Call stories

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RadOncAnon

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A lot of other specialty forums have their fun "call story" threads so I thought I'd start one for ours.

So I got a page ~ 10 pm last night.

60 y/o M w/ biopsy-proven widely metastatic NCSLC. He had a one month h/o worsening back pain and a few day h/o of worsening lower extremity weakness. When he woke up on the morning of admission, he could barely move his legs.

Admitted to Medicine, MRI ordered that showed cord compression @ T5-T7 inclusive.

Medicine intern: Hi is this Radiation Oncology?
Me: Yes, what's up?
Intern: <relates story above>
Me: Sounds like a convincing story, did you start him on steroids?
Intern: Yes, we gave him a 10 mg loading dose and then 4 mg q 6h.
Me: OK, what did Neurosurgery say?
Intern: We paged them as well, one of their residents is coming down.
Me: Well it sounds like you guys did a dynamite work up. Just so you know, <quote Patchell study>*
Intern: Thanks, good to know.
Me: Anyway we will staff this tomorrow, I will talk to our chief resident first thing in the morning, good night. <I go back to sleep with my beautiful wife>
Intern: Good night <hangs up phone in disgust as he is paged by the ED for yet another admission>

*Patchell Study: also known as the holy grail of RadOnc call. Basically a prospective, randomized trial that showed surgical decompression + XRT > XRT alone for cord compression caused by metastatic disease.

Anyways, after a hellish intern year full of worthless admissions and broken, sleepless nights I have to say that this was a pleasant change.;)

The kicker to the whole story? I sauntered up to the medicine inpatient floor ~ 10 am the next day, saw the pt did a full exam and spoke to both the pt and his family. Then I went off to discuss the case w/ the attending. The neurosurgery resident (bless his soul) did the exact same thing except he did so @ 1:30 am . . .
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very hospital dependent. How about my resident who was called the other night because the primary team was "sitting around talking" and thought that may be rt to the asymptomtic liver mets of their patient could "decrease tumor burden" and may that would prolong surivial? Or the not as uncommon as you'd think RT to a compression fraction of a verterbral body? more later.
 
stephew said:
very hospital dependent. How about my resident who was called the other night because the primary team was "sitting around talking" and thought that may be rt to the asymptomtic liver mets of their patient could "decrease tumor burden" and may that would prolong surivial? Or the not as uncommon as you'd think RT to a compression fraction of a verterbral body? more later.
Click to expand...
which reminds me of one....
Called for b/l UE weakness r/o cord compression. C-spine MRI showed prolapsed disk, no soft tissue malignancy, which was confirmed by the neuroradiologist and neurosurgery. Interview revealed longstanding (like many years prior to ca dx) b/l UE weakness attributed to the same prolapsed disk. I didn't offer RT, but the med onc raised cain all the way to the top. We made the right medical decision. The accusation was we were too lazy and cheap to open the center to treat an emergency requiring radiation. Didn't know RT could cure prolapsed disks.
 
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Called tonight to see 54 y/o man. 3w SOB, occ hemoptysis, f/c/s, significant wt. loss. Long time smoker. Chest CT shows giant R hilar/mediastinal mass, lung still inflated, some impingement on vascular structures. Question to me: do you want to radiate now so he doesn't lose blood supply to his lung? (a new question to me, I must admit).

Of course, he just walked through the door tonight, so no biopsy. I went to see him to be polite. He was speaking easily, in no distress, O2sat 100% on room air. No RT tonight (honestly, if you wanted to take a stab at guessing the histology based on the CT, I'd say it's small cell, and he should get chemo).
 
