A Thankless Job
Mr. Santana is a 60 year old diabetic who had undergone an amputation of his right leg below the knee 6 months prior to our meeting. He presented for increasing pain, swelling, and foul smelling drainage from his left foot, and his toes were obviously beginning to become gangrenous.
"It looks to me like you are going to need another amputation at some point," I told him. "We can try some antibiotics and get the specialists together to see what we can do to make things better, but it doesn't look good."
He was none too happy about the prospect of losing his only remaining leg, and he acted like nobody had ever mentioned the possibility to him before. He looked at me with a combination of distrust and fear, like I was the devil.
As it turned out, he had just undergone an angioplasty of the arteries in this leg one week before, but we didn't have the records available. So I called the Cardiologist who did the procedure to see what his recommendations were. Fortunately, or not, he happened to be on call:
"Why are you calling me at 11 PM? I did my procedure and if it didn't work, then he needs to have an amputation. Thank you VERY MUCH for the FYI!!!!!!" He practically spat at me over the phone.
"Well, Dr. Ramakandathani, sorry to wake you up. I thought you might have another procedure you could perform, or maybe you wanted to recommend a specific surgeon. Mr. Santana seemed surprised when I mentioned the possibility of amputation."
"No. Admit him to the Medicine service. Goodnight."
As expected, the Internal Medicine physician on call was none to happy to getpaged dumped on at 11 PM either, particularly since it was his 14th admission of the day and really more of a surgical patient anyway. But at least he wasn't sarcastic. He sounded more tired than angry.
Sigh. I can relate.
"It looks to me like you are going to need another amputation at some point," I told him. "We can try some antibiotics and get the specialists together to see what we can do to make things better, but it doesn't look good."
He was none too happy about the prospect of losing his only remaining leg, and he acted like nobody had ever mentioned the possibility to him before. He looked at me with a combination of distrust and fear, like I was the devil.
As it turned out, he had just undergone an angioplasty of the arteries in this leg one week before, but we didn't have the records available. So I called the Cardiologist who did the procedure to see what his recommendations were. Fortunately, or not, he happened to be on call:
"Why are you calling me at 11 PM? I did my procedure and if it didn't work, then he needs to have an amputation. Thank you VERY MUCH for the FYI!!!!!!" He practically spat at me over the phone.
"Well, Dr. Ramakandathani, sorry to wake you up. I thought you might have another procedure you could perform, or maybe you wanted to recommend a specific surgeon. Mr. Santana seemed surprised when I mentioned the possibility of amputation."
"No. Admit him to the Medicine service. Goodnight."
As expected, the Internal Medicine physician on call was none to happy to get
Sigh. I can relate.
Labels: ER, nightshifts, patients
posted by scalpel at 8:51 AM
28 Comments:
I can see calling the surgeon for a surgical problem, but sometimes some of our docs make some ludicrous late-night phone calls.
A couple of days ago, a lady attempted suicide with a lovely cocktail of 3 or 4 things, including Fioricet and iron. She was going to be admitted and the ER doc called the gynecologist first since she'd delivered a baby 3 months ago and had no other doctor listed/medical history.
He went through the whole story of all the pills she took and whatnot, and I'm sitting there scratching my skull...and oddly enough the poor OB-GYN whom he called at 3 am said, "Get an intensivist or an internal medicine doctor to see the patient." Geez. Duh. Her downtown area was just fine, doc, what's the OB going to do about it?
/Rant On
I have to speak up on this one. Why was this patient even seeing a cardiologist? He has no interest in lower extremity vascular disease and problems other than doing the PTA of a lesion (and any comcommitant $$). It ignores the rest of the patient. His one dimensional 'treatment' is obvious by the lack of follow up and/or follow through on the patient a week later.
