What would you do?

[thegenius]

A woman came in to get her stitches removed. 2 weeks ago she had a b/l breast lift with implants, some sort of armpit tuck, and a tummy tuck in Tijuana. She saved 40K doing it in Mexico. She has stitches around her areolas, armpits, and in her bellybutton. All the wound edges looked great. From what i can tell, they all appear to be interrupted sutures, a few might be buried. There are probably 30-40 stitches.

I told her she doesn’t have a medical emergency. She knew that and admitted it as such. She went to a UC earlier that day who referred her to a Kaiser ER (her health care provider) who said no...then came to my ED.

I actually told her I’m tempted to say no. I asked her what her plan was to get her stitches removed because she went to Mexico, and she said her plan was to remove them herself. Then she realized she couldn’t, and her husband didn’t want to.

She was very nice. I wanted to help...and I ended up removing some but there were some weird sutures that were not simple interrupted around her areola and I stopped and told her she needs to see a plastic surgeon or go back to Mexico to have them removed.

What would you have done?

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[GonnaBeADoc2222]

A woman came in to get her stitches removed. 2 weeks ago she had a b/l breast lift with implants, some sort of armpit tuck, and a tummy tuck in Tijuana. She saved 40K doing it in Mexico. She has stitches around her areolas, armpits, and in her bellybutton. All the wound edges looked great. From what i can tell, they all appear to be interrupted sutures, a few might be buried. There are probably 30-40 stitches.

I told her she doesn’t have a medical emergency. She knew that and admitted it as such. She went to a UC earlier that day who referred her to a Kaiser ER (her health care provider) who said no...then came to my ED.

I actually told her I’m tempted to say no. I asked her what her plan was to get her stitches removed because she went to Mexico, and she said her plan was to remove them herself. Then she realized she couldn’t, and her husband didn’t want to.

She was very nice. I wanted to help...and I ended up removing some but there were some weird sutures that were not simple interrupted around her areola and I stopped and told her she needs to see a plastic surgeon or go back to Mexico to have them removed.

What would you have done?

Prob referral to plastics right off the bat.

As an aside i've seen some reallllly bad complications from this kind of medical tourism involving breast surgery.

 

[Rendar5]

I'm not a surgeon and don't know enough about those procedures to know what I should be doing (too many unknown unknowns for me). Referred back to Mexico or to my local plastics guy.

 

[Groove]

I wouldn’t touch that with a ten foot pole. I’d tell her to hop on a plane and attend her post up appt with the shady Tijuana doctor.

 

[Zebra Hunter]

I’m not sure if she “saved” much after 2 unnecessary ER visits, an UC visit, and a likely trip back to Mexico for a follow up appointment. Breast implants don’t cost $40k.

 

[TooMuchResearch]

Refer to plastics. Depending on which hospital, I might actually call them to make sure they will see her (a phone call goes a long way).

 

[Birdstrike]

A woman came in to get her stitches removed. 2 weeks ago she had a b/l breast lift with implants, some sort of armpit tuck, and a tummy tuck in Tijuana. She saved 40K doing it in Mexico. She has stitches around her areolas, armpits, and in her bellybutton. All the wound edges looked great. From what i can tell, they all appear to be interrupted sutures, a few might be buried. There are probably 30-40 stitches.

I told her she doesn’t have a medical emergency. She knew that and admitted it as such. She went to a UC earlier that day who referred her to a Kaiser ER (her health care provider) who said no...then came to my ED.

I actually told her I’m tempted to say no. I asked her what her plan was to get her stitches removed because she went to Mexico, and she said her plan was to remove them herself. Then she realized she couldn’t, and her husband didn’t want to.

She was very nice. I wanted to help...and I ended up removing some but there were some weird sutures that were not simple interrupted around her areola and I stopped and told her she needs to see a plastic surgeon or go back to Mexico to have them removed.

What would you have done?

How you respond depends on which world you live in:


IDEAL WORLD

She should have them removed by the surgeon who put them in or another plastic surgeon. To dump this on some other physician, especially in a different specialty is inappropriate.

