Consults- Memorable/Dismal/Ridiculous/Unique

[mimelim]

A consult I have appallingly seen multiple times: Old man sitting at home abruptly stops moving a single leg. Cannot feel nor move the entire leg. The leg is painful. STAT consult to neurosurgery for cauda equina. No imaging done, or maybe a CT or xray of lower back is done but negative, but I must evaluate patient IMMEDIATELY. I always ask "how are the pulses in the limb"? Always the same response "pulses palpable. Why do you ask?" Go see the patient. Leg is pale. Shiny. No pulses in the leg in question, including a femoral while the contralateral side has bounding femoral pulses. The leg is cold while the other is not. Patient is a heavy smoker, history of PAD/CAD. I usually call vascular surgery myself and the patient ends up getting rushed to OR/IR for thrombectomy.

Another awesome consult that occurs a couple times a month: patient PEA in field, coded for 45 minutes - 1 hour. Gets ROSC. Admitted to MICU. Head CT done showing global edema, MRI might show massive hypoxic-anoxic brain injury. Generates a STAT consult for bolt or surgical decompression. I go see patient. Patient is always off sedation, appears brain dead. No brainstem reflexes. My response is always the same, I am not a transplant surgeon. I don't do surgery on dead people....

It's been a little while, but a couple months ago I got an ER consult for a brain tumor because it was, "well vascularized". That was a new one...

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[LucidSplash]

Had a consult (vascular) a few weeks back for an old lady on warfarin who had fallen a week or so prior and had a huge hematoma under her skin that had caused the skin to necrosis. Definitely needed to be taken for debridement but... had bounding palpable pulses. No vascular structures involved. Told them to call general surgery. ED was adamant that warfarin and hematoma = needs vascular, even though had a CTA showing it was all skin level.

And the worst part is we reinforced bad behavior by the ED and did it because we didn't have that many cases that day and the bosses like to see the case census high.

 

[Apollyon]

I got the email chain as an F/Y/I in August for a patient I saw in March or April. Heavy smoker, vasculopathic, noncompliant. Stated her left foot had been "dead" for 3 days. (This lady is under 50). It's cold and pale. I work out in the boon docks - closest vascular surgeon is 30 miles away (and just a guy that did GS residency - no fellowship), but he is not on call (and I don't trust/like/respect him or his work, either). The mother ship is 100 miles away, and that is our "go to" for transfer. CT-angio shows obstruction (didn't have an US tech that day). I ordered heparin. The vascular surgeon states to send her by ground, and caution her that, although unlikely, it is definitely a consideration for amputation, due to the time frame. I do that. The last I know, she goes.

So, August comes around, and I get the email chain. There was no complaint against me by the pt, and no peer review, but, it seems that, sometime between heparin being started, and arriving at the Uni hospital, she revascularized. Apparently, the vascular surgeon saw the pt, the now not cold foot, and told her, in essence (or maybe literally), "You didn't need to be transferred. I don't know why you are here". I don't know if he discharged her there, or admitted for observation, or what. She is complaining that she should not have been sent (and, in case you didn't know, "If I don't want to pay the bill, I'll complain").

So, our patient relations person has to cover for the vascular surgeon throwing us en masse under the bus. (And, unlike the vast number of posts here, no residents or fellows anywhere in sight.)

 

[VisionaryTics]

Another NG tube consult to ENT. From the SICU service, no less!

The transplant surgeon and surgical intensivist watched me snake a tube down this woman's nose without complication. Bizarre.

 

[dpmd]

Another NG tube consult to ENT. From the SICU service, no less!

The transplant surgeon and surgical intensivist watched me snake a tube down this woman's nose without complication. Bizarre.

Had someone tried and failed or did she have some kind of anatomical weirdness that made them afraid to try?

 

[VincentAdultman]

Another NG tube consult to ENT. From the SICU service, no less!

The transplant surgeon and surgical intensivist watched me snake a tube down this woman's nose without complication. Bizarre.

LOL preeety sure I did those as an ortho intern. After being shown once.

