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ER Goddess

ER Goddess

A Broken Arm and a Frighteningly Broken System

Simons, Sandra Scott MD

Emergency Medicine News: May 2022 - Volume 44 - Issue 5 - p 4
doi: 10.1097/01.EEM.0000831212.37107.f9
    FU1-6
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    contract management groups, corporate medicine, private equity, staffing
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    What kind of care will our children receive when they roll into an ED without us, especially in today's culture of corporate medicine where EDs are staffed to maximize shareholder profit rather than patient treatment? I found out after my 17-year-old son crashed while snowboarding.

    Cole presented with a displaced humerus fracture to an ED near the ski resort he was visiting with his father. I was asleep with my phone on silent, so unfortunately, I was oblivious until I saw the missed texts from Cole and my ex-husband the next morning.

    “It felt barbaric,” was how my ex-husband described my son's fracture treatment. He texted me the x-ray, pictured here, and explained, “They splinted it as is, wrote a prescription for pain meds, and told him to follow-up with ortho today. The tech who splinted him seemed uncomfortable doing it; we heard him say he was afraid of causing internal bleeding.

    “I had to stop the tech to ask why Cole wasn't getting more meds for splinting. Even the nurse agreed he hadn't gotten enough for pain. I kept asking why they weren't trying to line up his bone better, and they said their on-call orthopedic surgeon said it wouldn't stay anyway, so he needed to call his own orthopedic surgeon today. And the doc never set foot in our room. We only ever saw the PA.”

    Orthopedists vary in their recommendations for displaced humerus fractures. The orthopedist on call that night said not to reduce it because it was an operative fracture and unlikely to maintain reduction. I subsequently have heard from multiple orthopedists who have said it should have been reduced. We can't say Cole received inappropriate treatment because no expert consensus exists about the appropriateness of splinting his fracture without attempting to align the bone better.

    But medically appropriate treatment is clearly not the same as good care. Cole and his father were decidedly uncomfortable with the encounter. Some people will never be happy, but my son and ex-husband are reasonable people who had appropriate concerns. No one with the level of expertise they were seeking addressed those concerns or involved them in decision-making. Many of the risks in this case were related to the fracture's proximity to the radial nerve, but Cole and my ex-husband heard nothing about any nerve near the fracture.

    Betrayed by EM

    “I never want to go back there,” Cole said. It broke my heart that my child, who has spent birthdays and Christmases with his mom in the ED to doctor others, didn't feel that he was important enough to see the doctor when he found himself in an ED with a potentially limb-threatening injury. I feel betrayed by the specialty to which I have devoted my life knowing that rather than making my teenage son and his father feel comfortable, an ED basically said, “Here's a splint. Good luck.”

    The next day I managed to speak to the attending who had been in the ED when Cole was there. He confirmed that he never saw my son, although he reviewed the x-ray and advised the PA to consult ortho. The reason, he said, was a neonatal resuscitation. As a single-coverage night doc, I get it. The orthopedist made his recommendations to the PA over the phone, also without seeing my son. After years of dealing with orthopedists who refuse to come in at night unless there's an open fracture or neurovascular injury, I get that too.

    My son and his dad knew, however, that he was never seen by a physician. The PA never involved her attending beyond showing him the initial x-ray despite my ex-husband expressing concern. The reason the attending offered was that this particular PA had a history of being too autonomous.

    Listening to this ED attending, who was sincerely apologetic, I realized that I could have been the one working a neonatal code and unable to see other emergent patients. I've been in his shoes many nights. It's frustrating to feel like we can do our best to save the life of a newborn, but it's still not enough.

    Losing Faith

    The culture of emergency medicine increasingly embraces PAs as sufficient replacements for EPs. It is failing doctors and patients alike. The pendulum is swinging to an unreasonable point where PAs and NPs are considered interchangeable with MDs and DOs. The other day I signed a consent form that said “proceduralist” where the physician signs.

