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trauma-list Digest, Vol 57, Issue 11
Sunil Auplish sunilauplish at yahoo.co.ukWed Mar 12 11:57:09 GMT 2008
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If have a simple (minded!) take on this. You can deal with it if you have the time, experience and facilities. If not, it belongs to the hand guy! trauma-list-request at trauma.org wrote: Send trauma-list mailing list submissions to trauma-list at trauma.org To subscribe or unsubscribe via the World Wide Web, visit http://list.mistral.net/mailman/listinfo/trauma-list or, via email, send a message with subject or body 'help' to trauma-list-request at trauma.org You can reach the person managing the list at trauma-list-owner at trauma.org When replying, please edit your Subject line so it is more specific than "Re: Contents of trauma-list digest..." Today's Topics: 1. Shell Game (ROBERT ARNOLD) 2. Re: Shell Game (Andrew J Bowman) 3. RE: Shell Game (Bjorn, Pret) 4. Trauma Critical Care & Acute Care Surgery 2008 (KMATTOX at aol.com) From: ROBERT ARNOLD <robsidarn at msn.com> Subject: Shell Game Date: Mon, 10 Mar 2008 06:34:41 -0600 To: <trauma-list at trauma.org> I will present a case for discussion: 47 y/o female presents to urgent care clinic with dogbite, her American Bulldog (rabies-low risk), to her left index and middle fingers. x-ray confirms open fracture of distal tuft, index finger. both digits have partial avulsion injuries to radial aspect, that is, distal radial half of both dangling by threads and index finger nailbed disruption, nail angulated 45 degrees ulnarly. i called the hand guy and he said, 'aah, that sounds like you can take care of that.' aaack, sid From: trauma-list-request at trauma.orgSubject: trauma-list Digest, Vol 57, Issue 10To: trauma-list at trauma.orgDate: Mon, 10 Mar 2008 12:00:22 +0000Send trauma-list mailing list submissions to trauma-list at trauma.org To subscribe or unsubscribe via the World Wide Web, visit http://list.mistral.net/mailman/listinfo/trauma-listor, via email, send a message with subject or body 'help' to trauma-list-request at trauma.org You can reach the person managing the list at trauma-list-owner at trauma.org When replying, please edit your Subject line so it is more specificthan "Re: Contents of trauma-list digest..." --Forwarded Message Attachment--From: rfsmithmd at comcast.netSubject: RE: specialists really neededDate: Sun, 9 Mar 2008 09:42:31 -0400To: trauma-list at trauma.org From my cynical side: If the purpose is a return to productive societymost of the patients I have seen would benefit more form a alcohol or drugrehab specialist than a hand specialist. Reality just crushes the life outof my idealism. But i guess it is heavily dependant on patient populations. Mike Mike, As your resident touchy feely Left winger I don't think that thought iscynical at all. It's important to recognize and try to address the needs ofthe population you serve. It's especially important for us to do what wereasonably can to try to lessen the likelihood of future injury for ourpatients. Universal screening coupled with an immediateevaluation/intervention and seamless transfer to outpatient rehab (notwaiting 6-8 weeks) has been advocated. Carl Soderstrom at Maryland isprobably foremost in the trauma field re: substance abuse issues. There isactually sometimes money to help with programs like this. Rob Smith --Forwarded Message Attachment--From: aberson at agvscs.comSubject: RE: Hand Call Coverage at Busy Urban Trauma CentersDate: Sun, 9 Mar 2008 11:55:49 -0600To: trauma-list at trauma.orgThat's helpful AJB -----Original Message-----From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of kmattox at aol.comSent: Friday, March 07, 2008 10:44 AMTo: Trauma & Critical Care mailing listSubject: Re: Hand Call Coverage at Busy Urban Trauma Centers The very injury you described were for decades managed by general surgeonswith good results. This injury can and are currently managed by interestedgeneral, pediatric, orthopedic, plastic, vascular, and even neuro surgeons.It is not a turf war it is a value and committment issue to the disciplineof surgery. I tend to believe that surgeons that find reasons they mustexcessively limit their surgery skills simply should not be surgeons. Sent via BlackBerry by AT&T -----Original Message-----From: "Dr. Andrew Berson" Date: Fri, 7 Mar 2008 07:14:15 To:"'Trauma & 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 isoccuring. The muddy issue centers around injuries that are somewhere inbetween. 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 aqualified orthopedic surgeon, but we are getting significant push back inthis 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.comSent: Thursday, March 06, 2008 8:44 PMTo: trauma-list at trauma.orgSubject: 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 theimmediate 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 ahand 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 thecase 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 intransfer 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 shouldbe 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 handscan wait till the morning. That's how it is done in most teaching hospitalsin South Africa. Where I work, we have so much hand trauma that there is adaily 'hand list' done under axillary block or some other localanaesthetic. The occasional abscess needs to be drained at night and somedebridemens should be done - surely a ortho guy can do that? As long as youcan make a plan that there is someone who can reimplant fingers and handswhen that occasionally occurs, I think