Are ER docs disliked by other specialties?

[WilcoWorld]

---

Members don't see this ad.

a) PTA drainage is easy and certainly within the scope of EM when the patient is cooperative and the diagnosis is straightforward.
b) I view PTA drainage as diagnostic: If I get a bunch of pus when I drain, there's no need to do a CT.
c) As GV mentioned, PTA's probably don't actually need to be drained (unless they're causing airway compromise).

However, I wonder how much of the story our visiting ENT resident is leaving out. How many times have you sent home 4 chest pain patients, and then when you called to admit the 5th one (who has a good story and a bad ECG) Cardiology complained that you admit every chest pain? Or how about when you're seeing your third abdominal pain patient of the shift, and you call surgery while the labs are cooking because it's a slam dunk appy, yet the surgery resident complains about the "knee jerk" consult? I could go on, but you get the point. If I call an ENT resident about a drooling PTA who can only open his mouth 1cm I doubt he'll say, "well this is obviously a good case to call me on." No, he's much more likely to say something like "Grumble grumble, decadron, Unasyn (which were already given), grumble, grumble."

There's also this - I've worked in hospitals where the Ortho service wants every fracture evaluated by the Ortho resident in the ED. This is mandated by Ortho, not EM. I think it's silly to hold onto a boxer's fracture until the Ortho resident sees the patient, but if I don't - good luck getting follow up. Do those Ortho residents complain about the policy? No, they complain about the ED.

Sure, there are some lazy EM docs out there, and they give us all a bad name, but there are also a lot of specialty residents who will complain about entirely reasonable consultations.

 

[Apollyon]

c) As GV mentioned, PTA's probably don't actually need to be drained (unless they're causing airway compromise).

All abscesses have to be drained, unless they spontaneously rupture and drain. Veers stated pts go out with referral - that is to ENT for drainage.

 

[WilcoWorld]

All abscesses have to be drained, unless they spontaneously rupture and drain. Veers stated pts go out with referral - that is to ENT for drainage.

I reviewed the literature on PTA about a year ago, and at that time there were authors suggesting that ABX & steroids without drainage were an option. I don't have the citations handy, but I encourage you to do a lit search and decide for yourself.

Perhaps Veers can clarify his meaning for us.

 

[GeneralVeers]

I reviewed the literature on PTA about a year ago, and at that time there were authors suggesting that ABX & steroids without drainage were an option. I don't have the citations handy, but I encourage you to do a lit search and decide for yourself.

Perhaps Veers can clarify his meaning for us.

I give ABX + steroids + Toradal for the vast majority of PTAs without drainage. If the patient can't open their mouth, has evidence of airway compromise, or looks septic then I will consider drainage or call ENT.

All PTAs that I discharge without drainage have referral to our ENT on call with strict instructions to follow-up in the next 1-2 days or return to the ER if worse.

Anecdotally I'd say 80% of these PTAs get better almost immediately with steroids and abx.

 

[gutonc]

I give ABX + steroids + Toradal for the vast majority of PTAs without drainage. If the patient can't open their mouth, has evidence of airway compromise, or looks septic then I will consider drainage or call ENT.

All PTAs that I discharge without drainage have referral to our ENT on call with strict instructions to follow-up in the next 1-2 days or return to the ER if worse.

Anecdotally I'd say 80% of these PTAs get better almost immediately with steroids and abx.

My personal anecdotal experience (i.e. my PTA) puts that at 100%. I didn't even get 'roids, just the bug juice. Felt better before my 2nd dose of augmentin. It was sort of amazing frankly.

 

[neusu]

The "not knowing the exam" is indefensible. Depending on your specialty, the "no studies" part is a huge gray area. Ignoring the really time critical diagnoses (penetrating trauma with shock not responding to fluids, fx/dislocation with vascular compromise, etc), there is a huge variability in when surgeons want to be called in the work-up. Take appendicitis for example. I've been yelled at for not calling prior to examining the patient (pt was waiting in lobby and took 2 hrs to be brought back), for calling with a classic story with consistent exam (who after he finished reaming me out, took the patient to the OR before labs were even back), for calling prior to CT scan, and once for calling after the CT was done.

