Opinions on case?

[Zebra Hunter]

30 something y/o gentleman presents for right hand wound infection. Pt was previously seen in our ED three days prior for lacerations to b/l hands after getting into a fight with a window. He was imaged for retained FBs (none found), sutured up, and d/c'd. Pt then presented to an outside facility 1 day prior to presentation for swelling and pain in his R hand. His hand was imaged, which demonstrated multiple retained FBs, was started on bactrim, and told to return to us. Pt now is presenting with a swollen hand with significant purulent drainage from sutured lacerations. No fevers or n/v.

PE is significant for significantly swollen R hand up to wrist with fingers held in flexed position. There is a 5 cm laceration to the dorsolateral aspect of hand. Purulent drainage is present on exam. There is no flexor tendon tenderness on palpation or flexion. Pt was tachy to 110s.

Pt showed me his X-Rays that he took a picture of at the outside facility which clearly demonstrates retained FB. We get repeat imaging, and are unable to visualize any FBs. We got basic labs which demonstrate WBC of 11.

We decide to remove the sutures, start IV vanc and IM rocephin, consult hand, and plan to admit for IV abx and potential OR for wound washout.

I call Hand surgeon on call. Hears the story and asks, "why am I being called about this? This should've been taken care of by the outside hospital's Hand surgeon or Hand should've been consulted when he first presented here."

I told him unfortunately neither of those things happened so now we are consulting you, and would like you to come see him. He replies "just d/c him with clinda". I tell him we are not comfortable d/cing this pt given signs of systemic infection and are planning to admit. He again states that we should d/c pt with clinda.

We admit anyway to medicine.

I'm an intern, I don't have much experience yet, so I'm not sure if it's common to send these pt's home, however, neither I nor my attending felt comfortable doing so. What do you do at your shop, especially if ortho is telling you to send him home?

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[LuckyMD2b]

I'm a general orthopedist who takes hand call. This is actually a very common scenario. You did the right thing. There is no question that patient needed to be admitted and will likely need debridement in the OR.


Unfortunately in this case it is not uncommon to get push back from the on call guy. However, you are seeing the patient the surgeon isn't.

there are many times I've gotten called for things that don't need an orthopedic consult and on the other hand there are times I've thought "why are they calling me for this" then I go see the patient and am surprised by how bad the situation looks in person.

You have to stand up to your consultants when it is in your patient's best interest.

Good luck.

 

[Zebra Hunter]

I'm a general orthopedist who takes hand call. This is actually a very common scenario. You did the right thing. There is no question that patient needed to be admitted and will likely need debridement in the OR.


Unfortunately in this case it is not uncommon to get push back from the on call guy. However, you are seeing the patient the surgeon isn't.

there are many times I've gotten called for things that don't need an orthopedic consult and on the other hand there are times I've thought "why are they calling me for this" then I go see the patient and am surprised by how bad the situation looks in person.

You have to stand up to your consultants when it is in your patient's best interest.

Good luck.

Thank you for your input. I think I was definitely afraid to push harder while talking to hand because I didn't want to burn any bridges with consults in my second month of residency. I figured medicine would end up consulting him anyway.

 

[Perrin]

You did the right thing. Admit all day every day for this. He has multiple retained FB in hand, failing outpatient abx therapy, pussed out hand, it's his freakin' hand, systemic symptoms, just pick one for an easy admit. Hand surgeon sounds like he/she is upset about having to deal with a CF and probably feels like they are being dumped this pt. Bottom line is, you're the 3rd contact this guy has had with the medical field for a worsening problem, obviously something the previous folks have done isn't working. Remembering the definition of insanity, it's time to do something different.

 

[deleted547339]

Young guy losing function of his hand = bad news. Hand surgeon would 100% throw you under the bus in court "well, I said he COULD dc him with clinda and he said 'fine, sounds great!' - if he told me how bad it was I would have taken him to the OR immediately. I never actually saw the patient, the ER doc messed up, not me"

As a new intern, you should know that hand stuff is one of the top 10 reasons for lost malpractice cases in EM (maybe top 2-3 IIRC).

