Consults- Memorable/Dismal/Ridiculous/Unique

[mimelim]

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.

AVG thrombosed. They got that part right at least

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[deleted547339]

AVG thrombosed. They got that part right at least

What. The. Hell.

I’m so confused on so many levels.

 

[Raryn]

AVG thrombosed. They got that part right at least

I don't get it. Maybe it's an artifact of where I trained, but why does the ER need a vascular surgeon at 1am to place temporary dialysis access? If it's that emergent, they should place it themselves. Or the ICU can do it when the patient goes there (given that if it's that emergent, they better be unstable). If it's not that urgent (which a K of 5.8 wouldn't be to me), it can wait till the morning.

 

[dpmd]

I don't get it. Maybe it's an artifact of where I trained, but why does the ER need a vascular surgeon at 1am to place temporary dialysis access? If it's that emergent, they should place it themselves. Or the ICU can do it when the patient goes there (given that if it's that emergent, they better be unstable). If it's not that urgent (which a K of 5.8 wouldn't be to me), it can wait till the morning.

The answer is they don't need them, but since they have an excuse to consult vascular (the graft thrombosis) they will go ahead and dump the semi related procedure they don't want to do.

Where I trained there was no vascular and they would try to get us to do temporary catheters. Our answer was a categorical no. We would place tunneled catheters during business hours when space was available in the or. Otherwise they needed to do their own (usually would be medicine not er but same principle). If they didn't have a senior capable of supervising the procedure (as in not signed off because there was a list of what procedures people could do with what supervision) then we would supervise whoever of their team wished to get taught while the other members of said team watched. That way it cut down on the just not wanting to spend the time on it calls and strictly kept it to times where it was urgently needed but the night folks weren't experienced enough to do it by themselves.

 

[LucidSplash]

It’s institutionally dependent. Some places I interviewed it was vascular responsibility to place temp HD cath,some Gen Surg, some VIR. Usually there was a historical incident long before anyone’s memory that made it so.

 

[deleted50541]

It’s institutionally dependent. Some places I interviewed it was vascular responsibility to place temp HD cath,some Gen Surg, some VIR. Usually there was a historical incident long before anyone’s memory that made it so.

I had a similar experience. At one hospital as a gen surg resident, we were often paged to be the overnight "line service". It happened a few times to me, and I don't recall being too annoyed. Usually whoever called, said it was a difficult stick or they didn't "feel comfortable". Uh huh.

My favorite line though was "Hey sorry, we caused a pneumo and need a chest tube. BTW, can you put a line in while you're here?".

But eventually someone complained to the program director about it and he said this was no longer allowed.

 

[Psai]

I had a similar experience. At one hospital as a gen surg resident, we were often paged to be the overnight "line service". It happened a few times to me, and I don't recall being too annoyed. Usually whoever called, said it was a difficult stick or they didn't "feel comfortable". Uh huh.

My favorite line though was "Hey sorry, we caused a pneumo and need a chest tube. BTW, can you put a line in while you're here?".

But eventually someone complained to the program director about it and he said this was no longer allowed.

Our ED gets giddy about procedures

 

[mimelim]

I don't get it. Maybe it's an artifact of where I trained, but why does the ER need a vascular surgeon at 1am to place temporary dialysis access? If it's that emergent, they should place it themselves. Or the ICU can do it when the patient goes there (given that if it's that emergent, they better be unstable). If it's not that urgent (which a K of 5.8 wouldn't be to me), it can wait till the morning.

The answer is they don't need them, but since they have an excuse to consult vascular (the graft thrombosis) they will go ahead and dump the semi related procedure they don't want to do.

Where I trained there was no vascular and they would try to get us to do temporary catheters. Our answer was a categorical no. We would place tunneled catheters during business hours when space was available in the or. Otherwise they needed to do their own (usually would be medicine not er but same principle). If they didn't have a senior capable of supervising the procedure (as in not signed off because there was a list of what procedures people could do with what supervision) then we would supervise whoever of their team wished to get taught while the other members of said team watched. That way it cut down on the just not wanting to spend the time on it calls and strictly kept it to times where it was urgently needed but the night folks weren't experienced enough to do it by themselves.

