Don’t give away ED coverage

Taking emergency call continues to be a complex problem and defies all reasoning. Orthopaedic surgeons respond in a variety of ways to the “call issue.” Some orthopaedists want to take emergency call; others don’t. Some are willing to take call only if they get paid for it, and others don’t want to take call regardless of the amount of the remuneration. Some believe that, as orthopaedists trained in trauma care, we are obligated to take call; others do not consider this an ethical problem, but a hospital or manpower problem.

Emergency call usually is a small part of most orthopaedists’ practices, but it can cause multiple practice problems. It interferes with a stable office and elective surgery schedules. Subspecialists in fields other than trauma may not be comfortable treating the variety of cases seen on call, making it seem an especially litigious area. Because remuneration for call is such a small percentage of an orthopaedic practice’s income, many consider that it’s not worth the agony and frustration. In my 30 years of responding to emergency call, my happiest day was the day I went “off call.”

No easy solutions
While the problem worsens, the solutions have been only a “moist sponge” put on the “open fracture.” The AAOS has wrestled with the problem for many years. The most recent efforts began in 2006 and are continuing today. Two different project teams have made recommendations such as preparing a new position statement and developing Standards of Professionalism (SOPs) on emergency care. Realistically, a statement by the AAOS is probably not going to have much effect, and SOPs will only tell orthopaedists what not to do, not how to solve the problem. Such a large problem cannot be regulated by AAOS members alone, but needs a multidisciplinary approach.

This issue of AAOS Now has three articles and two letters to the editor about taking call, all emphasizing the complexity and magnitude of the problem. The issues facing the solo practitioner trying to “do the right thing” in a small community are quite different from those facing a large group trying to manage its call schedule. Preventing violations of the Emergency Medical Treatment and Active Labor Act (EMTALA) rules and structuring compensation for emergency coverage under EMTALA’s anti-kickback rules are additional concerns.

In “Getting paid for taking call” (cover), consultant Joshua D. Halverson proposes the following strategies: “outsourcing” or contracting with another group of specialists to provide emergency coverage; using full-time hospitalists, traumatologists, or other surgical specialists; using physician assistants, general practitioners, and nurse practitioners to provide initial stabilization and primary treatment; and setting aside a dedicated operating room (OR) for early morning cases from the previous night’s emergencies.

It seems to me, however, that what is considered an emergency today is different from what was considered an emergency 35 years ago when I first started taking call. Back then, patients with puncture wounds or open fractures went immediately to the OR; fractures were reduced immediately; infections, especially those of the joints, were drained immediately. Today, major trauma cases are sent to level 1 trauma centers, but patients with displaced fractures and infections may wait 5 to 7 hours until the designated OR opens at 7:00 a.m.

Several research studies have shown that this shift in procedure does not affect either outcomes or incidence of complications. For example, according to the recent literature, a supracondylar fracture in a child who has a good pulse can wait to be pinned for 7 to 10 hours and still heal as well as one that is pinned immediately. Some authors suggest that waiting until a competent OR staff is present may be better than proceeding in the “wee” hours of the night. (As I recall, there is no “we” in the middle of the night—it’s usually just “me”!)

A changing standard of care?
In this modern day of antibiotics, sterile techniques, and multiple surgeries, maybe such changes are acceptable. Many nonsurgical fractures seen in the ED are minimally reduced or left unreduced by ED physicians, nurse-practitioners, or others on staff and referred to an orthopaedic office the next day. Perhaps the only true “emergencies” are irreducible dislocations and neurovascular-compromised (pulseless) extremities. Like it or not, this seems to be becoming the standard of care.

I have no axe to grind about the standard of care or how EDs decide to treat different fractures. My only concern is that the “orthopaedic nation” does not abdicate its responsibility to care for trauma and fractures. Fracture care is what we were trained to do. ED call won’t go away, and we may not want it to.

I have been in this profession long enough to see general surgeons “give away” most of what orthopaedists now treat, including hip fractures. As orthopaedists, we too have “given away” much of what was once within our purview, such as physical therapy, foot and ankle care, and sports medicine (to family physicians). As physicians, we have “given away” our hospitals to administrators. Let’s not let this happen in trauma and fracture care.

It could happen—particularly if orthopaedists refuse to take ED call or price ourselves out of the market. According to the August 2008 Employee Benefit News, from 2006 to 2008, the median cost reported by trauma centers for physician on-call payments rose 88 percent; nontrauma centers are paying 91 percent more now than just 2 years ago for physician on-call payments.

The winner’s curse
We need to be careful what we wish for! It is not a great leap to note that if we abdicate fracture care to others, pediatricians and family physicians will be seeing simple, “bread-and-butter” fractures in the ED and the office, leaving only the more complex fractures for orthopaedists.

Although adequate on-call emergency orthopaedic care is a worsening problem, orthopaedists are still the most qualified physicians to provide musculoskeletal care. Orthopaedists want to serve their communities by providing orthopaedic emergent care, but this requires that we work together with other stakeholders to find solutions that we can all live with. The problem of providing emergency care won’t go away, but let’s keep what we do best and not give it away or let someone else take it.