3dtp said:
which reminds me of one....
Called for b/l UE weakness r/o cord compression. C-spine MRI showed prolapsed disk, no soft tissue malignancy, which was confirmed by the neuroradiologist and neurosurgery. Interview revealed longstanding (like many years prior to ca dx) b/l UE weakness attributed to the same prolapsed disk. I didn't offer RT, but the med onc raised cain all the way to the top. We made the right medical decision. The accusation was we were too lazy and cheap to open the center to treat an emergency requiring radiation. Didn't know RT could cure prolapsed disks.
Click to expand...

the way to deal with this: a nice chart note. Thank you for this consult. Write up the whole thing. History, physical. In your conclusions: findings : prolapsed disk. Not randomized controlled trials to support the use of radiation in the treatment of prolapsed disc. Thank you very much for this consult. discussed with attending who concurs. We had a similar care recently.
 
IndyXRT said:
Called tonight to see 54 y/o man. 3w SOB, occ hemoptysis, f/c/s, significant wt. loss. Long time smoker. Chest CT shows giant R hilar/mediastinal mass, lung still inflated, some impingement on vascular structures. Question to me: do you want to radiate now so he doesn't lose blood supply to his lung? (a new question to me, I must admit).

Of course, he just walked through the door tonight, so no biopsy. I went to see him to be polite. He was speaking easily, in no distress, O2sat 100% on room air. No RT tonight (honestly, if you wanted to take a stab at guessing the histology based on the CT, I'd say it's small cell, and he should get chemo).
Click to expand...

lose blood supply to his lungs?
someone needs to go back to anatomy class.
BTW who here knows a good simple PE test for SVC syndrome?
 
btw inspite of Ct findings, most likely cause in NSC lung. and youre absolutely right to see him. not just to "be polite". you want YOUR assessment of the case. You dont want to leave it to some resident who wants you to irradiate so patient doesnt "loose blood supply to the lung"
 
i once played a mean practical joke on a junior by calling in a fake consult that was rather grotesque. cracks me up to this day.
 
stephew said:
the way to deal with this: a nice chart note. Thank you for this consult. Write up the whole thing. History, physical. In your conclusions: findings : prolapsed disk. Not randomized controlled trials to support the use of radiation in the treatment of prolapsed disc. Thank you very much for this consult. discussed with attending who concurs. We had a similar care recently.
Click to expand...
Which is exactly what we did. Only problem with this type of consult is the patient gets an unnecessary bill.
 
Not to be a downer, but knowing what I knew as a 3rd year medical student about radiation oncology, if I was a medicine resident, I'd probably have the same questions/consults ... They are asking for our expertise. Even if it is a prolapsed disc. Hell, pretty soon I won't even know what the protocol is for chest pain.

I did get asked if a patients' fever could be attributed to the photons. I said I wasn't sure, but the patient hadn't started treatment yet, so I was pretty it wasn't the cause in this case :)

-S
 
3dtp said:
Which is exactly what we did. Only problem with this type of consult is the patient gets an unnecessary bill.
Click to expand...

actually not true. all inpt services are included in one (at least in boston). anyway trust me, your consult wont be breaking the bank.
 
3dtp said:
Venous distention in the neck that gets worse when lying flat?
Facial swelling with hoarseness before steroids?
Click to expand...

another one i was thinking of. something you can manipulate.
 
stephew said:
btw inspite of Ct findings, most likely cause in NSC lung. and youre absolutely right to see him. not just to "be polite". you want YOUR assessment of the case. You dont want to leave it to some resident who wants you to irradiate so patient doesnt "loose blood supply to the lung"
Click to expand...

By being polite, I was more referring to the fact that there was no tissue diagnosis. The attending I was on call with has a strict "no tissue diagnosis = no RT" policy. Had I not been in the office doing paperwork anyway, I might have been tempted to delay the consult until a weekday based on that.
 
While what you are saying is true, specialty consults should probably not be requested without the attending's approval, for this exact reason. Obviuosly, some attendings (like the one in this case) are not that bright.

SimulD said:
Not to be a downer, but knowing what I knew as a 3rd year medical student about radiation oncology, if I was a medicine resident, I'd probably have the same questions/consults ... They are asking for our expertise. Even if it is a prolapsed disc. Hell, pretty soon I won't even know what the protocol is for chest pain.
-S
Click to expand...
 
ive got one brewing which may get make it into the annals
 
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