Consults- Memorable/Dismal/Ridiculous/Unique

[dpmd]

Meh. The ER is filled with these people and crap doctors that build false expectations. People are strange, but this seems unsurprising. Just this week, I saw:

Sent by PCP for SBP of 180 told they would be admitted. Nope - Asymptomatic, sent home.
Sent by urgent care for dizziness told they needed an MRI - not necessary.
Sent by trauma told that ortho would come down to tap a knee to rule out septic arthritis - ortho would laugh at me if I asked them to come down and tap a knee.
Sent by some doc (don’t remember who) because she “might have a concussion”.

Doctors don’t even understand what other doctors do. And patients want testing, meds and drama.

The acting like smq just offered to eat her out in the office is what I considered strange, not the asking for testing advised by another doc.

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[LucidSplash]

Awww...I thought we were going next year when you were done!

Please do not tempt me! I am trying very hard to keep making responsible life plans with an eye to the longterm. But it is so hard!

Its ok to "Fangirl": I had an attending whom I did the same thing to. He owned a home in Jackson Hole, was alway vacationing somewhere cool and although I went on several overseas trips as a resident, I could never afford this kind of luxury (or even dream of it. I didn't grow up in a family of vacationers. Vacation was visiting family, not going to an exotic location). So I was always asking him for pictures of his trips.

Same here. Personally I grew up half white trash. My first vacation was my honeymoon when I was 21 (not married anymore obviously, a different story for another time).

I’ve been able to take some very enjoyable “upscale on a budget” trips as a resident but only because I generally obsessively track flights and prices OR leave the time reserved and then take whatever super cheap deal pops up right beforehand. Being single without kids has its perks at times. But I do spend most of my vacation traveling to visit my family. One of the reasons I’m trying to get a job in that area for next year. I would like to not feel guilty for going on more adventurous vacations in lieu of visiting family.

 

[LucidSplash]

Back to consults.

Intern just called with an ED consult. Kidney transplant patient with prior AVF that has been ligated. All transplant work and fistula work done at OSH except some outflow angioplasty done by IR. Patient complaining of tingling in her arm. Has a palpable radial and brachial pulse, motorsensory otherwise intact. Absolutely no workup done by ED. No labs. No imaging. Not even really an exam. They didn’t even look at the records to see who did the angioplasty in the past.

Vascular consult because? Has had a fistula in the past. Now has tingling.

What. The. ****.

I got mad and called the intern back and made him put the ED resident on the phone. What I got out of him was:

1) Sorry this isn’t my patient
2) We ordered a DVT study it isn’t done yet
3) Who did the fistula work? Oh yeah that’s a good question I can look it up, probably IR...
4) What exactly is the consult for? Um...

 

[ThoracicGuy]

Back to consults.

Intern just called with an ED consult. Kidney transplant patient with prior AVF that has been ligated. All transplant work and fistula work done at OSH except some outflow angioplasty done by IR. Patient complaining of tingling in her arm. Has a palpable radial and brachial pulse, motorsensory otherwise intact. Absolutely no workup done by ED. No labs. No imaging. Not even really an exam. They didn’t even look at the records to see who did the angioplasty in the past.

Vascular consult because? Has had a fistula in the past. Now has tingling.

What. The. ****.

I got mad and called the intern back and made him put the ED resident on the phone. What I got out of him was:

1) Sorry this isn’t my patient
2) We ordered a DVT study it isn’t done yet
3) Who did the fistula work? Oh yeah that’s a good question I can look it up, probably IR...
4) What exactly is the consult for? Um...

And you still had to go see it, didn't you?

 

[Jolie South]

Back to consults.

Intern just called with an ED consult. Kidney transplant patient with prior AVF that has been ligated. All transplant work and fistula work done at OSH except some outflow angioplasty done by IR. Patient complaining of tingling in her arm. Has a palpable radial and brachial pulse, motorsensory otherwise intact. Absolutely no workup done by ED. No labs. No imaging. Not even really an exam. They didn’t even look at the records to see who did the angioplasty in the past.

Vascular consult because? Has had a fistula in the past. Now has tingling.

What. The. ****.

