periorbital vs orbital cellulitis

[Stitch]

Hey guys I wondered if I could pick your brains for a minute. I'm a peds guy working in a dedicated peds ED. We end up seeing a fair amount of periorbital cellulitis, and have to ask ourselves 'does this kid need a CT to eval for orbital cellulitis?'

Specifically there was a recent case of a 12 month old who had periorbital cellulitis. Clearly moving his eyes around and would track my light easily. No proptosis, and was also able to open the affected eye spontaneously. I admitted him for IV clinda based on his rapid rate of presentation (hours) and severity of the cellulitis, given his age.

The hospitalist later criticized me saying I should have done a CT scan. For my end I felt comfortable with my exam. Moreover CT scans are not benign, and we are trying to decrease the number of scans and overall radiation exposure for the younger age groups. Not to mention that scanning him would require sedation in order to get a clear picture.

So my question is this: do you all have any data on periorbital vs orbital cellulitis in younger children (say under two or especially under one year)? Should I not trust my exam in this age group? Do you feel they should all be scanned?

Any input is appreciated!

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[jefguth]

Hey guys I wondered if I could pick your brains for a minute. I'm a peds guy working in a dedicated peds ED. We end up seeing a fair amount of periorbital cellulitis, and have to ask ourselves 'does this kid need a CT to eval for orbital cellulitis?'

Specifically there was a recent case of a 12 month old who had periorbital cellulitis. Clearly moving his eyes around and would track my light easily. No proptosis, and was also able to open the affected eye spontaneously. I admitted him for IV clinda based on his rapid rate of presentation (hours) and severity of the cellulitis, given his age.

The hospitalist later criticized me saying I should have done a CT scan. For my end I felt comfortable with my exam. Moreover CT scans are not benign, and we are trying to decrease the number of scans and overall radiation exposure for the younger age groups. Not to mention that scanning him would require sedation in order to get a clear picture.

So my question is this: do you all have any data on periorbital vs orbital cellulitis in younger children (say under two or especially under one year)? Should I not trust my exam in this age group? Do you feel they should all be scanned?

Any input is appreciated!

Trust your exam, the CT is really not that necessary, eitherway your treatment plan is pretty much the same. I really only feel imaging is necessary when you have a bilateral orbital cellulitis or when its not responding to treatment or if there have been several occurrences.

 

[cme2c]

Trust your exam, the CT is really not that necessary, eitherway your treatment plan is pretty much the same. I really only feel imaging is necessary when you have a bilateral orbital cellulitis or when its not responding to treatment or if there have been several occurrences.

Wow.

 

[Eyefixer]

Trust your exam, the CT is really not that necessary, eitherway your treatment plan is pretty much the same. I really only feel imaging is necessary when you have a bilateral orbital cellulitis or when its not responding to treatment or if there have been several occurrences.

OMG. You have obviously not taken care of any children with orbital cellulitis. Orbital cellulitis in children tends to be more aggressive secondary to thinner bones that separate the orbit from paranasal sinuses, being caused by more virulent bacteria (H. Flu, etc.), and difficulty distinguishing from preseptal cellulitis (difficult exam). Any child with suspected orbital cellulitis should have orbital imaging and possibly an admission for IV antibiotics with frequent ophthalmic monitoring for possible progression. If progression is detected, re-imaging, ID and ENT (if abscess is identified) involvement is indicated. I have taken care of several children in residency that have lost vision despite of the most aggressive measures.

 

[MR1]

Agree with last post. If there is ANY doubt, then CT scan them. If it is totally isolated to the skin, minimal to no pain, motility is really full (no offense but many times there is an obvious limitation that someone else called full), vision is same in both eyes and the eye is white and quiet looking then you could consider admitting for Abx w\o scanning them. Again would have low threshold esp with the younger ones.

Treatment is not always the same, some need surgery, can get worse fast.

I re-read and realized you are talking about kiddos under 2, yeah I would probably scan them all b\c you can't get an accurate motility most of the time and obviously can't check vision.