For many people, if their only tool is a hammer, then every problem is a nail. For this cardiologist his hammer is a wire and a PTA balloon. Where was the limited debridement that should have been done at the initial revascularization? What about a repeat PTA? Atherectomy? Endarterectomy? Treatment of synchronous lesions elsewhere in the lower exretrimty circulation? What about (gasp!) a lower extremity bypass with a vein graft? There are many therapuetic options that might be available to help this patient and avoid another major amputation (although that is still a possibility given any treatment). Ego and laziness must be precluding the cardiologist from continuing the care and arranging appropriate consultation by a specialist who CAN possibly do something more. Why the abandonment (admittedly a harsh word if viewed from the Board of Medicine adverse action prism)?
This patient should have (IMHO) seen a vascular surgeon early on. Even now, a vascular surgeon could potentially help this patient. You should give your PV surgeon a call instead next time. The poor internist that got dumped on hopefully has done this by consultation. Scalpel, I hope the surgoens you have access to are decent docs.
/Rant Off
DocinKY
I think too often we look at BKA as a failure when it can be a very liberating procedure. Often these patients are very sick and "whittling" away with multiple trips to the OR is no way to live and dangerous to boot. If anything it is a great operation that is too often shunned. Most of the problem is patient fear, but with the prosthetic options that they have today alot of that is unfounded.
I agree with all of the points above. As the last physician known to be involved in the care of this patient, and with the complete medical record temporarily unobtainable, I was hoping the Cardiologist could at least provide some information that would help me better manage the patient. Like maybe which antibiotics the patient was already taking (the patient didn't know). Or if a vascular surgeon had been involved yet, and if so, which one to call (nope).
We have several specialists who are quite good, but if you admit a patient to the wrong one, they freak out. They bitch about us when we admit to the wrong doc, and then a few of them bitch at us when we call them to see who the right doc is.
I'll call any physician, at any time, for any question I have about their patient. If I'm awake in the middle of the night seeing THEIR patient, they can wake their ass up too and help me make a disposition. Most of them don't mind.
I think I talked with that same cardiologist tonight on call, and I'm in Ohio. Sheesh! I can definitely relate to being on the other end of that type of late night dumpage, er admission....
Scalpel,
I am the editor of Blue H News. I would like to publish "A Thankless Job" in our upcoming issue.
Please email me at editor@bluehnews.com
Thanks!
George
Former hospitalist here:
Your thread highlights one of the big reasons I went back to fellowship. I can't tell you how many times specialists would just say "admit to medicine and I will c/s in the AM". Often appropriately. Often not. I have admitted 25 yo's with fractures and no medical problems because ortho didn't want to come in. I have admitted people with cholecystitis and no other medical problems because surgery didn't want to come in. I have admitted people with suicidal ideation because psych's coverage at the hospital I worked at was a sick joke. Every single neuro pt would come to me including those getting TPA. The list goes on and on. I am not arguing about those patient's who are better served on medicine with specialist c/s. What I see is an abdication of responsibility by those who would rather not be a doctor anymore besides their little niche. It is all rather pathetic. The response above about having vascular see the pt is laughable. You would see a vascular surgeon at night for that guy right after the cardiologist came in.
Thats what happens when you have bargaining power. Everyone knows Ortho and Cardiology make the hospital go round. You can do without one or the other, but go without both and you are in deep doo doo. Ortho at my hospital was a consult only service through the E.R. and they were given a stipend for call. That's the only way we could get coverage and if we didn't do that we might as well have closed the doors or that decision would have been made for us and the hospitalists would be looking for a job elsewhere.
So when you have "bargaining power" that gives you the right to abdicate your responsibility as a doctor? Interesting justification. As far a hospitalist's looking for jobs elsewhere, I have been in fellowship now for two years and I still get letters, phone calls, emails, about hospitalist jobs on a weekly basis (not that I would ever take a job again in which I am shat upon by every specialist that doesn't want to be doctors anymore). So I would hardly talk aboutthe excess of hospitalists.
pardon my ignorance, but isn't the job of the hospitalist to admit sick patients to the hospital?
it seems like no one wants to take care of patients anymore. i didn't realize taking care of a sick person was getting dumped on.
