Consults- Memorable/Dismal/Ridiculous/Unique

[butterfly0660]

Advertisement - Members don't see this ad

Recent consult from medicine to colorectal surgery
IM resident: Hi. We have a patient with ESLD admitted for encephalopathy who was found to have a possible rectal mass on CT scan. It says rectal mass vs redundant mucosa from under distention, recommend colonoscopy.
Us: Did you call GI? They usually can get inpatients scoped quicker.
IM resident: yes. They scoped her today. It was normal.
Us: ok. Great. So what exactly did you need from us?
IM resident: recommendations on treatment of this rectal mass.
Us: I thought there was no mass on colonoscopy....
IM resident: right. But there was on CT scan.
Us: umm... There was a possible mass on scan. A colonoscopy is really a better test for that though. That's why the radiologist recommended it.
IM resident: So can you write a note that says there is nothing to do?
Us: didn't GI do that?
IM resident: Yes. But we'd feel better if you would write one too.

 

[Smurfette]

-Overhead page
*Perfusion STAT to L&D*Perfusion STAT to L&D*
Me (scratching my head, as I'm the only person allowed to call perfusion since I'm the one who would go on CPS): I guess I better go up there.
Me (after arriving): So, I heard a page for perfusion over head. I'm the CT surgery fellow. Can I help you guys?
Them: This patient needs an emergent C section.
Me: On bypass?
Them: She's anticoagulated.
Me: I guess that makes it easier to go on bypass, but why do you want us to do that?
Them: We need to know how to reverse her. So we figured we'd call perfusion.
Me: *palm to forhead* Just give 25 of protamine.
Of course, by that time my charge nurse was running up from the CT SICU with our sternotomy/ECMO cart and perfusion was there with a pump.

- While acting as a 'fellow' on cardiology, I sometimes hear consults. This one from gen surg to cardiology about a patient I knew well.
Them: So, we want to know when you are going to take the stents out.
Me: The ones "we" put in for her STEMI?
Them: Yes.
Me: What's your name?
Them: You mean the patient?
Me: No, yours. I want to keep an eye out for you when you do your CT SICU rotation.
Them: Uhhh... okay. I'm Dr X [love it when the interns use the Dr thing]. Well, what should I tell my chief.
Me: If I were you, nothing about this particular call. My guess is she wanted you to call urology about the stents placed for her colectomy.

-Call from MICU
*CT SURGERY STAT TO THE MICU*CT SURGERY STAT TO THE MICU* [overhead]
I go up and they're all in a room with nurses swarming and a very sweaty MICU resident looking like he had just attempted a subclavian line.
Me: What's on your mind?
Them: This patient has a TENSION PNEUMOTHORAX!!! We need a chest tube?
Me: [looking at vitals] Looks pretty stable to me. What happened?
Them: I NEED A CHEST TUBE RIGHT NOW!!!
Me: I'm here. Tell me the story.
Them: I WAS PUTTING IN A SUBCLAVIAN LINE AND THE PATIENT GOT HYPERTENSIVE AND TACHYCARDIC AND THE PULSE OX WENT TO UNREADABLE!!! SHE NEEDS A CHEST TUBE NOW!!!
Me: Ahhh -- HYPOtensive or HYPER?
Them: Hyper. But every tension pneumo I've ever caused was hypertension.
Me: [with admirable restraint] That's very interesting. When you had an unreadable pulseox, was there a pleth?
Them: A what?
Me: Okay. Do we have bilateral breath sounds.
Them: Yes. But every tension pneumo I've ever caused has bilateral breath sounds.
Me: Let's get a CXR first.
Them: BUT YOU DON'T GET A CXR FOR TENSION. You're just supposed to put in the tube.
Me: Honestly, I don't think this is a tension. I'll stand here, but we're getting an x ray first.
Me to RN: Could you please get a chest tube tray and some gowns and drapes please?
RN: I CAN'T DO THAT RIGHT NOW! I'M ADVOCATING FOR MY PATIENT!!!
Me: [feeling like I'm in the twilight zone] Okay. I guess we'll wait until you're done advocating to relieve the tension pneumothorax. [yes, I resisted air quotes]
CXR comes, no pneumothorax.
Me: Okay, there's no pneumothorax. See you later.
Them: YOU HAVE TO PUT IN A CHEST TUBE!!!
Me: Look. I've been pretty tolerant. But I don't have to do anything. So tell me why you think this patient needs a chest tube.
Them: I already needle decompressed her.
Me: [cringing] did you leave the needle in?
Them: Yes, it's right here.
Points to a 25 gauge local needle which is all of 1 1/2 cm long, stuck into her breast next to the areola and no where near her chest wall.
Me: That doesn't count. It's not in her chest. Get another CXR in 6 hours if you're worried.
And I fled. Fast.

😆😆😆 Awesome.

