You won’t help a critically ill child? Is this how low we’ve fallen?
One of my partners recently took care of a child with a retro-pharyngeal abscess. For the non-medical, this is a serious infection behind the throat that can easily result in loss of an airway. The child, some 20 months of age, was obviously very ill.
We frequently don’t an have Ear Nose and Throat physician on call at our hospital, and the night that child presented was typical. So, the only viable option was to transfer the child. However, when my partner tried to find an ENT surgeon to care for this child in a nearby town, he was met with this response: ‘I’m not on call for your hospital.’
Now, I understand not wanting to have ridiculous referrals. I understand not wanting to increase your already busy workload. I understand that being a surgeon is very time intensive already, so the doc in question probably didn’t need more work. But the thing is, it wasn’t a drunk with a broken jaw, an elective tonsillectomy, or even a fish-bone stuck in the throat. It was a child who might have died.
Well, I guess Hippocrates didn’t cover that scenario. You know, sick child from another town. After hours, and all that.
Is this how far we’ve fallen? See, we don’t have endless options for transfer. We practice in a semi-rural area. It isn’t Manhattan. There aren’t surgeons on every corner. Trust me, if we could have handled it, we would.
Is this what doctors have become? Technicians who feel no sense of urgency or obligation to the sick, in fact, to the most vulnerable of the sick? Is this how we want our children, or grandchildren, treated? Dismissively? With a ‘good luck’ and a hearty pat on the back? With a ’sorry, but you know how business is these days?’ I hope to heaven not.
That sort of behavior makes me feel angry, and a little sick. It makes me see how malpractice litigation could get out of hand, or how national health care might slip in the back door. If we’re so unprofessional that we can ignore a critically ill child on a technicality, then maybe we’ll deserve whatever happens.
Fortunately, the overwhelming majority of docs I know would never behave that way. Like the intensive care docs who ultimately accepted the child, they do the right thing at the right time, the way we were taught.
We need to call this behavior what it is; childish and unprofessional. And we need to remind ourselves, every day, of why we do our jobs. And that we have a duty to the sick and injured, convenient or not.
And we need to remember the words of scripture: ‘Be careful to be kind to strangers, for in so doing, some have entertained angels without knowing it.’
Have a great weekend!
Edwin
That is a sad story… unfortunately the ENT’s attitude is fairly common these days. When I was a medical student on an ICU rotation, one of our patients was crashing and about to code. The attending asked to speak with the patient’s nurse so he could figure out which meds she’d been given most recently. He was informed that the nurse was “on break” and wouldn’t come to the bedside. He was outraged and yelled at the messenger (another nurse) who shrugged and responded (cold as ice) “union rules.”
So you’d advocate that the ENT who turned you down become the dumping ground for all your local folks who can’t be bothered to take call? So your hospital will reward the local refusniks or will continue to fail in it’s duty to provide for such care, on the backs of other regional consultants?
So when the ER in the neighboring town is shortstaffed can they call YOU up in the middle of the night to haul your butt over to St. Elsewhere to provide care-possibly even for free?
How is it that your ICU was able to handle the case in the final analysis without your ENT consultant? (BTW are the ICU doc’s on salary?)
Knowing that you haven’t got the appropriate coverage for this service how is it that the ER and the hospital continue in it’s fraudulent advertising that it can in fact handle such emergencies? Why haven’t you got a contingency plan in place to handle such cases when you haven’t got coverage?
You can have all the heart in the world, but if you haven’t the resources to back it up, it’ll al be fro naught.
Dr. Kranky,
Let me address each concern in turn. We only have one ENT, and have just recruited another. The rules say he doesn’t have to be on call every night. We’ve struggled with this, and even have arrangements with nearby hospitals. However, no one wants to deal with our problems. Understandable. I seldom transfer any ENT patient; heck, we even tell most orbital fractures to follow up the next day or two.
Second, my partner wasn’t asking the ENT to come to our hospital, but only to accept the child in transfer since we don’t have pediatric ICU services. In fact, our ICU didn’t handle the child, but the child finally went to a regional pediatric ICU. Apparently I didn’t make that clear in my post. (I don’t know how those docs are paid).
When the neighboring ED needs help, we will help. Although I don’t go there to practice, we accept transfers from rural hospitals in NC and GA when they don’t have the capacity to handle the problem.