 

[TraumaLlamaMD]

LOL preeety sure I did those as an ortho intern. After being shown once.

If only everyone remembered! I remember being sent to put one in as a sub-I that the senior neurosurgery resident claimed he had attempted. Got it in one try.

 

[VincentAdultman]

If only everyone remembered! I remember being sent to put one in as a sub-I that the senior neurosurgery resident claimed he had attempted. Got it in one try.

I know right.

But I feel like an NGT for a surgical intensivist should be like me sticking a needle into a knee.

 

[balaguru]

I got the email chain as an F/Y/I in August for a patient I saw in March or April. Heavy smoker, vasculopathic, noncompliant. Stated her left foot had been "dead" for 3 days. (This lady is under 50). It's cold and pale. I work out in the boon docks - closest vascular surgeon is 30 miles away (and just a guy that did GS residency - no fellowship), but he is not on call (and I don't trust/like/respect him or his work, either). The mother ship is 100 miles away, and that is our "go to" for transfer. CT-angio shows obstruction (didn't have an US tech that day). I ordered heparin. The vascular surgeon states to send her by ground, and caution her that, although unlikely, it is definitely a consideration for amputation, due to the time frame. I do that. The last I know, she goes.

So, August comes around, and I get the email chain. There was no complaint against me by the pt, and no peer review, but, it seems that, sometime between heparin being started, and arriving at the Uni hospital, she revascularized. Apparently, the vascular surgeon saw the pt, the now not cold foot, and told her, in essence (or maybe literally), "You didn't need to be transferred. I don't know why you are here". I don't know if he discharged her there, or admitted for observation, or what. She is complaining that she should not have been sent (and, in case you didn't know, "If I don't want to pay the bill, I'll complain").

So, our patient relations person has to cover for the vascular surgeon throwing us en masse under the bus. (And, unlike the vast number of posts here, no residents or fellows anywhere in sight.)

The only thing I'd complain about is if you sent the patient without imaging on disc; otherwise, it all sounds like pretty appropriate management. If you did send the disc then I would ask if it was reviewed by the vascular surgeon.

 

[DoctwoB]

The only thing I'd complain about is if you sent the patient without imaging on disc; otherwise, it all sounds like pretty appropriate management. If you did send the disc then I would ask if it was reviewed by the vascular surgeon.

Piece of cake case to defend. Exam and CT Angio showed evidence of critical limb ischemia. Transferred to vascular surgeon. The end. The only area you opened yourself up for liability was by ground transfer. If they lost the leg could have argued that faster transport might have saved it (though likely false).

 

[Apollyon]

Piece of cake case to defend. Exam and CT Angio showed evidence of critical limb ischemia. Transferred to vascular surgeon. The end. The only area you opened yourself up for liability was by ground transfer. If they lost the leg could have argued that faster transport might have saved it (though likely false).

I was thinking that, but I had the vascular surgeon on a taped line stating ground.

And I certainly sent the imaging on disc! A picture is worth a thousand words.

 

[Psai]

I got the email chain as an F/Y/I in August for a patient I saw in March or April. Heavy smoker, vasculopathic, noncompliant. Stated her left foot had been "dead" for 3 days. (This lady is under 50). It's cold and pale. I work out in the boon docks - closest vascular surgeon is 30 miles away (and just a guy that did GS residency - no fellowship), but he is not on call (and I don't trust/like/respect him or his work, either). The mother ship is 100 miles away, and that is our "go to" for transfer. CT-angio shows obstruction (didn't have an US tech that day). I ordered heparin. The vascular surgeon states to send her by ground, and caution her that, although unlikely, it is definitely a consideration for amputation, due to the time frame. I do that. The last I know, she goes.

So, August comes around, and I get the email chain. There was no complaint against me by the pt, and no peer review, but, it seems that, sometime between heparin being started, and arriving at the Uni hospital, she revascularized. Apparently, the vascular surgeon saw the pt, the now not cold foot, and told her, in essence (or maybe literally), "You didn't need to be transferred. I don't know why you are here". I don't know if he discharged her there, or admitted for observation, or what. She is complaining that she should not have been sent (and, in case you didn't know, "If I don't want to pay the bill, I'll complain").

