Consults- Memorable/Dismal/Ridiculous/Unique

[Gate Closed]

I was paged by the medicine PGY2 for patient s/p kidney transplant 5 years ago. The graft was rejected 2 years ago and the patient has been on HD since. He presented with a fever and had a high creatinine. The question was first whether "there is a risk of rejection given high creatinine" (I'm like dude this ship has sailed - pt has been on HD and has not even been on immunosuppression for like 2 years now...). When he was reassured that there is no such risk (...), he asked me if I see any value in doing a graft nephrectomy, since a "graft infection might be the cause of his fever". I really really enjoyed this conversation!

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[WheezyBaby]

I was paged by the medicine PGY2 for patient s/p kidney transplant 5 years ago. The graft was rejected 2 years ago and the patient has been on HD since. He presented with a fever and had a high creatinine. The question was first whether "there is a risk of rejection given high creatinine" (I'm like dude this ship has sailed - pt has been on HD and has not even been on immunosuppression for like 2 years now...). When he was reassured that there is no such risk (...), he asked me if I see any value in doing a graft nephrectomy, since a "graft infection might be the cause of his fever". I really really enjoyed this conversation!

So did you take the kidney out??

 

[Gate Closed]

So did you take the kidney out??

It was tempting - how many times do we get to log a nephrectomy. But then my 2-year old son suggested looking for a different solution to the patient's problem. I relayed his concerns to the bright medicine PGY-2 and we aborted the procedure.

 

[Jolie South]

Called for cold right leg from ER. I am told no pulses/signals and has hx bypass.

I go talk to the patient. Complaining of bilateral lower extremity pain and weakness. My evaluation has positive signals and pulse in bypass. Easily discovered. I am thinking WTF.

Call the ER guy back to tell him my findings and insinuate his physical exam skills suck. Then, I say the limb isn’t threatened and this isn’t a bypass problem.

“But the leg is cold”

Lol wut

 

[LucidSplash]

Called for cold right leg from ER. I am told no pulses/signals and has hx bypass.

I go talk to the patient. Complaining of bilateral lower extremity pain and weakness. My evaluation has positive signals and pulse in bypass. Easily discovered. I am thinking WTF.

Call the ER guy back to tell him my findings and insinuate his physical exam skills suck. Then, I say the limb isn’t threatened and this isn’t a bypass problem.

“But the leg is cold”

Lol wut

Ah. Another case of the dreaded acute sock deficiency.

 

[ThoracicGuy]

Called for cold right leg from ER. I am told no pulses/signals and has hx bypass.

I go talk to the patient. Complaining of bilateral lower extremity pain and weakness. My evaluation has positive signals and pulse in bypass. Easily discovered. I am thinking WTF.

Call the ER guy back to tell him my findings and insinuate his physical exam skills suck. Then, I say the limb isn’t threatened and this isn’t a bypass problem.

“But the leg is cold”

Lol wut

Was it a consult sent from the guy who signed out to him?

 

[Jolie South]

Was it a consult sent from the guy who signed out to him?

This guy did examine the patient and is just that stupid apparently. He tried to give me a lot of attitude actually.

 

[LucidSplash]

ED consult for patient txfr from OSH for carotid dissection and vision changes. Please see quickly to eval for stroke.

Not usually how that works but ok sure.

Images reviewed. Patient with an ascending aortic dissection extending into the carotid. Call ED back to tell them emergent CT surg eval and that carotid is secondary issue.

ED wants to know if I’m sure about that because of possible stroke and CT surg unlikely to operate until we “clear” then from stroke risk.

I ask to speak to attending.

 

[ThoracicGuy]

This guy did examine the patient and is just that stupid apparently. He tried to give me a lot of attitude actually.

You could have given him an inservice on bedside doppler use.

 

[ThoracicGuy]

ED consult for patient txfr from OSH for carotid dissection and vision changes. Please see quickly to eval for stroke.

Not usually how that works but ok sure.

Images reviewed. Patient with an ascending aortic dissection extending into the carotid. Call ED back to tell them emergent CT surg eval and that carotid is secondary issue.

ED wants to know if I’m sure about that because of possible stroke and CT surg unlikely to operate until we “clear” then from stroke risk.

I ask to speak to attending.

 

[TraumaLlamaMD]

Called for cold right leg from ER. I am told no pulses/signals and has hx bypass.

I go talk to the patient. Complaining of bilateral lower extremity pain and weakness. My evaluation has positive signals and pulse in bypass. Easily discovered. I am thinking WTF.

Call the ER guy back to tell him my findings and insinuate his physical exam skills suck. Then, I say the limb isn’t threatened and this isn’t a bypass problem.

