Residency: This kid has a supracondylar fracture, page ortho to come down.
Community: This kid has a supracondylar fracture. Let’s see here now, there’s the hospital ortho group and the community ortho group and I happen to know it’s the community group’s night to take call. There are three of them, one will see supracondylar’s but the other two “don’t feel comfortable” and always ask us to arrange follow up with the pediatric orthopedic surgeons in the referral city down the road. I walk over to the call schedule and slowly look to see which one is on, muttering “please be supracondylar guy please be supracondylar guy” so I can be done with this patient but “damn!” it’s a worthless non-supracondylar guy whose name comes up on the list.
Ok then. I go through the chart to see what kind of insurance this kid has, since any kind of insurance means paging the pediatric orthopedic surgeon to arrange out-patient followup, but no insurance means transferring them to the big city ER, the exact details of why it is this way still fuzzy to me but somehow someway I’m told that some amount of money is recovered by the pediatric orthopods if the patients are funneled to them through their affiliated ER.
This particular kid happens to be uninsured so I call the big city ER and usually they say fine but I must have a new guy or something who is unaware of the arrangement because I get a lot of resistance: he asks me “why can’t your orthopods take care of a simple supracondylar fracture” and I say “I don’t know, because they ‘don’t feel comfortable’” and then he says “well didn’t they go through an ortho residency?” and I say “look all I can tell you is what they’ve told me” and then he plays his trump card and says “well did they even come in and see the patient?” and I sigh and say “no they just looked at the xray from home” and then he gets uppity and says “well they need to at least personally evaluate the patient” and hangs up as I’m trying to just explain that there is already a system in place not to mention we both know the orthopod doesn’t really need to come in I mean it’s not some complicated HIV/dialysis/heart failure/septic patient or anything it’s just a healthy kid for crying out loud and he’s seen the film and I told him the fracture was closed and neurovascularly intact and that’s all there is to know but the big city ER guy probably thinks I’m trying to dump an uninsured patient on his overwhelmed ER and of course they are uninsured but the truth of the matter is it’s not a dump our orthopod doesn’t manage any supracondylars insured or not and I sure don’t care whether or not they have insurance and I don’t care where they go, I just want someone to take this patient off my hands because I have 14 others to worry about and a packed waiting room myself.
So now I’m left to decide whether to call the big city pediatric orthopod to see if I can get him to call the big city ER to tell this guy to go ahead and accept the patient in transfer or call my community orthopod to come in and evaluate the patient and I decide to call the local guy since that’s what the big city ER guy is asking for and because he’ll probably call back faster than the out of town guy and let’s not forget to mention if this board certified orthopedist would just take care of freaking non-displaced uncomplicated bread-and-butter supracondylar fractures I wouldn’t be wasting all of this time. I decide to walk over to triage and announce to the nurse that while I’ll continue to see straightforward chest and abdominal pain, I am finding more and more that I just “don’t feel comfortable” with dizziness and ask her to refer those patients on south. Unfortunately she doesn’t take me seriously.
The local guy calls back and I explain the situation to him and he agrees to come in. He evaluates the patient, calls the big city ER, and the patient is accepted for transfer. We fill out lots and lots (and lots) of paperwork, print out the xrays, call for nursing report, call for an ambulance, and finally the patient is loaded up and on his way to the next ER.
In residency you learn how to diagnose a supracondylar fracture. Out in the community you learn how to disposition it.
July 6, 2009 at 10:11 am
Excellent post. I especially like the sweat-on-the-brow melodramatic dizziness discomfort announcement to the unimpressed triage nurse.
So now I’m left to decide whether to call the big city pediatric orthopod to see if I can get him to call the big city ER to tell this guy to go ahead and accept the patient in transfer or call my community orthopod to come in and evaluate the patient and I decide to call the local guy since that’s what the big city ER guy is asking for and because he’ll probably call back faster than the out of town guy and let’s not forget to mention if this board certified orthopedist would just take care of freaking non-displaced uncomplicated bread-and-butter supracondylar fractures I wouldn’t be wasting all of this time.
I just wanted to point out that this is one sentence, and it’s perfectly written that way. I feel like throwing a chart or beating a defenseless midget or something after reading it.
July 6, 2009 at 11:04 am
Luckily at my hospital we just splint them and the on call person sees them within the next day or two no questions asked. If they are not “comfortable” with them, they arrange the follow-up from there. Your scenario sounds like a typical community hospital disposition nightmare.
July 6, 2009 at 11:46 am
Great post. People in the non-medical world think my job is hard because of heart attacks and sick babies. People in the medical world think my community job is hard because of lack of OB and trauma surgeons. I will now point them here to explain what drives me to drink.
July 6, 2009 at 11:51 am
Even more than dying parents and terminally ill babies and horrific injuries, THIS right here is why I’m glad I don’t have what it takes to get into the medical field.
I don’t think I’d make it out without killing someone.
July 6, 2009 at 12:39 pm
And this is what makes you Dr. 10/10. I am going to be in your shoes next year and I am so scared to step out in the real world and face all these challenges.
