An Inappropriate Transfer

A while back I arrived to my morning report to learn that an overnight partner of ours had accepted a patient for transfer from an outside facility. This facility is not in the woods. It is a fairly full service hospital with most specialists available. It has it's own ICU and can do most critical care services.

What we were asked to accept was a septic patient.

Sounds good to me. I love taking care of sepsis.

There was one problem, the suspected source of the sepsis was a knee.

That knee just happened to be a total knee arthroplasty.

I was very leery about accepting a patient with sepsis who's potential source was a knee that a surgeon "owned"

Let me tell you like it is in the real world. Surgeons hate, hate, hate, hate, hate operating or getting involved in the organ, site, near site of any prior surgery performed by a previous surgeon. My experience with surgeons, has been: Once they operate on it, they own it.

Forever.

In this patients example, I made some quick phone calls. You see, my night partner had accepted the patient a little while prior, and she was already gone for the day. So I called out to the hospital looking for the transferring doc. Apparently, being a weekend, he had already checked out to his partner. I was unsuccessful in obtaining that doc, so I moved on to the on call doc.

And that's when the story gets a bit more clear. Since I never heard it first hand, I can't verify the accuracy of the details. But this is what I was told.

The transferring doc admitted the patient the night before with sepsis. The suspected source was a knee. A knee that had a total knee arthroplasty, performed by an orthopaedic surgeon in their community. My understanding is that the transferring doctor requested the orthopaedic surgeon to see the patient, "that night", and the surgeon refused, stating he will see the patient in the morning.

My understanding is that this upset the transferring doctor enough that he requested the transfer. Was it out of anger? Was it out of spite? I have no idea. I was also told that the knee was tapped several days previously and this was the apparent basis by the surgeon for lack of urgency in the situation.

Now, here I am being told that the suspected source of sepsis is a total knee performed by an orthopaedic surgeon in their community and I am being asked, as a hospitalist (who by the way doesn't perform knee surgery) to accept a patient with, what sounds like a primary medical problem, as a result of a primary surgical problem.

I had to do a take back. I unaccepted the patient. I am generally very liberal in my accepting admissions. If the patient needs help, I feel our hospital can help them. However, hospital politics and the nature of the current status of our system has made some specialists less accessible than others.

In my experience, all medical specialists are always available. Pulmonary, GI, cards, ID, Neuro. You name it. They are there to help. The vast majority of time, I can call up a medical specialist and they will always see the patient, minus a doctor here and there with a personality disorder.

Now surgical specialists are another story (at least in my experience)

I have had to argue with more surgeons that I can ever imagine, or ever thought I would have to.

Some complain we don't call them enough. That we play favorites. That we only call them with the uninsured. We only call them with the difficult surgical, long post op recovery times. Let me tell you, it simply isn't true. The reason we call you is because we like working with you.

The reason why we don't call you, most likely is because you complain, you bitch, and you obstruct my ability to care for patients. You may be the best damn surgeon in the world, but if you can't get a long with people in a respectful, civilized way, you will never get a call from me.

At our hospital the only time any surgeon HAS to see a patient is if the surgeon is consulted to see a patient from the ER.

The transferring doc (I'm sure tongue in cheek), said he would discharge the patient and have them go to our ER. Then he asked why I couldn't discharge the patient upon arrival as a direct admit and send him to our ER.

Two scenarios which are clearly not going to happen.

What I have learned in my 5 years is not to accept a primary surgical (or even possibly surgical) patient if there is any reason that a surgeon will decline the consult.

This has happened. And not infrequently. I am left with a surgical problem and no surgeon. That makes it a very difficult problem for me.

In this situation, a possible complication on a surgical problem performed by another surgeon.

I can only hear the laughs in the background as the surgeon at my hospital is telling his colleagues at the cocktail party about how I requested him to see a septic total knee done by someone else.

It is so laughable for me to think any surgeon would agree to this consult, that I unaccepted the patient for transfer.

Until the system is fixed, I can't be the social worker and hand holder for everyone.