So, our patient relations person has to cover for the vascular surgeon throwing us en masse under the bus. (And, unlike the vast number of posts here, no residents or fellows anywhere in sight.)

"Hey doc, thanks so much for saving my leg!"

just kidding, these entitled patients screw themselves over with their terrible habits and will never thank you for your help

 

[Jolie South]

"Hey doc, thanks so much for saving my leg!"

just kidding, these entitled patients screw themselves over with their terrible habits and will never thank you for your help

Which is why I don’t mind vascular and patients with shtty problems. They are largely self created. Don’t want to comply? Fine, but I will be cutting your leg off sooner or later.

 

[LucidSplash]

Yay Christmas call.

Went to ICU a few hours ago at the request of normally very competent ICU attending. Sick lady post MI, has Impella, pressors, needs HD cath. History of Aortobiiliac graft. Which everyone is terrified of for unclear reasons. Has end-to-end anastomoses with external iliacs, which we have already told them about (and what ch you can see on CT).

ICU attending wanted me to come to confirm that the femoral vein he was seeing on ultrasound was the vein and not the graft before he put HD cath in.

At least I was still in-house and not at home.

 

[armybound]

Medicine is finally on to us and our secret stash of luxury catheters. We got consulted to see if we had any more well tolerated Foley catheters, since the patient's previous Foley was uncomfortable for him.

 

[ThoracicGuy]

Yay Christmas call.

Went to ICU a few hours ago at the request of normally very competent ICU attending. Sick lady post MI, has Impella, pressors, needs HD cath. History of Aortobiiliac graft. Which everyone is terrified of for unclear reasons. Has end-to-end anastomoses with external iliacs, which we have already told them about (and what ch you can see on CT).

ICU attending wanted me to come to confirm that the femoral vein he was seeing on ultrasound was the vein and not the graft before he put HD cath in.

At least I was still in-house and not at home.

View attachment 227032

Why isn't he putting an ij line in for hd?

 

[ThoracicGuy]

Medicine is finally on to us and our secret stash of luxury catheters. We got consulted to see if we had any more well tolerated Foley catheters, since the patient's previous Foley was uncomfortable for him.

 

[dpmd]

Why isn't he putting an ij line in for hd?

In my experience medicine always puts the temp dialysis cath in the groin

 

[Raryn]

In my experience medicine always puts the temp dialysis cath in the groin

Nephrology often prefers it that way to save the upper veins for more permanent access in case something gets screwed up, but with the patient described above (anatomic issues, and likely no need for permanent access given the chance there will be no permanent), even medicine should have just stuck it in the IJ. Mind you, it's been a couple years, but I was putting non-tunneled dialysis lines in the neck as a resident when indicated.

 

[ThoracicGuy]

Nephrology often prefers it that way to save the upper veins for more permanent access in case something gets screwed up, but with the patient described above (anatomic issues, and likely no need for permanent access given the chance there will be no permanent), even medicine should have just stuck it in the IJ. Mind you, it's been a couple years, but I was putting non-tunneled dialysis lines in the neck as a resident when indicated.

Yes, save the subclavian, but I'd use the ij every day and twice on Sunday.

 

[LucidSplash]

Why isn't he putting an ij line in for hd?

Central line in one IJ, occluded contra, Impella in LSCA cutdown, right fem aline after radial crapped out, so left fem only open spot. 3 pressors, etc etc etc.

 

[ThoracicGuy]

Central line in one IJ, occluded contra, Impella in LSCA cutdown, right fem aline after radial crapped out, so left fem only open spot. 3 pressors, etc etc etc.

So when's the impella going to get switched over to ECMO?

 

[dpmd]

So when's the impella going to get switched over to ECMO?

More importantly when are they going to let that poor bastard rest in peace.

 

[ThoracicGuy]

More importantly when are they going to let that poor bastard rest in peace.

Can't die without dialysis and ECMO...

