Consults- Memorable/Dismal/Ridiculous/Unique

[VA Hopeful Dr]

My favorite line from people requesting a consult when I ask them to describe the problem. “ uh, I don’t know what I’m looking at here”

Usually in referral to hypospadias (iatrogenic or otherwise), buried penis, phimosis, paraphimosis, etc.

I hope you respond to those statements with a simple "probably a penis"

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[swoopyswoop]

Got a consult from a neurosurgery PA to repair a head lac on a post-op patient who fell down and had a cut on their head. Apparently she called medicine and they told her she better call general surgery. I asked if she had spoken to the neurosurgeons in charge of the patient who had operated on him yesterday and she had not. I advised her to see if they considered a head lac within their wheelhouse.

Also got a consult for metastatic pancreatic cancer to ask if they were resectable.

 

[vhawk]

Got a consult from a neurosurgery PA to repair a head lac on a post-op patient who fell down and had a cut on their head. Apparently she called medicine and they told her she better call general surgery. I asked if she had spoken to the neurosurgeons in charge of the patient who had operated on him yesterday and she had not. I advised her to see if they considered a head lac within their wheelhouse.

Also got a consult for metastatic pancreatic cancer to ask if they were resectable.

And what did you tell them for the latter? Not trying to be combative but I don't think that's an inappropriate consult at all, both because "metastatic pancreatic cancer" sometimes just means locally advanced, metastatic PNET, etc. And also because, at least in 2018, it isnt absolutely CRAZY to consider resection in some situations for metastatic pancreatic cancer. There are trials for doing liver resections for oligometastatic disease, etc.

I dont know your scope of practice but I dont think the principle that everyone with panc cancer should at least be seen or reviewed by a surgeon is all that crazy

 

[swoopyswoop]

And what did you tell them for the latter? Not trying to be combative but I don't think that's an inappropriate consult at all, both because "metastatic pancreatic cancer" sometimes just means locally advanced, metastatic PNET, etc. And also because, at least in 2018, it isnt absolutely CRAZY to consider resection in some situations for metastatic pancreatic cancer. There are trials for doing liver resections for oligometastatic disease, etc.

I dont know your scope of practice but I dont think the principle that everyone with panc cancer should at least be seen or reviewed by a surgeon is all that crazy

We recommended outpatient f/u with medical oncology and surgical oncology if needed once work up was complete. I didn't include all the info - they don't even have a tissue diagnosis yet, but it is presumed pancreatic cancer. The mets in question were multiple pulmonary mets.

Edit: some more imaging resulted showing likely pancreatic mass, colon mass, peritoneal and omental tumor implants.....

 

[vhawk]

We recommended outpatient f/u with medical oncology and surgical oncology if needed once work up was complete. I didn't include all the info - they don't even have a tissue diagnosis yet, but it is presumed pancreatic cancer. The mets in question were multiple pulmonary mets.

Yeah I tried to caveat that I wasnt trying to argue with you since of course you had way more info, I just end up spending a lot of my time combatting the surprisingly common opinion among pcps, gis and even surgeons and med oncs that panc ca is always a death sentence and whipple is the devil. Something like half of potentially resectable patients never even get referred to a surgeon

 

[Arcan57]

My favorite line from people requesting a consult when I ask them to describe the problem. “ uh, I don’t know what I’m looking at here”

Usually in referral to hypospadias (iatrogenic or otherwise), buried penis, phimosis, paraphimosis, etc.

I’ve got those, but every once in a while will see a tumor (usually glans) where there’s such distortion of the anatomy that I’m not sure what fissured oozing hole is actually urethra. I assume it’s the one urine is coming from if they can urinate spontaneously but I don’t alway get that lucky.