    Terms like proceduralist and provider warn of an upcoming departure by physicians seeing every critical patient. ED patients with acute complaints should have an opportunity to see a doctor. Unfortunately, the way EDs are staffed—frequently with just one EP supervising multiple PAs and NPs—it's now standard for EPs not to see patients unless the nonphysician providers request it. My son's PA thought she didn't need to involve her attending, and like many PAs in many EDs, the autonomy to make that choice was hers.

    Nothing is more reassuring to a nervous patient than a physician saying, ‘If you were my child or parent, this is exactly what I'd want done for you.” EPs genuinely want to tell all patients that they are getting the how-I'd-want-my-family-treated gold standard of care. The reality is that we're overextended in a system that is about moving people through with the least amount of resources, and too often we can't give patients the care we would want for our own families.

    It's hard as a physician to feel that we're disappointing patients; it's exponentially harder as a parent when the disappointed patient is your child. Hearing about my son's experience at the hands of today's profit-over-patient medical culture gutted me.

    Just five days after Cole broke his arm, my dad went to the ED at 2 a.m. with shortness of breath. Fortunately, this time I had left my phone ringer on because I knew he wasn't feeling well. When my mom called to say EMS was at their house, my trust in our health care system was still so shaken by Cole's ED visit that I jumped out of bed and raced to the ED to hover at my dad's bedside.

    He got great care, but it's unsettling that I could not feel confident that he would. When my loved ones go to the ED, I know they're at the mercy of today's staffing paradigm that spreads emergency physicians too thin. I've lost faith in our medical system. Cole's care crystallized for me that health care, even more than his humerus, is frighteningly broken.

    Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter@ERGoddessMD, and read her past columns athttp://bit.ly/EMN-ERGoddess.

    Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
    • jdbashore2:10:54 PMYour concerns are absolutely valid, Dr. Simons. As a parent, my heart too aches at this story of an entirely regrettable circumstance and very poor care. But this is not typical for emergency medicine PAs. I think you probably know that, though, and undoubtedly work with some excellent EM PAs. The attending EP in question also regrettably failed in his responsibility--as the attending physician--to know what was going on in his ED. This is comparable with the captain of a ship being responsible for everything that occurs during his command. Throwing the PA under the bus (or over the side since we're already using naval analogies) with the craven excuse of the PA in question being too autonomous is weak sauce. And the entirely valid and alarming systemic deficiencies you describe aside, your issue was with that particular PA, not the entire profession. We (PAs) didn't spring up spontaneously out of the ground hellbent on being usurpers to the crown of medicine. Nor are we dangerous know-nothings and medical dilettantes. Far from it. Physicians invented us a half-century ago. And the physician-PA team concept is a sound and well-established one and almost always works incredibly well, delivering excellent care. I'm sorry your son and his father ran into a situation where that was broken and both the PA and the EP abdicated their responsibilities. I'm sorry your son suffered and that you suffered the anguish of knowing how much better it could have been.
    • rscottrankin1:55:57 PMA question I have always wanted to ask administrators: "Is your quarterly bonus based upon financial metrics or patient care metrics?"
    • booth1980612:47:08 PMHealth care is indeed broken, but your anger is misguided at the PA in this case. From what you describe, the PA did nothing wrong; he&#160;evaluated, diagnosed, consulted the appropriate specialist and treated accordingly. Why did you mention the radial nerve proximity to the fracture issue? Did the PA not do a neuro exam? It's as though it was intended for the reader to think that the PA could not have known about the anatomy of the upper extremity. If your ex-husband was so concerned, he could have demanded (and waited for) the EP to come see them. Do you think the outcome would have been any different? This article comes across as very elitist and condescending. Physicians seem to get giddy when they have a chance (warranted or not) to bash on PAs. Lot of complaining here, but I don't see that any negative outcome actually occurred. Except that the EP grabbed the opportunity to throw his PA under the bus. Typical behavior of EPs, though.<br>
    • chechtmd11:35:35 AMAnd who led us to this dystopia? Those contract holding &quot;leaders&quot;&#160;who went before us. They got burned out so they sold out,&#160;and physicians and patients are suffering the result of their greed. Until all&#160;physicians can speak with one voice against the corporatization of medicine, nothing will change. Until all&#160;medical students can stand up against onerous tuition, nothing will change. Until all&#160;doctors are free to actually call out dangerous patient behavior, nothing will change. The art of medicine has become symptom-pill&#160;and rule/score-based decision making. And thanks to the recent pandemic, questioning dogma puts you at risk of losing your board certification and being labeled a conspiracy theorist...and we stand for it.
    • saunders_md053299:55:33 AMAs an emergency physician for 39 years and recently retired, I am disgusted with the present medical system. I have been an advocate for several octogenarians and have seen firsthand the failing of this system. You have aides instead of RNs doing the intial interface, and they&#160;have little clinical experience.&#160;And NPs or PAs are not adequately supervised. When I challenge/advocate for my people, I have had people get flustered and then get the attending. On several occasions, the attending was a person who&#160;I had trained, and suddenly all the blustering bravado evaporates. This profit over good patient care, instruction, and&#160;compassion is&#160;horrible. I am glad that I am now retired. I was one of the first FACEP female physicians, and I always treated my patients like a beloved family member. I truly feel&#160;betrayed by the present system.
    • pbonucci9:49:24 AMThe phrase “profit-over-patient medical culture” is very insightful. Where else in the world is the injury or illness of our fellow citizens seen as a profit opportunity?
    • wdurkinmdmba6:42:49 PMSadly, one needs an advocate each time he&#160;becomes a patient in a hospital. I've had similar experiences, especially in the four&#160;months preceding my mom's passing. Some just need to know that you are watching them, some need to be pushed a little, others care and strive to do their best despite it all. Absent an advocate, the system will just do what is expedient and move on. It never used to be that way!
    • deanhillel3:15:44 PMI did ortho before seguing into EM. Patent nonsense all the way around. How long does a neonatal resuscitation last? You triage constantly. That includes all patients remaining in the ED after dealing with whatever emergency required one's undivided attention. Ortho doesn't want to come in? Tough.&#160;They're on call and getting paid. This wasn't a broken toe or stable ankle fracture. &quot;I'm uncomfortable treating this&quot; are all the words that should need to be said. In fairness, that fracture really is difficult if not impossible to stabilize with a splint. There's just nowhere to go proximally, just like for a mid-femur fracture.
    • ergoddess4:14:14 PMThank you. Sadly, we are replaceable cogs in the big medical industry machine. Frustrating for sure.
    • ergoddess12:34:59 PMThank you. It’s not fair to APPs either to put them in situations beyond their training. The current system is frustrating to docs, APPs, and patients alike.
    • ghotai10:15:15 PMAs an emergency physician for 36 years, I have to completely agree. While emergency medicine residencies have produced a plethora of physicians to fill the workforce gap, the gap has been filled by hospital administrators, contract management&#160;groups (CMGs), and other third parties as a cheap replacement for residency-trained, board-certified emergency physicians. These providers,&#160;now called advanced practice&#160;providers&#160;(APPs),&#160;include physician assistants (PAs) and nurse practitioners (NPs) who have a modicum of education and training compared with&#160;those they are replacing. The vast majority of the time, APPs do an OK&#160;job. The APPs who truly understand their limits and seek the help and advice of their onsite supervising physician&#160;do an even better job. The too-autonomous&#160;APP is as dangerous as the too-autonomous&#160;medical student, who, incidentally has more training than the APP. But none of the APPs approaches the level of care available from a residency-trained, board-certified emergency physician. Unfortunately,&#160;APPs are now pervasive throughout medicine. Why? Because they are cheaper, and are viewed as a profit center&#160;by management, which doesn't look at excellent patient care as the goal&#160;but rather profit.
    • scordovano9:34:12 AMDr Simons, I completely agree. EPs have been and will continue to be undervalued, underappreciated, underpaid, and overworked as long as corporate interests control our EDs. When will the hospital board wake up? Profits over patients fails everyone except shareholders.