Consults- Memorable/Dismal/Ridiculous/Unique

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Well, when the primary draw of your specialty is "shift work" and being "off when you're off", are you that surprised?
No I wasn't surprised about that (I was surprised when his PD basically told him to suck it up especially since he was the one who wanted to do a Trauma rotation).

I was surprised about the inability to follow instructions and just walk out of the SICU seemingly with nary a care in the world.

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It does boggle the mind doesn't it?

We frequently had issues with the off service rotators on trauma. It was never the surgical subspecialties but almost invariably the EM guys. IIRC this particular intern also complained about the work hours and overnight call. We didn't have an emergency medicine residency program based at our hospital at that time. He came to us from a smaller community program that had relatively little trauma and perhaps he wasn't used to having a (female) surgical resident telling him what to do.

I always liked holding pressure on those balloon pump removals as an intern. It was the only time I got relieved of my pager for an entire hour!

well maybe i'm doing it wrong but my hands started to hurt after 15 minutes
mine were getting all numb
 
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well maybe i'm doing it wrong but my hands started to hurt after 15 minutes
mine were getting all numb
There are ways to position your hand that are worse than others but i don't know that it will ever feel good. I think ws's pager was just more painful.
 
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What I've learned from pulling countless IABP/arterial lines in coagulopathic patients (my record was two hours of pressure, while checking every 30 minutes or so, for a balloon pump) is to get the room setup. I turn on the TV and change the channel to a good movie. Or I bring a journal article or notes to study. Then you have something to do while you're holding pressure.

And yes, your fingers are supposed to go numb (after the initial period when they just hurt). And don't bend your wrist back or just rely on finger strength or those muscles will shake and be useless for a while afterwards...
 
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Covering the vascular service this weekend, got consulted by the transplant fellow in the evening.

Fellow: "Hi, can you do me a favor? We have a patient and we think he has a DVT in his arm."
Me: "Okay, what did the ultrasound say?"
Fellow: "Ultrasound team isn't here. We need you to evaluate the patient."
Me: "...For what?"
Fellow: "For a DVT. His arm is swollen and he is in a lot of pain."
Me: "Why don't you start him on a heparin drip if you think he has a DVT?"
Fellow: "My attending told me we should consult you."
Me: "........"
Fellow: "This is a very complicated patient and my attending asked me to call."
Me: "So you want the vascular surgery team, who has never seen this patient before, to start a heparin drip on your very complicated post-transplant patient who you have been managing for weeks?"

Unless they want us to take off the arm, why consult vascular surgery on a DVT? Also, I called back a few minutes later and the fellow had already gone home for the day. And when I saw the patient, his arms were exactly the same size, he had mild forearm tenderness, and told me he'd had an IV in there earlier that day that his nurse had removed because it was infiltrated. I can't even.
 
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on emergency surgery, was consulted by medicine for a post-ERCP cholecystectomy eval on a 96 y/o patient w/o any symptoms... who didn't want surgery.
 
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Please forgive me for the times my attending makes me call a BS consult from the ED. I promise that by the time it gets to that point, I've already put up a fight and lost.
 
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Yep...if you just started out with, "I think this is BS but my attending is insisting", it would be a whole lot easier for everyone.

Unfortunately a lot of the time my attending is sitting right next to me....
 
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Yeah most of us have been there, either on the receiving end of a ridiculous attending requested consult or being the one calling the consult in.

Thus I expect anyone with experience would be able to interpret the underlying meaning.

I did that once. "I have a consult my attending wants you to come see....." My attending heard me and was not pleased, lol.

Now that I am a senior resident I am a little more vocal about my displeasure on bogus consults and am more likely to win that battle. I also have a lot less GAF when it comes to making people mad.
 
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As I posted before (in my Gen Surg residency days), there are three main reasons people call a consult:

(1) You're consulting a service for a particular task that no one else can do - e.g. calling Renal for dialysis, or ID for Zyvox approval, etc.
(2) You have a specific clinical question - e.g. asking ID what duration of IV ABX the non-op patient with recurrent endocarditis needs
(3) You have no idea what's going on and just want someone else to help and take care of the problem

Unfortunately, in Gen Surg, so many of the consults from Medicine/ER fall into the 3rd category. "Uh, yeah, we have this guy here with belly pain and the CT scan is equivocal...so can you come lay hands on him?" Or "our sick MICU patient has a lactate of 2 and his belly is a little distended but we can't tell if he has abdominal pain since he's intubated and sedated so can you come rule out mesenteric ischemia?" That's what is so infuriating.
 
