American ER Doc Gone Walkabout Episode 016
Retrievals: we don’t use the term in the US – moving a patient from one hospital to another, even in the rare instance that a Doctor is in attendance, is a transfer.
I had a golden retriever who loved to go to the lake and fetch a stick that I threw out into the water. She’d retrieve the stick, and come to shore wet and shaggy, and shake water all over me. While I was in Taz, every time I heard the term retrieval, I got that image in my head. Some retrieval doctor, all wet and soggy, bringing me a comparably bedraggled patient and then shaking water. Sometimes when you have to learn a new usage for an old term, it’s hard to rid yourself of old images. Just sayin’.
In the US it’s a transfer: here I sit in a little 8 bed rural ER. I’ve got an active upper GI bleeder, limited blood supply, and pseudo-stable vital signs. The nearest gastroenterologist is nearly 200 km away, but no beds. I’ve got 8 potential hospitals nearly 400 km away, no GI on-call or no beds. 550 km away, 3 more calls. Nothing. Albuquerque, different state, same distance. Maybe. Try the first hospital again, 13th call, somebody died or something, we have a bed! Patient reasonably stable. Couple more calls to talk to the GI consultant, then the hospitalist who will actually be the admitting doctor. Now, calls to my little hospital’s transportation manager. The sending hospital will pick up the costs of the transfer, so everything goes through contracting channels (Can we save some money with a BLS ground transfer? How about ground ALS – probably 4 hour round trip? I think not.) Weather check: no snowstorms, no dust storms in the desert, we’re good to go. Finally, helicopter arrival, flight nurse handover, and away he goes.
In Launceston, I have a 60 year old guy, known 6 cm AAA but high surgical risk so not repaired (not sure why endovascular hadn’t been considered). Now, severe abdominal and back pain, vomiting. Observations pretty good – tachycardia, but blood pressure OK. Retrieval to Hobart to try a now even higher risk surgery? Or comfort care in Lonnie. Since immediate trip to theatre isn’t an option, a CT to confirm working diagnosis shows that the working diagnosis is wrong – the guy actually has pancreatitis from a CBD stone with an inflammed pancreas sitting right on top of the AAA. Pretty cool images. We’re already providing comfort care, so delete the “only” part of comfort care, add an ERCP and CBD stone retrieval (I think comfort is good, even if you don’t die). Skip the retrieval.
Lonnie again: Thoracic aortic dissection, retrieval heading to Melbourne. Only a little bit of esmolol in the ER. Search the whole hospital – a bit from theatre, a bit from ICU. I think we’ve got enough esmolol for the retrieval reg to make it to the airport at Melbourne (Launceston’s best known suburb). Smooth retrieval – only a couple phone calls.
Lonnie again: Small subdural, mental status pretty good, no other significant injuries. Download PACS images into my gmail account and email them to neurosurg reg in Hobart (can’t do that in the US, 20 years in jail for violating privacy rules – no penalty for violating rules of common sense). Advice from neurosurgeon: Ought to be able to watch that and rescan in 6-8 hours. Save the trip (plus, tight on beds in Hobart, too). Nobody goes crazy! Nobody yells and screams about legal liability! This can’t be America! (Plus, I know that in the US, at University Hospital, we’d get the same advice: keep him in the ER, we don’t have inpatient beds, scan again in 6 hours, if he’s stable we can let him head home.) No retrieval tonight.
Back in the States: Indian Health Service: shovel fight (I’m not sure why, but shovels seem to be the weapon of choice on the Rez – rare to see a gunshot wound or knife stabbing, but people whack each other with shovels). GCS 14, looks pretty good, localized traumatic SAH – maybe a few pixels thick. And an orbital blowout fracture, with some entrapped fat and no discernible globe injury. If he was at University Hospital – 6 hour obs, repeat CT, home to follow up with one of the facial surgery or ophthalmology services (if they’d see him with no insurance – not an issue on the Rez – almost as civilized as Oz). If I was working the overnight shift on the Rez, I’d just keep him in the ER and do the same, but I’m going off service. The trauma surgeon wants nothing to do with trauma above the clavicles. The nearest trauma center has a neurosurgeon and will be glad to take the head injury, but has no ENT on call for the weekend and therefore (despite my assurances that the blowout fracture can wait a few days) won’t take the face. I did a quick review of anatomy and learned that the face and brain are permanently attached, so on to more phone calls and eventually a 350 km air transfer, at a charge of $15,000 for no immediate treatment. Something seems wrong here, people.
OK, so enough of the stories.So, are there some differences (remember this is just one Doc’s experience, with limited reference to the broader picture) between Oz and the country to the Northeast?
Perhaps the most noticeable: Doctors on the retrievals. In the states, the retrieval is invariably a nurse and/or paramedic. Generally works fine, but occasionally, especially on longer transfers with complex patients (aortic dissections crossing the bass strait) having that extra physician expertise is reassuring. Not sure what the NNT for one improved outcome would be – might be an interesting study.