What if you start removing them and the wounds start to dehisce or they get infected because it was some rogue back alley surgeon? Then it leads to a disfiguring cosmetic results and the surgeons start drooling at the chance to get paid $1000 per hour to tell lawyers it's the fault of some ER doctor that thought he was a plastic surgeon. If this lady walks into any other physicians office, they won't do it.

She can use some of that $40K she saved and buy a ticket back down to Cabo Wabo for suture removal.


PRESS-GANEY WORLD

You remove the sutures, knowing no one else will do it and she's not going to use her $40K to go back to Mexico for it. She's already spent that money on a Brazilian butt lift, trout pout and a handbag. Also, you know the patient will just keep checking out and checking back in until she gets one of your partners that always undermines you, gives patients whatever they want and removes them. Then you look bad, because it was easy, the wounds turned out fine, the patient loved him for doing it, loves her new appearance and won't stop calling admin to tell them how you almost made her live with bad boobs.


Choose which world you live in.

 

[USCDiver]

Ma’am I have no idea how long sutures are supposed to be left in place after a procedure like that.

 

[Groove]

History is replete with poor outcomes from surgeries out of the country like this one. It's difficult to impossible to reclaim any money from a "surgeon" in Tijuana, assuming he actually had any formal medical training in the first place. Anyone who touches that runs the risk of being blamed for poor cosmetic outcome and there are multitudinous surgeons who would be willing to throw an EP under the bus for some extra $$$ as an expert witness claiming that subpar post op wound care and premature suture removal or improper suture removal are to blame. Press-Ganey and hospital administrators be damned, I'd 100% kick her out and give her a local plastics guy (who also would probably kick her out). How asinine to get a surgery out of the country, not stay for adequate post op appointments (if they were even scheduled) and then expect US physicians to take over care. They can keep checking in until one of my partner "suckas" starts snipping on that, at which point you've now become the first US doctor to initiate any post operative care on the pt. When she goes to sue for her mutated breasts the plaintiff attorney is not going to ask what Tijuana physician did her surgery, but what US doctor with malpractice insurance touched her first.

 

[Hercules]

I have had this happen several times. I just explain that they’re going to have to follow up with their international surgeon or find a surgeon in town who is willing to assume care for her surgery. I view this the same way I do chronic pain patients who come to the ED to have their pain managed. Do they have a legitimate issue? Possibly. Is it one that is appropriate to manage in the ED? No.

 

[southerndoc]

I would not remove them unless there was a medical emergency requiring their removal (like an abscess). What happens if you remove them and things fall apart? Guess who gets sued? You, not the doctor out of country.

People like this need to budget their money to go back to the operating surgeon and have them do their follow-up.

Why in the world did sutures need to be removed? I've never heard of breast augmentation or even breast reductions having anything other than absorbable sutures placed usually in combination with Dermabond. That's messed up.

On another note, because this is a follow-up from a routine cosmetic surgery, insurance likely will not pay for it. We've had denials for people who are admitted for PE's post breast augmentation. The insurance company said it was a complication from an elective/cosmetic procedure that was not medically necessary. Therefore, the patient was responsible for her entire hospital bill.

 

[thegenius]

Yea i should have just discharge her. Everything that was said here were things that I was thinking, and I even told her some of them. I didn’t even consider the payment issue thing too. 100% insurance is not going to reimburse that visit to the ER.

 

[thegenius]

On another note, because this is a follow-up from a routine cosmetic surgery, insurance likely will not pay for it. We've had denials for people who are admitted for PE's post breast augmentation. The insurance company said it was a complication from an elective/cosmetic procedure that was not medically necessary. Therefore, the patient was responsible for her entire hospital bill.

So that patient had a legitimate EMC, a real one, and insurance denied payment? (I guess that’s a rhetorical question because you already answered it)

 

[CajunMedic]

Only gonna get worse, now that employers are getting on board with the idea to save money. When are we going to start seeing more of these?