 

[AJSmith]

Good God almighty, that's horrific.

Yeah, I kept wondering when I was going to wake up... or find out I was on candid camera or something. Our medical residents are usually pretty reasonable. The thing I want to know is, who was actually putting in chest tubes for this guy? I heard later he had caused three similar 'tensions' and someone had put chest tubes in all three. I think he just needs better local technique, you know?

 

[Buzz Me]

I wanna play too [CT surgery, so be prepared for that flavor]

Awesome stories! 👍

 

[cpants]

Had one a couple of weeks ago at about midnight.

Medicine resident: Hi this is Dr. X the medicine intern. We have a patient admitted for gastroenteritis. She had some belly pain and the radiologist is reading the CT as a perforated appendicitis. Can you come see her?

Me: Does she look sick?

Medicine: No. She's fine.

I pull up the scan from about 2 hours earlier. Massive free air and fluid mostly on the left side (and read that way btw). I tell a nurse to page my chief to the floor and hustle over there. She is tachy and diaphoretic with a 22 gauge in her left hand infusing D5 half at 50/hr. :-O No antibiotics running. No MD in sight on the floor. No note in the chart for more than 24 hours. We had her in the OR 30 minutes later and found a belly full of stool from a perfed sigmoid.

 

[45408]

She is tachy and diaphoretic with a 22 gauge in her left hand infusing D5 half at 50/hr. :-O No antibiotics running. No MD in sight on the floor. No note in the chart for more than 24 hours.

Hmmmm, sounds familiar....

We had one of these...consult for "massive free air" seen incidentally on a chest x-ray... only the chest x-ray was actually nearly 36 hours old at that point. It had been ordered as a "routine" instead of "stat" image at the VA on a weekend...which meant it didn't get read by radiology until the next day and no one from the medicine team had looked at the image.

So does that!

 

[europeman]

Got called to eR to eval 29 year old with "incarcerated ventral hernia" yesterday. She had he of mental ******ation

Um. She was pregnant.


I told them don't try and reduce it and signed off

 

[dilated]

.
Me: [cringing] did you leave the needle in?
Them: Yes, it's right here.
Points to a 25 guage local needle which is all of 1 1/2 cm long, stuck into her breast next to the areola and no where near her chest wall.
Me: That doesn't count. It's not in her chest. Get another CXR in 6 hours if you're worried.

And I fled. Fast.

This.. can't be real. All the rest of the story aside, someone tried to decompress a tension pneumo with a 25ga short? And stuck it into the breast?

 

[Skinceutical]

And a reminder that we are by no means immune from the ridiculous consult call...

+1

I got called by gen surg to r/o vasculitis vs. drug eruption in a post-op patient, so I drove in on a Sunday night to see her.

The patient had mild bruising at venipuncture and IV sites. She was also on a heparin drip. The intern actually apologized for the consult when I called to let him know what it was.

That said, you guys tend to be way better than medicine at keeping the BS consults to a minimum. Carry on.

 

[Dissected]

Got called to eR to eval 29 year old with "incarcerated ventral hernia" yesterday. She had he of mental ******ation

Um. She was pregnant.


I told them don't try and reduce it and signed off

 

[goooooober]

"Hey, this is M*** from ED, I have a patient here with unilateral gluteal alopecia, can you help us out?"

 

[Smurfette]

"Hey, this is M*** from ED, I have a patient here with unilateral gluteal alopecia, can you help us out?"

Can't resist asking...did you bring down a razor or go for the hot wax for a smoother finish? 😀

 

[McLovin]

This one a standard "breast mass" consult.

Only memorable because it came from "Dr. X, hospitalist".

Only significant because "Dr. X" is a nurse practitioner. Apparently the DNP has infiltrated even the backwoods of Arizona (this was a small town about an hour outside of PHX).

Our MICU used to employ a NP. He had a white coat that did not have "Dr" or "MD" on it, but read "B** L*****, Pulmonary & Critical Care" in the same coloring and font as the staff MD's.

He'd introduce himself as "I'm B** with the ICU team" to patient families, without mentioning he was an NP. I'm pretty sure families thought he was a "real" doctor.....

 

[McLovin]

Why? Because shut up and admit the patient, that's why.

😀

I'm a "medicine" guy and approve this post!

 

[Buzz Me]

He'd introduce himself as "I'm B** with the ICU team" to patient families, without mentioning he was an NP. I'm pretty sure families thought he was a "real" doctor.....

I've seen that happen quite often.

 

[45408]

Ridiculous consult

88 y/o woman admitted for hypertensive urgency. Keen hospitalist noted that her blood pressure was significantly different from one arm to the other, so he called a vascular consult.

