MD & DO Away Rotator Pimping Residents

[Wordead]

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I'm a board-certified medicine attending.

My acute management of suspected nec fasc is such:

1) Assess the patient
2) Put the patient on antibiotics (typically triple therapy with a beta lactam, vanc, and clinda. Everyone always forgets the clinda)
3) Order the labs to calculate a LRINEC score (if not done. The chem panel and CBC usually are, the CRP usually isn't) with the understanding that the followup trials haven't shown it to be as reliable for ruling out nec fasc as the pivotal trial was
4) If very high suspicion (rapid progression or crepitus on exam) and/or an elevated LRINEC score, get a surgical consultation.

Notice what isn't in that sequence? Imaging. To quote uptodate: "Surgical exploration is the only way to establish the diagnosis of necrotizing infection." The bold is theirs. They go on to say "Radiographic imaging can be useful to help determine whether necrotizing infection is present but should not delay surgical intervention when there is crepitus on examination or rapid progression of clinical manifestations"

If my suspicion is moderate but I'm not convinced of my assessment? I might order imaging at the same time (or before) surgical consultation. But unlike what apparently you would have done as an M2, the assessment of an experienced surgeon is the definitive test for nec fasc.

Dude come on. We're not talking about obvious rapid progression and hard signs in this scenario. Intern thought it was maybe a little crackly.

Are you really telling me that you don't think a medicine team should be able to assess for nec fasc and it requires a surgeon (or in reality a surgery intern) to lay magic hands on them to assess? Are you agreeing with @OrthoTraumaMD that a MEDICINE attending should ever get a pass for not being able to differentiate between nec fasc gout and arthritis? I mean this stuff is truly mind boggling to me. It might be reasonable coming from psych or ophtho or something. Not medicine.

 

[Wordead]

Okay so I get the criticism on here, and I’m the first one to be a bit annoyed when I get consulted without xrays... But.... the whole point of consults is to help someone. The internists don’t know their ass from their elbow in ortho, literally. They don’t know if it’s nec fasc, arthritis, or gout. That’s why we are the specialists. The amount of time people bitch and argue about consults and what should or shouldn’t have been done beforehand is more than the time it takes to just go and see the patient, and help your fellow doctor who doesn’t know what to do for the patient but knows that something is wrong. I’m a fellowship trained traumatologist, able to fix an acetabulum or Masquelet an open fracture with bone loss, and do a flap to boot. And yet most of my daily life on call consists of shoulder and knee pain consults, usually not even acute. And I just get my ass up and go, though I’m salaried and not RVU-based. It’s not a waste of my time. Because when I want help with BP meds, I don’t want the internist going, “well why can’t you begin the workup yourself?” If I thought I was the best person for the job, I wouldn’t be calling.


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I'm not going to belabor the point and continue arguing with 2 attendings over this, but why on earth would chronic shoulder and knee pain need to be seen inpatient? And sure you might salaried and not be getting anything out of it but someones billing for it. Our medical system is bloated enough without that nonsense waste of resources. We get these types of consults all the time - so the resident comes and wastes his time, we scope the patient, bill patient/insurance for a $1000 and add nothing that is going to change an inpatient course. Is it common and accepted? Sure. Is it right? No.

 

[OrthoTraumaMD]

I'm not going to belabor the point and continue arguing with 2 attendings over this, but why on earth would chronic shoulder and knee pain need to be seen inpatient? And sure you might salaried and not be getting anything out of it but someones billing for it. Our medical system is bloated enough without that nonsense waste of resources. We get these types of consults all the time - so the resident comes and wastes his time, we scope the patient, bill patient/insurance for a $1000 and add nothing that is going to change an inpatient course. Is it common and accepted? Sure. Is it right? No.

They don’t NEED to be seen. But often these patients never make it to the doctor as an outpatient. Where I practice, many times they use the ER as their doctor, and they’re scared of physicians. So when they’re in for chest pain, it may be their only chance to get seen by someone for that knee pain that’s been bothering them, and maybe even get an injection for their arthritis. I don’t see that as a waste of my time or resources. If I’m helping that patient, that is all I care about.
Also your words “the resident comes and wastes his time” are frankly terrible. The point of residency is to see everything and learn from everything, no matter how mundane.


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[username456789]

If I had a nickel for every time surgery and/or medicine consulted me for “bilateral lower extremity cellulitis” in residency, I would have a lot of nickels.

Everyone has something to learn.

 

[Raryn]

Dude come on. We're not talking about obvious rapid progression and hard signs in this scenario. Intern thought it was maybe a little crackly.

Are you really telling me that you don't think a medicine team should be able to assess for nec fasc and it requires a surgeon (or in reality a surgery intern) to lay magic hands on them to assess? Are you agreeing with @OrthoTraumaMD that a MEDICINE attending should ever get a pass for not being able to differentiate between nec fasc gout and arthritis? I mean this stuff is truly mind boggling to me. It might be reasonable coming from psych or ophtho or something. Not medicine.

"Maybe a little crackly" is an indication for surgical consultation. Somehow I doubt that there's any scenario only a surgery intern would see the patient (maybe only a surgery resident, but if they thought it was "maybe a little crackly" too, their attending would probably get a call). If the surgical resident (or intern+resident) weren't hyperacutely concerned? That's fine, can get the CT scan.

And I generally do agree with @OrthoTraumaMD. I'd be ashamed of any internist who can't tell the difference between gout and neck fasc, but there's plenty of times I can't tell the difference between gout and septic arthritis acutely... and the answer there is the patient needs an arthrocentesis. And while I have done those in training, when working as a hospitalist, I don't anymore, so it very well might merit an ortho consult.

I'm also a subspecialist, and we get all kinds of consults that can be managed as an outpatient. The best advice I can give in that scenario by is to abide by the principle of charity - treat the consult as one of your colleagues asking for help with something they aren't comfortable with. Explain your reasoning and move on.

 

[LucidSplash]

If there’s a concern for “crackly” then getting the xray is a better choice IMHO (as a board-certified general surgeon since we seem to be throwing around titles in here). If there’s subq air on the xray, I wouldn’t get the CT, I’d take the patient to the OR. If no air in the xray then can proceed to CT.

Xray is generally faster and can be done at bedside and is enough for operative exploration if positive.

 

[Psai]

If I had a nickel for every time surgery and/or medicine consulted me for “bilateral lower extremity cellulitis” in residency, I would have a lot of nickels.

Everyone has something to learn.

I had a bilateral LE cellulitis patient once. Came in looking pretty sick with dizziness, malaise b/l redness fever white count inflammatory markers, found some vre in his blood and got better with linezolid.

 

[username456789]

I had a bilateral LE cellulitis patient once. Came in looking pretty sick with dizziness, malaise b/l redness fever white count inflammatory markers, found some vre in his blood and got better with linezolid.

You should play the lottery next.

 

[Psai]

You should play the lottery next.

I also handled it myself with no consults. Are you proud of me yet?