 

[MstaKing10]

Given the morbidity of missing an orbital cellulitis (blindness, cavernous sinus thrombosis, meningitis...death), I would have a very low threshold to scan someone, especially children who may not present with the classic signs seen in adults. Not only that, but a CT scan may assist you in figuring out if there is an abscess that needs to be drained or significant sinusitis that needs to be adressed. This is better done sooner rather than later. CT scans can be done relatively quickly, and I use the mild sedation in our ER to perform my fundus exam.

 

[Stitch]

Thanks guys, it helps to hear from you. I definitely have a low threshold for scanning, but worried about radiation exposure. It sounds like maybe we should be scanning anyone coming in for IV antibiotics given the known risks of missing an orbital cellulitis or delaying surgery.

 

[hello07]

Jefguth, from one fellow optometrist to another: keep your mouth shut. You disgrace us as a profession, it's bad enough we as optometrist are divided among us when it comes to certain issues(board certification in the usa) and what OMD's think of us.......if you don't know the answer....don"t talk out of your butt. Staggering answer you gave. Shame on you.......................

 

[Meibomian SxN]

Thanks guys, it helps to hear from you. I definitely have a low threshold for scanning, but worried about radiation exposure. It sounds like maybe we should be scanning anyone coming in for IV antibiotics given the known risks of missing an orbital cellulitis or delaying surgery.

No offense but do you have access to opthalmology/optometry consults? Being that orbital cellulitis is a true ocular emergency, I would think its better you refer/consult rather than play Dr. House, MD...

 

[Stark]

I think the terminology of the whole argument is a little confusing.

The two distinct conditions, as I divide them in my mind are "Preseptal cellulitis" meaning it only affects the outer layers of the lid. Then "Orbital cellulits" meaning it affects the tissues of the orbit.

On the exam, it pays to look closely. Is the eye red, have discharge, or swollen shut? Is the eyelid hard or indurated? Is there any sign, that the inflammation is affecting anything other than the most superficial layers of the eyelid (the "preseptal" layers). If yes - scan immediately. If unknown or you just can't decide - scan.

If it is absolutely, totally superficial, without any doubt - consider not scanning.

Regarding management - a 1 year old even with preseptal cellulitis should probably be admitted for IV abx and a check no more than 12 hours later. As pointed out, preseptal cellulitis can worsen rapidly in these young children. Admission for IV abx is the treatment for orbital cellulitis as well.

The CT may be useful in helping you differentiate one from the other - but they probably need IV abx either way (due to the young age). If there is indeed orbital cellulitis, a CT could identify a sub-periosteal abscess which may require surgical drainage (although some published studies have documented their resolution with IV abx alone).

Basically - low threshold for CT. Think of the conditions as "Preseptal" (only the very most superficial layers of the lid) and "Obital" (involvement of any other tissue).

And yes - get the consult.

Stark

 

[Mirror Form]

I have a low threshhold for a CT scans too, mainly for liablitiy reasons. Orbital cellulitis can progress very quickly in young patients. However, if the patient is admitted and on IV abx (as this patient was), then he'll probably be fine.

What would a CT scan have offered your patient? We know for a fact that CT scans on a 12 month old do increase rates of cancer. But by the time he dies from cancer, you'll be retired! Whereas, if he had any issues with orbital cellulitis it could result in a lawsuit now.

 

[DrMassacre]

We know for a fact that CT scans on a 12 month old do increase rates of cancer. But by the time he dies from cancer, you'll be retired! Whereas, if he had any issues with orbital cellulitis it could result in a lawsuit now.

 

[Stitch]

No offense but do you have access to opthalmology/optometry consults? Being that orbital cellulitis is a true ocular emergency, I would think its better you refer/consult rather than play Dr. House, MD...

We do, and I have no intention of 'playing House' at all. We consult both ophto and often ENT as well to help guide our decision making. Some kids are clear cut one way or the other. The ones in between it's a more difficult decision, hence my question as to how you guys practice. I scan the majority of them, but not everyone if they are clearly opening their eye and looking around/can follow my light.

