Consults- Memorable/Dismal/Ridiculous/Unique

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How about family consult? Ie my family should have consulted me but didn’t...

Chatting with my stepmother last night.

SM: OK I’ve gotta go. I have to rebandage your Dad’s toe.
Me: What’s wrong with Dad’s toe?
SM: Oh he had a crack in it and it turned into a wound we’ve been trying to get to heal up for 3 months.

(Dad is DM2, recently quit smoking in September after having an MI. Also had major ankle reconstruction on that leg about 5-6 years ago after a bad accident.)

Me: :confused:
Me: Has he seen a doctor?
SM: Yeah a podiatrist or an orthopedist. Something like that.
Me: What about a vascular surgeon? Can you feel pulses in his feet?
SM: Oh he saw one last year when his PCP couldn’t feel pulses in his feet but they said it was fine because he didn’t have any problems.
Me: But now he has a wound on his toe that isn’t healing...
SM: Yeah it’s been a real pain. Oh and you should have seen the Xray they took of his foot! You could see the blood vessels! He has ‘sclerosis.’
Me: :eek::bored:o_O
Me: He needs to go back to the vascular surgeon ASAP.
SM: Really? Ok, I’ll try to convince him. You know how your Dad is. He’s afraid they will cut off his toe.
Me: If he doesn’t go soon he may be lucky if that’s all they cut off.

:shrug:
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Epistaxis.

I know, seems dumb, right? But I've seen a few transfusions due to severe epistaxis (usually on the 98 year old patient on coumadin for afib who is too confused to take the dose appropriately...you know, because you want to decrease that lifetime risk of stroke no matter how much they bleed). But it's one of the most common things I get called for, and it's amazing that no medical science has actually trickled down to the primary care level, let alone to the patients.

When I ask what they've done to control the bleeding, it's like opening a farmer's almanac from 1876.

"I put an ice pack on the back of my neck." "I put a matchbook/pennies under my upper lip." "I put pressure on the hard part of my nose." "I tilt me head back, but the blood just runs down my throat (not putting any pressure of any kind anywhere.)" "Every time I get it to stop, it just starts again (but he's forcefully blowing a clot out of his nose every single time)." "I can't figure out why it just keeps happening!! (watching the adult patient repeatedly rub and pick their nose while they're talking to me)."

ER: "I've got this guy with a "high volume" nosebleed (not sure what that means, exactly, and I treat epistaxis for a living) and we just can't get it under control...."
Me: "what's his bp? is he on anticoagulants?"
ER: .............uh.....let me check.........I'll call you back....
ER: (calling back) his BP is 195/90, his HR is 152 and he's on coumadin and aspirin and his INR is 5.
Me: Look, man, I'll come see him but I'm not a miracle worker. Maybe you could treat one or two of those things while I'm on my way.


ER: "I have this guy with a nosebleed. I think it's posterior (they always do. if it's not on the outside of the nose, it's posterior.) he had a septoplasty in 1974 (amazing, btw, that they obtained that history considering the things they regularly miss), so I don't really think I should be packing his nose. Could you come see him?"
Me: "yeah, I can. I'll probably end up packing his nose."
ER: "Really? I was really hoping he wouldn't need that."
Me: "Do you have an endoscope in the ER? A headlight? Silver nitrate? A nasal speculum? Any one of those things?"
ER: ...."no".....
Me: "well, then the only thing I can do is pack his nose, assuming you've applied afrin and pressure for 20 minutes."
ER: .......ah...yeah....we did that......
Me: (dubious) "great, well then packing his nose is really the option we have other than taking him to the ER at 9pm for a nosebleed that we can probably control with packing until I can see him in clinic tomorrow...and that's probably more cost effective."
 
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LucidSplash said:
How about family consult? Ie my family should have consulted me but didn’t...

Chatting with my stepmother last night.

SM: OK I’ve gotta go. I have to rebandage your Dad’s toe.
Me: What’s wrong with Dad’s toe?
SM: Oh he had a crack in it and it turned into a wound we’ve been trying to get to heal up for 3 months.