You did the right thing. This may even be a case worth getting in a fight over (seriously, a young guy losing function of his hand is a REALLY BIG DEAL). If a consultant does that, I tell them that I am formally requesting a consult. If someone refuses a consult, that is a BIG deal to the hospital and you should talk to hospital administration, because in that case they are paying for a consultant who isn't fulfilling his or her duties. If he says "sure, admit to medicine for IV abx and I'll see them in the morning" I would not make a big deal out of it.

But DON'T get into a pissing match with a consultant in the note - stay professional. Simply document "discussed patient presentation and physical findings with Dr. Hand at time X at which time I formally requested a hand consult. I informed the surgeon that I am concerned the patient needs emergent surgical evaluation and likely urgent debridement." That is all factual - leave it at that.

 

[Vandalia]

1) As discussed previously, you can never go wrong documenting facts.

2) My mind is definitely addled after a long - one of those - nights. However, I am a bit concerned that you - as an intern - are the one talking to the hand surgeon. Now there is tremendous diversity in training programs and the level of responsibility devolved on trainees. Now maybe you are at a VA or a mega county hospital where you are it, but... in a case where there is conflict with a consultant, especially when it is not a completely obvious "slam dunk" admit then that should be bumped to the attending level. It is not for an intern - less than 2 months in - to be fighting these battles.

I know it happens .... but it is not a good situation for anyone. Patient, resident, or consultant. It should be pretty obvious that a consult from an intern and from an attending are going to be viewed very differently. Human nature dictates that an intern's judgement is going to be questioned, while an attending's is much less likely to be.

Back when I trained, this was probably more common than I would expect today. But then again, maybe it shows how out of it I actually am.

 

[Zebra Hunter]

1) As discussed previously, you can never go wrong documenting facts.

2) My mind is definitely addled after a long - one of those - nights. However, I am a bit concerned that you - as an intern - are the one talking to the hand surgeon. Now there is tremendous diversity in training programs and the level of responsibility devolved on trainees. Now maybe you are at a VA or a mega county hospital where you are it, but... in a case where there is conflict with a consultant, especially when it is not a completely obvious "slam dunk" admit then that should be bumped to the attending level. It is not for an intern - less than 2 months in - to be fighting these battles.

I know it happens .... but it is not a good situation for anyone. Patient, resident, or consultant. It should be pretty obvious that a consult from an intern and from an attending are going to be viewed very differently. Human nature dictates that an intern's judgement is going to be questioned, while an attending's is much less likely to be.

Back when I trained, this was probably more common than I would expect today. But then again, maybe it shows how out of it I actually am.

It might not be the best thing for my patients, but I ask my attendings to allow me to speak with all consults, regardless of which patient it is. How else am I going to be prepared for difficult consults in the future? I do tell them whenever I run into trouble, however, so it's not like I'm operating on my own.

In this case, I let my attending know what was going on, and he said there was no need to call back because we are admitting to medicine regardless, and they will put in a formal consult.

 

[Daiphon]

It might not be the best thing for my patients, but I ask my attendings to allow me to speak with all consults, regardless of which patient it is. How else am I going to be prepared for difficult consults in the future? I do tell them whenever I run into trouble, however, so it's not like I'm operating on my own.

Spot on. Residency isn't just the medicine, it's the logistics. Kudos to you for trying to solve the problem yourself...

...that said, especially early on, don't worry about getting your attending involved if you get pushed back. Doing so isn't a sign of weakness, but rather one of maturity - knowing one's limitations is an important step in becoming a competent EP.

Think of it as a consult - when you're over your head or beyond your scope, you don't hesitate to call cards/gi/surgery/etc, so don't hesitate to involve me (doubly important as my name's on the chart, too).

Otherwise I agree with above - document it, but don't sow discord in the chart. Only bad things come of it.