A Mexican Hospital, an American Surgeon, and a $5,000 Check (Yes, a Check)

n=1, but I dealt with 2 botched gastric sleeves in the ED and on my surgery month from those places. One patient will probably never tolerate solid food again. Found out the hard way, it's not even worth attempting to get an op note or any records

 

[RoyBasch]

I've seen a few of these patients before, always hard pass, I tell them we do not do routine surgical follow up in the ER. Not an emergency. When I trained surgeons told me emphatically "never touch another surgeon's sutures." You don't know exactly where they go, how they are anchored, what their indication and anticipated duration is, etc. I tell the patient, Ideally you need to follow up with your operating surgeon--usually not possible because they are in Mexico--and baring that, a different plastic surgeon. So I refer them to our PRS group.

 

[RuralEDDoc]

I think it says a lot that her kaiser ER doctor didn’t remove them. Kaiser really emphasizes patient satisfaction and if that doctor didn’t feel comfortable touching them and was willing to take a hit on the patient survey, there’s probably a reason. I’m glad you didn’t touch the areola sutures - who knows where they go. (Her surgeon).

 

[Tenk]

Hell no.

 

[Brigade4Radiant]

Good discussion we are only going to see more of this.

A Mexican Hospital, an American Surgeon, and a $5,000 Check (Yes, a Check) (Published 2019)

A novel twist on medical tourism to avoid the high cost of U.S. health care saves an employer money and even earns the patient a bonus.

www.google.com

 

[jurassicpark]

Not an ER doc, but boy do I get my fair share of cosmetic disasters under my service. And not just from Mexico, but from boutique outpatient cosmetic centers a city or two away. It's absolutely hilarious the ways they try to cover up their mistakes, partly by knowing that most docs will try to follow their recommendations to avoid blame for causing a "bad outcome." It's a no-win situation for most

 

[Goro]

A woman came in to get her stitches removed. 2 weeks ago she had a b/l breast lift with implants, some sort of armpit tuck, and a tummy tuck in Tijuana. She saved 40K doing it in Mexico. She has stitches around her areolas, armpits, and in her bellybutton. All the wound edges looked great. From what i can tell, they all appear to be interrupted sutures, a few might be buried. There are probably 30-40 stitches.

I told her she doesn’t have a medical emergency. She knew that and admitted it as such. She went to a UC earlier that day who referred her to a Kaiser ER (her health care provider) who said no...then came to my ED.

I actually told her I’m tempted to say no. I asked her what her plan was to get her stitches removed because she went to Mexico, and she said her plan was to remove them herself. Then she realized she couldn’t, and her husband didn’t want to.

She was very nice. I wanted to help...and I ended up removing some but there were some weird sutures that were not simple interrupted around her areola and I stopped and told her she needs to see a plastic surgeon or go back to Mexico to have them removed.

What would you have done?

This would make a great interview question!

 

[emergentmd]

Is this even a discussion? I would Probably fail Goro's interview question and be the heartless doc who didn't care enough about the pt to take simple stitches our.

Lets think this through

1. Did I or another ER/UC doc put stitches in which i have put in many times before? NO
2. Will I now be assuming Plastic surgery care being the only American Doc to participate in her care? Yes
3. Will I or the nursing staff confident that all of the stitches were taken out? NO
4. Will every complication fall on my Lap as no other surgeon would touch her with a 10 foot pole if she gets a post op complication? Yes
5. Am I practicing outside of my scope of care? Yes
6. Do I take out stitches from other specialists procedures without explicit understanding that they will follow up with said doctor? NO

Seems like alot of negatives and very little positives. That is the reason why 3 other providers told her no including her healthplan hospital.
She saved $40K, she can use some of that $$$ to go back to Mexico

 

[GeneralVeers]

Yep wouldn't touch this at all. It's another case of a patient taking a "them problem" and making it a "you problem". Go back to Mexico and get the sutures taken out. I'm not becoming responsible for any of these turds.

 

[hundreddaysoff]

A woman came in to get her stitches removed. 2 weeks ago she had a b/l breast lift with implants, some sort of armpit tuck, and a tummy tuck in Tijuana. She saved 40K doing it in Mexico. She has stitches around her areolas, armpits, and in her bellybutton. All the wound edges looked great. From what i can tell, they all appear to be interrupted sutures, a few might be buried. There are probably 30-40 stitches.

I told her she doesn’t have a medical emergency. She knew that and admitted it as such. She went to a UC earlier that day who referred her to a Kaiser ER (her health care provider) who said no...then came to my ED.

