, I want to make it as easy as possible for everybody else.

This is the difference between someone who actually isn't comfortable vs a lazy physician trying to punt with the least amount of effort.

I'm amazed at the amount of doctors in highly competitive specialities that suddenly no longer have any sense of integrity or work ethic.

The most "incapable" physicians seem to be fellowship trained orthopods... especially ironic given graduating in the top 1/3 of their class and then 5 years of residency plus 1-2 years of fellowship. Very unfortunate...

 

[EctopicFetus]

Its pretty simple. They arent hungry and feel no moral obligation. In my city, we have 1 ENT on call which happens to be at an academic center (aka residents). This is probably for a catchment of 3+M people.

Reality is they dont need the hospitals, they will get the outpt referrals and get paid for their work. From what I hear this is a national problem. I can see their perspective but it is bad for the system.

I dont blame them fully, in many instances hospitals dont want to pay stipends. I dont see the CEO, CMO,CNO etc coming in at 2 am.

 

[DissocativFugue]

Do your surgeons get ranked by raw mortality?

(Allegedly) this is an issue with UK cardiothoracics

As far as I'm aware, they are only ranked by God and the Texas medical board. Oh and maybe lawyers/trial juries.


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[Psai]

As far as I'm aware, they are only ranked by God and the Texas medical board. Oh and maybe lawyers/trial juries.


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They rank themselves?

 

[gman33]

I agree with asking about specific issues.
Maybe they would be better served with a different intervention.
I don't pretend to understand all the interventional options, and if someone can't do what is best for the patient, I'm fine with the transfer.

What does suck is when someone is trying to avoid work, or transferring a patient who isn't really a surgical candidate.

Ideally the consultant should come see the patient, put a note in the chart and help facilitate the transfer.

But we don't work in an ideal world.

 

[pulmoblast]

Can the ED say I am not comfortable transferring this patient ? Whose responsibility is it if the aneurysm bursts in the van and the patient dies ?


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[Arcan57]

For all you seasoned docs out there, what have you done in the past if you have a specialist on cal who balks when you call them. For instance, someone having a mycotic abdominal aneurysm (6.7 cm with free fluid and contained rupture!) and we have CT surgery on call. They stated they wouldn't be comfortable with the case and recommended transfer to the local academic center. They stuck to their guns even after mentioning EMTALA. I called ad sup who bumped it up admin and in parallel got transfer center involved. Patient was accepted by the other facility prior to resolution in house. Luckily, BP was stable.

I've also run into this with ORS stating they are not comfortable with this or that fracture and recommending transfer, but those are within our large system of hospitals making EMTALA an unlikely scenario but still concerning. It always feels like they are doing a wallet biopsy before denying or accepting care. How far do you question their practice recommendations? Who do you get involved to help with these conundrums. Our other docs just go by what their rec is for the most part even though they think it is sketch too. While I don't want to ruffle feathers unnecessarily, I feel they are acting a little chicken **** and being paid on call to do so.


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Admin generally isn't happy to hear that they're paying money to docs on call who are shifting operative cases to another hospital.

Can the ED say I am not comfortable transferring this patient ? Whose responsibility is it if the aneurysm bursts in the van and the patient dies ?

The ED doc. You can say you're not comfortable transferring but then you're on the hook for delaying transfer when the patient dies in your hospital. It's a bad situation all around.
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[DissocativFugue]

They rank themselves?

It's a polytheistic system from our perspective. Maybe not theirs.


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[JustPlainBill]

On these weak transfer requests, I always ask the consultant what SPECIFICALLY they need that we don't have at our hospital. If they can't give me a specific thing or they give me some BS thing like "I'm not comfortable", I tell the consultant that I will start the transfer, but should the receiving specialist give me a bunch of heat about it or really wants to know why it isn't being handled locally, I will forward the call to our specialist's cell, so he/she can plead their own case for the transfer. Works great.
I have successfully taken myself out of the middle of some BS urology, NSGY and ortho transfers with that move. They have a specialist to specialist discussion and I get a call back from the transfer center with an acceptance or my consultant calls back and takes the patient. Either way it works for me.