I got mad and called the intern back and made him put the ED resident on the phone. What I got out of him was:

1) Sorry this isn’t my patient
2) We ordered a DVT study it isn’t done yet
3) Who did the fistula work? Oh yeah that’s a good question I can look it up, probably IR...
4) What exactly is the consult for? Um...

I got a consult for a patient for “PAD” in a 30s ish patient with what is described as a bug bite with a blister on her medial calf in the ER. I call back and ask what are they concerned about with this patient? Does the patient have pulses? “Well, uh, the chart says she has PAD. So I am consulting for that. I don’t know if she has pulses.” I can hear her asking around in the background to other staff members who may have examined the patient. “She has pulses.”

Ok, well I am looking here in the chart and it looks like she recently had ABIs that are completely normal and this doesn’t look like a vascular problem so....might want to consult someone else or you know manage a bug bite/abscess yourself.

 

[LucidSplash]

And you still had to go see it, didn't you?

F*** no. Not at 11pm. I told the intern to put the patient on the list, drop a short consult note, and order PVRs and venous duplex. I went back to sleep. We saw her on rounds with the attending so she could sign the note. Studies didn’t get done overnight (vascular lab staff leave at 11p) so when she gets them and they are normal today we will sign off.

I’m on home call. I’m actually pretty quick to come in if there’s something not clear or actually concerning or even to make an ED attending feel better by seeing my face instead of the intern or senior. But I don’t think this kid ran this **** by anyone and I’m not required to go see every consult overnight thank goodness.

 

[tkim]

Back to consults.

Intern just called with an ED consult. Kidney transplant patient with prior AVF that has been ligated. All transplant work and fistula work done at OSH except some outflow angioplasty done by IR. Patient complaining of tingling in her arm. Has a palpable radial and brachial pulse, motorsensory otherwise intact. Absolutely no workup done by ED. No labs. No imaging. Not even really an exam. They didn’t even look at the records to see who did the angioplasty in the past.

Vascular consult because? Has had a fistula in the past. Now has tingling.

What. The. ****.

I got mad and called the intern back and made him put the ED resident on the phone. What I got out of him was:

1) Sorry this isn’t my patient
2) We ordered a DVT study it isn’t done yet
3) Who did the fistula work? Oh yeah that’s a good question I can look it up, probably IR...
4) What exactly is the consult for? Um...

Educate me - what labs and what would they do to help to determine the problem being/not being vascular.

Imaging - downthread you mention that imaging could not be done overnight and was done the next day. Were those studies available to order at the time of the consult? I'm assuming the it would be ultrasound because IV contrast on a kidney transplant is probably a no-no, but what information would a US give that a palpable thrill and bruit not give?

I don't have vascular at my small community hospital, nor overnight imaging. Doubtful that I would immediately leap to a vascular or fistula problem with a complaint of of tingly arm but hey, it's all in the presentation.

 

[LucidSplash]

Educate me - what labs and what would they do to help to determine the problem being/not being vascular.

Imaging - downthread you mention that imaging could not be done overnight and was done the next day. Were those studies available to order at the time of the consult? I'm assuming the it would be ultrasound because IV contrast on a kidney transplant is probably a no-no, but what information would a US give that a palpable thrill and bruit not give?

I don't have vascular at my small community hospital, nor overnight imaging. Doubtful that I would immediately leap to a vascular or fistula problem with a complaint of of tingly arm but hey, it's all in the presentation.

The studies were available at 6pm when she was put into a room in the ED. Before the studies, the palpable radial pulse in the setting of a ligated fistula in an arm without swelling negates the need for the studies I mentioned (for me) but I understand physical exam is not something I can expect them to go on because then they have no “hard data” to prove what the physical exam plainly shows. The curse of the ED, at least in my experience. Unwilling to go on physical exam alone because of fear of zebra lawsuits.

“Isolated arm tingling” in the setting of a palpable pulse is not a vascular problem. Especially when you can’t even coherently state what your concern is.

Oh, and then there were the extensive notes I found in the EMR about her prior workup for steal at our institution. A workup that was all negative. And our recommendation about referral to a neurologist. Like a year ago.