“But the leg is cold”

Lol wut

I got one of these recently where the ED resident had used an OB Doppler probe and, somehow!, couldn’t find any DP or PT signal.

To add insult to injury, DP turned out to be palpable.

 

[vhawk]

A lot of times when consults seem really dumb to us it just reflects a little bit of a lack of awareness of how much experience we have and how our expertise makes questions that are actually very understandable kind of seem dumb.

But as someone who is by my own admission really ****ing dumb and terrible when it comes to vascular stuff, these last couple vascular ones are hilariously bad

 

[Thanatos]

ED consult for patient txfr from OSH for carotid dissection and vision changes. Please see quickly to eval for stroke.

Not usually how that works but ok sure.

Images reviewed. Patient with an ascending aortic dissection extending into the carotid. Call ED back to tell them emergent CT surg eval and that carotid is secondary issue.

ED wants to know if I’m sure about that because of possible stroke and CT surg unlikely to operate until we “clear” then from stroke risk.

I ask to speak to attending.

lol nice! In cardiac i get a lot of interesting conversations related to dissections, most of the time they just don't know any better which I try not to hold against them. I've gotten the stroke one before too.........one time I had a young guy with a type A in the ED who I booked emergently, went to talk to the OR team then ran back to the ED to grab him and the resident was like oh no don't go in his room for a minute......they were letting him strain on the bedside commode taking a **** while waiting on anesthesia to arrive. I believe that is the opposite of anti-impulse medical therapy but they say common sense isn't so common.

I do get amused though when there is a stunning lack of the basics....I got a panicked call from an ED attending one time about a patient with a "bad dissection" and they need me right away and etc. Concerned that maybe the guy was coding or something (tear through the root or coronary, rupture with tamponade etc) I asked about vital signs.
"yeah umm don't know. He's not here yet."
Okay thats fine, what did the imaging show from outside, how did they describe the tear or is there a pericardial effusion??
"Yeah umm not sure where the tear was exactly...."
Okay that's fine too...hmmm...is it a type A? or.....a type B??
And i swear the answer I got was something like "well look that doesn't matter, its a dissection pal we need u here when the patient arrives okay!?! He's coming to bed whatever in 5 minutes"

It was a completely stable asymptomatic type B dissection, which for me is an easy note to write and they go to cardiology for beta blockers so I wasn't upset or anything but it just struck me as kinda funny.....actually when you're calling a cardiac surgeon the differentiation between type A and type B matters quite a bit. If I have a heads up on a type A i can mobilize a team, and in an emergency situation where time is of the essence that would be helpful to know. Sometimes the outside hospitals don't relay that information to our accepting ED, and while that seems ridiculous that's not the fault of our ED so if they just don't know I get it....but I thought this one was a little suboptimal. I don't want to be the mega specialist picking on the generalist, but I feel like that one's pretty basic.

A lot of times when consults seem really dumb to us it just reflects a little bit of a lack of awareness of how much experience we have and how our expertise makes questions that are actually very understandable kind of seem dumb.

But as someone who is by my own admission really ****ing dumb and terrible when it comes to vascular stuff, these last couple vascular ones are hilariously bad

Could not agree more, there are plenty of specialties I know nothing about in which case I just plead ignorance. What has concerned me over the years is I can't help but feel people are just bending the truth to get you to come see the patient faster or just being lazy and dumping the work....I saw hundreds of consults as a general surgery resident for an acute abdomen or cold leg or nec fasc when the ED/medicine person calling me said the exam was really concerning, and they used specific "scary" sound terminology from the books: no palpable pulses or doppler signals, pain out of proportion to exam, crepitus.....like holy **** I need to get there!! and all too often I would fine a generally well appearing person with a complaint of leg pain/abd pain or whatever but nothing close to those findings....it happened too often to be a coincidence. I used to investigate (lol!) and i usually figured out it was the nurse who did the exam and called the resident who called me, or that the ED resident had not actually examined the patient. We used to ask the ED person consulting us "does the patient speak english?" and if they hesitated for a few seconds you knew they didn't actually talk to them....this was a frighteningly common occurrence.

When I was an intern I had a chief who put the fear of God into us about seeing every patient you got called about, putting something into motion, then calling for help/advice only if you couldn't figure it out....look it up if you have to. My first night on call as an intern a nurse paged me for a patient who "acutely desaturated to 85%." I was nervous and thought about calling my senior right away but I remembered what he said so I didn't. I quickly went to the room thinking the whole time what I was gonna do and I decided I would start oxygen, CXR, full set of labs, ABG, CT PE (what if I can't get the stick, what if the guy codes, this is the first night this would be my luck etc). I found a patient fast asleep, snoring like a freight train. I woke him up and he's sats went back to 95%....the nurse said on my way out the door "yeah he does this every night."