I saw this and it raised a question --- I'm a newly minted FM attending -- been out about 3 years; My first job out of residency was as an employed physician at a critical access hospital --- mainly outpatient but 6 of us rotated weekend coverage -- the other 5 docs had outpatient practices and 2 had a LOT of nursing home patients plus we had a VA hospital and we took their patients when there was no room at the local large VA center about 60 miles away. The hospital had a small 3 bed ER, no specialists available, an "ICU" which was more of a step down unit -- the next biggest hospital was 30 minutes away by ambulance, ER didn't even have a bougie in the crash cart, much less a cric kit, nurses did pretty much what they wanted, including admit patients to the physician's service without telling the physician, etc.

Anyway, one night I got a call from the FM hospitalist who was working the ER as part of an ER staffing firm doing some locums work -- calls me one night for an admission -- 89 y/o WM with PMH of COPD, CHF, DM with bilateral PNA per XRays, SpO2% in the low 90s who had gone into new onset aFib in the ER but was now back in NSR --- I lived 30 minutes away at the time --- I declined the admission stating that I felt the patient needed a higher level of care than we could provide at the time. The hospitalist started busting my chops as to why I was declining, all the patient needed was "IV floods" and IV Unasyn and observation in the "ICU" --- I pretty much told him that the acuity was more than I felt comfortable handling, especially without a dedicated, trained ICU nurse (they would just pull floor nurses over to watch the "ICU" patients), a patient who already had low sats with multiple comorbidities who had gone into aFib with no cardiology/pulmonology support -- transfer the patient.....

To me, it was the right call, given the context --- The administrators wanted to take anything and everything, including surgical cases with no SICU or nursing support, I left shortly after that as things were getting a little iffy ---

 

[BAM!]

I've run into this situation. If I think it's a BS transfer, I bring up EMTALA. If it's a weird one that would be better served by a tertiary care center (and not by community surgeon 20 yrs out of residency), then I make the call for the transfer, but also have them do a doc-to-doc discussion. If I get pushback from the transfer center then I tell them our specialist does not do that procedure.

in most cases, transferring this weird stuff, mycotic ruptured AAA, would probably be better at an academic tertiary care institution.

 

[em1234]

I saw this and it raised a question --- I'm a newly minted FM attending -- been out about 3 years; My first job out of residency was as an employed physician at a critical access hospital --- mainly outpatient but 6 of us rotated weekend coverage -- the other 5 docs had outpatient practices and 2 had a LOT of nursing home patients plus we had a VA hospital and we took their patients when there was no room at the local large VA center about 60 miles away. The hospital had a small 3 bed ER, no specialists available, an "ICU" which was more of a step down unit -- the next biggest hospital was 30 minutes away by ambulance, ER didn't even have a bougie in the crash cart, much less a cric kit, nurses did pretty much what they wanted, including admit patients to the physician's service without telling the physician, etc.

Anyway, one night I got a call from the FM hospitalist who was working the ER as part of an ER staffing firm doing some locums work -- calls me one night for an admission -- 89 y/o WM with PMH of COPD, CHF, DM with bilateral PNA per XRays, SpO2% in the low 90s who had gone into new onset aFib in the ER but was now back in NSR --- I lived 30 minutes away at the time --- I declined the admission stating that I felt the patient needed a higher level of care than we could provide at the time. The hospitalist started busting my chops as to why I was declining, all the patient needed was "IV floods" and IV Unasyn and observation in the "ICU" --- I pretty much told him that the acuity was more than I felt comfortable handling, especially without a dedicated, trained ICU nurse (they would just pull floor nurses over to watch the "ICU" patients), a patient who already had low sats with multiple comorbidities who had gone into aFib with no cardiology/pulmonology support -- transfer the patient.....

To me, it was the right call, given the context --- The administrators wanted to take anything and everything, including surgical cases with no SICU or nursing support, I left shortly after that as things were getting a little iffy ---

So in this scenario, if I called you, you would tell me that this patient needs cards and pulm, none of which you had at your little hospital in the middle of no where. That would get no push back from me to transfer and away they'd go.