you can tell the greedy guys to getlost. My two cents Dean LutrinJHB, South Africa -----Original Message-----From: trauma-list-bounces at trauma.org[mailto:trauma-list-bounces at trauma.org]On Behalf Of Dr. Andrew BersonSent: Thursday, March 06, 2008 11:45 PMTo: 'Trauma & 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 callcoverage issues are being handled. Specifically, is this coverage providedby the ortho traumatologist or by a separate hand call list. The issuethat we are dealing with is that after years of a very successful callroster for this subspecialty, we are running into a very untenablesituation. In the past this coverage was provided by theortho-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-handsurgery colleagues might be on call for general ortho trauma. Now, thehand surgeons are refusing to provide this coverage unless they are givenan additional stipend. The general ortho-trauma physicians do not feelcomfortable in caring for significant hand issues, since this is not partof their elective practice. The question is, should a board certified orthopedic surgeon, on a paidtrauma call list at a busy level II trauma center be capable of evaluatingan injured hand and at least providing initial management of the injury,until their "hand surgery" partner is available the next day, or are weforced to give into the demands of the hand specialists and provide anotherstipend position on the call roster. (It should be mentioned that theamount being requested outpaces the stipend paid to the IN HOUSETrauma/Acute Care surgeon, even thought hand call is a home based callwhich does not receive many true emergencies). Please give any constructive feedback. I would also be interested to knowhow many list members are seeing similar issues with their hand callrosters. Thank you in advance. Andrew J. Berson, M.D.Assist. Trauma DirectorMemorial Health System,Colorado Springs, CO --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ **************It's Tax Time! Get tips, forms, and advice on AOL Money & Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001)--trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --Forwarded Message Attachment--From: aberson at agvscs.comSubject: RE: Hand Call Coverage at Busy Urban Trauma CentersDate: Sun, 9 Mar 2008 12:08:24 -0600To: trauma-list at trauma.orgThank you so much for the helpful input. Andy -----Original Message-----From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of William BrombergSent: Friday, March 07, 2008 7:08 AMTo: 'Trauma & Critical Care mailing list'Subject: Re: Hand Call Coverage at Busy Urban Trauma Centers Background on the site:Memorial Health University Med. Center, SavannahState Level I, ACS unverified (dropped when the neurosurgeons refused topublish a backup call schedule) 1300-1400 registry admits, 2200-2300activations Our plastics and ortho hand trained/privileged individuals split hand call(about 1:5) they get paid a stipend (about $750/night I think). Prior tothis we had a hand call schedule that all the ortho and plastics people wereon without a stipend - it was a HUGE hassle to get someone to come in with alot of pass the buck being played. No-one would do replants ("We're not acenter!"). Now it's just a moderate hassle to get someone to come in. There's stillsome pass the buck (the plastics people don't have wrist privileges havingbeen blocked years ago by the ortho guys so if there's a wrist injury theyget passive aggressive and say to call ortho, etc. etc. etc.). Nobody willdo replants. If you do give in and pay up make sure that there's a contract to definewhat "hand call" means. Bill >>> "Dr. Andrew Berson" 3/6/2008 4:45 PM >>> To list members: I'm looking for input from busy level I and II centers on how hand callcoverage issues are being handled. Specifically, is this coverage providedby the ortho traumatologist or by a separate hand call list. The issue thatwe are dealing with is that after years of a very successful call roster forthis subspecialty, we are running into a very untenable situation. In thepast this coverage was provided by the ortho-traumatologists that had arobust elective hand surgery practice. These surgeons are already part ofthe paid call roster for orthopedics, and were providing hand "coverage" onnights where one of their non-hand surgery colleagues might be on call forgeneral ortho trauma. Now, the hand surgeons are refusing to provide thiscoverage unless they are given an additional stipend. The generalortho-trauma physicians do not feel comfortable in caring for significanthand issues, since this is not part of their elective practice. The question is, should a board certified orthopedic surgeon, on a paidtrauma call list at a busy level II trauma center be capable of evaluatingan injured hand and at least providing initial management of the injury,until their "hand surgery" partner is available the next day, or are weforced to give into the demands of the hand specialists and provide anotherstipend position on the call roster. (It should be mentioned that theamount being requested outpaces the stipend paid to the IN HOUSETrauma/Acute Care surgeon, even thought hand call is a home based call whichdoes not receive many true emergencies). Please give any constructive feedback. I would also be interested to knowhow many list members are seeing similar issues with their hand callrosters. Thank you in advance. Andrew J. Berson, M.D.Assist. Trauma DirectorMemorial Health System,Colorado Springs, CO --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --Forwarded Message Attachment--From: nmcswai at tulane.eduSubject: RE: Hand Call Coverage at Busy Urban