Consults- Memorable/Dismal/Ridiculous/Unique

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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?


Agree totally about being called for all postop patients regardless of issue. First off, many non surgical physicians have no idea what may or may not be related to the operation. Second, if indeed it's nothing, it is a quick conversation and everyone can move on. I HATE it when a postop rectal cancer gets admitted to medicine for acute renal failure for high ileostomy output (rare but happens). And I hear "oh, I didn't think you would be interested." Really? You mess with my rectal cancer patients- we're gonna have problems!

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I'm a big believer in getting in touch with the surgeon on recent post-surgical patients. With length of stay pressures on the inpatient side, it's not uncommon to see post-op complications we didn't used to have to deal with because they used to occur when the patient was still in house. The one thing that I hate about trying to get in touch with the surgeon is when it was done at a private surgery center or another hospital system and the surgeon refuses to answer pages because they "don't cover that emergency department". Calling my surgeon on call to deal with the complication of another surgeon because they won't call back gives the same "dead inside" feeling that attending mandated BS consults in residency did.
 
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I'm a big believer in getting in touch with the surgeon on recent post-surgical patients. With length of stay pressures on the inpatient side, it's not uncommon to see post-op complications we didn't used to have to deal with because they used to occur when the patient was still in house. The one thing that I hate about trying to get in touch with the surgeon is when it was done at a private surgery center or another hospital system and the surgeon refuses to answer pages because they "don't cover that emergency department". Calling my surgeon on call to deal with the complication of another surgeon because they won't call back gives the same "dead inside" feeling that attending mandated BS consults in residency did.
Yes. Somehow my exchange doesn't page the actual surgeons involved and just automatically calls the on call. I get that at 2 in the morning b8t in the middle of the day at least try them first. Drives me nuts because I have repeatedly told them i want to get called about any of my patients unless i specify that i am unreachable (like when i go on a cruise). I think the other guys don't want the calls though so the exchange just goes with what they are used to.
 
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Maybe I've been lucky, but I've never encountered a surgeon who was unhappy to hear from me in situations like this. I've had several times where a patient who had surgery elsewhere shows up in our ER and the ED residents want to admit them to us...I call the surgeon and they are usually happy to take them back.
I just mostly mind getting the call when it is the same hospital the other guy works at when if they just called them directly it would save me a phone call. Also 9 times out of 10 if there is a patient that actually gets admitted and i take the call and ask the guy if they want to see it or should i they ask me to see it. So them getting called directly would eliminate that effect of me being too nice.
 
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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.

In regards to number 2, I think it depends on how it's handled. "Hey, I've got a guy upstairs who _____. Any ideas?," then yes... no name.

On the other hand, "I've got a consult for you... oh, it's ok to wait and follow up outpatient in a week? No worries..." should get a "discussed case with ____, outpatient follow up."
 
Bump.

Pager: "Notification of new consult and patient expiration, John Doe SICU-7"
 
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I once had a MICU consult for no urine from the foley. Turns out patient had bilateral nephrectomies and was on dialysis. I asked the MICU resident why he placed the foley and he said to see the adequacy of resuscitation.

Same resident, different day, different patient...our team had rounded on a consult and we clearly told him to start some sort of diuretic of the patient as she was volume overloaded and had good kidney function. Lo and behold I get a consult in the night for quinton catheter placement for urgent dialysis on the same patient. I was so confused and asked him what is going on, he replied that surgery had asked to get the patient dialysed.
Yes, you guessed it, poor kid thought we said dialysis when in fact we told him to use diuretics.
 
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Bump.

Pager: "Notification of new consult and patient expiration, John Doe SICU-7"
LOL...have I told the story of the MICU consult I got as a junior on Colorectal?

I arrived to find the patient dead.

"Thank you for this most interesting consultation. Patient does not require surgical intervention at this time."
 
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LOL...have I told the story of the MICU consult I got as a junior on Colorectal?

I arrived to find the patient dead.

"Thank you for this most interesting consultation. Patient does not require surgical intervention at this time."

Was the patient at least alive when they placed the consult?
 