I actually told her I’m tempted to say no. I asked her what her plan was to get her stitches removed because she went to Mexico, and she said her plan was to remove them herself. Then she realized she couldn’t, and her husband didn’t want to.

She was very nice. I wanted to help...and I ended up removing some but there were some weird sutures that were not simple interrupted around her areola and I stopped and told her she needs to see a plastic surgeon or go back to Mexico to have them removed.

What would you have done?

Depends. How many RVUs is that and how busy am I?

I work on the border and see this stuff all the time. It actually mystifies me that I get the number of drug seekers I do (antibiotic, narcotic, or otherwise) in my ER since anyone with a passport can just cross into Mexico and pick up any drug they want at la farmácia without a prescription, for waaay cheaper than it would be in the US.

 

[BoardingDoc]

Depends. How many RVUs is that and how busy am I?

I work on the border and see this stuff all the time. It actually mystifies me that I get the number of drug seekers I do (antibiotic, narcotic, or otherwise) in my ER since anyone with a passport can just cross into Mexico and pick up any drug they want at la farmácia without a prescription

.... because that isn't true? I'm sure there are some shady pharmacies out there, just like there are drug dealers anywhere, but my understanding is that you can't get strictly controlled substances from a Mexican pharmacy without an Rx anymore than you can in the US. Antibiotics and other ****, sure. Oxycodone and Xanax? I don't think so.

 

[deleted109597]

.... because that isn't true? I'm sure there are some shady pharmacies out there, just like there are drug dealers anywhere, but my understanding is that you can't get strictly controlled substances from a Mexican pharmacy without an Rx anymore than you can in the US. Antibiotics and other ****, sure. Oxycodone and Xanax? I don't think so.

Correct. But it's very easy to get the Rx. There are clinics all over that will give it.

 

[Fox800]

So that patient had a legitimate EMC, a real one, and insurance denied payment? (I guess that’s a rhetorical question because you already answered it)

By the same logic, any tobacco or obesity-related condition shouldn't be covered, because the patient made a bad decision. They made a decision to get surgery - a risk factor for VTE. They shouldn't be punished because the surgery was elective.

 

[Brigade4Radiant]

Insurance denies around 20% of claims without even looking at them.

 

[thegenius]

By the same logic, any tobacco or obesity-related condition shouldn't be covered, because the patient made a bad decision. They made a decision to get surgery - a risk factor for VTE. They shouldn't be punished because the surgery was elective.

My thought too.

 

[EctopicFetus]

Prob referral to plastics right off the bat.

As an aside i've seen some reallllly bad complications from this kind of medical tourism involving breast surgery.

Yeah also bariatric stuff in Mexico. I uusually get my specialists involved because I dont want to **** up the work and I know nothing about it. Tons of very serious complications from this stuff but also no shortage of people who are happy with outcome and cost savings. IMO this is insane unless you stay long enough for the recovery.

 

[deleted109597]

Issue is, you call plastics (if you're in the 10% that has them on call). Either they tell you on the phone "this isn't an emergency" or they come down and do the same. Then what?
The patient can go to their clinic and pay up front like any other person. So that's how I discharge them.
If there is an infection/complication/whatever, then sure, it might be an EMC.

 

[hundreddaysoff]

.... because that isn't true? I'm sure there are some shady pharmacies out there, just like there are drug dealers anywhere, but my understanding is that you can't get strictly controlled substances from a Mexican pharmacy without an Rx anymore than you can in the US. Antibiotics and other ****, sure. Oxycodone and Xanax? I don't think so.

I stand corrected. Mexican pharmacists can directly write a lot of scripts, but that doesn't include controlled substances. And oddly enough, according to Google, they also can't write for Cipro but they can for lots of other abx.

Agree w/ McNinja that there have to be a bunch of cheap shady clinics down there that *will* write for these. However they get them, I do see a fair number of pts who p/u controlled substances in Mexico and then come to me complaining they aren't working.