The "BS not comfortable" element comes into play when the resources you need are clearly there, and you balk at taking the patient. If you had pulm and cards available at that place and you still wanted to ship them because they were moderately sick and you lived too far away to feel that you could provide appropriate attention to the patient I'd recommend you come in and take your call from the inhouse call room or I'd be handing you the phone to explain the transfer. I'm quite certain, not having a dedicated ICU nurse is enough to justify the transfer, especially if that is the way your hospital routine handles these patients.

 

[southerndoc]

There are various reasons consultants don't want to take on cases, and I usually respect their decision if it seems reasonable. If an ophthalmologist hasn't seen a ruptured globe since his residency 10 years ago, do you really want that person operating on your family member or would you prefer it be sent to a place that sees them frequently?

 

[JustPlainBill]

So in this scenario, if I called you, you would tell me that this patient needs cards and pulm, none of which you had at your little hospital in the middle of no where. That would get no push back from me to transfer and away they'd go.

The "BS not comfortable" element comes into play when the resources you need are clearly there, and you balk at taking the patient. If you had pulm and cards available at that place and you still wanted to ship them because they were moderately sick and you lived too far away to feel that you could provide appropriate attention to the patient I'd recommend you come in and take your call from the inhouse call room or I'd be handing you the phone to explain the transfer. I'm quite certain, not having a dedicated ICU nurse is enough to justify the transfer, especially if that is the way your hospital routine handles these patients.

Thank you --- I went to a weak residency that was pretty abusive --- we were left to learn on our own without adult supervision and the upper levels had advanced cases of Stockholm Syndrome -- by your answer, you've confirmed again, that Yes, JPB, you really do know WTF you're doing, you just need to realize it -- in most cases, I've made the right call while others (administration and other physicians) have tried to bully me into risky situations for their own reasons.

 

[Atlas Shrugged]

There are various reasons consultants don't want to take on cases, and I usually respect their decision if it seems reasonable. If an ophthalmologist hasn't seen a ruptured globe since his residency 10 years ago, do you really want that person operating on your family member or would you prefer it be sent to a place that sees them frequently?

Serious question from a medical student: why is that ophthalmologist on call?

 

[shoal]

Serious question from a medical student: why is that ophthalmologist on call?

Because someone has to be on call ....


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[BAM!]

Serious question from a medical student: why is that ophthalmologist on call?

maybe you need to arrange follow up for a corneal ulcer or guidance with acute glaucoma medications, for example. Globe ruptures are rare. Sure he may be able to treat it, but if it's been 10 years since he's seen one then it's better to transfer to the trauma center.

Hospitals need to have a panel of at least some specialists. Even if they can't come in to take care of a ruptured globe, they may be able to offer some advice with regards to other disease processes.



On a side note: As a medical student, I understand you're still learning. Try to avoid the trap that millennials fall into of having unrealistic expectations and standards. These consultants are people, just like you and me, with limitations of their abilities. Just because they don't feel comfortable handling the most serious complication of the eye at a janky hospital (which likely doesn't even have a good slit lamp) doesn't mean they are incompetent or shouldn't be on call at all.

 

[Doctor Bob]

The difficulty lies in teasing out the difference between "I don't feel comfortable taking care of condition X because I haven't seen it in years" and "I don't want to take care of condition X because it's risky / they're uninsured / I'm lazy" etc.
The consultant certainly isn't going to come out and say the latter.

So when it's an issue of institutional support for condition X, I make the call to transfer them. I can speak for why our hospital can't care for the patient.
If it's an issue of consultant comfort with taking care of condition X, I have the consultant call the receiving hospital to facilitate the transfer. They can speak as to why they specifically can't care for the patient.

 

[Gastrapathy]

There are some other considerations. Is the doctor a hospital employee? What do your bylaws say? Do you want to drive cash cow specialists who keep the lights on to go somewhere else? I know a GI group that was getting no stipend (or maybe a small one) who just stopped taking call. The hospital is paying for a locum and if they have a complication, they might come round but don't have to. I heard it was originally a negotiating ploy to get a real stipend but now they don't see any reason to go back. Hasn't hurt their business yet. They took the ~30% of their outpt business that they were doing at the hospital Endo center with them.