Entirely institution/hospital dependent. By virtue of some agreement many years ago, all quintons go to vascular surgery and all other lines go to general surgery. The logic being that we should be involved in all patients needing dialysis access because we are the primary provider of permanent dialysis access. The majority of quintons we place are for ESRD patients who have lost their permanent access or are newly initiating dialysis. Pretty rare we are placing something that is truly temporary. Everyone leaves the hospital with a plan A, B and C for their long term needs which is pretty nice tbh. We have 40+ nephrologists at our main hospital, the vast majority call us directly, even for patients in the ED or ICU or whatever. We try to turf them to the ICUs at least, but the ED doesn't really have residents that 'need their numbers', so we do most of those.

At our outlying hospitals virtually all lines are done by VIR which is fine by me.

 

[Jolie South]

It’s institutionally dependent. Some places I interviewed it was vascular responsibility to place temp HD cath,some Gen Surg, some VIR. Usually there was a historical incident long before anyone’s memory that made it so.

Thanks to baby Jesus that in residency and now in fellowship I have attendings that stand up to that garbage. We have ICU teams and IR that place all these lines.

If it’s emergent and patient is ICU level, ICU places. All others are placed by IR. I really don’t see the need for vascular to be involved in the quintons. We can do the vein mapping and see the patient for a new access or revision of existing access the next day and we do.

 

[deleted547339]

Where I did residency and fellowship, the ER and ICU placed all of our own temporary lines. VIR would place tunneled lines M-F but always pitched a fit about being asked to place one on a patient in the ICU. Vascular was never called at either - they were busy, doing, you know, vascular surgery.

 

[BigRedBeta]

These institutional differences that are policy are often aggravating in both directions.

Funny enough, where I did fellowship, the long time PICU division head over time had allowed a lot of things to be turfed out to other services. New division head comes in and is baffled that her ICU fellows aren't allowed to place HD/pheresis caths, IR does all PICC lines, chest tubes usually done by surgery, anesthesia runs the sedation service and so most everyone gets GA, etc. She comes in and starts trying to reclaim some PICU independence and people freak out, start digging in their heels, make claims that the billing is important to their bottom lines (mostly anesthesia and IR making that claim). Peds surgery didn't care and the relationship for comanaging chest tubes became more collegial when they realized we could troubleshoot without calling them. The only way she made any headway with anyone else though was to start demanding 24/7 access to theses services by arguing that she had fellows/attendings in house already willing and able. IR backed off after the first 2 months of the new schedules. However the nephrologists were convinced that IR placed HD caths worked better and so they began waiting to start renal replacement therapy until daylight hours if it could at all possibly wait.

 

[Arcan57]

Sorry mimelim, that's not the way it should be done. It is July and the interns don't know their heads from a hole in the ground, but at this stage there should be a "if you're thinking about calling a consult, talk to me first" rule from the attending or supervising resident in the ED. Unfortunately academics tends to promote pissing contests as everyone's afraid to back down lest 1) they're perceived as weak and 2) it encourages a consultant to be difficult and refuse to come in when it's actually needed. Kudos to you for handling it in what sounds like a professional manner.

 

[deleted547339]

Sorry mimelim, that's not the way it should be done. It is July and the interns don't know their heads from a hole in the ground, but at this stage there should be a "if you're thinking about calling a consult, talk to me first" rule from the attending or supervising resident in the ED. Unfortunately academics tends to promote pissing contests as everyone's afraid to back down lest 1) they're perceived as weak and 2) it encourages a consultant to be difficult and refuse to come in when it's actually needed. Kudos to you for handling it in what sounds like a professional manner.

It’s amazing how often these fights disappear when the attendings or fellows have the conversation instead of intern to intern.

 

[ThoracicGuy]

I don't get it. Maybe it's an artifact of where I trained, but why does the ER need a vascular surgeon at 1am to place temporary dialysis access? If it's that emergent, they should place it themselves. Or the ICU can do it when the patient goes there (given that if it's that emergent, they better be unstable). If it's not that urgent (which a K of 5.8 wouldn't be to me), it can wait till the morning.

Our er docs gave the excuse that their malpractice insurance didn't allow it. They put in central lines all the time.

 

[Radetzky]

I don't get it. Isn't the opportunity to do procedures part of the draw of ED? Why would surgeons need to be involved for non-tunnelled lines?

 

[Raryn]

Our er docs gave the excuse that their malpractice insurance didn't allow it. They put in central lines all the time.

