The standard of care for the physician is not “perfect” or “ideal” care. The standard of care is what a reasonable physician would have done under the circumstances. This takes into account the circumstances of the Emergency Department at the time, such as the number of critical patients present. In some instances the physician-in-charge may have control over those circumstances and sometimes the circumstances will be out of the physician’s control.

If, for instance, a physician during a natural disaster or large-scale terrorist attack is faced with an unexpectedly high number of critical patients, the physician would be required to use the disaster guidelines to triage those patients. Patients whose lives are at stake, and have a reasonable chance of recovery, may take priority over patients whose limbs are at stake. In such a case, the reasonable physician may be required to attend to life-threatening injuries over strictly limb-threatening injuries. On the other hand, if the circumstances are not so dire and there are mechanisms in place to contact backup physicians or divert patients to other hospitals, it may be the physician-in-charge who is liable.

The question of transfer of liability to the hospital is more difficult. In general, an employer is liable for an employee’s negligence or carelessness under the doctrine of respondeat superior. This doctrine assigns ultimate liability to an employer for damage caused by an employee’s carelessness. The relationship between doctors and hospitals, however, does not always fit so easily into the employer-employee relationship. Depending on the situation, the doctor may be considered more of an independent contractor to the hospital. Nevertheless, a hospital may be accountable for circumstances that lead to patient injury outside of the physician’s control, such as inadequate staffing, inadequate supply of medications, or carelessness of ancillary staff hired by the hospital, such as technicians.

If the orthopedic surgeon chose not to reimplant because the person was a poor risk for surgery because of general medical condition, then the whole thing does not make sense. No negligence as far as I can tell.

If the orthopedic surgeon chose not to reimplant because too much time had passed since the injury, then I could see the argument for negligence if there was a delay consulting orthopedics.

The orthopedist has the role of consultant to determine the likelihood of technical success and the risks of replant versus simple closure of the wound.
Further, as a private individual, he has the right to choose whether or not to enter into a contract of service with a patient. Even if he concludes that replant might be in the patient’s interest risk/benefit wise, he is not under any servitude to provide this task for the patient. Like any businessman in america, the doc can choose any work he wishes, and turn down any he wishes so long as it is not because of membership in a protected group (sex, race, religion, etc.)

Was there delay in consulting orthopedics? Or was the delay because the orthopedists thaought reimplantation was not indicated, so they took their time getting around to a simple repair because there was no hurry?

O’Shea v. State of NY

Many injuries or conditions have so called ‘golden windows’ of opportunity. Six hours to close a compound fracture, but the medical system has pissed away 5.5 hours and suddenly at 1 am it is a crisis that they can punt to us. In a timely manner the case would have been done and we’d all be in bed, and the patient would have a better chance at successful repair (earlier in the golden window is better than late in the golden window).

This case just doesn’t make sense. Given the pressure on ERs to rapidly obtain a disposition on patients and the relative simplicty of finding a home for this one (in the OR) that a quick call to ortho would have been just the ticket. I wonder if there is more than is admitted to however. Were ortho consultants difficult to find (did the patient have insurance?) and what other factors might have played a role that the hospital is not admitting.

EMTALA says the patient has to be stable, he doenst have to be “fixed”

Fingers cut off.

No subtlety here. Call orthopedics first. Then get studies to see if there may be more work needed than a “simple” (relatively speaking) reimplantation. Maybe there’s more occult trauma in the hand….fine.

And yes, maybe the patient has a cardiac history that may need to be addressed as best one can in a short time. Fine. Get the studies.

But it seems the first call is to ortho.

Something doesn’t seem right in the whole picture.