Regarding management - a 1 year old even with preseptal cellulitis should probably be admitted for IV abx and a check no more than 12 hours later. As pointed out, preseptal cellulitis can worsen rapidly in these young children. Admission for IV abx is the treatment for orbital cellulitis as well.

The CT may be useful in helping you differentiate one from the other - but they probably need IV abx either way (due to the young age). If there is indeed orbital cellulitis, a CT could identify a sub-periosteal abscess which may require surgical drainage (although some published studies have documented their resolution with IV abx alone).
Stark

This pretty much sums up what I do. Admit them for IV antibiotics (usually clinda) with ENT/Ophtho consults. The issue is really do they need an immediate scan in the ED with the sedation that it entails. Our surgeons seem to be less aggressive in terms of drainage, and in general they want at least one dose of clinda in before they decide to cut (if the kid's eye is reasonably good appearing). Which again is why I raised the question: how aggressive with radiation should one be if you're admitting them anyway, and the exam isn't overly concerning (though I understand it can be misleading), and the surgeons tell you they're unlikely to cut.

What would a CT scan have offered your patient? We know for a fact that CT scans on a 12 month old do increase rates of cancer. But by the time he dies from cancer, you'll be retired! Whereas, if he had any issues with orbital cellulitis it could result in a lawsuit now.

True, but I'm waiting to see a commercial where a lawyer points at the sceen and says 'Have YOU been diagnosed with astrocytoma or glioblastoma? Have YOU had a CT scan in the past 20 year? Then YOU could be entitled to money! It's going to happen...

 

[Meibomian SxN]

True, but I'm waiting to see a commercial where a lawyer points at the sceen and says 'Have YOU been diagnosed with astrocytoma or glioblastoma? Have YOU had a CT scan in the past 20 year? Then YOU could be entitled to money! It's going to happen...

LOL, so true! I'm surprised I have not seen those commercials during the SuperBowl!

 

[jdh71]

No offense but do you have access to opthalmology/optometry consults? Being that orbital cellulitis is a true ocular emergency, I would think its better you refer/consult rather than play Dr. House, MD...

I love the way the sub-specialists love to mother-**** the primary care guys. It's kind of ironic in a way, you know, the way I have to admit your suspected orbital cellulitis from your clinic for IV abx and scan, because you no longer know how to deal with diabetes or hypertension (hint: continue the home meds . . . unless, of course, you don't know when that's appropriate, or not, right?). I'm just glad there are a few people left around who actually prefer to spend their days as real doctors, or as you call them, "Dr. House, MD".

It'd also make everyone's lives a whole lot easier, if we're to do all this extra consultation, if you'd actually be willing to come in when we ask without all of the bitching, moaning, and complaining when we ask for "expert" opinion. Don't be an "expert" if you don't want to be asked for your opinion. Also, of note, we don't keep bankers hours, mostly because cancer, MI, and sepsis don't go home at 5PM, only to return the following morning at a reasonable 9AM, always minding those weekends (golf, you know!!).

To the OP scan 'em. Especially kids. Just scan 'em. Then you'll know for sure.

 

[DOCTORSAIB]

I love the way the sub-specialists love to mother-**** the primary care guys. It's kind of ironic in a way, you know, the way I have to admit your suspected orbital cellulitis from your clinic for IV abx and scan, because you no longer know how to deal with diabetes or hypertension (hint: continue the home meds . . . unless, of course, you don't know when that's appropriate, or not, right?). I'm just glad there are a few people left around who actually prefer to spend their days as real doctors, or as you call them, "Dr. House, MD".

It'd also make everyone's lives a whole lot easier, if we're to do all this extra consultation, if you'd actually be willing to come in when we ask without all of the bitching, moaning, and complaining when we ask for "expert" opinion. Don't be an "expert" if you don't want to be asked for your opinion. Also, of note, we don't keep bankers hours, mostly because cancer, MI, and sepsis don't go home at 5PM, only to return the following morning at a reasonable 9AM, always minding those weekends (golf, you know!!).