At my old shop, you didn't go to the OR prior to CT and at my current shop the surgeons will admit on my H&P +/- labs and sound genuinely puzzled if you bring up CT'ing a classic appy. You may be (as much as your attendings allow) internly consistent on when in the work-up you want to be notified, but the overall variability is huge. So I call when I think your involvement is going to benefit the patient.

Also, if your attending sent a stable patient over from his clinic to the ED for admission instead of making the patient a direct admit then you are getting paged as soon as my exam is done.

I can understand the frustration with the general surgery folks who chew you out either way on an appy.

FWIW, I'm neurosurgery.

I have a cadre of examples of things that make me hate the ER docs where I work. Unfortunately, it seems any sort of feedback mechanism has not facilitated any change (personal conversations, medical error reporting system, conversations with hospital management).

I won't go off on a tirade regarding my hospitals, but when we specifically ask for things please try to accommodate us.

 

[Apollyon]

I reviewed the literature on PTA about a year ago, and at that time there were authors suggesting that ABX & steroids without drainage were an option. I don't have the citations handy, but I encourage you to do a lit search and decide for yourself.

Perhaps Veers can clarify his meaning for us.

I know it's not your intention, but you kinda sound sort of dickish in this post.

However, I did do a lit search, hampered by my not having personal access to various papers. However, looking back to 2005, using the term "peritonsillar abscess" did not yield what you say. This paper from 2010 stated that "However, anteceding antibiotic therapy did not only fail to prevent abscess evolvement, as also reported earlier, but may also have altered positive cultures incidence and results, having S viridans the more frequently isolate in this group."

Also searching for the term "quinsy", the heavy preponderance of papers referred to ABX preventing suppurative sequelae. I found no reference to nonoperative/nonsurgical treatment of known abscess. There was a differentiation between PTA and peritonsillar cellulitis, which mimics PTA, and will improve with ABX and steroids. However, if there is no "there" there (i.e., purulence) to be drained, then one could suspect that their PTA resolved without drainage.

However, right through 2011, the literature in English (at least what I found) stated unequivocally that drainage - needle aspiration, incision and drainage, or tonsillectomy - was a mainstay of treatment.

 

[Rendar5]

One of my attendings taught me that if there's no trismus, there's likely no PTA, just PTC. Confirmed this in a case with an u/s.

 

[Birdstrike]

.

 

[WilcoWorld]

I know it's not your intention, but you kinda sound sort of dickish in this post.

However, I did do a lit search, hampered by my not having personal access to various papers. However, looking back to 2005, using the term "peritonsillar abscess" did not yield what you say. This paper from 2010 stated that "However, anteceding antibiotic therapy did not only fail to prevent abscess evolvement, as also reported earlier, but may also have altered positive cultures incidence and results, having S viridans the more frequently isolate in this group."

Also searching for the term "quinsy", the heavy preponderance of papers referred to ABX preventing suppurative sequelae. I found no reference to nonoperative/nonsurgical treatment of known abscess. There was a differentiation between PTA and peritonsillar cellulitis, which mimics PTA, and will improve with ABX and steroids. However, if there is no "there" there (i.e., purulence) to be drained, then one could suspect that their PTA resolved without drainage.

However, right through 2011, the literature in English (at least what I found) stated unequivocally that drainage - needle aspiration, incision and drainage, or tonsillectomy - was a mainstay of treatment.

OK, I'll recheck my findings next time I have good access to the literature and the time to search. Did the search on-shift over a year ago, so I don't remember the specs nearly well-enough to argue now.

I'm actually a little disappointed that the point of my post was lost in the drain vs not discussion. That point being that many (most?) consultants who complain about EM do so because they lack an understanding of it.

 

[EctopicFetus]

Maybe I am too stupid or just miss out on these cues or perhaps my work environment is pretty good. Outside of Urology and one plastics doc (who I havent seen since) our specialists never get all pissed off. I work all nights so def not the time they want to be bothered either.

Its not uncommon for them to call me during shift and ask questions about friends or family. While I have no doubt they dont love me calling them at 330 am.. they respect what I do and my knowledge of my field. At least thats how I take it.

 

[Old_Mil]

they, without fail, seem to have CT scans when the H&P are clear cut.

Maybe this EM residency just sucks ass. I don't know.

Well, the perspective on the other side of the phone is this.

