The problem with GMOs...

[IgD]

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I think a good way to describe the problem with GMOs to the line commanders is it is a lost opportunity. A board certified FP could hit a problem aggressively up front and nip it in the bud before it reaches critical mass. This would prevent lost days at work, reduce disability, clear up fitness for duty log jams, etc. Commanders need a Marcus Welby, MD type physician that they can turn to for any medical situation including involving family members.

The same could be said about mental health. A Marine Corps regiment needs a board certified psychiatrist who could work closely with the FP to provide a more comprehensive set of mental health services.

I'm sure malpractice situations have occurred with GMOs but I don't think that's the issue. A lot of times what they do is reasonable but could have been handled in a better way by a physician with more training and experience.

 

[NavyFP]

I think a good way to describe the problem with GMOs to the line commanders is it is a lost opportunity. A board certified FP could hit a problem aggressively up front and nip it in the bud before it reaches critical mass. This would prevent lost days at work, reduce disability, clear up fitness for duty log jams, etc. Commanders need a Marcus Welby, MD type physician that they can turn to for any medical situation including involving family family members.

The same could be said about mental health. A Marine Corps regiment needs a board certified psychiatrist who could work closely with the FP to provide a more comprehensive set of mental health services.

I'm sure malpractice situations have occurred with GMOs but I don't think that's the issue. A lot of times what they do is reasonable but could have been handled in a better way by a physician with more training and experience.

I will, as a rule, agree and give you an example. I was doing a midshipman cruise with a squadron of YP boats. We had a day in port in Norfolk. One of our young ladies had an abcessed Bartholin's gland. She went to sick call at Sewell's Point (I was playing golf, and they didn't call me.) and saw a GMO who prescribed antibiotics, motrin, and sitz baths (on a YP boat 😱 ). Well, as you can guess, she wasn't feeling better and they finally decided drag me out of bed that night. We hopped in the van, went to Portsmouth, I drained it, no fuss, no muss, and she finished the cruise without a problem. A simple problem that any well trained (and not so well trained) FP could handle.

The global problem is that we don't have enough FPs to fill all the GMO positions. Otherwise, would love to see it done.

 

[BigNavyPedsGuy]

I will, as a rule, agree and give you an example. I was doing a midshipman cruise with a squadron of YP boats. We had a day in port in Norfolk. One of our young ladies had an abcessed Bartholin's gland. She went to sick call at Sewell's Point (I was playing golf, and they didn't call me.) and saw a GMO who prescribed antibiotics, motrin, and sitz baths (on a YP boat 😱 ). Well, as you can guess, she wasn't feeling better and they finally decided drag me out of bed that night. We hopped in the van, went to Portsmouth, I drained it, no fuss, no muss, and she finished the cruise without a problem. A simple problem that any well trained (and not so well trained) FP could handle.

I would have responded exactly like that GMO. Given my level of training, I am not comfortable or trained to drain a Bartholin's gland cyst. I actually had one on the ship and had to look it up just to confirm my diagnosis. The next step after looking in a textbook is rarely to approach the patient with a knife.

 

[NavyFP]

I would have responded exactly like that GMO. Given my level of training, I am not comfortable or trained to drain a Bartholin's gland cyst. I actually had one on the ship and had to look it up just to confirm my diagnosis. The next step after looking in a textbook is rarely to approach the patient with a knife.

Well you would if you were a surgeon. 😀

 

[Dimoak]

Well you would if you were a surgeon. 😀

Minus the textbook part. 😉

 

[i want out]

I would have responded exactly like that GMO. Given my level of training, I am not comfortable or trained to drain a Bartholin's gland cyst. I actually had one on the ship and had to look it up just to confirm my diagnosis. The next step after looking in a textbook is rarely to approach the patient with a knife.

The time honored mantra of teaching medicine is See one, Do One, Teach one.

The GMO frequently gets the order out of sequence if he/she is in a remote location:

Do one, Teach One, THEN See one when you return to Residency and see what you were doing wrong.