 

[dpmd]

The studies were available at 6pm when she was put into a room in the ED. Before the studies, the palpable radial pulse in the setting of a ligated fistula in an arm without swelling negates the need for the studies I mentioned (for me) but I understand physical exam is not something I can expect them to go on because then they have no “hard data” to prove what the physical exam plainly shows. The curse of the ED, at least in my experience. Unwilling to go on physical exam alone because of fear of zebra lawsuits.

“Isolated arm tingling” in the setting of a palpable pulse is not a vascular problem. Especially when you can’t even coherently state what your concern is.

Oh, and then there were the extensive notes I found in the EMR about her prior workup for steal at our institution. A workup that was all negative. And our recommendation about referral to a neurologist. Like a year ago.

Why not stand by your exam and not order unnecessary studies then?

 

[LucidSplash]

Why not stand by your exam and not order unnecessary studies then?

Because I am a fellow and I don’t make the rules. And the rules where I am are you order PVRs even with palpable pulses so there is “hard evidence” to show medicine/neuro/ED whoever that you are telling the truth or they will not stop calling everytime the patient needs socks*.

*See prior posts about rampant cases of acute sockemia.

 

[dpmd]

Because I am a fellow and I don’t make the rules. And the rules where I am are you order PVRs even with palpable pulses so there is “hard evidence” to show medicine/neuro/ED whoever that you are telling the truth or they will not stop calling everytime the patient needs socks.

Weak sauce

 

[LucidSplash]

Weak sauce

Literally the truth. If I tried to sign off a patient without PVRs I would get overruled and also verbally assaulted every time. Not worth the abuse. Ask me again in a year when I’m elsewhere.

 

[dpmd]

Literally the truth. If I tried to sign off a patient without PVRs I would get overruled and also verbally assaulted every time. Not worth the abuse. Ask me again in a year when I’m elsewhere.

I meant your staff, not you

 

[BigRedBeta]

Are you ENT?

Then again I guess if you hadn't intubated a kid in a couple months, maybe it makes sense to get someone else? How is this person on call for peds anesthesia!?

Nope, PICU.
And it was a normal 6 week old. But those kids with congenital issues are the ones that get me thinking I may need anesthesia backup...it was an asinine request to say the least

 

[tkim]

The studies were available at 6pm when she was put into a room in the ED. Before the studies, the palpable radial pulse in the setting of a ligated fistula in an arm without swelling negates the need for the studies I mentioned (for me) but I understand physical exam is not something I can expect them to go on because then they have no “hard data” to prove what the physical exam plainly shows. The curse of the ED, at least in my experience. Unwilling to go on physical exam alone because of fear of zebra lawsuits.

If not ordering labs and imaging is part of your complaint, then the fear of zebra lawsuits isn't an isolated ED problem. Just saying.

Isolated arm tingling” in the setting of a palpable pulse is not a vascular problem. Especially when you can’t even coherently state what your concern is.

Oh, and then there were the extensive notes I found in the EMR about her prior workup for steal at our institution. A workup that was all negative. And our recommendation about referral to a neurologist. Like a year ago.

And the labs they were supposed to order? Which ones would be helpful when I call vascular for a problem like this, that doesn't require neuro.

 

[LucidSplash]

If not ordering labs and imaging is part of your complaint, then the fear of zebra lawsuits isn't an isolated ED problem. Just saying.



And the labs they were supposed to order? Which ones would be helpful when I call vascular for a problem like this, that doesn't require neuro.

Basic labs for any transplant/ESRD/CKD patient would be nice. You want a surgeon to evaluate your patient then presumably you think they might need surgery. So a CBC, Coags and RFP are appropriate IMHO.

And I mean, she was a woman so for all I know she could have been having atypical MI symptoms. I wouldn’t fault an EKG either or a baseline trop in that situation.

Literally this patient had zero work up and the resident who called the consult couldn’t even tell us the exam. He said it wasn’t his patient but I’m not sure who’s it was or why he was calling a consult on a patient that wasn’t his.

 

[Apollyon]

That is SO academic. Trust me - when you get into the real world, it doesn't suck - as much.

I had a pt with a cold foot. Vascular was 100 miles away. Started heparin. Delay for ambulance. Sometime in the 3-3.5 hours, the pt revascularised.