Cheers!
-d

 

[Vandalia]

Two things:

1) There are a lot of things you need to learn in an EM residency. However, that does not mean you need to be doing them 2 months into your PGY-1 year. You should definitely be the one calling the consults to other residents (fellows) from day 1. Maybe even a slam-dunk case to an attending general surgeon (if such creatures exist in your training program.) However, sub-specialty attendings (especially plastics/hand) can be difficult even under the best circumstances. That is multiplied given a questionable case with some non-medical complications. Given all that, if it were me, I would make the call or leave it to a PGY2/3. In private practice, it takes a lot of work to build up enough trust to the point when you tell the hand/plastics guy "You need to come in and see this patient" that they trust you and come in without question. If I was an EM attending at a training program that consulted sub-sub-specialty attendings - not residents/fellows - I would be concerned about that relationship and would have more advanced residents (or me) handle the consult. But that is my policy. I would not resign in protest if it was handled differently.

2) However, my primary concern was that I read your post to mean that you did not get the attending involved after the hand surgeon refused ("admitted to medicine.") Since this was clarified, it makes me feel much better about the situation.

 

[Birdstrike]

30 something y/o gentleman presents for right hand wound infection. Pt was previously seen in our ED three days prior for lacerations to b/l hands after getting into a fight with a window. He was imaged for retained FBs (none found), sutured up, and d/c'd. Pt then presented to an outside facility 1 day prior to presentation for swelling and pain in his R hand. His hand was imaged, which demonstrated multiple retained FBs, was started on bactrim, and told to return to us. Pt now is presenting with a swollen hand with significant purulent drainage from sutured lacerations. No fevers or n/v.

PE is significant for significantly swollen R hand up to wrist with fingers held in flexed position. There is a 5 cm laceration to the dorsolateral aspect of hand. Purulent drainage is present on exam. There is no flexor tendon tenderness on palpation or flexion. Pt was tachy to 110s.

Pt showed me his X-Rays that he took a picture of at the outside facility which clearly demonstrates retained FB. We get repeat imaging, and are unable to visualize any FBs. We got basic labs which demonstrate WBC of 11.

We decide to remove the sutures, start IV vanc and IM rocephin, consult hand, and plan to admit for IV abx and potential OR for wound washout.

I call Hand surgeon on call. Hears the story and asks, "why am I being called about this? This should've been taken care of by the outside hospital's Hand surgeon or Hand should've been consulted when he first presented here."

I told him unfortunately neither of those things happened so now we are consulting you, and would like you to come see him. He replies "just d/c him with clinda". I tell him we are not comfortable d/cing this pt given signs of systemic infection and are planning to admit. He again states that we should d/c pt with clinda.

We admit anyway to medicine.

I'm an intern, I don't have much experience yet, so I'm not sure if it's common to send these pt's home, however, neither I nor my attending felt comfortable doing so. What do you do at your shop, especially if ortho is telling you to send him home?

It sounds to me like you did what was right and you have someone on the other end of the line not wanting to do his job, and who is playing games in a way to get out of work, allowing the patient to suffer. This unfortunately is all too common and I could list hundreds of examples like this I've been through in EDs. It turns my stomach to hear this because you're going to go through this many more times and it's painful. A lot of on-call doctors act this way unfortunately, and do so with impunity as supported and/or ignored by hospital administration.

I guarantee you it says nowhere in the orthopedic textbooks or on the Ortho/hand boards that the proper treatment of severe hand infections that have failed outpatient treatment and oral antibiotics in patients with abnormal vital signs is to,

"First be an -------. Then cavalierly and without thought, recommend a knee-jerk, one-size-fits-all repeat of a previously failed treatment course certain to be a limb-threatening failure. Then when prompted to get off gluteus maximus and perform ones job, dig heals in further, double down on work-avoidant passive-aggressiveness while deflecting the conversation away from what the patient's serious and legitimate medical needs are and towards whiny, irrelevant and retrospective criticism of previous treating physicians who are no longer involved in the patient's care."

