You’re still a doctor, even if you’re not on call

Christmas morning at 1:30 am the phone chimes away. What the … I’m not on call.

“Please call Dr. Dred for patient Selma, perforated colon at local ER,” read the text message.

Why are they calling me, I’m not on call. Dr. Young is. Maybe something’s happened and they can’t find him.

So, I called. It was just as reported. There was a fifty year old female with abdominal pain for three days, hypotension and a CT Scan that revealed free intraperitoneal air and fluid. She was intubated and on pressors, maintaining a blood pressure of around 100 systolic. Dr. Young had been paged three hours before and had not called back.

I know Dr. Young very well. He is recently out of residency, very conscientious and a very good surgeon. The only reason he would not respond is if he was in the OR at another hospital or was incapacitated for some reason. I tried to call him myself, but he did not answer.

I called the ER back.

“Did you try to call another surgeon or transfer the patient to another facility?”

The answer was that they had called. The other two surgeons who worked in their hospital had refused to come. They had called the surgeon on call at another hospital less than a mile away and he had refused to accept the patient. They had called the surgeon on call at a second nearby hospital and he had also refused. They had called the major medical center downtown and they had refused. Everyone in the city of Houston had refused to come and see the patient or accept the patient in transfer. I hung up the phone and made calls to the operating rooms at the other local hospitals, to see if Dr. Young was scrubbed in surgery. No answer at any of them.

I lay in bed for about three minutes and then called back the ER.

“I’m coming in,” I said.

The patient was just as presented. Intubated, BP 100/50 on neosynephrine infusion (not my first choice), alert, however, with a diffusely tender abdomen and CT scan which suggested perforated colon. I’d called the OR crew in before I left my home and they were arriving at that moment and setting up the room. She was ready to go to surgery within thirty minutes of my arrival. As we were wheeling her to the OR, Dr. Young appeared. It seems he had been on call for the last four days and had been up each night with similar life threatening emergencies. He had put his phone down and fell asleep and had not heard it ring as he had left it in the bathroom. As soon as he saw the message he called and came in to the hospital. I told him that I’d take care of Selma and that he should get some rest. He thanked me and we proceeded to surgery.

Selma had suffered a perforated colon due to diverticulitis and had fecal peritonitis. She was treated with colon resection and colostomy, has recovered and now is home.

This case was a bit disturbing. The fact that the call doctor could not be reached was one issue. However, it is an unfortunate fact that doctors are actually human. I find no fault with Dr. Young. Suppose Dr. Young had been in an accident, was unavailable and it was not possible for him to even call the ER to inform them? What about the other surgeons? What doctor who calls himself a surgeon would allow a patient to die just because “I’m not on call.”

This patient was uninsured. I suspect this fact may have played a role in some of the decision making. It is almost impossible to transfer a patient who has no resources. It is possible that those surgeons at other hospitals did not believe she was stable for transfer, but if there is no alternative, is there a choice?

My greatest disappointment is with the two other surgeons who had privileges at local hospital and refused to come to see the patient. It is one of the facts of the general surgeon’s life that sick people are inconvenient. Until our government can legislate that people only become ill between the hours of 8:30 am and 5:00pm, and only Monday through Friday and not on holidays, there will be calls at any and all hours. Could any doctor let a patient die when it is within their power to prevent it?

The following morning, after the surgery, I talked about the case with my wife. She said she wasn’t surprised I went in to the hospital. She was surprised that so many other surgeons refused. I commented that I would have sat up all night worrying about the patient, and, rather than worry, it was best to take care of her.

Doing the right thing is always better.

David Gelber is a general and vascular surgeon who blogs at Heard in the OR and author of Behind the Mask.

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  • http://twitter.com/DavidGelberMD David Gelber MD

    The patient is recovering without serious complication. She is out of the hospital and healing fairly well.

    • Suzi Q 38

      Good doctor. I think a good friend of mine had a similar surgery, and she died within a year. The complication was c.difficil that could not be controlled after her surgery.
      Also, she was a highly addicted smoker and refused to give up her cigarettes even though she was gravely ill.

      Another mistake was that her insurance company refused to pay for the Vancomycin post op, as she wanted to go home with it. I told her to fill the prescription, even the the insurance refused to pay.
      Why? I knew that if you were on Vancomycin and had an infectious disease expert on your “medical team,” it was somewhat serious.
      I told her to put it on her credit card, and then dispute it later in insurance arbitration. She could even sue the insurance company later in small claims as the bill came to $5K.