I had one patient try to talk me into injecting his shoulder for a tendonitis.

The previous GMO had been on the Ortho track, and had been injecting this guys shoulder with apparently decent results. I get there, with no training on injecting joints, and he is trying to get me to do it rather than refer.

I didn't inject him.


Imagine a GMO on an LSD off the horn of Africa, away from the ESG with a bartholin's duct cyst...

Really what are their options, it has to be marsupialized, or at least drained, and you can't send the patient to a shore facility. Medevac would likely take days, and aint going to happen until the patient is septic because you have to align the sun, moon and stars to make this trek happen.

So essentially your choices are drain it to buy some time, then refer when able, marsupialize it yourself, or try a medevac that is unlikely to happen, and will take at the very least several days, and likely many cross deck transfers with some of them being foreign ships.

There are someplaces in the world where GMO's practice that timely medevacs only happen for life, limb or eyesight.



Another scenario, Your underway in the atlantic on an LSD doing independent training, and Seaman Schmuckitelli is running up a ladder when the top of his scalp contacts the edge of a scuttle and there is a 2.5 inch laceration.

You and a corpsman are irrigating the wound when you notice several small bone chips in the bottom of the wound.

Pt is currently fully alert, and fully neurologicly intact.

You discuss with CO and XO, and boat transfer aint going to happen because your more than 50 miles from shore, Helo is also not going to happen until after some neuro changes because its night time. The other reason that Helo ain't happening, is because your not within flight distance of any coast guard helo's.

So whats a GMO to do...

I finished irrigating the wound, did a layered closure, and then put a 1/2" drill bit in the autoclave, to ward off evil spirits. I also dosed the pt with Rocephin. I also used the Sat phone to call on duty ER doc at Naval hospital to run my plan by him. Mainly to have another name on the chart, as somebody that I had talked to. CYA as much as possible.

Pt slept in the ward that night with q15 neuro checks for 4 hours, followed by hourly neuro checks until morning.

Sailor did fine, but my pucker factor was high.

If his neuro status had changed, I would have been forced to think about doing a burr hole without ever having seen one done.

The night this happened, I discussed this at length with one of the only SWO's that I have any respect for, and his take on it, was that even though I wasn't really trained to do the procedure, I was the best trained on the ship at that moment, so the responsibility fell on me to make whatever needed to happen, happen.


i want out(of IRR)

 

[orbitsurgMD]

The time honored mantra . . .
You and a corpsman are irrigating the wound when you notice several small bone chips in the bottom of the wound.

. . . Helo is also not going to happen until after some neuro changes because its night time. . . .
So whats a GMO to do...

. . . . I was the best trained on the ship at that moment, so the responsibility fell on me to make whatever needed to happen, happen.

Brings back all those memories. Thanks.

 

[met19]

The time honored mantra of teaching medicine is See one, Do One, Teach one.

The GMO frequently gets the order out of sequence if he/she is in a remote location:

Do one, Teach One, THEN See one when you return to Residency and see what you were doing wrong.

I had one patient try to talk me into injecting his shoulder for a tendonitis.

The previous GMO had been on the Ortho track, and had been injecting this guys shoulder with apparently decent results. I get there, with no training on injecting joints, and he is trying to get me to do it rather than refer.

I didn't inject him.


Imagine a GMO on an LSD off the horn of Africa, away from the ESG with a bartholin's duct cyst...

Really what are their options, it has to be marsupialized, or at least drained, and you can't send the patient to a shore facility. Medevac would likely take days, and aint going to happen until the patient is septic because you have to align the sun, moon and stars to make this trek happen.

So essentially your choices are drain it to buy some time, then refer when able, marsupialize it yourself, or try a medevac that is unlikely to happen, and will take at the very least several days, and likely many cross deck transfers with some of them being foreign ships.

There are someplaces in the world where GMO's practice that timely medevacs only happen for life, limb or eyesight.