Luckily nowadays most of the premortem consults i get come with a disclaimer that they realize the pt is circling the drain and therefore probably shouldn't have surgery but they (or sometimes the family) just want to make sure. On occasion they die before i get a chance to see them but more often they are still circling when i get there and i help the family realize that surgery will only hurt them.
 
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My favorite ones so far:

On ENT rotation: Floor consult, patient complaining of ear pain, no one has otoscope on the floor to look inside his ear. Could ENT come see the patient?

On IM rotation: Please admit 30-year-old patient for 10/10 chest pain relieved by Xanax, first trop normal, EKG normal, would like to admit patient for cardiac rule out.

On Ortho rotation: "We've got this patient in resus 5 with his tibia sticking out, it's totally fractured." "Do you have x-rays?" "No, but there is obvious gross deformity and it's bloody." XR's negative, patient diagnosed with road rash, no other injuries.
 
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My favorite ones so far:

On ENT rotation: Floor consult, patient complaining of ear pain, no one has otoscope on the floor to look inside his ear. Could ENT come see the patient?

On IM rotation: Please admit 30-year-old patient for 10/10 chest pain relieved by Xanax, first trop normal, EKG normal, would like to admit patient for cardiac rule out.

On Ortho rotation: "We've got this patient in resus 5 with his tibia sticking out, it's totally fractured." "Do you have x-rays?" "No, but there is obvious gross deformity and it's bloody." XR's negative, patient diagnosed with road rash, no other injuries.

What kind of med student doesn't have an otoscope? Are they trying to avoid honors?
 
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LOL...have I told the story of the MICU consult I got as a junior on Colorectal?

I arrived to find the patient dead.

"Thank you for this most interesting consultation. Patient does not require surgical intervention at this time."

One of my favorites on thoracic: "MICU Bed 15: Patient just died, please come remove trach sutures."

Even better, when I called it back and asked why on earth this was a consult the answer from the otherwise very sweet NP was: "Well, I wasn't sure what else to do with them so I thought I would ask you to take them out."
 
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Can I complain about IR for a second? Nothing like getting a "consult" for a bleeding TDC that was placed by IR in the afternoon. I don't blame the FM resident, since I know that isn't something they're used to handling. But it irks the hell out of me that the response of the IR fellow to the FM resident's call is "Give some FFP and hold pressure...I'll be in at 6am."

I'm sorry that happened, but that is poor form by that IR fellow. If that happened to me, I would come in and take care of it rather than let an FM resident try to manage that problem. I hate when we have postprocedure bleeding issues from arterial/venous access or TDC's, but I make sure to see the patient and take care of it.
 
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One of my favorites on thoracic: "MICU Bed 15: Patient just died, please come remove trach sutures."

Even better, when I called it back and asked why on earth this was a consult the answer from the otherwise very sweet NP was: "Well, I wasn't sure what else to do with them so I thought I would ask you to take them out."

I've had this many times on patients with ventriculostomy drains. "Patient just died, can you take the drain out?" Not sure what they're worried about, it's not like they're going to make him more dead.
 
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I've had this many times on patients with ventriculostomy drains. "Patient just died, can you take the drain out?" Not sure what they're worried about, it's not like they're going to make him more dead.

Also I thought that when patients died in the hospital especially if an autopsy is planned, you left all drains and tubes in situ.


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Though why the nurses wouldn't just take care of it rather than bother a consultant is another issue. It isn't like they can do it wrong.

It's out of their scope of practice. They have a license to protect you know
 
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Though why the nurses wouldn't just take care of it rather than bother a consultant is another issue. It isn't like they can do it wrong.
I just pictured a scene with some horrified nurse holding a ventricular drain with half of the brain still dangling from it.
 
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I just pictured a scene with some horrified nurse holding a ventricular drain with half of the brain still dangling from it.
This reminds me of a story that the head and neck surgeon ia friends with told about resident who worked with him in some big case with a vascular anastomosis who had to leave before the end. He knew that was who would eventually pull the drain so he sutured an extra bit of vessel to the drain so the resident would think he pulled out the anastomosis or something when he pulled the drain. Seems really hilarious but really mean
 
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Bump.

