EPs often seek consults from various on-call specialists, but not as frequently if the issue is dermatological. “It is rare to be able to get dermatology consults in the ER in most hospital systems,” says Sahand Rahnama-Moghadam, MD, MS, assistant professor of clinical dermatology at Indiana University.

As a hospital dermatologist at the largest hospital in Indiana, Rahnama-Moghadam sees patients transferred from all over the state, specifically because there are no dermatologists to see them in EDs. “I also noted that some doctors — ER doctors, hospitalists, and infectious disease specialists — would be sued because they had trouble identifying or managing a severe dermatologic disease,” Rahnama-Moghadam says.

This seemed problematic, since these doctors are not trained to manage dermatologic diseases. “I wanted to do a study to shine a light on this,” Rahnama-Moghadam says.1

One surprising finding: No dermatologist was sued. “In retrospect, this makes sense. ED physicians would be sued because they have to make contact with all patients; they have to manage everything,” Rahnama-Moghadam says.

Sometimes, EPs call infectious disease specialists or rheumatologists for a challenging condition. Those patients have rashes, so the specialist is “roped in” to the case because he or she is available. “But this is clearly not a substitute for a hospital dermatologist. It puts everyone (the patient and the doctors) at peril, whether that is physical or legal,” Rahnama-Moghadam explains.

The hope is hospitals will become motivated to hire on-call dermatologists for the ED setting. “This should be a wake-up call for hospital systems, especially ones that advertise themselves for their quality. These systems should see the value of a hospital dermatologist who supports the other specialties in diagnosing and managing these conditions,” Rahnama-Moghadam says.

Without this type of dermatologist, there is a gap in the specialty care provided in the ED. It means other specialists consulting on dermatology patients in the ED choose between two bad options. Either the consultant manages conditions outside their scope, or they transfer the patient far from home and family to an academic medical center. “Transferring patients with skin disease is not good patient care, and sometimes not possible if the patient is too ill,” Rahnama-Moghadam says.

EPs can pursue education to become more familiar with hospital dermatology, such as lectures or courses. “But it is not realistic to expect someone outside the field of dermatology to be proficient in managing these rare diseases,” Rahnama-Moghadam cautions. To reduce patient safety and legal risks, if EPs find hospital dermatologists valuable, “they should make their voices known,” Rahnama-Moghadam says.

REFERENCE

  1. Rumancik B, Keele BJ, Rahnama-Moghadam S. Characterization of medical malpractice lawsuits relating to dermatologic emergencies in the inpatient and emergency setting. J Am Acad Dermatol 2020; Feb 14;S0190-9622(20)30223-1. doi: 10.1016/j.jaad.2020.02.015. [Online ahead of print].