Fraudulent advertising? ED’s across the country count on the ability to transfer. We are the only hospital in a large rural county, and serve a much larger area than that. Should we shut down and send everyone to other hospitals because we lack coverage for certain entities? After all, we transfer brain injuries and invasive cardiology too. Is that fraudulent?
The reality of modern medicine is that many facilities don’t have every specialty on earth. Should we limit medicine to large urban teaching centers that can provide everything, and just leave the rural world to fend for itself, since, after all we’re ‘advertising fraudulently.’
Finally, let’s get to the heart of this. It wasn’t a drunk mandible fracture; it wasn’t a nursing-home patient who needed a tracheostomy tube replaced; it wasn’t mastoiditis or a swallowed foreign body. It was a child with a disease process that threatened his airway, and that needed surgical involvement.
What’s so wrong about the way we handled it?
What if it were your child?
Edwin
Since you didn’t mention the outcome, I’m guessing everything worked out just fine. Maybe you found the physician who was supposed to be on call, maybe you found someone else. Point is, the physician who turned you down probably knew very well you wouldn’t have too much trouble finding someone else. And if you did, he probably would have expected to receive a second call saying there’s no one else, under which circumstance he would have taken the case. What I’m saying is don’t judge too harshly- just because he passed (on your first attempt), doesn’t mean he wouldn’t take it if he was the last line of defense.
If the hospital has set rules that the ENT doesn’t have to be on call every night, then doesn’t the burden fall on the hospital to come up with a backup plan? I think you answered this question by saying you have recruited a second ENT. So does this mean that the problem solved now?
A lot of people are arguing that there are already too many specialists. In a setting where there are too many specialists competing for too few patients, wouldn’t there be a lot of hungry doctors going after any chance they can get to have some work to do, rather than turning away work, especially a surgical case?
That doctor in a neighboring town who is being uncooperative will suffer the consequences of you no longer referring ANY patients to him, emergent or not. But your local ENT who also refused the case by playing the “I don’t have to be on call every night” card will still continue to benefit from your support and referrals, no?
I can’t think of a likely explanation for the ENT’s response except that he’s a jerk, but unfortunately, he’s allowed to be a jerk. I would not respond as he did, but, understanding that he’s a jerk, his response was rational. Working on sick infants at night is never easy, and for him, the risk/reward ratio was in favor of going back to sleep, watching TV, reading, or whatever he was doing when he was called. Accepting a sick child in most places sets the doc up for ~2 decades of potential liability, probable Medicaid (at best) reimbursement, and potential dealings with toxic parents. When we have HIPAA, EMTALA, hospital administrators, JCAHO, insurance companies, legislatures, and lawyers constantly telling us who we have to take care of, where we can take care of them, how long we have to get there, and what we are allowed to charge, not to mention the possible loss of our livelihood from a bad outcome, the motivation for picking up that extra emergency patient from an out of town hospital wears thin.
Come to think of it, he doesn’t have to be a jerk, just a rational actor. Practicing medicine in the USA in 2008 is not a rational activity.
According to Edwin’s logic, all pediatricians should be forced by law to take in whatever patients come in the door.
I think the ENT should have taken the child. But I do NOT think that the law should mandate that all ENTs (or any other subspecialty) should be forced to take referrals, or cover ERs.
The local ENT has set limits to his availability, so he doesn’t get worked to death. If Dr. Leap or his associate had called the local ENT, say reached him at home. The response would have been “I’m not on call today”.
And that would have been OK. Conceivably, he could have made an exception for the child. It wasn’t a drunk with a fractured mandible. But no, the doc has set limits. After all, “…..The rules say he doesn’t have to be on call every night……”
The University ENT’s have set limits on their availability. They will treat a certain number of people, and no more. So they don’t get worked to death. So if called, they would have said “We’ve treated all we can, and no more.” and that’s OK. After all, you can’t expect them to take care of everyone. Sure, maybe they could have squeezed in another patient. But they set a limit at “X” number of patients and no more.
And that’s OK.
The out-of-town ENT has also set limits on his availability, so he doesn’t get worked to death. He’s on call for a certain fixed number of hospitals, so he doesn’t get called from all over the country. So he says, “I’ll take patients from these hospitals, and no others.”
And that’s unprofessional in Dr. Leap’s view.
Why?