(Dad is DM2, recently quit smoking in September after having an MI. Also had major ankle reconstruction on that leg about 5-6 years ago after a bad accident.)

Me: :confused:
Me: Has he seen a doctor?
SM: Yeah a podiatrist or an orthopedist. Something like that.
Me: What about a vascular surgeon? Can you feel pulses in his feet?
SM: Oh he saw one last year when his PCP couldn’t feel pulses in his feet but they said it was fine because he didn’t have any problems.
Me: But now he has a wound on his toe that isn’t healing...
SM: Yeah it’s been a real pain. Oh and you should have seen the Xray they took of his foot! You could see the blood vessels! He has ‘sclerosis.’
Me: :eek::bored:o_O
Me: He needs to go back to the vascular surgeon ASAP.
SM: Really? Ok, I’ll try to convince him. You know how your Dad is. He’s afraid they will cut off his toe.
Me: If he doesn’t go soon he may be lucky if that’s all they cut off.

:shrug:
Click to expand...
I like the family consults I get. At least you get useful information.

My mother: “My friend says she has a colon problem. Does she need surgery?”

Me: Ummm

“Your aunt (non biologically related) has IBS and follows a diet to control her symptoms. I think I have it too. Whenever I eat xyz, I get cramping.”

Me: Ummmm

“This is my fifth episode of diverticulitis.”

Me: That is a lot. Has anyone ever talked to you about surgery? Or referred you to colorectal? When was your last colonoscopy?

“I don’t need surgery for that. I just won’t eat nuts anymore”

Me: ummmmm
 
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HighPriest said:
Epistaxis.

I know, seems dumb, right? But I've seen a few transfusions due to severe epistaxis (usually on the 98 year old patient on coumadin for afib who is too confused to take the dose appropriately...you know, because you want to decrease that lifetime risk of stroke no matter how much they bleed). But it's one of the most common things I get called for, and it's amazing that no medical science has actually trickled down to the primary care level, let alone to the patients.

When I ask what they've done to control the bleeding, it's like opening a farmer's almanac from 1876.

"I put an ice pack on the back of my neck." "I put a matchbook/pennies under my upper lip." "I put pressure on the hard part of my nose." "I tilt me head back, but the blood just runs down my throat (not putting any pressure of any kind anywhere.)" "Every time I get it to stop, it just starts again (but he's forcefully blowing a clot out of his nose every single time)." "I can't figure out why it just keeps happening!! (watching the adult patient repeatedly rub and pick their nose while they're talking to me)."

ER: "I've got this guy with a "high volume" nosebleed (not sure what that means, exactly, and I treat epistaxis for a living) and we just can't get it under control...."
Me: "what's his bp? is he on anticoagulants?"
ER: .............uh.....let me check.........I'll call you back....
ER: (calling back) his BP is 195/90, his HR is 152 and he's on coumadin and aspirin and his INR is 5.
Me: Look, man, I'll come see him but I'm not a miracle worker. Maybe you could treat one or two of those things while I'm on my way.


ER: "I have this guy with a nosebleed. I think it's posterior (they always do. if it's not on the outside of the nose, it's posterior.) he had a septoplasty in 1974 (amazing, btw, that they obtained that history considering the things they regularly miss), so I don't really think I should be packing his nose. Could you come see him?"
Me: "yeah, I can. I'll probably end up packing his nose."
ER: "Really? I was really hoping he wouldn't need that."
Me: "Do you have an endoscope in the ER? A headlight? Silver nitrate? A nasal speculum? Any one of those things?"
ER: ...."no".....
Me: "well, then the only thing I can do is pack his nose, assuming you've applied afrin and pressure for 20 minutes."
ER: .......ah...yeah....we did that......
Me: (dubious) "great, well then packing his nose is really the option we have other than taking him to the ER at 9pm for a nosebleed that we can probably control with packing until I can see him in clinic tomorrow...and that's probably more cost effective."
Click to expand...

Sounds like my experience too..

Exception is I tell them to pack the nose and call me if he still bleeds. That's a very basic ER skill that they should be able to do.