To the OP scan 'em. Especially kids. Just scan 'em. Then you'll know for sure.

 

[jdh71]

I don't want you to feel sorry me; I don't. I love my job. You couldn't pay me to do yours.

That post was written the way it was to make a point. I'm mildly surprised that reason was apparently lost on you. I thought only superstars when into ophtho?

It's just ridiculous the way consultants spend so much of their time mother****ing their primary care colleagues. It's easy to monday morning quarterback, because as a consultant you have the luxury of hindsight, and also lack the context of bigger picture of patient care because you don't do it (and would probably be malpractice if you tried).

The point being, should I sit around an sneer at my Ophtho colleagues when I'm asked to admit their wheelchair bound patient with CAD, DM2, COPD, HTN, with a gnarly bacterial keratitis with hypopyon because he's a social nightmare and they don't trust the patient or the family to get the multiple Q1 drops regimen correct? Should I then mother**** my Ophtho colleagues? Or, and I'm going out on a crazy, crazy, limb here, is it probably better to have an understanding that we all have our place and expertise in the medical world and when our colleagues ask for out help, it's better to actually help, then to sit around nit-picking everything you find wrong?

You tell me hoss. You're the one who went to medical school and no longer knows how to manage blood pressure. Do you really think you have some sort of special place to stand that gives you a special license to make fun or ridicule anyone else in medicine?

Peace.

 

[DKofLV]

I don't want you to feel sorry me; I don't. I love my job. You couldn't pay me to do yours.

That's why we dont pay you to do our job...and you're paid to do yours...that's why we're the eye surgeons/specialists.

Remember, things like aspirin or tylenol can actually kill a patient...we havent directly seen the poor outcome from this (or other meds) in a long time, but you have...and thus we respect your expertise in managing this train wreck knowing our limits.

We, on the other hand, have seen the poor outcome when a primary doctor gives a patient with eye pain (for example) tobradex...and that's why we have the expertise. A lot of medicine is pattern recognition, and if you dont keep seeing the pattern then you wont be the expert in recognizing/preventing the bad outcome.

Should I then mother**** my Ophtho colleagues?

you tell me...is their mother really that attractive?

 

[MR1]

First that post about not playing Dr House was from an OD.

Second no ophthalmologist should give you s*** about coming into see an orbital cellulitis.

Third as the OP asked, yes they should probably all be scanned in the ED so ophtho and ENT when needed knows what is going on in the orbit.

Fourth no MD should mother**** any other MD, it sucks when it happens

 

[jdh71]

That's why we dont pay you to do our job...and you're paid to do yours...that's why we're the eye surgeons/specialists.

Remember, things like aspirin or tylenol can actually kill a patient...we havent directly seen the poor outcome from this (or other meds) in a long time, but you have...and thus we respect your expertise in managing this train wreck knowing our limits.

We, on the other hand, have seen the poor outcome when a primary doctor gives a patient with eye pain (for example) tobradex...and that's why we have the expertise. A lot of medicine is pattern recognition, and if you dont keep seeing the pattern then you wont be the expert in recognizing/preventing the bad outcome.

You are correct about everything you've said, and any primary doc that doesn't follow the "no one puts ****ing steroids on the eye except for ophtho" rule probably should not be seeing patients in the first place.

We NEED eye experts, no one else gets enough time to 1) get any good at definitive dx and exam and 2) no one else can do anything about it surgically (if indicated) except for an eye expert. It's just so freaking annoying to have a surgical sub-specialist show up on a consult and just be a ****ing jackass. It's not necessary, furthermore, its always easier to snipe when you have hindsight and all you're dealing with is one specialized area.