I think the problem is that too many people are skipping that whole seeing the patient, put something into motion and think for a minute/look it up before you call someone part of medicine.

 

[vhawk]

"Does the patient speak English?" is a ****ing brilliant question for its intended purpose. Something you could reasonably need to know before going down that isnt obviously a gotcha question and yet something that you couldn't possibly NOT know if you had actually examined the patient yourself. A similar question I ask the junior residents (and now as attending the senior residents) is "what incisions do they have" or "was their previous chole open or lap?"

 

[LucidSplash]

Maybe I’m more grumpy than usual but this stuff is driving me nuts today. Usually I can just shrug and roll my eyes but it’s getting under my skin today.

Hospitalists and IM/EM docs in general, please please please stop consulting vascular for isolated occluded IMA when you have a patient with ischemic colitis. Especially when you already have gen surg see the patient. That’s probably the most important detail. They tend to know when they need us. If gen surg says they are taking the patient to the OR (or even if they aren’t) they know when to call us for mesenteric ischemia.

Probably the short way of saying that is learn that mesenteric ischemia and ischemic colitis are different entities.

 

[HighPriest]

I saw hundreds of consults as a general surgery resident for an acute abdomen or cold leg or nec fasc when the ED/medicine person calling me said the exam was really concerning, and they used specific "scary" sound terminology from the books: no palpable pulses or doppler signals, pain out of proportion to exam, crepitus.....like holy **** I need to get there!! and all too often I would fine a generally well appearing person with a complaint of leg pain/abd pain or whatever but nothing close to those findings....it happened too often to be a coincidence

Yep. Happens all of the time. I specifically remember a call as a senior resident from the ER:

ER: I have a guy here who has an emergent airway. we need you here ASAP. We have a "slash trach" set at the bedside, and you're going to need to trach him.

Me: Ok, I'm on my way. You may consider calling the general surgery resident as well, since he's in house. I'm at home. It's going to take me 20 minutes to get there.

ER: (now upset) you need to get here now!

Me: (already getting in my car) What's the story with this guy, anyway? Have you tried to establish an airway? Did you attempt an intubation? Did anesthesia see him? They're also in-house.

ER: He's decompensating. I think it's angioedema.

Me: Ok, how did he present?

ER: with trouble breathing, facial and lip swelling, swollen tongue.

Me: Ok, sounds legit. I'm almost there, you really should consider calling general surgery if he's that bad. (Or, you know, doing a cricothyroidotomy or whatever...you do work in an ER).

So I get there, and the patient is in a bay, by himself, in the dark, no telemetry, no nurses or ER staff around. Fortunately, he's sitting cross-legged and talking to someone on his cell phone so I think his airway is ok. Also fortunately, the trach set is in the room, in a locked cart...

So I get the ER resident and ask what the deal is, and her response is more or less "well, it's your job to come in and we are really busy..." So I tell her I'm happy to see the guy, but the way she brought me in was pretty inappropriate. She gets upset, and calls her senior resident to the scene and he asks me what the problem is, and I tell him "well, to begin with this guy is clearly not an emergent airway. Secondly, if he was, you'd think he'd be on telemetry with someone actually here with him. Thirdly, it really isn't your decision whether or not I need to do a trach. I'm a physician, I can make that call when I see the patient. This guy clearly doesn't need one. Lastly, if it was a real emergency, you are welcome to call me but you ought to think about calling someone in house or learning how to obtain an airway, because it takes me 20 minutes to get here. So if it was a real emergency, he'd probably be dead. And his response is "well, I guess ENT should start taking in-house call then."

Yep, because that's the answer. Everyone should stay in the hospital all of the time because the ER is inept.

 

[ThoracicGuy]

Yep. Happens all of the time. I specifically remember a call as a senior resident from the ER:

ER: I have a guy here who has an emergent airway. we need you here ASAP. We have a "slash trach" set at the bedside, and you're going to need to trach him.

Me: Ok, I'm on my way. You may consider calling the general surgery resident as well, since he's in house. I'm at home. It's going to take me 20 minutes to get there.

ER: (now upset) you need to get here now!

Me: (already getting in my car) What's the story with this guy, anyway? Have you tried to establish an airway? Did you attempt an intubation? Did anesthesia see him? They're also in-house.

ER: He's decompensating. I think it's angioedema.

Me: Ok, how did he present?

ER: with trouble breathing, facial and lip swelling, swollen tongue.