 

[deleted836128]

OMG, I wouldn’t touch this. Most of us don’t know a damn thing about these procedures. Keep in mind this is also an elective, cosmetic procedure which makes touching those sutures a HELL NO. I’ve been presented with situations like this a few times and I just want to help the darn patient but the liability is major. This sounds dumb but I had a patient come into the ER to have her IUD removed. When I asked her why, she said something about filing a lawsuit about something she saw on TV that was IUD related. She didn’t have any acute symptoms and there was no reason to take it out emergently. I’ve removed only two in my life - both on patients with raging PID, and I had no choice, and was directed by the OBGYN on call in those cases. So in this case I refused and told her to see her OBGYN. She got so mad she cussed me out. Sure, in most cases it’s as simple as pulling the string and “bye” but it’s hard to justify doing a procedure that’s not in my scope for no medical indication.

 

[BoardingDoc]

OMG, I wouldn’t touch this. Most of us don’t know a damn thing about these procedures. Keep in mind this is also an elective, cosmetic procedure which makes touching those sutures a HELL NO. I’ve been presented with situations like this a few times and I just want to help the darn patient but the liability is major. This sounds dumb but I had a patient come into the ER to have her IUD removed. When I asked her why, she said something about filing a lawsuit about something she saw on TV that was IUD related. She didn’t have any acute symptoms and there was no reason to take it out emergently. I’ve removed only two in my life - both on patients with raging PID, and I had no choice, and was directed by the OBGYN on call in those cases. So in this case I refused and told her to see her OBGYN. She got so mad she cussed me out. Sure, in most cases it’s as simple as pulling the string and “bye” but it’s hard to justify doing a procedure that’s not in my scope for no medical indication.

I have literally never removed an IUD in my life and I suspect I never will. It is not an emergency 99.9% of the time. The 0.1% of the time where it is, they should be seeing a gynecologist anyway.

 

[GonnaBeADoc2222]

OMG, I wouldn’t touch this. Most of us don’t know a damn thing about these procedures. Keep in mind this is also an elective, cosmetic procedure which makes touching those sutures a HELL NO. I’ve been presented with situations like this a few times and I just want to help the darn patient but the liability is major. This sounds dumb but I had a patient come into the ER to have her IUD removed. When I asked her why, she said something about filing a lawsuit about something she saw on TV that was IUD related. She didn’t have any acute symptoms and there was no reason to take it out emergently. I’ve removed only two in my life - both on patients with raging PID, and I had no choice, and was directed by the OBGYN on call in those cases. So in this case I refused and told her to see her OBGYN. She got so mad she cussed me out. Sure, in most cases it’s as simple as pulling the string and “bye” but it’s hard to justify doing a procedure that’s not in my scope for no medical indication.

Would never do this.

 

[deleted836128]

I have literally never removed an IUD in my life and I suspect I never will. It is not an emergency 99.9% of the time. The 0.1% of the time where it is, they should be seeing a gynecologist anyway.

Would never do this.

Okay, good to know I am not alone in this! Always thought I was being a little bit over the top for refusing. Seems like a stupid thing but I am not comfortable with it. Weirdly I never even had the opportunity to do it in my OB/GYN rotation but even if I had, I still probably wouldn't do it unless absolutely indicated.

 

[RuralEDDoc]

Removed one in the setting of PID. Can’t imagine doing it electively in the ED.

 

[Janders]

Oddly I removed an IUD last month.


Granted the sepsis, rigors, 103 fever, pus pouring out of the cervical os, and patient very kindly asking me to remove the damned thing tilted my view in that direction.

 

[thegenius]

I pulled one or two out. By the time I was down there and I told the patient "well I have my fingers on the strings" and she just BEGGED me to pull it out. "PLEASE PLEASE PLEASE!!!!!" I asked thrice to make sure this is what she wanted and she said "YYYYEEESSSSSSS!!!!"

So I pulled it out, she felt better and was so relieved.

But I try to avoid it. Had one 1 month ago...and I said no we don't do that. Plus it was very hard to feel it anyway. It's not that easy to clasp it with your fingers. I guess you could use a tool to grab it, but I'm not gonna hunt for one in the ER to do that.

 

[Birdstrike]

I pulled one out once. I initially wasn't going to do it. I called her OB. I said, "I'm not pulling this out. I'm sending her to you."