:(
To Anon 4/16 08:45
Do not paint all surgeons with the same brush. In my hospital, general and vascular surgery come in regularly to see patients in the ED. I am a vascular surgeon. Do I admit everyone to my service all the time? No, but I have seen the patient and made diagnostic & treatment plans and coordinated the care from there with either the pt's own MD on staff, or with our hospitalist - from the ER at 2:00 am if need be. Especially if it is my patient returning for a potential complication.
I agree at many hospitals one would never get a specialist in to see a patient after hours. However, please do not assume all specialists are like that.
DocInKY
I agree with Scalpel---an ER doc ought to be able to call any of the patient's docs with a question when they need to. It's not like they just decide to wake people up in the night for the hell of it.
One time in an ER, our poor ER doc made the rounds of the patient's various docs, finally getting the surgeon to agree to come in and see the pt. By then, the patient had c/o pain and had received Toradol. I'll NEVER forget that grouchy surgeon bellowing at me when he arrived: "Don't you EVER give one of my pre-op patients Toradol! Dammit, you might as well as given him LIQUID ASPIRIN!" I didn't tell him that we hadn't known that anybody was going to operate at the time the Toradol had been ordered.
Anyway, a few months later, in the ER, I was prepping a pre-op patient for that surgeon. He came down and signed the papers, commenting cheerily to me: "Did you get him all ready for me, Bo?" I could NOT resist replying (in front of everybody in the ER) "Yep, and I gave him 60 mg of Toradol."
As everybody looked horrified and the surgeon started to turn red and puff up like a giggled bullfrog, I replied: "Gotcha". (He had the grace to start laughing, remembering how he'd bellowed at me....)
Yes, the medical world is a fun place to work.....
That was supposed to be "gigged" bullfrog, not "giggled".
Bullfrogs never giggle when they're gigged.....
Place a hyperbarics consultation! We'll perform TCOM's on the leg/foot and see if he's a candidate for HBOT. You'd be amazed at how many diabetic foot/toes/limbs I've been able to save from amputation due to poorly healing wounds & osteomyelitis. If they have decent TCOM's they're salvageable.
Echoing a previous commenter, this is a perfect example why cardiologists have no business whatsoever doing procedures like this. None. Some interventional radiologists, yeah; especially those that work as co-equal partners with vascular surgeons. Cardiologists? Horrifying.
Anon 10:09:
It is about what is best for the patient. An otherwise healthy patient with acute cholecystitis is NOT best served on a hospitalist service. I don't know if you read the article (or if you are even a doc). But after forteen admissions the lone internist has probably not at his/her best and certainly is tired of admitting every other service's patients. But hey don't believe me, I am just one of those ex-suckers who left internal medicine.
why would a radiologist be better than a cardiologist?
scalpel-
"I'll call any physician, at any time, for any question I have about their patient. If I'm awake in the middle of the night seeing THEIR patient, they can wake their ass up too and help me make a disposition. Most of them don't mind."
---
nice attitude. i'm sure that's helpful when you are waking someone up. :)
Anon 9:52
Hip fractures admitted to medicine have a lower mortality rate and less postoperative complications than those admitted to the orthopedic service so perhaps they are trying to do the "best" for the patient.
How did they abdicate responsibility? They still take care of the patient. Cardiology and Ortho are two of the biggest money makers a hospital has. They are nearly always net positive service. Hospitalist services depending on the payor mix can be a net negative service. So administration will be much more in tune with making those groups happy lest they leave and take their ball and go home to the surgicenter. Complaints of a hospitalist, they don't care because as far as they are concerned a "hospitalist's" job is to take care of people in the hospital, that's what they are paying them to do. I used to admit my own hip fractures until I had a hard time getting the hospitalist to follow them at all postoperatively or get them ready in the first place. I had enough, I went to administration made a few idle threats and now I haven't admitted one in 8 months and the bottomline is that patients get better care.