BTW OP, Your example is a text book case of a patient that should transfer to the tertiary center. Not dying this minute and would benefit from someone who has done that surgery this year. Why would you make that surgeon come in when it's obvious over the phone? I'd want my Dad transferred.

Oh, and @Psai, IM will always be a dumping ground. That's why there are subs.

 

[betamale]

For all you seasoned docs out there, what have you done in the past if you have a specialist on cal who balks when you call them. For instance, someone having a mycotic abdominal aneurysm (6.7 cm with free fluid and contained rupture!) and we have CT surgery on call. They stated they wouldn't be comfortable with the case and recommended transfer to the local academic center. They stuck to their guns even after mentioning EMTALA. I called ad sup who bumped it up admin and in parallel got transfer center involved. Patient was accepted by the other facility prior to resolution in house. Luckily, BP was stable.

I've also run into this with ORS stating they are not comfortable with this or that fracture and recommending transfer, but those are within our large system of hospitals making EMTALA an unlikely scenario but still concerning. It always feels like they are doing a wallet biopsy before denying or accepting care. How far do you question their practice recommendations? Who do you get involved to help with these conundrums. Our other docs just go by what their rec is for the most part even though they think it is sketch too. While I don't want to ruffle feathers unnecessarily, I feel they are acting a little chicken **** and being paid on call to do so.


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consultant understood their limitations and the institution's limitations. I've seen many cases get transferred if the surgeon does not trust the capabilities of the hospital staff or the institution lacks equipment or subspecialty support.

 

[Psai]

There are some other considerations. Is the doctor a hospital employee? What do your bylaws say? Do you want to drive cash cow specialists who keep the lights on to go somewhere else? I know a GI group that was getting no stipend (or maybe a small one) who just stopped taking call. The hospital is paying for a locum and if they have a complication, they might come round but don't have to. I heard it was originally a negotiating ploy to get a real stipend but now they don't see any reason to go back. Hasn't hurt their business yet. They took the ~30% of their outpt business that they were doing at the hospital Endo center with them.

BTW OP, Your example is a text book case of a patient that should transfer to the tertiary center. Not dying this minute and would benefit from someone who has done that surgery this year. Why would you make that surgeon come in when it's obvious over the phone? I'd want my Dad transferred.

Oh, and @Psai, IM will always be a dumping ground. That's why there are subs.

I'm just saying don't get pissy at me when you're bringing that "nonoperative" patient to the OR for the third time and the patient should go back to sicu

 

[UKEMdoc]

I thought aneurysms did better if you transferred them to someone who knows what they're doing? If you do less than one a year you might as well use magic crystals for all the good you're going to do.

My understanding is that once they crash in front of you then they're probably going to die. All resuscitation does is speed up the bleeding.

 

[Jlaw]

Why not just refer everyone to the academic center and cut the lazy people out of the pie?

 

[deleted109597]

Why not just refer everyone to the academic center and cut the lazy people out of the pie?

There aren't enough of them, and the ones that are there are usually pretty full.
And again, while some of the consultants are lazy, they all aren't. Some aren't good at certain things. Invariably when I need ophthal on call, they sub-subspecialize in the part of the eye that isn't the problem. Things like, the retina guy won't help me with herpes keratitis.

Remember your Malcolm Gladwell. You want to be somewhere where the people do a lot of the procedure and are therefore good at it. Any of us could learn the mechanics of taking out an appendix. Very few of us would be good at it.

 

[Jlaw]

There aren't enough of them, and the ones that are there are usually pretty full.
And again, while some of the consultants are lazy, they all aren't. Some aren't good at certain things. Invariably when I need ophthal on call, they sub-subspecialize in the part of the eye that isn't the problem. Things like, the retina guy won't help me with herpes keratitis.

Remember your Malcolm Gladwell. You want to be somewhere where the people do a lot of the procedure and are therefore good at it. Any of us could learn the mechanics of taking out an appendix. Very few of us would be good at it.