 

[Dr.LeoSpaceman]

Can't die without dialysis and ECMO...

Its not really over until he gets his laparotomy because his lactate is 12 and his pressor requirements are increasing, and there "might be dead gut".

Yes, Dr. MICU attending, I can guarantee there is dead gut in your alive in name only patient. Don't need a laparotomy to know that.

 

[WheezyBaby]

Can't die without dialysis and ECMO...

 

[LucidSplash]

Its not really over until he gets his laparotomy because his lactate is 12 and his pressor requirements are increasing, and there "might be dead gut".

Yes, Dr. MICU attending, I can guarantee there is dead gut in your alive in name only patient. Don't need a laparotomy to know that.

How did you guess the lactate exactly?

 

[armybound]

Its not really over until he gets his laparotomy because his lactate is 12 and his pressor requirements are increasing, and there "might be dead gut".

Yes, Dr. MICU attending, I can guarantee there is dead gut in your alive in name only patient. Don't need a laparotomy to know that.

As long as he dies in SICU instead of MICU.

 

[mimelim]

Why isn't he putting an ij line in for hd?

In my experience medicine always puts the temp dialysis cath in the groin

Nephrology often prefers it that way to save the upper veins for more permanent access in case something gets screwed up, but with the patient described above (anatomic issues, and likely no need for permanent access given the chance there will be no permanent), even medicine should have just stuck it in the IJ. Mind you, it's been a couple years, but I was putting non-tunneled dialysis lines in the neck as a resident when indicated.

Yes, save the subclavian, but I'd use the ij every day and twice on Sunday.

I'm going to preface my post by saying that this is what we do, it is certainly not backed up by a wealth of data. That having been said, we do roughly 50 access cases a week, 6-10 quintons a week and my google drive nephrologist Rolodex has 69 nephrologists on it (no, I'm not kidding, I can't keep track of all of them, their partners and preferences so I started a database to keep everything straight). I've spent a fair amount of time arguing with my staff, IR and our nephrology colleagues about this topic. So that having been said...

Every line placement should be individualized, availability of sites and expectation of the patient's course should dictate where exactly the line should be placed. Our standard location for non-tunnelled dialysis (Quinton) catheters is the femoral vein. This goes for anyone coming in with a thrombosed, malfunctioning or infected access needing temporary dialysis. We expect these lines to be gone within 2 days and 1-2 dialysis sessions unless they are coming in with some sort of bacteremia, in which case it may be slightly longer. Between the short length of catheter duration and the safety profile of a femoral line, we feel that it should be the preferential location for catheter placement. Another confounding factor in our population is that many if not most have some level of central venous stenosis which drops the chances of success. Personally, when I put in TDCs, I strongly prefer to not have a catheter already on that side from an infectious risk standpoint and getting the catheter to lie exactly how I want it to. We do not place lines that are not going to be used immediately, in other words, if it is 10pm, we aren't putting in the line unless someone is putting in dialysis orders for that night. It is actually fairly rare for us to put in IJ quintons. Obviously ICU players are different and again, if someone is fixing to have this line for a while, I'm more inclined to use an IJ preferentially. But, that having been said, for many of those people I may even just put in a TDC and be done with it.

I did my 3rd carotid repair s/p central line stabbing this past November. People lie to themselves about their complications rates, especially about central venous and other access issues. While I've also seen my fair share of femoral pseudoaneurysms and cold legs from the groins being used, I'd take those every day of the week over the MCA stroke...

 

[cpants]

Central line in one IJ, occluded contra, Impella in LSCA cutdown, right fem aline after radial crapped out, so left fem only open spot. 3 pressors, etc etc etc.

Gotta say that sounds like a line some sort of surgeon should be putting in? I'm not an access expert, but doesn't seem like there were many good options remaining? Wouldn't you rather just get one in than get called when the MICU doc mucked it up and you have zero options? Especially when the guy isn't even confident he's looking at the the femoral vein?

