Consults- Memorable/Dismal/Ridiculous/Unique

[Dan Plainview]

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Was consulted (by a medical student 😡) on a patient because "he has an ostomy."
That was it.

At y'all's institutions, do medical students routinely call consults? I was never allowed to (and never wanted to, for fear of exposing my own ignorance, which hasn't diminished as an intern ).

 

[balaguru]

👍

Never got to do one during residency.

Yeah. Thought I was going to go through residency never having done one and trauma is gonna be a big part of my practice.

Was consulted (by a medical student 😡) on a patient because "he has an ostomy."
That was it.

At y'all's institutions, do medical students routinely call consults? I was never allowed to (and never wanted to, for fear of exposing my own ignorance, which hasn't diminished as an intern ).

No. Next time ask the student to have his/her resident page you with the consult so that you can better understand the question. No sense in getting upset at the students since they are probably just doing what they are told to do. When you hear from the resident make it clear that having the student consult other services is inappropriate especially if they are unprepared to ask a meaningful question. If don't hear back just go see the patient and sort it out. Hopefully, your upper level will take it from there. Don't get too hung up on it because in the real world you may get consults from nurses or the EMR system and trying to fight that will be a loosing battle.

 

[dpmd]

Was consulted (by a medical student 😡) on a patient because "he has an ostomy."
That was it.

At y'all's institutions, do medical students routinely call consults? I was never allowed to (and never wanted to, for fear of exposing my own ignorance, which hasn't diminished as an intern ).

As a student I often called the consults, but that was only on patients I knew and for reasons I understood (obligatory ID consult because we want to use XYZ abx-per hospital policy, but I would know the infx and what abx had failed or what the sensitivities showed, renal consult for the patient who might need dialysis inpt and I knew the labs and clinical scenario). As an intern I usually did it myself or had the student call while I was with them. As a resident I didn't really instruct the interns one way or the other, and would call a consult myself if it was busy or if there was something special about it.

What did the consult end up being for, or was it actually just because there was an ostomy? I wouldn't rule it out.

 

[45408]

Was consulted (by a medical student 😡) on a patient because "he has an ostomy."
That was it.

Nice. The dumb consults come from all levels. I got an awful one from a PGY-3 in medicine who couldn't even articulate what the question was. I finally gave up and called the GI doc and asked what his question was. It was a silly question, but it was at least a well-formed question.

If we got a call for "the patient has an ostomy," and that was literally the only question, I'd just give them the phone number for the ostomy nurse and not see the consult.

At y'all's institutions, do medical students routinely call consults? I was never allowed to (and never wanted to, for fear of exposing my own ignorance, which hasn't diminished as an intern ).

I only did them as a sub-I on medicine.

 

[Winged Scapula]

As a student and an intern, I often hated being asked to call consults because I knew I would get asked questions that I hadn't an answer for.

There are lots of things we can do better and faster ourselves, and I admit to going over the intern's head and calling consults myself to expedite the process, but this robs them of the opportunity to learn.

The fact is that if they aren't told how to call the consult, we can't expect that it will be done right. The worst ones are those that:

a) don't have a clinical question;

b) are "just because they have something icky and surgical (like a stoma) that we don't know anything about. Psychiatry was notorious for this at my residency program. Self-harmers would come in, and they wouldn't even unwrap dressings but would automatically consult surgery. I wish I had a nickel for every one I saw that literally barely broke skin.

c) TELL you to do something (ie, you have to come and put a line/port/chest tube in) as if you were their jockey;

d) don't include enough information. I fielded a consult call from a Prelim IM intern (going into Derm, natch) that went like this:

Intern: "We want you to see a patient of ours that has pain"
Me: "Ok, what is your differential?"
Intern: "Its abdominal pain"
Me: "Ok....do you think its a surgical abdomen?"
Intern: "I don't think he's had any surgeries before."
Me: "<sigh> What are you worried about?"
Intern: "His abdominal pain"
Me: "Alright...what's his name?"
Intern: "Hmmm...I don't know but he's on the 5th floor."
Me: "Ok...so we're supposed to stand in the rotunda and shout, seeing if anyone has belly pain? Call me back when you have a clinical question and most importantly, the patient's name and room number" <click>

Seriously. I guess I was "mean" to her so she made one of the residents call us back. I suggested that they teach their interns, especially her, how to call consults.

One of my Chief residents used to hang up if med students called him and would brag about it. He was a terrific DB. Hated him.

Bottom line: I don't ask medical students to call consults unless I am with them and can coach them.

 

[blue2000]

The whole calling ridiculous consults brings me back to my intern year, when the intern would take 24 hours of call on the entire CT service, including all ICU patients, fresh transplants, etc. It was a brutal, anxiety producing call where not only the volume of work was overwhelming, but so was the intensity of illness really pushed all of us to our limits.

Anyways, the CT fellow told me to call a cards consult about a patient with bradycardia. I didn't know the patient, didn't really know the clinical picture, and was generally totally overwhelmed. I dutifully called the cardiology fellow to consult. He gently and nicely probed what the exact question was. Finally I told him "I'm the intern, I'm overwhelmed, fellow told me to call the consult so I'm calling the consult." Not my finest moment as an intern, but the cards fellow took pity on me, looked at the tele record, and (correctly) deduced that the consult wasn't for the bradycardia but rather the v-tach that had preceded it (something I wasn't present for and wasn't made aware of).

