Consults- Memorable/Dismal/Ridiculous/Unique

[Apollyon]

8yo with an "owie" on his hand and a negative hand XR. The ED doc was trying to put a splint on his finger to "protect it" and the kid was going nuts because he had autism. The mom was going nuts because the ED doctor didn't show respect for the autism diagnosis (parents tend to get very attached to this diagnosis). I got consulted to help put a metal splint on his finger. Examined the patient, built up some rapport with the mother, and explained why the splint was unnecessary they went home happy with the kid moving his hand well after some reassurance.

5yo with a bruise on his shoulder from running into a door, and a negative XR. Consulted for orthopaedic follow up and a sling. Went into the room and the patient was doing the wave with both hands above his head and said his shoulder felt much better since the XR. Examined the patient, built up some rapport with the mother, and explained why the sling and ortho follow-up were unnecessary they went home happy.

I swear the ED regresses to intern level when dealing with children. These are actual consults from ED attendings to a surgeon for a minor contusion and a bruise. For the love of all that is holy, I don't have time for these consults in addition to actual surgical consults.

I swear, you are in an academic ED. You know why docs do academics? Think of wild animals - some have to live in the zoo, because they CANNOT function/survive in the wild. Believe it or don't, when you get into the "real world" (provided you don't become ortho faculty), you will realize that most of us are not **** ups. For me, "ortho follow up" is a phone number to call in the morning.

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[deleted859535]

I swear, you are in an academic ED. You know why docs do academics? Think of wild animals - some have to live in the zoo, because they CANNOT function/survive in the wild. Believe it or don't, when you get into the "real world" (provided you don't become ortho faculty), you will realize that most of us are not **** ups. For me, "ortho follow up" is a phone number to call in the morning.

Seriously. I'm a cautious guy, but what in the world are my colleagues doing over there...

 

[HighPriest]

Just the opposite situation would be foreign bodies in the ears and noses of kids. To be honest, I'd prefer that the ER not even touch them. If it's a chip shot, so be it, but what typically happens is they macerate the ear canal and/or nose, cause a ton of bleeding and swelling, and freak the child out to the point that it's impossible to remove the FB without anesthesia. Whereas in most cases if I see them in the clinic the same day, where I have the appropriate equipment, I can take it out with minimal drama. Just have to talk to the parent and the kid a bit.

 

[Jolie South]

This one is for @Jolie South .

Taking Vascular first call for the first time in awhile. ED consult for older woman with history of scleroderma and Raynaud's, usually in her fingers. For the past 3 days has had a blue toe. ED physician says she has no pain, no ulceration, no sensory or motor deficits and palpable bilateral DP pulses. Wanted to "make sure it's her Raynaud's and nothing macrovascular".

 

[dpmd]

Just the opposite situation would be foreign bodies in the ears and noses of kids. To be honest, I'd prefer that the ER not even touch them. If it's a chip shot, so be it, but what typically happens is they macerate the ear canal and/or nose, cause a ton of bleeding and swelling, and freak the child out to the point that it's impossible to remove the FB without anesthesia. Whereas in most cases if I see them in the clinic the same day, where I have the appropriate equipment, I can take it out with minimal drama. Just have to talk to the parent and the kid a bit.

What do you think of that method where you plug the side of the nose without the foreign body and blow in the kids mouth (by the parent that is) to dislodge it?

 

[Apollyon]

What do you think of that method where you plug the side of the nose without the foreign body and blow in the kids mouth (by the parent that is) to dislodge it?

That one is great (for me), especially if it is Mom that has brought the kid to the ED. I warn Mom that the object is covered in boogers, to make sure she knows. But, then, when I tell the kid, "Mommy's going to give you a BIG kiss", they sorta even look forward to it! Then, the snot rocket is blasted out, and Mom is covered in mucus.

 

[LucidSplash]

ED Triage just called me to give me a heads up on a woman with tingling in her arm. No workup yet, “ordered” per the person on the phone.

Me: “Do they have palpable pulses?”
Them: “Yes”
Me: “Call me if you find a vascular problem”
Them: “So you’re not coming to see her?”

 

[Jolie South]

ED Triage just called me to give me a heads up on a woman with tingling in her arm. No workup yet, “ordered” per the person on the phone.