Trauma CentersDate: Sun, 9 Mar 2008 12:31:42 -0500To: trauma-list at trauma.orgyou seem to be "right on" Norman Norman McSwain MDTrauma Director, Charity HospitalProfessor of Surgery, Tulane UniversityNew Orleans LA504 988 5111norman.mcswain at tulane.edu ________________________________ From: trauma-list-bounces at trauma.org on behalf of Michael Stein M.D.Sent: Sat 3/8/2008 4:18 PMTo: 'Trauma & Critical Care mailing list'Subject: RE: Hand Call Coverage at Busy Urban Trauma Centers Ken, Rick, Jeff and others.. I have always wanted to say this but never had the guts, since it isprobably politically incorrect. There is no doubt that there is some added value to be treated for a complexhand injury by a qualified hand surgeon. However, most hand injuries can bedealt with adequately by a "General" Trauma Surgeon, or a "General"Orthopedic Surgeon. Since the FIRST world society developed themedico-legal environment that promotes some of the behavior mentioned in theprevious posts on this issue, those "altruist" "General" docs will not takethe risk anymore. Since that same FIRST world society became clients instead of patients, theydemand the best of care and nothing less (even theoretically). The courtsfollowed the trend and supported this society. Thus, our bunch of dedicateddocs, full of altruism faded out sometime in the last century (the 20th). But now, this FIRST world society of clients (not patients) wants to bargainabout the amount of money they are prepared to pay these "super" handsurgeons. Well, if they are not prepared to pay they do not deserve the service. Aswe say here, "This society made this cake - now the same society should eatit" - or something like that. Sorry about this emotional post. Mickey Stein -----Original Message-----From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of KMATTOX at aol.comSent: Saturday, March 08, 2008 2:23 AMTo: trauma-list at trauma.orgSubject: Re: Hand Call Coverage at Busy Urban Trauma Centers I can imagine many, if not the MAJORITY of emergencies that are manifest on the HAND, I would RATHER have a NON-DECLARED HAND SPECIALIST to care for myself or my family , than someone with the narrow declared focus of the DECLARED HAND SPECIALIST. I would hope that every emergency roomphysician wouldcomprehend and appreciate that. k In a message dated 3/7/2008 6:18:09 P.M. Central Standard Time, Rick.Moore at TriadHospitals.com writes: ED physician thinks the patient needs aspecialist, specialist says "I don't repair that type of injury" andthen the higher level of care center refuses to take the patient. Atthis point the patient is at the mercy of an ED physician or generalorthopedist who may or may not handle the care appropriately. I am veryconfident in our ED Physicians and our General Orthopedists, but if thehand belongs to my wife, my children or myself, I want the Hand Surgeon!And our patients deserve no less.Rick Moore **************It's Tax Time! Get tips, forms, and advice on AOL Money &Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001)--trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ _________________________________________________________________ Climb to the top of the charts! Play the word scramble challenge with star power. http://club.live.com/star_shuffle.aspx?icid=starshuffle_wlmailtextlink_jan From: "Andrew J Bowman" <andrewj.bowman at gmail.com> Subject: Re: Shell Game Date: Mon, 10 Mar 2008 09:45:09 -0400 To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org> Yes you probably could, but at the detriment to all of the other patients who now have to wait for you to finish. You are at an urgent care and probably have a couple dozen more patients waiting for you. Time to move that one along to the hand guy. Andrew ----- Original Message ----- From: "ROBERT ARNOLD" To: Sent: Monday, March 10, 2008 8:34 AM Subject: Shell Game I will present a case for discussion: 47 y/o female presents to urgent care clinic with dogbite, her American Bulldog (rabies-low risk), to her left index and middle fingers. x-ray confirms open fracture of distal tuft, index finger. both digits have partial avulsion injuries to radial aspect, that is, distal radial half of both dangling by threads and index finger nailbed disruption, nail angulated 45 degrees ulnarly. i called the hand guy and he said, 'aah, that sounds like you can take care of that.' aaack, sid From: trauma-list-request at trauma.orgSubject: trauma-list Digest, Vol 57, Issue 10To: trauma-list at trauma.orgDate: Mon, 10 Mar 2008 12:00:22 +0000Send trauma-list mailing list submissions to trauma-list at trauma.org To subscribe or unsubscribe via the World Wide Web, visit http://list.mistral.net/mailman/listinfo/trauma-listor, via email, send a message with subject or body 'help' to trauma-list-request at trauma.org You can reach the person managing the list at trauma-list-owner at trauma.org When replying, please edit your Subject line so it is more specificthan "Re: Contents of trauma-list digest..." --Forwarded Message Attachment--From: rfsmithmd at comcast.netSubject: RE: specialists really neededDate: Sun, 9 Mar 2008 09:42:31 -0400To: trauma-list at trauma.org From my cynical side: If the purpose is a return to productive societymost of the patients I have seen would benefit more form a alcohol or drugrehab specialist than a hand specialist. Reality just crushes the life outof my idealism. But i guess it is heavily dependant on patient populations. Mike Mike, As your resident touchy feely Left winger I don't think that thought iscynical at all. It's important to recognize and try to address the needs ofthe population you serve. It's especially important