I understand that people specialize in certain things but there is nothing that infuriates me more in medicine than people trying to talk their way out of doing their job, or deciding that they will only hand parts of their job that are easy for them. Do you really need any more skills to handle herpes keratitis vs retina after you've been trained as an optho? Thats like us saying I'm an emergency medicine doc who specializes in dispo'ing head injury but I don't do chest tubes. I guess I'm going to be getting into some fights.

 

[Apollyon]

I understand that people specialize in certain things but there is nothing that infuriates me more in medicine than people trying to talk their way out of doing their job, or deciding that they will only hand parts of their job that are easy for them. Do you really need any more skills to handle herpes keratitis vs retina after you've been trained as an optho? Thats like us saying I'm an emergency medicine doc who specializes in dispo'ing head injury but I don't do chest tubes. I guess I'm going to be getting into some fights.

I had a **** job once, and, one lovely Saturday afternoon, two patients came in within 4 minutes of each other. The fast track NP is really good. One injury is an intra-articular finger fracture. The other is a Colle's fracture. Ortho on call? He tells the NP that the Colle's fracture is "too complex" to do there, so the pt needs to be transferred. However, the intra-articular fracture? Not too complex, and he'll see that in the office on Monday.

**** job.

 

[DissocativFugue]

I had a **** job once, and, one lovely Saturday afternoon, two patients came in within 4 minutes of each other. The fast track NP is really good. One injury is an intra-articular finger fracture. The other is a Colle's fracture. Ortho on call? He tells the NP that the Colle's fracture is "too complex" to do there, so the pt needs to be transferred. However, the intra-articular fracture? Not too complex, and he'll see that in the office on Monday.

**** job.

Thanks for everyone's view points. I suppose I could have expounded. What irritated me is not mycotic aneurysm going to a university hospital. It's the point made above. The specialist that states one fx is too complex for them at 9 pm but is happy to see it at 10 am. The CT surgeon in my example looked at the images and then was like "yeah that's not an infected aneurysm, but let's go ahead and transfer." I get it though, now that I've had some time to reflect. This person does plenty of aneurysm surgeries but probably not infected ones. I was just using the example as a talking point for everyone's decision making when it comes to transfers.


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[Siggy]

I understand that people specialize in certain things but there is nothing that infuriates me more in medicine than people trying to talk their way out of doing their job, or deciding that they will only hand parts of their job that are easy for them. Do you really need any more skills to handle herpes keratitis vs retina after you've been trained as an optho? Thats like us saying I'm an emergency medicine doc who specializes in dispo'ing head injury but I don't do chest tubes. I guess I'm going to be getting into some fights.

Strange... I have the same question when EM admits the peritonsilar abscess to IM with ENT following instead of EM draining it at bedside.

 

[The White Coat Investor]

Why not just refer everyone to the academic center and cut the lazy people out of the pie?

The academic docs push back because they feel dumped on all the time and they're on salary. We're transferring their institution money, but not to them directly. "Don't you guys have an ophthalmologist out there? Have you called him?"

 

[JustPlainBill]

Strange... I have the same question when EM admits the peritonsilar abscess to IM with ENT following instead of EM draining it at bedside.

Ah, yes, off topic a bit -- I recall the look on the 19 year old's face when, while he was sitting in a trauma bay at Chateau Parkland, he had a bottle of Hurricane spray and a laryngoscope in his hand and was instructed to spray where it hurt the most and then hold his tongue down with the laryngoscope --- as I pulled the syringe with the spinal needle/sleeve clipped 1cm short combination from behind my back and jammed the needle straight into the obvious abscess and withdrew about 5cc of thick, nasty, purulent drainage, his eyes got about as wide as quarters but once I removed the syringe, he gasped out,"Oh, God, Thank you doc" where he couldn't even speak before --- the Chief Resident turns to me and says,"Perfect" --- first one I did during my rotation there while an FM resident --- so then I go look at the anatomy and started shaking when I realized how close I was to some fairly significant structures ---- but hey, I had the Chief there with me and he knew his stuff....good times....