On questioning the patient, she said that she's always had this, and it's because they told her she had problems with the blood flow to that arm ever since her MI in 1995. Fortunately our EMR goes back that far, and the cardiac cath notes that she had an occluded left subclavian and left common iliac (explains the lack of a DP pulse). Funny thing was that the cardiologist who did the cath in '95 was sitting across from me when I looked this up. Thanked him for his help 😉

Left a brief note more or less saying that her asymptomatic problem that was first noted 16 years ago could just be monitored without any intervention at this time. God forbid the primary team look at prior imaging or ask the patient if this is a new finding.

 

[skiz knot]

Ridiculous consult

88 y/o woman admitted for hypertensive urgency. Keen hospitalist noted that her blood pressure was significantly different from one arm to the other, so he called a vascular consult.

On questioning the patient, she said that she's always had this, and it's because they told her she had problems with the blood flow to that arm ever since her MI in 1995. Fortunately our EMR goes back that far, and the cardiac cath notes that she had an occluded left subclavian and left common iliac (explains the lack of a DP pulse). Funny thing was that the cardiologist who did the cath in '95 was sitting across from me when I looked this up. Thanked him for his help 😉

Left a brief note more or less saying that her asymptomatic problem that was first noted 16 years ago could just be monitored without any intervention at this time. God forbid the primary team look at prior imaging or ask the patient if this is a new finding.

Just be happy the medicine team actually picked up on the fact that there were differential pulses. That is a step in the right direction.

 

[45408]

Just be happy the medicine team actually picked up on the fact that there were differential pulses. That is a step in the right direction.

The electronic medical record had a special prompt that warned you not to check blood pressures in her left arm when you opened her chart. Not sure he was the one who noticed anything 😉

 

[Guile]

Ridiculous consult

88 y/o woman admitted for hypertensive urgency. Keen hospitalist noted that her blood pressure was significantly different from one arm to the other, so he called a vascular consult.

On questioning the patient, she said that she's always had this, and it's because they told her she had problems with the blood flow to that arm ever since her MI in 1995. Fortunately our EMR goes back that far, and the cardiac cath notes that she had an occluded left subclavian and left common iliac (explains the lack of a DP pulse). Funny thing was that the cardiologist who did the cath in '95 was sitting across from me when I looked this up. Thanked him for his help 😉

Left a brief note more or less saying that her asymptomatic problem that was first noted 16 years ago could just be monitored without any intervention at this time. God forbid the primary team look at prior imaging or ask the patient if this is a new finding.

Why didn't you ask them to take the consult out so the patient didn't get charged for something so stupid? And did this guy really get a vascular surgery consult for simply different blood pressures in the arms? No imaging?

 

[ACSurgeon]

Why didn't you ask them to take the consult out so the patient didn't get charged for something so stupid? And did this guy really get a vascular surgery consult for simply different blood pressures in the arms? No imaging?

Are you suprised that a medicine doctor put so much emphesis on ONE piece of information? how about:
1- medicine team cultures a patient POD 0 for a fever of 38.5
2- medicine team calls a surgical consult because the x-ray says obstruction. The patient is passing gas, having BM's, and tolerating PO just fine, but still, the x-ray said it.
3- appendicitis consult for RLQ that was there 12 hours ago, but not anymore.
4- anesthesia giving an otherwise healthy young patient TEN liters of fluids during the case because his BP was read as low (erroneously so... his BP, UOP, etc were all fine). The anesthesia resident was ready to start an a-line and had called pharmacy to send over pressors. That's when we noticed the crazziness and helped them place the BP cuff better...

the list can go on forever...

 

[Trail Boss]

.

 

[cpants]

Med: Patient with PICC line placed today.... now oozing blood from site. Please consult.

Me: You really need a surgical consult for that? Does your attending know you are calling this consult?

Med: We don't know what to do. Can we spray fibrin glue on it?

Me: Hold pressure for 10 minutes. If still bleeding repeat. Might want to check coags. I'm not seeing this unless your attending calls.

Didn't hear back from them...

 

[45408]

Why didn't you ask them to take the consult out so the patient didn't get charged for something so stupid? And did this guy really get a vascular surgery consult for simply different blood pressures in the arms? No imaging?

All they want you to do is put ink on the chart so that they can check off the box. We get consults "to get surgery on board" just so that when they sign out their team to the next hospitalist, they can say their bases are all covered. This is only what the dumb hospitalists do. We have a handful of them that virtually never call us, because they're so good at what they do. If it can be handled at all as an outpatient, they'll just send it for outpatient follow-up.

We had one the other day where they were recommended to get a colorectal surgery consult. We don't have specific colorectal surgery call, but there was a colorectal surgeon on the day before (while the patient was there, and after the oncologist had recommended the consult), but they didn't call then. They waited until it was an acute care/trauma surgeon on, and even then, they could have specifically called and requested one of the colorectal guys (if you ask nicely, they'll usually see a consult even when not on call). Nope. "We just want surgery on board."