Another scenario, Your underway in the atlantic on an LSD doing independent training, and Seaman Schmuckitelli is running up a ladder when the top of his scalp contacts the edge of a scuttle and there is a 2.5 inch laceration.

You and a corpsman are irrigating the wound when you notice several small bone chips in the bottom of the wound.

Pt is currently fully alert, and fully neurologicly intact.

You discuss with CO and XO, and boat transfer aint going to happen because your more than 50 miles from shore, Helo is also not going to happen until after some neuro changes because its night time. The other reason that Helo ain't happening, is because your not within flight distance of any coast guard helo's.

So whats a GMO to do...

I finished irrigating the wound, did a layered closure, and then put a 1/2" drill bit in the autoclave, to ward off evil spirits. I also dosed the pt with Rocephin. I also used the Sat phone to call on duty ER doc at Naval hospital to run my plan by him. Mainly to have another name on the chart, as somebody that I had talked to. CYA as much as possible.

Pt slept in the ward that night with q15 neuro checks for 4 hours, followed by hourly neuro checks until morning.

Sailor did fine, but my pucker factor was high.

If his neuro status had changed, I would have been forced to think about doing a burr hole without ever having seen one done.

The night this happened, I discussed this at length with one of the only SWO's that I have any respect for, and his take on it, was that even though I wasn't really trained to do the procedure, I was the best trained on the ship at that moment, so the responsibility fell on me to make whatever needed to happen, happen.


i want out(of IRR)

that second scenario is messed up. even me the ED resident wouldn't drill a freakin' burr hole into a skull. too much could go wrong. if you're even thinking about autoclaving the drill, you need to be on the phone getting the transfer set up ASAP.

 

[i want out]

that second scenario is messed up. even me the ED resident wouldn't drill a freakin' burr hole into a skull. too much could go wrong. if you're even thinking about autoclaving the drill, you need to be on the phone getting the transfer set up ASAP.

Here is the problem with being a GMO, and as an EM resident you should recognize this because you will spend the rest of your practice life dealing with it.

Your assuming that I knew all the complications that could happen with drilling a burr hole, (not covered all that well in the reference material I had available).

Your also assuming that Medevac would happen, and occur in a timely fashion, this just shows you haven't been a GMO on a single GMO platform.

Your second guessing me without all the information, which is exactly what every other doctor in the hospital is going to do to you for your entire practice.

If this kid had a bad outcome, I would have taken the fall, but with the medevac system we had at the time, and I assume is still in place, he wasn't leaving the ship unless he was actually showing signs of neurologic decline, no matter what I did.

Thats not to say that there weren't a few times when I fudged the facts a little to make a medevac happen, or bullied somebody into accepting a patient, but the above case was relatively early in my time as a GMO.



I want out (of IRR)

 

[stonewall22]

Are GMOs strictly (strictly is too strong, how about usually) residents with a year of two of training, or do residency trained docs get sent on GMOs outside their specialty?

 

[BigNavyPedsGuy]

Are GMOs strictly (strictly is too strong, how about usually) residents with a year of two of training, or do residency trained docs get sent on GMOs outside their specialty?

The majority of GMOs have just completed intership. Recently there has been a higher percentage of residency trained docs, but most are still just internship trained.

 

[IgD]

I will, as a rule, agree and give you an example. I was doing a midshipman cruise with a squadron of YP boats. We had a day in port in Norfolk. One of our young ladies had an abcessed Bartholin's gland. She went to sick call at Sewell's Point (I was playing golf, and they didn't call me.) and saw a GMO who prescribed antibiotics, motrin, and sitz baths (on a YP boat 😱 ). Well, as you can guess, she wasn't feeling better and they finally decided drag me out of bed that night. We hopped in the van, went to Portsmouth, I drained it, no fuss, no muss, and she finished the cruise without a problem. A simple problem that any well trained (and not so well trained) FP could handle.