      She hated hospitals. She was in a Southern state and I am living in California. I had no idea what was a good hospital out there that could give her the better care or comprehensive workup.
      I regret not getting on a plane to make sure she was O.K.
      Her family made sure she was well clothed and had nice things, but their insurance was just basic.
      In our defense, we all knew she was ill, but no one dreamed she was so near death.

      She was released from the hospital and then died a week later at home, with only her frantic husband trying to save her life.

      She was only 59.

  • Suzi Q 38

    I used to say, “Doctors make mistakes, they are only human.”
    As far as this example I would have to say that “It is sad we live in a time of doctor’s attitudes changing, not for the better.” What those doctors did was so wrong.
    Being a doctor in the United States is not easy. We don’t always need emergency surgery just from 9:00-5:00. We are not England or Canada, where they would just allow you worsen or “expire” if there was no surgeon available. As Dr. Behar described on another blog, look what happened to Princess Diana.
    There should be changes. Yes, there should be a doctor on call.
    Also, there should be doctor #2 and #3 on call, for “insurance.”
    Dr. #1 should pay a sizable bonus to Dr. #2 if he could not be reached or scrub in for any reason, accept accident or death, LOL.

    You did the right thing. I don’t know you, but I suspect you would do the right thing. I am glad there are still doctors that think the way you do.
    I hope I “run into” a few of them out there if I need one.

    Bravo. Christmas morning, no less.

    • ColdHands

      That’s a little harsh on UK healthcare. While not perfect, at least we don’t have doctors refusing treatment or patients not getting vancomycin because they aren’t insured. That will simply not happen. I totally agree though that it’s disgusting that so many surgeons and hospitals refused to treat a critical patient. Whatever you think of the NHS that wouldn’t happen generally. I won’t say never, there are always horrible exceptions. Waiting for a non-emergent elective surgery, that does have longer waiting times. As I say, not perfect, but I’d argue neither is the US system right now.

      No insult etc intended, I generally agree with much of what you post, and mean no disrespect.

      • Suzi Q 38

        Sorry for the harsh words, as this is not your healthcare as you know it. It is only how I imagine it after reading Dr. Behar’s post, and other stories in the media. My “bad.”

        In the U.S. are at the “gates” of transition, and many of us patients are not looking forward to the change. Luckily, I can afford decent insurance coverage, but this “eats up” a sizable part of our income.
        Our daughter is a nurse and she is happy that the uninsured will finally get the proper care, and I won’t have to worry if I can not work due to illness and need medical care.

        My fear is that I have been spoiled.
        I have tried to surround myself with decent to good medical care. At times it has been very good, at other times it has been very bad. Nonetheless, the care that I have received through my PPO (very expensive) insurance has been mine to choose.

        I could say to my neurosurgeon: “Doctor, my symptoms are escalating day by day…could you please move up my surgery from 4 weeks to STAT?” I also made plans to two other neurosurgeons just in case he was not able to do so.

        The other two neurosurgeons were “gems.” I wouldn’t have been able to sleep that night without the comfort they gave me
        when they said: “Yes, come to see me and we can schedule a surgery STAT.” That was my back up plan.

        Thank goodness the hospital surgery department from the first surgeon called me to schedule a surgery within 7 days.

        I am not sure that I could have gotten my surgery that quickly.
        I would not have died, but I probably would have been paralyzed.

        Would I have been able to schedule a surgery that quickly and choose from what I perceived as the best surgeons in my area at 3 different well-known teaching hospitals with good ratings?

        I don’t live in the UK, so I am not sure.

        I do agree that a lot of this fear of the new “health care,” is just me.
        I welcome any positive and negative information from actual participants.

        • drdoctormd

          Unfortunately if you weren’t insured or even if you had Medicaid, you would not find any neurosurgeon or hospital so charitable.

          • Suzi Q 38

            That’s what I thought.
            I had 3 every good surgeons (and good people) offering to do my surgery once it was determined that I did not have MS and surgery was advised by the neurologists.
            I knew it wan’t only because I was a good person that needed help.
            I realized that we had wisely chosen PPO insurance
            ($850 a month on top of the $1K that the employer pays)
            for our insurance.
            That is the cost of a year of college tuition at our state schools, a nice car, or IRA’s for retirement.

      • ninguem

        “…..While not perfect, at least we don’t have doctors refusing treatment or patients not getting vancomycin because they aren’t insured……”

        What’s the word…..”bollocks”

        We refer to a different organ system in the bull, but same idea.