And the Ortho/hand guy knows this is wrong and knows that he's putting the patient at risk. But he doesn't give a ----. He's doing it anyways, because he knows he can. And he's making it someone else's problem, because he knows more ethical people (you and the hospitalist) will certainly pick up the slack for his callous disregard for a patient's well being and lack of honor in stepping up to do what's right.

Unfortunately, you'll deal with this a thousand times more in your career. These are the things that make being a good doctor, and particularly a good emergency doctor, very hard and very emotionally draining. It's not the emergencies. It's these soul-sucking detours from what should be the simplest trip from point A to point B, created by every single systemic, personal, ethical, staff, consultant, administrative or patient failure to allow you to do what should be so very simple and routine.

Before you can build a certain level of experience and a certain level a respect from consultants it can be difficult and very frustrating. Fortunately, you'll get very good at identifying, deflecting and maneuvering through these minefields of passive-aggressive work-avoidant sabotage. It may sound like hyperbole to describe these bait and switch techniques of some consultants this way, but if you fall for these tactics, patients can die or lose limbs and you and only you will be blamed and held responsible, not the consultant who denies ever saying what you claim they did and who never signed the chart. Gaining experience combined with earned respect from a track record of competence, professionalism and assertiveness over time, will allow you to be much more equipped to deal with these situations.

PS-A classic EM board question is to present a case similar to this. One of the choices will be to do what the consultant tells you to do, as bait for an incorrect answer choice. Then they'll have doing what you did as the correct answer choice, to see if you second guess yourself in the setting of unethical or incompetent consultant recommendations, and to see if you know the difference.

Stick to your guns.

 

[link2swim06]

A few things to add...

1. I have actual sent pictures via text to consultants. A picture is a lot of time better than a verbal description and sometimes can get them to act more appropriately.

2. For this dude you are basically asking for likely debridement in the OR now. Sometimes saying what you 'think' needs to happen can help you get on the same page with the consultant. i.e. "Thank you for calling back, I'm Dr. link2swim06, one of the ER residents, I have a 30 yo male with a severe hand infection, I am concerned may need emergent debridement....(then go on with the whole story)" or "I have a 50 yo male with a concerning story for ACS that I am concerned needs admission to likely see cards and get serial troponin." This make it more clear why I am waking them up at 2am.

3. Using the correct terminology is KEY. Certain things equate to surgical emergencies. I use these terms upfront when taking with consultants I just woke up to put us on the same page. Things like nec fascitis, acute compartment syndrome, type a aortic dissection, etc will make it clear immediately you are calling them with an emergency and not bull****. You have to speak the language of the consultants when taking to consultants.

4. Be honest. Don't make up **** just to get them to come in. You need to have them trust the ED somewhat. Avoid calling them with crap that doesn't need them in the middle of the night.

5. Finally if they are not coming in then this needs to be a conversation between your attending and the consultant.

When I was an intern the biggest difficulty in calling consultants was lack of understanding of why you are calling them. Yes, you know you have a dude with a hand infection...but why are you waking up the hand surgeon at 2am. Eventually you understand..."I am calling consultant X to get the wound evaluated and likely debridement urgently." Or "I am calling hospitalist X to admit the pt for a MRI as he has signs of central vertigo" instead of..."I have this dude with really bad vertigo I'd like to get admitted."

 

[Vandalia]

3. Using the correct terminology is KEY. Certain things equate to surgical emergencies. I use these terms upfront when taking with consultants I just woke up to put us on the same page. Things like nec fascitis, acute compartment syndrome, type a aortic dissection, etc will make it clear immediately you are calling them with an emergency and not bull****. You have to speak the language of the consultants when taking to consultants.

4. Be honest. Don't make up **** just to get them to come in. You need to have them trust the ED somewhat. Avoid calling them with crap that doesn't need them in the middle of the night.

5. Finally if they are not coming in then this needs to be a conversation between your attending and the consultant.

When I was an intern the biggest difficulty in calling consultants was lack of understanding of why you are calling them. Yes, you know you have a dude with a hand infection...but why are you waking up the hand surgeon at 2am. Eventually you understand..."I am calling consultant X to get the wound evaluated and likely debridement urgently." Or "I am calling hospitalist X to admit the pt for a MRI as he has signs of central vertigo" instead of..."I have this dude with really bad vertigo I'd like to get admitted."

