The potential pitfalls of the "curbside" consult

[BuzzPhreed]

So, I'm on-call over the weekend this past weekend. The whole weekend. That's how we do it in my practice. (It's home call so it ain't that bad.) But, that's not what this story is about...

Last night I get a call from the ED while I'm eating dinner with my wife. The doc there says to me, "Hey, I gotta reduce this shoulder."

I asked, "Okay, do you need me to come in?"

"No, no, no," he says, "she's a 84-year-old COPD patient from a nursing home who's a little demented and I just tried with 5 of midazolam and couldn't get it in. Do you think it would be okay if I gave her some propofol?"

Again, I asked, "Dude, do you want me to come in? Have you lined-up an ortho guy in case we have to go to the OR?"

He says back to me, "I don't think we need all that. She's got a lot of laxity there. I just wanted to run this by you and get an idea how much propofol you'd give her. She's pretty somnolent now and I'm a little worried about her lungs."

DO NOT FALL INTO THIS TRAP!

Conducted by a team of researchers from the University of Colorado, the study found that the information given to the curbside consultant was incomplete or inaccurate roughly half the time, and that management advice offered via the two forms of consultation differed 60 percent of the time.

http://community.the-hospitalist.or...rs-of-curbside-consults-and-why-we-need-them/

"Even if you have no responsibility, you still have to go through all the pain, expense, and heartache of getting yourself dismissed from the suit," she explains. "What makes the curbside consultation easy and convenient for the consulting physician is what turns it into a legal nightmare for both of them." Because the consult is on the run, the consulting physician may not give all the information that reveals the whole clinical picture.

http://www.medscape.com/viewarticle/565468_4

The gist of the articles is that we should provide some advice when asked. I'm okay with that. But in the cases where similar situations have come up before, I've been able to eyeball the patient and look at the chart. Not so here. I was at home. There's no way that I could provide a reasonable assessment from the dinner table.

Look, I know this particular ED doctor. He's a good guy. Been to his house for BBQ and beers and whatnot. But, bottom line, I have no idea what he's going to write in the chart, nor do I know what's really going on with this patient without seeing her and doing my own evaluation.

Here's what I told him: "Okay, I can't tell you how much propofol to give her because I don't know this patient, whether she's eaten, or any other things that may be a problem. I'd be happy to come in and help you if you want."

"No, that's okay. I'll figure it out." And we left it at that.

Some of you may have handled this differently. But, just recognize that you are potentially opening yourself to liability if you do.

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[deleted126335]

So, I'm on-call over the weekend this past weekend. The whole weekend. That's how we do it in my practice. (It's home call so it ain't that bad.) But, that's not what this story is about...

Last night I get a call from the ED while I'm eating dinner with my wife. The doc there says to me, "Hey, I gotta reduce this shoulder."

I asked, "Okay, do you need me to come in?"

"No, no, no," he says, "she's a 84-year-old COPD patient from a nursing home who's a little demented and I just tried with 5 of midazolam and couldn't get it in. Do you think it would be okay if I gave her some propofol?"

Again, I asked, "Dude, do you want me to come in? Have you lined-up an ortho guy in case we have to go to the OR?"

He says back to me, "I don't think we need all that. She's got a lot of laxity there. I just wanted to run this by you and get an idea how much propofol you'd give her. She's pretty somnolent now and I'm a little worried about her lungs."

DO NOT FALL INTO THIS TRAP!



http://community.the-hospitalist.or...rs-of-curbside-consults-and-why-we-need-them/



http://www.medscape.com/viewarticle/565468_4

The gist of the articles is that we should provide some advice when asked. I'm okay with that. But in the cases where similar situations have come up before, I've been able to eyeball the patient and look at the chart. Not so here. I was at home. There's no way that I could provide a reasonable assessment from the dinner table.

Look, I know this particular ED doctor. He's a good guy. Been to his house for BBQ and beers and whatnot. But, bottom line, I have no idea what he's going to write in the chart, nor do I know what's really going on with this patient without seeing her and doing my own evaluation.

Here's what I told him: "Okay, I can't tell you how much propofol to give her because I don't know this patient, whether she's eaten, or any other things that may be a problem. I'd be happy to come in and help you if you want."

"No, that's okay. I'll figure it out." And we left it at that.

Some of you may have handled this differently. But, just recognize that you are potentially opening yourself to liability if you do.

The ER doc was looking to dilute out responsibility in case of a bad outcome. Plain and simple.

 

[gasdoc77]

Is your ER familiar with Ketamine?

 

[BuzzPhreed]

Is your ER familiar with Ketamine?

Ketamine? In an 84-year-old demented patient? Certainly not something I'm going to suggest over the phone for the aforementioned reasons.