Had a run in with urology on wednesday. Had a lady come in early last friday morning from outside boondock facility - gram neg rods in blood and urine, acute renal failure, with pulmonary edema. So we spent most of the weekend making sure this lady didn't die, initial ultrasound showed unilateral mild hydronephrosis but nothing else to write home about. Boondock facility won't return calls on culture and sensitivities all weekend (was anyone working?). On Tuesday I finally get through to someone, and get the speciation and sensitivities - Proteus in the blood and urine. Ok. We should CT-scan her for stones. Rads spends much of Tuesday NOT scanning this lady only to do it very last Tuesday night. I get to work on Wednesday look at the scan - don't need a report - large stone sitting in the renal pelvis. Page to urology resident made. Later that morning I get an earful from the Urology attending because they weren't called sooner, as an obstructed infected kidney can kill someone. Really? I mean really?!??! You're joking an obstructed infected kidney can kill someone?!?! NOH WAI!! They knew as soon as I knew. Stone is now done and patient is doing fine. So I consulted the experts when I recognized I had an expert type of problem, but for my pleasure I get mother****ed. My attending later pointed out to the Urology attending that he was free to admit urosepsis from now on, or even take primary on this patient if his ox was so gored by our management.

And that just ONE run in with ONE surgical sub-specialist that I have to deal with every single day. And it's almost always like this. And I don't think it's necessary.

I think a little more understanding of the situation and context would do wonders for so many of my surgical sub-specialty colleagues.

EDIT: Maybe it was just a long floor month (thank God it's over), and I'm cranky. My bad if over-inflammatory in your neck of the woods.

 

[speyeder]

I love the way the sub-specialists love to mother-**** the primary care guys. It's kind of ironic in a way, you know, the way I have to admit your suspected orbital cellulitis from your clinic for IV abx and scan, because you no longer know how to deal with diabetes or hypertension (hint: continue the home meds . . . unless, of course, you don't know when that's appropriate, or not, right?). I'm just glad there are a few people left around who actually prefer to spend their days as real doctors, or as you call them, "Dr. House, MD".

It'd also make everyone's lives a whole lot easier, if we're to do all this extra consultation, if you'd actually be willing to come in when we ask without all of the bitching, moaning, and complaining when we ask for "expert" opinion. Don't be an "expert" if you don't want to be asked for your opinion. Also, of note, we don't keep bankers hours, mostly because cancer, MI, and sepsis don't go home at 5PM, only to return the following morning at a reasonable 9AM, always minding those weekends (golf, you know!!).

To the OP scan 'em. Especially kids. Just scan 'em. Then you'll know for sure.

Totally inappropriate post. Just because you are frustrated dealing with subspecialists doesn't give you the right to go on a profanity-ridden tirade against an entire profession. I don't know how things run in your hospital, but I can tell you that at my hospital we can't get medicine to admit a patient with 19 medical problems. The best they will do is serve as a consultant. Ophtho admits every patient who comes in with an eye complaint, even if they have comorbidities that would be better managed by internists.

Last year medicine admitted a total of 2 really sick patients for ophtho, and that was after having ophtho attendings call the medicine attendings. Conversely I can't tell you how many pink eye, blurry vision & fungemia patients we're consulted on. And I don't even mind getting consulted for these things, but only about 10% of the time is the vision or pupils even checked. I mean, how are you going to call an ophtho consult and not even look at the eye? Would you call a cardiology consult without auscultating the heart or getting an EKG?

So bottom line is, internists need subspecialists to exist and vice versa, and the frustration that you talk about goes both ways.

 

[Eyefixer]

EDIT: Maybe it was just a long floor month (thank God it's over), and I'm cranky. My bad if over-inflammatory in your neck of the woods.

Bingo! It sounds like you need a vacation. I sincerely hope you have one coming up. Remember, it does get better after residency. Peace.

 

[jdh71]

Totally inappropriate post. Just because you are frustrated dealing with subspecialists doesn't give you the right to go on a profanity-ridden tirade against an entire profession.

Somebody missed the irony . . . apparently

And "profanity-ridden"? The filter censored one word. Define "ridden". Maybe there is some kind of new definition for "ridden" that I am unaware of . . .