 

[LucidSplash]

Gotta say that sounds like a line some sort of surgeon should be putting in? I'm not an access expert, but doesn't seem like there were many good options remaining? Wouldn't you rather just get one in than get called when the MICU doc mucked it up and you have zero options? Especially when the guy isn't even confident he's looking at the the femoral vein?

It wasn’t a MICU doc. It was a SCC trained anesthesiologist in the cardiovascular ICU. And they didn’t ask me to put it in, just point to the vein in the ultrasound screen because they were afraid the graft (which wasn’t even in the groin) would look different enough from an artery that they couldn’t tell the difference. It’s one thing to ask me to put the line in, it’s other to ask me to come to bedside to point at something on an ultrasound because you are afraid of something that isn’t there.

 

[Jolie South]

It wasn’t a MICU doc. It was a SCC trained anesthesiologist in the cardiovascular ICU. And they didn’t ask me to put it in, just point to the vein in the ultrasound screen because they were afraid the graft (which wasn’t even in the groin) would look different enough from an artery that they couldn’t tell the difference. It’s one thing to ask me to put the line in, it’s other to ask me to come to bedside to point at something on an ultrasound because you are afraid of something that isn’t there.

I am of the opinion that any critical care trained physician should be able to put in a femoral dialysis line. And at this point, I think standard of care dictates ultrasound guidance. If you can tell the difference between an artery and a vein, I don’t understand what is so difficult about telling the difference between a graft and a vein.

I am lucky that at my institution vascular surgery never places any temporary dialysis access. It’s all on critical care or IR for a tunneled line.

 

[mimelim]

*sigh* Called in for 5 ER consults all at once this evening...

"spots on leg" - On coumadin and plavix for DVT and recent PCI, no idea what they are, but it sure as heck isn't being fixed by a vascular surgeon
"BKA wound" - Patient has both legs, does have a fasciotomy wound, which looks fantastic, there are even pictures in the patient's last clinic visit a couple weeks ago that show it looking the same or better...
"Cold leg" - leg is indeed cold, but alas has a palpable pulse
"Back/belly pain, history of aneurysm repair" - history of a TEVAR repair... CTA from last week and recent clinic visit
"Cold leg" - still waiting to arrive from one of our satellite ERs

 

[Jolie South]

I just got a consult on a guy who got a DVT 5 years ago after a plane ride. PCP, for god knows what reasons, ordered a duplex now though the patient is completely asymptomatic and finished one year anticoagulation. Result of duplex: chronic DVT in same distribution. PCP told the patient to hurry to the ER for this BS. What in the actual f$*%?!?!

 

[cpants]

It wasn’t a MICU doc. It was a SCC trained anesthesiologist in the cardiovascular ICU. And they didn’t ask me to put it in, just point to the vein in the ultrasound screen because they were afraid the graft (which wasn’t even in the groin) would look different enough from an artery that they couldn’t tell the difference. It’s one thing to ask me to put the line in, it’s other to ask me to come to bedside to point at something on an ultrasound because you are afraid of something that isn’t there.

Agree that is a BS consult, but if I were that patient I wouldn't want that guy touching my one virgin vein.

 

[dpmd]

I think we have a tendency to forget that we have specialized knowledge that makes some stuff seem stupidly easy but that other doctors aren't necessarily going to know. If you have never seen a graft on ultrasound you won't know what it should look like. Granted the anatomy knowledge to know that the graft won't be near the femoral vein should be available to all that presumes they know what sort of procedure they had more than just "they put some new plumbing in me because things were blocked" that the patient might be telling them. Maybe they thought it was an aortobifem and didn't want to screw up something when a simple phone call could prevent it.

 

[LucidSplash]

You missed the part from the OP where I’d already had a conversation that told them this. And showed them the CT scan images showing where th graft ended. (When we were consulted for the arm that was ischemic because of the Impella in the subclavian artery and recommended they move it to the groin).

 

[dpmd]

You missed the part from the OP where I’d already had a conversation that told them this. And showed them the CT scan images showing where th graft ended. (When we were consulted for the arm that was ischemic because of the Impella in the subclavian artery and recommended they move it to the groin).