for us to do what wereasonably can to try to lessen the likelihood of future injury for ourpatients. Universal screening coupled with an immediateevaluation/intervention and seamless transfer to outpatient rehab (notwaiting 6-8 weeks) has been advocated. Carl Soderstrom at Maryland isprobably foremost in the trauma field re: substance abuse issues. There isactually sometimes money to help with programs like this. Rob Smith --Forwarded Message Attachment--From: aberson at agvscs.comSubject: RE: Hand Call Coverage at Busy Urban Trauma CentersDate: Sun, 9 Mar 2008 11:55:49 -0600To: trauma-list at trauma.orgThat's helpful AJB -----Original Message-----From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of kmattox at aol.comSent: Friday, March 07, 2008 10:44 AMTo: Trauma & Critical Care mailing listSubject: Re: Hand Call Coverage at Busy Urban Trauma Centers The very injury you described were for decades managed by general surgeonswith good results. This injury can and are currently managed by interestedgeneral, pediatric, orthopedic, plastic, vascular, and even neuro surgeons.It is not a turf war it is a value and committment issue to the disciplineof surgery. I tend to believe that surgeons that find reasons they mustexcessively limit their surgery skills simply should not be surgeons. Sent via BlackBerry by AT&T -----Original Message-----From: "Dr. Andrew Berson" Date: Fri, 7 Mar 2008 07:14:15 To:"'Trauma & 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 isoccuring. The muddy issue centers around injuries that are somewhere inbetween. 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 aqualified orthopedic surgeon, but we are getting significant push back inthis 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.comSent: Thursday, March 06, 2008 8:44 PMTo: trauma-list at trauma.orgSubject: 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 theimmediate 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 ahand 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 thecase 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 intransfer 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 shouldbe 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 handscan wait till the morning. That's how it is done in most teaching hospitalsin South Africa. Where I work, we have so much hand trauma that there is adaily 'hand list' done under axillary block or some other localanaesthetic. The occasional abscess needs to be drained at night and somedebridemens should be done - surely a ortho guy can do that? As long as youcan make a plan that there is someone who can reimplant fingers and handswhen that occasionally occurs, I think you can tell the greedy guys to getlost. My two cents Dean LutrinJHB, South Africa -----Original Message-----From: trauma-list-bounces at trauma.org[mailto:trauma-list-bounces at trauma.org]On Behalf Of Dr. Andrew BersonSent: Thursday, March 06, 2008 11:45 PMTo: 'Trauma & 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 callcoverage issues are being handled. Specifically, is this coverage providedby the ortho traumatologist or by a separate hand call list. The issuethat we are dealing with is that after years of a very successful callroster for this subspecialty, we are running into a very untenablesituation. In the past this coverage was provided by theortho-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-handsurgery colleagues might be on call for general ortho trauma. Now, thehand surgeons are refusing to provide this coverage unless they are givenan additional stipend. The general ortho-trauma physicians do not feelcomfortable in caring for significant hand issues, since this is not partof their elective practice. The question is, should a board certified orthopedic surgeon, on a paidtrauma call list at a busy level II trauma center be capable of evaluatingan injured hand and at least providing initial management of the injury,until their "hand surgery" partner is available the next day, or are weforced to give into the demands of the hand specialists and provide anotherstipend position on the call roster. (It should be mentioned that theamount being requested outpaces the stipend paid to the IN HOUSETrauma/Acute Care surgeon, even thought hand call is a home based callwhich does not receive many true emergencies). Please give any constructive feedback. I would also be interested to knowhow many list members are seeing similar issues with their hand callrosters. Thank you in advance. Andrew J. Berson, M.D.Assist. Trauma DirectorMemorial Health System,Colorado Springs, CO --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ **************It's Tax Time! Get tips, forms, and advice on AOL Money & Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001)--trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --Forwarded Message Attachment--From: aberson at agvscs.comSubject: RE: Hand Call Coverage at Busy Urban Trauma CentersDate: Sun, 9 Mar 2008 12:08:24 -0600To: trauma-list at trauma.orgThank you so much for the helpful input. Andy -----Original Message-----From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of William BrombergSent: Friday, March 07, 2008 7:08 AMTo: 'Trauma & Critical Care mailing list'Subject: Re: Hand Call Coverage at Busy Urban Trauma Centers Background on the site:Memorial Health University Med. Center, SavannahState Level I, ACS unverified (dropped when the neurosurgeons refused topublish a backup call schedule) 1300-1400 registry admits, 2200-2300activations Our plastics and ortho hand trained/privileged individuals split hand call(about 1:5) they get paid a stipend (about $750/night I think). Prior