ER Dumping

[cyanide12345678]

We've all seen silly things sent to the ER by NPs - I mean they don't know any better, arent as well trained.

But sometimes PCPs really aren't that far behind.

Received a phone call from a PCP somewhat frantic about a bleeding injury to the hand. On the phone this PCP says she saw a patient who had a lot of bleeding from a wound on their hand. They apparently had a blister that popped. She says "I had no idea what to do so I'm sending it over. I actually initially told the patient to go to the regional trauma center so vascular surgery could see him, but then I saw they had 13 patients in their waiting room and I called the patient to detour to the nearest ER so they could be seen sooner. So they're turning around to come to you".

On arrival, patient had a 5 mm (yes milimeter) superficial tissue loss (skin pinched by a closing door 2 days ago) that started bleeding. Minimal blood. Lesion is smaller than the tip of my pinky finger, located on the hypothenar area of the hand - so no where near any large meaningful artery. The wound is superficial as well, nothing deep.

I put 2 bandaids on, bleeding stopped. Then just discharged him.

This is a M.D with 20+ years of attending experience. What is going on?!?!?!?!?!?! Vascular surgery for a skin tear of the hand? Literally this patient was initially told to drive 40 minutes away to the level 3 hospital for a surgical evaluation. I mean...this isn't even remotely close to a large artery and the patient was expressing how his PCP was really worried that he had an arterial bleeding. No. He just lost his epidermal layer of skin, and that too happened 2 days ago -_- This wasn't even a situation where the patient hadn't been seen. Patient was seen in clinic and sent to ER frantically because of uncontrolled bleeding and concern for "arterial injury requiring vascular surgery".

Rant over.

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[valianteffort]

if it requires more than 1 bandaid, it usually goes to the ER. seems appropriate as you had to place 2.

 

[Major]

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This video encapsulates it pretty well haha

 

[cyanide12345678]

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This video encapsulates it pretty well haha

Except the patient was seen by the MD pcp. Examined, then determined to have a life threatening issue requiring emergency care - 2 bandaids 😂

 

[emergentmd]

We've all seen silly things sent to the ER by NPs - I mean they don't know any better, arent as well trained.

But sometimes PCPs really aren't that far behind.

Received a phone call from a PCP somewhat frantic about a bleeding injury to the hand. On the phone this PCP says she saw a patient who had a lot of bleeding from a wound on their hand. They apparently had a blister that popped. She says "I had no idea what to do so I'm sending it over. I actually initially told the patient to go to the regional trauma center so vascular surgery could see him, but then I saw they had 13 patients in their waiting room and I called the patient to detour to the nearest ER so they could be seen sooner. So they're turning around to come to you".

On arrival, patient had a 5 mm (yes milimeter) superficial tissue loss (skin pinched by a closing door 2 days ago) that started bleeding. Minimal blood. Lesion is smaller than the tip of my pinky finger, located on the hypothenar area of the hand - so no where near any large meaningful artery. The wound is superficial as well, nothing deep.

I put 2 bandaids on, bleeding stopped. Then just discharged him.

This is a M.D with 20+ years of attending experience. What is going on?!?!?!?!?!?! Vascular surgery for a skin tear of the hand? Literally this patient was initially told to drive 40 minutes away to the level 3 hospital for a surgical evaluation. I mean...this isn't even remotely close to a large artery and the patient was expressing how his PCP was really worried that he had an arterial bleeding. No. He just lost his epidermal layer of skin, and that too happened 2 days ago -_- This wasn't even a situation where the patient hadn't been seen. Patient was seen in clinic and sent to ER frantically because of uncontrolled bleeding and concern for "arterial injury requiring vascular surgery".

Rant over.

This reminds me of the opposite. Working in the pit, get a called from renal floor for a bleeding fistula. Yeah, yeah. I know I shouldn't but I liked our renal guys so I would go up and throw in a figure 8 stitch. Packed my stuff up, go to the floor to find a nurse putting a finger over a wound. Took her finger off and there was literally a high pressure spout the size of my thumb. Shook my head and told them to call renal/vascular.

 

[CoolDoc1729]

This reminds me of the opposite. Working in the pit, get a called from renal floor for a bleeding fistula. Yeah, yeah. I know I shouldn't but I liked our renal guys so I would go up and throw in a figure 8 stitch. Packed my stuff up, go to the floor to find a nurse putting a finger over a wound. Took her finger off and there was literally a high pressure spout the size of my thumb. Shook my head and told them to call renal/vascular.