The coda to this story is that the cardiology fellow is now my husband, so evidently I wasn't a total idiot...

 

[Winged Scapula]

The whole calling ridiculous consults brings me back to my intern year, when the intern would take 24 hours of call on the entire CT service, including all ICU patients, fresh transplants, etc. It was a brutal, anxiety producing call where not only the volume of work was overwhelming, but so was the intensity of illness really pushed all of us to our limits.

Anyways, the CT fellow told me to call a cards consult about a patient with bradycardia. I didn't know the patient, didn't really know the clinical picture, and was generally totally overwhelmed. I dutifully called the cardiology fellow to consult. He gently and nicely probed what the exact question was. Finally I told him "I'm the intern, I'm overwhelmed, fellow told me to call the consult so I'm calling the consult." Not my finest moment as an intern, but the cards fellow took pity on me, looked at the tele record, and (correctly) deduced that the consult wasn't for the bradycardia but rather the v-tach that had preceded it (something I wasn't present for and wasn't made aware of).

The coda to this story is that the cardiology fellow is now my husband, so evidently I wasn't a total idiot...

😍

And obviously, neither was he.

 

[Buzz Me]

👍

Never got to do one during residency.

What?! 😱 While I disliked certain things about my residency, at least I had my fair share of ER thoracotomies.

Now? 3-5 thoracotomies every single week. What was the big deal again? 😛

 

[Winged Scapula]

What?! 😱 While I disliked certain things about my residency, at least I had my fair share of ER thoracotomies.

Remember, you trained in a town with a lot of penetrating trauma.

I did not, with the exception of arms/legs being caught in augers (really more of a ripping trauma). Even though we were the only Level 1 in the area, the GSW/stabbings, etc. happened downtown and were taken to Pinnacle most often.

I also was a "white cloud" when it came to call.

 

[Gastrapathy]

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.

.

I think its worse than that. I think "get surgery on board" = someone to blame if the patient gets sicker and the surgeon decides not to operate (which we didn't really want him/her to do anyway). I don't call surgeons unless I think a surgery might be indicated and want their assessment to answer that question. I tell our folks all the time that once we've called, its not up to us anymore and that our note needs to say that we asked the surgeons to determine whether they needed to intervene for x.

The question of who should call a consult is a hard one for me. I want our question communicated accurately and thats not a skill that early learners can achieve. PGY1 need to start making those calls. I find that if they do a bad job they will blame me (Dr G wants you to see the patient becomes the entire consult). This wastes the consultant's time but I always seem to get feedback.

When I'm on the other side being consulted, I've stopped listening. I just want to know the name and bed.

 

[anonperson]

Was consulted (by a medical student 😡) on a patient because "he has an ostomy."
That was it.

At y'all's institutions, do medical students routinely call consults? I was never allowed to (and never wanted to, for fear of exposing my own ignorance, which hasn't diminished as an intern ).

Haven't had a medical student call a consult, but I estimate that 90% of the consults our service gets is done by a unit clerk who has no real clinical training and maybe has a 5 word description of the clinical scenario. At this point, I'd probably prefer a medical student calling in the consult.

 

[coldleg]

1. "Stat" vascular consult from the OB/GYN resident ...call back... "Well, patient getting discharged today and she really wants to see someone for her varicose veins. She's really demanding, so if you could hurry and see her in the next hour, that'd be great."

2. Hosptialist's NP calling my program directors secretary to have her call me for an emergent vascular consult on the floor. No patient name, no details, just a room number. I haul ass across the hospital, to find a patient in bed just smiling, chilling out. No staff anywhere to be found. Made sure the guy was OK, then got a hold of the NP who called:

"Oh, my attending wanted a vascular consult to evaluate this guy for possible AVF placement"

"Why did you call my program director's office to have them page me emergently???"

"Well, I figured that way you would come faster and see the patient."

Me:

 

[45408]

"Oh, my attending wanted a vascular consult to evaluate this guy for possible AVF placement"

"Why did you call my program director's office to have them page me emergently???"

"Well, I figured that way you would come faster and see the patient."

I would run that one past the PD again, because that would not go over well here.

 

[Winged Scapula]

Haven't had a medical student call a consult, but I estimate that 90% of the consults our service gets is done by a unit clerk who has no real clinical training and maybe has a 5 word description of the clinical scenario. At this point, I'd probably prefer a medical student calling in the consult.

Interestingly, my hospital just instituted a new policy that consults are to be called physician to physician because of this practice.

During residency and fellowship, the residents called of course, but when I moonlighted, the ward clerk would often call and I was like, "WTF?". Now like Gastropathy, just give me the room number and name and I'll figure it out on my own.

 

[Winged Scapula]

Me:

Even for a surgeon, that's sort of a gross GIF.

 

[Winged Scapula]

I would run that one past the PD again, because that would not go over well here.

Exactly. I would contact the Hospitalist or whomever employs the NP because that is a clear abuse of the paging system, the resident and the consult process. Totally inappropriate.

As a matter of fact, I'm so pissed about it right now, give ME the contact information and I'll make a formal complaint! LOL...