tothis we had a hand call schedule that all the ortho and plastics people wereon without a stipend - it was a HUGE hassle to get someone to come in with alot of pass the buck being played. No-one would do replants ("We're not acenter!"). Now it's just a moderate hassle to get someone to come in. There's stillsome pass the buck (the plastics people don't have wrist privileges havingbeen blocked years ago by the ortho guys so if there's a wrist injury theyget passive aggressive and say to call ortho, etc. etc. etc.). Nobody willdo replants. If you do give in and pay up make sure that there's a contract to definewhat "hand call" means. Bill >>> "Dr. Andrew Berson" 3/6/2008 4:45 PM >>> To list members: I'm looking for input from busy level I and II centers on how hand callcoverage issues are being handled. Specifically, is this coverage providedby the ortho traumatologist or by a separate hand call list. The issue thatwe are dealing with is that after years of a very successful call roster forthis subspecialty, we are running into a very untenable situation. In thepast this coverage was provided by the ortho-traumatologists that had arobust elective hand surgery practice. These surgeons are already part ofthe paid call roster for orthopedics, and were providing hand "coverage" onnights where one of their non-hand surgery colleagues might be on call forgeneral ortho trauma. Now, the hand surgeons are refusing to provide thiscoverage unless they are given an additional stipend. The generalortho-trauma physicians do not feel comfortable in caring for significanthand issues, since this is not part of their elective practice. The question is, should a board certified orthopedic surgeon, on a paidtrauma call list at a busy level II trauma center be capable of evaluatingan injured hand and at least providing initial management of the injury,until their "hand surgery" partner is available the next day, or are weforced to give into the demands of the hand specialists and provide anotherstipend position on the call roster. (It should be mentioned that theamount being requested outpaces the stipend paid to the IN HOUSETrauma/Acute Care surgeon, even thought hand call is a home based call whichdoes not receive many true emergencies). Please give any constructive feedback. I would also be interested to knowhow many list members are seeing similar issues with their hand callrosters. Thank you in advance. Andrew J. Berson, M.D.Assist. Trauma DirectorMemorial Health System,Colorado Springs, CO --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --Forwarded Message Attachment--From: nmcswai at tulane.eduSubject: RE: Hand Call Coverage at Busy Urban Trauma CentersDate: Sun, 9 Mar 2008 12:31:42 -0500To: trauma-list at trauma.orgyou seem to be "right on" Norman Norman McSwain MDTrauma Director, Charity HospitalProfessor of Surgery, Tulane UniversityNew Orleans LA504 988 5111norman.mcswain at tulane.edu ________________________________ From: trauma-list-bounces at trauma.org on behalf of Michael Stein M.D.Sent: Sat 3/8/2008 4:18 PMTo: 'Trauma & Critical Care mailing list'Subject: RE: Hand Call Coverage at Busy Urban Trauma Centers Ken, Rick, Jeff and others.. I have always wanted to say this but never had the guts, since it isprobably politically incorrect. There is no doubt that there is some added value to be treated for a complexhand injury by a qualified hand surgeon. However, most hand injuries can bedealt with adequately by a "General" Trauma Surgeon, or a "General"Orthopedic Surgeon. Since the FIRST world society developed themedico-legal environment that promotes some of the behavior mentioned in theprevious posts on this issue, those "altruist" "General" docs will not takethe risk anymore. Since that same FIRST world society became clients instead of patients, theydemand the best of care and nothing less (even theoretically). The courtsfollowed the trend and supported this society. Thus, our bunch of dedicateddocs, full of altruism faded out sometime in the last century (the 20th). But now, this FIRST world society of clients (not patients) wants to bargainabout the amount of money they are prepared to pay these "super" handsurgeons. Well, if they are not prepared to pay they do not deserve the service. Aswe say here, "This society made this cake - now the same society should eatit" - or something like that. Sorry about this emotional post. Mickey Stein -----Original Message-----From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of KMATTOX at aol.comSent: Saturday, March 08, 2008 2:23 AMTo: trauma-list at trauma.orgSubject: Re: Hand Call Coverage at Busy Urban Trauma Centers I can imagine many, if not the MAJORITY of emergencies that are manifest on the HAND, I would RATHER have a NON-DECLARED HAND SPECIALIST to care for myself or my family , than someone with the narrow declared focus of the DECLARED HAND SPECIALIST. I would hope that every emergency roomphysician wouldcomprehend and appreciate that. k In a message dated 3/7/2008 6:18:09 P.M. Central Standard Time, Rick.Moore at TriadHospitals.com writes: ED physician thinks the patient needs aspecialist, specialist says "I don't repair that type of injury" andthen the higher level of care center refuses to take the patient. Atthis point the patient is at the mercy of an ED physician or generalorthopedist who may or may not handle the care appropriately. I am veryconfident in our ED Physicians and our General Orthopedists, but if thehand belongs to my wife, my children or myself, I want the Hand Surgeon!And our patients deserve no less.Rick Moore **************It's Tax Time! Get tips, forms, and advice on AOL Money &Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001)--trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ _________________________________________________________________ Climb to the top of the charts! Play the word scramble challenge with star power. http://club.live.com/star_shuffle.aspx?icid=starshuffle_wlmailtextlink_jan-- trauma-list : TRAUMA.ORG To change your settings or unsubscribe visit: http://www.trauma.org/index.php?