July 6, 2009 at 1:56 pm
You captured the essence.
Now repeat some similar type of scenario for 4-5 other patients a shift……………..ane you want to quit.
July 6, 2009 at 6:38 pm
And if the pt had been 19 then internal medicine would be called to admit…
Amazing how all ER docs think that every other doctor exists solely to disposition their patients.
Ever call the ER doc to come up and help your crashing patient? It goes like this: “um, we don’t do that/we don’t get paid/it’s not a real emergency/call someone else…”
What’s the difference?
July 7, 2009 at 2:42 am
WTF 638 you cant take care of your own PT? I mean does it really take an ED physician to do that? Are you a doctor? I really hope not. Any physician should be care for one “crashing PT” without an ED physician to hold their hand. However, fractures shoud be handled by, oh I dont know, maybe ortho.
July 7, 2009 at 7:28 am
laughable er rn. you don’t want a psychiatrist 30 years out of residency taking care of a crashing patient, i am sure. if all docs could care for there crashing patients, we wouldn’t need an er.
the er guys are the one only specialty who insist they don’t need to actually pass acls, they are just acls certified by nature of the work. that’s why someone would call them-because of their expertise in crashing patients.
July 8, 2009 at 12:20 pm
I am not on-call for your admitted crashing patient, that is the difference. Even then I work a lot of nights, am the only doc in-house, and run all codes hospital wide.
But I digress. No group of docs as a whole are greater patient advocates than ER docs, not because of some inherent philanthropic trait, but because of that pesky unfunded mandate that puts the patient and their accompanying liability front and center.
July 6, 2009 at 7:34 pm
This scenario also reminds me of the other *PIA* situation, the psych patient who is in your ED in a hospital that doesn’t have a psych ward. Crank it up a notch and make it a Pediatric psych patient and you have yourself a 6-8 hour ordeal to find a place and get them accepted and transferred. (all while trying to find a sitter to watch this patient while you take care of your other 4-5 or whatever patients. Good times……
July 6, 2009 at 8:19 pm
The message of this whole thing is this: do not be an ER doctor. (Because it’s going to just keep happening)
July 7, 2009 at 10:18 pm
Kim speaks truth. Some unfortuante (usually young, very strong) person with either schizophrenia or bipolar disease is psychotic and the ER docs and nurses and punished for tyring to do the right thing.
Just as bad is when the patients decompensate from an infection – psychotic patient in DKA with pneumonia, a few days in ICU, better, but how do we get the poor patient the help he needs to fix his psychosis?
The system is not designed to help sick people…
July 7, 2009 at 10:34 pm
We run into this problem all the time. Our orthopods won’t see kids, will only see adults with certain kinds of insurance, and then we’re left to arrange follow-up with the Childrens or County Hospital, who then accuse us of dumping our patients on them and threaten us with EMTALA violations. This is why I need a drink after some of my shifts. Community hospitals just suck sometimes.
July 10, 2009 at 11:59 pm
Surely this is some morbid hoop-jumping game with various strategies and narratives. It’s only personal to the pt. Getting the one FNG who doesn’t understand the common narratives (“we do {A} then we call you and you ask us {B} and we tell you {C} and you do {D} so the patient gets transferred to {E}, someone beyond our little bee-dance for treatment”) and you start eyeing the bourbon and/or cricket bat with evil design. The Good Doctor does this all with a smile and keeps his or her nervous tic and homicidal urges in check, preferably burned off in some positive pursuit like splitting wood or working as a dominatrix.
I’ve dealt with onerous bureaucracy and public safety back in the nuclear industry, though my relationship to the “patient” was a lot less personal. I can’t claim to know what you go through, though frankly I’m amazed how many ER docs manage to avoid developing a great hatred for humanity from the stories I read. So the rare times I end up in the ER, generally with my wife (chest pains, severe pectus excavatum, wary of Marfan’s syndrome), I do my best to stay polite, out of the way, and looking for a way to write multiple someones a Thank You card. Insurance will take care of the money part; the only real payback I can give is psychic support. Telling people they’ve made a difference and showing appreciation for what they’ve done is all I can think to do to help keep the staff’s spirits up. I can’t say I believe in literal religious karma, but I can only hope that pragmatically it leads to more happiness in the long term.
And really, I do put my money where my mouth is. A year or so ago I dropped off a dozen or so warm cookies at my phlebotomist’s office. I can’t imagine anyone ever wants to be there (the staff or the patients), but my girl Yolanda kept me from passing out (syncope) and I wanted to pay it back. I think the staff was a bit dumbfounded for a few seconds when I gave them the box, but hopefully everyone got a cookie. It’s small but it’s something.
July 16, 2009 at 8:49 pm
arclight that was a very sweet thing to do. I used to work in a city hospital OPD and this little Albanian lady would bring me an apple every time she came to see me for follow up. That little gesture would make the day go better.
August 24, 2009 at 5:44 am
Disposition calls are so much fun- even more so when you are a Physician Assistant and the only guy around! I am not alone, I am not alone, I am not alone………