Me: “Do they have palpable pulses?”
Them: “Yes”
Me: “Call me if you find a vascular problem”
Them: “So you’re not coming to see her?”

Got a consult in a lady with a totally functional AV graft for “ischemic blue fingertips.” I’m like ok well maybe there is some steal or something.

Go talk to the patient. No pain, no sensory loss, no motor issues. Fingertips not discolored. Palpable distal pulse. Functioning graft.

I write as such in my note. I keep the patient on my list until my attending sees. FOR DAYS AFTERWARDS, they are still documenting “ischemic blue mottled fingertips”. I go back to see patient to make sure I didn’t miss something.

NOPE. A patient with no actual complaints or problems.

 

[HighPriest]

What do you think of that method where you plug the side of the nose without the foreign body and blow in the kids mouth (by the parent that is) to dislodge it?

I’m ok with it. That usually doesn’t traumatize the patient, and if it doesn’t work it’s no harm.

 

[TraumaLlamaMD]

ED Triage just called me to give me a heads up on a woman with tingling in her arm. No workup yet, “ordered” per the person on the phone.

Me: “Do they have palpable pulses?”
Them: “Yes”
Me: “Call me if you find a vascular problem”
Them: “So you’re not coming to see her?”

Our new ED interns started this week too.

 

[LucidSplash]

Our new ED interns started this week too.

This was a triage nurse, they tend to be pretty bad about it and apparently aren’t required to run this stuff by anyone.

Unsurprisingly CTA negative. ED was still nervous about stopping the heparin gtt when I told them to.

 

[Jolie South]

5 pm Friday consult for a recent BKA done at an outside hospital. Patient is here for rehab and has no incisional issues.

 

[Psai]

Our new ED interns started this week too.

God I am so looking forward to the posts in this thread

 

[Arcan57]

God I am so looking forward to the posts in this thread

From great pain comes great art.

 

[evilbooyaa]

5 pm Friday consult for a recent BKA done at an outside hospital. Patient is here for rehab and has no incisional issues.

The inpatient rehab at one hospital we covered was by far the worst. Pan-consult for every body part that was not 100% normal. Bad enough to the point the residency said the residents don't have to cover it because of lack of educational value. A surgical residency making a statement like that blew my mind at the time.

 

[FlowRate]

5 pm Friday consult for a recent BKA done at an outside hospital. Patient is here for rehab and has no incisional issues.

Visitor from psychiatry here. This made me feel a little better about my own 5PM consult today. ("We were going to let her leave but then the nursing supervisor started demanding that I page psych." Poor newbie intern.)

 

[Psai]

Visitor from psychiatry here. This made me feel a little better about my own 5PM consult today. ("We were going to let her leave but then the nursing supervisor started demanding that I page psych." Poor newbie intern.)

the nurse supervisor has zero say in medical decision making. Teach the intern.

 

[Jolie South]

the nurse supervisor has zero say in medical decision making. Teach the intern.

They don’t, but they will RRT the patient bc they feel the doctors aren’t responding to a patient care issue in a timely fashion.

I have gotten railroaded a number of times on issues I knew about and was addressing, but apparently the “patient met sepsis criteria and needs to go to the unit.” Or some other silliness.

 

[FlowRate]

the nurse supervisor has zero say in medical decision making. Teach the intern.

I get where he was coming from--it would absolutely suck to alienate the already enraged (at the patient) nursing staff in that moment and then have to work with them for another month... Not sure how complicit his senior or attending were in the consult, they are the ones who should do that teaching. We are the ones who get to teach the team that there's a very low bar for a medically stable patient to be allowed to leave AMA, the patient is probably not actually intending to leave AMA, and no, this patient is most definitely not manic.

 

[deleted50541]

This happens at least once every other month. Usually around 2AM.

ED: (sounds flustered and excited) "Hey, I've got an aortic dissection for you."
Me: "Ok, what's the story? Is there imaging?"
Look up patient, see we repaired their acute type A dissection years ago, have stable residual dissection that hasn't changed on serial imaging
ED: "I've got the esmolol drip going. When do you think they'll go for surgery?"
Me: *Sigh*..."You do realize this patient already had surgery, right? Did you even see this patient?"
ED: "Umm, well they just got transferred from (insert podunk ED) and I didn't get all the details."

Everytime, without fail.