I like this guy. But, he's done some whacky stuff in the past. I remember a couple years ago I was consulted to do an "urgent" lap chole for a "soft" cholecystitis (you know the whole "convenient for the surgeon" thing) when I was on call. I came to do the eval in the ED and dude had him on BiPAP and running 100mcg/kg/min of propofol infusion. I asked him "why" and he told me the guy was agitated, was mildly febrile, and he couldn't control his RUQ pain.

So much for "emergent" surgery that evening. Probably not surprisingly the patient ended-up intubated in the ICU, family had to be contacted, and the case was done first thing the next morning.

Stay away from these situations. Far, far away.

 

[Mman]

I don't consider somebody asking for a propofol dose over the phone to be a curbside consult. If they aren't qualified/competent to make the decision to use it and manage the consequences, then they shouldn't be giving it in the first place. What they are asking for is a bit more.

I'd suggest that if they think the patient needs it, then I'll be in to manage it.

 

[BuzzPhreed]

I don't consider somebody asking for a propofol dose over the phone to be a curbside consult. If they aren't qualified/competent to make the decision to use it and manage the consequences, then they shouldn't be giving it in the first place. What they are asking for is a bit more.

I'd suggest that if they think the patient needs it, then I'll be in to manage it.

I agree. But hard to say what he'd write in the record if I'd suggested one. "Spoke with Dr. Phreed over the phone and he suggested giving the patient X mg of propofol to facilitate shoulder reduction." I've seen this kind of thing before. And I wasn't going to get into that kind of discussion with him on the phone. He knows how to use it to intubate.

What's even more troublesome is that a lot of these guys use etomidate as "conscious sedation" in the ER for such procedures. I imagine that's what probably happened. I'll ask and find out tomorrow when I'm back in the hospital.

 

[Mman]

I agree. But hard to say what he'd write in the record if I'd suggested one. "Spoke with Dr. Phreed over the phone and he suggested giving the patient X mg of propofol to facilitate shoulder reduction." I've seen this kind of thing before. And I wasn't going to get into that kind of discussion with him on the phone. He knows how to use it to intubate.

What's even more troublesome is that a lot of these guys use etomidate as "conscious sedation" in the ER for such procedures. I imagine that's what probably happened. I'll ask and find out tomorrow when I'm back in the hospital.

Oh I agree. I'm just saying I wouldn't call that a curbside consult. They are asking for phone instructions on how to provide general anesthesia and/or deep sedation, neither of which somebody should be doing unless they already know how to do it.

It's one of those things where if you have to ask how to do it, then you shouldn't be doing it.

 

[BuzzPhreed]

I'm just saying I wouldn't call that a curbside consult.

"This is what I'm thinking. What would you do here? I want to be sure." Is that not the functional definition of a curbside?

I think we're spitting hairs/arguing semantics.

 

[deleted171991]

The ER doc was looking to dilute out responsibility in case of a bad outcome. Plain and simple.

Yep.

Never do curbside consults for important stuff, especially over the phone where it leaves a trace. It establishes a patient-doctor relationship, according to the courts.

In this case specifically I would have given him the choice to come in or not, but no specific advice. Like Buzz did.

 

[deleted547339]

It's one of those things where if you have to ask how to do it, then you shouldn't be doing it.

Agreed. Often, I will retrospectively pick the brain of a consultant while they are in the ED; e.g. - anesthesia is pre-op'ing someone and I'll say "hey, I sedated a guy last week with ketamine last week, had an emergence reaction...what do you like for that? Ativan? Valuum? Why?"

I'll curbside from the ED occasionally, but never on anything critical and never a patient specific question. For example, I curbsided psych today: I had a patient on a fairly benign antipsychotic who had a problem filling her prescription (long story related to Medicaid in my state being ridiculous). Came in, wanted a new rx written. She didn't know her dose. I talked to them just to ask what a starting dose of this med would be. I didn't ask "what should I prescribe her." She had followup, just couldn't get the rx. I wrote the rx and didn't document the conversation.

 

[fakin' the funk]

So, I'm on-call over the weekend this past weekend. The whole weekend. That's how we do it in my practice. (It's home call so it ain't that bad.) But, that's not what this story is about...
.

While you make a good point that we shouldn't fall into this trap, I wouldn't call this a curbside. As others have said, a curbside is more general and more about education ("what's the usual dose of x; when do you choose y test over z?"). In this case the other doc is basically requesting a consult but not wanting to actually do so, apparently in order to save face. Specific questions about how to murder a GOMER... that's just CYA nonsense.

 

[KLPM]

We had someone call from a different hospital.

"Hi, I'm calling from hospital X about a pregnant patient we have. Her bicarb is 18 at the moment. Would you replace it?"

That was literally all the details over the phone. The registrar basically said "well I can't tell you whether you should replace it or not without knowing more details like 1, 2, 3 ....... you should call the patient's managing obstetrician." To which the reply was "Well I'm not sure about 1, 2, 3 ..... but say this was your patient would you replace the bicarb?" This went on for another 30min.

