List Archives

Fri Mar 7 17:29:55 GMT 2008

The real issue here is the patient who gets delayed care or shuffled
around. EMTALA gives the on-call specialists the loophole to refuse to
accept cases that are outside their "comfort zone" or that they are not
credentialed for. EMTALA also states that the need to transfer for
higher level of care emergently is the decision of the sending
physician/facility not the receiving physician/facility. I will grant
you too many sub specialists abuse the loophole, but think of this from
a patient care point of view. ED physician thinks the patient needs a
specialist, specialist says "I don't repair that type of injury" and
then the higher level of care center refuses to take the patient. At
this point the patient is at the mercy of an ED physician or general
orthopedist who may or may not handle the care appropriately. I am very
confident in our ED Physicians and our General Orthopedists, but if the
hand belongs to my wife, my children or myself, I want the Hand Surgeon!
And our patients deserve no less.
Rick Moore

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Dr. Andrew Berson
Sent: Friday, March 07, 2008 8:14 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Hand Call Coverage at Busy Urban Trauma Centers

Dr. Mattox,

I agree with the care of the simple lacerations, etc and that is what is
occuring.  The muddy issue centers around injuries that are somewhere in
between. i.e. a deep laceration that severs tendons or neural
structures, but is not a near amputation.  I feel that this could/should
be handled by a qualified orthopedic surgeon, but we are getting
significant push back in this area.  Thoughts?

AJB

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of KMATTOX at aol.com
Sent: Thursday, March 06, 2008 8:44 PM
To: trauma-list at trauma.org
Subject: Re: Hand Call Coverage at Busy Urban Trauma Centers

I have no real idea what a "Trauma" orthopedist is that is different
from a

regular orthopedic surgeon?    I also have taken a close  look at what
has 
been attempted to be sent to us at the BTGH as "hand" trauma  from the
immediate 
14 count area.      Every day we  repeatedly get calls for a transfer
for a 
higher level of care for a "hand  trauma" case, because they do not have
a hand 
surgeon on  call.     When we ask about the case, it might be a minor
(or 
even major) hand bone fracture.   That is general  orthopedics.    If
the
case
comes to us, it will be treated by an  orthopedist, or a plastic
surgeon.
Our
"HAND SURGEON" is  called in for basically a "replantation" and a couple
of 
other  diagnoses.      So....................when we have a  finger tip 
amputation, that just needs a closure, we do not accept a patient in
transfer and ask that the emergency physician at the sending hospital
close the  wound, as 
will be done when we receive the patient.   NOT a higher  liver of care.
By
FAR the majority of cases  that are labeled "hand" can and probably
should be managed by the ACUTE CARE  SURGEON (the new name for what was
the routine 
garden variety "general surgeon  of the past.        

k

In a message dated 3/6/2008 9:35:02 P.M. Central Standard Time,
deanlutrin at gmail.com writes:

Andrew

Barring an amputation which could be immediately  salvaged, almost all
hands can wait till the morning. That's how it is done  in most teaching
hospitals in South Africa. Where I work, we have so much  hand trauma
that there is a daily 'hand list' done under axillary block or  some
other local anaesthetic. The occasional abscess needs to be drained at
night and some debridemens should be done - surely a ortho guy can do
that?  As long as you can make a plan that there is someone who can
reimplant  fingers and hands when that occasionally occurs, I think you
can tell the  greedy guys to get lost.

My two cents

Dean Lutrin
JHB, South  Africa

-----Original Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On  Behalf Of Dr. Andrew Berson
Sent: Thursday, March 06, 2008 11:45 PM
To:  'Trauma &amp; Critical Care mailing list'
Subject: Hand Call Coverage  at Busy Urban Trauma Centers

To list members:

I'm looking  for input from busy level I and II centers on how hand call
coverage issues  are being handled.  Specifically, is this coverage
provided by the  ortho traumatologist or by a separate hand call list.
The issue that we are dealing with is that after years of a very
successful call roster for this subspecialty, we are running into a very
untenable situation.  In the past this coverage was provided by the
ortho-traumatologists that had a robust elective hand surgery  practice.
These surgeons are already part of the paid call roster for
orthopedics, and were providing hand "coverage" on nights where one of
their non-hand surgery colleagues might be on call for general ortho
trauma.  Now, the hand surgeons are refusing to provide this coverage
unless they are given an additional stipend.  The general ortho-trauma
physicians do not feel comfortable in caring for significant hand
issues,  since this is not part of their elective practice.

The question is,  should a board certified orthopedic surgeon, on a paid
trauma call list at  a busy level II trauma center be capable of
evaluating an injured hand and  at least providing initial management of
the injury, until their "hand  surgery" partner is available the next
day, or are we forced to give into  the demands of the hand specialists
and provide another stipend position on  the call roster.  (It should be
mentioned that the amount being  requested outpaces the stipend paid to
the IN HOUSE Trauma/Acute Care  surgeon, even thought hand call is a
home based call which does not receive  many true emergencies).  

Please give any constructive  feedback.  I would also be interested to
know how many list members  are seeing similar issues with their hand
call rosters.

Thank you in  advance.

Andrew J. Berson, M.D.
Assist. Trauma Director
Memorial  Health System,
Colorado Springs, CO

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Hand Call Coverage at Busy Urban Trauma Centers