Had one transferred in for “vascular consult” for bleeding AVF - I threw in fig of 8 and it was fine - then the real work began: how to get the person back to their home in a rural area 4 hours away at 3 am 🤦🏻‍♀️

 

[NYEMMED]

Had one transferred in for “vascular consult” for bleeding AVF - I threw in fig of 8 and it was fine - then the real work began: how to get the person back to their home in a rural area 4 hours away at 3 am 🤦🏻‍♀️

I refuse to do this if I have vascular on call.
A friend had a case where they did this “to not bother the on call, it was easy” except it lead to failure of the AV fistula, and the entire vascular department threw the ED under the bus “we should have been called, this is why we are on call”


Ok cool, I’m calling you every time vascular

 

[Brigade4Radiant]

I refuse to do this if I have vascular on call.
A friend had a case where they did this “to not bother the on call, it was easy” except it lead to failure of the AV fistula, and the entire vascular department threw the ED under the bus “we should have been called, this is why we are on call”


Ok cool, I’m calling you every time vascular

AV fistulas fail all the time so the repair of the bleeding caused it but not the multiple pokes?

That's fine they can come in and do the stitch everytime

What's worse is that admin will get onto us if we tell PCPs what is inappropriate to send thing to the ED. Because we are turning away business and the CMG will "return us to the community" if we discourage urgent care and PCPs from sending level 5's in.

 

[NYEMMED]

AV fistulas fail all the time so the repair of the bleeding caused it but not the multiple pokes.

That's fine they can come in and do the stitch everytime

What's worse is that admin will get onto us if we tell PCPs what is inappropriate to send thing to the ED. Because we are turning away business and the CMG will "return us to the community" if we discourage urgent care and PCPs from sending level 5's in.

I agree, it wasn’t the suturing. But if vascular at my place likes to throw people under the bus, then they can come in and deal with it.


Also I agree with the rest of your post as well

 

[emergentmd]

I refuse to do this if I have vascular on call.
A friend had a case where they did this “to not bother the on call, it was easy” except it lead to failure of the AV fistula, and the entire vascular department threw the ED under the bus “we should have been called, this is why we are on call”


Ok cool, I’m calling you every time vascular

Yeah they make their own bed. Fistulas fail so not sure why vascular would even go down this road. When I was EM chair, this would have stopped with a quick call to the vascular head. Go forward with EM blaming and you will be called foe every NH fistula. Typically stops it.

 

[JacobMcCandles]

I agree, it wasn’t the suturing. But if vascular at my place likes to throw people under the bus, then they can come in and deal with it.


Also I agree with the rest of your post as well

Just because a department got their panties in a wad once wouldn’t make me change doing something that is better for the patient and the ED.

 

[WilcoWorld]

We've all seen silly things sent to the ER by NPs - I mean they don't know any better, arent as well trained.

But sometimes PCPs really aren't that far behind.

Received a phone call from a PCP somewhat frantic about a bleeding injury to the hand. On the phone this PCP says she saw a patient who had a lot of bleeding from a wound on their hand. They apparently had a blister that popped. She says "I had no idea what to do so I'm sending it over. I actually initially told the patient to go to the regional trauma center so vascular surgery could see him, but then I saw they had 13 patients in their waiting room and I called the patient to detour to the nearest ER so they could be seen sooner. So they're turning around to come to you".

On arrival, patient had a 5 mm (yes milimeter) superficial tissue loss (skin pinched by a closing door 2 days ago) that started bleeding. Minimal blood. Lesion is smaller than the tip of my pinky finger, located on the hypothenar area of the hand - so no where near any large meaningful artery. The wound is superficial as well, nothing deep.

I put 2 bandaids on, bleeding stopped. Then just discharged him.

This is a M.D with 20+ years of attending experience. What is going on?!?!?!?!?!?! Vascular surgery for a skin tear of the hand? Literally this patient was initially told to drive 40 minutes away to the level 3 hospital for a surgical evaluation. I mean...this isn't even remotely close to a large artery and the patient was expressing how his PCP was really worried that he had an arterial bleeding. No. He just lost his epidermal layer of skin, and that too happened 2 days ago -_- This wasn't even a situation where the patient hadn't been seen. Patient was seen in clinic and sent to ER frantically because of uncontrolled bleeding and concern for "arterial injury requiring vascular surgery".

Rant over.

The most remarkable thing about this story is that the regional trauma center ONLY had 15 in the waiting room.

 

[cyanide12345678]

The most remarkable thing about this story is that the regional trauma center ONLY had 15 in the waiting room.

50 percent of the days they usually have beds too. But this is still in a relatively small town with a level 3 with 50k annual ER volume.

The true mothership is always full with 3 day wait times except instant ER acceptance for stemi, stroke, optho issues and maxillofacial injuriesa