The Rural Surgeon

Rural Surgery - A View From the Front Lines: “I need to transfer this patient”


Nobody is happy when a patient needs to be transferred. A patient transfer is an unplanned event for all parties involved: the patient, the family, the surgeon requesting a transfer, and the accepting surgeon or physician.

Dr. Mark Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

Dr. Mark Puls

It’s a fact of life that a rural surgeon will, at times, need to transfer patients to a larger center. The reasons should come as no surprise to any surgeon. Sometimes there are simply not enough ICU beds, ICU nurses, ventilators, or respiratory therapists to care for patients. At times, very complicated surgical patients will present through the ED and sometimes a work-up on a hospitalized patient may reveal a complex surgical problem. Despite the best efforts of a rural surgeon, surgical complications will occur and a transfer can be the wisest choice. Trauma patients, especially those with a neurologic injury, will often need to be transferred. And then there is the exhaustion factor: A long stretch of on-call duty, or a series of difficult, time-consuming patients can deplete the mental and physical resources of a rural surgeon and the next patient who comes in the door with a complicated surgical issue will be transferred.

The transferring of patients from a rural hospital to a larger medical center with higher-level technology on hand is becoming more common. An example of this would be a patient with a blunt splenic injury. In years past, this patient could be carefully followed in a rural hospital, and a splenectomy could be done if necessary. With the ability of interventional radiologists to control splenic bleeding by embolization techniques, some of these patients do better if transferred to a larger center. Some rural hospitals used to operate on patients with a ruptured abdominal aortic aneurysm, but now many of these cases are transferred so that the patient can be treated with endovascular techniques. Some patients with GI bleeding are now transferred for possible treatment with embolization techniques.

In many ways, it has gotten easier in recent years to transfer a patient from a rural hospital. Almost all tertiary hospitals now have a transfer team or transfer coordinator that will determine bed availability, and arrange for a conference call between the rural surgeon and the accepting surgeon and other physicians at the larger hospital. Cell phones have allowed for much quicker communication between physicians. Many rural hospitals are now owned or affiliated with a larger medical center, which can allow for a quick transfer. As a result of Emergency Medical Treatment and Active Labor Act laws, a patient’s medical insurance status should not be a determining factor in a transfer.

Although transfers are easier than they once were, it should be noted that a transfer is not the easy or preferred option for most rural surgeons. Many rural surgeons inwardly groan when they realize that a patient needs to be transferred. Most surgeons can’t help having a feeling of defeat when a transfer is needed. Transfers can be very time-consuming, partly because there is usually no transfer team at a rural hospital and the surgeon has to be involved in making the arrangements and speaking with physicians at the larger center.

Because of the time commitment required for a transfer, it’s very important for the patient and his or her family to make a quick and definite decision about where they’d prefer the patient to be transferred to. Occasionally, after investing time to arrange for a transfer to a larger center, the rural surgeon is told that the accepting hospital will accept the patient, but that there are no open beds, which can mean that the patient can be waiting for several days for the transfer to occur, or that the rural surgeon needs to start the transfer process over again with another center. All this means can mean a further investment of time by the rural surgeon.

Ambulance transfer, whether by ground or air, is another complicating factor in transferring a patient. Medicare will pay the base rate and mileage for a medically necessary ambulance transport to the nearest facility that can care for the patient. Private insurance companies follow suit on this issue. If a patient and the family choose to go to a hospital that’s further away than the closest available facility, the patient will be required to pay for the extra mileage involved in the transfer. During a surgical emergency, patients and their families may have a difficult time with this concept, and it can fall to the surgeon to walk them through the decision and its financial implications. More time devoted to the transfer.

Since the rural surgeon best understands the reasons for the transfer, the rural surgeon should be the one making the phone calls to the larger center, and participating in the conference calls with the accepting physicians. This process should not be delegated to the hospitalist or anyone else. The rural surgeon should also take great care to ensure a complete record is sent with the patient and that pertinent x-ray studies are sent on a CD. The rural surgeon should make it clear to the accepting physicians that he/she will do whatever they can to help care for the patient once the patient returns home.

After the transfer has occurred, the rural surgeon should communicate with the accepting physician periodically to follow the patient’s progress. If the rural hospital and the accepting hospital have the same EHR system, the rural surgeon should follow the progress of the patient and communicate with the accepting physician through the EHR email system or some other means. It’s also very helpful to obtain a cell phone number of the patient, or of a key family member, so that the rural surgeon can communicate with the family after the transfer to monitor the patient’s progress.

There are several important principles regarding transferring patients. First and foremost, accepting physicians at larger hospitals should be treated like gold. A wise rural surgeon keeps a list of accepting physicians that he/she has worked with in the past, as well as their cell phone numbers and email addresses. A good reputation as a surgeon requesting a transfer is very helpful, and part of that is never looking to “dump a patient.” A rural surgeon also must work hard at “networking” to get to know personally as many surgeons and physicians at accepting hospitals as possible. This takes effort, but can be accomplished by being active in the state American College of Surgeons Chapter, regional surgical societies, or state medical society. Personally visiting accepting hospitals, and meeting the surgeons and specialists there, is another great way to develop personal contacts. Every experienced rural surgeon knows that personal connections can pay off in many ways, and in particular, making transfers much easier.

The need for patient transfers from rural hospitals will never go away. Rural surgeons certainly appreciate all the help they receive from larger hospitals when it becomes necessary. As a rural surgeon, I would like to thank all surgeons and physicians at larger facilities that help us care for rural patients. Rural surgeons and physicians at larger hospitals need to continue to work together to achieve the best results possible for patients.

Dr. Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

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