Seems like it would be a matter of a few minutes to check some boxes and get privileged and covered for vascath placement. I can't imagine it makes a meaningful difference in premiums relative to every other procedure they can do.

 

[ThoracicGuy]

Seems like it would be a matter of a few minutes to check some boxes and get privileged and covered for vascath placement. I can't imagine it makes a meaningful difference in premiums relative to every other procedure they can do.

Except they have done it before... so it's an excuse. If you can put in a central line, you can put in a dialysis line.

 

[deleted547339]

Seems like it would be a matter of a few minutes to check some boxes and get privileged and covered for vascath placement. I can't imagine it makes a meaningful difference in premiums relative to every other procedure they can do.

I doubt it’s an argument of the procedure, it’s the circumstances. As an Emergency Physician, you are credentialed to do anything necessary for an emergency. If a patient needs an HD line because their site of chronic dialysis isn’t available and there’s no acute indication for dialysis, I see the argument that’s it’s not an emergent procedure and shouldn’t be performed by an ER doc. K = 8, it’s an emergent line. Patient dialyze MWF and it just happens to be Friday, probably should go to IR or vascular. If there was a complication of a nonemegent procedure, I imagine you’d probably just be cutting a check.

I, personally, tend to just do it (whatever it is), but I’m relatively procedurally competent (did EM at a busy program and CCM at another busy program) and I tend to be a bit of a cowboy.

 

[akwho]

Called by heme/onc to aspirate a painful hematoma from the knee that had re-accumulated after an outside hospital had aspirated it (not septic, just big hematoma).

"It's really hurting patient, my attending wants you to aspirate it."

What is the patients INR and platelets? Well, the platelets are 9, oh the platelets are 9. INR is 1.2 though.

"We stopped bloodletting as a form medical therapy in the 1800's, I'm not about to be the one who brings it back. I'd try transfusing the patient."

End result, consult cancelled

 

[Arcan57]

I doubt it’s an argument of the procedure, it’s the circumstances. As an Emergency Physician, you are credentialed to do anything necessary for an emergency. If a patient needs an HD line because their site of chronic dialysis isn’t available and there’s no acute indication for dialysis, I see the argument that’s it’s not an emergent procedure and shouldn’t be performed by an ER doc. K = 8, it’s an emergent line. Patient dialyze MWF and it just happens to be Friday, probably should go to IR or vascular. If there was a complication of a nonemegent procedure, I imagine you’d probably just be cutting a check.

I, personally, tend to just do it (whatever it is), but I’m relatively procedurally competent (did EM at a busy program and CCM at another busy program) and I tend to be a bit of a cowboy.

It doesn’t apply in mimelim’s case but there’s an argument to be made for not doing every procedure you’re credentialed in. The ED is the easiest (and usually fastest) way to get anything done. If we start doing things like placing non-emergent vascaths or doing large volume paracentesis on pts that aren’t in objective respiratory distress, all the sudden we become inundated with requests for that procedure. A certain level of “Convenience” Room keeps the lights on and the nurse’s paid but most shops outside of big teaching institutes are light on both physician staffing and bedspace and can’t soak up the additional volume without compromising care of the truly sick.

 

[ThoracicGuy]

It doesn’t apply in mimelim’s case but there’s an argument to be made for not doing every procedure you’re credentialed in. The ED is the easiest (and usually fastest) way to get anything done. If we start doing things like placing non-emergent vascaths or doing large volume paracentesis on pts that aren’t in objective respiratory distress, all the sudden we become inundated with requests for that procedure. A certain level of “Convenience” Room keeps the lights on and the nurse’s paid but most shops outside of big teaching institutes are light on both physician staffing and bedspace and can’t soak up the additional volume without compromising care of the truly sick.

If someone is in an urgent enough need for dialysis, for instance significant hyperkalemia (8+), then the em guy can certainly put in a line.

 

[deleted547339]

If someone is in an urgent enough need for dialysis, for instance significant hyperkalemia (8+), then the em guy can certainly put in a line.

No argument here. I was just saying why you may have heard this in the past.

 

[ThoracicGuy]

No argument here. I was just saying why you may have heard this in the past.

I just think if they are willing to put central lines in without a problem, but refuse a dialysis line on the same patient at the same time, that's laziness. It happens more frequently than I would like. I really don't want to be the hospital iv tech and put in a bunch of dialysis lines...