 

[VA Hopeful Dr]

Yeah I tried to caveat that I wasnt trying to argue with you since of course you had way more info, I just end up spending a lot of my time combatting the surprisingly common opinion among pcps, gis and even surgeons and med oncs that panc ca is always a death sentence and whipple is the devil. Something like half of potentially resectable patients never even get referred to a surgeon

I'll openly admit that I assumed that was true.

That said, anything even remotely cancerous I refer to med onc and I try to be as vague as I can possibly be about what is going to happen next.

 

[dpmd]

And what did you tell them for the latter? Not trying to be combative but I don't think that's an inappropriate consult at all, both because "metastatic pancreatic cancer" sometimes just means locally advanced, metastatic PNET, etc. And also because, at least in 2018, it isnt absolutely CRAZY to consider resection in some situations for metastatic pancreatic cancer. There are trials for doing liver resections for oligometastatic disease, etc.

I dont know your scope of practice but I dont think the principle that everyone with panc cancer should at least be seen or reviewed by a surgeon is all that crazy

It is crazy to consult the acute care surgeon for that. Outpatient hepatobiliary or surg onc unless obstruction or something acute. You don't want the appy and chole surgeon making that surgical decision

 

[vhawk]

It is crazy to consult the acute care surgeon for that. Outpatient hepatobiliary or surg onc unless obstruction or something acute. You don't want the appy and chole surgeon making that surgical decision

I didnt realize they were an acute care surgeon, the post just said they got a consult for met panc ca. I can imagine many scenarios in which that is an entirely appropriate consult for a general surgeon. Presumably if the consult was to the acute care surgeon, SOMETHING brought the patient into the ED or hospital.

 

[dpmd]

I didnt realize they were an acute care surgeon, the post just said they got a consult for met panc ca. I can imagine many scenarios in which that is an entirely appropriate consult for a general surgeon. Presumably if the consult was to the acute care surgeon, SOMETHING brought the patient into the ED or hospital.

They might not be. But from my experience most of the time these consults are based on vague or chronic complaints bringing them into the hospital and then their horrendioma is found. They aren't emergent dying but hospitalist calls me like I am going to be able to swoop in and fix the patient. Sometimes I even get to be the one to break the news to the patient (that is always special). If they are actively bleeding and gi/ir already tried and failed, if they are obstructed, if they are perforated, etc then sure call me and I will see what I can do (though in that scenario I am probably going to be pushing for hospice) but otherwise get that patient to a specialist who can actually discuss all the options. Maybe this is at an academic center where the consult can be passed along to the right kind of surgeon but I am at a community hospital where that kind of surgeon doesn't exist in town.

 

[balaguru]

They might not be. But from my experience most of the time these consults are based on vague or chronic complaints bringing them into the hospital and then their horrendioma is found. They aren't emergent dying but hospitalist calls me like I am going to be able to swoop in and fix the patient. Sometimes I even get to be the one to break the news to the patient (that is always special). If they are actively bleeding and gi/ir already tried and failed, if they are obstructed, if they are perforated, etc then sure call me and I will see what I can do (though in that scenario I am probably going to be pushing for hospice) but otherwise get that patient to a specialist who can actually discuss all the options. Maybe this is at an academic center where the consult can be passed along to the right kind of surgeon but I am at a community hospital where that kind of surgeon doesn't exist in town.

NCCN Clinical Practice Guidelines in Oncology is an excellent resource for the physician wondering what to do next with a cancer or presumed cancer.

 

[dpmd]

NCCN Clinical Practice Guidelines in Oncology is an excellent resource for the physician wondering what to do next with a cancer or presumed cancer.

Sure. I use that all the time. But it doesn't mean I should discuss what kind of operation I think they ought to get based on what the guidelines say when I don't do any of those procedures. I mean hell there is even a big black box at the beginning of the pancreatic cancer one that says decisions on diagnostic management and resectability should involve multidisciplinary consultation at a high volume center.