        It’s too easy to follow the UK press now, not to mention follow UK physician blogs. Yes, cases every bit as bad happen there too, they get reported regularly in the UK press.

        • ColdHands

          As I said, we aren’t perfect, but it’s very rare that serious cases are ignored and as the drugs would be given free to those on low income and limited cost for others, max 7 quid something, and hospital meds are free for inpatients, you won’t find a patient refused an antibiotic. There are some newer, expensive, drugs that aren’t always funded, same as not all cosmetic surgery is free. But to suggest that a patient would be refused surgery for bowel perforation and peritonitis because they are poor is simply not true. Yes, mistakes happen, yes things go wrong…. but I sincerely doubt that you can say anything differently about the US. And the UK papers, much like all media, are not adverse to exaggeration, or creating scandel from anything. Nobody reports all the millions of people seen and treated or saved, that’s not how things work. And as someone who has had a dozen surgeries, and emergency admissions to a number of hospitals in the last 20 years,

          • ninguem

            “Crippen” closed his blog when he retired from general practice, here’s some of his post from a few years ago.

            http://www.health-news-blog.com/blogs/permalinks/4-2007/a-tale-of-two-cancers.html

            Two patients with the same cancer, offered completely different treatment based on their coverage. One had NHS only, the other private cover. That GP was not happy that day.

            You’ve had scandals of ambulances not allowed to unload their patients because of wait times in the A+E. There have been documented deaths and complications from the patients left in the ambulances, as well as people who could not GET an ambulance in a timely manner, when they were all parked in the A+E parking lot.

            Look up the term “postal code lottery” in your own country. They are NOT treated the same way in the NHS. Depends where you live. Government-run healthcare, no matter where you are, when the government is involved, it becomes a political football. Big scandals in your own press, just recently.

            http://www.independent.co.uk/life-style/health-and-families/health-news/nhss-darkest-day-five-more-hospitals-under-investigation-for-neglect-as-report-blames-failings-at-every-level-for-1200-deaths-at-stafford-hospital-8482566.html

            Are these all “exaggerations”? The case described here in this thread, a bad system caused a surgeon to allegedly neglect a patient by allegedly declining to attend the case. These UK hospitals, a bad system caused many patients to suffer when many people declined to attend patients. To get to the point described in this article, required systematic neglect by many doctors, nusese, and aides.

            I stand by what I said, the same thing happens in the NHS as well as here. Badly managed systems, both sides of the pond, the system works only because someone (doctor, nurse, someone) is willing to be abused.

            Then that person says “enough”, refuses the abuse, and you end up with a patient untreated in the emergency department.

            The difference, and I always find this rich, is when the problem is identified in the USA press, it is evidence of the evil capitalistic American healthcare system. When it happens in the UK NHS, it’s exaggeration in the press.

          • Guest

            You are taking my words out of context. I never said NHS was perfect. I never said that NHS treatment was exactly the same as private treatment. I never said that there aren’t sometimes queues at hospitals. I neversaid that tthere wasn’t the post code lottery for certain treatments. What I said was one specific example – that if someone poor, or without private insurance, turned up at the ER, they wouldn’t be refused treatment because of their financial care, nor would hospitals refuse a transfer because of their economic status! In fact, in emergency care, private healthcare rarely plays a part initially, only generally for elective or non emergent care. And I stand by the fact. I also stand by the fact that no person has to go without antibiotics like vancomycin following colon surgery because they can’t afford the prescription.

            The NHS is far fromperfect.

    • southerndoc1

      I’ve lived and worked in both the UK and continental Europe. The poster you reference is describing a socialist hell that has no existence outside his paranoid wingnut wet dreams.

      • Suzi Q 38

        Thank you for clarifying.

  • http://www.facebook.com/marisa.contibush Marisa Conti-Bush

    I would have done the same thing. I am sure Dr. Young was horrified, exhausted and thankful that you helped. I feel sorry that the ER was in the middle of it and had to make 100 phone calls for a young sick patient. Being an internist, I can understand their helplessness. The doctors who refused her should be reported to the hospital board. That is no way for a team to function. You would never have been able to sleep knowing that she needed you. Please don’t ever change. I would be honored to work with you!!

  • http://rk.md/ Rishi

    As a student, it’s inspiring to see experienced physicians with this mentality – hopefully this is more the norm than the exception.

  • http://www.facebook.com/lucy.hornstein.1 Lucy Hornstein

    Proud to be your cousin.