That pretty much articulates my point. I have no problem with how the original poster handled the case. However, as the attending, I would never put a young intern in that situation. PGY-3? Sure. Maybe even an intern in April. But not in August.

When you are dealing with someone who as an attending you know is going to be difficult, with a case you know he is going to complain about, it takes a certain amount of tact/persuasion to get him onboard. Now, that absolutely should not be the case. But unfortunately the difficult consultant is reality. It takes a certain amount of practice to be able to frame a consult correctly. That is why you start out with the residents who really have no choice in the matter.

But, the difficult consultant with a case you know he is going to go ballistic over is not something you start with on (essentially) day one.

 

[deleted547339]

That pretty much articulates my point. I have no problem with how the original poster handled the case. However, as the attending, I would never put a young intern in that situation. PGY-3? Sure. Maybe even an intern in April. But not in August.

When you are dealing with someone who as an attending you know is going to be difficult, with a case you know he is going to complain about, it takes a certain amount of tact/persuasion to get him onboard. Now, that absolutely should not be the case. But unfortunately the difficult consultant is reality. It takes a certain amount of practice to be able to frame a consult correctly. That is why you start out with the residents who really have no choice in the matter.

But, the difficult consultant with a case you know he is going to go ballistic over is not something you start with on (essentially) day one.

Maybe we're just hard on our 'terns (probably), but until it's really a cluster, we have the intern handle all of their own business. A lot of times, I'll coach them before they call. If the first conversation escalates or doesn't end how it should, we'll have him or her call back after some more coaching, at which point if the goal is not accomplished, the senior resident or attending will take over. Obviously this isn't hard and fast, but we make sure our interns handle their own business.

 

[Vandalia]

Fair enough. As someone who has had to build trust up with some of our consultants over the years I am a little protective of that relationship.

However, since it looks like we will be having residents/med students passing through in much greater numbers, I am working out in my own mind how we (I) will handle it.

EDIT: It is sort of funny, since I myself was thrown into the fire from day 1. However, I heard somewhere along the line that you often end up the opposite from how you were trained when you become the teacher.

 

[emergentmd]

Op did the right thing. Pt has retained FB, infected, failed outpt treatment. Next step is IV abx with likely washout. ITS a HAND. Repeat. ITS a HAND. Respect the HAND.

I rarely get these pushbacks but all you have to say is this in private practice and it will fix everything.

"Dr. on call, I feel this pt needs admission/consult. If you disagree, you can discharge the pt after seeing him. You are on call. If you will not see the pt, I will document this and arrange transfer. Please realize that this may result in an EMTALA violation."

Trust me, this will fix it. Involving Internal medicine without hand back up puts IM in a very difficult situation. It is not IM's battle to fight in house. It is the EM doc's battle to fight to assure hand involvement before admission.

 

[deleted109597]

Involving Internal medicine without hand back up puts IM in a very difficult situation. It is not IM's battle to fight in house. It is the EM doc's battle to fight to assure hand involvement before admission.

Agree with the first part, not with the second. It's not "our" battle to fight. It's administration's battle. Yes, advocate for the patient, but ultimately, I can't tell another doctor what to do or not do, other than simply stating that they are obligated to consult. If admin gets woken up because you have to call them about your potential EMTALA violoation due this clown monthly, it gets fixed a lot faster. Risk management also doesn't like getting called at night for preventable issues either.
Of course, so many of us have been beaten down that often I feel like I'm the only guy at my shop trying to do the right thing. It gets old, but every now and then it makes you feel better. And, when you get called on the rug you get the smug satisfaction of saying "I was doing what I thought was in the best interests of the patient, like it says so in the hospital charter/mission statement/corporate meme"

 

[vtucci]