 

[Dan Plainview]

As a student I often called the consults, but that was only on patients I knew and for reasons I understood (obligatory ID consult because we want to use XYZ abx-per hospital policy, but I would know the infx and what abx had failed or what the sensitivities showed, renal consult for the patient who might need dialysis inpt and I knew the labs and clinical scenario). As an intern I usually did it myself or had the student call while I was with them. As a resident I didn't really instruct the interns one way or the other, and would call a consult myself if it was busy or if there was something special about it.

What did the consult end up being for, or was it actually just because there was an ostomy? I wouldn't rule it out.

The consult was just that, the patient had an ostomy and was admitted to medicine for something unrelated, so they wanted us to look at it...just because. I called him back and (politely) told him that we have ostomy nurses who are happy to help them and troubleshoot any issues, and they would call us if they felt it needed a surgeon's attention. I'm sure it was a case of the student being told to do it or wanting to go above and beyond, and he was nice enough. But I still don't know how I feel about students calling in consults.

 

[Dan Plainview]

Me: "Ok....do you think its a surgical abdomen?"
Intern: "I don't think he's had any surgeries before."
Me: "<sigh>

This made me laugh for some reason. I see you being like this:

 

[Bostonredsox]

I think its worse than that. I think "get surgery on board" = someone to blame if the patient gets sicker and the surgeon decides not to operate (which we didn't really want him/her to do anyway). I don't call surgeons unless I think a surgery might be indicated and want their assessment to answer that question. I tell our folks all the time that once we've called, its not up to us anymore and that our note needs to say that we asked the surgeons to determine whether they needed to intervene for x.

The question of who should call a consult is a hard one for me. I want our question communicated accurately and thats not a skill that early learners can achieve. PGY1 need to start making those calls. I find that if they do a bad job they will blame me (Dr G wants you to see the patient becomes the entire consult). This wastes the consultant's time but I always seem to get feedback.

When I'm on the other side being consulted, I've stopped listening. I just want to know the name and bed.

This works both ways. I have had several post-op medical consults for 'medical management"....of a 46 year old elective hernia who takes an ACEI and a statin and whose resting BP preop was 130/60. At this point I also just say, 'gimme the name and the room'.....humorous thread to read though.

 

[BlondeDocteur]

I think it's perfectly appropriate for med students to call consults, provided someone at some point has taught them how to do it. However, my most dismal consult nearly changed my mind.

It was on transplant, and we took q2 home call converting the wards, any operations of course, and late-night admissions; we also did power weekends. The pager rang at 4 AM. An impossibly cheerful voice launched into an interminable social story about a guy moving to Seattle from Portland but he grew up in a small Oregonian town (which incidentally the speaker had visited, it was very nice..."

Me: "sorry, did you mean to page transplant surgery."
"Yes, my attending and I were just having a talk, since its kind of slow. Could you tell us the signs and symptoms of Graft Versus Host Disease?"
Me: " wait, do you have a patient with suspected GVHD?"
"right....[cutting it short, the guy in the anecdote had a kidney tx at OHSU and came to our ED with a rash, and was diagnosed with scabies].
Me: "so you think he has scabies, and he's already been discharged?"
"yes, well, I just matched into internal medicine last week and want to becme an oncologist, so i want to recognize GVHD if I ever see it. My attending told me to page transplant to ask."

Never knew UptoDate didn't work in the ED.

And to make it worse, I had my newborn baby sleeping in a little basket next to my pager, and of course this non-sult woke him up.

 

[balaguru]

Wow! From then on I would have paged the attending at all sorts of odd hours to ask random medicine questions.

I think it's perfectly appropriate for med students to call consults, provided someone at some point has taught them how to do it. However, my most dismal consult nearly changed my mind.

It was on transplant, and we took q2 home call converting the wards, any operations of course, and late-night admissions; we also did power weekends. The pager rang at 4 AM. An impossibly cheerful voice launched into an interminable social story about a guy moving to Seattle from Portland but he grew up in a small Oregonian town (which incidentally the speaker had visited, it was very nice..."

Me: "sorry, did you mean to page transplant surgery."
"Yes, my attending and I were just having a talk, since its kind of slow. Could you tell us the signs and symptoms of Graft Versus Host Disease?"
Me: " wait, do you have a patient with suspected GVHD?"
"right....[cutting it short, the guy in the anecdote had a kidney tx at OHSU and came to our ED with a rash, and was diagnosed with scabies].
Me: "so you think he has scabies, and he's already been discharged?"
"yes, well, I just matched into internal medicine last week and want to becme an oncologist, so i want to recognize GVHD if I ever see it. My attending told me to page transplant to ask."

Never knew UptoDate didn't work in the ED.

And to make it worse, I had my newborn baby sleeping in a little basket next to my pager, and of course this non-sult woke him up.

 

[deleted50541]

This works both ways. I have had several post-op medical consults for 'medical management"....of a 46 year old elective hernia who takes an ACEI and a statin and whose resting BP preop was 130/60. At this point I also just say, 'gimme the name and the room'.....humorous thread to read though.

Yeah, I hated calling in those "medical management" consults for issues that I could easily handle. It usually happened when I had a senior who'd been burned in the past by incompetent juniors and/or didn't have half a clue themselves when it came to basic medical care, or an attending who liked to consult everyone under the sun for anything non-surgical.