 

[Arcan57]

Had a first today (hypothetically). Pt sent from CRS’s office after (apparently partial) drainage in said office of a perirectal abscess to determine if we (the ED) thought the patient needed to be admitted. Nope, there were no other active medical problems. Apparently the two midlevels in the office disagreed about management and sent them to us as a tie breaker. SMH...

 

[deleted547339]

This happens at least once every other month. Usually around 2AM.

ED: (sounds flustered and excited) "Hey, I've got an aortic dissection for you."
Me: "Ok, what's the story? Is there imaging?"
Look up patient, see we repaired their acute type A dissection years ago, have stable residual dissection that hasn't changed on serial imaging
ED: "I've got the esmolol drip going. When do you think they'll go for surgery?"
Me: *Sigh*..."You do realize this patient already had surgery, right? Did you even see this patient?"
ED: "Umm, well they just got transferred from (insert podunk ED) and I didn't get all the details."

Everytime, without fail.

You do realize that most of these patients show up with EMS who knows nothing after being accepted by one of your vascular or CT attendings with no sign out to the ER physician?

In residency I got a lot of crap for these patients, but the frustration that is usually felt at academic institutions should be with your faculty, not the ER.

 

[dpmd]

You do realize that most of these patients show up with EMS who knows nothing after being accepted by one of your vascular or CT attendings with no sign out to the ER physician?

In residency I got a lot of crap for these patients, but the frustration that is usually felt at academic institutions should be with your faculty, not the ER.

They don't always call the specialist when the do an er to er transfer for higher level of care. In fact, the times a specialist is consulted and agrees to take a patient the transfer is often to an inpatient status bypassing the er (or directly to the or in certain cases). If it gets kicked to the er I would assume further workup is required and said specialist isn't immediately required until said workup is completed.

 

[Dr.LeoSpaceman]

You do realize that most of these patients show up with EMS who knows nothing after being accepted by one of your vascular or CT attendings with no sign out to the ER physician?

In residency I got a lot of crap for these patients, but the frustration that is usually felt at academic institutions should be with your faculty, not the ER.

What would signout to the ER really accomplish? I've taken these transfer calls myself, and the information received is often incomplete or wrong. If it's a patient known to the service from recent admission or operation, they'll often get directly admitted. If they need a pass through the ER, then yes the ER charge nurse will frequently be called.

But if it's a patient that no one has any knowledge about and they're being sent to the ED, then one might expect that they receive an initial workup and evaluation to actually determine what's going on. The phone calls that say "Hey, the patient is here and supposedly they have XYZ" aren't helpful. If that's all we get, why even have an ED?

 

[mimelim]

You do realize that most of these patients show up with EMS who knows nothing after being accepted by one of your vascular or CT attendings with no sign out to the ER physician?

In residency I got a lot of crap for these patients, but the frustration that is usually felt at academic institutions should be with your faculty, not the ER.

That is what a history and physical exam is for. I am among the first people to chastise physicians for ****ty communication, but the number of times I get the call of, "The patient is here, someone says they have XYZ, but I know nothing else and haven't seen the patient." borders on the absurd. It is one thing when it is ER triage/intake. It is another when it is the ER physician or their team.

 

[deleted547339]

What would signout to the ER really accomplish? I've taken these transfer calls myself, and the information received is often incomplete or wrong. If it's a patient known to the service from recent admission or operation, they'll often get directly admitted. If they need a pass through the ER, then yes the ER charge nurse will frequently be called.

But if it's a patient that no one has any knowledge about and they're being sent to the ED, then one might expect that they receive an initial workup and evaluation to actually determine what's going on. The phone calls that say "Hey, the patient is here and supposedly they have XYZ" aren't helpful. If that's all we get, why even have an ED?

Maybe I’m taking out personal frustration, but this was a huge point of contention in both my residency and fellowship. Yes, these patients are often directly admitted, but frequently the accepting physician will send them to the ER to have someone eyeball them and make sure they’re not going to be a rapid response as soon as they hit the floor. In these cases, the only signout we get is EMS saying “they’ve got a dead foot and are accepted by Dr. vascular.” The problem is that Dr. vascular can’t be bothered to tell his chief or the ER attending that the patient has been coming, whether this is an emergent straight to OR case or hep gtt then floor, what imaging has or hasn’t been done and whether or not they have already received a contrast load. Then that takes up an ER bed and leaves us playing telephone over something that should have been a smooth transition because lack of professional curtesy to just pick up the damned phone. Not to mention the odd medical legal implications of an accepting physician being the attending of record but having the patient show up in your ER.

