This question was originally posted on Quora.com and was answered by Sheaffer Williams, Anesthesiologist I’m going to weigh in here because what pisses a surgeon off in this case pisses every one off. Out here in the hinterlands, we have what are known as “Critical Access Hospitals”. These are hospitals with around 25 beds located 15 - 30 miles from any larger facility. To encourage these rural hospitals…“CAHs are paid for most inpatient and outpatient services to Medicare patients at 101 percent of reasonable costs.” https://www.cms.gov/Outreach-and... What does this mean? It means that a hospital and a surgeon can make 41% more money for doing a surgery at a CAH than they would make at a larger facility. For example a total knee or hip done at a free standing surgery center is reimbursed at 60% of reasonable cost. So you can see that there is quite an incentive to do surgery when you do 41% better financially. Most reputable surgeons will do minor outpatient surgeries in these hospitals but send older, sicker patients to a larger venue where the margin of safety is higher for their post-op recovery. Money is like poop. Where there’s a pile of it, flies are sure to follow. In this case small hospital administrators want more of it (money, not poop) and they don’t like it when surgeons refer patients out. How do they get around this problem? Enter the Fly-in Surgeon. These are surgeons from the larger cities who often have a private plane or a service that flies them and various crew (scrub tech, anesthesiologist, nurse) in to the remote small town’s airport. They fly in in the morning, operate all day, and fly out at night. Sounds great right? Have your spine surgery or total joint surgery done in your own home town just down the street. What could possibly go wrong? Let me tell you a little story that illustrates the answer. This represents no specific case but is a composite illustrative of my general experience. I’m sleeping soundly in my little anesthesiologist’s bed when my phone goes off. The ER doc on the other end sounds pretty worried. She tells me a terse medical story about a patient from an outlying critical access hospital who had had a multiple level anterior neck fusion. In the night their neck began to swell and they were found on the floor of their room unconscious and barely breathing. The small hospital’s night nurse called the CRNA in from home but they were unable to intubate because of the swelling. During the attempt, the patient’s airway completely closed off and they went into respiratory and then cardiac arrest. An esophageal obturator airway was stuffed in and a little air was exchanged. After a few chest compressions and some epinephrine, their heartbeat returned. Our hospital’s helicopter ambulance was dispatched to the scene. The poor unfortunate patient is choppered in the 30 miles to our hospital and dropped off in the ER with their airway beginning to close off. Flight nurses were not comfortable tangling with the swollen airway. Things worsened in the 15 minutes they were flying. It was becoming difficult to ventilate and the patient’s stomach was now grossly distended from leaked air. The amount of air entering the lungs is decreasing. The ER doc sounds a little desperate as she asks me to come in ASAP. I have them call the ENT surgeon and drive like a banshee to the ER. We meet at the bedside. He looks at the swollen neck and expresses doubt as to whether he can get into the trachea or find the cricothyroid membrane fast enough to help if things go south. He marks the likely surgical entry in purple skin marker just in case and gives the area a swipe with surgical skin prep. O2 sats are dropping into the 70’s so the time for discussion is fast fading. I remove the Obturator airway and suction. I go in with the videoscope. I struggle and swear (trust me it helps). Some RT student starts reciting the O2 saturations as if I am deaf and cannot hear the friggin’ beeping as it descends into the bass range. I select a black slit where the correct hole should be amid the distorted and swollen anatomy and screw the tube into the hole and inflate the balloon. We attach an end-tidal CO2 monitor and …Success! The ETCO2 pegs out at 120. The bass beeping of the O2 monitor rises in pitch to a lovely treble. The RT places a tube holder and I order a stat chest x-ray. We took the patient to the ICU but they never regained consciousness. The brain had been severely damaged by time without oxygen. They died a week later of multiple organ failure. I’m not sure if the fly-in surgeon ever heard about it or whether the other hospital recorded it as a peri-op mortality so the government would be aware. I’m quite certain that it wouldn’t get back to the small community and that this scene may occur again. TLDR: So to eventually answer your question. What surgeons hate is when other surgeons fly in to a small hospital with inadequate facilities and no medical presence in the hospital at night. They hate when these surgeons do large, complex surgeries on poorly selected candidates. They hate that, at the end of the day, the fly-in surgeon takes their anesthesiologist and their personal scrub and fly out of the state. They hate dealing with the fly-in surgeon’s errors, their post op emergencies, and their post op infections. Surgeons really hate dealing with the families of the people who suffer from fly-in complications who are angry and who often take it out on staff. Source