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As I posted before (in my Gen Surg residency days), there are three main reasons people call a consult:

(1) You're consulting a service for a particular task that no one else can do - e.g. calling Renal for dialysis, or ID for Zyvox approval, etc.
(2) You have a specific clinical question - e.g. asking ID what duration of IV ABX the non-op patient with recurrent endocarditis needs
(3) You have no idea what's going on and just want someone else to help and take care of the problem

Unfortunately, in Gen Surg, so many of the consults from Medicine/ER fall into the 3rd category. "Uh, yeah, we have this guy here with belly pain and the CT scan is equivocal...so can you come lay hands on him?" Or "our sick MICU patient has a lactate of 2 and his belly is a little distended but we can't tell if he has abdominal pain since he's intubated and sedated so can you come rule out mesenteric ischemia?" That's what is so infuriating.

That's a pretty fair argument. My attendings whom I respect the most say the only reason to call a consult is #1. They have something you need, be it a scalpel, a dialysis machine, a fiberoptic scope or a bed upstairs. #2 is more of a curbside. If I ever do number 2, I never include that I discussed with another doc in the chart - I think it's bad juju to bring someone else's name in a chart when they don't realize it.

How do ya'll feel about this: In a lot of post-surgical patients who come into the ED for non-surgical issues - (e.g. has some pain not controlled by PO pain meds, give some morphine, pain under control, send them to the house; or had some nausea, zofran/phenergan, tolerating PO --> home) some attendings have us call surgery to let them know their post-op patient came in. I've been told in surgical patients immediately post-op it's good form to let the surgeon know they're back regardless of whether or not you need their input or them to physically see the patient, especially in the community. What do ya'll think?
 
That's a pretty fair argument. My attendings whom I respect the most say the only reason to call a consult is #1. They have something you need, be it a scalpel, a dialysis machine, a fiberoptic scope or a bed upstairs. #2 is more of a curbside. If I ever do number 2, I never include that I discussed with another doc in the chart - I think it's bad juju to bring someone else's name in a chart when they don't realize it.

How do ya'll feel about this: In a lot of post-surgical patients who come into the ED for non-surgical issues - (e.g. has some pain not controlled by PO pain meds, give some morphine, pain under control, send them to the house; or had some nausea, zofran/phenergan, tolerating PO --> home) some attendings have us call surgery to let them know their post-op patient came in. I've been told in surgical patients immediately post-op it's good form to let the surgeon know they're back regardless of whether or not you need their input or them to physically see the patient, especially in the community. What do ya'll think?
Yes I want to know if my post op patient is in your ED, regardless of the reason.
 
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That's a pretty fair argument. My attendings whom I respect the most say the only reason to call a consult is #1. They have something you need, be it a scalpel, a dialysis machine, a fiberoptic scope or a bed upstairs. #2 is more of a curbside. If I ever do number 2, I never include that I discussed with another doc in the chart - I think it's bad juju to bring someone else's name in a chart when they don't realize it.

How do ya'll feel about this: In a lot of post-surgical patients who come into the ED for non-surgical issues - (e.g. has some pain not controlled by PO pain meds, give some morphine, pain under control, send them to the house; or had some nausea, zofran/phenergan, tolerating PO --> home) some attendings have us call surgery to let them know their post-op patient came in. I've been told in surgical patients immediately post-op it's good form to let the surgeon know they're back regardless of whether or not you need their input or them to physically see the patient, especially in the community. What do ya'll think?
If they are fresh enough post op that I haven't seen them yet it would be nice to hear they came in before they are actually in for their follow up. I especially hate hearing that they got put on antibiotics for a wound infection and the wound looks fine so now I have no idea if the ER guy was crazy or if there was really something going on. Then again I like my sleep so a 2 am call to tell me that my patient didn't fill her pain meds so came in for pain and is now going home with instructions to fill her stupid rx isn't awesome. I have given my cell number to most of the ER guys so sometimes they just text me a heads up. Also, things are different if they just had a mastectomy for cancer versus a removal of a tiny skin lesion with local anesthetic.
 