I guess he could have forgotten that detail. You didn't try to just reassure him by phone that he couldn't be looking at graft?

 

[LucidSplash]

I would have if I were at home already but I was still in house and it was easier just to walk over there.

 

[Apollyon]

*sigh* Called in for 5 ER consults all at once this evening...

"spots on leg" - On coumadin and plavix for DVT and recent PCI, no idea what they are, but it sure as heck isn't being fixed by a vascular surgeon
"BKA wound" - Patient has both legs, does have a fasciotomy wound, which looks fantastic, there are even pictures in the patient's last clinic visit a couple weeks ago that show it looking the same or better...
"Cold leg" - leg is indeed cold, but alas has a palpable pulse
"Back/belly pain, history of aneurysm repair" - history of a TEVAR repair... CTA from last week and recent clinic visit
"Cold leg" - still waiting to arrive from one of our satellite ERs

That HAS to be an academic department. Two days before Christmas, had a priest come in for swelling in his leg for 3 days. I got to righteously chew him out for waiting. I also encouraged him to call now (at noon) for coverage (Saturday vigil, Sunday service, and midnight mass - if you're Catholic, you get it, if not, it makes no sense), instead of at 4pm, when mass is at 5pm. First concerned for compartment syndrome, but it didn't have all (or more than 1 sign, and that was a soft sign at that). CT shows no flow beyond the calf, but the thing is, it's asymmetric. I told the pt that I didn't know what was going on, but I didn't have a surgeon available. I also warned the pt that he might be seen by vascular at the "ivory tower", and discharged. That is ~100 miles away. I did call the vascular surgeon on call, and told him what I had (or didn't know). Of course, he accepted the patient. However, it MAY have helped a bit that the priest had a name like McLaughlin, and the vascular guy had a name like O'Shaugnessy.

 

[MediCane2006]

*sigh* Called in for 5 ER consults all at once this evening...

"spots on leg" - On coumadin and plavix for DVT and recent PCI, no idea what they are, but it sure as heck isn't being fixed by a vascular surgeon
"BKA wound" - Patient has both legs, does have a fasciotomy wound, which looks fantastic, there are even pictures in the patient's last clinic visit a couple weeks ago that show it looking the same or better...
"Cold leg" - leg is indeed cold, but alas has a palpable pulse
"Back/belly pain, history of aneurysm repair" - history of a TEVAR repair... CTA from last week and recent clinic visit
"Cold leg" - still waiting to arrive from one of our satellite ERs

God I do NOT miss being the vascular resident.... I got mildly triggered just reading this list.

 

[dpmd]

I was the first person to go to a new vascular rotation. The housing they gave me was 25 miles away which wouldn't be terrible but this was in LA so it was an hour away easily. They really didn't know what to do with me as I was pretty much an extra body. So I never really had to take call (though I had to stay every day until prime traffic time which was torture enough).

 

[akwho]

This story is a program legend.

One of our graduated chief's when he was a consult resident didn't know if a hand consult he admitted was right-handed or left-handed, so he got deservedly roasted at pass-on's. Vowing to never let this happen again, we fast-forward to his next call. At pass-on's he presents a Lisfranc fracture as "this 23-year-old right-foot dominant male..." Cue old school gruff attending, "Right foot dominant? What the %&$# does that even mean?" Consult resident responds, "well he kicks the soccer ball with his right foot and drives with his right foot." Attending, "EVERYONE drives with their right foot."

Instant classic™ pass-on's story that no one ever let him forget.

 

[tiedyeddog]

*sigh* Called in for 5 ER consults all at once this evening...

"spots on leg" - On coumadin and plavix for DVT and recent PCI, no idea what they are, but it sure as heck isn't being fixed by a vascular surgeon
"BKA wound" - Patient has both legs, does have a fasciotomy wound, which looks fantastic, there are even pictures in the patient's last clinic visit a couple weeks ago that show it looking the same or better...
"Cold leg" - leg is indeed cold, but alas has a palpable pulse
"Back/belly pain, history of aneurysm repair" - history of a TEVAR repair... CTA from last week and recent clinic visit
"Cold leg" - still waiting to arrive from one of our satellite ERs

"DISPO IS KING!" - every ED resident in academic centers everywhere. Just looking for places to dump the ****.