This is such a sucky thing from the ER perspective. You want me to start from scratch on all of these transfers when your attending has already decided to emergently book it? Sure, I can delay the care by 3 hours getting more imaging and labs when this stuff has already been done and no one bothered to tell me.

This is a dump on the ER, plain and simply. These patients should have already been worked up at the outside ER and have been presented for transfer in the same manner that they would be if they were being admitted to you. If not, they shouldn’t have been accepted as a transfer.

Just pick up the damned phone when you ask for a patient to be sent to the ER. It takes five minutes, helps patient care and makes everyone’s lives better. Then you don’t do this “f the stupid ER doc” thing because no one told us about this patient. It’s so much easier to hear “hey this guy has an iffy sounding dissection, could you rescan him then call me?” Or “hey, 4 alarm fire, call me the second he hits the door” or “it’s provably nothing, can you get this stuff done - call me if anything’s crazy, otherwise ask medicine to admit and I’ll see tomorrow.”

**rant over***

I feel better.

 

[deleted547339]

That is what a history and physical exam is for. I am among the first people to chastise physicians for ****ty communication, but the number of times I get the call of, "The patient is here, someone says they have XYZ, but I know nothing else and haven't seen the patient." borders on the absurd. It is one thing when it is ER triage/intake. It is another when it is the ER physician or their team.

I’ve gotten screamed at for getting a quick history and physical and sending off labs because “this patient got here 20 minutes ago, how the f could you not call me the second they got here!?!?” Ive also gotten, why the hell are you calling me if you haven’t don’t x, y and z!?!?

You know more about the patient that we do when you accept them. Just show some professionalism and call. It makes all of this go away.

 

[dpmd]

Maybe I’m taking out personal frustration, but this was a huge point of contention in both my residency and fellowship. Yes, these patients are often directly admitted, but frequently the accepting physician will send them to the ER to have someone eyeball them and make sure they’re not going to be a rapid response as soon as they hit the floor. In these cases, the only signout we get is EMS saying “they’ve got a dead foot and are accepted by Dr. vascular.” The problem is that Dr. vascular can’t be bothered to tell his chief or the ER attending that the patient has been coming, whether this is an emergent straight to OR case or hep gtt then floor, what imaging has or hasn’t been done and whether or not they have already received a contrast load. Then that takes up an ER bed and leaves us playing telephone over something that should have been a smooth transition because lack of professional curtesy to just pick up the damned phone. Not to mention the odd medical legal implications of an accepting physician being the attending of record but having the patient show up in your ER.

This is such a sucky thing from the ER perspective. You want me to start from scratch on all of these transfers when your attending has already decided to emergently book it? Sure, I can delay the care by 3 hours getting more imaging and labs when this stuff has already been done and no one bothered to tell me.

This is a dump on the ER, plain and simply. These patients should have already been worked up at the outside ER and have been presented for transfer in the same manner that they would be if they were being admitted to you. If not, they shouldn’t have been accepted as a transfer.

Just pick up the damned phone when you ask for a patient to be sent to the ER. It takes five minutes, helps patient care and makes everyone’s lives better. Then you don’t do this “f the stupid ER doc” thing because no one told us about this patient. It’s so much easier to hear “hey this guy has an iffy sounding dissection, could you rescan him then call me?” Or “hey, 4 alarm fire, call me the second he hits the door” or “it’s provably nothing, can you get this stuff done - call me if anything’s crazy, otherwise ask medicine to admit and I’ll see tomorrow.”

**rant over***

I feel better.

Shouldn't you direct your frustration to your colleague at the outside er who didn't call you about a patient they are transferring to your care. That way you would know if this was "this dude has x and I spoke to dr y who wants z additional workup to see if they need w management" or "I think this dude has x and we don't have y specialty so we are shipping him to you because we have a transfer agreement in place, good luck"

 

[Dr.LeoSpaceman]

You know more about the patient that we do when you accept them. Just show some professionalism and call. It makes all of this go away.