Pager: "Notification of new consult and patient expiration, John Doe SICU-7"

I've been somewhat guilty of this once. Had an infant in the NICU we needed a NAT r/o on, so put in an ophtho consult around 8 am while the patient was looking reasonable from a cardiopulm standpoint (but abysmal prognosis neurologically), told ophtho anytime that afternoon should be fine. Had to call back early afternoon before the consultant had made it in. "Hey, so you remember that kid? Can that exam be done postmortem? pH 6.8, prob going toward CPR soon". Kid crumped quick, to be fair
 
I've been somewhat guilty of this once. Had an infant in the NICU we needed a NAT r/o on, so put in an ophtho consult around 8 am while the patient was looking reasonable from a cardiopulm standpoint (but abysmal prognosis neurologically), told ophtho anytime that afternoon should be fine. Had to call back early afternoon before the consultant had made it in. "Hey, so you remember that kid? Can that exam be done postmortem? pH 6.8, prob going toward CPR soon". Kid crumped quick, to be fair
At least you let them know why you would still be interested in their opinion postmortem
 
Also I thought that when patients died in the hospital especially if an autopsy is planned, you left all drains and tubes in situ.


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At my hospital if an autopsy is planned or required by law then yes everything is left in. If autopsy is not required my service typically pulls EVDs, bolts, or whatever.


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Though why the nurses wouldn't just take care of it rather than bother a consultant is another issue. It isn't like they can do it wrong.

I always take intracranial objects out myself and place a stitch. I'm always paranoid that brain will herniate out and family will see it. I doubt a nurse would even stitch it if I told them to take it out.


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This reminds me of a story that the head and neck surgeon ia friends with told about resident who worked with him in some big case with a vascular anastomosis who had to leave before the end. He knew that was who would eventually pull the drain so he sutured an extra bit of vessel to the drain so the resident would think he pulled out the anastomosis or something when he pulled the drain. Seems really hilarious but really mean
Thats awesome, and makes me want to try it. But....its gotta be apocryphal right? Not to be a killjoy, and as funny as that is, you are basically risking your entire career to play a practical joke. If that resident doesnt think its funny and reports you, how are you going to defend yourself? Or if the patient notices and asks questions.
 
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Thats awesome, and makes me want to try it. But....its gotta be apocryphal right? Not to be a killjoy, and as funny as that is, you are basically risking your entire career to play a practical joke. If that resident doesnt think its funny and reports you, how are you going to defend yourself? Or if the patient notices and asks questions.
This was the same guy that told me about doing succinylcholine races during training (basically just as it sounds, they would dose themselves with succ and run as far as they could before becoming paralyzed and the others would bag them till they could breathe again). He also had a policy that if you cut the same structure 3 times while operating with him that structure would then get named after you (when I got the anterior jugular vein of dpmd he consoled me by telling me about a fellow who got the facial nerve named for him). I suppose he could be lying, but it wasn't a "I heard that this was done" sort of thing, there were details and sheepish grins. Based on how he used to joke around with us and the OR staff (at times in ways that could lead to harassment complaints for the less humor inclined) I think he was just good at developing the kind of rapport that would let him get away with scaring the crap out of the resident.
 
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This was the same guy that told me about doing succinylcholine races during training (basically just as it sounds, they would dose themselves with succ and run as far as they could before becoming paralyzed and the others would bag them till they could breathe again).
dude. wtf?

literally.

wtf?
 
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I have been consulted three separate times on different patients all with conversion disorder for "Acute whole leg weakness" known for 5+ years followed by neuropsych at our same institution who clearly have notes in EPIC. All three had normal CTs/MRI of pan-spine/brain. The ED in all three cases said neurosurgery needed to come by "just to be sure there wasn't something else going on". Those were all painful conversations.

Other memorable consults are ones asking for intracranial pressure monitoring in people who are clinically brain dead.
 