 

[DKofLV]

Somebody missed the irony . . . apparently

And "profanity-ridden"? The filter censored one word. Define "ridden". Maybe there is some kind of new definition for "ridden" that I am unaware of . . .

I missed the irony too then apparently you "motherf*kr"

 

[jdh71]

I missed the irony too then apparently you "motherf*kr"

I would suggest re-reading the first post of mine to which you responded. If it still remains unclear. I shall come back and try and help you see.

 

[Mirror Form]

I would suggest re-reading the first post of mine to which you responded. If it still remains unclear. I shall come back and try and help you see.

You do realize that the person you responded to in your first post was an optometrist right? Yes, he was out of line telling a pediatrician when he needs to get a consult on a case of pre-septal cellulitis. But it's not really a big deal.

In regard to sub-specialists having medicine admit their patients, there really isn't any alternative. Sub-specialists don't stay current on advances in internal medicine. We don't know anything about changes in practice for managing blood pressure (or diabetes, etc.) since we graduated med school. Sure it's annoying as an internal medicine resident, but guess what? I spent an entire year of internship functioning as both gen surg and IM's total b*tch. So if they have to admit an optho patient once in a blue moon and find it annoying they can go mother**** themselves.

It's also funny b/c IM residents have all these interns running around doing all the work, yet they're so lazy they still complain about every admission. You should try admitting a patient as an optho resident sometime. You have no interns and no time alloted in your schedule for rounding on in-patients.

 

[DOCTORSAIB]

I don't want you to feel sorry me; I don't. I love my job. You couldn't pay me to do yours.

That post was written the way it was to make a point. I'm mildly surprised that reason was apparently lost on you. I thought only superstars when into ophtho?

It's just ridiculous the way consultants spend so much of their time mother****ing their primary care colleagues. It's easy to monday morning quarterback, because as a consultant you have the luxury of hindsight, and also lack the context of bigger picture of patient care because you don't do it (and would probably be malpractice if you tried).

The point being, should I sit around an sneer at my Ophtho colleagues when I'm asked to admit their wheelchair bound patient with CAD, DM2, COPD, HTN, with a gnarly bacterial keratitis with hypopyon because he's a social nightmare and they don't trust the patient or the family to get the multiple Q1 drops regimen correct? Should I then mother**** my Ophtho colleagues? Or, and I'm going out on a crazy, crazy, limb here, is it probably better to have an understanding that we all have our place and expertise in the medical world and when our colleagues ask for out help, it's better to actually help, then to sit around nit-picking everything you find wrong?

You tell me hoss. You're the one who went to medical school and no longer knows how to manage blood pressure. Do you really think you have some sort of special place to stand that gives you a special license to make fun or ridicule anyone else in medicine?

Peace.

I get your point. You're whining about a job that you signed up for.

No one in this forum has put down primary care physicians. We're all greatful for what you do. TRUST ME. So let's keep this discussion civil.

My question to you is -- Are you really suggesting an OUT-PATIENT specialist admit and manage patients in the hospital? Let's not talk about whether we can. That's a different conversation. But is it APPROPRIATE and best for the patient?

You realize ophtho residents/attendings spend the majority of their time in busy clinics seeing tons of patients. How will they manage the admitted patient? via the telephone? SERIOUSLY.

 

[MstaKing10]

Wow, this thread has really turned ugly! I think we all knew what we were signing up for to some degree when we chose our specialties. Of the many reasons that I chose ophtho, one was the fact that very little (if any) of my time would be spent on inpatient/ward services. I despised rounding, dealing with social issues and getting dumped on by other services. I found this out while doing my internal medicine and family practice rotations in med school. On the other hand I loved clinic and the OR much more. I found this out while on my ophtho rotation.

As an intern in IM, I wasn't surprised at all when orthopedics would ask one of their patients be admited to our service, or to have a patient on the wards sit around for weeks awaiting placement in a nursing home or the like. I knew this would happen. Why is it such a surprise to anyone that signed up for this job that it happen to them??