 

[balaguru]

Sure. I use that all the time. But it doesn't mean I should discuss what kind of operation I think they ought to get based on what the guidelines say when I don't do any of those procedures. I mean hell there is even a big black box at the beginning of the pancreatic cancer one that says decisions on diagnostic management and resectability should involve multidisciplinary consultation at a high volume center.

That wasn't what I was suggesting. Often the hospitalist leaves the newly diagnosed cancer patient with more questions than answers. Patients often find it helpful to go through consensus guidelines with the caveat that they will be referred to a specialist who will tailor their management according to the nuances of their specific case. Second, if a transfer is needed I think a surgeon to surgeon call is helpful especially when discussing particulars on imaging. Third, I get some educational value and build rapport with some of the specialists in the area often exchanging cell phone numbers. I've done this with a few borderline resectable pancreatic lesions and extremity sarcomas.

 

[deleted50541]

The amount of vascular stories in this thread makes me have flashback nightmares to my intern year. I wasn't allowed to have the level of snark mimelim has now (which is still very reasonable in the grand scheme of things). Just had to go see dumb af consults and present them to the team as seriously as possible.

Yes, Dr. X, they called us for lack of pulses in the distal right leg. When I examined the patient he had a BKA. Yes, Dr. X, I told them that's why he didn't have a pulse there. They would like us to still be on board. He's being admitted for pneumonia by hospitalist.

I was passing through the MICU on my way out today and overheard the following, "...yes the foot is warm and pink. I don't know about the doppler signals...".

I could only assume there was a vascular resident on the other end of that perpetually painful conversation, rolling their eyes as hard as they could.

 

[vhawk]

I think the preponderance of vascular stories in this thread point to the fact that a lot of the time even other surgeons aren’t so sure about vascular things. Every service and specialty has those consults they receive which are repetitively, annoyingly inappropriate. Vascular it seems there are a few things people know we do (AAA, leg not feel good, dialysis access please) but have no idea about most of it and definitely not the details of any of it. So for the most part it’s just fun to post in this thread about it but otherwise in general I just sort of say “ok thanks, we’ll see it.”

Here’s a new really terrible consult:

Patient diagnosed with infected pacemaker by ID. Patient however refusing pacemaker removal. So medicine team starts looking for “other sources of infection to explain sepsis.” So they consult vascular to rule out infection in what turns out to be the most well-healed TMA site in existence. We tell them it’s not infected and they say “yeah we know we just had to rule it out.” ?????? The pacemaker issue isn’t going away even if you identify something else...

100% agree with this. I rotated on vascular, I work with vascular surgeons more often than any other surgeons intraoperatively (vein and artery recons, etc) I put in ports and do ultrasound almost every day....and I still get super uncomfortable with even basic vascular stuff. It just feels so much different than any other organ or system that I work on. I would MUCH, MUCH rather take out a kidney, fix a ureter, take out an ovary or uterus, any of those sorts of things, than have to do a cutdown/embolectomy or a carotid or something. I dont know if its like some lizardbrain sense that, in vascular, everything is connected to the heart or something?

 

[vhawk]

Sure. I use that all the time. But it doesn't mean I should discuss what kind of operation I think they ought to get based on what the guidelines say when I don't do any of those procedures. I mean hell there is even a big black box at the beginning of the pancreatic cancer one that says decisions on diagnostic management and resectability should involve multidisciplinary consultation at a high volume center.

That wasn't what I was suggesting. Often the hospitalist leaves the newly diagnosed cancer patient with more questions than answers. Patients often find it helpful to go through consensus guidelines with the caveat that they will be referred to a specialist who will tailor their management according to the nuances of their specific case. Second, if a transfer is needed I think a surgeon to surgeon call is helpful especially when discussing particulars on imaging. Third, I get some educational value and build rapport with some of the specialists in the area often exchanging cell phone numbers. I've done this with a few borderline resectable pancreatic lesions and extremity sarcomas.