The global problem is that we don't have enough FPs to fill all the GMO positions. Otherwise, would love to see it done.

I just wanted to say we may not always agree on here but I've come to respect your posts. I really would like to see Navy medicine go to the next level. There has to be some way we can make things better.

 

[met19]

.
Your also assuming that Medevac would happen, and occur in a timely fashion, this just shows you haven't been a GMO on a single GMO platform.

Your second guessing me without all the information, which is exactly what every other doctor in the hospital is going to do to you for your entire practice.

If this kid had a bad outcome, I would have taken the fall, but with the medevac system we had at the time, and I assume is still in place, he wasn't leaving the ship unless he was actually showing signs of neurologic decline, no matter what I did.

I want out (of IRR)

Not second guessing you. just saying if your autoclaving the drill, you obviously thought out that this guy might go down, which is a good thought. getting the drill is better than nothing. But if he goes down, he needs a neurosurg-o-pod, not a gmo (not your fault the navy sends interns to act as attendings). As an EM, I would except a ship to shore call, and tell you transfer that guy. Also as an EM, when I get a call I am more conservative, I never would refuse a gmo transfer b/c I haven't seen that pt and the pt could be really really sick.

Sucks that you get the fall for a BS transfer system. And you're right, I haven't had the pleasure of doing a GMO (and i feel lucky in that regard). Asa GMO it shounds like number one job is make sure you don't get burned by a sick pt.

 

[BigNavyPedsGuy]

Not second guessing you. just saying if your autoclaving the drill, you obviously thought out that this guy might go down, which is a good thought. getting the drill is better than nothing. But if he goes down, he needs a neurosurg-o-pod, not a gmo (not your fault the navy sends interns to act as attendings). As an EM, I would except a ship to shore call, and tell you transfer that guy. Also as an EM, when I get a call I am more conservative, I never would refuse a gmo transfer b/c I haven't seen that pt and the pt could be really really sick.

Sucks that you get the fall for a BS transfer system. And you're right, I haven't had the pleasure of doing a GMO (and i feel lucky in that regard). Asa GMO it shounds like number one job is make sure you don't get burned by a sick pt.

It's not that he didn't want to transfer him it was impossible to do it. He was constrained by oceans. It's not that the ER wouln'dt accept the patient. It's that he was hundreds of miles from land.

Who cares about getting in trouble? I was just terrified that a patient would die right in front of me (from something preventable) and I couldn't do anything about it.

 

[crazybrancato]

The time honored mantra of teaching medicine is See one, Do One, Teach one.

thank you for this post. The description of this scenario paints a much better picture than the general moaning we hear here about GMOs, exactly what I was curious about! Sounds like you did the best you could do and kept a level head, I applaud you!

i guess in a sense what you described is a no-kidding operational setting, hardly ideal for medical practice . . .but that's the plight of the military, especially the operational military (a ship u/w, an infantry unit BOG in country). i don't think anyone would disagree with you that a) an MTF would be a better facility for tending to your patient and b) a resid trained MD would be the better physician.

regarding SWOdom, and specific scenrios like the one you described above, let me preach a little (as a prior SWO) in case in any of you come into a situ like this: look the CAPT straight in the eye and tell him to pull IPT or order a medavac (it can be done, if there's the will). Seriously. and document your recommendation (in the patients chart, in an email to someone, etc etc). Most COs of ships are sensible people (most!, not all), if you can convince them of the severity of the situation, they'll comply. They don't want to have a sailor die on them, they don't want to lose command. If you're confident and convincing, they'll listen to you. (of course, you have to make the determination as to how severe the case is, and i understand that's a tough call).

But, as Iwantout pointed out, CYA and document everything. If the CAPT refuses to order a bird or to turn the ship around, the outcome is on his head, NOT yours! (I cant imagine any CO refusing your recommendation, unless you're in a no-**** combat situ, in which case the harm to the patient may be viewed as a necessary casualty).

oh and you might piss off the XO, but F him.