What the cardiologist was really saying was, "Proceedure done. Pt. billed. Hands washed."
Anon 8:17: Perhaps you can show me the study where hip fractures WITH NO COMORBIDITIES (which is what I was talking about) do better on medicine than ortho.
Anon 8:30: thanks for clarifying that it is all about the money.
By point:
1: my hospitalist service was always positive. How do I know? no net positive cash flow...no bonus.
2: Your threat about outpt surgicenters doesn't hold water for the simple reason that any patient requiring a hospital stay (ie all hip/knee ORIF's) would be precluded.
3: A hospitalist's "job" is to take care of patient's who need the care of a boarded internist and need c/s care from an internist (including complicated medical patient's getting hip/kness ORIF's requiring internist care). NOT to babysit every pt in the hospital because subspecialists don't want to get called (ie writing for PCA orders on an otherwise healthy hip ORIF, sound familiar?).
4: "I used to admit my own hip fractures until I had a hard time getting the hospitalist to follow them at all postoperatively or get them ready in the first place."
Maybe you had hard time getting the hospitalists to follow some of your patient's because they thought you should be able to manage pain control on the otherwise well hip fx on your own I don't know. The fact is though an orthopedic surgeon should know how to manage post op pain on an otherwise healthy hip fx without the input of a hospitalist. If it is a complicated patient or their is a post op complication than that is a different story. I can tell you from my point of view one of the most frustrating phone calls was a "stat" call from the PACU to write postop PCA orders on a elective procedure when at the same time I was managing multiple critically ill patients. It shows a complete lack of respect to your collegues. Lastly, why would you want hospitalist's to "get your patient's ready" (by that I assume risk assess) for elective procedures. That is what a PCP is for.
Of course there is a bigger issue here. By getting a hospitalist involved, the patient is paying for another doctor's involvement. If it is a complicated medical patient...no argument. But frankly I would be p/o'd if I (who is healthy) payed for another docs services because you wouldn't write for pain management and post-op anticoagulation.
You see anon, if you have not managed a single patient in 8 months than the "bottomline" is you have abdicated responsibility. The simple fact is in patient's with no comorbidities (let me repeat that for anon 8:17, IN PATIENT'S WITH NO COMORBIDITIES), there is no evidence to support they get better care. You just don't have to deal with it. That after all is really the bottomline.
How many 80 year olds with hip fractures do you know with no comorbidities? They are about as common as the spotted owl.
1) I'm glad you bonused. Stats don't lie though the two of the biggest moneymakers for any hospital is cardiology and ortho.
2)My practice is 95% outpatient so yes it does hold water. I don't need the hospital. The hospital needs me. Like I said I can take my ball and go home. To another hospital or surgicenter or both.
3)No it doesn't sound familiar because I order all pain medicines for my patients.
4) I still manage all of my patients pain postoperatively and DVT prophalaxis. My complaint was nobody was monitoring their electrolytes postop if they were out of wack preop or managing their fluid, blood sugars, etc. Hard to do if you don't follow the patient's you are consulted on.
Last I checked a hip fracture is not entirely elective. Its not like a knee scope. If they don't get their hip fixed they die.
Read for comprehension I stated:
"Often not. I have admitted 25 yo's with fractures and no medical problems because ortho didn't want to come in."
I am not talking about 80 year old time bombs or acute hip fracture medical disasters. I am talking about patients with no comorbidities who can be managed by anyone who went through their third year of med school (ie. giving potassium to a patient with a K of 3.4, placing patients back in their basic home medications, etc etc)
Please do tell me about all the hip and kneee ORIF's you do as an outpatient.
I am glad you write for your patient's meds and DVT proph. Most of the ortho's I delt with did not.
This is the fact pal..you and I aren't going to agree. In my eyes (and probably most other docs), if you haven't taken care of a single
patient in 8 months of surgeries, you are abdicating your role as a doctor...period. The other fact is the only reason you make gobs of money, is because that is how medicare has set up reimbursement. Doctors in this country get paid to do procedures not think. That's not me whining, I left hospitalist medicine for fellowship. I'm done with it. That is simply the fact.