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If they are fresh enough post op that I haven't seen them yet it would be nice to hear they came in before they are actually in for their follow up. I especially hate hearing that they got put on antibiotics for a wound infection and the wound looks fine so now I have no idea if the ER guy was crazy or if there was really something going on. Then again I like my sleep so a 2 am call to tell me that my patient didn't fill her pain meds so came in for pain and is now going home with instructions to fill her stupid rx isn't awesome. I have given my cell number to most of the ER guys so sometimes they just text me a heads up. Also, things are different if they just had a mastectomy for cancer versus a removal of a tiny skin lesion with local anesthetic.

The two aren't mutually exclusive.
 
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It depends on why they are in the ER as to whether I want a call. Anything even remotely surgery-related, absolutely, I want to know, or major events like a post op stroke/MI/PE (all of which the ER and hospitalist have failed to call me about in the past; it would be nice to know the patient is going to be anticoagulated).

But if a patient s/p breast biopsy comes in for a sprained ankle, or for stitches if they cut themselves while making dinner, I may be a little annoyed about getting a phone call. I take a lot of ER call and sometimes I can't fall back asleep after getting paged, and that's when I'm actually on call; if not on call and my pager goes off at 3 am, I'm assuming the SHTF and I'm instantly at defcon 5 from adrenaline. Forward me the note in the EMR, I will read it. Or call me at the end of the overnight shift.
 
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As I posted before (in my Gen Surg residency days), there are three main reasons people call a consult:

(1) You're consulting a service for a particular task that no one else can do - e.g. calling Renal for dialysis, or ID for Zyvox approval, etc.
(2) You have a specific clinical question - e.g. asking ID what duration of IV ABX the non-op patient with recurrent endocarditis needs
(3) You have no idea what's going on and just want someone else to help and take care of the problem

Unfortunately, in Gen Surg, so many of the consults from Medicine/ER fall into the 3rd category. "Uh, yeah, we have this guy here with belly pain and the CT scan is equivocal...so can you come lay hands on him?" Or "our sick MICU patient has a lactate of 2 and his belly is a little distended but we can't tell if he has abdominal pain since he's intubated and sedated so can you come rule out mesenteric ischemia?" That's what is so infuriating.

I'd say that these are the 3 LEGIT reasons to call a consult. I dont think its terrible if the consult is in category 3, especially as a general surgeon...thats kind of our role.

But I do think that there is a 4th and a 5th reason, which are the illegitimate reasons to call a consult, and those are the ones that piss me off.

4) I'm not in house or I've got better things to do so even though I know what to do, I want you to come in and do it for me
5) I know what the right thing to do is and I know you won't actually do anything, but I'm covering my ass/passing the buck because I dont want to be the one who makes the decision (i.e. sending a chronic pain pt home from ED)

Those are the ones that, as you progress through training, you start to notice more and more often and are frequently pissed off by.
 
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I would much rather get the I need help because i don't understand this call than the something horrible has been going on for days and i am just calling about it now (at night usually) so now the patient has a worse prognosis and your life is made harder.
 
New low: Ob/gyn calling an ENT consult for DOBHOFF PLACEMENT in a healthy 25-year-old with hyperemesis gravidarum.

Okay, fine, 5 minutes of my time, attending collects a check, whatever. I tell the nurse to page ob/gyn house officer when confirmatory cxr comes back prior to starting tube feeds.

Two hours later, I get a page to check the chest x-ray because, quote, "the ob-gyn resident told me they didn't know what the read means".

Read: "Dobhoff tube projecting in the area of the gastric body."

Any particular part of this consult is absolutely ridiculous. But put it all together and it's just overwhelming.
 
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I mean aside from the ears it's all right there in the name. I can't wait to tell the nurse to call the ent resident next time. This should become a thing.
 
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I mean aside from the ears it's all right there in the name. I can't wait to tell the nurse to call the ent resident next time. This should become a thing.
Seriously.

Just think of all those late nights at the VA I could have saved having ENT place those.

What can we push off onto OB-Gyn?
 
ENT for a Dobhoff? Is that institutional practice or just stupid because someone figured, "tube, nose; nose, ENT"?

We are apparently experts at shoving stuff in peoples' noses. That was the line of thought of the on-call OB resident.
 
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I got called a few times a year as a resident before or usually after the general surgery resident tortured a pt with a severely deviated septum... Even had a GS attending call me and tell me he had never not be able to place one till now.. Our knowledge of nasal anatomy helps sometimes. Funny stuff happens during training
 
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New low: Ob/gyn calling an ENT consult for DOBHOFF PLACEMENT in a healthy 25-year-old with hyperemesis gravidarum.