Plastics/hand consults are often the most difficult. Agree with poster regarding pictures in the chart (or sending to specialist) and talking the talk. Your attending should have your back. Make sure you understand why you are calling the consult. This time in intern year often the greatest issue is being able to articulate why you need the consultant. Calling about MR #, located in Room 3, I am consulting you for x and I anticipate this (washout in OR). If you are not sure how to phrase it, run it by your senior resident or attending

 

[emergentmd]

Agree with the first part, not with the second. It's not "our" battle to fight. It's administration's battle. Yes, advocate for the patient, but ultimately, I can't tell another doctor what to do or not do, other than simply stating that they are obligated to consult. If admin gets woken up because you have to call them about your potential EMTALA violoation due this clown monthly, it gets fixed a lot faster. Risk management also doesn't like getting called at night for preventable issues either.
Of course, so many of us have been beaten down that often I feel like I'm the only guy at my shop trying to do the right thing. It gets old, but every now and then it makes you feel better. And, when you get called on the rug you get the smug satisfaction of saying "I was doing what I thought was in the best interests of the patient, like it says so in the hospital charter/mission statement/corporate meme"

I completely agree with this. My point is not a battle b/t me and the specialist. My point is I would not get another doc involved to battle the battle that should be done at the ED level. If you admit to medicine, plastics refuse to see the pt, where does that leave the internist? Atleast in the ED we have options which are much more than when they are admitted.

My steps for a difficult specialist is

1. discuss nicely
2. Inform that they need to see the pt b/c they are on call and bylaws state that they must come and consult
3. INform them that we will be transferring and they may have an EMTALA issue
4. Call Admin to tell them that we will be transferring b/c specialists refuse to see pt. I then wash my hands of the case and let admin decide if they want to force specialist to see or initiate transfer. I am too busy in the ED to referee this issue that is an admin/specialists issue. I try to move away from being the middle man as much as possible.

Plastics/hand/optho are the most difficult specialists to deal with.

 

[shookwell]

I would have admitted the patient to ortho. Never let a consultant tell you to discharge someone that you don't want to discharge, especially without them seeing the patient and writing a note in the chart. I would have made the attending orthopedist come see the patient if they didn't want an admission to their service. Then would have made that attending explain to the hospitalist why a medicine admission is appropriate.

Thankfully I work in a place where the ED attending has admitting privileges to every service in the hospital. The (x service) attending would have to come in to the ED and examine the patient, then either convince me not to admit or discharge the patient themselves. The other option is to discuss with the hospitalist and convince them to take the admission after which I am happy to admit to medicine (I do not play telephone or relay messages).

 

[iish]

A few things to add...

1. I have actual sent pictures via text to consultants. A picture is a lot of time better than a verbal description and sometimes can get them to act more appropriately.

2. For this dude you are basically asking for likely debridement in the OR now. Sometimes saying what you 'think' needs to happen can help you get on the same page with the consultant. i.e. "Thank you for calling back, I'm Dr. link2swim06, one of the ER residents, I have a 30 yo male with a severe hand infection, I am concerned may need emergent debridement....(then go on with the whole story)" or "I have a 50 yo male with a concerning story for ACS that I am concerned needs admission to likely see cards and get serial troponin." This make it more clear why I am waking them up at 2am.

3. Using the correct terminology is KEY. Certain things equate to surgical emergencies. I use these terms upfront when taking with consultants I just woke up to put us on the same page. Things like nec fascitis, acute compartment syndrome, type a aortic dissection, etc will make it clear immediately you are calling them with an emergency and not bull****. You have to speak the language of the consultants when taking to consultants.

4. Be honest. Don't make up **** just to get them to come in. You need to have them trust the ED somewhat. Avoid calling them with crap that doesn't need them in the middle of the night.

5. Finally if they are not coming in then this needs to be a conversation between your attending and the consultant.

When I was an intern the biggest difficulty in calling consultants was lack of understanding of why you are calling them. Yes, you know you have a dude with a hand infection...but why are you waking up the hand surgeon at 2am. Eventually you understand..."I am calling consultant X to get the wound evaluated and likely debridement urgently." Or "I am calling hospitalist X to admit the pt for a MRI as he has signs of central vertigo" instead of..."I have this dude with really bad vertigo I'd like to get admitted."