As I said, if I actually know the patient and know what I want done, it will get a call to the ED. If it's some random physician/NP/PA at St. Elsewhere who wants to send some new patient, then I don't really know more than you and I'm assuming they'll get some sort of assessment. If I wanted something different, then it's on me for not arranging it prior to patient arrival.

 

[deleted547339]

Shouldn't you direct your frustration to your colleague at the outside er who didn't call you about a patient they are transferring to your care. That way you would know if this was "this dude has x and I spoke to dr y who wants z additional workup to see if they need w management" or "I think this dude has x and we don't have y specialty so we are shipping him to you because we have a transfer agreement in place, good luck"

No. It’s on the receiving physician. It’s not his or her job to be your secretary and relay what you want done. When you accept them, it’s your patient - regardless of if it’s known to you previously or not.

 

[Dr.LeoSpaceman]

No. It’s on the receiving physician. It’s not his or her job to be your secretary and relay what you want done. When you accept them, it’s your patient - regardless of if it’s known to you previously or not.

All this assumes the patient arrives "as billed", which we both know is often not the case. I may want a CTA on a guy with a "cold leg", but what happens if the guy shows up and actually has pulses? Would you just do the CTA as the guy hits the door without actually doing an exam because that's what you were told would be the plan? That seems like a waste.

And it's only "my patient" if they show up and have a problem I treat. The guy with presumed appendicitis isn't mine when they show up and actually have gastroenteritis.

 

[mimelim]

I’ve gotten screamed at for getting a quick history and physical and sending off labs because “this patient got here 20 minutes ago, how the f could you not call me the second they got here!?!?” Ive also gotten, why the hell are you calling me if you haven’t don’t x, y and z!?!?

You know more about the patient that we do when you accept them. Just show some professionalism and call. It makes all of this go away.

The vast majority of the time we know very little about them. Maybe we know what was happening with them 6 months ago the last time we saw them, but what other facilities/providers tell us is limited or completely wrong. But, the rest of the time it is a new patient to me and there is nothing that I can tell you that is going to help. If I know what is going on with the patient or am worried about something, I'm going to either directly admit them or someone is getting a phone call.

Last night I got wind of one of my patients coming to the ER (text from one of the IM docs), I put in an SMA stent and ex-lapped her 6 weeks ago for acute mesenteric ischemia. She is a complex lady with complex problems. She apparently told the IM doc that she had BRBPR, but that is all we got in history. I left my cell with the triage desk and let the ER team know that we were expecting her at some point (driving in from 150+ miles away). Yes, I know her well and yes, she has complex issues that I know and understand better than any other person in our hospital system. But, that is substantially different than the 'cold leg' with palpable pulses that gets me pulled into the hospital at midnight. Or the "We need a quinton catheter." at 2am from last week when there were no plans for dialysis until morning.

 

[dpmd]

No. It’s on the receiving physician. It’s not his or her job to be your secretary and relay what you want done. When you accept them, it’s your patient - regardless of if it’s known to you previously or not.

There is a world of difference between "I accept responsibility for this patient", and "I will be available to consult if it turns out they actually have an issue i treat".

 

[LucidSplash]

So, having taken a lot of these phone calls as a chief resident, I can tell you where a lot of the disconnect is.

Just because an OSH ED says that vascular (or general or whoever) has accepted the patient or because the transfer center writes that down doesn’t make it so.

Frequently we would get a call with vague history, some kind of suspected diagnosis, but the OSH person isn’t really sure what’s going on but they are uncomfortable having the patient at podunk ED for the remainder of the workup. So they call and the vascular or whatever attending says “sure you can send that to our ED for evaluation.” Podunk ED and transfer center then write down that Dr. Vascular accepted the patient, when they did no such thing. OSH ED doc knows the patient is going to the ED at the other hospital but because they spoke with a doc already, they don’t feel like they need to talk to their counterpart, they’re just getting them out of their ER. It’s a nasty vicious circle.

 

[VisionaryTics]

So, having taken a lot of these phone calls as a chief resident, I can tell you where a lot of the disconnect is.

Just because an OSH ED says that vascular (or general or whoever) has accepted the patient or because the transfer center writes that down doesn’t make it so.