I'm also amazed at how many old people are on anticoagulation. When is enough enough?
 
Pir8DeacDoc said:
Sounds like my experience too..

Exception is I tell them to pack the nose and call me if he still bleeds. That's a very basic ER skill that they should be able to do.

I'm also amazed at how many old people are on anticoagulation. When is enough enough?
Click to expand...
To be fair, I usually make them pack as well. But our primary ER is just across the street, and since they screw up a pack about 50% of the time, sometimes it's just better to go do it. Humorous as it is to see a piece of merocel hanging out of the nose by about 3cm....They should be able to do a pack, but it's always a PA and they never work at the ER more than 1-2 years, so training each one every time is sisyphean.

And so far as anticoagulation, I get it if you're 60 with Afib. I'd be on coumadin too. But when you're 85.....if it's just for Afib, I think maybe you're not a gambler.
 
Pir8DeacDoc said:
That's a very basic ER skill that they should be able to do.
Click to expand...
It's an EM residency RRC requirement. Moreover, it's a specific skill for which, in my experience, at least, I have had to be specifically credentialed for epistaxis management. As such, if you get such bogus consults, that is a quite legit case for peer review.
 
Apollyon said:
It's an EM residency RRC requirement. Moreover, it's a specific skill for which, in my experience, at least, I have had to be specifically credentialed for epistaxis management. As such, if you get such bogus consults, that is a quite legit case for peer review.
Click to expand...

Then there's a big problem out there, because it is pretty common that ER staff don't know how to pack a nose - at least not properly if at all. Not MOST staff, mind you. But at least 1-2 at every place I've ever worked or done moonlighting.
 
HighPriest said:
Then there's a big problem out there, because it is pretty common that ER staff don't know how to pack a nose - at least not properly if at all. Not MOST staff, mind you. But at least 1-2 at every place I've ever worked or done moonlighting.
Click to expand...

Totally agree. The only chuckle I get out of an epistaxis call sometimes is seeing how incorrectly the pack is placed. I mean half hanging out won't work.
 
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Vertigo is another bane of the ENT existence. Because, of course, every single person on this side of the ground (and a few on the other) who has ever felt off balance for even a few seconds of their life ends up in my office. My favorites are the 99 1/2 year old with late stage macular degeneration, bilateral hip replacements, in a wheelchair, with parkinson's disease who gets referred to me for being "off balance." I mean....no $#!t. Let me just see if I can open up the heavens and heal with a touch today...

But two consults stand out specifically:

I saw a guy referred for "vertigo" who's only complaint was that periodically throughout the day he simply loses his vision. Doesn't fade out, isn't associated with dizziness or any other symptom. He suddenly just can't see anything for about five minutes. Happens while he's driving, too. Great chief complaint for an ENT clinic.

Actually, the best one was a patient referred to me routinely for vertigo. She was scheduled for a hearing test before she saw me in clinic, about 2 weeks after she presented to her PCP. The audiologist came to find me when the patient had an acute attack of vertigo in her office, but was confused as to why the attack presented with dysarthria and upper unilateral upper extremity paresthesia. Fortunately, we had this machine called an MRI that was able to diagnose her multiple strokes and we were able to get her to a stroke center a mere 2 weeks after presentation. She says she told her PCP about the dysarthria and the tingling, but the PCP must not have understood her, what with the mispronunciation and poor articulation.
 
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HighPriest said:
Vertigo is another bane of the ENT existence. Because, of course, every single person on this side of the ground (and a few on the other) who has ever felt off balance for even a few seconds of their life ends up in my office. My favorites are the 99 1/2 year old with late stage macular degeneration, bilateral hip replacements, in a wheelchair, with parkinson's disease who gets referred to me for being "off balance." I mean....no $#!t. Let me just see if I can open up the heavens and heal with a touch today...

But two consults stand out specifically:

I saw a guy referred for "vertigo" who's only complaint was that periodically throughout the day he simply loses his vision. Doesn't fade out, isn't associated with dizziness or any other symptom. He suddenly just can't see anything for about five minutes. Happens while he's driving, too. Great chief complaint for an ENT clinic.