I appreciate both of these views and I'm not saying that I'm right, but what balaguru is saying is what I was trying to say and is how I think about the issue. Even if the outlying surgeon says something that is misleading or flat out wrong, I've got a whole speech that I give about how these are complicated questions, there are lots of different approaches, if you asked 10 surgeons you'd get 8 answers, but this is how we do things and this is what I offer, etc, and I am always flattering and appreciative to the outlying surgeon who talked with the patient.

I dont necessarily think these patients NEED surgery consults, but I dont really think its inappropriate, and is at least as much a political/courtesy/patient satisfaction issue as it is a medical one.

 

[dpmd]

I appreciate both of these views and I'm not saying that I'm right, but what balaguru is saying is what I was trying to say and is how I think about the issue. Even if the outlying surgeon says something that is misleading or flat out wrong, I've got a whole speech that I give about how these are complicated questions, there are lots of different approaches, if you asked 10 surgeons you'd get 8 answers, but this is how we do things and this is what I offer, etc, and I am always flattering and appreciative to the outlying surgeon who talked with the patient.

I dont necessarily think these patients NEED surgery consults, but I dont really think its inappropriate, and is at least as much a political/courtesy/patient satisfaction issue as it is a medical one.

I suppose I can see that viewpoint and when that is the only patient I am consulted on that can certainly happen. However when I have 9 cases at three different hospitals to do on top of the nonoperative consults then what the patient is going to get is a short interview to screen for any emergent issue and if none is found (which honestly checking the chart beforehand is probably going to tell me what I need to know anyway) they are going to be told they have a cancer that I don't manage and are going to be referred to a specialist who will go over their options. Then I am going to extricate myself however I can so I can move on to the people I can help.

 

[Buzz Me]

My humble experience is generally speaking medicine doctors see all surgeons as Burger King technicians. They just order what they want and expect us to just do it. It's rude and often misguided.

I feel like we're often though of in a similar fashion to IR.

Need a CT-guided biopsy? Place an order for IR to do it.
Need an open lung biopsy/valve repair/CABG? Place an order for CTS to do it.

 

[DoctwoB]

I feel like we're often though of in a similar fashion to IR.

Need a CT-guided biopsy? Place an order for IR to do it.
Need an open lung biopsy/valve repair/CABG? Place an order for CTS to do it.

Had a NICU attending tell me they couldn’t allow a baby to go home because they “didn’t feel comfortable” (incidentally my 3 least favorite words in medicine) unless we operated on them.

To which the answer was “well keep them as long as you like,” we’re out.

The even more ridiculous part of this was the NICU nurses repeatedly telling the parents the baby had to have surgery, before AND after we spoke with them.

 

[swoopyswoop]

Had a NICU attending tell me they couldn’t allow a baby to go home because they “didn’t feel comfortable” (incidentally my 3 least favorite words in medicine) unless we operated on them.

To which the answer was “well keep them as long as you like,” we’re out.

The even more ridiculous part of this was the NICU nurses repeatedly telling the parents the baby had to have surgery, before AND after we spoke with them.

What surgery did they think the baby needed?

 

[DoctwoB]

What surgery did they think the baby needed?

Contralateral orchiopexy after an intrauterine testicular torsion in a premie. Most pediatric urologists probably would pexy the other side to prevent torsion, but we really have no data to compare the risk of developing contralateral torsion vs the risk of testicular atrophy from orchiopexy plus risks of anesthetic in a newborn. Unlike in older kids you essentially never are able to salvage a neonatal torsion, especially if intrauterine.

The reason most would operate is medicolegal, if they do happen to torse the other side, you’re up **** creek legally speaking. This attending (reasonably imo) believes we over operate on these kids and especially if parents are reliable then observation is best.

 

[swoopyswoop]

Contralateral orchiopexy after an intrauterine testicular torsion in a premie. Most pediatric urologists probably would pexy the other side to prevent torsion, but we really have no data to compare the risk of developing contralateral torsion vs the risk of testicular atrophy from orchiopexy plus risks of anesthetic in a newborn. Unlike in older kids you essentially never are able to salvage a neonatal torsion, especially if intrauterine.