 

[Arcan57]

I just think if they are willing to put central lines in without a problem, but refuse a dialysis line on the same patient at the same time, that's laziness. It happens more frequently than I would like. I really don't want to be the hospital iv tech and put in a bunch of dialysis lines...

Laziness? Or increased perception of risk? I’ve put in hundreds of CVCs, I’ve put in less then 20 quintons. Never had a problem during insertion except for the fact that the contents of the kit change radically every time I need to do it, but I don’t imagine peer review would look at me with kind eyes if I caused a complication. That doesn’t keep me from doing it if the patient needs it, but I have colleagues that feel differently.

 

[ThoracicGuy]

Laziness? Or increased perception of risk? I’ve put in hundreds of CVCs, I’ve put in less then 20 quintons. Never had a problem during insertion except for the fact that the contents of the kit change radically every time I need to do it, but I don’t imagine peer review would look at me with kind eyes if I caused a complication. That doesn’t keep me from doing it if the patient needs it, but I have colleagues that feel differently.

In everyone I've seen, the difference is a larger dilator and catheter. Otherwise the technique is exactly the same.

 

[dpmd]

In everyone I've seen, the difference is a larger dilator and catheter. Otherwise the technique is exactly the same.

In fairness that does mean bigger holes when you place it in the wrong thing.

 

[Arcan57]

In everyone I've seen, the difference is a larger dilator and catheter. Otherwise the technique is exactly the same.

I mean that our central lines are all from Arrow and have basically the same stuff in them every time. Ask for or pull a dialysis catheter kit and maybe it has the right caps, maybe it has the right drape, maybe it has flush, maybe it has lidocaine, maybe it has a dressing kit. Doesn’t effect putting it in unless the patient goes ape under the drape while waiting for the crucial piece to be fetched but adds about 10-15 minutes to length of procedure.

 

[deleted547339]

I mean that our central lines are all from Arrow and have basically the same stuff in them every time. Ask for or pull a dialysis catheter kit and maybe it has the right caps, maybe it has the right drape, maybe it has flush, maybe it has lidocaine, maybe it has a dressing kit. Doesn’t effect putting it in unless the patient goes ape under the drape while waiting for the crucial piece to be fetched but adds about 10-15 minutes to length of procedure.

That’s how I feel about our thora kits. Every freaking time I do one they are changed.

 

[bizdr]

Thanks for sharing the pain.



I agree to a point, though I think they need to learn. When med students rotate on our service, I make sure if they call consults an intern or resident is sitting next to them to swoop in and not waste the other service's time, or I teach them myself.

During R3 year on the consult service I got a call from an eager beaver medicine Sub-I with this consult: Went almost exactly like this.

Sub-I: "This is _____ the acting intern on Medicine. We want you to see a patient because of a "funky" CT scan."
Me: "What is the patient's name and MRN?"
Sub-I: "I don't know."
Me: "Tell me what you see on the CT scan. What is funky?"
Sub-I: "I haven't looked at it."
Me: "What is the patient complaining about?"
Sub-I: "I don't know, I haven't seen the patient."
Me: "Have your senior resident call me back with the consult." Then hung up. Though I wish I could say I left it at that.

...Then my Catholic guilt got to me, called the med student back and told him to stay where he was and went and taught him how to do an appropriate consult...with emphasis on seeing the patient first. Hopefully, these 10 minutes saved the next surgical service some pain when this joker called. Doubt it. A 4th year medical student should know how to do an appropriate consult.

I would always try to be kind with students & interns, remembering how rough those years were! As long as they seemed genuinely interested in learning.

 

[WheezyBaby]

This thread is quieter than it has any right to be in July/august

 

[wholeheartedly]

This thread is quieter than it has any right to be in July/august

Right?!

I no longer work at big teaching hospital, so I count on you guys to give me my fill.

 

[HighPriest]

Hard to blame the actual referring physician for this, because I am 99% sure the patient demanded to be seen but:

I had a referral for a patient to rule out cancer. Basically, about 30 years ago she swallowed a fly and she wanted to "make sure it hadn't turned in to a cancer." She wanted a bronchoscopy and a CT.

Those fly cancers. They're bad news. Did you know there's no cure for fly cancer? Not even a treatment. Check up to date.

 

[OtoHNS]

Those fly cancers. They're bad news. Did you know there's no cure for fly cancer? Not even a treatment. Check up to date.

