surgres88

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After this past weekend on call and a few too many "memorable" consults, I wanted to see how interesting consults for surgery residents can get. Hopefully, we can get a few laughs out of them, educate the medical students when it is appropriate to call consults (or hopefully educate how to do a consult), and maybe vent a little frustration out.

Here is one on the ridiculous side. An ER attending consulting surgery right after shift change (calling MD hadn't seen/examined patient-the impetus to start this thread.) for "rule-out appendicitis" in a 9 YO with 4 days of abdominal pain (non-localized to RLQ), a negative Ultrasound (non-visualized appendix), and a normal CT scan (contrast filled, <6mm appendix). Surgery was called after above diagnostic tests had been done and read by radiology. Final Dx: UTI.
 
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Dimoak

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CT-scanning a 9 yearold for r/o appy without even having done a physical exam first? I'm not an expert, but IMHO, that's a big no-no. Was this done by an attending or resident?
 
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SocialistMD

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CT-scanning a 9 yearold for r/o appy without even having done a physical exam first? I'm not an expert, but IMHO, that's a big no-no. Was this done by an attending or resident?
I think you are misunderstanding. The workup (including exam, radiologic studies, labs, etc...) had been done by the physician who was ending his/her shift, not the one calling the consult, who had just arrived and not actually seen the patient. You are correct that it is not a good idea to call a consult on a patient you haven't personally seen, but I don't think the studies were ordered without an exam first (at least, I hope not :eek:).
 

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-Consult for ingrown toenail

-Consult for bleeding tophus

-Consult for belly pain w/o ANY workup

-Consult to put in an a-line (you're a [email protected]#$!ing MICU resident...are you kidding me?)

-Any consult from a medical student
 

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I had a consult for ABIs and PVRs just the other day. I saw the patient and wrote a very polite note that those tests do not need to be ordered by a vascular surgeon. The patient just needed a good exam, graded exercise plan and nothing more. Still, I met a very nice gentleman who is going to do well.
 

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Not a surgery resident, just your friendly neighborhood neuro PA. However, we get our share of questionable consults.

My favorite and for some reason oft repeated consult goes something like this.

98 YO, nursing home resident with dementia, CAD, COPD, renal failure, DM who is DNR/DNI with a meningioma and is on deaths door. The family does not wish any intervention and the patient is going to be transferred to hospice.

"Consult for possible surgical management."

Really!?

There are so many things wrong with that I can't even tell you. N=5 in the last year.
 

Winged Scapula

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Lemme see...

breast pain in a MICU patient, Saturday night around 9 pm. Apparently the patient had complained about breast pain during her admission (for some cardiac what-not) to the MICU and hospital policy was that she couldn't be transferred out of the MICU until all "problems" had been addressed. I refused to see that one.

Vascular Surgery consult to manage varicose veins in a MICU patient

MULTIPLE pediatric surgery consults for r/o acute abdomen/appy in constipated patients

MICU consults to place chest tubes, A-lines, central lines

Various surgical consults like Chronic's: GOMER with some non-lifethreatening surgical problem. Uhh...grandpa can do without his roids being banded today, thank you.

my :love: consult: VA medicine service consults VA surgery service for placement of Foley. Reason? Can't find penis or meatus. I mean, he was obese, but not THAT obese. Or maybe I'm just really good at finding peni.
 
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surgres88

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Thanks for sharing the pain.

-

-Any consult from a medical student
I agree to a point, though I think they need to learn. When med students rotate on our service, I make sure if they call consults an intern or resident is sitting next to them to swoop in and not waste the other service's time, or I teach them myself.

During R3 year on the consult service I got a call from an eager beaver medicine Sub-I with this consult: Went almost exactly like this.

Sub-I: "This is _____ the acting intern on Medicine. We want you to see a patient because of a "funky" CT scan."
Me: "What is the patient's name and MRN?"
Sub-I: "I don't know."
Me: "Tell me what you see on the CT scan. What is funky?"
Sub-I: "I haven't looked at it."
Me: "What is the patient complaining about?"
Sub-I: "I don't know, I haven't seen the patient."
Me: "Have your senior resident call me back with the consult." Then hung up. Though I wish I could say I left it at that.

...Then my Catholic guilt got to me, called the med student back and told him to stay where he was and went and taught him how to do an appropriate consult...with emphasis on seeing the patient first. Hopefully, these 10 minutes saved the next surgical service some pain when this joker called. Doubt it. A 4th year medical student should know how to do an appropriate consult.
 

Dimoak

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I think you are misunderstanding. The workup (including exam, radiologic studies, labs, etc...) had been done by the physician who was ending his/her shift, not the one calling the consult, who had just arrived and not actually seen the patient. You are correct that it is not a good idea to call a consult on a patient you haven't personally seen, but I don't think the studies were ordered without an exam first (at least, I hope not :eek:).
Oops yeah, I missed the shift change part when I read the post the first time. I need to not assume that just because the H&P wasn't included that an H&P wasn't available. I figured a negative physical would've added zing to the post. :D
 

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I got a consult from the ER at midnight a couple of weeks ago for an obvious breast cancer, in a patient who was scheduled to see the local breast surgeon the next day in clinic. They wanted me to admit the patient and take her for an emergent mastectomy!
 
