An _Ivory Tower_ is supposed to be the tertiary referral center where they know everything and can take care of all difficult patients. So why is it when I have a specific need for a higher level of care that one of my _local_ Level 1 trauma centers, University of California, San Diego, balked.
I had a difficult patient. Suffice it to say that I needed someone capable of performing endovascular thoracic stent grafts. I was given contact by the patient’s insurer. I spoke with the Trauma fellow and the classic response was..
> Don’t you have a closer Level 1 Trauma Center?
Now I later did speak with a Cardiac Surgeon at Cedar’s who was willing and able but in the end the patient’s concomitant injuries were enough to have family withdraw supportive care. Back to the **real** problem.
When I was a resident our Attending Staff only wanted to know the answer to one question.
> Do you want to send the patient by ground or by air?
As he explained one day. We were here at the university, the _ivory tower_. We were expected to provide support and assistance to the surrounding communities’ surgeons. It was never a question of whether or not someone had insurance or that they were beyond salvage. We were there the help. In this case, help our fellow surgeons.
I guess in the 11 years since I’ve finished residency a lot has changed. Unfortunately, not for the better.