I don’t think that Dr. Leap was necessarily recommending that the ENT be somehow coerced to take the patient. I more or less interpreted his post as a plea for decency, for professionalism, and for a willingness to go the extra yard for the weakest and most dependent among us.
I don’t believe in slavery. I do believe in decency, in compassion, and in each health care professional’s coming to the realization that his or her responsibilities are somehow special.
John
No, Dr. Leap may not be recommending forcing the ENT to work.
Yet I have pointed out, and he has not responded……..that he has described THREE consultant ENT surgeons. One local, one University, one private but out-of-area. ALL THREE have declared limits to their availability. And for that matter, Dr. Leap himself declares limits to his own availability, unless he’s on-call 24/7. As a solo FP by the way, I *AM* on 24/7.
Any one of the three could have relaxed his/her own barriers, extended just a little bit to accomodate the child.
Yet somehow, for some reason, only ONE of the ENT surgeons in question, the out-of-area private ENT, is “unprofessional” in Dr. Leap’s view. I wonder why, and have not noticed an answer.
First, under EMTALA, a hospital specialist at MOST is expected to take call 10 days/month. So for a hospital with one ENT, you can expect gaps in coverage.
Second, under EMTALA, if you are on call for YOUR hospital, and you can provide a service another hospital cannot that day, then you are in fact on call for that other hospital. Fair or not, that is the letter of the law. This ENT created an EMTALA violation by not taking the patient.
If you are going to be on call anywhere, you better learn the law, or quickly you will be 50,000 poorer NOT covered by your malpractice.
If in fact CMS picks up on this blog, and quizes Dr. Leap regarding this case, someone will be in trouble soon….
Believe it or not, I had a great deal of sympathy for the child and the predicament of the ED physician.
By bringing up the flip threat of a fifty thousand dollar fine, I assure you that any sympathy I had is now gone.
You want to know why doctors won’t take ER call, I suggest you look in the mirror.
Any thought of appealing to the professionalism of the ENT that has been singled out for condemnation is now replaced by lawyering up. Is that ENT on call for the entire country? Just because the ER has singled him out when a pediatric center would have been more appropriate? Were they REALLY too busy? Having taught in a center that got burned on that one, they thought they were full, but weren’t in retrospect. Where did ten days a month come from? It is, of course, arbitrary. Did the doc really work ten days that month? Was there another place where the person could have gone? Was referral to an ENT appropriate, versus referral to a pediatric ICU with referral to an ENT if the airway were lost?
Now with the threat of massive fines for “violation” of HIPAA, even an inadvertent violation done in good faith, with the standard changing every week, and the ER docs on their high horses more than happy to drop a dime, I have lost any sympathy for the ED that I once had.
And I’m not a consultant, I’m a PCP.
now on healthbeatblog. great!
these blogs continue to erode at what is left at physician relationships. especially when the other side does not have an opportunity to present their side before poeple declare medicine a disaster and physicans untrustworthy.
let’s all look to ourselves to serve as (what we believe to be) a model of professionalism rather than accusing others of not being professional.
Taricha:
News to you: refusing a transfer is not “automatically” an EMTALA violation. Sorry if it breaks your tyrranical little heart, but being on call as a specialist does not extend your duties beyond that facility for which you have a coverage agreement. Never has. An ER doctor cannot force another facility to accept a transfer and cannot force a doctor on staff at that facility to accept the transfer either. Crazy as it might seem to you, we also have laws against that kind of thing. “Forcing” a transfer would be dumping, and that is an EMTALA violation.
If you think differently, give the cite. And don’t forget to show where that has been upheld.
Thank you beetles. I suspected the same, but my line of work does not put me in the line of fire of EMTALA too often, so wasn’t sure.
“…..Crazy as it might seem to you, we also have laws against that kind of thing……” The Thirteenth Amendment to the Constitution comes to mind.
I have to admit, when I hear people in the EM biz talk about EMTALA, I perceive a smirk on their part. It just about seeps through the screen online. Did the kids who liked to tell on their classmates to the teacher all go into EM?
And the high horse gets tiresome. “…..Am I the only one in the world who cares about this chi……..oops, shift over, time to go home…..”
Any appeal to professionalism to care for a child like this evaporates when EMTALA is invoked. The second I hear EMTALA, I will firmly take the side of any doctor who works to rule. When we get decent tort reform (at least in my state), and EMTALA is scrapped, then let’s talk about professionalism.