 

[i want out]

It's not that he didn't want to transfer him it was impossible to do it. He was constrained by oceans. It's not that the ER wouln'dt accept the patient. It's that he was hundreds of miles from land.

Who cares about getting in trouble? I was just terrified that a patient would die right in front of me (from something preventable) and I couldn't do anything about it.

Ditto, it was lack of availability of capability to transfer, not refusal of acceptance in that case.

I did have an ER attending tell me that he wouldn't accept a patient one night when I called and told him I was sending someone in by small boat to be picked up at the pier by an ambulance. My response, was that he had better turn him around then because he was already on the way, my call was a heads up not a request for acceptance. (this was a little later in my time as a GMO when I realized I had better keep my ass covered, or nobody would)

That patient got a CT in the ER, and had a large hot appy that was intact per the CT report, but ruptured either before going to the OR, or in the OR.

These are the ones that stick out in my mind, but I also sent lots of BS to the ER as well, because I didn't have either the equipment or training to handle it.

Like when the ship is in the yards, and doesn't have running water, suturing went to the ER because if you can't irrigate a wound, or wash your hands, you shouldn't be closing a wound.

I have to say, I absolutely hated to get a resident or attending on the phone who had never been on a ship. Its no slight against them, but they have absolutely no idea what constraints a GMO is working against to make things happen.

I doubt that I won many friends at the hospital, but I made a habit of asking the Name and Rank of whomever I was talking to when I called either the ER or a specialist to refer somebody to the hospital, and if they sounded like they didn't want to accept the transfer, I mentioned that I would be putting their name in the record as refusing the transfer without evaluating the patient. That ALWAYS worked to make the transfer happen.

had an ENT resident once dress me down for trying to send a peritonsillar abcess to him in his clinic. He said that about 70% of the possible PTA's from GMO's were not really PTA's, and that any idiot could see that.
I asked for his name, gave him my phone number, and asked him to call me back after he saw the patient to tell me why what I was looking at wasn't a PTA and how I could improve my diagnostic ability. He never called, but I looked in AHLTA, and the ENT that saw him had called it a PTA as well.


For those of you who have not done single GMO platform medicine, when you get a call from a GMO that tells you they are all alone, believe them.
They don't have another Doc down the P-way that they can ask to come take a look, board certified or otherwise.
They don't have the ability to sit on it and give it a few days. They certainly don't if they are about to get underway, even for a short 3-5 day exercise.
Their equipment frequently looks like it fell off the back of a truck in a third world country.
The few supplies that they do have, were probably stolen from you to begin with, either through sending corpsmen to the pharmacy with scrips to put supplys of meds in the ships pharmacy (HM3, why are you on 9 different anti-hypertensives, and three different anti deppressants?), or sending a corpsman who used to work in the hospital by to see his old friends with a gym bag in hand.

And if as a resident your wondering why they didn't phone a friend, you should look in the mirror, because with your PGY2-? training you have more training than they do, and you are their phone a friend, whether you like them or not.

i want out (of IRR)

 

[crazybrancato]

Ditto, it was lack of availability of capability to transfer, not refusal of acceptance in that case.

I did have an ER attending tell me that he wouldn't accept a patient one night when I called and told him I was sending someone in by small boat to be picked up at the pier by an ambulance. My response, was that he had better turn him around then because he was already on the way, my call was a heads up not a request for acceptance. (this was a little later in my time as a GMO when I realized I had better keep my ass covered, or nobody would)

That patient got a CT in the ER, and had a large hot appy that was intact per the CT report, but ruptured either before going to the OR, or in the OR.

These are the ones that stick out in my mind, but I also sent lots of BS to the ER as well, because I didn't have either the equipment or training to handle it.

Like when the ship is in the yards, and doesn't have running water, suturing went to the ER because if you can't irrigate a wound, or wash your hands, you shouldn't be closing a wound.

I have to say, I absolutely hated to get a resident or attending on the phone who had never been on a ship. Its no slight against them, but they have absolutely no idea what constraints a GMO is working against to make things happen.