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dude. wtf?

literally.

wtf?
Talk about trusting your colleagues. If they don't like you they could just let you die I guess. He had lots of interesting stories from his training days. Sounded like craziness. He told us about the VA making every surgeon that wanted to book an elective case do a hernia case first because they had a big backlog of patients needing hernia repairs. He said felt ok because they do some general surgery rotations, but he felt bad for the patients getting their repairs from the ophthalmologists.
 
This was the same guy that told me about doing succinylcholine races during training (basically just as it sounds, they would dose themselves with succ and run as far as they could before becoming paralyzed and the others would bag them till they could breathe again). He also had a policy that if you cut the same structure 3 times while operating with him that structure would then get named after you (when I got the anterior jugular vein of dpmd he consoled me by telling me about a fellow who got the facial nerve named for him). I suppose he could be lying, but it wasn't a "I heard that this was done" sort of thing, there were details and sheepish grins. Based on how he used to joke around with us and the OR staff (at times in ways that could lead to harassment complaints for the less humor inclined) I think he was just good at developing the kind of rapport that would let him get away with scaring the crap out of the resident.

This guy is a freaking legend
 
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I have been consulted three separate times on different patients all with conversion disorder for "Acute whole leg weakness" known for 5+ years followed by neuropsych at our same institution who clearly have notes in EPIC. All three had normal CTs/MRI of pan-spine/brain. The ED in all three cases said neurosurgery needed to come by "just to be sure there wasn't something else going on". Those were all painful conversations.

Other memorable consults are ones asking for intracranial pressure monitoring in people who are clinically brain dead.

To play devil's advocate, a not insignificant number of the "well-documented conversion disorders" end up being organic much later on. That being said, I see no reason to involve a surgeon over a neurologist.
 
See, all his stories sound outrageous but kinds plausible. It is more fun to believe him anyway.
I sat next to a guy on the airplane a few years ago who had THE most outrageous stories, including being on a reality TV show (Shipping Wars, in case you wonder). I thought it was all bull****, until he proved it. All of it.
 
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16 Yo kid who presented with sudden onset severe abdominal pain 8pm. Gets his ct scan at 2am, Rads resident misses half a belly of free air for 4hrs. I go into the belly and find a perforated gastric ulcer! Turns out he has had stomach pain intermittently for 2 years. H pylori positive so I started him on triple therapy. Waiting for gastrin level. Have any of you seen a perforated ulcer in a 16 Yo (my attending was taking bets on source. He was worst in rlq so I bet appy, he voted meckels...)
 
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16 Yo kid who presented with sudden onset severe abdominal pain 8pm. Gets his ct scan at 2am, Rads resident misses half a belly of free air for 4hrs. I go into the belly and find a perforated gastric ulcer! Turns out he has had stomach pain intermittently for 2 years. H pylori positive so I started him on triple therapy. Waiting for gastrin level. Have any of you seen a perforated ulcer in a 16 Yo (my attending was taking bets on source. He was worst in rlq so I bet appy, he voted meckels...)
Noticeable free air from an appy almost never happens. Haven't seen a perfed ulcer in a kid yet, but i have done lap choles for fat kids as young as 5 so I'm not surprised to see kids with adult problems anymore. I probably would have bet on perfed ulcer unless there was a big stool ball in the rectum in which case i would have guessed stercoral ulcer.
 
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ER referral Le Fort 3 fracture without imaging as clinically mobile upper palate.

Went to see the patient, the false teeth was indeed very mobile, but the palate was rock solid.
 
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Consulted by medicine for a guy with a history of permanent end colostomy 30 years prior after a trauma. Now admitted with "increased colostomy output."
Talked to the guy, he said he has episodes of diarrhea maybe once every 10 years and denies any other symptoms.
"No surgical intervention needed at this time. Thank you for this interesting consult. Please call with questions."
 
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I flew home after Christmas, mid-flight consult from flight attendants for asthma attack.

I was nervous the first time I cut on a patient.
I was even more nervous the first time I did my first endovascular case by myself without an attending in the room.
I was terrified the first time I did my first open case without an attending in the room (something about making an incision and only you are responsible).
But, none of that compared to being at 30 thousand feet, hearing, "Is there a doctor on board?" and being the only medical professional...
 