 

[45408]

3- appendicitis consult for RLQ that was there 12 hours ago, but not anymore.

"Please r/o appendicitis."

Response: the patient already did.

 

[SLUser11]

We had one the other day where they were recommended to get a colorectal surgery consult. We don't have specific colorectal surgery call, but there was a colorectal surgeon on the day before (while the patient was there, and after the oncologist had recommended the consult), but they didn't call then. They waited until it was an acute care/trauma surgeon on, and even then, they could have specifically called and requested one of the colorectal guys (if you ask nicely, they'll usually see a consult even when not on call). Nope. "We just want surgery on board."

I'd be careful with that situation. I've found in my current role that when there's a colorectal surgery team that the on-call general surgery resident doesn't cover, all of a sudden residents lose some basic surgical abilities if they occur near the colon or rectum.

I had a senior surgical resident on night float refuse to drain a perirectal abscess in the ER because it "sounded like a colorectal surgery issue." Imagine how unhappy I was to come in from home at 2am to drain butt pus, only to find out general surgery had turned the consult down. I had a similar situation with a GI bleed in the ER. I had a general surgery resident from another prestigious institution turn down an ER consult for "incarcerated" rectal prolapse (without examining the patient) because he didn't feel comfortable taking care of it.

What self-respecting general surgery resident would be willing to say these things are outside their scope of practice?

When there are tasks to be performed in the ER that fall into the common scope of general surgery, but the wimpy in-house resident punts it to the specialty service (dumping work uphill), usually it means somebody else has to step up...often driving in from home, and often having a full day ahead of them instead of being post-call.

Cholecystitis? Pancreatitis? Better call hepatobiliary.

 

[Xerxes1729]

All they want you to do is put ink on the chart so that they can check off the box. We get consults "to get surgery on board" just so that when they sign out their team to the next hospitalist, they can say their bases are all covered. "

Say there's a GI bleeder going to the ICU. If I didn't "make surgery aware" and he suddenly decompensated 12 hours later and I called you then, would you be pissed that you hadn't been "made aware" of the patient when he first got admitted? I ask because I generally hate calling those consults and often feel pretty stupid doing so, but a lot of attendings are pretty insistent on it.

 

[filter07]

Say there's a GI bleeder going to the ICU. If I didn't "make surgery aware" and he suddenly decompensated 12 hours later and I called you then, would you be pissed that you hadn't been "made aware" of the patient when he first got admitted? I ask because I generally hate calling those consults and often feel pretty stupid doing so, but a lot of attendings are pretty insistent on it.

There are several things to consider. The obvious one is that surgery never likes to get involved unless their active input or intervention is necessary. Being on board so that the medicine attending has piece of mind is like calling 911 just to have the firefighters aware that you're going to have a barbeque today.

On the other hand, medicine can be hit or miss with the management of really sick patients, especially acutely ill. There are countless stories of patients being under resuscitated with pathetic IV access and no one around who can confidently place a CVL. So yeah, in those cases, it isn't great to see a person who needs a laparotomy have poor access, renal failure, no antibiotics, etc.

Generally speaking, it's not like we are going to be at the bedside with a scalpel, ready to do a lap at the exact moment someone crumps. I can usually see an urgent consult and get things ready for the OR in just a few minutes, and let's face it, if they can't stay alive for that long, they probably won't make it out the OR anyway.

 

[Apollyon]

Wow...I just gotta tell you surgical guys that someone undercutting you in front of the patient is SO academic, and just doesn't fly in the community.

I've only called a surgical specialist once to give them a heads up - it was ENT for a patient with angioedema. I didn't formally consult him, and didn't put his name in the chart. I just told him the patient's name, in case he got an urgent call in the middle of the night, so that it wasn't completely out of the blue.

I'm an "n" of 1, but, if it's any consolation, I think of surgeons as how Slovis and Wrenn from Vandy described them: "Like a very sensitive and very specific test - a high-powered rifle, not a shotgun". I ain't callin' ya unless there is either an affirmative finding, or if I have a question. No CYA here.

 

[Doctor4Life1769]

We got the "on board" consult this week, and made the decision to offer the patient an operation.

The medicine attending flipped his lid saying they still needed to get this and that test, that we couldn't be sure about the diagnosis yet, and undermined our team in front of the patient saying we didn't know what we were talking about.

Don't call surgery if you don't want your patient to have surgery.

Damn, I've not seen that one yet.

 

[blue2000]

Wow...I just gotta tell you surgical guys that someone undercutting you in front of the patient is SO academic, and just doesn't fly in the community.

I've only called a surgical specialist once to give them a heads up - it was ENT for a patient with angioedema. I didn't formally consult him, and didn't put his name in the chart. I just told him the patient's name, in case he got an urgent call in the middle of the night, so that it wasn't completely out of the blue.