Actually, the best one was a patient referred to me routinely for vertigo. She was scheduled for a hearing test before she saw me in clinic, about 2 weeks after she presented to her PCP. The audiologist came to find me when the patient had an acute attack of vertigo in her office, but was confused as to why the attack presented with dysarthria and upper unilateral upper extremity paresthesia. Fortunately, we had this machine called an MRI that was able to diagnose her multiple strokes and we were able to get her to a stroke center a mere 2 weeks after presentation. She says she told her PCP about the dysarthria and the tingling, but the PCP must not have understood her, what with the mispronunciation and poor articulation.
Click to expand...

I guess it's this way for everyone. But your clinic sounds just like mine
 
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HighPriest said:
Vertigo is another bane of the ENT existence. Because, of course, every single person on this side of the ground (and a few on the other) who has ever felt off balance for even a few seconds of their life ends up in my office. My favorites are the 99 1/2 year old with late stage macular degeneration, bilateral hip replacements, in a wheelchair, with parkinson's disease who gets referred to me for being "off balance." I mean....no $#!t. Let me just see if I can open up the heavens and heal with a touch today...

But two consults stand out specifically:

I saw a guy referred for "vertigo" who's only complaint was that periodically throughout the day he simply loses his vision. Doesn't fade out, isn't associated with dizziness or any other symptom. He suddenly just can't see anything for about five minutes. Happens while he's driving, too. Great chief complaint for an ENT clinic.

Actually, the best one was a patient referred to me routinely for vertigo. She was scheduled for a hearing test before she saw me in clinic, about 2 weeks after she presented to her PCP. The audiologist came to find me when the patient had an acute attack of vertigo in her office, but was confused as to why the attack presented with dysarthria and upper unilateral upper extremity paresthesia. Fortunately, we had this machine called an MRI that was able to diagnose her multiple strokes and we were able to get her to a stroke center a mere 2 weeks after presentation. She says she told her PCP about the dysarthria and the tingling, but the PCP must not have understood her, what with the mispronunciation and poor articulation.
Click to expand...

We see the opposite. Episodic vertigo, transient loss of consciousness. HAS TO BE THE CAROTIDS!
 
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ThoracicGuy said:
You could be getting those with leg pain, but a normal ABI and palpable pulses...
Click to expand...


Please, I'm putting my neurologist buddy's kid through college with all of the restless leg syndrome patients that somehow all end up in my office.
 
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LucidSplash said:
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)...
Click to expand...
The analogous headache as the person calling the consult is when consultant A says “consult service B” and then the patient and primary team spend a week with A and B in a ping pong match about who should do something about the problem everyone agrees needs something done for. Sometimes you can even get a 3 way game going. Surgery thinks GI or IR should do something, GI thinks IR or surgery should, IR thinks GI or surgery should....:boom:
 
siliso said:
The analogous headache as the person calling the consult is when consultant A says “consult service B” and then the patient and primary team spend a week with A and B in a ping pong match about who should do something about the problem everyone agrees needs something done for. Sometimes you can even get a 3 way game going. Surgery thinks GI or IR should do something, GI thinks IR or surgery should, IR thinks GI or surgery should....:boom:
Click to expand...
At that point I tell them to call each other and I stay out of it
 
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ThoracicGuy said:
Or neck pain... that's the carotids too!
Click to expand...
I thought 100% of neck pain was an ear infection. No matter what the ear looks like. In fact, you don't even have to look in the ear. If someone has pain above the clavicle, it's an ear infection.
 
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When I need a lung physical exam, I send the patient to pulmonary or to a CT scanner. When I need an eye exam, I send to Ophtho, and when I need an ear exam, I send to ENT. And any skin lesion obviously gets a derm referral. Isn't that the point of being the expert in that field? /s
 
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evilbooyaa said:
When I need a lung physical exam, I send the patient to pulmonary or to a CT scanner. When I need an eye exam, I send to Ophtho, and when I need an ear exam, I send to ENT. And any skin lesion obviously gets a derm referral. Isn't that the point of being the expert in that field? /s
Click to expand...
For the eye exam that's actually somewhat true. Any non-ophtho who looks in a non-dilated adult eye and claims to see much of anything is lying. I even bought one of those pan optic ophthalmoscopes and I still can't see much.
 
