Outside Hospital

Started by Mattchiavelli
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Mattchiavelli

Mattchiavelli

Full Member
10+ Year Member
I know that in residency we are probably more conservative and err on the side of eval and admission... but does anyone ever get a history regarding care at other hospitals and do one of these 😱 (and yes, I have seen the video "outside hospital" and that's pretty much what I'm talking about)

I know that there is a lot of clinical judgement involved in patient care and we should give fellow practitioners the benefit of the doubt (because I'd want them to give me that), but at what point do you think you need to do something regarding just gross negligence? Say for example you're taking care of a transfer because the team at the old facility mismanaged the patient into the ground. I'm doing this from a place of getting the best care possible for patients so plz keep it civil.

also any good non-identifiable stories of 😱 that made your day/night longer due to your competence, feel free to share how you handled it
 
I once saw a patient treated with antibiotics for a few months for a skin cancer. Come to find out he was being treated by a RN at one of those minute clinics.
 
I've been having the opposite problem lately: I am currently working on an island with a 2 bed ER and a 10 bed hospital with 3 FP here doing everything.

I had a 70's WF come through the ER with obvious GB issues, confirmed by US on a Saturday. Gen Surg consulted by phone to transfer to the next facility 200 miles away. Was told that I needed to watch her overnight with fluids, abx, and recheck labs in the am because he wasn't going to accept a non-emergent pt for an outpt procedure that could fly up on commercial airline. OKAY....... so lady had poor pain control overnight, looks sick, white count jumps from 10 to 17, bili elevates, starting to run a fever. Anyone remember Charcot's triad? Reynold's Pentad??

Call the surgeon back he tells me that the jump in white count in a normal response to the abx. WTF??? Doesn't listen to me about the pain, looks bad, etc. I start getting scolded over the phone that he would not authorize a medvac flight on a weekend (thats not his call, it's mine but whatever) for an outpt procedure, tells me to send the patient on a commercial flight on Monday and he would do the surgery on Wed. I could only send the pt to him if she became hemodynamically unstable and it became a "real" emergency. Dang.......

Another factor is just because I get an accepting receiving doctor on the other end doesn't mean a plane can get to us because the weather changes by the hour.


Ok..... So I go to plan B. Call the surgeon south of me 150 miles the other direction, tell him the scenario, the pain control, the white count, the fever, etc. His response was get her on the plane ASAP, probably has a gangrenous GB. So get the plane to us in about 4 hours, leaves us about 5pm, gets to the next hospital about 9pm, surgeon sees her right away, takes her to OR then and there, she has a gangrenous GB and is septic. Spent the night in ICU on a vent. Had I waited much longer she would have likely died. Family happy with us, pissed at first hospital.

Family calls and complains to the head of the first hospital. Admin calls me to get the story from our end and I believe that first surgeon has been fired. The first hospital relies on transfers to keep the doors open and they lost revenue that day.


I have done 3 medevacs this week, each one has had issues, each one has been a bear to find an accepting physician. Most stuff I can handle myself but I don't have a surgeon, don't have inpatient psych, no ICU, and no way to put a pt on a vent. Such is life in rural medicine.
 
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cabinbuilder said:
Family calls and complains to the head of the first hospital. Admin calls me to get the story from our end and I believe that first surgeon has been fired. The first hospital relies on transfers to keep the doors open and they lost revenue that day.
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That kind of sounds like the restaurant manager saying that they just fired the waitress: they're telling you what they think you want to hear.

Most places do not have an excess of general surgeons, so they'd be loathe to just fire one. Certainly seems like he needs a talking to though.
 
TheProwler said:
That kind of sounds like the restaurant manager saying that they just fired the waitress: they're telling you what they think you want to hear.

Most places do not have an excess of general surgeons, so they'd be loathe to just fire one. Certainly seems like he needs a talking to though.
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I would generally agree with you but this individual has done this before and most of the time you don't have the luxury to wait in our location because of weather. There never should have been an arguement about taking the transfer.
 
cabinbuilder said:
I would generally agree with you but this individual has done this before and most of the time you don't have the luxury to wait in our location because of weather. There never should have been an arguement about taking the transfer.
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On further review, shouldn't you have been trying to transfer her to a gastroenterologist to do an ERCP/ES if your working diagnosis was cholangitis? Honest question.
 
TheProwler said:
On further review, shouldn't you have been trying to transfer her to a gastroenterologist to do an ERCP/ES if your working diagnosis was cholangitis? Honest question.
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Not practical given my location (remember than I am on an island) . My working diagnosis was cholecystitis with possible cholangitis. In someone 30's, with good pain control maybe could get to a GI (nearest one to me is 3-4 hours by plane, and maybe you could get them an appt?) vs someone in their 70's acutely ill with poor pain control, increasing white count with the nearest surgeon only an hour away by plane.
 
cabinbuilder said:
Not practical given my location (remember than I am on an island) . My working diagnosis was cholecystitis with possible cholangitis. In someone 30's, with good pain control maybe could get to a GI (nearest one to me is 3-4 hours by plane, and maybe you could get them an appt?) vs someone in their 70's acutely ill with poor pain control, increasing white count with the nearest surgeon only an hour away by plane.
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The hospitals with the surgeons that were 2hrs away had no GI on staff? yikes, that sucks. Patient doesn't sound like she would've been stable for a 4 hour transfer.
 