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I had the weirdest case...6 yo girl sent to ER by dentist, who her mom/grandma took her to after she busted a tooth jumping on the bed...dentist was concerned that the child seemed kind of "off." She got a brain MRI (!!), which showed a bullet lodged in her right frontal lobe, followed by maxillofacial CT that showed that it entered through contralateral the "busted tooth." DCS definitely involved on this one...
 
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I had the weirdest case...6 yo girl sent to ER by dentist, who her mom/grandma took her to after she busted a tooth jumping on the bed...dentist was concerned that the child seemed kind of "off." She got a brain MRI (!!), which showed a bullet lodged in her right frontal lobe, followed by maxillofacial CT that showed that it entered through contralateral the "busted tooth." DCS definitely involved on this one...

That is amazing
 
Got a consult on the OB portion of the hospital. Young girl, pretty far along in her pregnancy admitted with pre-eclampsia. The consult was for hypertension. I'm with urology. Called the nurse and asked what the deal was; did the patient have hydro, did she have hematuria, did she have stones? No, we were consulted because the patient had an outpatient appointment with nephrology and "they just wanted to get renal on board" due to her pre-eclampsia. I ended up having to call the faculty ob/gyn who again reiterated that she "wanted renal on board" and I explained yet again that I was with urology and could not help her. She sounded very annoyed like I was trying to get out of work by suggesting she consult nephrology instead of urology.
 
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Received a call one evening from a local stand alone ED. Lady with a "renal hilar mass," abd pain, and gross hematuria. They were transferring to our ED and wanted her evaluated by urology. This sounds potentially interesting. Fast forward a few hours and my ED calls to say she's there and that they evaluated her. I go in and pull up her CT. She does not have a "renal hilar mass." She has a para-aortic mass at the level of the renal hilum. Kidney is completely uninvolved. I take a look at the radiology read which basically confirmed what I was seeing, and went on about how it was encasing other non-GU structures. My guess is they misread the report they received. I'm a little annoyed at this point, but she was reported to have gross hematuria so I went and talked to her.

Me: Do you still have your monthly cycle?

Patient: Yes, I just got it two days ago and I'm bleeding like crazy!

She went through 2 ED attendings and an intern before anyone asked her if she was on her period. One quick straight cath specimen confirmed pseudohematuria.

I had another great one last week. Called by IM with "This guy has an erection and we're not sure for how long. He was prescribed trazadone as a home med, not sure if he takes it, and he has a foley catheter in place." I asked if this elderly gentleman had a penile prosthesis to which they replied absolutely not. I glance at the outpatient EMR and the second note is from a urologist mentioning his prosthesis (which is working fine). I go see the patient and ask him if he has a prosthesis- "Yep, had it since 200x." He wasn't even close to fully inflated.
 
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I posted this before elsewhere...

reason for consult to general surgery: "groin pain"

Me: "well what do you mean? Does he have a hernia? Some kind of a mass? Are you worried about an infection?"

Consulting physician: "I don't know. He wouldn't let me examine it because of the pain"

Me: "well did you look? Is there cellulitis or anything? Have you gotten any imaging"

Consulting physician: "I don't know. My attending wants you to see him"
They didn't at least CT him first?
 
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I had a couple good consults from an VA ER doc back in residency.

The first was a guy that was admitted to a medicine service with abdominal pain and pancreatitis. He left AMA and went home and drank and returned with more abdominal pain. She wanted a surgery consult. I suggest that perhaps this was exacerbation of his pancreatitis and to call the medicine team he was previously admitted to.

The second was a guy that had abdominal pain and we were asked to see to rule out appendicitis. I got there, went in the room, and asked the patient what brought him in. His words? "I think I've got a hernia." So I look at his belly and there's a scar in the RLQ. I ask him what it was from and he said he had his appendix removed in the past.

I was actually surprised, but she ended up getting fired a couple of years later. I didn't think it would have ever happened being VA employed.
 
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