Willingness to consult at a distance and not transfer. Aided by sensible privacy rules that allow us to share clinical information and images even if it’s not a perfectly secure connection (Good Lord, someone might look at that head CT and use it for a nefarious purpose!). And, lack of legalities. It was common in Lonnie to get a call from a GP in some town or some little island that I had never before know existed, with a question about how best to manage without transferring (sometimes that decision tree was aided by washed out roads or weather that promised to keep flights shut down for days). My experience in the US is that even trivial matters that are in “someone else’s specialty” get transferred: the minor traumatic SAH noted above. Or, the alcoholic in moderate withdrawal who has vomited a few times with specks of coffee grounds – thus turning him into ” a dread upper GI bleed.” Internal medicine can’t handle him here, gotta send him where there’s a gastroenterologist, where the patient is treated for withdrawal, a PPI is added, and eventually scoped if there is insurance payment for it. Quite a bit of cost for no identifiable clinical benefit. I’d like to think that the lawyers are the bad guys, but come on doctors, stand up and say we can do this at a minimal risk. I admit, it’s an understandable attitude: extra work for me, at some risk of having to defend my actions in the unlikely event that this turns into a major GI bleed that requires unavailable GI expertise. (Then again, the hospitalist who turns down the admission and insists on transfer of the incidental GI bleed, is not the person saddled with the 13 phone calls to arrange the transfer.)
Multiple phone calls. Some of this is just availability. At Lonnie, there were only one or two options, so rarely did I have to make calls. And, I understand that in many places on the mainland there are centralized options for arranging an accepting doctor and hospital as well as the retrieval itself. I am impressed that, in my setting in the States, the multiplicity of options generates a lower impetus to go an extra step: If there was only one available trauma center, the neurosurgeon might have accepted the head injury even without immediate ENT backup. But, there’s another trauma center down the road (or flight path) -try them. Or, we’re a little tight on beds, why don’t you try hospital X or Y or Z, I’m sure that they will be able to help. Things have improved in recent years in that most receiving hospitals have a call center or access center to minimize the number of calls to that specific hospital but lack of a clearinghouse to direct you to hospitals with available specialists and available beds can generate a lot of calls for the doctor at the sending hospital. In many cases, there is a complete disconnect between the specialist hospital and the retrieval service itself, thus necessitating another set of calls after the doctor has identified the receiving hospital. That process was similar in Tassie, but had only the medical layer, not the payment arrangement layer superimposed on the medical layer. Some places in the US get even a bit more complicated in that there are multiple overlapping (read that competing) air ambulance operations.
There was one funny incident of where the lack of payment issues generated interesting behavior. I got a teenaged girl with streptococcal pharyngitis and scarlet fever – moderately ill, transferred by fixed wing from a small outlying hospital. Turned out that the GP wasn’t terribly worried, but since there was a retrieval flight on the ground at his local airport for some other reason, just loaded the girl on and sent her back in to Launceston. A little fluids, a little steroids, and by the time the girl’s parents arrived by land a few hours later, she was ready to go home. Some might argue: terrible waste of resources. I would argue that an occasional retrieval that is non-therapeutic when retrospectively reviewed, is a small price to pay for a system that allows efficient arrangement of the retrievals that are important.
One other circumscribed instance in the US. We are now seeing more defined referral pathways for specific clinical scenarios. At the Indian Health Service hospital, we now have pre-specified trauma protocols for transfer to one of two trauma center options – as long as they aren’t grossly overloaded, or involving a subspecialty not available. And, an arrangement for STEMI patients that involves a single call with minimal nitpicking on the phone, a pre-specified pre-transfer treatment algorithim, and guaranteed acceptance unless truly unusual circumstances. We still have a second set of calls for the flight service. (We’ve also had to make a third set of calls for someone to take care of the horse that the STEMI victim rode to the ER. But, that’s a different issue.)
I hope that you Aussies have a little sympathy for me. I realize that my transfers ranging from 200 to 500 km are trivial compared to retrievals from places like Alice Springs and Broome. (Tassie and even transfers up to Melbourne were relatively compact compared to the big island.) And, such distances place a premium on retrieval doctors on the flights. And, such distances place a whole new light on the ability and willingness to handle, without transfer, moderately severe problems outside of your own specialty field. (I would argue that the Australian training system involving far more exposure to and experience with a broad range of medicine and surgery, prior to beginning specialty training, when compared with our American system that focuses on a specialty much earlier, is invaluable in dealing with such circumstances.) I recall that Australia is 3/4 the land mass of the US, with 1/13th of the population. And that the weather and traffic reports for all the major cities of the entire nation could be given on ABC in about 2 minutes (Cold and wet in Hobart, fine in the other 6 capital cities.)
I can imagine that when a 2000 km retrieval is involved, I would be delighted to see that retrieval registrar – even if, like my dog, he’s wet, bedraggled, and shakes water all over me.
Next time: And now for the news…
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