I doubt that I won many friends at the hospital, but I made a habit of asking the Name and Rank of whomever I was talking to when I called either the ER or a specialist to refer somebody to the hospital, and if they sounded like they didn't want to accept the transfer, I mentioned that I would be putting their name in the record as refusing the transfer without evaluating the patient. That ALWAYS worked to make the transfer happen.

had an ENT resident once dress me down for trying to send a peritonsillar abcess to him in his clinic. He said that about 70% of the possible PTA's from GMO's were not really PTA's, and that any idiot could see that.
I asked for his name, gave him my phone number, and asked him to call me back after he saw the patient to tell me why what I was looking at wasn't a PTA and how I could improve my diagnostic ability. He never called, but I looked in AHLTA, and the ENT that saw him had called it a PTA as well.


For those of you who have not done single GMO platform medicine, when you get a call from a GMO that tells you they are all alone, believe them.
They don't have another Doc down the P-way that they can ask to come take a look, board certified or otherwise.
They don't have the ability to sit on it and give it a few days. They certainly don't if they are about to get underway, even for a short 3-5 day exercise.
Their equipment frequently looks like it fell off the back of a truck in a third world country.
The few supplies that they do have, were probably stolen from you to begin with, either through sending corpsmen to the pharmacy with scrips to put supplys of meds in the ships pharmacy (HM3, why are you on 9 different anti-hypertensives, and three different anti deppressants?), or sending a corpsman who used to work in the hospital by to see his old friends with a gym bag in hand.

And if as a resident your wondering why they didn't phone a friend, you should look in the mirror, because with your PGY2-? training you have more training than they do, and you are their phone a friend, whether you like them or not.

i want out (of IRR)

nice rant! not a rant at all, very informative. agree with everything you said, about taking down names/ranks, etc. people act differently when you hold their feet to the fire. you should of found that resident and punched him in the face. no j/k

 

[i want out]

...Most COs of ships are sensible people (most!, not all)...

...oh and you might piss off the XO, but F him. ...

The initial situation that I described, we weren't within range to do any type of medevac, and getting within range took enough time, that the patient had declared himself to be less than critical.

It just so happens that I was blessed, or cursed with one of the less than sensible CO"s

Don't underestimate the pain associated with Pissing off the XO, I can speak from personal experience, that this can make your life quite miserable.

Crazy, from your time as a SWO, you will understand, that firing a CO means that he/she will retire probably at the same rank, and this is likely to be the worst punishment they get for whatever they did.

As a medical officer you have invested almost as many years getting there, as the average XO on a small deck, or Department head on a large deck.
If you have some judgement against you, you don't just get to ride off into the sunset, and sit at a desk until you retire. You have the likelyhood that this event if enough to report to the National Practitioner database will follow you for the remainder of your practice life, and depending on the nature of the event, may preclude you from getting a license in the state that you wanted to go to. Some events may even preclude you from practicing medicine in the field that you want.

eg on the last, the completely FUBAR Navy supply system delivers morphine to SK2 on the pier and he signs for it. Then its gone, and can't be found. You get fired, and this gets reported as a controlled substance event.
Now your done with your time in the Navy, but can't get an anesthesiology residency, because no self respecting anesthesiology residency is going to let anybody with a "questionable history with controlled substances" juggle half a dozen vials of fentanyl a day.

Crazy, I also understand that you have bought into the system, and as such you have to convince yourself that its not as bad as everyone makes it out to be. Depending on where you serve as an MO, it may not be. With your understanding of how the .mil works, you may make a better time of it than I did. But don't discount how traumatic it is for somebody to leave a civilian internship and arrive on an LSD and go from civilian to department head in the blink of an eye. Then spend most of their time as a GMO with a CO that hates medical, and shows it on almost a daily basis.

i want out(of IRR)

 

[IgD]

eg on the last, the completely FUBAR Navy supply system delivers morphine to SK2 on the pier and he signs for it. Then its gone, and can't be found. You get fired, and this gets reported as a controlled substance event.
Now your done with your time in the Navy, but can't get an anesthesiology residency, because no self respecting anesthesiology residency is going to let anybody with a "questionable history with controlled substances" juggle half a dozen vials of fentanyl a day.

