Dr James Auran Explains Challenges Faced by On-Call Ophthalmologists

James Auran, MD, a professor of ophthalmology at Columbia University Irving Medical Center and president of the American Society of Ophthalmic Trauma, discusses how a lack of providers has created a crisis in the United States.

When on-call ophthalmologists get called in to perform trauma care, the chances of getting reimbursed are slight, said James Auran, MD, a professor of ophthalmology at Columbia University Irving Medical Center and president of the American Society of Ophthalmic Trauma.


What are some of the legal and ethical challenges on-call ophthalmologists might face?

Surprisingly, legally, the chance of getting sued for trauma care, especially if you do it right, is really not that impressive. Some of our group, we've published a paper which just came out, we show that it's not the problem that I think people perceive it is. The key thing is to know what you're doing when you're going through trauma. One of the big problems is, well, there's a crisis in this country. There's a crisis because there's not enough doctors available to cover the health care facilities and to cover the entire population. A big part of this is because the doctors don't get paid to do this. Either there's no payment for call, for trauma call. And when you get called in, the chances0 of getting reimbursed for a trauma patient are slight. They unfortunately come in in the middle of the night, they come in on weekends. It's a crisis not only in the civilian world, but when it comes to the military, every time hostilities breakout, which is all too frequently, the military needs people who can handle ophthalmic trauma. Blast injuries often involve the head, often involve the face, and involve very devastating injuries to the eye. One thing that scares doctors away is that trauma involves 3 basic specialties. And nobody I know is good at all 3 of them. It involves oculoplastics, managing lacerations of the orbit and lid, and orbital fractures. It involves retina vitreoretinal, involving posterior segment ruptures. And it involves anterior segment trauma, cornea and lens. Although some of the retina doctors can handle the latter 2, I know of no one who can handle all 3. So it makes for a scary situation.

One of the things we're trying to do in the American Society of Ophthalmic Trauma is demystify it. Helping doctors understand how they can handle things that they're not qualified to surgically correct, but they can temporize. Everyone who has a degree in medicine who is board certified in ophthalmology really should have the capability of evaluating trauma. There's only, I'd say, 3 categories of trauma that need immediate care and every ophthalmologist should know how to take care of that. One is chemical burns, continuous irrigation. Secondly, is orbital compartment syndrome. There's a bleeding for example, behind the eye, the pressure's building up and crushing the nerve in the blood supply, decompressing it with a lateral canthotomy and lateral cantholysis. Everyone learns that in their medical school. The third category is if there is entrapment of the inferior rectus causing cardiac rhythm disturbances, decelerations, tachycardia or bradycardia, or an orbital entrapped inferior rectus in a child, inferior orbital floor fracture that needs to be taken care of right away, not necessarily by the covering doctor. They just have to make sure it's taken care of quickly. But everyone should be able to evaluate all the other traumas that come in. And most of the time, it's just a matter of covering with antibiotics, perhaps giving posttrauma tetanus prophylaxis, and protecting the eye until the patient can be transferred to a facility where they can have appropriate oculoplastic, orbital, or vitreoretinal repair.