It comes down the chain days or weeks later that the vascular surgeon told the pt (or, what they heard) was that I sent her for no reason. That vascular guy got a talking to from the chief surgeon of the whole system.

 

[vhawk]

Because I am a fellow and I don’t make the rules. And the rules where I am are you order PVRs even with palpable pulses so there is “hard evidence” to show medicine/neuro/ED whoever that you are telling the truth or they will not stop calling everytime the patient needs socks*.

*See prior posts about rampant cases of acute sockemia.

I think if you take a selfie of yourself with your finger on the radial while smiling (or frowning if no pulses) then that counts as hard evidence, legally speaking, but im not a lawyer

 

[LucidSplash]

I think if you take a selfie of yourself with your finger on the radial while smiling (or frowning if no pulses) then that counts as hard evidence, legally speaking, but im not a lawyer

 

[swoopyswoop]

consult for perianal pain due to copious diarrhea irritating stable, asymptomatic, known anal fistula

per patient: just wanted some pain control, for the love of god stop trying to CT scan me

 

[Pir8DeacDoc]

It's sad when the patient knows they're being severely over tested.

 

[mimelim]

I think if you take a selfie of yourself with your finger on the radial while smiling (or frowning if no pulses) then that counts as hard evidence, legally speaking, but im not a lawyer

I had a plastics resident record on their phone the triphasic sound and play it for me (because I didn't trust his exam). He then put it in the medical record. I didn't know that you could put a sound file into the medical record. I learned something... Very similar situation to the one mentioned above.

 

[tkim]

Basic labs for any transplant/ESRD/CKD patient would be nice. You want a surgeon to evaluate your patient then presumably you think they might need surgery. So a CBC, Coags and RFP are appropriate IMHO.

But you already determined that this wasn't a vascular problem, so why bring this not ordering labs as a failing of the ED? I mean, if you didn't think they needed ordering, why mention it?

I mean, she was a woman so for all I know she could have been having atypical MI symptoms. I wouldn’t fault an EKG either or a baseline trop in that situation.

But this wasn't why *you* were consulted, yes? I do get you're a physician first and a vascular surgeon second. However, throwing out ordering an EKG or trops - which you likely know that in a ESRD patient will probably be abnormal anyway, so useless most of time as a predictor for ACS, is a distractor.

this patient had zero work up and the resident who called the consult couldn’t even tell us the exam. He said it wasn’t his patient but I’m not sure who’s it was or why he was calling a consult on a patient that wasn’t his.

This is really the meat of the complaint - that the person calling for the consult didn't know why it was called and didn't have a coherent question to ask. Fair enough.

The rest of your complaint - no labs, no imaging, is the combination of delay tactic and order-shaming ("You didn't order that, why not?") that I see upper levels and snarky attendings roll downhill to people still trying to learn. I get that occasionally even at the attending level, and I absolutely call them on it and I make it abundantly clear that that I do not tolerate that ****.

 

[scootad.]

^^ I'm just a casual observer here, but you really need to take that stick out from your -ss

 

[tkim]

^^ I'm just a casual observer here, but you really need to take that stick out from your -ss

Why do you say that?

 

[LucidSplash]

But you already determined that this wasn't a vascular problem, so why bring this not ordering labs as a failing of the ED? I mean, if you didn't think they needed ordering, why mention it?



But this wasn't why *you* were consulted, yes? I do get you're a physician first and a vascular surgeon second. However, throwing out ordering an EKG or trops - which you likely know that in a ESRD patient will probably be abnormal anyway, so useless most of time as a predictor for ACS, is a distractor.



This is really the meat of the complaint - that the person calling for the consult didn't know why it was called and didn't have a coherent question to ask. Fair enough.

The rest of your complaint - no labs, no imaging, is the combination of delay tactic and order-shaming ("You didn't order that, why not?") that I see upper levels and snarky attendings roll downhill to people still trying to learn. I get that occasionally even at the attending level, and I absolutely call them on it and I make it abundantly clear that that I do not tolerate that ****.

