spotty coverage

[name?]

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What are you guys, or more importantly, what are your consultants doing in terms of specialist coverage and overlap between non-fellowship trained coverage? Can you ever get general ortho to cover hand? I'm beginning to dread hand cases anymore because the general ortho guys don't even cover Colle's fxs anymore--it's all hand, and we essentially never have anyone on staff on the call schedule so follow up is hell.

It seems like, just as we're forced to do, if the patient needs something that we can't do perfectly, that a board-certified residency trained orthopedist might step up and fill that role as best he or she can and only refer out if truly unable to care for them.

 

[Birdstrike]

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[EM_Rebuilder]

When does a 'specialist' need to see an Colles fractures in the ED?

We should be able to reduce most of the few that need reduced, shouldn't we?

Can't the others just be told to follow up with ortho or their PCP?

Open, neuro changes, etc...obviously thats a different story... And the above answered this well. If they refuse the obvious needed consult, call the big wigs in and I bet they get seen asap.

 

[name?]

When does a 'specialist' need to see an Colles fractures in the ED?

We should be able to reduce most of the few that need reduced, shouldn't we?

Can't the others just be told to follow up with ortho or their PCP?

Open, neuro changes, etc...obviously thats a different story... And the above answered this well. If they refuse the obvious needed consult, call the big wigs in and I bet they get seen asap.

That was just an example of my ortho guys not doing "hand." They(colle's) almost never need to be seen emergently; however, if there is no one on the call schedule, it is much harder to get patients seen in a timely follow up even in the office. The on-call doc theoretically is required to see our follow up patients in 48 hours if requested, but they hand guys(essentially never on call for our hospital) have very busy practices and it's much harder to guarantee said timely follow up.

The general ortho guys have gotten around these consults by not getting credentialled for hand procedures at our hospital, so I'm not sure how that affects the EMTALA issue raised. My issue has primarily stemmed from infection issues--FTS, felon with osteo, open phalanx fx from dog bites that I wanted seen for washout etc.

 

[Birdstrike]

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[la gringa]

birdstrike, you've hit the nails on their respective heads.

i recently worked at a moderate to high volume (70-80k visits/yr) ED in a major east coast city. we had no ORTHO on call PERIOD the majority of the time. anything remotely urgent had to be transferred to a sister hospital. there were plenty of orthopods on staff - they just weren't willing to be on call w/o some huge stipend, and since their elective cases made the hospital $$, they cow-towed to them and left us and sister hospital in the lurch. made me want to puke.

 

[alreadylernd]

Where I work we have spotty hand coverage. There are two ortho groups with the hospital and each has one or two guys who do hand. When I have a hand case, and one of those hand guys aren't on call, I page the orthopedist who is and ask him/her to arrange follow up with one of his partners who does hand. Then I document I spoke with Dr. X who has arranged for patient to follow up with Dr. Y of same orthopedic group.

 

[WilcoWorld]

Birdstrike - did you ever do what you're recommending? Did it lead to your decision to move out of EM?

I don't ask out of spite. I ask, because I work at a referral center where we get dumps all the time. On one shift last week I had an ENT call to transfer a Ludwig's angina patient to our ED, when I asked why an ENT was transferring an ENT case he said that the patient needed an ID consult. Later that shift a hand with vascular injury got transferred from a place with a hand surgeon on call "because he doesn't do this kind of repair". I informed the sending facility that we hand no hand coverage on that night, that I thought this might be an EMTALA violation, and guess what...they sent the patient anyway.

 

[Birdstrike]

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[name?]

I did this several times. The times I had to pull this card, it always came down to administration making a phone call, and the consultant backing down. I always try to work with other docs as much as possible to help them out, so I don't take things to this level of confrontation very often. The problem got so bad though, that a couple of times, partners of mine did take it to the level of transferring and flagging our own doc as EMTALA violators. It got very ugly, there was a big investigation, then a whole lot of nothing happened.

Ultimately, the hospital went to paying specialists a stipend for being on call. Then, paradoxically, the problem got worse. Consultants got more entitled. Then the hospital started telling groups, either we buy you out and you work for us or we kick you out. If we can't kick you out, we'll hire our own team of docs and overwhelm you with competition so we bankrupt your practice. Their solution now, is to "own" all the docs. Now, the docs they "own" are very well behaved.

I appreciate the insight. Very interesting how this stuff plays out. It's amazing how much other people's work avoidance can add to our own workload. I wouldn't have thought that it would take so much effort to get people to do what's right for the patient.

 

[EM2BE]

I remember being in the ED calling the ortho resident for a hand problem. They recommended calling hand. I call hand. Same resident answers the page. Don't know if he forgot he was also covering hand or if he was trying to buy time. Either way, wasted my time.