The OB said, "Ok fine. Whatever."

"By the way, how do you remove these?"

"You just pull it out," the OB said.

"That's it? You just pull it out?"

OB, "Yep."

"It's literally that easy? Just pull the string?"

OB, "Yep. Like a tampon."

So, I removed it. And yes, it was really easy. Is it an ER doc's job, though? No. Can 'IUD removal' go tragically bad? I have no idea, but I doubt it. If so, I'd probably have seen someone for that, at some point. Regardless, my n of 1, went fine, for what it's worth.

 

[d2305]

IUDs are easy to pull out. I found out that surgeons won't remove sutures done by another surgeon.

 

[emergentmd]

I have pulled a few IUDs out b/c the pt was nice and its not a big deal.

The reason a surgeon won't remove other's stitches is b/c the money is already made and getting involved adds you to the liability if something bad happens.

I can't remember how many times I have removed stitches that were not done in the ER. I can't really remember any time.

 

[deleted109597]

Suture removal is no longer covered under the global fee if done by a different office.
Just like in the ED. Telling them that they can come to the ED and get them removed for free is false.
The ED will always be the most expensive place to have them removed.

 

[Fox800]

Suture removal is no longer covered under the global fee if done by a different office.
Just like in the ED. Telling them that they can come to the ED and get them removed for free is false.
The ED will always be the most expensive place to have them removed.

Correct. PCPs get mad when I tell patients to go see their PCP for suture removal in X days. Well, hey, this person is your patient. It's an A-hole move to refuse and make them come back to see me and get another ED bill. I tell patients "it's the right thing to do".

 

[Groove]

I pulled one out once. I initially wasn't going to do it. I called her OB. I said, "I'm not pulling this out. I'm sending her to you."

The OB said, "Ok fine. Whatever."

"By the way, how do you remove these?"

"You just pull it out," the OB said.

"That's it? You just pull it out?"

OB, "Yep."

"It's literally that easy? Just pull the string?"

OB, "Yep. Like a tampon."

So, I removed it. And yes, it was really easy. Is it an ER doc's job, though? No. Can 'IUD removal' go tragically bad? I have no idea, but I doubt it. If so, I'd probably have seen someone for that, at some point. Regardless, my n of 1, went fine, for what it's worth.

I stopped removing them after I had a lady with one that had migrated through the entire anterior wall of her uterus. God knows what would have happened if I had grasped that thing and gave a big tug!

 

[bravotwozero]

Yeah wouldn't touch this with a 10 foot pole. Discharge home with plastics referral as outpatient, or she can go back to Mexico to her surgeon.

 

[KGflyboy]

Yeah wouldn't touch this with a 10 foot pole. Discharge home with plastics referral as outpatient, or she can go back to Mexico to her surgeon.

Would your plastic surgeon take this patient? If I don't physically call the on call surgeon, they likely won't see the patient without a referral from a PCP or other doc. If I called the plastic surgeon and attempted to arrange follow up, I have a feeling they would still not take the patient.

 

[bravotwozero]

If they don't, I don't think it's my problem. That being said, we do have a plastic surgeon on staff who is like some kind of an angel in human form. He will see and do pretty much anything and everything plastics related, and has helped us out in many a tough situation where other on call consultants were being total douchecanoe a$$hats, but that's neither here nor there.

 

[VA Hopeful Dr]

Correct. PCPs get mad when I tell patients to go see their PCP for suture removal in X days. Well, hey, this person is your patient. It's an A-hole move to refuse and make them come back to see me and get another ED bill. I tell patients "it's the right thing to do".

Yep, most of us are happy to do and bill for it. Easiest $40 of my day.

 

[Rendar5]

Correct. PCPs get mad when I tell patients to go see their PCP for suture removal in X days. Well, hey, this person is your patient. It's an A-hole move to refuse and make them come back to see me and get another ED bill. I tell patients "it's the right thing to do".

So global fee doesn’t exist anymore? I was always taught that if done at my own ED they could come back and have them out but if they went to a different ED or a PCP they would get charged. When did the rule change?

 

[deleted109597]

When did the rule change?

Beats me. I just know it isn't anymore.