There actually is a treatment. You just smack the patient repeatedly with a fly swatter until they leave your office.

 

[LucidSplash]

This thread is quieter than it has any right to be in July/august

Ok. I’ll help you out. Called to evaluate a 70ish y/o F POD 1 from elective total knee by ortho. Reason for consult “superficial thrombophlebitis.”

I assume this is from an infiltrated IV or something and go with intern to check it out since it’s August and I’m not sure they know what thrombophlebitis is or how to assess for suppurative etc.

No ultrasound done or site listed in the consult and can’t get ahold of anyone. I start to look at patient’s arms and she says “no my leg.” So I look and she has about the worst damn bruise I’ve ever seen covering her shin. It’s tender to the touch but it is very clearly a bruise. Not a hematoma. Not thrombophlebitis. Not infection.

She gets a venous U/S ordered by the ortho team that is negative. Very flustered ortho intern rushes up to me while I’m standing in the hall talking to my intern and says “So what do you guys think is going on?!? That leg looks crazy!!”

Me: “It’s a bruise dude. Send her home.”

 

[vhawk]

Hard to blame the actual referring physician for this, because I am 99% sure the patient demanded to be seen but:

I had a referral for a patient to rule out cancer. Basically, about 30 years ago she swallowed a fly and she wanted to "make sure it hadn't turned in to a cancer." She wanted a bronchoscopy and a CT.

Those fly cancers. They're bad news. Did you know there's no cure for fly cancer? Not even a treatment. Check up to date.

That is absolutely idiotic and completely inappropriate.

If she SWALLOWED the fly, she needs a GI consult and an EGD...

 

[vhawk]

Ok. I’ll help you out. Called to evaluate a 70ish y/o F POD 1 from elective total knee by ortho. Reason for consult “superficial thrombophlebitis.”

I assume this is from an infiltrated IV or something and go with intern to check it out since it’s August and I’m not sure they know what thrombophlebitis is or how to assess for suppurative etc.

No ultrasound done or site listed in the consult and can’t get ahold of anyone. I start to look at patient’s arms and she says “no my leg.” So I look and she has about the worst damn bruise I’ve ever seen covering her shin. It’s tender to the touch but it is very clearly a bruise. Not a hematoma. Not thrombophlebitis. Not infection.

She gets a venous U/S ordered by the ortho team that is negative. Very flustered ortho intern rushes up to me while I’m standing in the hall talking to my intern and says “So what do you guys think is going on?!? That leg looks crazy!!”

Me: “It’s a bruise dude. Send her home.”

What is the difference between a bruise and a hematoma?

 

[OrthoTraumaMD]

What is the difference between a bruise and a hematoma?

Technicality really. A hematoma is a giant bruise but it really implies an actual collection that you can see/drain rather than just contused soft tissues with capillary bleeding.


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[vhawk]

Technicality really. A hematoma is a giant bruise but it really implies an actual collection that you can see/drain rather than just confused soft tissues with capillary bleeding.


Sent from my iPhone using SDN mobile

Yeah I'd have thought that bruises were inside the Venn circle of hematomas

 

[HighPriest]

That is absolutely idiotic and completely inappropriate.

If she SWALLOWED the fly, she needs a GI consult and an EGD...

If she swallowed the fly, I'd have just fed her a spider.

 

[vhawk]

If she swallowed the fly, I'd have just fed her a spider.

I used to do that when I first started out in practice but by the time you are giving mongoose enemas to deal with the snakes, you start to wonder if there isnt a better way

 

[dpmd]

What is the difference between a bruise and a hematoma?

Ecchymosis (bruise) is flat blood collection. Hematoma is three dimensional.

 

[LucidSplash]

What is the difference between a bruise and a hematoma?

Hematomas are things that I sometimes need to do something about. Bruise are things I do not need to do anything about.

 

[vhawk]

Hematomas are things that I sometimes need to do something about. Bruise are things I do not need to do anything about.

Seems like second sentence is superfluous.

 

[LucidSplash]

Seems like second sentence is superfluous.

True. But it’s the part that matters to me.

But what it definitely wasn’t was “superficial thrombophlebitis” and it was clear the ortho intern didn’t even know what that was, they were just words he put in the consult order on the computer because they sounded like a vascular thing and he did not recognize what a bad bruise looked like.