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JackADeli

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...MICU consults to place chest tubes, A-lines, central lines...
mostly don't mind these as they are mostly individually billable in addition to billing for the decision making consult. Not bad in the general surgery world.

However, I hate getting a consult to.....
please remove central line (i.e. standard IJ or SC) as our nurses are not qualified to remove and the MD said he is not comfortable and the ED physician that placed line a week ago is not in the hospital!!!

or

STAT chest consult at midnight for PTHx....
after 8am placed central line that followed by a 9am STAT line placement chest xray to confirm position (yes, line OK and in use) that was reviewed by crosscover hospitalist at 11pm!!!

or

I generally dislike med-student called consults more and more. Honestly, should really be a physician calling. Many hospital "by-laws" are actually stating physician to physician consult calls. I don't think calling a consult takes a huge amount of experience that you need or must get in med-school. Interns & junior residents can be taught by more senior residents. We really do not have to continuously use the teaching excuse to allow/permit students to do tasks that others should do. Bring your students along and show them how you call the consult. If time permitting have them try to pitch you the consult first. But, please don't drag out the time of the individual on the other end of the line.

JAD
 
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umean2tellme

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Do other docs ever get reprimanded for making lots of ridiculous consults? I read this part of SDN a lot and I see a lot of surgeons say they get a bunch of bogus consults, do the consulting physicians ever get in trouble for consulting with actually seeing a patient?

Oh and if, for example, you get a consult for something like appendicitis and it turns out to be a uti or something else, if you dx it do you have to treat it (like order antibiotics or w/e meds are needed) or are you only supposed to do the surgical interventions and let the consulting guy do the actual prescribing of meds?
 
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JackADeli

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Do other docs ever get reprimanded for making lots of ridiculous consults? with (out) actually seeing a patient?...
Generally, no. Surgeons suffer in the dark. I think the number thrown around is something like ten crap consults for one good operative case. Surgeons are stuck with effectively kissing up to those that will consult and thanking for the "interesting case" in hopes of endearing some public affection and more consults. It is a real problem with the healthcare system. If we point out the incompetence, we will be isolated. In effect, we are stuck with enabling the incompetent to care for the patient.
...if, for example, you get a consult for something like appendicitis and it turns out to be a uti or something else, if you dx it do you have to treat it (like order antibiotics or w/e meds are needed) or are you only supposed to do the surgical interventions and let the consulting guy do the actual prescribing of meds?
In general, that is what the 2am thank you call to the requesting physician is for.... let him/her know you have seen the consult, figured out what the physicians problem is, and provide them recommendations. A patient in the ED will be treated for non-surgical problems by the ED. Patient on the floor will receive care for their non-surgical problem by their primary team. If patient shows up in my clinic for r/o appy and only has a UTI, I write a script and arrange f/u back with PCP or other physician that sent patient.

JAD
 

smq123

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I generally dislike med-student called consults more and more. Honestly, should really be a physician calling. Many hospital "by-laws" are actually stating physician to physician consult calls. I don't think calling a consult takes a huge amount of experience that you need or must get in med-school. Interns & junior residents can be taught by more senior residents. We really do not have to continuously use the teaching excuse to allow/permit students to do tasks that others should do. Bring your students along and show them how you call the consult. If time permitting have them try to pitch you the consult first. But, please don't drag out the time of the individual on the other end of the line.
Trust me, we hate calling them in just as much as you hate getting them.

Even if it were disguised as something educational, that would be one thing. The first time I called in a consult, the intern just told me to do it...but not a single word on HOW to do it. :rolleyes:
 
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Winged Scapula

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mostly don't mind these as they are mostly individually billable in addition to billing for the decision making consult. Not bad in the general surgery world.
Fair enough, but these things are so low paying as to not make it worthwhile, IMHO. $115 for a central line, $130 for a chest tube ain't worth the risks for the measly reimbursement. Even a 99255 consult will only get you around $200.

However, I hate getting a consult to.....
please remove central line (i.e. standard IJ or SC) as our nurses are not qualified to remove and the MD said he is not comfortable and the ED physician that placed line a week ago is not in the hospital!!!
Ha ha...got a few of those at Holy Spirit, including one from the Dialysis Unit. "We're qualified to access it, but not to remove it.":rolleyes:

STAT chest consult at midnight for PTHx....
after 8am placed central line that followed by a 9am STAT line placement chest xray to confirm position (yes, line OK and in use) that was reviewed by crosscover hospitalist at 11pm!!!
Classic. Another good one is the stat consult for the free air seen on AAS done the day before, but everyone waited for the radiology read to come back.
 

Winged Scapula

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Generally, no. Surgeons suffer in the dark. I think the number thrown around is something like ten crap consults for one good operative case. Surgeons are stuck with effectively kissing up to those that will consult and thanking for the "interesting case" in hopes of endearing some public affection and more consults. It is a real problem with the healthcare system. If we point out the incompetence, we will be isolated. In effect, we are stuck with enabling the incompetent to care for the patient.
Unfortunately, referrals drive your business. My partner and I have a local physician who sends us a fair number of patients. However they are always benign non-operative.

Its with gritting teeth I write the thousandth "thank you for this kind referral" when all I want to know is to whom does she send her operative patients?