The reason most would operate is medicolegal, if they do happen to torse the other side, you’re up **** creek legally speaking. This attending (reasonably imo) believes we over operate on these kids and especially if parents are reliable then observation is best.

Correct answer is to wait until 6 months or so to do the orchiopexy?

 

[vhawk]

I suppose I can see that viewpoint and when that is the only patient I am consulted on that can certainly happen. However when I have 9 cases at three different hospitals to do on top of the nonoperative consults then what the patient is going to get is a short interview to screen for any emergent issue and if none is found (which honestly checking the chart beforehand is probably going to tell me what I need to know anyway) they are going to be told they have a cancer that I don't manage and are going to be referred to a specialist who will go over their options. Then I am going to extricate myself however I can so I can move on to the people I can help.

I'm always a little uncomfortable when the way I manage a patient and a situation and a colleague depends on how busy I happen to be at the time. I'm not an idiot and I understand you have to triage your time, but it still always makes me uncomfortable and hesitant.

 

[DoctwoB]

Correct answer is to wait until 6 months or so to do the orchiopexy?

Actually not. Neonatal torsion is extravaginal, meaning occurs outside tunica vaginalis, not from the classic Bell clapper deformity that causes intravaginal torsion in adolescents. Extravaginal torsion isn’t thought to increase risk of subsequent intravaginal torsion, and basically occurs only in the first 30d of life. Correct answer is to pexy early or not at all.

 

[BigRedBeta]

The even more ridiculous part of this was the NICU nurses repeatedly telling the parents the baby had to have surgery, before AND after we spoke with them.

As a PICU attending, I can attest to the fact that NICU nurses are the worst. In every NICU I've ever been associated with, it's been a prominent and recurrent problem that stuff like that gets passed along and repeated to parents all the time. I'm not sure if it's because there's so much emphasis on what has to be done to go home (and before you say discharge criteria is important everywhere, it's 10x worse in the NICU when these babies have never been home, and there are so many boxes that have to be checked to get out) or how territorial NICU nurses are about their patients (lots of time spent being told you're a special person because of where you work can do that to you, I guess), but it's a real issue. I guarantee you there was also a lot of "I can't believe urology doesn't care about your baby's balls!?! Why won't they do something?!" said about y'all.

 

[vhawk]

As a PICU attending, I can attest to the fact that NICU nurses are the worst. In every NICU I've ever been associated with, it's been a prominent and recurrent problem that stuff like that gets passed along and repeated to parents all the time. I'm not sure if it's because there's so much emphasis on what has to be done to go home (and before you say discharge criteria is important everywhere, it's 10x worse in the NICU when these babies have never been home, and there are so many boxes that have to be checked to get out) or how territorial NICU nurses are about their patients (lots of time spent being told you're a special person because of where you work can do that to you, I guess), but it's a real issue. I guarantee you there was also a lot of "I can't believe urology doesn't care about your baby's balls!?! Why won't they do something?!" said about y'all.

As a dad who's first child spent a week in the NICU (the NICU of the hospital that I was a chief resident at) I can confirm this is true. They snatched that thing out of my hands on a daily basis and they looked at me like I was there to infect all the babies with smallpox every time.

 

[HighPriest]

Got a call last night from the ER. Nonagenerian with an INR of 7 and mastoiditis that has eroded into the posterior fossa and the cerebellum. The ER stated that they realized that this is "usually" the type of case that would require a neurosurgeon, but the patient has refused all interventional care. So, they tried to call the county hospital to transfer her, and the neurosurgery service stated that there really wasn't a point if she didn't want any intervention. Which makes sense. So they called me. To which I said "Ok. What can I do here?" To which they said "Well, we're admitting her to the hospitalist service, and they would like you to consult."
To which I said "Ok. What can I do there?"
"Well, you could suggest some antibiotics?"
"It's an otogenic encephalitis. I would defer to ID. Are they going to call ID?"
"Yeah, they have. But, you know, maybe you could make some other suggestions?"
"Ok. Well, she doesn't want any surgery. She understands that if she does nothing she will die. She understands that antibiotics may or may not work. Her INR is 7?"
"Yes."
"Ok. Yeah, sure. I'll see her tomorrow, I guess."