"Why are YOU dealing with that (e.g. minor BP issue, adjustments to insulin regimen, coumadin dosing)? Just call medicine already."
😕

 

[Buzz Me]

"yes, well, I just matched into internal medicine last week and want to becme an oncologist, so i want to recognize GVHD if I ever see it. My attending told me to page transplant to ask."

Never knew UptoDate didn't work in the ED.

And to make it worse, I had my newborn baby sleeping in a little basket next to my pager, and of course this non-sult woke him up.

That is absolutely ridiculous. 😡 Makes me angry.

 

[Winged Scapula]

I have to honestly believe that the internal medicine attending did not mean for his medical student to-page the resident at 4 AM to ask about graft versus host disease. Even if she were in a house that's just a horrific abuse of the resident and not something I would expect of another physician.

 

[Buzz Me]

I also was a "white cloud" when it came to call.

Ah. And I, a black cloud.

Yet ANOTHER type A dissection this past weekend. 🙁

 

[BlondeDocteur]

I have to honestly believe that the internal medicine attending did not mean for his medical student to-page the resident at 4 AM to ask about graft versus host disease. Even if she were in a house that's just a horrific abuse of the resident and not something I would expect of another physician.

It was the ED-- the med student in question was on her ER rotation. I know the attending very well and yes, he absolutely would. "Just page transplant, they're always in house."

 

[balaguru]

Oh, he's an EM doc. I guess you can't ask him medicine questions. Maybe you can ask him who is on call for medicine and treat him as your personal page operator.

It was the ED-- the med student in question was on her ER rotation. I know the attending very well and yes, he absolutely would. "Just page transplant, they're always in house."

 

[Winged Scapula]

Amusing consult from yesterday.

I was talking to a Urologist friend of mine in the OR Lounge this am about lame consults and he told me what happened to him yesterday, a Sunday.

He took a call from the ED about a 92 yo nursing home patient brought in for SOB who was noted to have priapism.

My friend comes in, notes the slightly demented patient, who complains only of SOB, does his History, no risk factors for Priapism noted, etc.

Examines the patient and finds a semi-rigid penile prosthesis as the cause for the "priapism". 🙄

 

[StritchMD2011]

Urology resident here. We get called almost daily for fairly lame consults.

My favorite is the ominous obese woman foley catheter. Invariably, it's a poor medicine intern who hasn't put a foley catheter in since 3rd year of medical school who calls stating they "tried very hard" to place a foley, but were unsuccessful. This is after "multiple nurses" failed (according to the intern - but it was likely one lazy nurse who claimed they couldn't get the foley in).

At first, I would just suck it up and do it myself. But after about 10 of these consults in a few months, I started making the medicine intern round up a team of 3-5 people (nurses, techs, etc.) and meet me at the bedside at my leisure.

I would explain to them that an inability to place a foley in a very obese woman is usually due to a lack of effort on the part of the operator. I'd make the 3-5 people hold the legs up in a pseudo-lithotomy position, with some retracting pannus and labia (if needed), and I'd supervise and coach the medicine intern into placing the foley.

I'll be dammed if the same intern ever had to call me twice.

 

[Smurfette]

Urology resident here. We get called almost daily for fairly lame consults.

My favorite is the ominous obese woman foley catheter. Invariably, it's a poor medicine intern who hasn't put a foley catheter in since 3rd year of medical school who calls stating they "tried very hard" to place a foley, but were unsuccessful. This is after "multiple nurses" failed (according to the intern - but it was likely one lazy nurse who claimed they couldn't get the foley in).

At first, I would just suck it up and do it myself. But after about 10 of these consults in a few months, I started making the medicine intern round up a team of 3-5 people (nurses, techs, etc.) and meet me at the bedside at my leisure.

I would explain to them that an inability to place a foley in a very obese woman is usually due to a lack of effort on the part of the operator. I'd make the 3-5 people hold the legs up in a pseudo-lithotomy position, with some retracting pannus and labia (if needed), and I'd supervise and coach the medicine intern into placing the foley.

I'll be dammed if the same intern ever had to call me twice.

Kudos to you...our GU residents often did the same thing when they got those consults from medical services. OTOH, when GS called GU for a consult, usually we'd already tried multiple size foleys/coudes/etc. and they knew they were in for a real challenge.

As an aside, we always did have transplant in-house during residency. That service was crazy.

 

[cpants]

Urology resident here. We get called almost daily for fairly lame consults.

My favorite is the ominous obese woman foley catheter. Invariably, it's a poor medicine intern who hasn't put a foley catheter in since 3rd year of medical school who calls stating they "tried very hard" to place a foley, but were unsuccessful. This is after "multiple nurses" failed (according to the intern - but it was likely one lazy nurse who claimed they couldn't get the foley in).

At first, I would just suck it up and do it myself. But after about 10 of these consults in a few months, I started making the medicine intern round up a team of 3-5 people (nurses, techs, etc.) and meet me at the bedside at my leisure.

I would explain to them that an inability to place a foley in a very obese woman is usually due to a lack of effort on the part of the operator. I'd make the 3-5 people hold the legs up in a pseudo-lithotomy position, with some retracting pannus and labia (if needed), and I'd supervise and coach the medicine intern into placing the foley.