Holy smokes! Where on earth do you admit a patient with central vertigo to the hospitalist service for an MRI?!!?!?!?!? That sounds wonderful. How do I practice there?

All of these patients at my shop end up sitting in the ED for the 10+ hours it takes to get the MRI then we have a discussion with neurology as to dispo.

 

[southerndoc]

Holy smokes! Where on earth do you admit a patient with central vertigo to the hospitalist service for an MRI?!!?!?!?!? That sounds wonderful. How do I practice there?

All of these patients at my shop end up sitting in the ED for the 10+ hours it takes to get the MRI then we have a discussion with neurology as to dispo.

Seriously? They don't even question it when we admit. In fact, if it needs an MRI, we almost always admit them. The exception is if it's possibly surgical (i.e., cauda equina).

 

[deleted547339]

Holy smokes! Where on earth do you admit a patient with central vertigo to the hospitalist service for an MRI?!!?!?!?!? That sounds wonderful. How do I practice there?

All of these patients at my shop end up sitting in the ED for the 10+ hours it takes to get the MRI then we have a discussion with neurology as to dispo.

Thus is how it is where I'm a resident.

Seriously? They don't even question it when we admit. In fact, if it needs an MRI, we almost always admit them. The exception is if it's possibly surgical (i.e., cauda equina).

This is how it is where I moonlight.

 

[emergentmd]

Holy smokes! Where on earth do you admit a patient with central vertigo to the hospitalist service for an MRI?!!?!?!?!? That sounds wonderful. How do I practice there?

All of these patients at my shop end up sitting in the ED for the 10+ hours it takes to get the MRI then we have a discussion with neurology as to dispo.

Standard of care changes yearly and at different facilities.

At my primary shop, getting MRI in the past was difficult. Usually either admit for inpt MRI or discharge.

Now, I get MRIs regularly almost 24 hrs a day. I prob ordered more MRIs in the ED over the past 2 yrs than I did for the previous 13. Every time I ask Neuro a question, they usually tell me to get an MRI and discharge if neg.

Central vertigo is a slam dunk admit for an MRI +/- neuro consult. How do you send someone home with persistent central vertigo?

 

[herewego]

PGY2 chiming in.

I had a similar case as an intern. It was a holiday. Gentleman comes in with an airhammer injury to his thumb. Thumb looks necrotic to me, although grossly neurovascularly intact, No hand coverage tonight, and the ortho residents can't take the patient because the ortho attending on call is orthospine, and he won't touch anything related to the hand. I try to get this patient transferred to FOUR DIFFERENT HOSPITALS, no luck. Poor ortho resident cannot admit the patient, and the ortho attending on call (orthospine) won't even look at him. My attending calls my ED Chair, who calls the Ortho Chair (this is a holiday again..) and it turns into a huge ****ing political mess.

I call medicine and I say, "I need your help." They're sympathetic that I;ve tried to transfer this patient for the last 4 hours, and admit to medicine. Ortho debrides the guys thumb in the AM, and the ortho attending sends my attending a nasty email saying "it probably could have been debrided on an outpatient basis."

Things I took away from this:

1) I did the right thing for the patient, and you did too. Don't lose sleep over it.
2) Any consultant who can brush off a patient that my attending and I are concerned about without actually physically evaluating the patient can go to hell

 

[emergentmd]

This may come off as a soapbox rant but I never understand why some physicians act like babies. We all went through med school together, all went to residency together, all went through very similar pains to become attendings. There should be a cordial brother/sisterhood when it comes to issues.

I have had to deal with these hand/optho issues too where I spend 3 hrs to ultimately send the pt to another City where there are 7 big hospitals in the city and I know there are Optho and hand coverage b/c there are two trauma centers here.

