CAQ : Trauma

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(No Transcript)
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Making ER Call Better
Professionalism
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Audience Survey

• Show of hands
• Believe that we have an Ortho-ED Coverage crisis?
• Believe that we have a professional and a social
  responsibility to take call?
• Think that all orthopaedic surgeons should
  maintain core credentials?

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ED Call Core Credentials

• Basic trauma patient evaluation and stabilization
• Community fractures hips, ankles..
• Soft tissue infections
• Fasciotomies
• Dislocations
• Wound Care

If one argues they lack these skills . Are they
professionals or amateurs?
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Ortho Emergency Care

• 80 - routine and relatively uncomplicated
• Community care appropriate core competencies
• 20 - complex
• Stabilize and transfer to higher level of care

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Climate Change

• EMTALA interpretations
• ? Reimbursement
• ? Risk
• ? Lifestyle
• ?Self-serving behavior

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Emergency Room Coverage Crisis
Professionalism Crisis
46 million under-insured
25 increased ED use
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Professionalism

• The marks of a profession are
• competence in a specialized body of knowledge and
  skill
• an acknowledgment of specific duties and
  responsibilities toward the individuals it serves
  and toward society
• the right to train, admit, discipline and dismiss
  its members for failure to sustain competence or
  observe the duties and responsibilities.

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AAOS Opinions on Ethics and Professionalism

• "VI. C. Physicians should be encouraged to devote
  some time and work to provide care for
  individuals who have no means of paying.
• "IX. A. The honored ideals of the medical
  profession imply that the responsibility of the
  orthopaedic surgeon extends not only to the
  individual but also to society as a whole.
  Activities that have the purpose of improving the
  health and well-being of the patient and/or the
  community in a cost-effective way deserve the
  interest, support, and participation of the
  orthopaedic surgeon."

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• Each physician has a moral and ethical
  obligation to care for the medically underserved.
  The objective of the medical professional is to
  care for the sick, to treat the ill without
  regard for who they may be, what their diseases
  are or whether they can pay. While reimbursement
  may follow, the pursuit of material gain is not
  the primary end of the medical profession.

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AAOS Opinions on Ethics and Professionalism

• The obligation of individual physicians to help
  care for the medically underserved is based in
  the concept of professionalism, including its
  pursuit of moral ideals such as justice and
  beneficence. By drawing on the physician's mercy,
  compassion and empathy, charity care strengthens
  the bond between physician and patient that have
  often been weakened by increased
  commercialization of medicine. Providing care to
  patients without expectation of payment reaffirms
  the primacy of medicine as a helping profession.

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• 35 yo recreational soccer player
• Tibia fracture
• N/V intact
• 3 AM transfer

Surgeon not comfortable
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US Fracture Care 2004

• ED Fracture Visits 3,495,000
• Office Visits 7,976,000
• Hospitalizations 885,000

AAOS 2006
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Acute Orthopaedic Care

• All patients receive care
• Fractures, dislocations, infections
• Ortho Surgeons providing care are picking up the
  slack from those who dont
• Surgeons avoiding call are shifting work to
  those still on call

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Shifting the Work

• To those still willing to take call
• Brother on brother warfare
• One AAOS members elects to have another pick up
  the load

Professionalism ?
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Dumping Patients

• The transfer of patients to other centers based
  on issues other than medical care
• Koval JBJS 2006
• Risk factors for transfers to a Trauma Center
  included
• non-white, male, uninsured, co-morbidities, time
  of day and day of week

Professionalism?
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Taking Call

• Cant dance around the issue
• Increased demand for Ortho ED Care
• No one really wants to take call
• New grads scheme to avoid
• Sub-specialists de-credential for general
  orthopaedics
• Surgi-Center proliferation is driving insured /
  outpatient only practice development

Professionalism or Amateurism ?
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If , then Approach

• If EMTALA, malpractice, reimbursement and
  lifestyle issues are fixed
• Then orthopaedic surgeons will cover the EDs

Professionalism ?
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Strategies

• High Ground (Professional)
• Patient Centric
• Based for the needs and BEST CARE of the patient,
  the community and public health
• Bad Terrain (Amateur)
• Surgeon Centric
• Based on the needs of the surgeon / specialty
• Fees, reimbursements, risk, life-style

Front page / mother test
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Professions Responsibility

• Provide Acute Musculoskeletal Care
• OR Provide a meaningful solution to the problem
• Cant have it both ways
• Restrict others from providing care
• General surgeons want ortho fracture call
• Podiatrists want LE trauma call
• While we are unable to provide the coverage

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ED Call Sucks!

• But it comes with the profession

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Orthopaedic ER View
Doing fine. Looks like the suns about break
though