Me: Ok, sounds legit. I'm almost there, you really should consider calling general surgery if he's that bad. (Or, you know, doing a cricothyroidotomy or whatever...you do work in an ER).

So I get there, and the patient is in a bad, by himself, in the dark, no telemetry, no nurses or ER staff around. Fortunately, he's sitting cross-legged and talking to someone on his cell phone so I think his airway is ok. Also fortunately, the trach set is in the room, in a locked cart...

So I get the ER resident and ask what the deal is, and her response is more or less "well, it's your job to come in and we are really busy..." So I tell her I'm happy to see the guy, but the way she brought me in was pretty inappropriate. She gets upset, and calls her senior resident to the scene and he asks me what the problem is, and I tell him "well, to begin with this guy is clearly not an emergent airway. Secondly, if he was, you'd think he'd be on telemetry with someone actually here with him. Thirdly, it really isn't your decision whether or not I need to do a trach. I'm a physician, I can make that call when I see the patient. This guy clearly doesn't need one. Lastly, if it was a real emergency, you are welcome to call me but you ought to think about calling someone in house or learning how to obtain an airway, because it takes me 20 minutes to get here. So if it was a real emergency, he'd probably be dead. And his response is "well, I guess ENT should start taking in-house call then."

Yep, because that's the answer. Everyone should stay in the hospital all of the time because the ER is inept.

Tell me you talked to the attending about these residents. This was highly inappropriate and if this sort of thing was the norm, it could lead to a true emergency not being taken seriously.

 

[deleted859535]

Tell me you talked to the attending about these residents. This was highly inappropriate and if this sort of thing was the norm, it could lead to a true emergency not being taken seriously.

This right here. I would have absolutely ripped into anyone pulling that ****.

 

[HighPriest]

Tell me you talked to the attending about these residents. This was highly inappropriate and if this sort of thing was the norm, it could lead to a true emergency not being taken seriously.

I talked to my attending (I was a resident at the time) and they talked to the ER staff. And yes, this was entirely inappropriate.

 

[HighPriest]

This right here. I would have absolutely ripped into anyone pulling that ****.

I...was probably less calm than my post makes it sound.

 

[HighPriest]

Hilariously enough (and I don't remember, I may have already post this somewhere on this thread) the exact same ER resident called my about a year before. Also for angioedema, although it was during business hours and so I was in the hospital anyway and she was much more calm. Patient with swollen face, lips, voice changes, suspect angioedema, please come evaluate the airway.

Turns out the patient came in for sore throat. The other stuff was because she was a transgender patient and just have very prominent, masculine features. I took a look at her photo ID from when she was still he about two years before and no change. I mentioned that to the ER resident, and she refused to believe it.

 

[Jolie South]

Maybe I’m more grumpy than usual but this stuff is driving me nuts today. Usually I can just shrug and roll my eyes but it’s getting under my skin today.

Hospitalists and IM/EM docs in general, please please please stop consulting vascular for isolated occluded IMA when you have a patient with ischemic colitis. Especially when you already have gen surg see the patient. That’s probably the most important detail. They tend to know when they need us. If gen surg says they are taking the patient to the OR (or even if they aren’t) they know when to call us for mesenteric ischemia.

Probably the short way of saying that is learn that mesenteric ischemia and ischemic colitis are different entities.

I got this consult this week also. Patient is an alcoholic with raging colitis per CT. I am like “um yea no role for revasc at this time.” Before anything else he probs needs at least sigmoidoscopy.

 

[Jolie South]

I get a consult today for “left SFA occlusion”.

Patient is a medical disaster who presented to the ED for “high BUN” per his wife. She said BUN like hamburger bun.

He is being worked up for endocarditis and has no leg symptoms or wounds. I look in the chart and literally every specialty ever is consulted. I look at his duplex. Same chronic occlusion as one year ago.

WTF. Nice enough patient, but like seriously, did you think this chronic SFA occlusion was contributing to sepsis?!

 

[ThoracicGuy]

I get a consult today for “left SFA occlusion”.

Patient is a medical disaster who presented to the ED for “high BUN” per his wife. She said BUN like hamburger bun.

He is being worked up for endocarditis and has no leg symptoms or wounds. I look in the chart and literally every specialty ever is consulted. I look at his duplex. Same chronic occlusion as one year ago.

WTF. Nice enough patient, but like seriously, did you think this chronic SFA occlusion was contributing to sepsis?!

Bypass that thing stat! If you don't get to it soon, the patient might be dead and then you'll be out the RVU!!!!

