17 December 2007

A Plea

To whom it may concern:

IF: you are a patient who has a complex ongoing medical problem, for example: cancer for which you are being treated; a major surgery for which you have had a series of awful complications; a recent transplanted organ; or some extremely rare genetic condition,

AND IF: your treatment is being coordinated by doctors at The Big Hospital Downtown

THEN: please, please, please for the love of God, do not come to my ER.

It's not that we don't want to see you. We would love to, but the fact is that we will not be able to care for you properly at our hospital, so don't come here. It's that simple. We are not bad doctors here, nor are we unused to to complex patients. Believe me, we have lots of cancer patients here, and our surgeons have lots of complications of their own, etc, etc, etc. But your doctors are not here. And your records are not here. I may not be able to get your records, and even if I do, it will take me hours and I will probably not get everything I wanted. Your care will be delayed and possibly harmed. And I may have trouble reaching your doctors because I don't know the secret access number to the paging services at The Big Hospital. And even if I am able to get your doctors on the phone, they don't know me, which means they won't trust me. They may assume that I am an idiot (a common prejudice towards community docs by academics), in which case they won't listen to a word I say. They may think that I am trying to "dump" a problem patient back on them, in which case they will resist any recommendation that I transfer you back to their hospital. Worse, they may actively try to "dump" a difficult case on us by refusing to accept you back. (It's funny how doctors' sense of "ownership" of a patient diminishes when the patient shows up at a distant hospital.) Or I may just get a resident who doesn't know you and doesn't give a crap; it's hard to get an academic attending on the phone at 2AM. And what's more, if the doctors at The Big Hospital Downtown refuse to aceept you in transfer, it's also possible that my specialists here will also refuse to take you on as a patient. They aren't supposed to, but it is predictable that they will tell me that you should just "go back Downtown." And then you, and I, are stuck in the middle with nowhere to go.
So don't come here. If you think you are getting worse, get in the car and drive yourself back to the Mecca where you were treated. By the way, that means don't call 911 for convenience of transport. They will ignore your protestations that you want to go Downtown and take you to the closest hospital, because they don't want to be out of service for an hour and half driving to the next county.
This is all assuming that you are not experiencing a true emergency. If you have sudden trouble breathing, or collapse, or have some other true, acute problem, then we are here for you.
Otherwise, don't come to my ER.
Thank you.


  1. Another frustration is that postoperative complications are the responsibility of the initial surgeon, and no insurer is going to pay another surgeon for treating a surgical complication during the 90 days following an operation.

    I can understand a patient's frustration with postop complications and their occasional desire to have another surgeon take over the case. But if they come to the ER expecting that we can make that happen for them, they are going to be very disappointed on their way home.

  2. replace your name with my own and both of us could claim equally, 100%, the same position.

    Taking care of very complicated multiple medical problems in the hospital is less costly, less repetitive and more likely to be efficient if you go to "your" hospital every time.

    That's where your records are.

  3. This is great advice. We have been focusing a great deal on how to keep non-urgent cases out of the ER, and patient education figures prominently in this strategy. But your advice to seriously ill patients will likely improve the quality of care they receive and not unnecessarily tax your ER. Another argument for interoperable EHRs STAT!

  4. I have a question for anyone in the know. Hypothetical at this point...thank God.

    Last winter I was supposed to have had re-constructive surgery on my ureter. My urologist wanted me in a teaching hospital with docs on staff 24/7 with a urology wing. He was initially suggesting Cornell docs in NYC but I wanted to stay in NJ and so decided to go to a hospital in the next county, met with the consulting surgeon etc. In the end...I did not need the surgery.

    However, if I did have it and had complications like sepsis or something after home, I would have wanted to go to my community hospital where my regular urodoc was. Now I know my reg urodoc said something about being under the care of a new surgeon for 90 days but I also understood that if I had to be taken care of in an emergency that he would do it up here in the community hospital but then if serious I would then have to go down to next county.

    Would that have been alright since I do have records in the community hospital and he is my uro doc up here or if surgery was involved does the patient ALWAYS have to go directly back to that surgeon as far as ins companies are concerned? And the local ED doc? Well...I am thinking local ED doc would just call the local urodoc.

  5. This was a good post - very informative.

  6. AMEN. AMEN. AMEN. This would seem like common sense but this plays out daily in our ER. The BIG hospital is not far. The County hospital is not far. The HMO hospital is not far. The other community hospital is not far yet people continually show up at the wrong place either ignorantly or purposefully. EMS seems to have no further common sense regarding the issues as well.

    To Seaspray hypothetical: I would say if it is a complication of the latest procedure with the latest uro go to his place if possible, unless you are truly dying.

  7. Another thing. I work where there are many different HMO health plans. On the patients health care card it tells them what hospital to go to. Did they come to right one? NO! ARRRGH.