I'm an "n" of 1, but, if it's any consolation, I think of surgeons as how Slovis and Wrenn from Vandy described them: "Like a very sensitive and very specific test - a high-powered rifle, not a shotgun". I ain't callin' ya unless there is either an affirmative finding, or if I have a question. No CYA here.

This is my experience in the blissful world of small town private practice. When I get called, someone needs real help, and potentially an operation.

We only have part time GI in my town, so I end up doing quite a bit of scoping, both above and below. When I was at a big institution, the guideline we gave medicine for calling surgical consult on a GI bleeder was >4 units in 24 hours or GI bleed with hemodynamic instability or if the GI attending asked for a surgical consult. Yeah, even in those cases we didn't often operate, but we often helped coordinate with GI (we had a good, close productive relationship) or IR, or just ensure that resuscitation was appropriate aggressive. It worked fairly well most of the time.

Going from big academic institution to small town practice has been so life-changing for me in terms of my approach to consults. I rarely, rarely get bogus consults. We have a great ER, that does great work ups on patients. Usually, they have a diagnosis and they call me. When they don't have a diagnosis, they have thought things through appropriately, and are asking for advice, not dumping work. My medicine colleagues do very few interventions, so I end up doing a lot of chip-shot stuff, but rarely in the middle of the night. I've been on call tonight, and I just admitted an 8 year old who fell down a ski slope and has a couple of rib fractures and a nothing-burger CT scan PTX. He'll go home in the morning. I don't get to be the amazing martyred academic surgeon, and I have to write my own orders (the horrors!) but life is pretty sweet and I even if it's a soft call for a consult, I feel like I'm helping one of my colleagues out rather than getting dumped on.

 

[Buzz Me]

Say there's a GI bleeder going to the ICU. If I didn't "make surgery aware" and he suddenly decompensated 12 hours later and I called you then, would you be pissed that you hadn't been "made aware" of the patient when he first got admitted?

Hopefully with experience will come the judgment of when to call surgery. Calling when a patient on four pressors is exsanguinating from a lower GI bleed after colonscopy, angio and tagged RBC scans have all been done? Might be a little late. But calling when they first hit the ER, are hemodynamically stable and haven't even been seen by Medicine/GI yet? Premature.

Don't call surgery if you don't want your patient to have surgery.

I always tell the consulting Medicine residents that you can't call for a STAT surgery consult (meaning you think there's a surgical emergency NOW!) and yet not at least make the patient NPO. I don't know how many times I've gone into a patient's room for a stat consult, only to interrupt them eating their meal.

 

[kitsunepixie]

I always tell the consulting Medicine residents that you can't call for a STAT surgery consult (meaning you think there's a surgical emergency NOW!) and yet not at least make the patient NPO. I don't know how many times I've gone into a patient's room for a stat consult, only to interrupt them eating their meal.

Has happened to me as well, too many times to count.

The medicine attending flipped his lid saying they still needed to get this and that test, that we couldn't be sure about the diagnosis yet, and undermined our team in front of the patient saying we didn't know what we were talking about.

Don't call surgery if you don't want your patient to have surgery.

This as well. I got paged by a (fresh) medicine attending at 2 AM demanding why I wasn't taking a patient to surgery in the middle of the night who was being admitted for 1.) COPD exacerbation and 2.) increasing spasticity from moderate cervical spondylotic myelopathy. We had already seen him the week prior when he was first admitted to Neurology to work-up his symptoms (who also ignored PT/OT's and our recommendations to send him to a Rehab facility) and had scheduled for surgery the day after he presented back, and I just couldn't get the attending to grasp that his issue was not a neurosurgical emergency and that he could wait until his COPD was adequately treated. He documented in the chart, "NUS resident ASSURES me that the patient won't suffer permanent neurologic insult by waiting 1 day to do his surgery." He also insisted on getting a "lumbosacral MRI" before we took him to surgery to check for "spinal cord compression elsewhere" even though we had already obtained t-spine MRI that showed no lesions between his conus and his OPLL at C5-6. Sometimes they forget that the spinal cord ends at about L1 and below that it's the cauda equina.The patient's problem was spasticity and upper extremity numbness and weakness, while he did have full lower extremity strength and intact bowel/bladder function. That same attending REFUSED to say whether he felt the patient was medically fit for surgery and deferred to Anesthesia to "make that call." My attending backed me up and agreed he was being an ass. Long story short, Anesthesia nearly cancelled the case but we went along as planned and the patient is doing well. His lumbar spine MRI was completely unremarkable, as I had suspected it would be.

 

[45408]

I'd be careful with that situation. I've found in my current role that when there's a colorectal surgery team that the on-call general surgery resident doesn't cover, all of a sudden residents lose some basic surgical abilities if they occur near the colon or rectum.

