Yesterday was the first time in 10 years, that I took ER call for Hoag. As my practice thrived, I dropped off the call schedule, naively believing that younger Plastic Surgeons shared the perception that service to Hoag, our base hospital was a prerequisite to building a practice. Apparently this was an obsolete notion, hence all were programmed into the ER call schedule, except those members, aged 65 years or older. After confirming with the division chief that I would be exempt from Hand surgery consults and should inform patients that they might be disadvantaged by having a higher “share of cost” for my services, as a nonparticipating provider, I am “out of network”, I steeled myself for a weekend day of call.
The first call was from the hospitalist to evaluate dehiscence of a circumferential body lift, which had been performed a mere 10 days ago, for a Massive weight loss patient, in Scottsdale, Arizona. You may well ask why patients travel “out of town” to have such extensive surgeries, however elective surgery patients are extremely well informed and are not constrained by insurance panels. The patient and his wife were articulate, accepting of my explanations and expedited my communication with their operating surgeon. Having lost 250 lbs, he seemed tired but not “toxic” and resolute in divesting the remnants of his obesity. In consultation with his Plastic Surgeon, a plan of wound care was devised. “Doing one’s job” involves evaluating and stabilizing the patient although additional complexity derived from the fact that his case fell within “surgical global period”, i.e. close to the time of operation, where his care is most proximately the responsibility of the operating surgeon. Additionally, as I informed the patient and his spouse, it was “out of the scope” of my usual practice, i.e. I don’t perform body lifts. By disqualifying myself as a leader in that type of procedure and working to secure an opinion from another member of staff whose practice emphasis includes MWL patients, patient care was well served.
The second call came at midnight, from the Hoag Irvine: complex full thickness lacerationavulsion involving the entire right upper eyelid and extending above the brow. Arriving at the bedside, the CHP patrolman gave the history: restrained driver, DUI, airbag vs face, with expected incarceration. The young man was placid. His globe exposed with both the right eyebrow and eyelid margins completely transected. I repaired the “jigsaw puzzle”, trimming ragged edges and restoring form and function, finishing at the “witching hour”, 2 a.m. Under the watchful eye of the ER medical assistant, the requisite sutures and supplies were provided and the patient disposition made. My reward? A grateful somewhat inebriate hug. Will he return for suture removal, as advised? Not sure, when the brief is “treat and street”. Job done. Sort of.
The reality is that we doctors only treat a symptom or diagnosis, without being able to meaningfully impact our patients lives. Rarely are we called upon to reward or treat “healthy” behavior and that is the essential regret of doing the ER job.
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