I was specifically asked what kind of things I would expect an ED doc would have done before calling a vascular consult in this kind of patient. I think I made a reasonable list of things I would assume as part of a basic workup on such a patient, things that would allow the specialist to get on with their job of ruling in or out a suspected diagnosis. I stand by my answer.

I actually get along really well with the ED attendings wherever I am and have the phone numbers of many because I give out my cell to them so I can be easily reached. And am pretty congenial and quick to respond to reasonable requests to evaluate patients. This simply wasn’t one. And I didn’t get any pushback from the attending on duty either.

So you can take your assumptions about me and my response to an inappropriate consult and kindly piss off.

Have a great day!

 

[tkim]

I was specifically asked what kind of things I would expect an ED doc would have done before calling a vascular consult in this kind of patient. I think I made a reasonable list of things I would assume as part of a basic workup on such a patient, things that would allow the specialist to get on with their job of ruling in or out a suspected diagnosis. I stand by my answer.

I actually get along really well with the ED attendings wherever I am and have the phone numbers of many because I give out my cell to them so I can be easily reached. And am pretty congenial and quick to respond to reasonable requests to evaluate patients. This simply wasn’t one. And I didn’t get any pushback from the attending on duty either.

So you can take your assumptions about me and my response to an inappropriate consult and kindly piss off.

Have a great day!

So, the bottom line is that you got an inappropriate consult. No argument there. But the line of "labs this, imaging that", when you yourself would not have needed any of them to make the determination that this did not require vascular is simply make-work and a delaying tactic and that's a separate issue, despite your proclamations that everyone likes you and you're rilly, rilly nice, which has nothing to do with the subject at hand. But way to veer off the subject. I've made no assumptions about you - everything I've said is exactly what you yourself wrote.

 

[Winged Scapula]

I think we can eliminate the less than collegial vibe here and stop taking things personally. This thread is meant to be fun.

 

[dpmd]

Had a lady a few months out from a hysterectomy present with significant pelvic pain and vag bleed after the husband got a little carried away during sex. Why was i consulted when I am a general surgeon not a gyn? Because the ct showed quite a but of free air. No real risk factors for gi perforation aside from I suppose the stress ulcer from the surgery but no preceding syptoms. Gyn hasn't left a note in the past three days since admit so I am not sure what they are thinking but patient tells me he says vaginal cuff is intact. She and her husband (who claims he felt her vagina give way while thrusting) are in my camp figuring it has to be that. This is actually the second patient I have cared for with this issue.

 

[tkim]

I think we can eliminate the less than collegial vibe here and stop taking things personally. This thread is meant to be fun.

Have not taken it personally. Have not told others they have a stick up their ass, or to piss off. Happy to call out snarky consultants 24/7. If that's a problem, happy to be banned.

 

[vhawk]

Had a lady a few months out from a hysterectomy present with significant pelvic pain and vag bleed after the husband got a little carried away during sex. Why was i consulted when I am a general surgeon not a gyn? Because the ct showed quite a but of free air. No real risk factors for gi perforation aside from I suppose the stress ulcer from the surgery but no preceding syptoms. Gyn hasn't left a note in the past three days since admit so I am not sure what they are thinking but patient tells me he says vaginal cuff is intact. She and her husband (who claims he felt her vagina give way while thrusting) are in my camp figuring it has to be that. This is actually the second patient I have cared for with this issue.

I have heard a (possibly apocryphal) story from one of my attendings about a young female patient with a modest amount of free air after being on the receiving end of a particularly vigorous and misguided attempt at oral sex.

Also maybe let that dude know that "tear that **** up" and "destroy that *****" are meant as aggressive metaphors, not to be taken literally

 

[vhawk]

Have not taken it personally. Have not told others they have a stick up their ass, or to piss off. Happy to call out snarky consultants 24/7. If that's a problem, happy to be banned.

As someone watching the exchange between you and Lucid from the outside, the issue seems to be that you are having two different conversations. She is ranting about a bad consult she got, and you are using some perhaps ill-considered portions of her rant to go on a mostly separate rant about an issue that is a pet peeve of yours. I do this frequently, but you could easily have minimized the conflict (im not claiming either of you are being rude or unprofessional) by just pointing it out a little more clearly that yours was a generalized rant and only tangentially related to anything she said. It seems clear to me you realized that was what was going on for at least the last few posts, if not then my bad.

