What happens in this case?

[Wackie]

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This thread is not meant for bashing surgeons btw.

You have a patient 4 days s/p gastric bypass with a perforated bowel. They're stable, good BP, HR wnl.

You call bypass surgeon who is skiing and has this other person on call for them. Wait for them to call back, wait for them to come and assess pt. After assessment they say that gen surg can take care of this. You argue about it because you know gen surg will not take care of this pt because of prior experience (regular bypass surg would have taken care of it since that's the way things are done in this particular ED). Bypass surg says to do it anyway.
Page gen surg. Gen surg refuses. Repage bypass surg. Pt is now hypotensive and tachycardic. Bypass surg calls back, you inform them gen surg won't take it, so bypass surg says they'll take them to surgery.

Say this patient dies in the OR. How does that work out for you legally? Do you chart like mad about the ping pong game? Will they still yank you into court?

 

[docB]

Let me first say: Been there.

We also need to know how far s/p bypass. 1 week is different than 1 year.

Here's my suggestion of how to deal with such a situation. Document everything. In the case you describe you are better off because the bariatric surgeon actually came in and saw the patient before refusing to do anything. In my part of the world they just refuse on the phone. If he has refused and if your staff bylaws don't compel him to care for his partner's patient then it goes to the surgeon on call and he can not refuse to come and assess the patient. If he does refuse then call the hospital administrator on call and the chief of surgery. If there is still no resolution and the patient is deteriorating transfer the patient to another facility with surgical services noting on the COBRA form the names of both surgeons who refused to care for the patient in accordance with EMTALA.

It's a pet peeve of mine when hospitals try to grab the CMS free cash they all see in bariatrics without setting up the needed infrastructure. In my opinion they should never open up a program without a high weight CT scanner (and some other things). They should absolutely state in the bylaws that the bariatric surgeons are responsible for their own complications. Dumping those on the general surgeons on call is grossly inappropriate.

Here's a letter I wrote to a hospital administrator a while back while they were setting up their bariatric program. You can tell you've been in administration for a while when you have old memos filed away on a lot of subjects.

As (2 hospitals) work toward the goal of developing bariatric surgery programs we should be mindful of the impact this will have on the EDs. Gastric bypass patients will present to the ER in droves for their postoperative care and complications. These are unhealthy people with multiple comorbidities and myriad ailments. These patients can really bog down the ED because providing them with care is often very difficult. Some major issues that should be addressed before the problems occur are:

CT Table weight limits – The weight limits if the CT tables at the institutions must be improved to the upper limit of patient weight that the surgical program will accept. There are two very common reasons that these patients present to the ER post op. These are abdominal pain, which needs a CT to evaluate leak and abscess, and chest pain, which needs a CT to evaluate PE. Because of their post surgical status and their obesity they are all high risk for PE. D Dimer is useless because they are post op (so it will be positive). Their risk profile mandates that they go straight to imaging. VQ in these patients is of dubious value because their obesity makes interpretation difficult. Admission for heparin and observation without imaging is dangerous because they are at risk of bleeding from their surgical wounds.

CT Contrast Protocol – In the event a CT can be obtained radiology must provide the nursing staff with the proper PO contrast regimen for these patients. They can not tolerate the usual PO contrast amount. There is also a faster transit time so these patients do not need to wait two hours for their contrast scans. This should be addressed before the patients begin to arrive in the ED.

Nuclear Medicine – These patients are also at high risk for cardiac ischemia and if they can be ruled out for PE will need a cardiac work up as well. Nuclear medicine must be prepared to accommodate morbidly obese patients for stress tests.

IV Access – These patients present a very difficult challenge for IV access. They usually have poor peripheral veins. Central access is difficult in the morbidly obese and has a higher morbidity. Ideally these patients would leave the hospital with PICC lines that would remain in for the immediate post surgical period.

Admissions – The process for admitting these patients must be addressed prior to the program beginning. Will surgery admit as primary and consult medicine or will medicine take the admission? Many of these patients will be post surgical but have medical complaints like chest pain and shortness of breath. Will the medicine attending be arranged by prior agreement with surgery? It would be inappropriate for these programs to go forward assuming that these difficult patients will be dumped on the on call internist or surgeon.

Transfers – The facilities undertaking these programs should be willing to accept these postsurgical patients back in transfer when they wind up at other area hospitals due to EMS diversion, patient ignorance, etc. The surgeons involved should agree that it would be inappropriate to leave one of their patients in a facility with no bariatric service to be attended by the general surgeon on call.

Big Boy beds – The ED will need access to big boy beds prior to admission of theses patients. Many of these patients can not be safely, let alone comfortably, placed on a standard gurney.

Predictably one of the CEOs involved said to me "Those are all great ideas. We're not going to do any of it."

 

[Wackie]

Let me first say: Been there.

We also need to know how far s/p bypass. 1 week is different than 1 year.

Edited for you. 4 days s/p

Predictably one of the CEOs involved said to me "Those are all great ideas. We're not going to do any of it."

Lovely. And predictable which is sad.

 

[docB]

Edited for you. 4 days s/p

In my opinion 4 days sp gastric bypass should definitely be the responsibility of the bariatric surgeon, or any surgeon who was just in the belly 4 days prior. I would say that the appropriate instutional policy in that situation is that the bariatric surgeon comes and assesses their patient and if for some reason they think it needs to be taken care of by gen surg they can get that consult. If they decide that the patient does not need to go to the OR they should take the patient on their service and they can consult or turf to medicine on their own.