In academics you can get away with more because the consultants have to use you; in PP and the community its totally different. Granted you might complain less because you get paid just as much to see a bogus consult as you do a real one, but the real one usually engenders some fun operating and operative billing. But telling your referring physicians to stop sending you ridiculous stuff? Not a wise move.
 

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Trust me, we hate calling them in just as much as you hate getting them.

Even if it were disguised as something educational, that would be one thing. The first time I called in a consult, the intern just told me to do it...but not a single word on HOW to do it. :rolleyes:
No kidding. The first time I called a consult I had been a 3rd year med student for about 3 days and my resident handed me a patient label with the name and MRN and said "hey page ortho and tell them we have a consult. Tell them x,y, and z." Eager to please, I was like "yes sir right away sir," got the resident on the phone and delivered what I was told...having never seen a consult done before and being exhausted I wasn't thinking clearly and figured this would be like ordering a pizza or something.

It must have been painfully obvious to this poor bastard I woke up in the middle of the night that I didn't know what I was talking about. Didn't know anything about the patient other than what I had been told and my resident had conveniently wondered off somewhere. Once he figured out my place on the totem pole he ripped me in half. For about 2 minutes he lectured (at the top of his lungs) about professionalism and how it should be an MD to MD call....it was brutal.

After he blew off the steam he finally put it together. "Let me guess....ur residents told u to do this didn't they? Don't let them leave you hanging like this ever again!"

He was cool about it in the end....and after that I didn't do ANYTHING without considering the possible beatdown that could accompany my actions.
 

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I did a consult a couple weeks ago for my service for removal of sutures...

The patient had a facial lac repaired in the ER and admitted for a fall. It was hospital day 7 so they consulted gen surg to remove them before the patient was to be discharged.
 

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I'm finishing up intern year (GS) and have been getting more and more annoyed by bogus consults. Last week I was consulted for kidney stones, benign abdomen. I told the medicine resident that this is a GU issue, to page the urology service. He pulled the classic line, "my attending wants me to call surgery." I examined the patient, reviewed the labs/CT, and called the medical attending at home at 1am. He was pissed and embarrassed, but in the end, I didn't have to fill out the consult sheet or add the patient to my list.
 

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I love these threads. I could do this all day. As a disclaimer, we have an ER that even visiting ER residents are ashamed of. I am aware that there are EDs out there staffed by intelligent, insighful physicians.

I have diagnosed:
Hydrocele, epididymitis, kidney stones, UTI, PID, Fecal impaction, scrotal cellulitis/abscess, colitis

Consults I enjoy:
Elective hernia repairs for Child's C cirrhotic patients
Non level I trauma for "clearance" prior to ortho fix, medicine admission, etc.
Stage IV metastatic patients ("Can't you just cut it out?")
Venous stasis ulcers
Dead bowel in the MICU patients on max pressors with a hard abdomen x 2 days
The ER classic - Non-examined, no-workup patient with abdominal pain (Usually get curbsided with these while doing something else - "hey could you take a look at this guy . . . ")

Luckily for us, there is a medicine procedure team who does all the central lines, paracentesis, dialysis catheters, etc. However, this often leads to the pneumothorax or femoral pseudoaneurysm consult secondary to procedure team intervention.
 

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hahaha to Thanatos ... as a med student, I feel your pain. Just one of those things I'll consciously avoid doing to med students when I'm an intern/resident.
 

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Non level I trauma for "clearance" prior to ortho fix, medicine admission, etc.
As painful as these are, the ACS feels that most trauma patients, level 1 or not, should be admitted to a surgical service and may actually pull level 1 status from hospitals with to many trauma-to-medicine admits. If ortho balks, GS is there (as always) to do the right thing.
 
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surgres88

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Thanatos- A lot of days your going to get the Ortho resident like that, regardless of your resident status.

It is nice to have a steady stream of entertaining consults a few of my unique ones:
First) Rectal Foreign Body...it was a super-sized water bottle that bicyclist have mounted on the bike frame. Completely in the Rectum...for 4 days...Perf'd the Distal Sigmoid...two priceless things 1) asked the sister to remove it, she tried twice! 2) The water bottle was labeled with a local HMO insignia, I told the attending we should arrange transfer and advise them to start labelling "External Use Only."

Second) Obstructing Colon Cancer in a Hobo (Yes, the guys that ride the trains, ride the "rails" as he called it.) who treated his obstructed state by drinking watered down Turpentine! His family caught him drinking this concoction (including wood stripper, wild berries, etc) and brought him in for evaluation.

I was on call with the same service for these. After 12+ hours of operating one Saturday with me, the attending looked at me and said:
"Why can't you get the simple stuff, an appy, a chole?...No it's always drama! Some hobo binging Turpentine or a rectal foreign body who was fisted by his sister." Priceless. I told the attending, I got his partner an obstructing GIST two Saturdays ago.
 
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debvz

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While covering for urology last year...

13 y/o boy brought in by his mother to the ER after literally rubbing himself raw while masturbating with her shea butter cream. Poor kid was so embarrassed while I was getting his H&P, he was practically begging for a rock to crawl under.

Somehow, I managed to keep a straight face -- until I got out to the nurse's station!
 