I'll be dammed if the same intern ever had to call me twice.

Haha. I love doing that.

We have had some 'difficult foley' consults when the patient was just delirious/demented and combative. That is, the patient had normal anatomy, but they couldn't get a foley in because the patient was throwing punches. One of my chiefs destroyed a medicine resident for this in the wee hours.

Re: the prosthesis consult - I once got a consult for a testis mass that turned out to be a penile prosthesis pump in the scrotum. They didn't even ask the patient about it. "Thank you for this fascinating consult."

My least favorite BS urology consult is incontinence in 90+ year old gomers. Usually can get out of the consult, but some hospitalists can't get it into their head that pissing yourself with end-stage dementia is pretty much standard and irreversible. Timed voiding and diapers/condom caths are all we have to offer. And no, incontinence of any type is, almost without exception, not an inpatient issue.

 

[Winged Scapula]

As an aside, we always did have transplant in-house during residency. That service was crazy.

We did too; times are achangin' though and I suspect more and more services are taking home call to get around work hours.

 

[45408]

We did too; times are achangin' though and I suspect more and more services are taking home call to get around work hours.

Yeah, which just results in an extremely painful rotation.

 

[Dissected]

Rotating in the ED and my resident just handed me the phone to wait for the call from surgery to present a consult. It made me think of this thread..hopefully I don't butcher it!

 

[Bostonredsox]

Urology resident here. We get called almost daily for fairly lame consults.

My favorite is the ominous obese woman foley catheter. Invariably, it's a poor medicine intern who hasn't put a foley catheter in since 3rd year of medical school who calls stating they "tried very hard" to place a foley, but were unsuccessful. This is after "multiple nurses" failed (according to the intern - but it was likely one lazy nurse who claimed they couldn't get the foley in).

At first, I would just suck it up and do it myself. But after about 10 of these consults in a few months, I started making the medicine intern round up a team of 3-5 people (nurses, techs, etc.) and meet me at the bedside at my leisure.

I would explain to them that an inability to place a foley in a very obese woman is usually due to a lack of effort on the part of the operator. I'd make the 3-5 people hold the legs up in a pseudo-lithotomy position, with some retracting pannus and labia (if needed), and I'd supervise and coach the medicine intern into placing the foley.

I'll be dammed if the same intern ever had to call me twice.

I would call you. I do not put in foleys. Lines, airways, chest tubes, and other physican performed procedures.. no problem. But I have never been one to put in foleys. I have maybe put in 3 in my life. If a nurse cant get one I tell them to call one of the MICU nurses. If the MICU nurse, who has more than likely put in >5,000 foleys in her life, cant get the foley in, there isnt anyway in hell I am getting one in. I tell them to call the on call urologist if we really need one that moment, otherwise slap a diaper on them and they can do it in the morning. And very few of my other IM collegue's have ever put in foleys. It is a nurses job. And If it is too difficult for the experienced nurse to put in, chances are they have some anatomical problem. I am not sticking a tube in them, easy uro consult. Never had a Uro attending holler at me for that. Usually they say hand the phone to the nurse, they give the nurse some orders and they come up and do it via cysto. Same deal with an IV. If 3 different competent nurses cant get a peripheral IV in someone I am not wasting my time dicking around trying to put an 18 into their antecub, there getting an IJ. There isnt time amidst the 400 floor calls and 600 f'n ED admissions to waste time with peripheral IVs, Foleys and other nursing procedures. Atleast that is my experience from a community shop.

 

[SLUser11]

I do not put in foleys. Lines, airways, chest tubes, and other physican performed procedures.. no problem. But I have never been one to put in foleys. I have maybe put in 3 in my life......otherwise slap a diaper on .....There isnt time amidst the 400 floor calls and 600 f'n ED admissions to waste time with peripheral IVs, Foleys and other nursing procedures. Atleast that is my experience from a community shop.

It's a shame there aren't any docs to consult when your shoes become untied.

One of the main reasons that people in this thread are upset is that other specialties decide that their time is more precious than ours. The bolded comments illustrate this concept well.

Even if you're busy, and you haven't placed a foley since med school (which is your fault, btw), you are certainly not above placing a foley or other "nursing procedures." Try to think past the waste of resources and money, and focus more on a little self-respect.

Using your logic, If a foley is needed in a critically ill patient in the middle of the night, your options are either to place a diaper, or call in the urologist. I doubt they would jump up out of bed if they knew the real reason for the consult was the MICU doc, who is boarded in critical care, can't figure out how to place a foley. Well, actually, he probably could, but he thinks he's above it, plus he's too busy, and it's the middle of the night, so he's calling you.

....countdown until you consult your local CRS to come wipe one of your patient's butts for you....

 

[Bostonredsox]

It's a shame there aren't any docs to consult when your shoes become untied.

One of the main reasons that people in this thread are upset is that other specialties decide that their time is more precious than ours. The bolded comments illustrate this concept well.

Even if you're busy, and you haven't placed a foley since med school (which is your fault, btw), you are certainly not above placing a foley or other "nursing procedures." Try to think past the waste of resources and money, and focus more on a little self-respect.