    • http://twitter.com/DavidGelberMD David Gelber MD

      Nice hearing from you, I think it’s been over thirty years since we met?

  • southerndoc1

    Not going to defend the other docs’s behaviour, but if society decides to not treat MDs like professionals, we’ll see more of them who decide to not act like professionals.
    This episode is symptomatic of an exhausted, demoralized work force. General surgeons are soon going to be as scarce as hen’s teeth.

    • drgg

      What a relief to read your post! Yes. We need to look at the big picture here. An exhausted demoralized workforce that I will add is working for FREE. And our government and as you say our society is allowing this. The key word in the whole blog was uninsured”. If this were a CEO of a company would they work for free?
      Society needs to decide if this is important to them. It reminds me of one of those awful awful republican debates where a question was asked about how to handle an uninsured patient with an emergency. And the republican audience cheered to let them die. I guess there is our answer.

      • kjindal

        you can bet that the hospital CEO (at home sleeping comfortably), nurses, OR techs who came in, and everyone else involved in this woman’s care was being paid. Everyone except the surgeon. And guess who gets sued when this train wreck goes south? It’s no surprise at all that the other surgeons wouldn’t come in.
        One approach would be to mandate hospitals to pay voluntary MDs for providing care to the uninsured. After all, hospitals get big subsidies for this, and pass NONE of it to doctors.
        Or there’s always cheaper noctors – lets train them to do surgery.

    • Anon

      It is contingent upon an individual to seek out insurance for themselves. They should work for it (employer-sponsored plan), pay for it (individual plan), or apply for indigent insurance (Medicaid). It is not the doctor’s responsibility to be the one left holding the (empty) bag whenever an individual or society feels health insurance is not an important priority.

      How much do you want to bet the 50 year old patient still doesn’t care about obtaining insurance and would rather spend her money on alcohol, cigarettes, etc.? She’d rather the doctors and hospital eat the costs and possibly go bankrupt.

    • ninguem

      ^^^ what southerndoc said ^^^

      Atlas has shrugged.

  • drdoctormd

    One of the deeper issues is disengagement of the Medical Staff from the hospital. I’m not going to complain about “the good old days,” but it is a different world, a different healthcare economy we live in. Formerly you took ER call at a hospital (or hospitals) because it was a responsibility and a duty in exchange for privileging — for allowing you to ply your trade. Physicians felt they had a voice in the operation of the hospital–they wanted to work a a good hospital, and be known as affiliated with “good” health systems. They participated in Medical Staff functions because they enjoyed the professional camaraderie and felt connected to something. Lately (past 10-15? years), specialists of all descriptions have demanded and required call pay to “cover” the inconvenience of unassigned call, and the inevitable rising likelihood that that unassigned patient is also unfunded. It doesn’t cover the economic cost nor (even remotely) the inconvenience and the medical-legal risk these patients often bring.

    Unfortunately, it leads to a situation where the physicians are suspicious of the administrators, the administrators view the physicians as mercenaries, or (worse), commodities, and there is less and less engagement, sense of duty, or collaboration. The employment of physicians and physician groups by hospitals and healthcare systems would seem to be a potential solution but we all know situations where physician productivity goes down once a physician earns a straight salary. It’s a different type of duty–to an employer, as opposed to the sense of belonging, professionalism, and one’s calling–that prevails.

    • drgg

      GOOD POINT! In a way, the unattended uninsured patient epic, was a message to the hospital administration who were home on X-mas oblivious to all of this or perhaps detached. If the patient died from lack of medical attention, guess who would be sued?

    • http://twitter.com/DavidGelberMD David Gelber MD

      I take call at three different hospitals (never on the same day) and get paid for call at two of the hospitals. Such pay is almost an economic necessity in this day and age. Reimbursements have fallen so low that it becomes almost economic suicide to take a lot of ER call and have to spend an inordinate amount of time caring for the uninsured. That being said, the hospitals that pay us receive disproportionate funding for caring for the indigent and for being Level 3 trauma centers. Of course,the burden for caring for these trauma patient falls on the general surgeons. I have no qualms about accepting this payment. The particular hospital for this case does not reimburse for ER call.

      • drdoctormd

        Dr. Gelber, I was not suggesting anything untoward about surgeons or anyone accepting call pay. Just commenting on the economic reality and necessity. As I noted call pay doesn’t cover the cost of uncompensated care to say nothing of the inconvenience. Unfortunately the unintended consequences of disengaged and disaffected medical staffs cannot be overlooked.