I mean.....I suppose I'll walk in to her room, scratch my chin a bit, nod and say "mmmm-hmmm....", walk to the other side of the bed and repeat that, and then walk out and write a note that says "Yep."

This is like the ER opening up a package that contains a pack of dynamite with a ticking clock attached, and then calling me for a consult because I know a thing or two about clocks. And I say "yeah, but that's a bomb. I don't know anything about bombs." and they say "yeah, but there's a clock attached, so we'd like you to be here when the bomb goes off."

 

[ThoracicGuy]

Got a call last night from the ER. Nonagenerian with an INR of 7 and mastoiditis that has eroded into the posterior fossa and the cerebellum. The ER stated that they realized that this is "usually" the type of case that would require a neurosurgeon, but the patient has refused all interventional care. So, they tried to call the county hospital to transfer her, and the neurosurgery service stated that there really wasn't a point if she didn't want any intervention. Which makes sense. So they called me. To which I said "Ok. What can I do here?" To which they said "Well, we're admitting her to the hospitalist service, and they would like you to consult."
To which I said "Ok. What can I do there?"
"Well, you could suggest some antibiotics?"
"It's an otogenic encephalitis. I would defer to ID. Are they going to call ID?"
"Yeah, they have. But, you know, maybe you could make some other suggestions?"
"Ok. Well, she doesn't want any surgery. She understands that if she does nothing she will die. She understands that antibiotics may or may not work. Her INR is 7?"
"Yes."
"Ok. Yeah, sure. I'll see her tomorrow, I guess."

I mean.....I suppose I'll walk in to her room, scratch my chin a bit, nod and say "mmmm-hmmm....", walk to the other side of the bed and repeat that, and then walk out and write a note that says "Yep."

This is like the ER opening up a package that contains a pack of dynamite with a ticking clock attached, and then calling me for a consult because I know a thing or two about clocks. And I say "yeah, but that's a bomb. I don't know anything about bombs." and they say "yeah, but there's a clock attached, so we'd like you to be here when the bomb goes off."

It's a rvu!

 

[HighPriest]

It's a rvu!

For sure. That is literally the only reason I'll probably end up going to see her. Although I feel like I'm looting a corpse.

 

[Apollyon]

Although I feel like I'm looting a corpse.

It's like real life "Diablo"!

 

[dpmd]

You guys ever do a consult that is essentially a pre mortem exam and then they die before you get the note in the computer. Always feels weird to me.

 

[ThoracicGuy]

You guys ever do a consult that is essentially a pre mortem exam and then they die before you get the note in the computer. Always feels weird to me.

Critical care code there!

 

[OtoHNS]

For sure. That is literally the only reason I'll probably end up going to see her. Although I feel like I'm looting a corpse.

With Medicare rates, it's like looting a corpse but all that's in their pockets is some loose change and a half-eaten slim jim.

 

[Apollyon]

You guys ever do a consult that is essentially a pre mortem exam and then they die before you get the note in the computer. Always feels weird to me.

Well, that right there is the true "expectant management"!

 

[HighPriest]

With Medicare rates, it's like looting a corpse but all that's in their pockets is some loose change and a half-eaten slim jim.

I could go for a slim jim. RIP Macho Man.

 

[dpmd]

Well, that right there is the true "expectant management"!

I "expected" them to die and then they did.

 

[Apollyon]

I "expected" them to die and then they did.