/s

 

[LucidSplash]

Verbatim from ED resident for another consult today for a patient transferred from OSH for iliofem DVT: “I am concerned the patient doesn’t have any pulses in their foot because that’s what the OSH documented. I haven’t see the patient.”

Resident was educated to look for pulses and see the patient. Resident reported no pulses.

Patient had palpable pulses.

It’s just not worth it. I give up.

<Despondently flings self off tower>

 

[siliso]

I think I was also consulted on this patient recently.

If my guy is still alive it’s a miracle from God. Mine understandably declined the offer of a translumbar amputation. There must be more such unfortunates than one might hope. The real bummer was he was a T5 para who could have had a reasonable QOL, opportunities to live and drive and work, but for those social determinants of health....

 

[HighPriest]

Verbatim from ED resident for another consult today for a patient transferred from OSH for iliofem DVT: “I am concerned the patient doesn’t have any pulses in their foot because that’s what the OSH documented. I haven’t see the patient.”

Resident was educated to look for pulses and see the patient. Resident reported no pulses.

Patient had palpable pulses.

It’s just not worth it. I give up.

<Despondently flings self off tower>

What part of the calf are they palpating for pedal pulses? I find that about 90% of the time, that's the problem: they have no idea where the anatomy is.
I get consulted not infrequently for mastoiditis when the patient has occipital head pain and no otologic symptoms.
OR (and this was a great consult), I got a call from an ER resident once for a neck abscess that they were worried about because it was "close to the carotid." It was a pimple. I $#!t you not, the guy had a pimple on his neck. Now, granted, it was a pretty gross looking pimple, but it was draining and no extension below the dermis, basically. A little surrounding redness. Now, technically, that is close to the carotid if you're comparing it to a pimple on the @$$, but.....BTW they did a CT on that guy which, if you really squinted, showed the area of concern.

If it's a REALLY good NP in the urgent care center, they'll show me how the patient has mastoid tenderness by jamming their thumb into the mastoid eminence as hard as they possibly can until the patient pulls away. Which, you know, super diagnostic.

 

[evilbooyaa]

Verbatim from ED resident for another consult today for a patient transferred from OSH for iliofem DVT: “I am concerned the patient doesn’t have any pulses in their foot because that’s what the OSH documented. I haven’t see the patient.”

Resident was educated to look for pulses and see the patient. Resident reported no pulses.

Patient had palpable pulses.

It’s just not worth it. I give up.

<Despondently flings self off tower>

FWIW, before I was on vascular as a med student (and then again as an intern) I sucked at palpating pulses too, primarily on exactly where they were located and how to follow the path of the artery if the main area was edematous/covered by surgical dressing, etc.. Take the resident, put your finger on a palpable pulse, take their finger and replace yours. If they can't feel it then call a stroke alert because clearly they've lost sensation in their arm and are having a stroke. However, it may save you a call from at least that resident in the future for the same dumb ****. Once you teach him, you can let other the other EM residents know to go to him first for a proper pulse exam before they call you.

Regardless, your avatar is getting more and more on point.

 

[LucidSplash]

Regardless, your avatar is getting more and more on point.

Yeah I used to have a ladybug. As a PGY8 though, that Bitmoji is basically my face all the time. Why did I think a fellowship was a good idea?

 

[vhawk]

FWIW, before I was on vascular as a med student (and then again as an intern) I sucked at palpating pulses too, primarily on exactly where they were located and how to follow the path of the artery if the main area was edematous/covered by surgical dressing, etc.. Take the resident, put your finger on a palpable pulse, take their finger and replace yours. If they can't feel it then call a stroke alert because clearly they've lost sensation in their arm and are having a stroke. However, it may save you a call from at least that resident in the future for the same dumb ****. Once you teach him, you can let other the other EM residents know to go to him first for a proper pulse exam before they call you.

Regardless, your avatar is getting more and more on point.

I'm learning a lot of useful tricks from this thread, and although I dont think this is what you meant "I'll come see it but could you ask your co-resident Kevin to take a look first, I know he knows what a reducible hernia looks like since I taught him last month" is also amazing

 

[evilbooyaa]

Something about give a man a fish he eats for a day, teach a man to fish and you don't have to come down to the ED for BS consults as much.... hopefully.

 

[HighPriest]

Give a man a fish and you feed him for a day. TEACH a man to fish, and he'll start protesting to petition congress to provide a basic fish allowance because he feels that he gets an unfair number of fish for the amount of work required to fish.

Because, you know, you can lead a horse to water but you can't force it's head under. Unless you're, like, super strong.

 

[vhawk]

I think its "give a man a fish and, after pan-scanning it, he will ask you to come see the fish for an elevated lactate"

 

[coldleg]

Asked twice this week to perform temporal artery biopsies on patients with documented positive biopsies in the past, already on steroids.