HighPriest said:
I thought 100% of neck pain was an ear infection. No matter what the ear looks like. In fact, you don't even have to look in the ear. If someone has pain above the clavicle, it's an ear infection.
Click to expand...

Ah ha. I found a difference. in my world Every single symptom above the clavicles is from the sinuses. And forget trying to convince someone with a normal scope and CT with headache that it probably isn't an ENT issue.
 
Pir8DeacDoc said:
Ah ha. I found a difference. in my world Every single symptom above the clavicles is from the sinuses. And forget trying to convince someone with a normal scope and CT with headache that it probably isn't an ENT issue.
Click to expand...
That’s a sinus headache. All headaches are sinus headaches. And I don’t have any allergies, either. I have rhinorrhea, congestion, itchy eyes, and that’s because I get the sinus every year around this time, now fix it! And don’t try your anti-histamine or immunotherapy black magic!
Yeah, I get plenty of those too. Fortunately sinus problems are common enough up here that that particular blind squirrel finds a nut more often than not. Then you just gotta convince them there’s more than one thing going on.
 
This call weekend is shaping up great. Consult by ED for "periumbilical abscess 2 weeks after EVAR and fem fem."

Yes it is an abscess, very distant from fem fem and EVAR. Please call the general surgeons.
 
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LucidSplash said:
This call weekend is shaping up great. Consult by ED for "periumbilical abscess 2 weeks after EVAR and fem fem."

Yes it is an abscess, very distant from fem fem and EVAR. Please call the general surgeons.
Click to expand...
Not worried about the grafts getting seeded? Or is it that there isn't anything to be done about that possibility besides treating the abscess
 
upload_2018-5-11_21-11-50.png

Someone asked me to takeover as primary on an end stage liver disease patient for which we repaired a femoral artery from an IR intervention. Patient currently intubated with hepatorenal syndrome.
 
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I've finally recovered from my call the day before yesterday... 14 consults from 6pm to 6am -.- and not a single one operative.

I'd share some of them, but I'm still too angry to even type them out -.-
 
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mimelim said:
I've finally recovered from my call the day before yesterday... 14 consults from 6pm to 6am -.- and not a single one operative.

I'd share some of them, but I'm still too angry to even type them out -.-
Click to expand...

And I'm sure you had to go in to see them all too, they couldn't wait until the morning...
 
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mimelim said:
I've finally recovered from my call the day before yesterday... 14 consults from 6pm to 6am -.- and not a single one operative.

I'd share some of them, but I'm still too angry to even type them out -.-
Click to expand...

Acute sock deficiency?
 
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Also, here is some field evidence of the ED examining foot for pulses.

giphy.gif
 
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ThoracicGuy said:
And I'm sure you had to go in to see them all too, they couldn't wait until the morning...
Click to expand...

akwho said:
Acute sock deficiency?
Click to expand...

VincentAdultman said:
It’s three days later. Just sayin...
Click to expand...

dpmd said:
He is still really angry. They were really bad consults!
Click to expand...

"Patient's legs are cold."
"Do they have signals?"
"What do you mean?"
"What is the pulse exam?"
"No."
"What do you mean no... that isn't an answer to the question?"
"Which attending is staffing the consult?"
"No."
"I'm sorry?"
10 second pause
"No."
"Oh, never mind, the patient is coding, we'll call you if we need you."
(CCU patient on ECMO)

------------------------------------------------------

"Your patient is here in triage."
"Which patient?"
"Dr. Smith's patient Mary Joe"
"I don't know who Dr. Smith is or who Mary Joe is."
"Isn't this vascular surgery?"
"Affirmative, how can I help?"
"Mary Joe is here."
"I got that, what is she here for?"
"She is bleeding from her neck"
"Okay, I'm coming down, what happened?"
"I don't know that is what her son told me, the patient is still in the bathroom, haven't had a chance to examine her."
(Patient had a nose bleed after walking into a glass door.)