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Dead bowel in the MICU patients on max pressors with a hard abdomen x 2 days
Unfortunately this is all too common....along with bilateral cyanotic toes in a patient who coded three times today with fixed and dilated pupils who is maxed out on 3 pressors....Seriously? Do they not realize that's what pressors do at high doses??
 

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For anyone that is on facebook there is a group devoted to bad consults. They come from around the world and are remarkably similar from country to country. I think the page is called "i hate stupid consults from stupid people" or something like that.
 

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From Hospitalist: Spine consult for urinary incontinence in an 87 year old. No back pain, no new neurologic deficit, no trauma, no urologic work up.

When I explained that there are about 1000 other causes of incontinence that are more likely the source, her response was, "but isn't this a symptom of cauda equina" I'd just like to have your consult on the chart. WTF!


:mad::mad::mad::mad::mad::mad::mad::mad::mad::mad:
 

45408

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Fair enough, but these things are so low paying as to not make it worthwhile, IMHO. $115 for a central line, $130 for a chest tube ain't worth the risks for the measly reimbursement. Even a 99255 consult will only get you around $200.
Wow, that is pretty sad. My wife is an RN who can now put in PICC lines, and she gets $120 apiece, and they take her maybe an hour. She doesn't have any overhead on that either.
 

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I always get a chuckle out of the ones that you get consulted for a supposed acute abdominal issue, who have a full diet sitting in front of them.

I've also had 2 inpatient weekend consults this year for suspected cutaneous melanoma (1 of who was admitted from our ER for this diagnosis on a Friday night).
 

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My tops has to be a 2am Friday night consult from Medicine. They admitted a patient with jaundice and abdominal pain for the last 2 months. CT scan (without contrast of course....with normal renal function) showed a pancreatic head mass. However, the medicine intern failed to notice the multiple liver lesions.

Now not only did this medicine intern think we were going to do a stat whipple in the middle of the night for pancreatic CA, but thought she was doing us a favor by calling the OR and letting them know we would be having a stat abdominal case coming in.

Now, many things are wrong with this, I will just hit the highlights.
1. A major stat case with the ONLY lab ordered was a BMP (not even liver functions with visible jaundice).
2. No such thing as a stat whipple outside of trauma.
3. Medicine residents should not even be given the number of OR scheduling.
4. Interns....especially medicine ones....should talk to their senior before making big decisions....or most any decision for that matter (and no, she did not talk to her senior or chief) and should NEVER call the surgery senior on call without checking with their chief or the surgery intern on call.
5......I can't go on, you can all imagine the things wrong with this....

It ends up this intern caught me on a very bad night and really heard about it. They still INSISTED that this needed to be operated on right away because of the "fast growing nature of pancreatic cancer."

Then came 15 minutes of chewing her a few new ones and ended with "pick up any medicine book and read about the surgical treatment of pancreatic cancer....then read it again. Then write out the appropriate steps to work up THIS patient and bring it to me before you go home tomorrow. Fail to do this and I will make your life a living hell."

7am the next morning not only did I have a nice writeup on a proper workup under my call room door, but had gotten calls from the medicine senior, chief AND attending apologizing for the interns actions the previous night and congratulating me on a very creative way to teach her something. Apparently she called ALL of them crying about the big mean surgery senior.....with the same result.
 

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Wow, that is pretty sad. My wife is an RN who can now put in PICC lines, and she gets $120 apiece, and they take her maybe an hour. She doesn't have any overhead on that either.
Well in terms of time and money, she is woefully underpaid. The reimbursement is about the same for a PICC or a central line/TLC but it takes me NO where near an hour to do the latter.

But she also pays a heap less malpractice insurance if she threads that PICC through the heart or someplace else important.

I suppose if you did a ton of these it might be worth it, but when you consider that most of these consults are middle of the night, I'm not so interested in coming in. I remember as a resident, the PP attendings would not come in to "supervise" those lines and chest tubes because it just wasn't worth it to come in and get so little (and of course, I'm not counting the cost of business, billing company, etc. not factored into that $115 you might get). I stopped putting in chemotherapy ports when I realized how little it paid (ie, not much more than taking one out) relative to the risks and time involved.
 

smq123

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My tops has to be a 2am Friday night consult from Medicine. They admitted a patient with jaundice and abdominal pain for the last 2 months. CT scan (without contrast of course....with normal renal function) showed a pancreatic head mass. However, the medicine intern failed to notice the multiple liver lesions.

Now not only did this medicine intern think we were going to do a stat whipple in the middle of the night for pancreatic CA, but thought she was doing us a favor by calling the OR and letting them know we would be having a stat abdominal case coming in.
A stat Whipple for Stage IV Pancreatic CA? :laugh: Nice.

2. No such thing as a stat whipple outside of trauma.
This is the thing that I have HATED the most about being told to call in a consult as a medical student. While being told to call in a consult without being told HOW to call in a consult is annoying enough, it's extremely irritating to call in a consult when you know what the answer is going to be.

I've been told by medicine interns to call in general surgery consults because they found a pancreatic mass on workup for painless obstructive jaundice...because "surgery will DEFINITELY want to operate within the week." Uh, after spending a month on HPB, I can tell you that they'll want to see the patient in the office first - and sure enough, that's what the HPB chief screamed into the phone at the me 10 minutes later. :mad:

I've been told by peds residents to call urology once every hour to find out when Patient X is going to go to the OR...because evidently the phrase "First Available Room" isn't self-explanatory....