 

[tiedyeddog]

I got a consult for evaluating the safety of systemic anticoagulation on a patient with a history of cerebral subdural evacuation two years prior in the setting of known DVT. Head CT two weeks before showed no blood. In the period between head CT and the consult the patient developed severe liver dysfunction and an INR > 5 for almost 10 days straight. No head CT was done during this period. I was called the day INR was < 2. When I pointed out the patient had been auto-anticoagulated already and no one blinked an eye the IM resident laughed at me and said "yeah, I guess you're right. So it is it safe?"

 

[deleted547339]

"DISPO IS KING!" - every ED resident in academic centers everywhere. Just looking for places to dump the ****.

I didn’t invent the rules in the House, I just live by them.

 

[deleted547339]

I got a consult for evaluating the safety of systemic anticoagulation on a patient with a history of cerebral subdural evacuation two years prior in the setting of known DVT. Head CT two weeks before showed no blood. In the period between head CT and the consult the patient developed severe liver dysfunction and an INR > 5 for almost 10 days straight. No head CT was done during this period. I was called the day INR was < 2. When I pointed out the patient had been auto-anticoagulated already and no one blinked an eye the IM resident laughed at me and said "yeah, I guess you're right. So it is it safe?"

A lot of the liver folks with INRs > 2 are hypercoagulable and may need anticoagulation. Their thromboelastography can be impressive. There is also no reason to scan the head of a medical patient who is asymptomatic just because they have a high INR. Further, even if the liver injury caused a resolving/resolved coagulopathy, the safety of long term anticoagulation still needs to be addressed. Feel free to laugh at the fleas for not knowing 2 years is a long time, but that seems like a fairly reasonable consult and no one would think twice outside of the hyperjudgemental world of academia.

 

[tiedyeddog]

A lot of the liver folks with INRs > 2 are hypercoagulable and may need anticoagulation. Their thromboelastography can be impressive. There is also no reason to scan the head of a medical patient who is asymptomatic just because they have a high INR. Further, even if the liver injury caused a resolving/resolved coagulopathy, the safety of long term anticoagulation still needs to be addressed. Feel free to laugh at the fleas for not knowing 2 years is a long time, but that seems like a fairly reasonable consult and no one would think twice outside of the hyperjudgemental world of academia.

So why consult me after the INR is now self-corrected to a normal number? The consult would have made sense at the start of period of high INR not after it was over. That's why it is ridiculous.

These are akin to consults I get in a similar scenario when the patient has already been on therapeutic anticoagulation for days wanting to assess the safety of anticoagulation. I really have to fight the urge to say "well, you have tested if it is safe. The patient isn't dead or neurologically devastated. Apparently it is safe."

 

[Jolie South]

So why consult me after the INR is now self-corrected to a normal number? The consult would have made sense at the start of period of high INR not after it was over. That's why it is ridiculous.

These are akin to consults I get in a similar scenario when the patient has already been on therapeutic anticoagulation for days wanting to assess the safety of anticoagulation. I really have to fight the urge to say "well, you have tested if it is safe. The patient isn't dead or neurologically devastated. Apparently it is safe."

Or the contrary consult, this is a “20 yo female with 3 spontaneous abortions, antiphospholipid antibody syndrome, with metastatic cancer and a DVT who maybe had a dark colored stool 3 years ago after eating some beets. Are you sure she needs anticoagulation? Oh, really, probably indefinite? Why not a filter?”

 

[armybound]

Nothing particularly memorable about the consults, but we've had a few lately for sperm banking (which we don't do, but we have an info sheet on where to get it done in town) for young guys about to get chemo. The last 2-3 times this has happened we go talk to the patient and the patient isn't interested.

Is it really too much to ask the heme/oncs to ask the patient if they'd be interested in sperm banking before consulting us to set it up?