 

[Dr.LeoSpaceman]

I think its "give a man a fish and, after pan-scanning it, he will ask you to come see the fish for an elevated lactate"

Also "Teach a man to fish, and after catching said fish he will call you to drive in from home to see said fish 'just to be sure it isn't necrotizing fasciitis'".

 

[VincentAdultman]

lol nice! In cardiac i get a lot of interesting conversations related to dissections, most of the time they just don't know any better which I try not to hold against them. I've gotten the stroke one before too.........one time I had a young guy with a type A in the ED who I booked emergently, went to talk to the OR team then ran back to the ED to grab him and the resident was like oh no don't go in his room for a minute......they were letting him strain on the bedside commode taking a **** while waiting on anesthesia to arrive. I believe that is the opposite of anti-impulse medical therapy but they say common sense isn't so common.

I do get amused though when there is a stunning lack of the basics....I got a panicked call from an ED attending one time about a patient with a "bad dissection" and they need me right away and etc. Concerned that maybe the guy was coding or something (tear through the root or coronary, rupture with tamponade etc) I asked about vital signs.
"yeah umm don't know. He's not here yet."
Okay thats fine, what did the imaging show from outside, how did they describe the tear or is there a pericardial effusion??
"Yeah umm not sure where the tear was exactly...."
Okay that's fine too...hmmm...is it a type A? or.....a type B??
And i swear the answer I got was something like "well look that doesn't matter, its a dissection pal we need u here when the patient arrives okay!?! He's coming to bed whatever in 5 minutes"

It was a completely stable asymptomatic type B dissection, which for me is an easy note to write and they go to cardiology for beta blockers so I wasn't upset or anything but it just struck me as kinda funny.....actually when you're calling a cardiac surgeon the differentiation between type A and type B matters quite a bit. If I have a heads up on a type A i can mobilize a team, and in an emergency situation where time is of the essence that would be helpful to know. Sometimes the outside hospitals don't relay that information to our accepting ED, and while that seems ridiculous that's not the fault of our ED so if they just don't know I get it....but I thought this one was a little suboptimal. I don't want to be the mega specialist picking on the generalist, but I feel like that one's pretty basic.



Could not agree more, there are plenty of specialties I know nothing about in which case I just plead ignorance. What has concerned me over the years is I can't help but feel people are just bending the truth to get you to come see the patient faster or just being lazy and dumping the work....I saw hundreds of consults as a general surgery resident for an acute abdomen or cold leg or nec fasc when the ED/medicine person calling me said the exam was really concerning, and they used specific "scary" sound terminology from the books: no palpable pulses or doppler signals, pain out of proportion to exam, crepitus.....like holy **** I need to get there!! and all too often I would fine a generally well appearing person with a complaint of leg pain/abd pain or whatever but nothing close to those findings....it happened too often to be a coincidence. I used to investigate (lol!) and i usually figured out it was the nurse who did the exam and called the resident who called me, or that the ED resident had not actually examined the patient. We used to ask the ED person consulting us "does the patient speak english?" and if they hesitated for a few seconds you knew they didn't actually talk to them....this was a frighteningly common occurrence.

When I was an intern I had a chief who put the fear of God into us about seeing every patient you got called about, putting something into motion, then calling for help/advice only if you couldn't figure it out....look it up if you have to. My first night on call as an intern a nurse paged me for a patient who "acutely desaturated to 85%." I was nervous and thought about calling my senior right away but I remembered what he said so I didn't. I quickly went to the room thinking the whole time what I was gonna do and I decided I would start oxygen, CXR, full set of labs, ABG, CT PE (what if I can't get the stick, what if the guy codes, this is the first night this would be my luck etc). I found a patient fast asleep, snoring like a freight train. I woke him up and he's sats went back to 95%....the nurse said on my way out the door "yeah he does this every night."

I think the problem is that too many people are skipping that whole seeing the patient, put something into motion and think for a minute/look it up before you call someone part of medicine.

You know what’s really really cool?

When the ER uses that “scary” terminology to get me into the ER for innocuous stuff then when the real deal rolls through the doors they totally miss it.

 

[Jolie South]

You know what’s really really cool?

When the ER uses that “scary” terminology to get me into the ER for innocuous stuff then when the real deal rolls through the doors they totally miss it.

“Yea, I got this patient with a foot wound that stinks. I put him way in the back in an isolation room bc it smells bad. Can you come put some recs for santyl or something?”

 

[deleted859535]

Sorry to see some of my EM breathren suck. Jesus.