Conversation A:

ER Doctor: "Hey Dr. General Surgeon, I've got a 22 year old male patient here, febrile, epigastric abdominal pain now in the RLQ x 2 days with N/V and loss of appetite. No diarrhea, tenderness over McBurney's point on exam. 18K white count. I think he has appendicitis."

GS: "G!%)(*%)! D)(!@$()*! IT! It's 2am! What's the patient's white count? What does the CT show? Why the $@)(*!$ are you calling me without a complete workup? <click>"

Conversation B:

ER Doctor: "Hey Dr. General Surgeon, I've got a 22 year old male febrile male with abdominal pain. WBC count of 18k, elevated CRP, CT scan shows appendicitis."

GS: "G!%)(*%)! D)(!@$()*! IT! It's 2am! I'll be down in a bit."

The moral of the story is order everything a consultant could possibly want up front so that when they are on the phone, they can't block the consult or the admit.

 

[DeadCactus]

So what if you don't want to order the CT? Is it just political fallout or can the surgeon really refuse to come see the patient because you refuse to order an non-indicated test?

 

[Rotors]

So what if you don't want to order the CT? Is it just political fallout or can the surgeon really refuse to come see the patient because you refuse to order an non-indicated test?

Wait, you're CT scanning people who have suspected appendicitis?

Our Radiologist would throw an absolute fit and probably channel the overwhelming rage into superhuman strength, pick up the CT scanner and clobber us with it if we asked for that!

We rely on good old physical exam down here and then if we suspect appendicitis it's a quick phone call to the Surgical Registrar to get them to come review the patient for their surgical opinion seeing as how Emergency Physicians and GP's are not surgeons.

 

[cpants]

Generally have a lot of respect for the ED guys and I think the job is very difficult. That said, the things that piss me off are:
-Consults when you haven't examined the patient yourself, especially any call which includes the phrase "I got in signout..."
-"We just want your blessing..." If you don't really think it's a surgical problem 99 times out of a 100 we won't either. If it is something that is managed as an outpatient, please don't insist we see the patient at 3am.
-Consults on stable patients with inappropriate/inadequate workup. I'm not saying you have to have the guy teed up for the OR every time, but for most stuff you should at least have some labs back before you call me. If the guy is actively crumping, I won't begrudge an urgent consult.
-Dispo consults: Ortho won't admit the patient, but his pain is uncontrolled. Now five hours later we want a trauma consult for admission. (I get that you can't admit patients, but you can imagine how annoying this is).
-"The chief needs to see this patient right NOW." "I'm paging your attending too". "Better call the OR now." "This is a surgical abdomen." etc. etc. These phrases are meaningless to us, as we have heard wolf cried too many times. Just tell us the story and let us decide for ourselves.

I know that a lot of this stuff comes in based on your attending preferences, and sometimes you are forced to call a consult that you know is weak. Realize this is annoying for us as we are forced to do a bunch of paperwork and give up a good hour of our very limited time. Yes it's our job to come in from home or put aside whatever else we are doing whenever you call, but you don't need to remind me of that. Try to be a little understanding if we are grumpy, especially on a soft consult. Even if yours is legit, realize that I just got done with 5 completely nonsense consults from medicine before I got there. If I'm on home call I have a full day of OR and floorwork ahead of me. I know, boohoo. Just don't expect me to be thrilled to give my blessing to a benign abdomen in the wee hours.

 

[xaelia]

Wait, you're CT scanning people who have suspected appendicitis?

Some might be.

We called surgery for suspected appendicitis the other day with nothing but our H&P and vital signs. No labs, no scan. Other than asking that we not give him pain medication prior to their exam (hello, that's barbaric), they were very reasonable.

I think most of us endeavor to perform CTs only when we aren't sure what's going on, and we want to make sure we aren't missing appendicitis or another surgical emergency.

 

[Rendar5]

Some might be.

We called surgery for suspected appendicitis the other day with nothing but our H&P and vital signs. No labs, no scan. Other than asking that we not give him pain medication prior to their exam (hello, that's barbaric), they were very reasonable.

I think most of us endeavor to perform CTs only when we aren't sure what's going on, and we want to make sure we aren't missing appendicitis or another surgical emergency.

only our pediatric surgeons will touch an appy without imaging and not be pissed off on calling consults before labwork is back. That said, I can count on one hand the number of times there was a slam dunk appy's that didn't have any likely mimickers. In those situations, peds surg residents would come down right away, and take to the OR after a CBC and urine, and gen surg residents would need to wait for labs to see the pt and the CT to take them to the OR. And unfortunately, CT for appy at my current place requires PO contrast, and our u/s techs couldnt' find an appendix to save their lives.