Frequently we would get a call with vague history, some kind of suspected diagnosis, but the OSH person isn’t really sure what’s going on but they are uncomfortable having the patient at podunk ED for the remainder of the workup. So they call and the vascular or whatever attending says “sure you can send that to our ED for evaluation.” Podunk ED and transfer center then write down that Dr. Vascular accepted the patient, when they did no such thing. OSH ED doc knows the patient is going to the ED at the other hospital but because they spoke with a doc already, they don’t feel like they need to talk to their counterpart, they’re just getting them out of their ER. It’s a nasty vicious circle.

Drives me nuts. Happens all the time.

I specifically tell the outside ER calling me "I am not accepting patient, I am recommending ER-to-ER transfer and our ER will evaluate them when they get here."

 

[deleted547339]

Drives me nuts. Happens all the time.

I specifically tell the outside ER calling me "I am not accepting patient, I am recommending ER-to-ER transfer and our ER will evaluate them when they get here."

The problem is that unless you do explicitly what you’ve described (which is the exception), you’re just dumping on your ER. If you refuse a transfer but suggest that they send it to your ER, a phone call will happen to the ER - otherwise it’s an emtala violation.

The vast majority of people say “sure, send them to the ER” without the understanding that they are legally accepting responsibility for that patient. The appt that turns out to be gastro is still legally yours if you accept it. If you’re not accepting it, you need to be clear in your refusal. If you refuse and the OSH ER doc calls me, I’m happy to have them transferred, but only if someone calls me. If it ends up being something other than billed, we’re happy to help dispo as appropriate.

Think about it like this: I can’t accept a patient to your service. The ED is my service. You can’t admit to my service. We are bound by emtala, so if you recommend someone be evaluated, we will evaluate them. But if the patient is under the care of another physician, they have to have an accepting physician otherwise they can’t transfer. If you’re accepting the patient, they’re yours. We’re ALWAYS happy to help, but a simple phone call asking for help. Again, if it turns out to not be as billed, they are still yours on paper.

 

[Apollyon]

I work out in the boonies. When I am at work, for about 2/3 of the day (I work 24s), I am the only doc in house. I have ortho coverage 9am Monday to 1pm Friday, with many vacations (including 1 month every summer back to Greece). GSx is 5pm Tuesday until 5pm Thursday. That's it. No hospitalist, no specialists of any type, and the anesthesiologist is pain only. He nominally supervises the 2 CRNAs (the closer one lives 40 minutes away), but hasn't done an anesthesia case since I've been here (4+ years). It is - literally - "the hospital in the woods".

When I need to transfer to the "ivory tower", it is ~100 miles away. With one exception, I always speak to the attending. Only resident I ever get is ENT. However, also, it is a complete pain to get that ENT resident. Often, it takes more than 1 hour. Then, if ENT says they need GSx (or they call it a "trauma", and GSx is the coordinator), the clock starts over. But, when I get the attending, I tell them exactly what I've found. If I just need a telephone consult, I get that, too (with one neurologist who won't do it, and one endocrinologist down in Pittsburgh who would not). Ortho at the tertiary care place is especially helpful. However, also, I don't hang them out to dry. What has happened of late is I take a picture of the EKG or Xray, and text it to the doc. One case was ortho, with a diabetic woman with an open fracture of the 5th toe. My ortho guy was out of town. The doc on the phone said that I could just wash it out with a bulb syringe and close it best I could. I said, "what if I text you the Xray?" He calls back, and says, "Send her up. She might need pinning."

If your transfer center isn't getting the receiving doc on the phone, they're not worth it. UPMC Med Call confirms the name, and to what service. And, if I don't know who I need or what service, or which hospital has the service, they figure it out. That REALLY helps. And, when you get out of residency, it should get A LOT better. No one says, "I'm not accepting the patient." Even when it is exigent, and the EKG looks like a STEMI, but it turned out to be a dissection (but I didn't yet know that), the cardiologist said, "as soon as you can, send him up. Put my name on it." That's a lot better than him telling me, "call vascular". I did call vascular, but Rob (cards) was willing to accept him, just to keep things moving.

 

[Dr.LeoSpaceman]

The vast majority of people say “sure, send them to the ER” without the understanding that they are legally accepting responsibility for that patient. The appt that turns out to be gastro is still legally yours if you accept it. If you’re not accepting it, you need to be clear in your refusal. If you refuse and the OSH ER doc calls me, I’m happy to have them transferred, but only if someone calls me. If it ends up being something other than billed, we’re happy to help dispo as appropriate.