 

[HighPriest]

I used to do that when I first started out in practice but by the time you are giving mongoose enemas to deal with the snakes, you start to wonder if there isnt a better way

The hard part is always finding a spider who is also an oncologist.

 

[mimelim]

Tonight's adventures... Not really consults, but whatever...

11pm
Nurse: My patient can't move his arm, it is completely limp. He has a strong pulse and can't feel the arm at all.
Me: What did the patient have?
Nurse: Fistulagram and some sort of revision by Dr. XYZ.
Me: Did they block the patient?
Nurse: I don't know, the patient came from dialysis and we don't get report from them.
Me: Is there anything else going on? Vitals, pain, etc?
Nurse: No, the patient just says that he hasn't been able to move his arm since surgery.
Me: They blocked the patient. It is normal to not be able to move or feel your arm for hours after surgery.
Nurse: Are you sure?
Me: Yes.
Nurse: That doesn't sound right. Surgery is over.
Me: ???

2am - Called in for a groin hematoma + cold leg after attempted ELVO
Me: What closure device does Dr. ABC use?
NSGY junior resident: I have no idea, you can look in the chart.
Me: I did look in the chart, there is no op-note or other documentation. If I need to operate on this, I should know what happened in the case.
NSGY: I don't know I haven't done angios with Dr. ABC.
Me: ???

Never mind that I show up and there isn't a single NSGY person anywhere near the patient. I will never understand this, regardless of specialty. When you have a complication, how do you not hang around until the cavalry show up? This seems to happen all the freakin time. If I call CRS or GI to scope someone I'm worried about having ischemia after I do an aortic repair, I'm looking over their shoulder as they do it. I'm not already home or on the golf course.

 

[OrthoTraumaMD]

Tonight's adventures... Not really consults, but whatever...

11pm
Nurse: My patient can't move his arm, it is completely limp. He has a strong pulse and can't feel the arm at all.
Me: What did the patient have?
Nurse: Fistulagram and some sort of revision by Dr. XYZ.
Me: Did they block the patient?
Nurse: I don't know, the patient came from dialysis and we don't get report from them.
Me: Is there anything else going on? Vitals, pain, etc?
Nurse: No, the patient just says that he hasn't been able to move his arm since surgery.
Me: They blocked the patient. It is normal to not be able to move or feel your arm for hours after surgery.
Nurse: Are you sure?
Me: Yes.
Nurse: That doesn't sound right. Surgery is over.
Me: ???

2am - Called in for a groin hematoma + cold leg after attempted ELVO
Me: What closure device does Dr. ABC use?
NSGY junior resident: I have no idea, you can look in the chart.
Me: I did look in the chart, there is no op-note or other documentation. If I need to operate on this, I should know what happened in the case.
NSGY: I don't know I haven't done angios with Dr. ABC.
Me: ???

Never mind that I show up and there isn't a single NSGY person anywhere near the patient. I will never understand this, regardless of specialty. When you have a complication, how do you not hang around until the cavalry show up? This seems to happen all the freakin time. If I call CRS or GI to scope someone I'm worried about having ischemia after I do an aortic repair, I'm looking over their shoulder as they do it. I'm not already home or on the golf course.

That second one… If I gave that “you can look in the chart” response to an attending as a junior resident, or even as a senior, I would have my head ripped off and stuffed up my ass by my PD.


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[evilbooyaa]

I used to do that when I first started out in practice but by the time you are giving mongoose enemas to deal with the snakes, you start to wonder if there isnt a better way

And then a snake enema to deal with the mongoose? Which way does it go again?

 

[HighPriest]

And then a snake enema to deal with the mongoose? Which way does it go again?

You just leave the mongoose. Mongoose-associated cancers are extremely rare.

 

[Smurfette]

Never mind that I show up and there isn't a single NSGY person anywhere near the patient. I will never understand this, regardless of specialty. When you have a complication, how do you not hang around until the cavalry show up? This seems to happen all the freakin time. If I call CRS or GI to scope someone I'm worried about having ischemia after I do an aortic repair, I'm looking over their shoulder as they do it. I'm not already home or on the golf course.

I don't get this either. If I am coming emergently to help you due to a complication, look like you care when I show up. And if you do need to run somewhere else, come back and check on the patient afterward at some point. Running away and pretending it didn't happen will be remembered, and not in a good way.