Using your logic, If a foley is needed in a critically ill patient in the middle of the night, your options are either to place a diaper, or call in the urologist. I doubt they would jump up out of bed if they knew the real reason for the consult was the MICU doc, who is boarded in critical care, can't figure out how to place a foley. Well, actually, he probably could, but he thinks he's above it, plus he's too busy, and it's the middle of the night, so he's calling you.

....countdown until you consult your local CRS to come wipe one of your patient's butts for you....

most community shops do not have MICU atendings. They have one hospitalist at night covering all 130+ floor patients and the ICU patients...such as it here, not every hospital has the luxury of droves of inhouse attendings, fellows and residents at night. Here there are also 2-3 residents on getting swamped in the ED with admits and trying to get to floor calls. And we are talking about a complicated procedure in that multiple experienced people have failed to succeed. This hasnt happened as of yet but if for some reason after trying to put in a line I could not get it, I would call the surgeon, who theoretically has more experience. If I cant get the LP, Ill call neuro or ask IR to do it under flouro. However, it is virtually impossible to think that a medicine intern, resident or attending for that matter, who collectively, probably have placed a dozen foleys, as again, it is nursing procedure that is placed without difficulty 99% of the time, will have any better luck placing it then the experienced nurse. It is an exercise in futility and a waste of time for me to even come try. If it is a complicated foley, its getting a consult. Your a urologist. Come place the foley. And I have called the urology attending at 3am, he came in, put the foley in, waved good night and went home. No problems.

In academia, you are all busy. In the real world of community medicine (which makes up 85% of all hospitals) the medicine service is the busy service. The consulting services come in at 9 and leave at 5. We are the ones carrying 90% of the patients and are responsible for all of the care 24/7. We are taking all th ER admits. Regardless of chief complaint or admitting diagnosis whether it be Uro, Gen surg, ortho, whatever, it is "admit to medicine and consult me in the morning" . Consultants come in, fix their issue and sign off. So while the urologist is home sitting on his couch since 5 we are getting hammered with admits and floor problems. In this situation, my time IS more valuable. And the consulting attendings realise it as such and thus they dont complain, they come in, do their procedure or whatever we needed them for, collect their consult fee, and go back home long before we ever leave.

And I suffer no insult to my self respect for this. I dont put in foleys. I dont put in PICCs. Just not a procedure I do. Most surgeons, anesthesiologists and such are greatful as the majority of community hospitalists dont do those and ALSO dont put in lines, intubate, do their own LPs, thoras, para's, alines etc etc etc. They consult out everything as they either cant do them, or arent reimbursed for them so why waste my time, just consult. Our consultants are quite happy that I do all of those named procedures and dont need to consult them almost ever for any of them. So the rare foley that the nurse cant get, I have seen 2 in 2 years, the urologist happily places.

 

[SLUser11]

most community shops do not have MICU atendings. They have one hospitalist at night covering all 130+ floor patients and the ICU patients...such as it here, not every hospital has the luxury of droves of inhouse attendings, fellows and residents at night.

I am very familiar with community practice environments as I spent the first 5 years of my training in one. I promise that surgeons are getting hammered in these environments, day and night, although you may only see a fraction of it because they cover multiple hospitals.

You are over-estimating the abilities (or motivation/determination) of nurses to place foleys. If you are in house, and a foley needs placement, I recommend giving it the old college try prior to dragging a consultant out of bed.

 

[SLUser11]

I am very familiar with community practice environments as I spent the first 5 years of my training in one. I promise that surgeons are getting hammered in these environments, day and night, although you may only see a fraction of it because they cover multiple hospitals.

You are over-estimating the abilities (or motivation/determination) of nurses to place foleys. If you are in house, and a foley needs placement, I recommend giving it the old college try prior to dragging a consultant out of bed.

I'm probably being a little overly-harsh toward you, but I found the "I don't do foleys" line a little unsettling, as if you're above it, but we are not.

Also, I know you are trying to paint a picture of private practice where you are the martyr workhorse, and surgeons are the happy-go-lucky consultants, well-rested and happy-to-please, but you know as well as I do that the only reason those urologists come in at 0300 with a smile on their face is that hospitalists and general practitioners hold consultants under a constant unspoken threat that if you're unavailable or unpleasant, then the GP won't "use you" anymore, and your consults will dry up. Among other things we've discussed on SDN, one of the hardest parts of being a private practice surgeon is the inability to say "no," even if it's the 4th night in a row you've come in at 2am to place a foley or art line.

 

[Bostonredsox]

No it's ok your not harsh. I am not 'above' foleys, it's just a procedure I have never learned nor do I particularly care to learn. Same way many many internists don't place lines, it's just not a procedure they do, they consult them out every time. And the surgeons do world hard here. That's why I never consult them for a line or tube in fact we do almost all of them for the non teaching services to both help the IM people be more proficient and save the surgeons work. There is almost never a line consult in this hospital since the medicine residency program started. Foleys may simplistic compared to a line, but to me it's just the way it is. I do one, I don't do the other. Same with PICCs. I'm sure I could learn, but I don't want to. So the vascular access nurse places them. And I get the primary care feeding the surgeon mentality....but I am a soon to be critical care hospitalist In a surgeon deprived area so if I have a pt that needs a procedure I can't perform or needs a true surgical procedure, I consult them, regardless if I like them or if they have helped me in the past when I needed them. If my patient needs them, I consult them.