If you're offering to take all the transfer calls for new patients, I'd happily oblige and let you do it. Because that's going to be much easier for me than taking a phone call (often while I'm in the OR) and then taking another break to call down to the ED. Alternatively, we can have the ED build
an area staffed with NPs and nurses to handle these transfer patients that need diagnostic workup and triage, and we can be the supervising docs and do the billing. I'll call it an "Emergency Surgical Evaluation Department".

At my place, I'd also say you should take it up with hospital administrators. We are under strict instructions to basically accept every patient, and make it as easy as possible for referring docs to send patients in. If I start declining transfers and referring to ED, I'm going to hear about it.

I'm also still puzzled as to how referring someone with an unclear diagnosis to be transfered to the ED is a "dump". (And yes, I consider most things being transferred in as "unclear" unless I can see the imaging in our system, or I have a working relationship with the person referring in.)

 

[Apollyon]

Oh, and, if the attending is accepting the patients in transfer, but doesn't call you, the resident or fellow, to tell you a patient is coming, then that is either lazy or ****ty professionalism. Don't be that person when you are that person.

 

[Smurfette]

I guess I am just too conscientious that the above scenario seems foreign to me. If I accept the patient, it's a direct transfer to floor/ICU/pre-op holding and I make a ton of phone calls to make it happen. It's pretty rare I directly accept as a surgeon (I'm not at a tertiary center), nor is there a "transfer center" as I have to arrange stuff myself by calling the appropriate persons based on the time of day. If I instead direct a patient to the ED (or ask one to be transferred there from OSH), I always call and give the ER doc a heads up and what my concern is for (or what tests I think they need). Sometimes they seem annoyed by this although I'm generally not one to send BS things to the ER. I'd much rather hang up with a patient/outside doc and immediately call the ER than be rudely awakened in an hour or two---likely just after finally falling back asleep---by the ER doc wondering what is going on.

 

[EMDOC17]

Gotta poke some fun.

45 yo with Abdominal pain. Tender to right mid and lower quadrant. Labs with wbc of 13 so end up scanning. Radiology hedge on a “appendix on upper edge of normal.”

Well that’s a call to the surgeon. They come down and eval and asks me to come back to the room with him.

“Does this look like shingles to you?”

“No that’s a classic Miller sign!”

“Huh?”

“It means I owe you a goddamn beer.”

D/C with valcyclovir.

When the surgeon diagnoses your patients shingles it’s a miserable consult. Luckily we get along well and it wasn’t 2 am.

 

[dpmd]

Gotta poke some fun.

45 yo with Abdominal pain. Tender to right mid and lower quadrant. Labs with wbc of 13 so end up scanning. Radiology hedge on a “appendix on upper edge of normal.”

Well that’s a call to the surgeon. They come down and eval and asks me to come back to the room with him.

“Does this look like shingles to you?”

“No that’s a classic Miller sign!”

“Huh?”

“It means I owe you a goddamn beer.”

D/C with valcyclovir.

When the surgeon diagnoses your patients shingles it’s a miserable consult. Luckily we get along well and it wasn’t 2 am.

Was there a time gap in which the rash maybe declared itself, or had you just not lifted the gown initially?

 

[HighPriest]

ICU resident: We have a 27 year old patient, iv drug user. He was admitted yesterday with a very swollen neck. CT angio was normal, except for edema. We were wondering if you could come take a look at his neck to see if there's anything you can do about the swelling.

Self: Well, probably not. You could give him some steroids, but I wouldn't unless he has an airway issue or it's really bothering him.

ICU resident: Well, it's not bothering him, he's on a ventilator because he has an anoxic brain injury.

Self: Huh. Ok. I feel like I'm missing something here. Why does he have anoxic brain injury?

ICU resident: Oh, he hanged himself.

Self: Well, that explains the swelling. Seems like something one mentions up front. CT was otherwise negative, though. (I checked) Not much I can do to help.

ICU resident: Well, we just wanted to be certain there wasn't another reason for the swelling.

Self to Self: "No, I think you've solved the case, Watson."