 

[xaelia]

Fascinating.

Whenever I've felt strongly enough about a case, I've always been able to get the surgery residents to come see the patient prior to imaging. They are not always happy about it. If they still request imaging after having seen the patient, no problem.

This is obviously different from community practice, anyway.

 

[TrumpetDoc]

A big thing to remember too, is that the "culture" of your particular site is perhaps the biggest factor.
Academic settings, although seemingly awesome to have a "service" for every conceivable entity, can be a literal hell in getting said service to consult and/or admit.
Community setting, get to know your med staff colleagues. You'll know the surgeons that will play ball with "clinical" diagnoses etc and it makes for a much more fun working environment.







Sent from my iPhone using Tapatalk

 

[GeneralVeers]

Wait, you're CT scanning people who have suspected appendicitis?

Our Radiologist would throw an absolute fit and probably channel the overwhelming rage into superhuman strength, pick up the CT scanner and clobber us with it if we asked for that!

We rely on good old physical exam down here and then if we suspect appendicitis it's a quick phone call to the Surgical Registrar to get them to come review the patient for their surgical opinion seeing as how Emergency Physicians and GP's are not surgeons.

90% of our surgeons want a CT scan before even considering the OR. They are afraid of doing a "negative laparotomy" and potentially getting sued.

 

[docB]

There are 2 things I have seen that increase consults that haven't been mentioned yet.

First are the situations where there is a policy that specialtists get consulted for cases. In academic centers I've seen situations where department chairmen have demanded that their services be consulted for all cases in their area no matter what because they know that they are the final word for that condition and they will not be the ones personally doing the work. Similarly in private settings I have seen department heads (usually the non-practicing owners of large groups) demand that their minions be consulted for every case to increase their billing volume. For example, I am familiar with a hospital whose cardiology department wanted a cardiologist consulted for every chest pain rule out.

I have also seen many situations where a specialist has refused to treat a patient who had a complication from a procedure by an ER doc. Draining that PTA is great but what do you do when you come up dry and the swelling gets worse and the ENT refuses to see "someone else's complication." Believe me, that situation will result in bad blood and often in the ED refusing to do that procedure for a long time.

 

[deleted109597]

And unfortunately, CT for appy at my current place requires PO contrast, and our u/s techs couldnt' find an appendix to save their lives.

Then order it as a "r/o renal stone" and force them to not identify it. Just like we argue with surgeons who don't want people to get pain medicine before the exam, we should argue with radiologists who don't keep up with their own literature.

 

[tkim]

Well, the perspective on the other side of the phone is this.

Conversation A:

ER Doctor: "Hey Dr. General Surgeon, I've got a 22 year old male patient here, febrile, epigastric abdominal pain now in the RLQ x 2 days with N/V and loss of appetite. No diarrhea, tenderness over McBurney's point on exam. 18K white count. I think he has appendicitis."

GS: "G!%)(*%)! D)(!@$()*! IT! It's 2am! What's the patient's white count? What does the CT show? Why the $@)(*!$ are you calling me without a complete workup? <click>"

Conversation B:

ER Doctor: "Hey Dr. General Surgeon, I've got a 22 year old male febrile male with abdominal pain. WBC count of 18k, elevated CRP, CT scan shows appendicitis."

GS: "G!%)(*%)! D)(!@$()*! IT! It's 2am! I'll be down in a bit."

The moral of the story is order everything a consultant could possibly want up front so that when they are on the phone, they can't block the consult or the admit.

More like:

GS: It's 6AM - this is a clear-cut appy, you didn't need these labs and CT - why did you wait to call me? Do you want this guy to perf?

You can't win.

 

[xaelia]

Our surgery department took one of their attendings to M&M for delay in care after he came and saw a clear-cut appy in a teenager and asked for a CT. Their Chief of Staff e-mailed me personally to apologize.

 

[docB]

Our surgery department took one of their attendings to M&M for delay in care after he came and saw a clear-cut appy in a teenager and asked for a CT. Their Chief of Staff e-mailed me personally to apologize.