I had a senior surgical resident on night float refuse to drain a perirectal abscess in the ER because it "sounded like a colorectal surgery issue." Imagine how unhappy I was to come in from home at 2am to drain butt pus, only to find out general surgery had turned the consult down. I had a similar situation with a GI bleed in the ER. I had a general surgery resident from another prestigious institution turn down an ER consult for "incarcerated" rectal prolapse (without examining the patient) because he didn't feel comfortable taking care of it.

What self-respecting general surgery resident would be willing to say these things are outside their scope of practice?

When there are tasks to be performed in the ER that fall into the common scope of general surgery, but the wimpy in-house resident punts it to the specialty service (dumping work uphill), usually it means somebody else has to step up...often driving in from home, and often having a full day ahead of them instead of being post-call.

Cholecystitis? Pancreatitis? Better call hepatobiliary.

That's not what I'm saying at all. We don't have a separate colorectal team. In most cases, I would still be the one seeing the consult, but I would be staffing it with a surgeon who was willing and capable to do something about it. Low rectal cancer? Yeah, the acute care/trauma surgeon isn't/shouldn't going to do anything for it. Maybe if the patient were hemorrhaging or acutely obstructed, but that was not the issue at all.

 

[45408]

Say there's a GI bleeder going to the ICU. If I didn't "make surgery aware" and he suddenly decompensated 12 hours later and I called you then, would you be pissed that you hadn't been "made aware" of the patient when he first got admitted? I ask because I generally hate calling those consults and often feel pretty stupid doing so, but a lot of attendings are pretty insistent on it.

No? Call us if you need something done or think something needs to be done. If you feel confident at this point that nothing can or should be done, don't call.

There are several things to consider. The obvious one is that surgery never likes to get involved unless their active input or intervention is necessary. Being on board so that the medicine attending has piece of mind is like calling 911 just to have the firefighters aware that you're going to have a barbeque today.

Love it.

On the other hand, medicine can be hit or miss with the management of really sick patients, especially acutely ill. There are countless stories of patients being under resuscitated with pathetic IV access and no one around who can confidently place a CVL. So yeah, in those cases, it isn't great to see a person who needs a laparotomy have poor access, renal failure, no antibiotics, etc.

Generally speaking, it's not like we are going to be at the bedside with a scalpel, ready to do a lap at the exact moment someone crumps. I can usually see an urgent consult and get things ready for the OR in just a few minutes, and let's face it, if they can't stay alive for that long, they probably won't make it out the OR anyway.

Agree on all counts.

Going from big academic institution to small town practice has been so life-changing for me in terms of my approach to consults. I rarely, rarely get bogus consults. We have a great ER, that does great work ups on patients. Usually, they have a diagnosis and they call me. When they don't have a diagnosis, they have thought things through appropriately, and are asking for advice, not dumping work.

Our ED is good, but almost all of the attendings have been there for quite a few years and are quite competent. The problem with our hospitalists is that it's a very high turnover and many of them are quite green. They do get dumped on pretty often as well, and I do feel bad for some of what they deal with.

 

[ACSurgeon]

All they want you to do is put ink on the chart so that they can check off the box. We get consults "to get surgery on board" just so that when they sign out their team to the next hospitalist, they can say their bases are all covered. This is only what the dumb hospitalists do. We have a handful of them that virtually never call us, because they're so good at what they do. If it can be handled at all as an outpatient, they'll just send it for outpatient follow-up.

We had one the other day where they were recommended to get a colorectal surgery consult. We don't have specific colorectal surgery call, but there was a colorectal surgeon on the day before (while the patient was there, and after the oncologist had recommended the consult), but they didn't call then. They waited until it was an acute care/trauma surgeon on, and even then, they could have specifically called and requested one of the colorectal guys (if you ask nicely, they'll usually see a consult even when not on call). Nope. "We just want surgery on board."

I think it's because they know that we are good at identifying and solving problems. They might consult you for something stupid, but chances are you'll notice that the patient is having an MI (or insert other medical disaster) that they aren't recognizing. It's sad if you ask me.

 

[skiz knot]

Has happened to me as well, too many times to count.



This as well. I got paged by a (fresh) medicine attending at 2 AM demanding why I wasn't taking a patient to surgery in the middle of the night who was being admitted for 1.) COPD exacerbation and 2.) increasing spasticity from moderate cervical spondylotic myelopathy. We had already seen him the week prior when he was first admitted to Neurology to work-up his symptoms (who also ignored PT/OT's and our recommendations to send him to a Rehab facility) and had scheduled for surgery the day after he presented back, and I just couldn't get the attending to grasp that his issue was not a neurosurgical emergency and that he could wait until his COPD was adequately treated. He documented in the chart, "NUS resident ASSURES me that the patient won't suffer permanent neurologic insult by waiting 1 day to do his surgery." He also insisted on getting a "lumbosacral MRI" before we took him to surgery to check for "spinal cord compression elsewhere" even though we had already obtained t-spine MRI that showed no lesions between his conus and his OPLL at C5-6. Sometimes they forget that the spinal cord ends at about L1 and below that it's the cauda equina.The patient's problem was spasticity and upper extremity numbness and weakness, while he did have full lower extremity strength and intact bowel/bladder function. That same attending REFUSED to say whether he felt the patient was medically fit for surgery and deferred to Anesthesia to "make that call." My attending backed me up and agreed he was being an ass. Long story short, Anesthesia nearly cancelled the case but we went along as planned and the patient is doing well. His lumbar spine MRI was completely unremarkable, as I had suspected it would be.