 

[Winged Scapula]

Have not taken it personally. Have not told others they have a stick up their ass, or to piss off. Happy to call out snarky consultants 24/7. If that's a problem, happy to be banned.

It does seem that you’re taking this personally because I was not addressing you but rather everyone in the snarky conversation.

The user who made the above comment to you received admin action against his account for that comment.

 

[dpmd]

I have heard a (possibly apocryphal) story from one of my attendings about a young female patient with a modest amount of free air after being on the receiving end of a particularly vigorous and misguided attempt at oral sex.

Also maybe let that dude know that "tear that **** up" and "destroy that *****" are meant as aggressive metaphors, not to be taken literally

He looks like he feels bad about it. I think it was just a case of it having been so long and that their first attempt previous to this one didn't go well so he was timid at first then when she was feeling good he got lost in the moment. Based on some frank discussion with her I think his penis is just too long for her current vaginal length. Not sure if this will remain a permanent issue or if things will get stretchier once the healing is fully complete.

 

[vhawk]

He looks like he feels bad about it. I think it was just a case of it having been so long and that their first attempt previous to this one didn't go well so he was timid at first then when she was feeling good he got lost in the moment. Based on some frank discussion with her I think his penis is just too long for her current vaginal length. Not sure if this will remain a permanent issue or if things will get stretchier once the healing is fully complete.

I imagine he wiill be too embarrassed to tell anyone such as all of his friends, co workers, neighbors, people he meets on the bus, etc

 

[Pir8DeacDoc]

So, the bottom line is that you got an inappropriate consult. No argument there. But the line of "labs this, imaging that", when you yourself would not have needed any of them to make the determination that this did not require vascular is simply make-work and a delaying tactic and that's a separate issue, despite your proclamations that everyone likes you and you're rilly, rilly nice, which has nothing to do with the subject at hand. But way to veer off the subject. I've made no assumptions about you - everything I've said is exactly what you yourself wrote.

Seem like you'd be a lot of fun to work with...

 

[swoopyswoop]

consulted for bad acne because a CT showed an "abscess" (Disagreed with the read, more consistent with soft tissue swelling, and definitely no abscess on exam)

 

[Jolie South]

Had a lady a few months out from a hysterectomy present with significant pelvic pain and vag bleed after the husband got a little carried away during sex. Why was i consulted when I am a general surgeon not a gyn? Because the ct showed quite a but of free air. No real risk factors for gi perforation aside from I suppose the stress ulcer from the surgery but no preceding syptoms. Gyn hasn't left a note in the past three days since admit so I am not sure what they are thinking but patient tells me he says vaginal cuff is intact. She and her husband (who claims he felt her vagina give way while thrusting) are in my camp figuring it has to be that. This is actually the second patient I have cared for with this issue.

I had a similar patient with a vaginal cuff dehiscence that I got repeatedly consulted for “appendicitis.” Appendix clearly visualized with no signs of appendicitis on scan. Got a call early one night shift for this and said “call her gyn.” Came back 24 hours later to work and ER consulted me AGAIN bc gyn said it was not their problem even though the lady had a hysterectomy a few months back and sex brought on her pain.

I eventually had to get the chief of surgery involved bc why should I have to take care of another specialty’s surgical complications.

 

[dpmd]

I had a similar patient with a vaginal cuff dehiscence that I got repeatedly consulted for “appendicitis.” Appendix clearly visualized with no signs of appendicitis on scan. Got a call early one night shift for this and said “call her gyn.” Came back 24 hours later to work and ER consulted me AGAIN bc gyn said it was not their problem even though the lady had a hysterectomy a few months back and sex brought on her pain.

I eventually had to get the chief of surgery involved bc why should I have to take care of another specialty’s surgical complications.

Note finally showed up and gyn says cuff rupture presumptive dx. I signed off. Yay!

 

[tkim]

It does seem that you’re taking this personally because I was not addressing you but rather everyone in the snarky conversation.

The user who made the above comment to you received admin action against his account for that comment.