 

[dpmd]

ICU resident: We have a 27 year old patient, iv drug user. He was admitted yesterday with a very swollen neck. CT angio was normal, except for edema. We were wondering if you could come take a look at his neck to see if there's anything you can do about the swelling.

Self: Well, probably not. You could give him some steroids, but I wouldn't unless he has an airway issue or it's really bothering him.

ICU resident: Well, it's not bothering him, he's on a ventilator because he has an anoxic brain injury.

Self: Huh. Ok. I feel like I'm missing something here. Why does he have anoxic brain injury?

ICU resident: Oh, he hanged himself.

Self: Well, that explains the swelling. Seems like something one mentions up front. CT was otherwise negative, though. (I checked) Not much I can do to help.

ICU resident: Well, we just wanted to be certain there wasn't another reason for the swelling.

Self to Self: "No, I think you've solved the case, Watson."

That is just spectacular.

 

[Dr.LeoSpaceman]

Self to Self: "No, I think you've solved the case, Watson."

Fanstastic. Was this an intern? If so, they need to learn quick that for consults like these you have to liberally pepper in "I know it's ridiculous" and "My senior/attending really would like your input". It's the only way to blunt the shame of being the one to have to make the call.

 

[HighPriest]

Was this an intern?

God, I hope so.

 

[OtoHNS]

ICU resident: We have a 27 year old patient, iv drug user. He was admitted yesterday with a very swollen neck. CT angio was normal, except for edema. We were wondering if you could come take a look at his neck to see if there's anything you can do about the swelling.

Hahaha wow.

 

[EMDOC17]

Was there a time gap in which the rash maybe declared itself, or had you just not lifted the gown initially?

No I’m sure it was there when I saw them. This was a super busy shift (no excuse) where I went in and pressed on the belly over the clothes. As a pretty new attending (almost one year now) sometimes you are humbled to go back to the basics.

 

[mimelim]

From last week...

ER: We have a patient that needs a quinton.

Me: Are they going to dialyze tonight?

ER: Yes, their potassium is 5.8.

Me: Who is the nephrologist? I really doubt that someone is actually going to start dialysis at 2am.

ER: Dr. ABC is the nephrologist. We haven't talked to them yet.

Me: Then how do you know they will do dialysis tonight? (Only nephrologists can put in dialysis orders)

ER: My attending says that they will need urgent dialysis, I told you, their potassium is 5.8. "That is really high!" (Exact words)

Me: Can I talk to them?

ER attending: This patient must get dialysis now, they haven't had dialysis in two days.

Me: Patients normally only get dialysis every two days.

ER attending: Well, they need dialysis because their potassium is high and the nephrologist agrees.

Me: I'm on my way in. (1am mind you)


I drove in and called the nephrologist from the car (friend of mine), his opening line after I told him why I was calling was, "**** you calling me for? You don't need my permission to tell the ER to stop being stupid." I feel a little bad for it, but I was not too happy with that ER attending when I got there at 1:30am and told them pointblank never to lie about talking to other consulting services in front of their intern they had calling me.

 

[dpmd]

From last week...

ER: We have a patient that needs a quinton.

Me: Are they going to dialyze tonight?

ER: Yes, their potassium is 5.8.

Me: Who is the nephrologist? I really doubt that someone is actually going to start dialysis at 2am.

ER: Dr. ABC is the nephrologist. We haven't talked to them yet.

Me: Then how do you know they will do dialysis tonight? (Only nephrologists can put in dialysis orders)

ER: My attending says that they will need urgent dialysis, I told you, their potassium is 5.8. "That is really high!" (Exact words)

Me: Can I talk to them?

ER attending: This patient must get dialysis now, they haven't had dialysis in two days.

Me: Patients normally only get dialysis every two days.

ER attending: Well, they need dialysis because their potassium is high and the nephrologist agrees.

Me: I'm on my way in. (1am mind you)


I drove in and called the nephrologist from the car (friend of mine), his opening line after I told him why I was calling was, "**** you calling me for? You don't need my permission to tell the ER to stop being stupid." I feel a little bad for it, but I was not too happy with that ER attending when I got there at 1:30am and told them pointblank never to lie about talking to other consulting services in front of their intern they had calling me.

If they hadn't had dialysis in two days it implies that they did have dialysis before that. What ****ing access did they use then that they couldn't use now.