 

[Apollyon]

Sorry to see some of my EM breathren suck. Jesus.

Almost (but not quite) invariably, these are stories about residents. I WISH I had a surgeon where I work (beyond 48 hours of call coverage mid week from a senior, senior citizen). The guys at the "ivory tower" 100 miles away are happy to get my patients.

 

[ThoracicGuy]

Almost (but not quite) invariably, these are stories about residents. I WISH I had a surgeon where I work (beyond 48 hours of call coverage mid week from a senior, senior citizen). The guys at the "ivory tower" 100 miles away are happy to get my patients.

Yeah, most of my EM stories are residents, though there are always a few attending stories... Now that I'm out of training, our EM group is great. I have no major issues with them on anything.

 

[DoctwoB]

Almost (but not quite) invariably, these are stories about residents. I WISH I had a surgeon where I work (beyond 48 hours of call coverage mid week from a senior, senior citizen). The guys at the "ivory tower" 100 miles away are happy to get my patients.

Perhaps because it is not the surgeon at said Ivory Tower who will see that patient at 2 AM but their junior resident. Also referral centers become/stay that way by being the dumping ground of the region. I don't know about you guys but our center basically has a rule that no transfers are refused.

 

[HighPriest]

Perhaps because it is not the surgeon at said Ivory Tower who will see that patient at 2 AM but their junior resident. Also referral centers become/stay that way by being the dumping ground of the region. I don't know about you guys but our center basically has a rule that no transfers are refused.

It is AMAZING how friendly and accepting an attending physician will be when he has a stable of residents who will deal with all of the crap associated with ill/morbid/pain-in-the-@$$ patients. That's why I don't have an issue with sending difficult patients to these guys. Why won't I come in at 3 am and see the orbital fracture in a 300 lbs, drunk, belligerent, uncontrolled diabetic with glaucoma? Because that's what resident training programs are for, and my quality of life is more important to me than the $300 bill he'll never pay anyway.

 

[Apollyon]

Perhaps because it is not the surgeon at said Ivory Tower who will see that patient at 2 AM but their junior resident. Also referral centers become/stay that way by being the dumping ground of the region. I don't know about you guys but our center basically has a rule that no transfers are refused.

Well, I still talk to the general surgery/trauma or ortho attending, so they still get awakened. But, totally, I hear you. I said that same thing about Duke - the attendings are all bright and shiny and happy, and that is built on the backs of 1000+ residents and fellows, ground down to a nub. That was like Eloi and Morlocks.

 

[Jolie South]

I got consulted by orthopedics for a pelvic abscess unrelated to anything vascular “because general surgery doesn’t want to do anything and Dr Vascular Attending might do something because he helps with anterior spine approaches.”

That’s not how this works.

 

[akwho]

I got consulted by orthopedics for a pelvic abscess unrelated to anything vascular “because general surgery doesn’t want to do anything and Dr Vascular Attending might do something because he helps with anterior spine approaches.”

That’s not how this works.

Hail Mary. It works 100% of the time, 60% of the time.

 

[coldleg]

Called by small community ED for a STAT consult. Primary clinic sent in a guy with no palpable radial pulse, no doppler signal over the radial. His other arm has a 2+ palpable radial. He has a history of some heart stuff, but come quick! Ischemia!

I haul ass to find a pleasant old guy (eating a tray of course). He has no idea why he's in the ED. Feels fine. I roll up his sleeves and find the most well healed RADIAL ARTERY HARVEST SITE known to man. Not only that, the patient was well aware that his artery had been used for his CABG 15 years ago. So clearly no one had not only examined the patient, but hadn't bothered listening to him.

My note: Absent radial pulse secondary to absent radial artery. Thank you for this interesting consult, call with questions.

The kicker? They keep the guy in observation, get a call from the RN the next morning to see if I want a heparin drip.

Then I suffered a hemorrhagic stroke and my eyeballs popped out of my head.

 

[smq123]

I got consulted by orthopedics for a pelvic abscess unrelated to anything vascular “because general surgery doesn’t want to do anything and Dr Vascular Attending might do something because he helps with anterior spine approaches.”

That’s not how this works.

http://gomerblog.com/2017/08/shtty-consult/

 

[Thanatos]

I got consulted by orthopedics for a pelvic abscess unrelated to anything vascular “because general surgery doesn’t want to do anything and Dr Vascular Attending might do something because he helps with anterior spine approaches.”

That’s not how this works.

I don't understand this phenomenon but I see it weekly in some version or another. Non surgical team finds something and consults surgery team for surgical management of possible surgical issue. Surgery team evaluates and says no surgery for whatever reason.....not indicated, can't be done, shouldn't be done, etc. Non surgical team then kicks/screams/begs/pleads consults every other procedural service on the planet (and sometimes at other hospitals) for management of previous finding.