It is amazing the number of clearly myelopathic patients that only have a lumbar MRI as their workup. The level of musculoskeletal medicine that is taught in medical school and to non-ortho/neuro/PMNR residents is absolutely insufficient.

 

[kitsunepixie]

It is amazing the number of clearly myelopathic patients that only have a lumbar MRI as their workup. The level of musculoskeletal medicine that is taught in medical school and to non-ortho/neuro/PMNR residents is absolutely insufficient.

Yeah...I often get consulted on "hey we think this guy with incontinence has cauda equina syndrome but there's nothing on his lumbar spine MRI...wtf do we do?" and when I ask, "Are there upper motor neuron signs?" I get, "What's that mean?" I examine the patient and sho' nuff, they're weak in their arms and proximal lowers and floridly myelopathic. The consulting person is like, "Wow, how'd you figure out it was their NECK?" I heard some med schools don't require a clinical neuroscience rotation either, which I don't understand how that can be possible or copacetic. 😱

And I agree that not enough MSK is taught. I went out of my way to take a PMR rotation and rotate with my mom's orthopedic surgeon and it has really helped me out in my field to be able to identify hip/joint/etc. pathology and send it your way. We had a visiting Ortho MD give us all a lecture with demonstrations how to examine joints and some of our attendings were scribbling notes frantically, so now it's become a yearly thing. 👍

 

[OtoHNS]

It is amazing the number of clearly myelopathic patients that only have a lumbar MRI as their workup. The level of musculoskeletal medicine that is taught in medical school and to non-ortho/neuro/PMNR residents is absolutely insufficient.

I think you could generalize this statement to pretty much all surgical subspecialties. At least it's very true for ENT. I think in my med school, we had 2 lectures sometime M2 year that supposedly covered all of ENT. We also had a physical exam session that was supposed to cover the head and neck exam which was taught by an ENT attending. That was it in 4 years. I don't remember much more being taught about urology/ophtho/ortho/neurosurg/etc.

 

[Doctor4Life1769]

I think it's because they know that we are good at identifying and solving problems. They might consult you for something stupid, but chances are you'll notice that the patient is having an MI (or insert other medical disaster) that they aren't recognizing. It's sad if you ask me.

Damn, you're just a surgical intern, right?

 

[45408]

I think it's because they know that we are good at identifying and solving problems. They might consult you for something stupid, but chances are you'll notice that the patient is having an MI (or insert other medical disaster) that they aren't recognizing. It's sad if you ask me.

I don't particularly think we're good at solving problems, but I do think we're good at resuscitating sick patients and staying on top of them, hence the above comment to the effect of "the patient had one dinky peripheral IV and fluids running at 60/hr, despite the impending shock."

 

[Buzz Me]

I don't particularly think we're good at solving problems, but I do think we're good at resuscitating sick patients and staying on top of them, hence the above comment to the effect of "the patient had one dinky peripheral IV and fluids running at 60/hr, despite the impending shock."

Plus unless you're scrubbed, you tend to go see the consult promptly. People tend to exploit that characteristic of General Surgery.

 

[45408]

Plus unless you're scrubbed, you tend to go see the consult promptly. People tend to exploit that characteristic of General Surgery.

This too. We're in one of those fields where a delay on the requesting provider's part or on our part can easily result in a huge problem for the patient (cold foot, mesenteric ischemia, etc), so we go see things pretty quickly. Anesthesia and CT surgery are the two fields that come to mind that can have patients go downhill faster than us (ENT as well, when it comes to the airway), but our patients can go down the toilet quickly.

Plus, it's just a mindset of "go see the patient" that prevails.

 

[Dr.LeoSpaceman]

Just got one today on peds surgery that was interesting in that it was an epic fail on a couple levels.

13 year old girl with a 1 year history of back pain. Tanner 5 but has not had her first period. 30 second physical exam reveals a visible uterine fundus and bulging membrane at the introitus. Janitor walking by the room yells "Hey, that looks like an imperforate hymen."

The sad part is that she had been seen by her PCP for the last year with this back pain (that was cyclic...interesting). Got sent to ortho, then physical therapy, then a chiropractor. Back to ortho where they got an MRI which apparently showed a "large bladder". More PT and thoughts of getting urology involved.