/community/ From: "Bjorn, Pret" <pbjorn at emh.org> Subject: RE: Shell Game Date: Mon, 10 Mar 2008 10:06:13 -0400 To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org> I disagree. I suffered similar but arguably more severe injuries from a table saw a few years ago. Expected a hand referral and completion of at least one distal amp. Instead, the ED guy simply washed the sawdust from the shredded mess and reapproximated everything, stuffed the nails back into anatomic approximation, and sent me home. It wasn't pretty, to be honest. Took half an hour under local. I would be referred to Hand if there was any complication or longterm functional dissatisfaction. Otherwise, take my antibiotics and remove my own stitches when the wound looked competent. A few months later I was back to full function with nearly normal sensation. The cosmetic result (if it matters) is really remarkable. Saved me thousands on the consultation and operation, and probably at least a fifth of a digit. I LOVE our hand guy, and never would have questioned a direct referral; but can't imagine that in my case his experience would have added much. Pret -----Original Message----- From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Andrew J Bowman Sent: Monday, March 10, 2008 9:45 AM To: Trauma & Critical Care mailing list Subject: Re: Shell Game Yes you probably could, but at the detriment to all of the other patients who now have to wait for you to finish. You are at an urgent care and probably have a couple dozen more patients waiting for you. Time to move that one along to the hand guy. Andrew ----- Original Message ----- From: "ROBERT ARNOLD" To: Sent: Monday, March 10, 2008 8:34 AM Subject: Shell Game I will present a case for discussion: 47 y/o female presents to urgent care clinic with dogbite, her American Bulldog (rabies-low risk), to her left index and middle fingers. x-ray confirms open fracture of distal tuft, index finger. both digits have partial avulsion injuries to radial aspect, that is, distal radial half of both dangling by threads and index finger nailbed disruption, nail angulated 45 degrees ulnarly. i called the hand guy and he said, 'aah, that sounds like you can take care of that.' aaack, sid From: trauma-list-request at trauma.orgSubject: trauma-list Digest, Vol 57, Issue 10To: trauma-list at trauma.orgDate: Mon, 10 Mar 2008 12:00:22 +0000Send trauma-list mailing list submissions to trauma-list at trauma.org To subscribe or unsubscribe via the World Wide Web, visit http://list.mistral.net/mailman/listinfo/trauma-listor, via email, send a message with subject or body 'help' to trauma-list-request at trauma.org You can reach the person managing the list at trauma-list-owner at trauma.org When replying, please edit your Subject line so it is more specificthan "Re: Contents of trauma-list digest..." --Forwarded Message Attachment--From: rfsmithmd at comcast.netSubject: RE: specialists really neededDate: Sun, 9 Mar 2008 09:42:31 -0400To: trauma-list at trauma.org From my cynical side: If the purpose is a return to productive societymost of the patients I have seen would benefit more form a alcohol or drugrehab specialist than a hand specialist. Reality just crushes the life outof my idealism. But i guess it is heavily dependant on patient populations. Mike Mike, As your resident touchy feely Left winger I don't think that thought iscynical at all. It's important to recognize and try to address the needs ofthe population you serve. It's especially important for us to do what wereasonably can to try to lessen the likelihood of future injury for ourpatients. Universal screening coupled with an immediateevaluation/intervention and seamless transfer to outpatient rehab (notwaiting 6-8 weeks) has been advocated. Carl Soderstrom at Maryland isprobably foremost in the trauma field re: substance abuse issues. There isactually sometimes money to help with programs like this. Rob Smith --Forwarded Message Attachment--From: aberson at agvscs.comSubject: RE: Hand Call Coverage at Busy Urban Trauma CentersDate: Sun, 9 Mar 2008 11:55:49 -0600To: trauma-list at trauma.orgThat's helpful AJB -----Original Message-----From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of kmattox at aol.comSent: Friday, March 07, 2008 10:44 AMTo: Trauma & Critical Care mailing listSubject: Re: Hand Call Coverage at Busy Urban Trauma Centers The very injury you described were for decades managed by general surgeonswith good results. This injury can and are currently managed by interestedgeneral, pediatric, orthopedic, plastic, vascular, and even neuro surgeons.It is not a turf war it is a value and committment issue to the disciplineof surgery. I tend to believe that surgeons that find reasons they mustexcessively limit their surgery skills simply should not be surgeons. Sent via BlackBerry by AT&T -----Original Message-----From: "Dr. Andrew Berson" Date: Fri, 7 Mar 2008 07:14:15 To:"'Trauma & 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 isoccuring. The muddy issue centers around injuries that are somewhere inbetween. 