Print that email and put it under bulletproof glass in a booth at ACEP. Charge ER docs $5 each to see it. I'll have $10 with your name on it because I plan to see it twice.

 

[Birdstrike]

.

 

[Birdstrike]

.

 

[southerndoc]

Wait, you're CT scanning people who have suspected appendicitis?

Our Radiologist would throw an absolute fit and probably channel the overwhelming rage into superhuman strength, pick up the CT scanner and clobber us with it if we asked for that!

We rely on good old physical exam down here and then if we suspect appendicitis it's a quick phone call to the Surgical Registrar to get them to come review the patient for their surgical opinion seeing as how Emergency Physicians and GP's are not surgeons.

I'm surprised at how often I see a patient with presumed appendicitis who ends up with a newly diagnosed Crohn's disease instead.

I agree with the general surgeons where I practice. I would rather CT and make sure its appendicitis instead of taking the patient to the OR. There really isn't a good reason to have a negative appendectomy these days. Not even sure if insurance would pay for that now. General anesthesia and surgery have way more complications than risk of cancer or CIN from a single CT scan.

 

[southerndoc]

Then order it as a "r/o renal stone" and force them to not identify it. Just like we argue with surgeons who don't want people to get pain medicine before the exam, we should argue with radiologists who don't keep up with their own literature.

That's easy until something gets missed and the radiologist has written "This study is grossly limited due to lack of PO and IV contrast." It's hard to defend yourself when that's written.

Thankfully our radiologists do not require PO or IV contrast except in thin patients. We use a lot of point-of-care testing, so I do a lot of IV contrast only.

 

[Rotors]

I'm just jealous you blokes have the resources to chuck somebody with a sore guts who you think has appendicitis through the CT scanner

And if you're afraid of getting sued over an open laparotomy try a laproscopy instead? Man I should have been a surgeon!

 

[deleted109597]

That's easy until something gets missed and the radiologist has written "This study is grossly limited due to lack of PO and IV contrast." It's hard to defend yourself when that's written.

Except 2 things. If you really think there's something going on, you can add contrast later.
Second, the court case would be pretty easy. "Sir, can you point out in the radiology literature where it says you have to have PO and IV contrast?"
They can write all they want. Doesn't make it a fact.

Again, only radiology can get away with making comments about other doctors. If there was a consult note that said something akin to "this patient is grossly limited by the poor choice of medicines by the primary team" people would be up in arms. But the group that can bill retroactively, edit their medical documents (you know, draft vs final), and avoid patients is allowed to do so.

 

[docB]

Except 2 things. If you really think there's something going on, you can add contrast later.
Second, the court case would be pretty easy. "Sir, can you point out in the radiology literature where it says you have to have PO and IV contrast?"
They can write all they want. Doesn't make it a fact.

Again, only radiology can get away with making comments about other doctors. If there was a consult note that said something akin to "this patient is grossly limited by the poor choice of medicines by the primary team" people would be up in arms. But the group that can bill retroactively, edit their medical documents (you know, draft vs final), and avoid patients is allowed to do so.

They can obscure the issure by presenting a lot of experts who will testify contrast is better.

 

[bulgethetwine]

Generally have a lot of respect for the ED guys and I think the job is very difficult. That said, the things that piss me off are:
-Consults when you haven't examined the patient yourself, especially any call which includes the phrase "I got in signout..."
-"We just want your blessing..." If you don't really think it's a surgical problem 99 times out of a 100 we won't either. If it is something that is managed as an outpatient, please don't insist we see the patient at 3am.
-Consults on stable patients with inappropriate/inadequate workup. I'm not saying you have to have the guy teed up for the OR every time, but for most stuff you should at least have some labs back before you call me. If the guy is actively crumping, I won't begrudge an urgent consult.
-Dispo consults: Ortho won't admit the patient, but his pain is uncontrolled. Now five hours later we want a trauma consult for admission. (I get that you can't admit patients, but you can imagine how annoying this is).
-"The chief needs to see this patient right NOW." "I'm paging your attending too". "Better call the OR now." "This is a surgical abdomen." etc. etc. These phrases are meaningless to us, as we have heard wolf cried too many times. Just tell us the story and let us decide for ourselves.