 

[tkim]

I do not put in foleys. [...] Same deal with an IV.

I do, though most of the time the nurses can get them. But if an outtie suprapublic cath rolls in, I'm it. And I'll jam viscous lido into that stoma and squirrel a Foley in there so I do not have to call a urologist at 3am. And if I have to call them, I can honestly say that I tried before calling. They appreciate that.

They aren't worried about not getting the referrals ... they're the only uro group in town so they get it whether I refer to them or not.

As for IV's. Well, I'm actually better than some of the nurses, but that wasn't because of med school, but my previous medic experience. Sometimes throwing an EJ will make the nurses happy and avoid an unnecessary IJ.

 

[cpants]

I think the thing that is offensive about the above mentioned foley consults is that the catheter was not truly difficult to place, but rather lazy nursing did not provide enough retraction of pannus or lazy doctor did not properly sedate a delirious patient. If you call a Foley consult to me, I expect you to provide me with the following information: why the catheter is indicated, any pertinent history (ie. prior GU surgery), what catheters and how many attempts were made, and where the hangup seems to be (ie. blockage at the prostate or can't find the meatus or we didn't actually try). Believe it or not, this makes a difference to what equipment I will bring and what I will try when I arrive. If you don't know this basic information, which astonishingly few medicine residents seem to, I'm not coming to do a catheter. The catheter is neither indicated or difficult until you tell me why.

I think urologists can be a little touchy about a catheter placement because the vast majority of the time, the catheter is not actually difficult. A simple bedside procedure that takes <3 minutes for you to try, robs me of 2 hours of sleep by the time I drive in, get the info, place the catheter, write a consult, and drive home. A hard pill to swallow when the catheter flies in and I'm looking forward to another bleary-eyed day in the clinic and OR tomorrow.

 

[MediCane2006]

And we are talking about a complicated procedure in that multiple experienced people have failed to succeed. This hasnt happened as of yet but if for some reason after trying to put in a line I could not get it, I would call the surgeon, who theoretically has more experience. If I cant get the LP, Ill call neuro or ask IR to do it under flouro. However, it is virtually impossible to think that a medicine intern, resident or attending for that matter, who collectively, probably have placed a dozen foleys, as again, it is nursing procedure that is placed without difficulty 99% of the time, will have any better luck placing it then the experienced nurse. It is an exercise in futility and a waste of time for me to even come try. If it is a complicated foley, its getting a consult. Your a urologist. Come place the foley.


And I suffer no insult to my self respect for this. I dont put in foleys. I dont put in PICCs. Just not a procedure I do. Most surgeons, anesthesiologists and such are greatful as the majority of community hospitalists dont do those and ALSO dont put in lines, intubate, do their own LPs, thoras, para's, alines etc etc etc. They consult out everything as they either cant do them, or arent reimbursed for them so why waste my time, just consult. Our consultants are quite happy that I do all of those named procedures and dont need to consult them almost ever for any of them. So the rare foley that the nurse cant get, I have seen 2 in 2 years, the urologist happily places.

If you sincerely think that placing a foley, even one that "the nurses couldn't get" qualifies as a complicated procedure....

I've done a LOT of uro moonlighting at community programs. I can assure you that were I the person you paged to come place a foley in that situation, I would INSIST that you tried with a uro-jet and a coude first. And no, that's not a "complicated procedure" it's a med-student level procedure requiring significantly less skill than starting an IV. Then if you couldn't get it I would meet you at the bedside and we would place it together. Slapping the patient with a bill for a urology consult for an uncomplicated foley just because you feel like its a "nursing procedure" is absurd.

Oh, and your assumption that just because "the nurses couldn't get it" it's automatically a complicated or difficult foley is truly laughable to anyone who has ever taken one of those consults....

 

[MediCane2006]

It's a shame there aren't any docs to consult when your shoes become untied.

....countdown until you consult your local CRS to come wipe one of your patient's butts for you....

This. 👍

 

[cpants]

I do, though most of the time the nurses can get them. But if an outtie suprapublic cath rolls in, I'm it. And I'll jam viscous lido into that stoma and squirrel a Foley in there so I do not have to call a urologist at 3am. And if I have to call them, I can honestly say that I tried before calling. They appreciate that.

They aren't worried about not getting the referrals ... they're the only uro group in town so they get it whether I refer to them or not.

As for IV's. Well, I'm actually better than some of the nurses, but that wasn't because of med school, but my previous medic experience. Sometimes throwing an EJ will make the nurses happy and avoid an unnecessary IJ.

God bless you. It's like pulling teeth to get anyone to change an SPT around here.

 

[Pir8DeacDoc]

I think the thing that is offensive about the above mentioned foley consults is that the catheter was not truly difficult to place, but rather lazy nursing did not provide enough retraction of pannus or lazy doctor did not properly sedate a delirious patient. If you call a Foley consult to me, I expect you to provide me with the following information: why the catheter is indicated, any pertinent history (ie. prior GU surgery), what catheters and how many attempts were made, and where the hangup seems to be (ie. blockage at the prostate or can't find the meatus or we didn't actually try). Believe it or not, this makes a difference to what equipment I will bring and what I will try when I arrive. If you don't know this basic information, which astonishingly few medicine residents seem to, I'm not coming to do a catheter. The catheter is neither indicated or difficult until you tell me why.