It is an extremely rare circumstance where a patient with social issues and multiple medical problems be admited to an IM service for ophthalmology at our program, very rare. All of our post ops (with rare exception) are appropriately admitted to our service. So please don't whine for the occasional admit. We are asking for your help, just as you ask for ours when you have a patient with an eye problem and don't know what to do.

Finally, most ophthalmology residents take home call. If a patient were to require immediate attention, we could literally not provide it since we are not in house. We actually had a patient code on our service, they paged the resident on call who was like "I live 30 minutes away!" The code team showed up, pt was transferred to ICU, etc. He wasn't a particularly sick guy either (DM, HTN, and the like). This is a prime example of why it is not always appropriate to have a primarily outpatient service having inpatients.

 

[orbitsurgMD]

You do realize that the person you responded to in your first post was an optometrist right? Yes, he was out of line telling a pediatrician when he needs to get a consult on a case of pre-septal cellulitis. But it's not really a big deal.

In regard to sub-specialists having medicine admit their patients, there really isn't any alternative. Sub-specialists don't stay current on advances in internal medicine. We don't know anything about changes in practice for managing blood pressure (or diabetes, etc.) since we graduated med school. Sure it's annoying as an internal medicine resident, but guess what? I spent an entire year of internship functioning as both gen surg and IM's total b*tch. So if they have to admit an optho patient once in a blue moon and find it annoying they can go mother**** themselves.

It's also funny b/c IM residents have all these interns running around doing all the work, yet they're so lazy they still complain about every admission. You should try admitting a patient as an optho resident sometime. You have no interns and no time alloted in your schedule for rounding on in-patients.

Agree.

Not only is it not always in the best interest of the patient for a subspecialist to do the admit, sometimes it is simply not allowed, even if you have "full" admitting privileges. Such now is the power of the UR committee.

I have had the circumstance of having one patient's admissions orders I wrote being refused because I was not their primary care physician, and that patient's HMO required all admissions under the name of the primary (who ever so collegially accused me of dumping even as I explained how I was not allowed to admit her under my own name solely for insurance reasons, go figure.)

 

[Meibomian SxN]

You do realize that the person you responded to in your first post was an optometrist right? Yes, he was out of line telling a pediatrician when he needs to get a consult on a case of pre-septal cellulitis. But it's not really a big deal.....

WOW! Look what I miss in 1 day!

I simply ASKED the Peds doc did they have consults available, especially on a rare but true ocular emergency. No milk was spilled, no feelings were hurt but if so sorry for the sarcasm...

I'm just glad there are a few people left around who actually prefer to spend their days as real doctors, or as you call them, "Dr. House, MD...

WOW! I know residents are over-worked but sheesh! But if you really need a place to vent your frustrations about where you are on the medical food chain pyramid then curse/expletive away! Its better you do it here than at the hospital, lest you end up treating yourself with HTN meds!

 

[cme2c]

WOW! Look what I miss in 1 day!

No kidding. I kind of thought the House comment was a little funny. (For those of who that don't watch House, they have had some ridiculous eye stuff on there. My favorite was the episode where they did a retinal biopsy at the slit lamp. They went straight through the central cornea and lens to get to the retina.)

That said, let's face it, as docs we all end up "dumping on each other" in various ways. What matters is how you do it. I understand that my friends in IM don't have have the expertise to treat a severe red eye. So when they call at the end of clinic, I say send them over. They understand when I need help with an inpatient or a preop clearance and help me out. Residents call these dumps, in practice they are called referrals. Obviously for the residents they see it as a waste of time, the practicing doc sees them as revenue.

That said, I can count on one hand the number of times I have had IM/FP admit a patient, yet I can't even begin to count the number of stupid inpatient consults for blurred vision without a visual acuity/history, 5PM phone call for red eye mistreated for 3 weeks, etc. I say thank you for the kind referral.