Of course the next time you can't find a hospitalist to babysit you 25 yo ORIF's then you will have some idea what is wrong.
Could the court reporter read back the last statement?
Perhaps you can show me the study where hip fractures WITH NO COMORBIDITIES?
The Vast Majority (>90%) of Hip Fractures are Elderly. I responded to that line, a question. I did not respond to the 25 year old with "fractures", a statement.
I'm not sure if I have ever seen a "hip fracture with no comorbidities" and that was my attempt to answer your question. Maybe in your judgement a poor attempt, but an attempt none the less. I think it is about the same as this question have you seen anyone that was allergic to Toradol, Advil, Aleve, Celebrex, Lodine, Darvocet and Tylenol and not allergic to Ultram. I'm sure they are out there, probably rare though.
Read for Comprehension.
I do hip and knee ORIFs because I like to. I don't do them because I have to, big difference. I can opt out of call whenever I want too. Knee Arthroscopy, ACLs, Shoulder Scopes, Most Hand and Foot and Ankle are all outpatient, which like I said make up 95% of my surgeries. And I have a junior partner who said he would gladly take inpatient stuff if I want to give it to him.
I do agree with one point. I do like to write my own pain and DVT meds and I am sorry you were treated poorly in that regard.
I haven't taken care of a single patient in 8 months? I did the most important thing. I did their surgery. Without it they die. Plain and simple. Eliminate the Orthopod from the equation and see what happens to hip fractures. And you believe you don't think when you do a procedure. Spoken like someone who doesn't know their way around the OR. If it was as easy as you say and you don't have to think in the OR, I suspect anyone with a GED could slam in a hemiarthroplasty and have them do great.
"I haven't taken care of a single patient in 8 months? I did the most important thing. I did their surgery. Without it they die. Plain and simple. Eliminate the Orthopod from the equation and see what happens to hip fractures"
You just don't get it do you. Nobody is talking about eliminating orthopods from fracture care you jackass. The question is, does the patient need medicine input and not a babysit because you don't want phone calls. I am not/or have ever talked about patient's with multiple medical comorbidities. frankly I am tired of trying to get that through your thick head. If you think every fracture is a 90 year old with CABG, renal failure, DM, etc, etc, than you clearly don't work at a major hospital with traumatic injuries. For one second think outside your box. Think about hospitalists who admit ortho patients with no/minimal comorbidities. Then add surgical patients with no comorbidities. Then throw in your psych patients with no where to go. Go on and on for every service in the hosptial. Then add the REAL medicine patients in the ICU and everything else. This is your idea of the best care? Most hospitalist services are way way overloaded (have you ever even bothered to talk with those that you worked with?). The fact remains (you clearly don't read medicare payment schedules) is doctors get paid to do procedures, not manage patients. Read the payment schedules. In conclusion, if you haven't managed a patient in 8 months, than you are not the type of ortho I would want to work with. Goodbye, I am done with this circular argument.
Obviously this is a hot-button issue, but let's not have any personal attacks or name-calling please.
I'm a Canadian GP. Surely arranging simple post op care is the job of the family doctor... and so is co0ordinating all the referrals to specialists. Nurse Kelly should have been asked to get the GP on call for the suicide lady's care... if there was one. Almost certainly there was no family doc at all, and she was getting her primary care from an expensive gynecologist. Crazy.
If you push GPs out of hospital care, specialists are going to be getting those midnight pill calls.
If Mr. Below Knee Amputation is a vasculopath, his GP should have laid out the options for a fat old guy who continues to smoke... if there was a GP.
When we get our ritzy new regional general hospital 40 km away from our little city, we'll have to depend on hospitalists... who will probably be GPs.
Thank heavens for skilled surgeons, trained internists and hospitalists who take care of very ill patients... but the GP should captain the ship.
Post a Comment
<< Home