10 October 2009

Managing the Inappropriate Plastics Consult
















  1. yep, we deal with this scenario all the time. the otehr part is that the community pediatricians often tell the parent to "bring the kid to the ER and they will get a plastic surgeon to close it." so you get it both ways. my approach is similar to yours, though and it usually works well.

  2. my favorite is the self-pay/no-pay that demands a "free" plastics closure. when it is not necessary.

  3. "I'm quite doubtful that the cosmetic outcome is going to differ much whether the ER doc or the plastic surgeon does the repair. "

    Wow. You really can do anything.

  4. Another important element is the nurses, starting at triage, nip the parent's plastic surgeon expectations in the bud. "Oh, our doctor's can repair that as well or better than any plastic surgeon. They repair these types of injuries all the time, actually more often than the plastic surgeons. If there's the slightest chance that they feel a plastic surgeon can get a better result than they will, they'll call one but this laceration is very simple to fix..."

    "No tissue missing, simple closure, wouldn't want you to have to wait hours for the plastic surgeon to come in, so stressful for little Suzy, blah blah blah..."

    Is it an EMTLA violation if is refused a plastic surgeon if one isn't necessary. If I go to the ER with a sprained ankle can I demand that the orthopedist on call come in and examine and splint me?

  5. It's especially true at academic centers. If the wound is a simple linear laceration, then insisting on a plastic surgeon will get you the plastics intern or subintern, who has far less experience than an EM attending, or even most upper-level EM residents.

  6. WTH?? If I didn't cut an artery or some major vein, I sew it up myself. (Yes I really do. After proper sterlization of course.)

  7. If the patient has insurance, our plastics docs LOVE to be called for simple lacs. They usually do not balance bill the patient, being more than happy with the typical 1000+ dollar payment as an out of network emergency provider. If they have no insurance, I do almost all of them. Most people realise they will get a huge bill and are OK with me doing the repair.