Shell Game
Bjorn, Pret
pbjorn at emh.org
Mon Mar 10 14:06:13 GMT 2008
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" <robsidarn at msn.com>
To: <trauma-list at trauma.org>
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
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--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"
<aberson at agvscs.com> Date: Fri, 7 Mar 2008 07:14:15 To:"'Trauma &
Critical Care mailing list'" <trauma-list at trauma.org>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
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Time! Get tips, forms, and advice on AOL Money & Finance.
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--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"
<aberson at agvscs.com> 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
<mailto:norman.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
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