  8. Thanks Gerry. fortunately my body has been healing and was able to avoid all of that. i wanted to go to the local if it involved uncomplicated procedures because it is just easier although I know all follow-up would have been with the operating surgeon. Although...i was hoping to have all appointments that were routine follow-ups like urine tests, etc done at urodocs up here (15 minute drive vs an hour or so) and I think they were willing to do that but maybe with insurance not allowed.

    The thing is...the operating urodoc doesn't take any insurances. All office visits have to be paid up front when you go in and then they will bill the visit for you. They do bill the insurance company for the surgery though and wait for the reimbursement.

    I wanted to go to him because of his reputation. That being said...even though I liked him and had an instant rapport with him...I preferred to have my reg urodoc do as much as possible up here and I preferred the community hospital.

    Also, with me not working it would have been difficult to have to pay the doctor up front for every office visit and from my experience there is a lot of urologic follow-up that quickly brings a pt to frequent flier status. :)

  9. If you've really got sepsis, then dont waste time, go to the closest ER quickly. Thats an emergency life threatening situation and you cant afford to jack around by going to distant hospitals.

  10. Thank you anonymous.

    I did have sepsis once and was refusing to go to th ED. I Had been working in ED registration that New Years Eve with what I thought was a UTI. Saw the ED doc, got meds for a UTI and even though I got the most God awful chills 3 times over the next 20 hours along with feeling REALLY sick...I kept saying the medicine just has to work. 104 or so fever and 3rd time I had chills I actually did feel like I might die before I got to the ED. I will never make that mistake again.
    And these chills were a lot more intense then anything I ever had with a flu. The dx was sepsis, pyelonephritis and hydronephrosis from a totally constricted ureter and all from scarring from a kidney stone. I drink a lot of water these days. :)

    Thanks again. :)

  11. I just wanted to give you a sort of insight to EMS. Unfortunately we are forced to take patients to the closest ER because of EMTALA and Health Department rules here in Texas. It sucks because I would gladly bypass our hospital here to go 40 miles to the trauma facilities or stroke centers if needed. But rules are rules, though i tend to bend them because I feel they need to be changed and want them changed and am working to get them changed. I am not bad mouthing you by any means, just wanted to give you insight to EMS, if you didn't know how they have to operate in certain situations. Also, I am not the medical director for the service i am still at but we are allowed to do pericardiocentesis in the field. Your views? I dont think that it is a good idea. Now the medics have to go through 6 extra months of training and of course being an R2 i fell ok about doing them but not in the back of a box. What do you think?

  12. resident medic:

    True, in many jurisdictions the medics have no flexibility. In our area, there are a number of hospitals and in "appropriate cases" a medic may take a patient to the hospital of their choice. But when the patient's choice is across county lines and the complaint is non-urgent, there are good operational reasons for saying 'no' and simply taking the patient to the closest facility to let us sort it out. I don't view that as an EMS dump or anything. It's our job to sort it out. But I did want patients to understand that EMS is not a taxi service -- I suspect we both agree on that!

  13. EMTALA does not apply to ambulances unless they are hospital owned or on hospital property.

  14. We diverdge but in PA you go to the closest hospital, execpt in cases of trauma or special care (burns, peds). EMTALA says that once we present with the patient with in X feet then the hospital must accept the patient. Also, recently it is an EMTALA violation to hold an EMS unit with patient in waiting for a bed for an extended length of time.

  15. By the same token, if you stub your toe, sprain your ankle, or do something else with an extremely low acuity, that has NOTHING to do with your medical condition, do not request to bypass the community hospital that is 0.6miles away, in order to drive 20miles through urban rushhour traffic to get to Man's Best Hospital.

  16. Ok. So I am one of those patients with ongoing/chronic issues. I have Ehlers-Danlos syndrome (As well as chronic migraines). Most doctors have no idea what that is (I live in Canada BTW), and I have done a lot of studying, and am quite well versed. I also have a medic alert bracelet with a *very* brief description of what the condition is, as well as instructions to see my wallet for further medically-relevant information.

    Would I be put on your sh*t list if I arrived in your ED with a severely dislocated joint, considering I would most likely refuse any form of pain-killer?

    There have been studies done in Europe on EDS and they've shown that we don't respond well to pain killers, or local anaesthetics. I've personally found that demerol, and morphine do nothing but make me nauseous, and I go without freezing if I'm at the dentist.

    Oh, and to top it all off, "my" regulardoctors include: a family doctor who is not accepting any new patients, I see him on a walk-in basis, a geneticist (it takes approx 2 years to get an appintment with him), a shoulder surgeon who has told me she can't help me, a knee and hip surgeon who has told me the same, and a rheumatologist whom I have seen once.

    Who should I call on if I have any issues with my chronic genetic disorder? Is a dislocation considered an emergency?


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