I think urologists can be a little touchy about a catheter placement because the vast majority of the time, the catheter is not actually difficult. A simple bedside procedure that takes <3 minutes for you to try, robs me of 2 hours of sleep by the time I drive in, get the info, place the catheter, write a consult, and drive home. A hard pill to swallow when the catheter flies in and I'm looking forward to another bleary-eyed day in the clinic and OR tomorrow.

But let's be honest. And I'm in your camp on this one about giving a good reason for a consult. But I've never seen a urologist in the hospital at night. Not the ED. Not the OR. I know things come up (sometimes literally) but lets not act like you are some poor overworked soul- bleary eyed from working too much. And this is coming from someone who stays home at night as much as possible. But I wouldn't try and tell folks otherwise.

 

[cpants]

But let's be honest. And I'm in your camp on this one about giving a good reason for a consult. But I've never seen a urologist in the hospital at night. Not the ED. Not the OR. I know things come up (sometimes literally) but lets not act like you are some poor overworked soul- bleary eyed from working too much. And this is coming from someone who stays home at night as much as possible. But I wouldn't try and tell folks otherwise.

Guess you are at a quiet hospital or not looking hard enough. There are a bunch of urologic emergencies and patients who need admission, plus we usually have a relatively big inpatient census. As a resident, I am in the hospital almost every call night (q2-4) at our busiest hospital. Our attendings have to come in about a third of that to operate. Not to mention that even when I am not coming in I am fielding calls from ER and floor nurses all night, none of which even gets recorded as duty hours. Home call sucks. I miss my post call days a lot.

 

[dpmd]

But let's be honest. And I'm in your camp on this one about giving a good reason for a consult. But I've never seen a urologist in the hospital at night. Not the ED. Not the OR. I know things come up (sometimes literally) but lets not act like you are some poor overworked soul- bleary eyed from working too much. And this is coming from someone who stays home at night as much as possible. But I wouldn't try and tell folks otherwise.

If they aren't used to coming in at night, it just makes it that much worse for them the next day, especially if they take a lot of call because it is expected to be minimal overnight activity. Saving them the wake up if you can is nice. But if you really aren't comfortable with it it is doubtful you will be successful, so I guess bostonredsox isn't necessarily bad for calling. At least he makes them call a different nurse. Sometimes that is all you need to overcome laziness issues.

The PIV thing is interesting. I wonder how many people would try for a peripheral after a good nurse has tried (you made them get the NICU nurse or something so it isn't just a laziness thing)? I've done it before, but I trained as a medic then nurse in the Army so I have some tricks up my sleeve.

 

[BlondeDocteur]

As the intern on Urology, learning to place a difficult Foley was a) extremely, extremely useful and b) not that hard. Obviously I never did anything uroscopically but the hospital had a 'difficult foley' cart with lido-jet, coudes, smaller sizes and glidewires, and >90% of the time where the standard 18F foley could not be placed (by a diligent, earnest nurse), I could get it in. I really thought it was so phenomenally useful a skill that I couldn't believe it wasn't routinely taught.

Also, urology residents generally cover multiple hospitals. Although urology inpatients aren't that sick [I took home call for the service and never came in once], there are a high number of ER consults between the University, county, VA and pediatric hospitals; high sphincter tone in general at the children's hospital necessitating in-person parental soothing, and at Harborview enough Fournier's cases + IP bladder ruptures that a middle-of-the-night case wasn't uncommon. I thought they were pretty hard-working folks.

 

[dpmd]

As the intern on Urology, learning to place a difficult Foley was a) extremely, extremely useful and b) not that hard. Obviously I never did anything uroscopically but the hospital had a 'difficult foley' cart with lido-jet, coudes, smaller sizes and glidewires, and >90% of the time where the standard 10F foley could not be placed (by a diligent, earnest nurse), I could get it in. I really thought it was so phenomenally useful a skill that I couldn't believe it wasn't routinely taught.

Also, urology residents generally cover multiple hospitals. Although urology inpatients aren't that sick [I took home call for the service and never came in once], there are a high number of ER consults between the University, county, VA and pediatric hospitals; high sphincter tone in general at the children's hospital necessitating in-person parental soothing, and at Harborview enough Fournier's cases + IP bladder ruptures that a middle-of-the-night case wasn't uncommon. I thought they were pretty hard-working folks.

I agree it isn't hard to get a difficult foley in, but I remember the first time I did it that someone helped me (it was one of my fellow gsurg residents, but the important thing was that there was someone to tell me if I was pushing too hard or not hard enough, etc). Without that, I can see someone not being very successful.

The bolded part reminds me of one time when my husband was sleeping next to me while I was on call for peds. He overheard a conversation between the nurse and me just under an hour from when we typically round (I get ready fast so wasn't going to wake up for a little bit). She was calling because there was a call MD if less than some number per hour of urine and the last hour the kiddo only had some number minus 0.5). I told her fine, just keep track for the next hour and we will be rounding by then. He then shouted "see if you can squeeze a few more drops out of the kid", but thankfully she had hung up before that. He had a point though considering the rest of the night the kid's UOP had been fine (and was fine afterward without any action on my part) Funny how some people are such sticklers. Honestly if I had been that nurse I would have tried to get some extra out to avoid a call.