10 October 2009

Managing the Inappropriate Plastics Consult

In the comments, a question was posed from reader "Seattle Plastic Surgery on Lake Union" (an online handle that is as unwieldy as it is descriptive).  He asks:
I would like to hear your opinion on a topic that is rapidly growing near and dear to my heart...the scenario is thus:

I'm on call, the local plastic surgeon, for the local ER. You are seeing a nice family with a child that has sustained a simple facial laceration. No fractures, no missing tissue, just a simple, linear, forhead laceration.

The Mom asks that a plastic surgeon be called to come in from home and close the wound. You reply that you are able to do the closure, the child is medically stable, and that a you are qualified to close the wound. The family presses you: call the plastic surgeon.

Can you tell me, from an ER doc's standpoint- what is the most appropriate response from the on call plastic surgeon?

In your experience, are families aware that they may be sent a second bill for the ER laceration closure by the on-call plastic surgeon? Are they made aware of this possibility?

Without question, if an ER doc tells me that they need me to close a laceration, due to its location, complexity etc...I come in to close it. But these 'parent requests' plastic surgeon call are becoming more frequent.

This is a pretty easy one, in my mind.  As posed, it's a wound that could even be treated with dermabond -- utterly ridiculous to consider calling in plastics.  There are times when it's OK to say no.  In fact, as the ER doctor, I would not even call the plastic surgeon in such a case.  I'd say no to the family straight off, and not make the surgeon be the bad guy.

But all life is a negotiation, and there are so very many shades of gray.

Consider a slightly more complex situation, where it's not a toddler with a simple forehead lac, but a fifteen-year-old girl with a stellate laceration of the forehead right between the eyebrows. This is a case where cosmesis is legitimately going to be very important to the patient/family.  But let's be honest: there's going to be a scar, and I'm quite doubtful that the cosmetic outcome is going to differ much whether the ER doc or the plastic surgeon does the repair.  In this example, the family's request for a plastic surgeon is more reasonable, but it's still probably not necessary.  How best might we handle this situation?

It should go without saying, but I'll say it anyway; the ER doc's first tactic in managing the family's request is to walk it back and attempt to build trust with the family.  Many people have no idea what ER doctors do, what our experience and training is, and some education can terminate the difficult interaction.  My general approach is to explain that ER physicians train extensively in plastic and reconstructive surgery (which was true for me, anyway. YMMV.) and that I had planned on specializing in plastics but realized that my attention span was short enough that ER was a better fit (also true).  Further, I explain, injuries like this one are the sort of thing I fix every single day and I have a lot of experience at it.  (This line seems to be more effective now that I have a bit of gray in my hair.)   I project confidence that I can do this; people pick up on that sort of thing, and any waffling from the doc is utterly fatal to getting buy-in from the family.  Then I offer the hook: I offer to go ahead and fix this up now and arrange follow-up with the surgeon to ensure that it heals as well as it possibly can.  This is having prefaced the discussion with the fact that there will be a scar no matter what -- some people have a slightly mystical notion of the powers of a plastic surgeon.  With my exceptional interpersonal skills (cough cough) I rarely have any problems with this approach.

So what when that fails?  When the family irrationally insists on an inappropriate consult?  For clear-cut cases, I tell the family flat-out that the surgeon will not come in for this.  They don't like that, but it's the truth.  But for the "gray zone" cases, I generally make the call.  I'm often surprised by the response I get.  Depending on the time of day, the person on call, and how the stock market is doing I can get very divergent answers.  Most commonly, however, the surgeon asks me if I am comfortable doing the repair, and if I am, they ask me to do it.

It hasn't happened to me that I recall, but there is always the possibility that you get off on the wrong foot with the family, or they're just really high-strung, and they draw a line in the sand: you are not going to touch my child.  This is when creative thinking can be your friend.   I know that I can compel the plastic surgeon to come in; EMTALA and all that.  But it's a bad decision to do so; you burn bridges that way, and soon enough either you're out of a job or your call schedule has no plastic surgeon on it.  My opinion is that a reasonable compromise approach to the adamant demand for a plastic surgeon is this: the ER doctor should extensively irrigate the wound and place a temporary closure, whether it be steri-strips or a couple of stitches to tack the meat back together.  In return for not having their rear end dragged out of bed at midnight, it's fair to ask the surgeon to commit to seeing the patient in the office within a reasonable timeframe for a definitive closure.

In fact, I have used this approach for cases that I knew would require a plastic surgeon.   When you have a nasty wound that is going to require revision, flap undermining, etc, but doesn't need to be done in the OR, there's an argument to be made that the surgeon may be able to better accomplish it in the controlled environment of the office surgical suite, where they have the all their tools and an assistant and all the time they need.  Moreover, I think it's highly likely that a surgeon will do better work at 9AM than at 2AM.  The time-sensitive aspects of wound management are irrigation and hemostasis: if the ER doc can do them in the middle of the night, the surgeon can do a lovely repair in the morning.

So, SPSOLU, there's my answer for you: offer to see them in the morning.  And if the family complains about having to have more than one procedure on their delicate child, explain that's the price of having a specialist perform the repair.


rlbates said...


Susan petry said...

yep, we deal with this scenario all the time. the otehr part is that the community pediatricians often tell the parent to "bring the kid to the ER and they will get a plastic surgeon to close it." so you get it both ways. my approach is similar to yours, though and it usually works well.

Anonymous said...

my favorite is the self-pay/no-pay that demands a "free" plastics closure. when it is not necessary.

Anonymous said...

"I'm quite doubtful that the cosmetic outcome is going to differ much whether the ER doc or the plastic surgeon does the repair. "

Wow. You really can do anything.

pdx rn said...

Another important element is the nurses, starting at triage, nip the parent's plastic surgeon expectations in the bud. "Oh, our doctor's can repair that as well or better than any plastic surgeon. They repair these types of injuries all the time, actually more often than the plastic surgeons. If there's the slightest chance that they feel a plastic surgeon can get a better result than they will, they'll call one but this laceration is very simple to fix..."

"No tissue missing, simple closure, wouldn't want you to have to wait hours for the plastic surgeon to come in, so stressful for little Suzy, blah blah blah..."

Is it an EMTLA violation if is refused a plastic surgeon if one isn't necessary. If I go to the ER with a sprained ankle can I demand that the orthopedist on call come in and examine and splint me?

Xerxes1729 said...

It's especially true at academic centers. If the wound is a simple linear laceration, then insisting on a plastic surgeon will get you the plastics intern or subintern, who has far less experience than an EM attending, or even most upper-level EM residents.

chuckr44 said...

WTH?? If I didn't cut an artery or some major vein, I sew it up myself. (Yes I really do. After proper sterlization of course.)

ERP said...

If the patient has insurance, our plastics docs LOVE to be called for simple lacs. They usually do not balance bill the patient, being more than happy with the typical 1000+ dollar payment as an out of network emergency provider. If they have no insurance, I do almost all of them. Most people realise they will get a huge bill and are OK with me doing the repair.