I suppose I have been guilty of all the mortal sins at one time or another (lust having been a particular favorite) but an early lesson for me in treating patients at the Mecca was “practice humility at all times, or expect to get your ass handed to you… often.” So I have remained diligently humble and open minded so that if nothing else I do not allow Pride to affect my judgement as it is not only the root of all mortal sin but also the root of all medical mistakes. In a case a few months ago, however, my old nemesis Pride came calling once more and this time for some inexplicable reason I embraced it… although I am not exactly sure why I did, nor why it is still on my mind.
First, some background about the ER in general. The ER is the fishbowl of the hospital; every physician in every specialty feels it is their God given right to not only dump patients onto the already overburdened ER but to also mandate how each patient is treated in regard to their specialty. The latter nearly always in hindsight and usually without scientific evident to back it up. The ER staff must constantly answer to other departments about “why we gave antibiotic x instead of y” or “why we called general surgery instead of internal medicine for a diabetic foot”, et cetera, yet many times when we call in the middle of the night for an opinion or because a patient requests a specialist the answer is “do what you can for them and send them to me next week”. (See the Dookie chute post)
Not too long ago the Mecca was having major problems retaining surgical subspecialists. Orthopaedics, Plastic Surgery, and Neurosurgery were all in extremely short supply. The plan was to treat patients as usual only consulting the above specialists (after hours) if surgery is needed. Well it wasn’t long before old Trenchy met up with a patient who insisted upon having a plastic surgeon consulted for a minor problem.
It was a Saturday morning shift in July and the triage nurse brought a chart to me specifically saying, “you don’t want the intern to see this (remember they start on July 1)… this lady has a scratch on her face and they want a plastic surgeon.”
So I put down my coffee, put on my clean white coat and went in with my super-caring-see-I-am-actually-bright-and-speak-English-ER-doctor routine. Greeting the nicely dressed middle class couple I realized within about 30 seconds that the 1.5cm laceration on the lady’s cheek would probably heal best with a simple dab of neosporin and it was also about that time that my evaluation was interrupted with, “thanks and all but we really just want you to call a plastic surgeon.”
Trenchy: “I understand yall are worried about the cosmetic outcome… we COULD place an adhesive glue over the wound but stitches are really not necessary and could make the wound worse in the long run.”
Husband: “well great, just call a plastic surgeon to come tell us that and we’ll be on our way.”
Trenchy: “It is not just that simple to get a plastic surgeon involved… we have a shortage of specialists right now and they are only consulting for problems that require surgery.”
Wife: “HONEY… I don’t want some JOKER IN THE ER WORKING ON MY FACE!” (I don’t know how to write in staccato)
Husband: “don’t worry, he won’t be… (to me) listen, we are not here to argue with the ER doctor, just call whoever is on call.”
Trenchy: “listen, I am trying to help you… if I call the plastic surgeon on call you will get someone with alot less experience than me.”
Husband: “is he a surgeon?”
Trenchy: “yes, a surgery resident.”
Husband: “then call him.”
So I paged the plastic surgery attending hoping beyond hope that he would come down and speak to my irksome patient. It happened that the attending and resident were both in surgery together and I talked with him by speakerphone…
“It sounds like a load of bullshit Trenchy… you know we are shorthanded and your Department Chief said yall would handle this kind of crap for us… I have 3 cases today from all the shit you consulted us for overnight…”
“I know sir, but they are insisting on a plastic surgeon, won’t let me touch them…”
“and you say it’s 1.5cm and doesn’t need approximating?….. God dammit, I’ll send the resident down… but I WILL be calling your Chief about this on Monday.”
Beautiful. Get in line.
So about a hour (and a dozen dirty looks from the happy couple) later the unsuspecting surgical intern be-bops down to the ER, glances over the chart and walks into the hornet’s nest… emerging back out of the room like a scolded pup within minutes.
Intern: “they told me they want a plastic surgeon.”
Trench: haha “well you ARE the one on for plastics, dog.”
Intern: “yeah, but they asked how long I have been a doctor and then the wife told me to ‘get the hell out’ .”
So I took a deep breath a went back into the room.
Trenchy: “listen… I spoke with the plastic surgeon, he is NOT coming down here for this. I really wish you would let me help you. It would take two minutes.”
The wife gave me a “pssk” scowl as I spoke and I soon agreed to try to call other plastic surgeons that were not on-call to see if someone would see her in the ER. None of the calls being returned, I faced them once again.
“No plastic surgeons are calling me back… I am sorry that your expectations have not been met but honestly they were incredibly unrealistic for what we have to offer. I really don’t know what else I can do for you.”
At that point the husband asked for a phone book and they spent the next hour calling plastic surgery offices to no avail. In the meantime, the ER had really begun to get busy with particularly ill patients for a Saturday and I had basically expected to see them simply walk out as so many others do when our services are far below what is expected. Alas, I would not be so lucky… the husband motioned me back into the room.
“Listen, could you tell us a little more about the surgical adhesive that you would like to do?”
I was stunned. They had been in the ER for 3 hours. I had been amiable all morning despite their ridiculous expectations and patronizing attitude. I suffered humiliation (and probably rightly so) from a colleague to bow to their demands, and now this? My Pride could take no more. That ghastliest of sins not only had me in it’s grip, it began to control my speech.
“I’d say if you can find a plastic surgeon, you may want to ask them about that but honestly… simple cleaning and treatment with neosporin while it heals and you probably won’t have a visible scar in six months or so.”
“So you aren’t going to glue it for us?”
“No sir, I performed a medical screening exam as is required by law and called plastic surgery like you asked… I am no longer involved in your care, but the nurse can clean it up and put some neosporin on it if you would like.”
To the staffs great relief, they immediately storm out of the ER.
I still live by my mantra, but these days I keep Pride in my pocket, for just such an Emergency.