I was told by my medicine attending to consult surgery to do a "skin biopsy" in order to rule out bullous pemphigoid - on a homeless guy who was found unconscious in a dumpster in the middle of January. (I managed to deflect this consult for the GS service). Call me crazy, but I would figure that his skin blisters would more likely be from frostbite, and not bullous pemphigoid....which is what the dermatologist said, too. :rolleyes:

<sigh>
 
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It has always amazed me what other specialties think we do.

They must think we sit around a lot, do a little operating and have tons of time to fit cases in because, as smq notes, I've had many, many consults which were finished with, "oh, you don't have to do it right away, you can just add them on to be done first thing in the morning" (almost always for some "stat" peds MediPort), or "I made the patient NPO so you can take this patient (invariably with some unworked up problem, or Stage IV cancer, on Coumadin, etc.) right away to the OR today."

There must be some sense that we have oodles of free time and that all cancer operations are stat.:rolleyes:
 

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My two favorite consults came from the same ER the same night

1. Got paged to come see an "acute cholecystitis", said ok, ill be right down, got down there and the patient was unconscious, i asked to nurse what meds she had recently been given and the ER doc had ordered phenergen for her nausea, thats ok, but NOT 100mg!!!! at once!!! So besides not being able to examine the patient the diagnosis was wrong too. WBC 6, U/S no stones, no wall thick, cbd 4mm, no pericholecystic fluid

2. Same ER attending called me 3 hours later ... "ive got this abscess on this ladies belly that need to be drained, ive placed the I/D kit at the bedside, just come down and drain it" ... which im sure we have all heard before and love. The ER doc said that the pt had no prior abd surgeries (lie) and that he himself had examine the patient (lie) and that a CT scan confirmed it was an abscess (wrong, and why did he get a CT scan???)
I was very skeptical, went down to actually see the patient examine her and itverview her. I also reviewed her CT scan myself. Turns out she was a stage 4 unresectable pancreatic cancer pt, with mult prior abd surgeries with an incarcerated ventral incisional hernia, that when you put you sthestecope on it had bowel sounds, not pus. Sure glad he called me to see the pt than drain the "abscess" himself other wise we would have had a great time that night taking that lady to surgery for a bowel perforation and frozen abdomen
 

46&2

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Ventral hernia that is actually diastasis recti. Usually referred by a primary care physician, but sometimes seen on an emergent basis.

The only thing I want to hear from a consult anymore is: Name, Medical Record Number, patient's bed, reason for consult. Faster to figure it out from there than to talk/argue.
 

45408

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Call me crazy, but I would figure that his skin blisters would more likely be from frostbite, and not bullous pemphigoid....which is what the dermatologist said, too.
lol, nice. congrats on the upcoming 4000th post ;)
 
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umean2tellme

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Can this bad consult thing work both ways? Is it much less common for surgery to consult medicine for something that really isn't consult-worthy?
 

VincentAdultman

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A good general surgeon should know enough about acute medical issues that they rarely have to consult a general medicine service.

Which is not to say medicine does not get BS consults. Ortho works very hard to see to that.
 
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surgres88

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Can this bad consult thing work both ways? Is it much less common for surgery to consult medicine for something that really isn't consult-worthy?
There is an unwritten rule in our program not to consult medicine and try to manage acute issues ourselves. Exception to this rule...Post-op MIs. If EKG shows changes c/w STEMI or NSTEMI from baseline...CARDIOLOGY CONSULT. Once when I was an intern on the vascular service, the R3 consulted endocrine/medicine for diabetic management on a patient. The attending the next day asked him if he was lazy and didn't want to think for himself.

Random note: This attending has some great quotes. My favorite was when on SICU rounds in front of the whole team he told the resident:
"A monkey would have taken better care of this patient, because a monkey would have done nothing, and that would have been better than what you did."
When we went through the SICU...We used to joke and tell each other, "you just have to be better than a monkey."
 

OTD

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Can this bad consult thing work both ways? Is it much less common for surgery to consult medicine for something that really isn't consult-worthy?
Not really. As someone has already said surgery doesn't consult medicine very much. I can count on one hand the number of consults to medicine I have made. It is a very rare patient that surgery can't manage and you don't have to deal with the noon (when they finally round) silly questions.

One of the best all time that I have personally taken care of was a "rectal mass" that was sent over from the primary care "physician" office (you will see why the quotes later). The poor kid was scared to death, he was 22 and he had a "rectal mass". I performed the physicial exam and he had a comedone, a tiny one at that, right on the edge of his anus.

My attending almost fell over. Seems this "physician" didn't even examine the "mass" (after all he would have to touch the patient for that and I think there is some new rule that Medicine isn't allowed to touch a patient). The kid came in for his yearly "physical exam" and when he mentioned it the "pcp" just sent him to our office as a work in for "rectal mass". At least it wasn't an in house consult at 2am.

The kid was visibly relieved, embarrassed, and in the market for a real primary care physician.

