Sunday, April 15, 2007

E.R. Call

Panda Bear MD poses the following ED scenario for an on-call orthopedic specialist:

“Good morning, Dr. Smith. Sorry to wake you up but this is Dr. Bear at the County Hospital Emergency Department. I’ve got a 25-year-old gentleman, snowmobile versus barn, with an open mid-shaft fracture of the left femur but otherwise without significant injuries. We have him in a traction splint and his distal pulses and sensation are intact. On the way through the barn he dragged the end of his broken femur through approximately fifteen feet of cow manure and I’m afraid it was about thirty minutes before his drunken friends decided that he probably wasn’t going to walk it off.”

“How’s he doing now? Fine. He’s fully alert and oriented and threatening to sue everybody in the place. Can you come in and see him?”

Would you come in? It is easy to come up with a similar scenario for psychiatry. Yet, it has been a long time since psychiatrists gave up on ERs. I don't have figures, but I'd wager that it is not easy to find an ED where a psychiatrist evaluates the guy with the overdose or the woman with new-onset paranoid auditory hallucinations. More often, they have social workers evaluating these patients. The problem is, many of these patients are better served with a physician with psychiatric expertise, as a good percentage of these folks have medical problems which are dressed up as "psychiatric problems"... things like steroid psychosis, metabolic encephalopathy, and drug-induced syndromes.

Hospitals are increasingly paying specialists to be on call, recognizing the increased risks of treating ED patients, many of whom lack insurance and regular medical care. That includes psychiatrists. The hospitals are now able to see the savings in terms of improved patient flow, higher quality care, reduced liability, and lower length of stay, when using ED psychiatrists. The trouble is finding docs who are willing to take on this lifestyle. Psychiatric hospitalists are starting to crop up more, as they tend to work shifts (eg, 8a-8p), have staggered work days (eg, 5 days on, 4 days off), and get benefits. These are primarily consultation-liaison psychiatrists (like me). Any of you CL docs out there, let us know about any ER call you do.