Reminds me of a story: our now semi-retired surgeon was called for a pt in the ED that was a very elderly woman who had infarcted her bowel. The surgeon - a Filipino guy, about 5'6" - walks into the pt's room, and just puts up his hand, waved, and says, "Bye bye, lady!", and turns around and walks out.

 

[OrthoTraumaMD]

Reminds me of a story: our now semi-retired surgeon was called for a pt in the ED that was a very elderly woman who had infarcted her bowel. The surgeon - a Filipino guy, about 5'6" - walks into the pt's room, and just puts up his hand, waved, and says, "Bye bye, lady!", and turns around and walks out.

Omg


Sent from my iPhone using SDN mobile

 

[dpmd]

Reminds me of a story: our now semi-retired surgeon was called for a pt in the ED that was a very elderly woman who had infarcted her bowel. The surgeon - a Filipino guy, about 5'6" - walks into the pt's room, and just puts up his hand, waved, and says, "Bye bye, lady!", and turns around and walks out.

Not exactly kind but it isn't like he is wrong (but hopefully lady was out of it because that is just too mean)

 

[Apollyon]

Not exactly kind but it isn't like he is wrong (but hopefully lady was out of it because that is just too mean)

Nope - C/A/O x3. Now expired (obviously).

 

[dpmd]

Nope - C/A/O x3. Now expired (obviously).

I had a bad ischemic bowel patient once that stayed alert and oriented for a really long time before finally succumbing

 

[Apollyon]

I had a bad ischemic bowel patient once that stayed alert and oriented for a really long time before finally succumbing

Ugh. Not a good way to die.

 

[dpmd]

Ugh. Not a good way to die.

Pain was well controlled when I saw him. Maybe the honeymoon period between the bowel dying and gangrene setting in?? Because dying tissue hurts but dead tissue doesn't.

 

[Jolie South]

Pain was well controlled when I saw him. Maybe the honeymoon period between the bowel dying and gangrene setting in?? Because dying tissue hurts but dead tissue doesn't.

Like the patient with a long dead leg that is near mummified. “Well, I can’t move my toes, but it doesn’t hurt. What do you mean my leg is dead?”

 

[vhawk]

Reminds me of a story: our now semi-retired surgeon was called for a pt in the ED that was a very elderly woman who had infarcted her bowel. The surgeon - a Filipino guy, about 5'6" - walks into the pt's room, and just puts up his hand, waved, and says, "Bye bye, lady!", and turns around and walks out.

My favorite note in any chart ever was one of our general surgeons, who was about 1.5 years away from retirement, had a patient similar to that, old, highly comorbid, clearly a bunch of dead bowel. So he writes the following(this was when we still had paper charts)

"Patients operative mortality 100%. To the OR!!"

That was his entire note

 

[Jolie South]

My favorite note in any chart ever was one of our general surgeons, who was about 1.5 years away from retirement, had a patient similar to that, old, highly comorbid, clearly a bunch of dead bowel. So he writes the following(this was when we still had paper charts)

"Patients operative mortality 100%. To the OR!!"

That was his entire note

They are 100% dead without OR and maybe 99% dead with OR. So I guess it’s a choice of dying with a bunch of dead bowel or an open abdomen.

We had one super sick guy we had to do an aortic graft explant on. We told him you will most likely die. He said “I am going down with guns blazing.” We took him. He died POD2. He indeed did go down with guns blazing.

 

[dpmd]

They are 100% dead without OR and maybe 99% dead with OR. So I guess it’s a choice of dying with a bunch of dead bowel or an open abdomen.

We had one super sick guy we had to do an aortic graft explant on. We told him you will most likely die. He said “I am going down with guns blazing.” We took him. He died POD2. He indeed did go down with guns blazing.

The awake patient I mentioned I gave him the choice to go to the or and likely die in the icu or not go and be able to talk and say goodbye for a while longer. I think he made the right choice not to go.