Okay, fine, 5 minutes of my time, attending collects a check, whatever. I tell the nurse to page ob/gyn house officer when confirmatory cxr comes back prior to starting tube feeds.

Two hours later, I get a page to check the chest x-ray because, quote, "the ob-gyn resident told me they didn't know what the read means".

Read: "Dobhoff tube projecting in the area of the gastric body."

Any particular part of this consult is absolutely ridiculous. But put it all together and it's just overwhelming.

:grumpy: to think of all the lovely people who didn't match into ob this year
 
Why would a feeding tube help anyway (won't they just puke up the tube feeds) and why is a doctor needed for it anyway (let alone a surgeon)

This. If anything severe hyperemesis needs TPN... patients are physically capable of eating, they just puke. Also any OB who can't put in a Dobhoff or an NG tube had an inadequate oncology experience.

What can we push off onto OB-Gyn?

You could be about to take a patient to the OR for necrotizing fasciitis and call me for fetal monitoring of her 8 week embryo, and then ask me to take her on my antepartum service post-op...
 
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I got called a few times a year as a resident before or usually after the general surgery resident tortured a pt with a severely deviated septum... Even had a GS attending call me and tell me he had never not be able to place one till now.. Our knowledge of nasal anatomy helps sometimes. Funny stuff happens during training

At my institution this pt gets it done under fluoro by IR
 
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Well someone should let the general guys know at my training program...
 
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I know yer joking but there is zero chance that amount of fluoro is harmful even if the patient was getting weekly ngts for life.
 
Seriously.

Just think of all those late nights at the VA I could have saved having ENT place those.

I still have to occasionally place NG tubes.

Or manipulate them after they get dislodged in post-esophagectomy patients.

Or bridle them because the patient keeps pulling them out.

Or deal with NGT-related trauma (esophageal perforation, tracheal injury, bronchopleural fistula).
 
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Got another great one the other day - elderly lady in the ICU, trached and ventilated, fungemic, on dialysis, on and off pressors, recent STEMI, heart transplant recipient. The consult? A breast "mass" which was first documented 2 years ago and has not changed since.

..................
 
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Got another great one the other day - elderly lady in the ICU, trached and ventilated, fungemic, on dialysis, on and off pressors, recent STEMI, heart transplant recipient. The consult? A breast "mass" which was first documented 2 years ago and has not changed since.

..................

Did you ask them to pass the probe over it next time she gets an echo?
 
Seriously.

Just think of all those late nights at the VA I could have saved having ENT place those.

What can we push off onto OB-Gyn?
Evaluation for acute exacerbation of periodic vaginal bleeding in a post-op patient? Bonus points if the cramping is bad enough you can turf to them for further work-up of their lower abdominal pain since you've already fixed their surgical problem.
 
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Got another great one the other day - elderly lady in the ICU, trached and ventilated, fungemic, on dialysis, on and off pressors, recent STEMI, heart transplant recipient. The consult? A breast "mass" which was first documented 2 years ago and has not changed since.

..................

So when did you schedule that sweet case?
 
Got another great one the other day - elderly lady in the ICU, trached and ventilated, fungemic, on dialysis, on and off pressors, recent STEMI, heart transplant recipient. The consult? A breast "mass" which was first documented 2 years ago and has not changed since.

..................
I actually get very similar consults from time to time. It appears that some ICUs have a policy that states that all problems documented on the medical record must be addressed during the stay or prior to transfer to another level of care.

Thus the ridiculous consults I get in ICU patients for chronic breast masses, pain or my recent favorite one, swelling in a patient with anasarca.
 
It depends on why they are in the ER as to whether I want a call. Anything even remotely surgery-related, absolutely, I want to know, or major events like a post op stroke/MI/PE (all of which the ER and hospitalist have failed to call me about in the past; it would be nice to know the patient is going to be anticoagulated).

But if a patient s/p breast biopsy comes in for a sprained ankle, or for stitches if they cut themselves while making dinner, I may be a little annoyed about getting a phone call. I take a lot of ER call and sometimes I can't fall back asleep after getting paged, and that's when I'm actually on call; if not on call and my pager goes off at 3 am, I'm assuming the SHTF and I'm instantly at defcon 5 from adrenaline. Forward me the note in the EMR, I will read it. Or call me at the end of the overnight shift.

DEFCON 1 is actually the most alert state. I have messed this up so many times as well.
 
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