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 aqualified orthopedic surgeon, but we are getting significant push back inthis 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.comSent: Thursday, March 06, 2008 8:44 PMTo: trauma-list at trauma.orgSubject: 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 theimmediate 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 ahand 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 thecase 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 intransfer 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 shouldbe 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 handscan wait till the morning. That's how it is done in most teaching hospitalsin South Africa. Where I work, we have so much hand trauma that there is adaily 'hand list' done under axillary block or some other localanaesthetic. The occasional abscess needs to be drained at night and somedebridemens should be done - surely a ortho guy can do that? As long as youcan make a plan that there is someone who can reimplant fingers and handswhen that occasionally occurs, I think you can tell the greedy guys to getlost. My two cents Dean LutrinJHB, South Africa -----Original Message-----From: trauma-list-bounces at trauma.org[mailto:trauma-list-bounces at trauma.org]On Behalf Of Dr. Andrew BersonSent: Thursday, March 06, 2008 11:45 PMTo: 'Trauma & 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 callcoverage issues are being handled. Specifically, is this coverage providedby the ortho traumatologist or by a separate hand call list. The issuethat we are dealing with is that after years of a very successful callroster for this subspecialty, we are running into a very untenablesituation. In the past this coverage was provided by theortho-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-handsurgery colleagues might be on call for general ortho trauma. Now, thehand surgeons are refusing to provide this coverage unless they are givenan additional stipend. The general ortho-trauma physicians do not feelcomfortable in caring for significant hand issues, since this is not partof their elective practice. The question is, should a board certified orthopedic surgeon, on a paidtrauma call list at a busy level II trauma center be capable of evaluatingan injured hand and at least providing initial management of the injury,until their "hand surgery" partner is available the next day, or are weforced to give into the demands of the hand specialists and provide anotherstipend position on the call roster. (It should be mentioned that theamount being requested outpaces the stipend paid to the IN HOUSETrauma/Acute Care surgeon, even thought hand call is a home based callwhich does not receive many true emergencies). Please give any constructive feedback. I would also be interested to knowhow many list members are seeing similar issues with their hand callrosters. Thank you in advance. Andrew J. Berson, M.D.Assist. Trauma DirectorMemorial Health System,Colorado Springs, CO --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ **************It's Tax Time! Get tips, forms, and advice on AOL Money & Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001)--trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --Forwarded Message Attachment--From: aberson at agvscs.comSubject: RE: Hand Call Coverage at Busy Urban Trauma CentersDate: Sun, 9 Mar 2008 12:08:24 -0600To: trauma-list at trauma.orgThank you so much for the helpful input. Andy -----Original Message-----From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of William BrombergSent: Friday, March 07, 2008 7:08 AMTo: 'Trauma & Critical Care mailing list'Subject: Re: Hand Call Coverage at Busy Urban Trauma Centers Background on the site:Memorial Health University Med. Center, SavannahState Level I, ACS unverified (dropped when the neurosurgeons refused topublish a backup call schedule) 1300-1400 registry admits, 2200-2300activations Our plastics and ortho hand trained/privileged individuals split hand call(about 1:5) they get paid a stipend (about $750/night I think). Prior tothis we had a hand call schedule that all the ortho and plastics people wereon without a stipend - it was a HUGE hassle to get someone to come in with alot of pass the buck being played. No-one would do replants ("We're not acenter!"). Now it's just a moderate hassle to get someone to come in. There's stillsome pass the buck (the plastics people don't have wrist privileges havingbeen blocked years ago by the ortho guys so if there's a wrist injury theyget passive aggressive and say to call ortho, etc. etc. etc.). Nobody willdo replants. If you do give in and pay up make sure that there's a contract to definewhat "hand call" means. Bill >>> "Dr. Andrew Berson" 3/6/2008 4:45 PM >>> To list members: I'm looking for input from busy level I and II centers on how hand callcoverage issues are being handled. Specifically, is this coverage providedby the ortho traumatologist or by a separate hand call list. The issue thatwe are dealing with is that after years of a very successful call roster forthis subspecialty, we are running into a very untenable situation. In thepast this coverage was provided by the ortho-traumatologists that had arobust elective hand surgery practice. These surgeons are already part ofthe paid call roster for orthopedics, and were providing hand "coverage" onnights where one of their non-hand surgery colleagues might be on call forgeneral ortho trauma. Now, the hand surgeons are refusing to provide thiscoverage unless they are given an additional stipend. The generalortho-trauma physicians do not feel comfortable in caring for significanthand issues, since this is not part of their elective practice. The question is, should a board certified orthopedic surgeon, on a