Is that a real situation you are describing? Never heard anything quite like that.

 

[BigNavyPedsGuy]

Is that a real situation you are describing? Never heard anything quite like that.

I've heard of a ship where some morphine went missing and the SMO got replaced - mid-deployment

 

[i want out]

Is that a real situation you are describing? Never heard anything quite like that.

The exact scenario is not one that I have seen personally, so I can't say that it has happened.

the other preceeding were personal experience.

I have had controlled substances show up in my supply chain without proper chain of custody. I was fortunate enough, that the SK who signed for them either didn't know what was in the boxes, or didn't care.

Yes, loss of controlled substances will get an MO Fired, depending on how it happened, there is likely to be a letter of reprimand that may or may not have long reaching effects.

How the NPDB treats events by .mil physicians is still unknown so, its not that far fetched that a vindictive CO (and thats what I served under) could make the effort to send something off and have it entered regardless of what Navy policy is.

I want out(of IRR)

 

[orbitsurgMD]

The exact scenario is not one that I have seen personally, so I can't say that it has happened.

the other preceeding were personal experience.

I have had controlled substances show up in my supply chain without proper chain of custody. I was fortunate enough, that the SK who signed for them either didn't know what was in the boxes, or didn't care.

Yes, loss of controlled substances will get an MO Fired, depending on how it happened, there is likely to be a letter of reprimand that may or may not have long reaching effects.

How the NPDB treats events by .mil physicians is still unknown so, its not that far fetched that a vindictive CO (and thats what I served under) could make the effort to send something off and have it entered regardless of what Navy policy is.

I want out(of IRR)

If a CO did that, the blowback could be serious. Simply filing a report is a violation of due process. It could be construed as libel and open both that CO and any endorsing authority to grievance process under UCMJ Art. 138 as well as charges of violating general orders, conduct unbecoming and other typical military justice rubbish which could derail his career. If it was enough of a deviation from accepted procedure, you might even have cause for private legal action in state court. Once official process is started, no promotions, no transfers nothing moves until the process is completed.

 

[i want out]

If a CO did that, the blowback could be serious. Simply filing a report is a violation of due process. It could be construed as libel and open both that CO and any endorsing authority to grievance process under UCMJ Art. 138 as well as charges of violating general orders, conduct unbecoming and other typical military justice rubbish which could derail his career. If it was enough of a deviation from accepted procedure, you might even have cause for private legal action in state court. Once official process is started, no promotions, no transfers nothing moves until the process is completed.

I don't know that the possibility of legal issues would have stopped this particular CO. He pretty regularly skirted legal issues, and frequently did stuff that should have gotten him fired, but nobody myself included had the cajones to send up a flag to see who would salute.

One phrase that I learned pretty early on:
"when you pull the pin on a 'crap' grenade, you also get covered in the ensuing 'crap'storm."

And don't try to tell me otherwise, I saw way to many situations that demonstrated the truth in that phrase.

i want out (of IRR)

 

[met19]

Ditto, it was lack of availability of capability to transfer, not refusal of acceptance in that case.

I did have an ER attending tell me that he wouldn't accept a patient one night when I called and told him I was sending someone in by small boat to be picked up at the pier by an ambulance. My response, was that he had better turn him around then because he was already on the way, my call was a heads up not a request for acceptance. (this was a little later in my time as a GMO when I realized I had better keep my ass covered, or nobody would)

That patient got a CT in the ER, and had a large hot appy that was intact per the CT report, but ruptured either before going to the OR, or in the OR.

These are the ones that stick out in my mind, but I also sent lots of BS to the ER as well, because I didn't have either the equipment or training to handle it.