I know that a lot of this stuff comes in based on your attending preferences, and sometimes you are forced to call a consult that you know is weak. Realize this is annoying for us as we are forced to do a bunch of paperwork and give up a good hour of our very limited time. Yes it's our job to come in from home or put aside whatever else we are doing whenever you call, but you don't need to remind me of that. Try to be a little understanding if we are grumpy, especially on a soft consult. Even if yours is legit, realize that I just got done with 5 completely nonsense consults from medicine before I got there. If I'm on home call I have a full day of OR and floorwork ahead of me. I know, boohoo. Just don't expect me to be thrilled to give my blessing to a benign abdomen in the wee hours.

You're going to have trouble enjoying your job for the rest of your career. That's okay -- it's your burden to carry, not mine.

 

[cpants]

You're going to have trouble enjoying your job for the rest of your career. That's okay -- it's your burden to carry, not mine.

Nah. I love my job. Just don't love going to the ER for BS. Probably will feel slightly less grumpy about when I actually get paid for each consult.

 

[GeneralVeers]

Nah. I love my job. Just don't love going to the ER for BS. Probably will feel slightly less grumpy about when I actually get paid for each consult.

We don't like calling you for B.S., but realize we are in a no-win scenario.

If I do call for B.S. I get yelled at. If I don't call, I have the Chief of Staff sending me nastygrams about why I didn't call a surgeon for a B.S. issue that their patient was in the E.R. for.

Given that all **** rolls downhill, and most of it ends up in the ER, you are going to get a little bit of it chucked back into your face from time to time.

 

[Birdstrike]

.

 

[docB]

I love how so called "specialists" like to talk s--t about how some ER doc is an idiot for not knowing how to practice their field as well as they do, yet they would be dangerous, incompetent and as lost as a medical student on their first day of clinicals if asked to work an ER shift, and practice the specialty of emergency medicine. When you disrespect other specialties it lowers you to the level of people who posses mainly a combination of common arrogance with even more common ignorance.

I accept the grumbling. It goes with the territory of giving people work.

I agree that I get irritated by the widely held assumption by consultants that they could do my job better than me. Many of them truly believe this. I had on OB/Gyn who fought every single consult and told everyone, on every single phone call, how he had been an ER doc back in the day (someone finally pinned him down and it turned out he had moonlit in some ER back east during his residency).

I have noticed that the docs who spend more time in the ED, e.g. the hospitalist who admits 10 ER patients a day, understand us better and have the attitude "I'm glad you do what you do 'cause I couldn't do it." That's the attitude I have about their job, i.e. respect.

On the other hand I had a cardiologist who was annoyed by a screaming baby ask me once "So who takes care of the kids and pregnant women here?" 🙄

 

[WilcoWorld]

Had an internist gripe at me today that the ED should be comfortable adjusting insulin dosages. I considered asking her how she manages a variety of fractures, or severe croup, or status epilepticus, or pregnant vaginal bleeding but instead I just pointed out that the patient in question was on her 4th visit to the ED this month (and was just admitted last week) for hypoglycemia (always with AMS and a 911 activation), so perhaps a quick ED med adjustment wasn't the best plan in this patient.

 

[cpants]

I love how so called "specialists" like to talk s--t about how some ER doc is an idiot for not knowing how to practice their field as well as they do, yet they would be dangerous, incompetent and as lost as a medical student on their first day of clinicals if asked to work an ER shift, and practice the specialty of emergency medicine. When you disrespect other specialties it lowers you to the level of people who posses mainly a combination of common arrogance with even more common ignorance.

Hope you weren't talking about me. Like I said, I have a lot of respect for what you guys do, and while I think I could do the job (if I was properly trained in it), I certainly don't think I could do it well with my current training. I just don't like getting my time wasted. No one does. On your side of the spectrum, I'm sure you guys get pissed when surgeons or primary care docs send non-urgent patients from their office to the ER for admission instead of just doing it directly. Wastes everyone's time. I'm sure you don't relish those walk-ins with sinusitis or low back pain.

 

[Birdstrike]

.

 

[cpants]

I was not talking about you, just speaking in general terms.

At an academic center, wasting other people's time is the name of the game. BS consults are the norm. It's a bunch of people who don't quite have it figured out yet, wasting the time of others who don't quite have it figured out yet, and vice versa. A bunch of house staff creating work for other house staff, and a lot of griping in between, because you get paid the same no matter what. So, it's easier to dump it on some other resident and say, "My attending wanted a consult".

