Sunday, April 15, 2007

E.R. Call

Panda Bear MD poses the following ED scenario for an on-call orthopedic specialist:

“Good morning, Dr. Smith. Sorry to wake you up but this is Dr. Bear at the County Hospital Emergency Department. I’ve got a 25-year-old gentleman, snowmobile versus barn, with an open mid-shaft fracture of the left femur but otherwise without significant injuries. We have him in a traction splint and his distal pulses and sensation are intact. On the way through the barn he dragged the end of his broken femur through approximately fifteen feet of cow manure and I’m afraid it was about thirty minutes before his drunken friends decided that he probably wasn’t going to walk it off.”

“How’s he doing now? Fine. He’s fully alert and oriented and threatening to sue everybody in the place. Can you come in and see him?”

Would you come in? It is easy to come up with a similar scenario for psychiatry. Yet, it has been a long time since psychiatrists gave up on ERs. I don't have figures, but I'd wager that it is not easy to find an ED where a psychiatrist evaluates the guy with the overdose or the woman with new-onset paranoid auditory hallucinations. More often, they have social workers evaluating these patients. The problem is, many of these patients are better served with a physician with psychiatric expertise, as a good percentage of these folks have medical problems which are dressed up as "psychiatric problems"... things like steroid psychosis, metabolic encephalopathy, and drug-induced syndromes.

Hospitals are increasingly paying specialists to be on call, recognizing the increased risks of treating ED patients, many of whom lack insurance and regular medical care. That includes psychiatrists. The hospitals are now able to see the savings in terms of improved patient flow, higher quality care, reduced liability, and lower length of stay, when using ED psychiatrists. The trouble is finding docs who are willing to take on this lifestyle. Psychiatric hospitalists are starting to crop up more, as they tend to work shifts (eg, 8a-8p), have staggered work days (eg, 5 days on, 4 days off), and get benefits. These are primarily consultation-liaison psychiatrists (like me). Any of you CL docs out there, let us know about any ER call you do.


Rach said...

Roy, please clarify for me - what is "on-call"? In my business, on-call means that I'm available by pager and phone, but don't need to be on site. I do need to be in a situation that I can come into work if needbe. Is that what you're referring to?

Roy said...

Yes, on-call in this instance would mean that if a consult is requested by the ER doc, you'd have to go in and do the evaluation.

Anonymous said...

I've been interested in your topics about emergencies, and it is particularly timely since my therapist cancelled my appointment this week because he had to go out of town for an "emergency". He's a social worker, what the heck kind of emergency could he have? I'm going to ask him when he gets back, it should be interesting.

Rach said...

anon, it could be a family matter, or a personal thing... therapists have lives too.

Anonymous said...

Oops, of course you are right. I forgot to mention that he said he had to go out of town for business and it was an emergency.

Dinah said...

I haven't done night call in an ER since I was a resident, and then I stayed in the hospital, they didn't call me in.

Okay, but years ago, I did cover the ER during the day, but as backup rubber stamp to a social worker. So here's my favorite story: social worker calls me, patient was brought in by police for walking naked on highway. It's okay, though, patient has an outpatient evaluation already scheduled at a clinic for tomorrow, social worker signing him out, wants my rubber stamp. I'm left to point out that said naked patient walking in the middle of the highway might not live to make it to appointment tomorrow, and wouldn't it be better if he spent a little time inpatient where he could be dressed and out of traffic? No rubber stamp.

My second favorite is not my story but Camel's: Managed care company asked if gun patient was pointing at his head was loaded. Apparently they don't allow inpatient admission if you point an unloaded gun at your head and say you're gonna kill yourself.

Oh, to sleep through the night without any calls from Dr. Bear...

NeoNurseChic said...

I remember one shift where I was in the ER for my critical care rotation (there for 5 weeks - last rotation in school), we had a really busy night with at least 4 psych emergencies. My psychiatrist was the resident on call. That was kinda weird, to tell the truth, but I sort of liked watching from behind the scenes. We didn't have to work together at all as none of the psych patients were mine, and I don't think he knew I was also in the ER. I told him later that I had been there working.

Don't know if that would have been weird for him, too. I'm just you're average Jane of a person really - nothing to worry about what I might say or do - I've never been inappropriate in a public place, and I probably would have said hi and moved on....not sure if any of those patients had been mine if I would have given them up, because that would mean having to explain to the RN that I can't have that patient because my psychiatrist is working with them...and that would be more personal than I'd want to go!

So at our hospital at any rate, the resident on-call does the ER evals...not just in psychiatry, but in all areas. The fellow is next in line - and lastly would the attending be called in. We also utilize hospitalists - there are 2 that work in neonatology. But we're a big academic med ctr where we have the ability to do that! :)

Take care,
Carrie :)