I got a million of them, most of them are by Medicine, then next in line is EM. One person had an ATV accident two months prior and was admitted overnight for obs due to rib fractures. He presented to the ED for chest pain (substernal not ribs). The freakin ED doc punted, told him he was a "trauma patient" and that he would have trauma to look at him when trauma clinic started at 0900. To make matters worse he didn't tell anyone he was sending him to clinic, and definately didn't tell us he was having chest pain. We got to him at about 1100, but he came to the ED at 0700. Completely inappropriate but if the ED can come up with any reason what so ever to punt the patient to surgery they won't even touch the patient, not even for chest pain because he was a trauma 2 months ago. It's pathetic but that time the attending chewed the ED doc up one side and down the other for punting a chest pain (usually because the residents are the only ones that get the misery they put up with the crap, but this time the stuff hit the fan). They are supposedly EM trained but don't do lines, don't sew lacs, and don't even start any work up if they think they can get surgery involved, no labs, nothing, just "abdominal pain, call surgery". 3 of the 4 ER's I have been involved with have been that way.
 
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chael

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STAT consult from the MICU for profuse rectal bleeding:

"Is GI going to scope the pt?" "Gi hasn't been called"
"Is the pt going to IR?" "haven't called them either"
"What's the pt's HCT?" "oh, the pt was just admitted, haven't had time to see what the HCT is"
"Did you see anything actively bleeding on rectal exam?" "haven't examined the pt, but I've initiated the massive transfusion protocol because of all the bleeding"

ok, so I go see the pt right away. and while there is bloody fluid in the pt's bed, its coming from the vagina, not the rectum. done with consult. ;-)
also, they had to send back all the blood and FFP back to the blood bank as the pt was quite stable.
 

smq123

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STAT consult from the MICU for profuse rectal bleeding:

"Is GI going to scope the pt?" "Gi hasn't been called"
"Is the pt going to IR?" "haven't called them either"
"What's the pt's HCT?" "oh, the pt was just admitted, haven't had time to see what the HCT is"
"Did you see anything actively bleeding on rectal exam?" "haven't examined the pt, but I've initiated the massive transfusion protocol because of all the bleeding"

ok, so I go see the pt right away. and while there is bloody fluid in the pt's bed, its coming from the vagina, not the rectum. done with consult. ;-)
also, they had to send back all the blood and FFP back to the blood bank as the pt was quite stable.
Did that patient also tend to experience this "profuse rectal bleeding" approximately every 28 days?

One of my OB chiefs told me that she got a 3 AM consult for a patient on the medicine floor who was "hemorrhaging." When she got to the patient's room, the patient said incredulously, "I can't believe that they woke you up at 3 AM because I got my period!!!!"
 

filter07

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My tops has to be a 2am Friday night consult from Medicine. They admitted a patient with jaundice and abdominal pain for the last 2 months. CT scan (without contrast of course....with normal renal function) showed a pancreatic head mass. However, the medicine intern failed to notice the multiple liver lesions.

Now not only did this medicine intern think we were going to do a stat whipple in the middle of the night for pancreatic CA, but thought she was doing us a favor by calling the OR and letting them know we would be having a stat abdominal case coming in.

Now, many things are wrong with this, I will just hit the highlights.
1. A major stat case with the ONLY lab ordered was a BMP (not even liver functions with visible jaundice).
2. No such thing as a stat whipple outside of trauma.
3. Medicine residents should not even be given the number of OR scheduling.
4. Interns....especially medicine ones....should talk to their senior before making big decisions....or most any decision for that matter (and no, she did not talk to her senior or chief) and should NEVER call the surgery senior on call without checking with their chief or the surgery intern on call.
5......I can't go on, you can all imagine the things wrong with this....

It ends up this intern caught me on a very bad night and really heard about it. They still INSISTED that this needed to be operated on right away because of the "fast growing nature of pancreatic cancer."

Then came 15 minutes of chewing her a few new ones and ended with "pick up any medicine book and read about the surgical treatment of pancreatic cancer....then read it again. Then write out the appropriate steps to work up THIS patient and bring it to me before you go home tomorrow. Fail to do this and I will make your life a living hell."

7am the next morning not only did I have a nice writeup on a proper workup under my call room door, but had gotten calls from the medicine senior, chief AND attending apologizing for the interns actions the previous night and congratulating me on a very creative way to teach her something. Apparently she called ALL of them crying about the big mean surgery senior.....with the same result.
I'd like to subscribe to your newsletter
 

SLUser11

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STAT consult from the MICU for profuse rectal bleeding:

"Is GI going to scope the pt?" "Gi hasn't been called"
"Is the pt going to IR?" "haven't called them either"
"What's the pt's HCT?" "oh, the pt was just admitted, haven't had time to see what the HCT is"
"Did you see anything actively bleeding on rectal exam?" "haven't examined the pt, but I've initiated the massive transfusion protocol because of all the bleeding"

ok, so I go see the pt right away. and while there is bloody fluid in the pt's bed, its coming from the vagina, not the rectum. done with consult. ;-)
also, they had to send back all the blood and FFP back to the blood bank as the pt was quite stable.
While I agree that the medicine resident went about this the wrong way, it sounds like you did as well. From your phone conversation, it seems you were ready to "punt" to another service without evaluating the patient, either.......i.e. trying to get GI to do your scope for you, and setting up angiography without knowing how severe the bleed was. Even if this wasn't the case, that is the impression that the medicine resident probably got.