 

[Wackie]

In my opinion 4 days sp gastric bypass should definitely be the responsibility of the bariatric surgeon, or any surgeon who was just in the belly 4 days prior. I would say that the appropriate instutional policy in that situation is that the bariatric surgeon comes and assesses their patient and if for some reason they think it needs to be taken care of by gen surg they can get that consult. If they decide that the patient does not need to go to the OR they should take the patient on their service and they can consult or turf to medicine on their own.

No doubt. My question revolved around where the EP stands in such a situation should there be a suit, or in any situation where consults are trying to turf and it results in delay that causes (or may cause) a poor outcome.

 

[docB]

No doubt. My question revolved around where the EP stands in such a situation should there be a suit, or in any situation where consults are trying to turf and it results in delay that causes (or may cause) a poor outcome.

Sorry I hijacked a little. Anytime there is conflict and it gets documented, as it would in this case, it makes everyone look bad. However, the reality is that we can't take a patient to the OR or the cath lab. We can get them the consult and if the consultant does not feel that intervention is indicated after assessing the patient then the liability for that decision is on them. To successfully get the EP in that situation the plaintiff has to argue that the EP should have somehow overrulled the consultant or called another consultant. This is a relatively hard case to make. I think that in the case you outlined the EP would be safe and the bariatric surgeon would be screwed.

 

[roja]

Document. Document. Document.

This is a political nightmare because of the concept of 'chartwars'. basically when something crappy hits the fan because someone refused, then they get pissy because you documented that they refused.

However, you can document the time you called and then spoke to the bariatric surgeon. You can document that the general surgeon was called and spoken with and then that the bariatric surgeon was called again and spoken too.

 

[Castro Viejo]

Doesn't everyone just lose when something like this happens?

If the situation was resolved, as it was in this case, then why document the ping-pong and if and when the fit hits the shan, everyone will be covered in it? (Yes, including the EP)

If the patient was neglected by the General Surgeon and the Bariatric Surgeon to the point where the patient dies or has an adverse event (i.e., codes), then document like hell and pull yourself off the sinking ship, but if it's resolved I don't see the need to do it other than to be a pain in the butt.

(And, no, I'm not insinuating that it wasn't anxiety-producing for you -- I acknowledge that -- but EVERYONE's been in these types of situations, including myself, and I refrain from making my physician colleagues look bad in the chart unless it's grossly obvious)

 

[docB]

Doesn't everyone just lose when something like this happens?

If the situation was resolved, as it was in this case, then why document the ping-pong and if and when the fit hits the shan, everyone will be covered in it? (Yes, including the EP)

If the patient was neglected by the General Surgeon and the Bariatric Surgeon to the point where the patient dies or has an adverse event (i.e., codes), then document like hell and pull yourself off the sinking ship, but if it's resolved I don't see the need to do it other than to be a pain in the butt.

(And, no, I'm not insinuating that it wasn't anxiety-producing for you -- I acknowledge that -- but EVERYONE's been in these types of situations, including myself, and I refrain from making my physician colleagues look bad in the chart unless it's grossly obvious)

What frequently happens to us is that in the light of day the retrospectoscope comes out and the scapegoating begins. Often the patient's actual surgeon gets mad that his coverage left his patient hanging and wants heads to roll. If it's not documented who was called and what they do or didn't do then he will blame the EP for his patient getting turfed to another surgeon. When you write it up we don't make them look bad, we record the facts.
2120- Dr. X covering Dr. Y called.
2150- Dr. X has seen patient and want surgery on call to take case.
2215- Surg on call Dr. Z called.
2300- Dr. Z has seen patient and wants Dr. Y to take case
... and so on.

 

[Hayduke]

If the patient was neglected by the General Surgeon and the Bariatric Surgeon to the point where the patient dies or has an adverse event (i.e., codes), then document like hell and pull yourself off the sinking ship, but if it's resolved I don't see the need to do it other than to be a pain in the butt.

Documentation post-badness has serious repercussions. This can be construed as augmenting the chart to clear yourself thereby implying guilt. Revising a medical record is illegal. If it is not included in some post-MM QA type novella, going in the progress note and giving times and titles called can be interpreted as 'late entry'. This has a terrible legal track record with cases that have included threatened prison time for EPs.

So how will anyone know?
Charts go places we can't imagine. I learned the other evening that every time one of my patients goes to any out-department diagnostic area, the chart is copied. This includes Nuc Med, OB, our big boy scanner upstairs etc. These are returned after the patient comes back and are retained as part of the complete ED record. Not having a continuous time course of progress (contradicted by the real chart vs. the copies) is a set up for 'getting got'.

DocB's example is concise, historically accurate and does not assign blame. Like a good record should, it gives a factual and unbiased account of what happened.

 

[southerndoc]

It's my understanding that you can later add notes to a chart so long as you date and time your addendum. There is no limit to the time you can add notes, but it will get suspicious if you add a note 2 years after seeing a patient v. 2 days.

 

[Hayduke]

It's my understanding that you can later add notes to a chart so long as you date and time your addendum. There is no limit to the time you can add notes, but it will get suspicious if you add a note 2 years after seeing a patient v. 2 days.

Truth.

I wasn't implying that you cannot amend, rather that a cohesive and accurate account of the visit at that time always keeps you looking shiny.