        Thank God you were available and willing to save this patient’s life. I hope she and the administrators understand that.

  • Suzi Q 38

    Thank you for your comments.
    It is nice to know that we can go private if we wish, too.

    • ColdHands

      You also have the ability to choose where you are referred to on the NHS. For example, I’ve been to three different hospitals because each one has the best specialist for that specific condition. Like everything, it’s not perfect. and you.may have to wait longer for certain referrals, but yes, you can choose where you are seen. Hope that helps and I hope your fears don’t come to pass with the current changes to your own system. :)

      • Suzi Q 38

        Thanks.

  • http://www.facebook.com/Overcomer013 Elizabeth Williams

    Thanks to Dr. David Gelber, as a Ruptured brain aneurysm survival, l put myself in the position of that patient. As a non practicing physician l can only pray that my colleagues receive the strength and guidance from God to do the right thing at all times. I know is hard but you need the grace of God. Not to excuse the doctors who declined and mortgaged their conscience but to see the unwaranted fear that descended on them and resulted in an unfortunate decision. Thank God no one declined to see me when l had a bleeding brain vessel and no insurance. Dr. Elizabeth B. Williams, MD, LNFA.

  • http://www.facebook.com/balynn1234 Beverly Ann Lynn

    you are the type of doctor i would want to go to anyways. thanks for being a good guy and surgeon and caring.

  • ColdHands

    You are taking my words out of context. I never said NHS was perfect. I never said that NHS treatment was exactly the same as private treatment. I never said that there aren’t sometimes queues at hospitals. I neversaid that tthere wasn’t the post code lottery for certain treatments. What I said was one specific example – that if someone poor, or without private insurance, turned up at the ER, they wouldn’t be refused treatment because of their financial care, nor would hospitals refuse a transfer because of their economic status! In fact, in emergency care, private healthcare rarely plays a part initially, only generally for elective or non emergent care. And I stand by the fact. I also stand by the fact that no person has to go without antibiotics like vancomycin following colon surgery because they can’t afford the prescription.

    The NHS is far from perfect. So is the social care system. I know this. But I stand by the position that nobody needs to go without treatment because they can’t pay the bill. That was my only point, nothing more.

    • ninguem

      “What I said was one specific example – that if someone poor, or without
      private insurance, turned up at the ER, they wouldn’t be refused
      treatment because of their financial care, nor would hospitals refuse a
      transfer because of their economic status!”

      When the homeless person is shuttled around with the fingerpointing over who’s budget that person’s care will cover them, that person is being denied care because of economic status, even if you don’t choose to recognize it as such.

      • ColdHands

        *sigh* I wasn’t talking about private care vs NHS though. I was talking about just NHS. But you know what? I’m done arguing with someone who refuses to listen to my points properly and for some reason cannot accept that there is a fundamental difference between optional private treatment for non emergent care on top of a free at the point of contact care for everyone, vs obligatory insurance that still requires you to pay several grand for your emergency care somehow, even.before the insurance company pays out, but only if you go to the right hospital, or have the right boxes ticked. As such, I shall leave you to your opinions, because clearly we aren’t going to agree.

  • ninguem

    Actually, what this incident reminds me of, more than anything else, was the Ravenswood Hospital incident in Chicago, about 15 years ago.

    Because the neighborhood was rough, high-crime, the administration had posted a rule, no personnel off the hospital property for any reason, while on duty, and made it a severe offense that could get an employee fired.

    If someone were hurt off hospital property, you were not allowed to get the patient, even if within sight. You had to call the police and ambulance. The administration meant it, and threatened to fire anyone who disobeyed.

    Then one day, some kid got stabbed in a gang fight. The gang dumped the bleeding kid across the street from the hospital, actively bleeding.

    Hospital personnel saw what had happened, but following orders, did not go to help the kid. They called the police, and the response was significantly longer than what it would have been to just run across the street with a stretcher.

    At the same time, the other kids did not bring the bleeding gang member across the street, lest they be identified and arrested later.

    The kid was left to bleed, and the delay to wait for police and ambulance led to his death.

    It made national news at the time.

    Lots of calls for a single-payer system at the time, based on the incident.

    There’s lots of reasons for and against a single-payer system. This incident was not one of them. The kid died because of poor administration.

    The hospital, to my knowledge, no longer exists.

    This thread is about a breakdown in the system, and doctors who perceived themselves abused and wanted to turf the work to someone else.

    Anyone who thinks that sort of thing only happens in the USA……