That being said, you obviously did the right thing by going to see the patient right away. As I'm sure you know, you can never tell exactly how sick a patient like this is until you go evaluate them yourself. I've rushed to the bedside to find crashing patients that were communicated to me as stable, etc, and I've also rushed to see a "crashing" patient sitting up in bed, NAD and eating a sandwich.
 

JackADeli

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... it seems you were ready to "punt" to another service without evaluating the patient, either.......i.e. trying to get GI to do your scope for you, and setting up angiography without knowing how severe the bleed was. Even if this wasn't the case, that is the impression that the medicine resident probably got.

That being said, you obviously did the right thing by going to see the patient right away...
1. It's not a "punt" to ensure the patient is getting the right care with the proper consults.
2. "get GI to do your scope for you".... see number one. If a patient is admitted to an ICU for "massive bleeding", it is important to identify where the bleeding is from. This does not necessarily mean a general surgeon needs to do a scope. In numerous institutions with a "good critical care unit", it is quite common if not standard for GI to be involved first.
3. All being said, anyone can interpret questions as a "punt" if they like. However, if you are going to get involved, it is crucial to ascertain who else is involved or getting involved and what work-up has occurred.
4. Again, maybe just an animal of residency, but, in practice, a general surgeon going promptly to bedside for every consult is innefficient and impractical... especially from a critical care unit. You need to sort a great deal of these things out by the phone first.

In summary, it would have been best to never have reached the patient's bedside.... I actually think you did the wrong thing! You should have received vitals over the phone and insisted the physician/resident/ICU.... nurse or someone confirm where blood was coming from at the onset..... then not punt, rather confirm OB/Gyn was being called for vaginal bleed. We can pride ourselves as general surgeons for identifying the obvious if you like.... I say no pride in wasting the time to identify something the janitor could have determined. The time it took you to walk to unit was wasted time that could have been used calling the correct people.

JAD
 

Trinity12

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Ventral hernia that is actually diastasis recti. Usually referred by a primary care physician, but sometimes seen on an emergent basis.

The only thing I want to hear from a consult anymore is: Name, Medical Record Number, patient's bed, reason for consult. Faster to figure it out from there than to talk/argue.
I recently saw someone in the ER for an "incarcerated hernia". He had an incisional hernia about a mile wide with a hard mass to the lateral side of it (completely unrelated to the hernia)... there was a small puncture site centered over the mass. I asked for an U/S before writing up my consult (as there were a million things to do at the same time). Turned out to be a hematoma from the guy's Fragmin injection, as I had expected. Thankfully, the somewhat embarrassed emerg resident dealt with the discharge which was nice (the ER here tends to dump stuff then never see the pt again even if it's a bogus consult).
 

SLUser11

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1. It's not a "punt" to ensure the patient is getting the right care with the proper consults.
2. "get GI to do your scope for you".... see number one. If a patient is admitted to an ICU for "massive bleeding", it is important to identify where the bleeding is from. This does not necessarily mean a general surgeon needs to do a scope. In numerous institutions with a "good critical care unit", it is quite common if not standard for GI to be involved first.
3. All being said, anyone can interpret questions as a "punt" if they like. However, if you are going to get involved, it is crucial to ascertain who else is involved or getting involved and what work-up has occurred.
4. Again, maybe just an animal of residency, but, in practice, a general surgeon going promptly to bedside for every consult is innefficient and impractical... especially from a critical care unit. You need to sort a great deal of these things out by the phone first.

In summary, it would have been best to never have reached the patient's bedside.... I actually think you did the wrong thing! You should have received vitals over the phone and insisted the physician/resident/ICU.... nurse or someone confirm where blood was coming from at the onset..... then not punt, rather confirm OB/Gyn was being called for vaginal bleed. We can pride ourselves as general surgeons for identifying the obvious if you like.... I say no pride in wasting the time to identify something the janitor could have determined. The time it took you to walk to unit was wasted time that could have been used calling the correct people.

JAD
There's a big difference between the private practice General Surgeon and the resident working in an academic environment, as you point out. However, you forget which of these situations the resident found himself in.

While you may not have the time, etc, as a practicing surgeon to see these things, you've finished 5 years of residency. My argument would be on several levels:

1) the resident was in house, so the time suck is a little different.

2) he's a resident, so his ability to determine over the phone who needs to be seen emergently and who doesn't isn't as well developed as your own.

3) After the initial conversation with the marginal medicine resident, I don't think I'd trust their assessment of vaginal versus rectal bleeding even if I somehow forced them to look and report back to me over the phone....even if we think a janitor should have those simple skills.

4) While all of your demands are being met, the clock is ticking, and the actually sick and exsanguinating patient is dying in their MICU bed.....sure this patient would have done fine, but you really can't decide that based on the information the med resident could give to you.

5) If you're called to see a patient for rectal bleeding, and you say you want the GI doc to do the scope, you are not going to get the next consult....it will go to the GI doc. It's not like an open ended "who else is involved" question. The resident gave an impression of wanting other doctors to handle the problem. What if GI and IR had gotten involved in this case at the surgery resident's request? Obviously that would have wasted even more people's time when a simple bedside exam could reveal the diagnosis.