Finally she came to the ED and will have her problem resolved with a 23 hour admit.

Part of me wants to call the PCP and ask if she ever bothered to do a pelvic exam on this girl. It also leaves me less than impressed with the radiologist.

 

[SLUser11]

Just got one today on peds surgery that was interesting in that it was an epic fail on a couple levels.

13 year old girl with a 1 year history of back pain. Tanner 5 but has not had her first period. 30 second physical exam reveals a visible uterine fundus and bulging membrane at the introitus. Janitor walking by the room yells "Hey, that looks like an imperforate hymen."

The sad part is that she had been seen by her PCP for the last year with this back pain (that was cyclic...interesting). Got sent to ortho, then physical therapy, then a chiropractor. Back to ortho where they got an MRI which apparently showed a "large bladder". More PT and thoughts of getting urology involved.

Finally she came to the ED and will have her problem resolved with a 23 hour admit.

Part of me wants to call the PCP and ask if she ever bothered to do a pelvic exam on this girl. It also leaves me less than impressed with the radiologist.

I'm not sure how much of an "epic fail" this is. How many PCPs do pelvic exams on 13 year old girls? How many imperforate hymens will a PCP encounter in his/her career, and how much clinical suspicion should someone really have just because a 13yo girl has back pain?

The diagnosis got missed, but I doubt it's due to incompetence on the PCP's part. If anything, it's an imaging fail, but was the uterus always that big, or was that a new finding?

Either way, I'm happy she has a chance at a cure. Now, if her back pain continues after you deal with her imperforate hymen, what will you do then?

 

[45408]

Just got one today on peds surgery that was interesting in that it was an epic fail on a couple levels.

13 year old girl with a 1 year history of back pain. Tanner 5 but has not had her first period. 30 second physical exam reveals a visible uterine fundus and bulging membrane at the introitus. Janitor walking by the room yells "Hey, that looks like an imperforate hymen."

Probably oughta close the door...

The sad part is that she had been seen by her PCP for the last year with this back pain (that was cyclic...interesting). Got sent to ortho, then physical therapy, then a chiropractor. Back to ortho where they got an MRI which apparently showed a "large bladder". More PT and thoughts of getting urology involved.

Finally she came to the ED and will have her problem resolved with a 23 hour admit.

Part of me wants to call the PCP and ask if she ever bothered to do a pelvic exam on this girl. It also leaves me less than impressed with the radiologist.

Most of our patients see providers that are all within our system, so one thing we can do is just forward our consult note/H&P/discharge summary to them electronically. Might be some useful feedback. It's pretty bad to call the uterus a bladder.

The only way this story could have been better is if the chiropractor were the one to diagnose it.

 

[maxheadroom]

I'm not sure how much of an "epic fail" this is. How many PCPs do pelvic exams on 13 year old girls? How many imperforate hymens will a PCP encounter in his/her career, and how much clinical suspicion should someone really have just because a 13yo girl has back pain?

The diagnosis got missed, but I doubt it's due to incompetence on the PCP's part. If anything, it's an imaging fail, but was the uterus always that big, or was that a new finding?

Either way, I'm happy she has a chance at a cure. Now, if her back pain continues after you deal with her imperforate hymen, what will you do then?

Agree. Hindsight is 20/20 and the Surgical Service frequently gets the benefit of hindsight. "How could you miss this obvious diagnosis?" is a douchey question on a patient like this. Back pain does not usually elicit a pelvic exam on a 13 year-old girl.

 

[Dr.LeoSpaceman]

Agree. Hindsight is 20/20 and the Surgical Service frequently gets the benefit of hindsight. "How could you miss this obvious diagnosis?" is a douchey question on a patient like this. Back pain does not usually elicit a pelvic exam on a 13 year-old girl.

No, but you figure at some point the kid might get a general physical exam which would include a belly exam, at which point you would do a pelvic when you feel the giant uterus.

And last I checked, at least an external genital exam is part of a routine well-child physical. I'm not talking about a bimanual here.

 

[VincentAdultman]

rn: I can't do that right now! I'm advocating for my patient!!!

lol

 

[balaguru]

Had to bump. Just did my first ED thoracotomy. It. Was. Awesome. Not the cluster I was expecting. Lost too much in the field from a left subclavian vessel to keep him out of v fib despite controlling the blood loss. This was followed by a GSW to the abd that was almost boring. Not a bad call.

 

[Winged Scapula]

Had to bump. Just did my first ED thoracotomy. It. Was. Awesome. Not the cluster I was expecting. Lost too much in the field from a left subclavian vessel to keep him out of v fib despite controlling the blood loss. This was followed by a GSW to the abd that was almost boring. Not a bad call.

👍

Never got to do one during residency.