Rendar5 said:
The hospitals with the surgeons that were 2hrs away had no GI on staff? yikes, that sucks. Patient doesn't sound like she would've been stable for a 4 hour transfer.
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No patient was not stable by the time I got someone to accept transfer. I am on an island in southeast alaska currently. The nearest hospitals to me are Juneau and Ketchikan who have surgeons. The nearest GI person to me is Anchorage or Seattle. Even Fairbanks doesn't have GI and that is a 200 bed hospital. Gotta call who you know can help. Plus not my problem to find a GI, just a person who can help in the here and now. If the surgeon want's to collaborate with a GI (who doesn't exist near me) then that's up to them. My job is to see the need for higher level of care and get that patient to the proper facility with the care that I can't provide. I don't even have a ventilator where I am, or and ICU bed. We are strickly deal with the minor issues, or stabilize and ship.
 
cabinbuilder said:
No patient was not stable by the time I got someone to accept transfer. I am on an island in southeast alaska currently. The nearest hospitals to me are Juneau and Ketchikan who have surgeons. The nearest GI person to me is Anchorage or Seattle. Even Fairbanks doesn't have GI and that is a 200 bed hospital. Gotta call who you know can help. Plus not my problem to find a GI, just a person who can help in the here and now. If the surgeon want's to collaborate with a GI (who doesn't exist near me) then that's up to them. My job is to see the need for higher level of care and get that patient to the proper facility with the care that I can't provide. I don't even have a ventilator where I am, or and ICU bed. We are strickly deal with the minor issues, or stabilize and ship.
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I don't envy you. any transfers >1-2 hours are very concerning in patients needing ICU level care, not to mention having to tube someone and bag them for an entire transport...
 
cabinbuilder said:
No patient was not stable by the time I got someone to accept transfer. I am on an island in southeast alaska currently. The nearest hospitals to me are Juneau and Ketchikan who have surgeons. The nearest GI person to me is Anchorage or Seattle. Even Fairbanks doesn't have GI and that is a 200 bed hospital. Gotta call who you know can help. Plus not my problem to find a GI, just a person who can help in the here and now. If the surgeon want's to collaborate with a GI (who doesn't exist near me) then that's up to them. My job is to see the need for higher level of care and get that patient to the proper facility with the care that I can't provide. I don't even have a ventilator where I am, or and ICU bed. We are strickly deal with the minor issues, or stabilize and ship.
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By the following morning, it sounds like the patient was getting fairly unstable, so I'm not arguing that. Initially though, it sounds like the patient would've been better served with an ERCP than an open CBD exploration, which is probably what the general surgeon would have been doing.
 
TheProwler said:
By the following morning, it sounds like the patient was getting fairly unstable, so I'm not arguing that. Initially though, it sounds like the patient would've been better served with an ERCP than an open CBD exploration, which is probably what the general surgeon would have been doing.
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In the lower 48 this may be true. However, the surgeon should have known better knowing they are just as remote as me and the nearest GI is another 3 hours by plane past their facility. Not practical, Not safe. It still would have been an medevac.
 
cabinbuilder said:
No patient was not stable by the time I got someone to accept transfer. I am on an island in southeast alaska currently. The nearest hospitals to me are Juneau and Ketchikan who have surgeons. The nearest GI person to me is Anchorage or Seattle. Even Fairbanks doesn't have GI and that is a 200 bed hospital. Gotta call who you know can help. Plus not my problem to find a GI, just a person who can help in the here and now. If the surgeon want's to collaborate with a GI (who doesn't exist near me) then that's up to them. My job is to see the need for higher level of care and get that patient to the proper facility with the care that I can't provide. I don't even have a ventilator where I am, or and ICU bed. We are strickly deal with the minor issues, or stabilize and ship.
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Why can't you intubate an unstable patient and place them on one of the disposable ventilators. You should be able to do that, especially so considering your location.
 
1. Honestly, I'm not ever sure what that is and I definitely know I don't have anything like that here.
2. If a person arrives that is that sick they would need intubation, I highly doubt they would live.
3. The last person who had a major heart attack here (before I got here) had to wait 18 hours for the weather to clear before they got shipped for a heart cath.
4. I just had to send a patient out who was in DKA because the nursing staff didn't know how to take care of them with all the K' levels and lab draws and insulin drips, etc.
 
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