Yes, when "consults = cash", the mindset sometimes changes. Then when you're established and you're more busy than you can deal with, the b--ching starts again.

Again, speaking in general terms.

Yeah. Sounds about right.

 

[AmoryBlaine]

Generally have a lot of respect for the ED guys and I think the job is very difficult. That said, the things that piss me off are:
-Consults when you haven't examined the patient yourself, especially any call which includes the phrase "I got in signout..."
-"We just want your blessing..." If you don't really think it's a surgical problem 99 times out of a 100 we won't either. If it is something that is managed as an outpatient, please don't insist we see the patient at 3am.
-Consults on stable patients with inappropriate/inadequate workup. I'm not saying you have to have the guy teed up for the OR every time, but for most stuff you should at least have some labs back before you call me. If the guy is actively crumping, I won't begrudge an urgent consult.
-Dispo consults: Ortho won't admit the patient, but his pain is uncontrolled. Now five hours later we want a trauma consult for admission. (I get that you can't admit patients, but you can imagine how annoying this is).
-"The chief needs to see this patient right NOW." "I'm paging your attending too". "Better call the OR now." "This is a surgical abdomen." etc. etc. These phrases are meaningless to us, as we have heard wolf cried too many times. Just tell us the story and let us decide for ourselves.

I know that a lot of this stuff comes in based on your attending preferences, and sometimes you are forced to call a consult that you know is weak. Realize this is annoying for us as we are forced to do a bunch of paperwork and give up a good hour of our very limited time. Yes it's our job to come in from home or put aside whatever else we are doing whenever you call, but you don't need to remind me of that. Try to be a little understanding if we are grumpy, especially on a soft consult. Even if yours is legit, realize that I just got done with 5 completely nonsense consults from medicine before I got there. If I'm on home call I have a full day of OR and floorwork ahead of me. I know, boohoo. Just don't expect me to be thrilled to give my blessing to a benign abdomen in the wee hours.

Tell you what pal, you guarantee me excellent quality of every single resident carrying the consult pager for your specialty and 100% sensitivity in your interns grasping really serious situations and I'll stop saying this on the 0.1% of the consults I call you with.

 

[Hamhock]

Tell you what pal, you guarantee me excellent quality of every single resident carrying the consult pager for your specialty and 100% sensitivity in your interns grasping really serious situations and I'll stop saying this on the 0.1% of the consults I call you with.

I think this issue can be solved by having a senior resident or attending make that 0.1% call...or at least the junior resident notify the consultant that that the attending has fully evaluated the patient and completely agrees.

Then again, I doubt junior residents are calling fellows and attendings without the above.

HH

 

[cpants]

Tell you what pal, you guarantee me excellent quality of every single resident carrying the consult pager for your specialty and 100% sensitivity in your interns grasping really serious situations and I'll stop saying this on the 0.1% of the consults I call you with.

Every consult gets run by the attending, and usually seen by a chief resident too. We see all consults within an hour with few exceptions. The emergent ones we are usually there within minutes. Surgical residents (yes, even the interns) are generally pretty good at telling whether or not someone is sick. No they aren't 100% sensitive, but they are a hell of a lot more sensitive than the ER attendings at knowing whether or not someone needs to go to the OR urgently. Calling my attending before I've seen the patient does nothing except piss me off. The attending is just going to call me and tell me to see the patient and let them know what is going on, which I was on my way to do anyway.

 

[coldweatherblue]

No they aren't 100% sensitive, but they are a hell of a lot more sensitive than the ER attendings at knowing whether or not someone needs to go to the OR urgently. Calling my attending before I've seen the patient does nothing except piss me off. The attending is just going to call me and tell me to see the patient and let them know what is going on, which I was on my way to do anyway.

Surgical interns are "a hell of a lot more sensitive than ER attendings at knowing whether or not someone needs to go to the OR"...

excellent.

the ole "intern/resident knows more than the attending" gag is probably the most entertaining thing to watch play out in all of medicine.. if it weren't for the MICU/SICU pt lingering in an ed bed overnight..