Later on at Children's Dallas, kid came in with an abscess -- got admitted and was taken by ENT down to surgery for drainage -- kid was 15....

God I miss my time at the Parkland ER. Great team of people and a good place to learn.

 

[Psai]

Why not just refer everyone to the academic center and cut the lazy people out of the pie?

Because we have enough on our plate. I find it strange that their board certified consultants can't do the things that our residents and fellows can.

 

[vendtex]

What you "can do" in the context of a training hospital with well trained nurses and subspecialty support isn't necessarily relevant to a community hospital. Also if you are salary based vs e.g. RVU based compensation and don't have hospitalists or residents it may be impractical to keep a patient that consumes too much of your time at the expense of seeing patients on the outpatient side.


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[maxxor]

What you "can do" in the context of a training hospital with well trained nurses and subspecialty support isn't necessarily relevant to a community hospital. Also if you are salary based vs e.g. RVU based compensation and don't have hospitalists or residents it may be impractical to keep a patient that consumes too much of your time at the expense of seeing patients on the outpatient side.


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Similar thing happened here when I was on surgery as an intern.

50s M comes in with cold feet. CTA shows chronic aortic occlusion. Virgin abdomen. Vascular surgeon on call requests transfer because "the post-op care will not be adequate here for the open repair he needs". The surgery may be doable at the community hospital 30 miles from the big center, but if the nurses and associated staff are not comfortable with that sort of patient, that's a recipe for bad outcomes.

 

[BAM!]

...Thats like us saying I'm an emergency medicine doc who specializes in dispo'ing head injury but I don't do chest tubes. I guess I'm going to be getting into some fights.

I'm and emergency medicine doc who doesn't do ingrown toenails. ;D

 

[BAM!]

Thanks for everyone's view points. I suppose I could have expounded. What irritated me is not mycotic aneurysm going to a university hospital. It's the point made above. The specialist that states one fx is too complex for them at 9 pm but is happy to see it at 10 am. ...

I'm OK with referring non-emergency problem to specialist to evaluate when he's wide awake and not sleepy. Trust me, just like the rest of us, surgeons do better work when they are well rested.

 

[Jlaw]

Strange... I have the same question when EM admits the peritonsilar abscess to IM with ENT following instead of EM draining it at bedside.

I pop those suckers and send em home or call ENT to come deal with it in the ED.

 

[Jlaw]

I'm and emergency medicine doc who doesn't do ingrown toenails. ;D

I enjoy anything I can do a nerve block on and just hack off.

 

[ThoracicGuy]

For all you seasoned docs out there, what have you done in the past if you have a specialist on cal who balks when you call them. For instance, someone having a mycotic abdominal aneurysm (6.7 cm with free fluid and contained rupture!) and we have CT surgery on call. They stated they wouldn't be comfortable with the case and recommended transfer to the local academic center. They stuck to their guns even after mentioning EMTALA. I called ad sup who bumped it up admin and in parallel got transfer center involved. Patient was accepted by the other facility prior to resolution in house. Luckily, BP was stable.

I've also run into this with ORS stating they are not comfortable with this or that fracture and recommending transfer, but those are within our large system of hospitals making EMTALA an unlikely scenario but still concerning. It always feels like they are doing a wallet biopsy before denying or accepting care. How far do you question their practice recommendations? Who do you get involved to help with these conundrums. Our other docs just go by what their rec is for the most part even though they think it is sketch too. While I don't want to ruffle feathers unnecessarily, I feel they are acting a little chicken **** and being paid on call to do so.


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Do your CT surgeons typically do vascular surgery as well? Do they do many abdominal aneurysm open repairs?

 

[gman33]

Recently had a case where a smaller hospital wanted to send me a patient because their on call specialist refused to see a patient due to insurance reasons. Clear violation.

The patient needed help, so I told them to send them over.

The irony was that I found out the same doc was providing coverage at my hospital.

I didn't take no for an answer.

 

[Psai]

I enjoy anything I can do a nerve block on and just hack off.

Read this wrong and thought you were from New York for a second

 

[RustedFox]

Read this wrong and thought you were from New York for a second

Zzzzzing!