What is wrong with these doctors? They spend more time blocking a consult when they can just deal with it in an hr tomorrow instead they argue for hours on why they will not take the pt. Then we all have to meet with admin later to go through the same tiresome arguments. Yes, everyone have valid points and there are always reasons not to help with care, but medicine has many shades of gray.

I get calls all of the time to work up the specialist patients. How would they like it if I told them to just hang around their office for another 2 hrs and get the tests as an outpt. How many DVT rule outs have I done for a painful leg when they could easily do the U/S the next day? I probably discharge 50% of patients sent to the ED for workups but I don't tell the other physician what to do esp when I am not by the pts bedside. Why would any other doc tell me what to do if they never laid their hands on the pts? I do not get it.

I even go way out of my ED responsibilities for the specialists. I go to the floor to put in central lines, suture lacs, stop fistula bleeds. Thats not even in my job description and the surgeons could come in and take care of it as it is THEIR pts and within their scope of practice. But I am in the hospital, it takes me 30 min to take care of it, and its just the nice thing to do. And I work in a BUSY ED. I either do it after my shift or I take time out of my dictation time to deal with it.

A final rant is writing off bills. As a medical director, I write off bills all the time esp for other doctors. I wrote off an anesthesiologist bill for a kidney stone workup which I am sure saved him atleast $500. When my wife needed an epidural and I received the anesthesiologist bill, I ask to have this written off. I got a flat out NO. Are you kidding me? Don't be a hippocrate and ask to have your bill written off and not to write my bill off.

OK... off my soapbox.

 

[southerndoc]

Central vertigo is a slam dunk admit for an MRI +/- neuro consult. How do you send someone home with persistent central vertigo?

You should never really discharge central vertigo if your index of suspicion is high, even with a negative MRI. Keep in mind that 6% of posterior fossa strokes will be negative on the initial MRI.

 

[deleted547339]

You should never really discharge central vertigo if your index of suspicion is high, even with a negative MRI. Keep in mind that 6% of posterior fossa strokes will be negative on the initial MRI.

Wha wha what?????

 

[Xerxes1729]

It would be a rare hand infection that couldn't wait until the morning to go to the OR (although obviously there would be some). If I get push back from the hand surgeon, I usually compromise with admitting to medicine and a consultation in the AM. I've never had someone say they would refuse to consult the next day on a patient I admitted overnight.

 

[southerndoc]

Wha wha what?????

http://www.ajnr.org/content/21/8/1434.abstract

(Nearly all "stroke protocol" MRI's are diffusion-weighted and not FLAIR, even with FLAIR imaging it only cuts it down to 3% missed rate. I'm not comfortable sending a patient out with a 6% miss rate for a cerebellar stroke if their symptoms have been less than 24 hours. This actually isn't specific to cerebellar strokes, but all ischemic strokes.)

 

[emergentmd]

Wha wha what?????

Persistent Central Vertigo gets admitted if a workup/MRI is negative. I don't care if I can't find anything. A healthy pt with central vertigo, that walks like a drunk gets admitted.

I put myself in the pts situation. If you are 60 and suddenly could not walk straight, and a fall risk then why would I want to go home without fixing it?

Even if its peripheral vertigo and pt cant walk straight, they are getting admitted all day.

 

[RustedFox]

Persistent Central Vertigo gets admitted if a workup/MRI is negative. I don't care if I can't find anything. A healthy pt with central vertigo, that walks like a drunk gets admitted.

I put myself in the pts situation. If you are 60 and suddenly could not walk straight, and a fall risk then why would I want to go home without fixing it?

Even if its peripheral vertigo and pt cant walk straight, they are getting admitted all day.

Agree. This is an easy admit. All day long.

 

[southerndoc]

I put myself in the pts situation. If you are 60 and suddenly could not walk straight, and a fall risk then why would I want to go home without fixing it?

I understand what you're saying, but just wanted to point out that the majority of stroke patients that have central ataxia aren't fixed when they're in the hospital. They're discharged to a SAR to learn how to adapt to their new baseline.

You're right though... can't walk, you get admitted. I don't even have to mention twice while I'm admitting them.