 

[cpants]

Surgical interns are "a hell of a lot more sensitive than ER attendings at knowing whether or not someone needs to go to the OR"...

excellent.

the ole "intern/resident knows more than the attending" gag is probably the most entertaining thing to watch play out in all of medicine.. if it weren't for the MICU/SICU pt lingering in an ed bed overnight..

Do you really think your attendings know more about glaucoma than a first year optho resident? more about operative fractures than the ortho intern? more about stone disease than the urology intern? Maybe first week in July, but in general...no. But when it comes to the belly everyone's an expert...

 

[deleted109597]

Do you really think your attendings know more about glaucoma than a first year optho resident? more about operative fractures than the ortho intern? more about stone disease than the urology intern? Maybe first week in July, but in general...no. But when it comes to the belly everyone's an expert...

Now, I expect you to take this the same way you've taken the rest of the advice here, but here it is anyway.
You're still an intern. Thus, I did more of a surgical internship than you, because I did the whole year. And yet, I know more now than I did at the end of that year. Strange how that works. Sure, the technical details about some procedures have been lost, but the sick vs not sick has been much more finely honed. And while there may be some stellar doctors out there in every specialty, there's bad ones too. I've known plenty of surgical seniors (my own included) who couldn't make a decision to save their life. They were slow, and didn't get the attending down there in a timely fashion.
I'm sure your exposure to emergency physicians has been poor and/or clouded, as you seem to despise our existence in most threads. I disagree with that sentiment, and I can tell you that I have had some ED thoracotomy patients live, so your 100% mortality rule is false.
No, I don't know about surgical treatment of glaucoma (at least not the technical details), but I know how to diagnose and treat it and refer it to the right person. I have never performed lithotripsy or put a double J stent in someone for stones, but I have seen hundreds of patients with them and treated them appropriately. That's my job. Identify the urgent or emergent problem and get it taken care of. I'm sorry you seem to get all panties in a wad about your consults, but that's what you're there for. In residency, you're there to learn. So learn what you can from those who have been there before you.

There's a reason you can't sign off on a consult until the attending sees the patient.

 

[Birdstrike]

.

 

[cpants]

Now, I expect you to take this the same way you've taken the rest of the advice here, but here it is anyway.
You're still an intern. Thus, I did more of a surgical internship than you, because I did the whole year. And yet, I know more now than I did at the end of that year. Strange how that works. Sure, the technical details about some procedures have been lost, but the sick vs not sick has been much more finely honed. And while there may be some stellar doctors out there in every specialty, there's bad ones too. I've known plenty of surgical seniors (my own included) who couldn't make a decision to save their life. They were slow, and didn't get the attending down there in a timely fashion.
I'm sure your exposure to emergency physicians has been poor and/or clouded, as you seem to despise our existence in most threads. I disagree with that sentiment, and I can tell you that I have had some ED thoracotomy patients live, so your 100% mortality rule is false.
No, I don't know about surgical treatment of glaucoma (at least not the technical details), but I know how to diagnose and treat it and refer it to the right person. I have never performed lithotripsy or put a double J stent in someone for stones, but I have seen hundreds of patients with them and treated them appropriately. That's my job. Identify the urgent or emergent problem and get it taken care of. I'm sorry you seem to get all panties in a wad about your consults, but that's what you're there for. In residency, you're there to learn. So learn what you can from those who have been there before you.

There's a reason you can't sign off on a consult until the attending sees the patient.

Don't despise them at all. As I've repeatedly said in this thread I respect ER physicians. It's a tough job, and generally you do a great job at it. My only negative responses have been to posters who have been attacking me directly or surgical residents in general. There are bad interns and bad seniors. If you feel that you need to go over their heads to advocate for your patient, by all means go for it, but it's generally pretty inappropriate before you've even given the resident a chance to see the patient. Anyway, I've lost interest. Once I get accused of trolling and posters start researching my post history looking for some phantom bias against the ED I'm out. Talk about 'panties in a wad'...sheesh.

 

[coldweatherblue]

Do you really think your attendings know more about glaucoma than a first year optho resident? more about operative fractures than the ortho intern? more about stone disease than the urology intern? Maybe first week in July, but in general...no. But when it comes to the belly everyone's an expert...

considering that PGY-1 for most opHtho, ortho and urology residents is spent mostly outside their respective specialities learning how to be a physician, not a specialist, yes I would expect an EM attending to know more about treating emergent conditions relating to those fields than any of the above interns.