paidtrauma call list at a busy level II trauma center be capable of evaluatingan injured hand and at least providing initial management of the injury,until their "hand surgery" partner is available the next day, or are weforced to give into the demands of the hand specialists and provide anotherstipend position on the call roster. (It should be mentioned that theamount being requested outpaces the stipend paid to the IN HOUSETrauma/Acute Care surgeon, even thought hand call is a home based call whichdoes not receive many true emergencies). Please give any constructive feedback. I would also be interested to knowhow many list members are seeing similar issues with their hand callrosters. Thank you in advance. Andrew J. Berson, M.D.Assist. Trauma DirectorMemorial Health System,Colorado Springs, CO --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --Forwarded Message Attachment--From: nmcswai at tulane.eduSubject: RE: Hand Call Coverage at Busy Urban Trauma CentersDate: Sun, 9 Mar 2008 12:31:42 -0500To: trauma-list at trauma.orgyou seem to be "right on" Norman Norman McSwain MDTrauma Director, Charity HospitalProfessor of Surgery, Tulane UniversityNew Orleans LA504 988 5111norman.mcswain at tulane.edu ________________________________ From: trauma-list-bounces at trauma.org on behalf of Michael Stein M.D.Sent: Sat 3/8/2008 4:18 PMTo: 'Trauma & Critical Care mailing list'Subject: RE: Hand Call Coverage at Busy Urban Trauma Centers Ken, Rick, Jeff and others.. I have always wanted to say this but never had the guts, since it isprobably politically incorrect. There is no doubt that there is some added value to be treated for a complexhand injury by a qualified hand surgeon. However, most hand injuries can bedealt with adequately by a "General" Trauma Surgeon, or a "General"Orthopedic Surgeon. Since the FIRST world society developed themedico-legal environment that promotes some of the behavior mentioned in theprevious posts on this issue, those "altruist" "General" docs will not takethe risk anymore. Since that same FIRST world society became clients instead of patients, theydemand the best of care and nothing less (even theoretically). The courtsfollowed the trend and supported this society. Thus, our bunch of dedicateddocs, full of altruism faded out sometime in the last century (the 20th). But now, this FIRST world society of clients (not patients) wants to bargainabout the amount of money they are prepared to pay these "super" handsurgeons. Well, if they are not prepared to pay they do not deserve the service. Aswe say here, "This society made this cake - now the same society should eatit" - or something like that. Sorry about this emotional post. Mickey Stein -----Original Message-----From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of KMATTOX at aol.comSent: Saturday, March 08, 2008 2:23 AMTo: trauma-list at trauma.orgSubject: Re: Hand Call Coverage at Busy Urban Trauma Centers I can imagine many, if not the MAJORITY of emergencies that are manifest on the HAND, I would RATHER have a NON-DECLARED HAND SPECIALIST to care for myself or my family , than someone with the narrow declared focus of the DECLARED HAND SPECIALIST. I would hope that every emergency roomphysician wouldcomprehend and appreciate that. k In a message dated 3/7/2008 6:18:09 P.M. Central Standard Time, Rick.Moore at TriadHospitals.com writes: ED physician thinks the patient needs aspecialist, specialist says "I don't repair that type of injury" andthen the higher level of care center refuses to take the patient. Atthis point the patient is at the mercy of an ED physician or generalorthopedist who may or may not handle the care appropriately. I am veryconfident in our ED Physicians and our General Orthopedists, but if thehand belongs to my wife, my children or myself, I want the Hand Surgeon!And our patients deserve no less.Rick Moore **************It's Tax Time! Get tips, forms, and advice on AOL Money &Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001)--trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ --trauma-list : TRAUMA.ORGTo change your settings or unsubscribe visit:http://www.trauma.org/index.php?/community/ _________________________________________________________________ Climb to the top of the charts! Play the word scramble challenge with star power. http://club.live.com/star_shuffle.aspx?icid=starshuffle_wlmailtextlink_j an-- trauma-list : TRAUMA.ORG To change your settings or unsubscribe visit: http://www.trauma.org/index.php?/community/ -- trauma-list : TRAUMA.ORG To change your settings or unsubscribe visit: http://www.trauma.org/index.php?/community/ From: KMATTOX at aol.com Subject: Trauma Critical Care & Acute Care Surgery 2008 Date: Mon, 10 Mar 2008 19:05:55 EDT To: trauma-list at trauma.org Yes, as the web site stipulates and as I warned all of you, we have closed both the TCCACS 2008 course AND the Medical Aspects of Disaster 2008 ( _www.trauma-criticalcare.com_ (http://www.trauma-criticalcare.com) ) . We did save out a few spaces for friends and especially members (or friends of members of this list server. It get those spots, you can call to Lisa Villarreal at 713 798 4557 or 713 873 3440 or e-mail at _Plisa at aol.com_ (mailto:Plisa at aol.com) . But you better have a hotel room. **************It's Tax Time! Get tips, forms, and advice on AOL Money & Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001) -- trauma-list : TRAUMA.ORG To change your settings or unsubscribe visit: http://www.trauma.org/index.php?/community/ --------------------------------- Sent from Yahoo! Mail. The World 's Favourite Email.
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