Like when the ship is in the yards, and doesn't have running water, suturing went to the ER because if you can't irrigate a wound, or wash your hands, you shouldn't be closing a wound.

I have to say, I absolutely hated to get a resident or attending on the phone who had never been on a ship. Its no slight against them, but they have absolutely no idea what constraints a GMO is working against to make things happen.

For those of you who have not done single GMO platform medicine, when you get a call from a GMO that tells you they are all alone, believe them.
They don't have another Doc down the P-way that they can ask to come take a look, board certified or otherwise.


i want out (of IRR)

as someone who works in an ed, i would never deny you a transfer. thats a foolish attending/resident. they never saw the pt and are couting on an intern to make a dx. no way, you accept the transfer and put your ahnds on the belly or look in the mouth, etc. those are the times someone could be burned. good idea if they decline transfer to get name/rank

 

[NavyFlightDoc]

Here is another problem with GMO's. I stand MOOD watch stateside (Medical Officer On Duty). Most of my calls are pediatric. I don't feel comfortable with peds in the office, let alone over the phone. As a consequence, I am uncomfortable with my options. Either I can send them to an urgent care or ED, or offer advice over the phone. I send most of my calls to the ED, which wastes Tricare money, but I don't really feel like I have a better option. I did a surgical internship, so my pediatric experience as a physician is limited to peds surg. If they have a umbilical hernia or intussusception i'm cool, otherwise it's uncharted territory. Not fair to me, and not fair to the patients/parents who spend hours waiting for a doctor to tell them that they didn't need to seek care yet.

 

[mitchconnie]

Here is another problem with GMO's. I stand MOOD watch stateside (Medical Officer On Duty). Most of my calls are pediatric. I don't feel comfortable with peds in the office, let alone over the phone. As a consequence, I am uncomfortable with my options. Either I can send them to an urgent care or ED, or offer advice over the phone. I send most of my calls to the ED, which wastes Tricare money, but I don't really feel like I have a better option. I did a surgical internship, so my pediatric experience as a physician is limited to peds surg. If they have a umbilical hernia or intussusception i'm cool, otherwise it's uncharted territory. Not fair to me, and not fair to the patients/parents who spend hours waiting for a doctor to tell them that they didn't need to seek care yet.

I would like to suggest that this post illustrates another problem with the current GMO system--the heterogeneity of interships that "qualify" one to be a GMO. I have no doubt that someone who did a peds internship could field simple telephone consults on pediatric issues. But surgery internship offers zero training for this. Similarly, surgery intership may be good preparation to triage/manage some trauma--but IM or psych?...not so much.

I think it might be possible to train someone to fill the GMO role in only one year of GME, but it would have to be a true rotating internship. Maybe 2 months peds, 2 months IM, 2 months GYN, 2 months outpatient ortho, 1 month psych, and 3 months general surgery with one of those months on the trauma service. Unfortunately (or fortunately), the medical education system in this country moved away from this paradigm 30-40 years ago. Virtually no one does GME designed to produce a competent generalist.

 

[i want out]

I would like to suggest that this post illustrates another problem with the current GMO system--the heterogeneity of interships that "qualify" one to be a GMO. I have no doubt that someone who did a peds internship could field simple telephone consults on pediatric issues. But surgery internship offers zero training for this. Similarly, surgery intership may be good preparation to triage/manage some trauma--but IM or psych?...not so much.

I think it might be possible to train someone to fill the GMO role in only one year of GME, but it would have to be a true rotating internship. Maybe 2 months peds, 2 months IM, 2 months GYN, 2 months outpatient ortho, 1 month psych, and 3 months general surgery with one of those months on the trauma service. Unfortunately (or fortunately), the medical education system in this country moved away from this paradigm 30-40 years ago. Virtually no one does GME designed to produce a competent generalist.

I did a civilian rotating internship and still don't think I was ready for independent practice.

i want out (of IRR)