 

[BuzzPhreed]

While you make a good point that we shouldn't fall into this trap, I wouldn't call this a curbside.

I didn't see the patient. I was asked a question about this specific patient. I was given some cursory medical history on the same patient. I was not officially consulted to take care of this patient. Yet, this doc wanted advice on how to treat this patient. There was nothing "theoretical" about it.

Again, I'm not exactly sure what you guys consider a curbside, but in my book that meets the definition.

 

[risnwb]

I've had "curbside"issues lately with both orthopedists and gynecologists who are unable to place appropriate post op pain med orders. They call asking me to "tell them what to write" regarding standard pca orders. (It's as if I'm dealing with first year residents but that's beside the point) sometimes they frame the request as a curbside, other times they ask for a post op pain consult, either way it's irritating because 1) they should know how to write a standard dilaudid pca, 2) they shouldn't need a formal anesthesia consult for post op pain management in uncomplicated opioid naive patients...


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[Mman]

Again, I'm not exactly sure what you guys consider a curbside, but in my book that meets the definition.

Curbside consult = asking what they should do for a patient without the official consult. You were instead asked what you would personally do (or what dose you would give), not what they should do.

 

[Promethean]

Curbside consult = asking what they should do for a patient without the official consult. You were instead asked what you would personally do (or what dose you would give), not what they should do.

Asking "what would you do?" is essentially the same as asking "what should I do?" just in more ego-sparing language for the asker. What does it matter what you would do, unless they intend to employ your hypothetical action to guide their next moves. And when it could well end up written in the chart as "So-and-so told me to...," why risk that?

 

[pgg]

I've had "curbside"issues lately with both orthopedists and gynecologists who are unable to place appropriate post op pain med orders. They call asking me to "tell them what to write" regarding standard pca orders. (It's as if I'm dealing with first year residents but that's beside the point) sometimes they frame the request as a curbside, other times they ask for a post op pain consult, either way it's irritating because 1) they should know how to write a standard dilaudid pca, 2) they shouldn't need a formal anesthesia consult for post op pain management in uncomplicated opioid naive patients...

Those stupid pain consults in uncomplicated patients could be the low-hanging fruit for a profitable pain service ...

 

[Mman]

Asking "what would you do?" is essentially the same as asking "what should I do?" just in more ego-sparing language for the asker. What does it matter what you would do, unless they intend to employ your hypothetical action to guide their next moves. And when it could well end up written in the chart as "So-and-so told me to...," why risk that?

The difference is if I ask someone what I should do, I'm asking for an opinion of what they think I can accomplish. If I'm asking what they would do, I'm trying to pretend like I'm as skilled at them at whatever they do and do it instead of them.

For some things there is no difference, but in this situation it is a big difference IMHO. What would a BC anesthesiologist do is different than what a BC emergency doc should do. Maybe the answer is I would give 50 mg of propofol. But I am also familiar with how to treat complications that could arise from that where as the EM doc might not necessarily be. I'm not trying to throw the EM doc under the bus with that assumption, but they are basically asking how to possibly induce general anesthesia. I couldn't in good conscience talk someone through that over the phone.

 

[Mman]

Those stupid pain consults in uncomplicated patients could be the low-hanging fruit for a profitable pain service ...

Not on medicare/caid or self pay patients. On 100% privately insured, you might make a small sum of money over enough patients.

 

[pgg]

Not on medicare/caid or self pay patients. On 100% privately insured, you might make a small sum of money over enough patients.

Hmm, well that's unfortunate. I guess the best thing that could be said about it is it could add something to the group's value to the hospital. Or not.

I've seen orthopods who just have hospitalists admit all their patients, so they can spend all their time in the OR and clinic. It must be worthwhile for the hospitalists, or the hospital that pays them.

 

[Arch Guillotti]

I've had "curbside"issues lately with both orthopedists and gynecologists who are unable to place appropriate post op pain med orders. They call asking me to "tell them what to write" regarding standard pca orders. (It's as if I'm dealing with first year residents but that's beside the point) sometimes they frame the request as a curbside, other times they ask for a post op pain consult, either way it's irritating because 1) they should know how to write a standard dilaudid pca, 2) they shouldn't need a formal anesthesia consult for post op pain management in uncomplicated opioid naive patients...

It's worse than a first year resident. At least a resident can figure out something as easy as writing pca orders. Most places seem to have premade order sets where you just have to check a few boxes.

 

[Mman]

Hmm, well that's unfortunate. I guess the best thing that could be said about it is it could add something to the group's value to the hospital. Or not.

I've seen orthopods who just have hospitalists admit all their patients, so they can spend all their time in the OR and clinic. It must be worthwhile for the hospitalists, or the hospital that pays them.

My assumption is the hospital must be paying them for that because the surgical fee they are collecting covers pre and post surgical care and you know insurers and medicare aren't going to pay twice for postop care.