 

[dr zaius]

I keep getting consulted on the same patient, over and over again.

He's an older gentleman on dialysis with significant peripheral vascular disease. He had an AKA a few months ago, at the hospital I am at, and the patient and family are convinced that someone secretly circumcised him. They are under this impression because after his amputation he had a catheter...unsure why he had a catheter because he is anuric and on dialysis. While this catheter was in place all of a sudden his foreskin vanished. His catheter was removed shortly after his covert circumcision and he was discharged home. His glans became massively swollen, per family, and then turned black. This is obviously a missed paraphimosis that occurred when nursing did not reduce his foreskin after nursing driven mandatory bull**** catheter care. He has dry gangrene of his glans with a perfectly circumferential line just proximal to the corona with clearly healthy shaft tissue. No evidence of infection at all.

He gets admitted again for something else and the consult rolls in. No big deal. Examine him, state the obvious, and wait for his mummified tip to fall off. Patient goes home, admitted again for infected AV graft, re-consulted because someone finally looks at his Johnson. He gets discharged and re-admitted 4 more times. Every time they consult.

"YOU WON'T BELIEVE THIS PENIS! YOU HAVE TO COME SEE IT RIGHT AWAY!"

Did you look at the 2983476289374 other consult notes from urology which are present in the electronic medical record discussing this very penis?

When I call a consult I make sure I look at the chart for pertinent information. I'm not going to call cards without checking to see if they have a cardiac history or take a stab at EKG interpretation. I hate it when consults are called with no physical exam, no chart review, and unfortunately no information directly from the patient or family.

 

[LucidSplash]

I keep getting consulted on the same patient, over and over again.

He's an older gentleman on dialysis with significant peripheral vascular disease. He had an AKA a few months ago, at the hospital I am at, and the patient and family are convinced that someone secretly circumcised him. They are under this impression because after his amputation he had a catheter...unsure why he had a catheter because he is anuric and on dialysis. While this catheter was in place all of a sudden his foreskin vanished. His catheter was removed shortly after his covert circumcision and he was discharged home. His glans became massively swollen, per family, and then turned black. This is obviously a missed paraphimosis that occurred when nursing did not reduce his foreskin after nursing driven mandatory bull**** catheter care. He has dry gangrene of his glans with a perfectly circumferential line just proximal to the corona with clearly healthy shaft tissue. No evidence of infection at all.

He gets admitted again for something else and the consult rolls in. No big deal. Examine him, state the obvious, and wait for his mummified tip to fall off. Patient goes home, admitted again for infected AV graft, re-consulted because someone finally looks at his Johnson. He gets discharged and re-admitted 4 more times. Every time they consult.

"YOU WON'T BELIEVE THIS PENIS! YOU HAVE TO COME SEE IT RIGHT AWAY!"

Did you look at the 2983476289374 other consult notes from urology which are present in the electronic medical record discussing this very penis?

When I call a consult I make sure I look at the chart for pertinent information. I'm not going to call cards without checking to see if they have a cardiac history or take a stab at EKG interpretation. I hate it when consults are called with no physical exam, no chart review, and unfortunately no information directly from the patient or family.

But... did you see his penis?!?!

But seriously, I feel your pain. See also demented bedbound gentleman with chronic osteo of his calcaneous and a small heel wound. Patient’s family has repeatedly refused an amputation which is his only option. Everytime he gets admitted with something else, we get consulted for heel wound, osteo (on yet another useless MRI), and lack of pulses. No one asks the family if they’ve changed their mind about amputation or reads the previous notes before getting the MRI or calling us. Sigh.

 

[TraumaLlamaMD]

You guys ever do a consult that is essentially a pre mortem exam and then they die before you get the note in the computer. Always feels weird to me.

Equally depressing corollary, when you’re called to evaluate a patient who has already expired, but nobody noticed yet. Happened more than once at our inner city site.