------------------------------------------------------

Seeing patient with sensory changes and a down bypass as a direct transfer from another hospital. (Keep in mind that this is Thursday)
"When did symptoms start?"
"Last Wednesday, I went to the OSH ER"
"What did they do for the last week?"
"Nothing, they just told me that they didn't have a way to help me."
"And they waited a week to transfer you?"
"Ya. I've been there since last Wednesday."
"It says in your transfer paperwork they did an angio?"
"Ya, they did it last Wednesday."
"They did an angio 8 days ago and then didn't do anything."
"Ya"

It took almost 30 minutes for me to figure out that when these people (patient and 2 family members) say "Last Wednesday", they mean yesterday.

------------------------------------------------------

Had a MICU attending get upset with me because I wouldn't take their patient to the OR for PA thrombolysis. Normal echo, no cardiac markers, nothing on CT to indicate heart strain, "But, the PE looks big on the CT." At that point (~4am), it was the 3rd place on the "most impressive PE on CT" for the evening.

------------------------------------------------------

Got a consult about a left leg, turned out that the consult was actually for the right arm.

I kinda wish I was kidding, I'm not sure how you **** that one up, but ya know...

------------------------------------------------------

Got consulted by the ER for a 3.8cm AAA in a 95+yo patient in septic shock.

------------------------------------------------------

I think I have suppressed the rest.
 
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Consult for “s/p TEVAR, left lung collapsed, aorta compressing bronchus”

Look at CT, no obvious compression of bronchus, just full of crap.

Spoke with hospitalist who put in the consult, apparently he put it in after the pulm guy who bronched the patient said he pulled an impressive mucous plug out of the bronchus and it must be because the aorta is compressing it?

No acute vascular intervention. Thank you for this interesting consult.
 
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If it's any consolation you made my night a little bit better. The highlight of my weekend was getting consulted for a possible infected mediport in a 94 yo with metastatic pancreatic cancer. They wanted to know if it was still ok to use the port or if it needed to come out and delay his chemo

Not a typo, 94
 
vhawk said:
If it's any consolation you made my night a little bit better. The highlight of my weekend was getting consulted for a possible infected mediport in a 94 yo with metastatic pancreatic cancer. They wanted to know if it was still ok to use the port or if it needed to come out and delay his chemo

Not a typo, 94
Click to expand...
They will give the last dose of chemo in the mortuary if you let them.
 
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dpmd said:
They will give the last dose of chemo in the mortuary if you let them.
Click to expand...

"What would you think about VA ECMO so we can squeeze in this next cycle of 6th line chemo?"

You know the orthopedic saying about the heart being a way to get ancef to the bone? Perhaps even more true of med oncs.
 
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vhawk said:
If it's any consolation you made my night a little bit better. The highlight of my weekend was getting consulted for a possible infected mediport in a 94 yo with metastatic pancreatic cancer. They wanted to know if it was still ok to use the port or if it needed to come out and delay his chemo

Not a typo, 94
Click to expand...

Old joke. Why do they nail coffins shut? So the oncologist can’t give anymore chemo.
 
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vhawk said:
If it's any consolation you made my night a little bit better. The highlight of my weekend was getting consulted for a possible infected mediport in a 94 yo with metastatic pancreatic cancer. They wanted to know if it was still ok to use the port or if it needed to come out and delay his chemo

Not a typo, 94
Click to expand...
Is the dude at least not totally demented and bedbound? Or are they flogging a gomer?
 
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LucidSplash said:
Consult for “s/p TEVAR, left lung collapsed, aorta compressing bronchus”

Look at CT, no obvious compression of bronchus, just full of crap.

Spoke with hospitalist who put in the consult, apparently he put it in after the pulm guy who bronched the patient said he pulled an impressive mucous plug out of the bronchus and it must be because the aorta is compressing it?

No acute vascular intervention. Thank you for this interesting consult.
Click to expand...

You didn’t want to book the aortic resection?
 
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