When it comes to hand injuries, do you know what to tackle yourself, when to call the orthopedist or general plastic surgeon, and when to call a hand surgery specialist? ACEP Now Medical Editor in Chief Kevin Klauer, DO, EJD, FACEP, recently sat down with hand surgeon Scott D. Lifchez, MD, FACS, to shed some light on these questions and to explore the professional relationship between emergency physicians and hand surgeons.

Dr. Lifchez is associate professor of plastic surgery and orthopedic surgery, program director of the Johns Hopkins/University of Maryland plastic surgery residency program, and director of hand surgery at Johns Hopkins Bayview Medical Center in Baltimore. He’s also a member of the American Society for Surgery of the Hand (ASSH), the biggest national organization of hand surgeons in the United States, with about 2,500 to 3,000 active members who are certified in the subspecialty of hand surgery.

Here are some highlights from their conversation.

KK: What is the short list of those things that really need your level of expertise that can’t be handled by the general orthopedist or the general plastic surgeon?

SL: The obvious lead one would be digital amputations. For the most part, the generalists don’t do that or wouldn’t feel comfortable doing that. Some things that might be better treated by a hand surgeon are necrotizing infections of the hand and compartment syndromes of the hand. While in theory a hand surgeon might be better at handling them, the acuity may not allow enough time for the patient to get to the hand surgeon or the hand surgeon to get to the patient. Mangling injuries involving multiple tendons and/or multiple bones of the forearm, wrist, or hand are things that typically the general plastic surgeon or orthopedist is going to correctly say, “That’s beyond what I can do.”

KK: What about other specialized types of fractures, like Bennett’s or Rolando’s?

SL: Those often do not need to take a helicopter ride in the middle of the night. Those of the carpometacarpal (CMC) joint, Bennett, Rolando, perilunate injuries, and scaphoid injuries are probably best served by somebody with hand expertise. It gets a little contentious when we start talking about the distal radius. Hand surgeons generally believe that we do the best job, but orthopedists, or especially orthopedic traumatologists, will rightly say, “We take care of the most of these in the US, and we do a good job.” There’s some overlap, but I would agree that certain carpal bone injuries, especially those needing surgery and CMC joint injuries, often do need a hand surgeon.

KK: From an emergent transport or transfer standpoint, it’s probably just a small number that you would say, “Listen, I need to see them tonight.” What would some of those things be?

SL: The mangling injuries usually need to get to somebody who can give definitive care pretty quickly. Finger or thumb amputations also. The research says that if you get them within 24 hours, it’s the same as if you get them on within two hours, but understandably, it is a very high-end and anxiety-inducing injury for the patient, their family, and the initial provider who is seeing them.

KK: I want to circle back for a minute on the workforce. Do you and the ASSH really feel like you have met the workforce needs for hand surgery in the United States?

SL: As far as I know, we aren’t doing any initiatives to try to grow the number of hand surgeons. We are trying to make sure that those communities that may be too small to support a hand surgeon full-time know where their nearby hand surgeons are, how to get to them, and when they need them.

KK: Roughly how many graduates are coming out of hand fellowships every year?

SL: That number is around 150 per year.

KK: Tell me, from either your personal perspective or things that you’ve heard, what are some of the things that are frustrations about the emergency physician–hand surgeon relationship?

SL: I think there’s both the academic training institution perspective and then there’s the community perspective. I am mostly in an academic institution. The complaint we often get is the sometimes seemingly ultra-low threshold to call somebody with the rationale of, “oh, they need to learn how to do this because they are a resident in training,” or, “we’ve got 27 other things to do.” We sometimes will get some calls for a paronychia or a rule-out paronychia, or calls about a minimally displaced boxer’s fracture that just needs a splint and a clinic visit. Those can be very frustrating. I want my residents to learn, but at the same time, they don’t need to see their twelfth one at two in the morning. From the community standpoint, I know that there’s certainly a higher level of intervention that the attending emergency physicians are willing to do. We need to make sure that the emergency medicine residents know, if they are in the community, they’re supposed to be reducing the metacarpal fracture. They’re supposed to be draining the paronychia, and they need to be able to do a straightforward distal radius reduction.

Another complaint I’ve heard is where the emergency physician will just put the patient in a splint, which was reasonable, but then they’ll bill the patient not only for the visit but for CPT codes for closed management of a fracture, which are supposed to be used for managing a fracture for 0 to 90 days. I think it’s totally appropriate if an emergency physician does the reduction, but if they’re just putting the patient in the splint and then somebody else is going to do all of the management, I think that’s not appropriate.

KK: From your perspective as a hand surgeon, in what ways, if any, can we improve care?

SL: I would start with just good-quality splint application. I know many emergency departments are big fans of Ortho-Glass because it’s so user-friendly, but it doesn’t always immobilize the fracture well. If it doesn’t get molded well, the fracture that started out in a good position may not stay there, and then a second intervention is needed. I see patients come into my office with a full-length aluminum-foam splint going from the fingertip to the distal forearm for metacarpal or fingertip injury. It is very uncomfortable for the patient, and either goes much longer than it needs to or the splint stops right where the fracture line is.

KK: What is your society’s perspective on the on-call physician’s responsibility under EMTALA, and how do your society and hand surgeons view that responsibility?

SL: Even within our society we don’t fully agree, so I can’t really say that we have a position on it. There are those who say once you’re on the schedule, you’re on the hook. There are those who say, “I’m on the hook to be called, but I have a right to say that I can’t do this.”

KK: It’s a frequent misconception that at least one follow-up visit is required under EMTALA. A lot of the care we provide in emergency medicine is uncompensated, and we are proud to deliver that care. How committed are hand surgeons to actually getting that patient a follow-up visit?

SL: If they have no insurance, we just take care of it. However, I understand the pressures in the community where the physician says, “Look, I’ve got to keep my lights on. I have to pay my office staff, and if I do too much of this care for free, I can’t provide care to anybody because I can’t even make an even bottom line.”