Typically if I consult for something outside of my specialty, I usually just follow their recs. Maybe I'm just lazy....or maybe after way too many years of training I've come to the realization that super specialists know more about their specialty than I do. If I start someone on antifungals in the middle of the night because they're sick and transplant ID comes through the next day and says "you know actually in 87.2% of this transplant population with this presentation they're not indicated so we should stop them or there is a 19.85% chance of blah blah blah...." I just stop them, because I sure as **** don't know as much about transplant ID as the transplant ID people, and I'm cool with that.

So I'm always curious about these above quoted events.....take a big step back and think....one doctor called another for help with something they know nothing about. When the consulting doctor said there's nothing to do, instead of accepting the expert advice they then called an unrelated specialty to try to coerce them into OPERATING because they work in roughly the same part of the body, sometimes......I mean that's crazy right?!? But it happens all the time. Do they think we're just lazy and don't want to do the work? I think we can all provide ample evidence that's not the case, and I've been called a lot of things in the hospital but lazy has not been one of them. I'm not a psychiatrist, but I'm beginning to wonder if the 8-5 or shift work mentality specialties are projecting their true inner characteristics (of generalized laziness) onto us instead

Called by small community ED for a STAT consult. Primary clinic sent in a guy with no palpable radial pulse, no doppler signal over the radial. His other arm has a 2+ palpable radial. He has a history of some heart stuff, but come quick! Ischemia!

I haul ass to find a pleasant old guy (eating a tray of course). He has no idea why he's in the ED. Feels fine. I roll up his sleeves and find the most well healed RADIAL ARTERY HARVEST SITE known to man. Not only that, the patient was well aware that his artery had been used for his CABG 15 years ago. So clearly no one had not only examined the patient, but hadn't bothered listening to him.

My note: Absent radial pulse secondary to absent radial artery. Thank you for this interesting consult, call with questions.

The kicker? They keep the guy in observation, get a call from the RN the next morning to see if I want a heparin drip.

Then I suffered a hemorrhagic stroke and my eyeballs popped out of my head.

This is just phenomenal, and maybe the best one so far.

 

[LucidSplash]

I don't understand this phenomenon but I see it weekly in some version or another. Non surgical team finds something and consults surgery team for surgical management of possible surgical issue. Surgery team evaluates and says no surgery for whatever reason.....not indicated, can't be done, shouldn't be done, etc. Non surgical team then kicks/screams/begs/pleads consults every other procedural service on the planet (and sometimes at other hospitals) for management of previous finding.

Typically if I consult for something outside of my specialty, I usually just follow their recs. Maybe I'm just lazy....or maybe after way too many years of training I've come to the realization that super specialists know more about their specialty than I do. If I start someone on antifungals in the middle of the night because they're sick and transplant ID comes through the next day and says "you know actually in 87.2% of this transplant population with this presentation they're not indicated so we should stop them or there is a 19.85% chance of blah blah blah...." I just stop them, because I sure as **** don't know as much about transplant ID as the transplant ID people, and I'm cool with that.

So I'm always curious about these above quoted events.....take a big step back and think....one doctor called another for help with something they know nothing about. When the consulting doctor said there's nothing to do, instead of accepting the expert advice they then called an unrelated specialty to try to coerce them into OPERATING because they work in roughly the same part of the body, sometimes......I mean that's crazy right?!? But it happens all the time. Do they think we're just lazy and don't want to do the work? I think we can all provide ample evidence that's not the case, and I've been called a lot of things in the hospital but lazy has not been one of them. I'm not a psychiatrist, but I'm beginning to wonder if the 8-5 or shift work mentality specialties are projecting their true inner characteristics (of generalized laziness) onto us instead



This is just phenomenal, and maybe the best one so far.

Don’t forget the close relative of this situation: consulting two overlapping services simultaneously (vascular and ortho for a nasty toe, colorectal and GI for a scope)...

 

[OrthoTraumaMD]

Don’t forget the close relative of this situation: consulting two overlapping services simultaneously (vascular and ortho for a nasty toe, colorectal and GI for a scope)...

Yep.
Consult for ortho from IM: “possible compartment syndrome.”
Me: *sees patient* “they don’t have compartment syndrome.”
An hour later:
Consult for general surgery: “possible compartment syndrome.”
...sigh.
General surgeon calls me:
GS: “Hey, I’m being called about this—“
Me: “I know.”
GS: “They don’t have—“
Me: “I know.”
....sigh again.

Rinse, repeat.


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