Ethics 101: The Doctor Is Out To Dinner




Health and Healthcare CategoryIn an effort to make this blog more interactive, I’ve decided to start a new series of posts focusing on Ethics and Medicine. In this series I will post a series of cases and see what my readers think. Some of these will focus on the ethics of the doctor, some the patient, the hospital, and other the health care system in general. I hope you enjoy the series and feel free to let me know what you think.

In a fit of rage, a thirty year old otherwise healthy man punches a hole through his window. He’s been arguing with his girlfriend over the telephone and finally loses his cool. He bleeds profusely from his arm and there are obvious glass shards stuck in his skin. He drives to the local ER because he is worried that he has done some serious damage to his hand.

fade to blackUpon evaluation in the ER, the Emergency Physician documents that he has some numbness in his ring and pinky fingers. He is also not able to bend those fingers much. A X-ray does not show any broken bones but you can see glass shards under the skin. The ER physician is worried because he can’t see the glass sticking out of the skin. He also believes that the patient has lacerated some tendons and maybe even nerves. Thus he feels that a hand surgeon should be consulted. Unfortunately, there is no hand surgeon in the community that takes on-call service for the ER. Thus, the ER doctor calls various community hand surgeons to see if they will take care of the patient.

Finally, the ER is able to get a hand surgeon who will answer his pager. The hand surgeon agrees to get involved with the care of the patient. He listens to the story over the telephone and feels in his best judgment that the patient will need an exploration of his hand in the operating room. Studies show that there is no difference whether this happens sooner or later as long as it is done within 24 hours. Thus he explains to the ER doctor that he is out to dinner with his family and won’t be able to see the patient until the morning. He tells the ER physician to either discharge the patient and have him come to his office in the morning, or to admit the patient and that he will see the patient in the morning.

There are many ethical questions here:

  • Should the hand surgeon come to the ER to evaluate the patient to confirm the diagnosis in an emergent manner?
  • Should the ER even accept to evaluate patients with injuries for which they have no specialists to treat?
  • Should the hospital even allow the hand surgeon to have hospital privileges even though he refuses to take ER call?
  • Does the average patient believe this is acceptable care?
  • P.

    If it is really true that a patient in this condition can be seen any time within 24 hours then I believe it is appropriate to discharge the patient from the ER to home and tell him to see the hand surgeon in his office in the morning. We, as patients, realize physicians have lives and know that if a situation is not an immediate emergency we can wait. If a situation is truly a life threatening emergency of course it would be a different story.

  • Christie

    An emergency room is just that, for emergencies. That being said I feel the doctor should have at least come in to see the patient and confirm whats going on. Especially since the ER doctor was concerned enough to call all the hand surgeons.

    As for being turned away from the ER in triage because there is no specialist at that hospital that is a slippery slope that is at best scary. That should never happen.

    A doctor who is not on call should not have hospital privileges taken away for not responding to an ER call, especially if out to dinner. There is a chance that there was alcohol consumed. Even if its one glass of wine I would not want that surgeon working on my hand. I would also prefer a well rested surgeon as most people would. That being said I think the doctor should at least come in an evaluate the situation that night.

    The average patient would proably find this situation very distressful. Basically every conscious person in an ER is in a state of panic on some level. Waiting who knows how long in a waiting room then in a bed without a nurse seeing them then even longer for a doctor to have the doctor say he or she needs to contact another doctor is not pleasant. And to wait all that time in this hightened state of agitation to find out the doctor is too busy at dinner to bother coming in that night even when he is finished would be extremely irritating. And since the person in the hospital bed is there because of an accident related to rage they are in a more vulnerable state to fly off the handle. So I dont think any patient in the ER would find it acceptable. As someone not in the situation I say sure the doctor can have his own life but as someone who spends a lot of time in ER beds I would have to say the doctor should have at least dropped by the hospital after dinner.

  • EEP

    Physicians with privileges should be required to take call (not necessarily come in if not necessary but to take call) at least a few times per month — that is not unreasonable and it is one of the reasons they get paid pretty well. The patient was seen by the ER doc and the specialist consulted and a follow up appointment made, the patient could be seen the next day.

    Should people who do stupid things to themselves get the same treatment as those who are victims of accidents?

  • CD

    Should people who do stupid things to themselves get the same treatment as those who are victims of accidents?

    This gets off the topic, I’d say. Judging people’s actions as “stupid things” or “not stupid things” before accepting the patient for treatment is problematical, don’t you think? If your heart attack is the result of your overindulging in chocolate cake for the last 20 years, do you have to suck it up and die for the “stupid thing” you’ve done to yourself?

  • http://mormonmd.wordpress.com Doc

    I think the evidence you site of no difference in outcome by waiting tells me it is okay to wait. However, It also seems reasonable to me that the physician be required to take at least some call. This becomes problematic in a shortage area because that translates to nightly call, which doesn’t do anyone any good, as the surgeon becomes overtired in the OR and burnout worsens the shortage. In the end, I agree with you, there are no clear cut answers.

  • http://malayalidoc.blogspot.com charakan

    I think the most important thing here is communication.If everything is communicated to the patient and if he is reassured enough he can go home and come next morning.If the patient is unsure let him be admitted with an assurance that the Hand surgeon will come in case of any emergency situation developing.
    The communication skill of the ER doc is most important here.

  • http://rebeldoctor.blogspot.com// Michael Rack, MD

    http://rebeldoctor.blogspot.com/2008/06/er-call-ethics.html

    1. I do not think that physicians have an ethical obligation to provide hospital/ER call. I think this is a matter of negotiation between hospitals and the doctors who apply for medical staff privileges. Hospitals have the right to refuse medical staff privileges to doctors who don’t want to meet the hospitals’ call requirements. Doctors have the right not to apply for privileges at hospitals that have onerous call requirements. To attract physicians of certain specialties, some hospitals may need to pay the doctors for taking call, though this is a legally tricky area.

    2. Regarding the specific case, once the surgeon “agrees to get involved with the care of the patient”, I think he is obligated, at least from a medicolegal perspective, to go in and see the patient that night. If he wasn’t prepared to go in that night, he should have told the ER doctor that in general that type of injury requires surgery within 24 hours, but that he couldn’t comment on the specific patient. If I was in that surgeon’s place, I would have offered to see the patient in the morning, but made clear that the ER doc was responsible for the patient until then and that no doctor patient relationship would exist until and unless the patient arrived at my office. I would tell the ER doctor that if he was uncomfortable with that disposition, he could always send the patient to a university hospital/tertiary care center (if the ER doc thought the patient was stable for transfer).

  • Pingback: Ethics 101 - Patients Who Hide The Truth | Brain Blogger()

JC, MD

Dr. JC is a medical doctor who has a passion for health promotion and education.
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