I respect your opinion....but I humbly disagree. As a resident in an academic environment.....whose in house on call.......once you've identified over the phone that the person giving you info is incompetent, and that a patient is possibly actively dying, the next move is to see the patient emergently.

It is absolutely not time-efficient.....and it will result in you finding some patients with nothing wrong, or a non-surgical problem. Knowing those things, I still do it. That's because I know that maybe nine times out of ten it doesn't make a difference, but the tenth time the patient can benefit greatly from my "over-enthusiasm."
 

JackADeli

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...you forget which of these situations the resident found himself in...
Nope, I don't forget. I recognize the resident is in academic setting and the patient of concern is in an academic ICU.
...My argument would be on several levels:
1) the resident was in house, so the time suck is a little different.
Alas, after five plus years, I have come to realize the plight of residents need NOT be one of stupidity and innefficiency. The continuous beating of run to every patients bedside because the medicine resident is incompetent and every patient will die... except when you are on vacation, at the annual graduation ceremony, in the trauma room or in the operating room, etc.... enough already
2) he's a resident, so his ability to determine over the phone who needs to be seen emergently and who doesn't isn't as well developed as your own.
I pray it does not take so much to ask for vitals and insist the MICU or his/her senior back-up actually look at the patient. Some things may actually be determined by the phone even for a poorly developed resident
3) After the initial conversation with the marginal medicine resident, I don't think I'd trust their assessment of vaginal versus rectal bleeding even if I somehow forced them to look and report back to me over the phone....even if we think a janitor should have those simple skills.
Again, with the bravado of the almighty surgeon unable to trust anybody thus vanquished to a life of saving the world from the marginal other resident, other attending, other specilialist.... resident in MICU... in academic setting. My limited experience (SICU 1 res on-call; MICU 3 res on-call) was that MICU residents usually had a flock of additional residents in MICU more senior and junior.... and then the mighty MICU attending within close reach... If there is anywhere that a marginal medical resident can get a second opinion via perineal inspection... well it is in an academic MICU.

Yes, I believe most janitors can tell the difference between the vagina and the anus. I dare say, if you have such doubts about a medicine resident's ability to distinguish between these two structures... you now have a true obligation... report to their program director and report to license board. Otherwise, it is just so much hyperbole of surgical residency. Great glory in the ability to do very little more then what one probably could do in the back seat of a car at night in high school.
4) While all of your demands are being met, the clock is ticking, and the actually sick and exsanguinating patient is dying in their MICU bed.....sure this patient would have done fine, but you really can't decide that based on the information the med resident could give to you..
Yes, I do demand that a consult requesting physician act to the very basics that a MS2/3 could do. Check the vitals and actually look at the patient. Those basic demands actually save lives; as believing such basics wait until the mighty surgeon gets to bedside kills patients.

Let's be real, dispense with the surgeon melodrama & savior complex. The "massive transfusion protocol" was already initiated. If the patient was going to die because time was taken to look in her shorts... running would not have helped. Yes, in the community hospital with less residents, etc... somehow the patient would survive a vitals check, physical exam, and surgeon drive accross town! The further you go in residency the slower you find yourself walking to so called "emergencies".
5) If you're called to see a patient for rectal bleeding, and you say you want the GI doc to do the scope, you are not going to get the next consult....it will go to the GI doc...
And, in an academic setting, most surgery residents would be very happy if every vaginal bleed consult went to GI first.
It's not like an open ended "who else is involved" question. The resident gave an impression of wanting other doctors to handle the problem. What if GI and IR had gotten involved in this case at the surgery resident's request? Obviously that would have wasted even more people's time when a simple bedside exam could reveal the diagnosis.
Well, at my GSurgery residency program, there was a routine protocol in the MICU for "GI Bleeds". It did routinely involve GI being called first and often IR simultaneously to ensure the crew & gear were ready to go. I read the residents post on this subject rather similar to the standard questions used in my residency. I can not chastise him/her for asking reasonable questions of the consult requesting physician.
.... I humbly disagree. As a resident in an academic environment.....whose in house on call.......once you've identified over the phone that the person giving you info is incompetent, and that a patient is possibly actively dying, the next move is to see the patient emergently...
It might be the under-called consult with "you can see it in the morning, no big deal" (only to find dead gut an hour later) or the over-called vaginal bleed... Patients will die. Every patient of every consult to surgery "is possibly actively dying". The truth is residents and residency programs have spent a great deal of time trying to indoctrinate new residents into total self sacrifice with these arguments... akin to the ever prevalent "the patient comes first". We as surgeons wrap ourselves in this like a patriot wrapped in the American flag. It is too often a technique to justify abuse, failure to have time to educate residents, and failure to fix problems. Remember, you're running to the MICU because you have doubts in the physician's ability to distinguish between the anus and the vagina.... Or maybe it's because you should read the numbers on the monitor or inflate the blood pressure cuff.

We will just have to agree to disagree. I just speak from my own experience as a recent general surgery resident. Too often the emergency at an academic center with numerous house staff, midlevels, resources, and attendings with too much time on their hands do not seem so emergent when you strip away all of that. Yet, I don't see so much death as you might expect.

JAD
 
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pRotAgOnIsT

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Yeah, I have to completely agree with JAD on this. The notion that everyone else is incompetent and that only a general surgery resident evaluation is sufficient for every patient is comical.
 
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