Nope. Just wanted to be clear that if admin actions come raining down, they fall on the right accounts. This posting in general but meaning specific people makes everyone sit up and take notice, but does that mean I'm taking it *personally*. Come on.

 

[tkim]

As someone watching the exchange between you and Lucid from the outside, the issue seems to be that you are having two different conversations. She is ranting about a bad consult she got, and you are using some perhaps ill-considered portions of her rant to go on a mostly separate rant about an issue that is a pet peeve of yours. I do this frequently, but you could easily have minimized the conflict (im not claiming either of you are being rude or unprofessional) by just pointing it out a little more clearly that yours was a generalized rant and only tangentially related to anything she said. It seems clear to me you realized that was what was going on for at least the last few posts, if not then my bad.

Except that it's not. Outside of the fishbowl that is the ED, it's (in)famous for the supposed shotgun approach to labs, imaging and consults. I get that and I sympathize. The consultant who says that the consult wasn't necessary, that they could have told you that with just a physical exam, but then goes further to say that the ED should have ordered labs and imaging, this brings on a disconnect that I'm pointing out. Well, which one was it - needed labs and imaging or didn't?

It's the double-edged sword of calling consultants - why did you/didn't you - order these labs - order that imaging - call me sooner/now/at all.

As I've said in probably every reply to my first reply, I get that this was a poorly initiated consult and probably not necessary. Could've stopped there. But the part about them not ordering labs or imaging, that's weak sauce, and saying that had she seen that patient, would not have needed those things, drops the grousing about it as unnecessary.

 

[dpmd]

Except that it's not. Outside of the fishbowl that is the ED, it's (in)famous for the supposed shotgun approach to labs, imaging and consults. I get that and I sympathize. The consultant who says that the consult wasn't necessary, that they could have told you that with just a physical exam, but then goes further to say that the ED should have ordered labs and imaging, this brings on a disconnect that I'm pointing out. Well, which one was it - needed labs and imaging or didn't?

It's the double-edged sword of calling consultants - why did you/didn't you - order these labs - order that imaging - call me sooner/now/at all.

As I've said in probably every reply to my first reply, I get that this was a poorly initiated consult and probably not necessary. Could've stopped there. But the part about them not ordering labs or imaging, that's weak sauce, and saying that had she seen that patient, would not have needed those things, drops the grousing about it as unnecessary.

I had the same thought, which was why I asked why they still ordered all that stuff. Answer to that is her attendings are the weak sauce. I don't think you crossed any line but I think you could have approached it differently and not triggered the defensiveness. Should you have to? No. But we are supposed to be in the kinder gentler sdn so I guess it would be helpful.

 

[LucidSplash]

So, I agree with what everyone else has said and if I responded strongly, I apologize. But truthfully, this is the Surgery forum. This is a thread for surgeons to post consult experiences. I don’t hang out in the EM forum looking for complaints about surgeons to respond to with the surgery perspective; I’m sure there are a few but I see that as your space and respect it.

I didn’t make a generalized ad hominem attack against the ED. That’s not my style anyway if you want to review my post history but whatever. You may have thought my response was snarky as depicted but it was about a specific incident as you already pointed out. You took that opportunity to voice a broader complaint about consultants to the ED which is frankly not the topic of this thread. What I post here I post for surgeons. It isn’t against TOS for you to add your 2 cents but to me it seems out of place, because I would consider it rude to come into your space and do something similar.

Maybe I’m the only one who feels this way. But that’s my personal opinion and I in no way am intending to speak for all the surgeons here. We have plenty of good collegial interspecialty conversations in this forum, I’m just not interested in that in this thread unless a surgeon specifically reaches out and asks for another specialty’s opinion. So I took your post as a rude unwanted intrusion and still see it that way. I likely reacted mostly to that. I apologize for coming off strongly because of that but my opinion otherwise stands.

 

[Raryn]

Except that it's not. Outside of the fishbowl that is the ED, it's (in)famous for the supposed shotgun approach to labs, imaging and consults. I get that and I sympathize. The consultant who says that the consult wasn't necessary, that they could have told you that with just a physical exam, but then goes further to say that the ED should have ordered labs and imaging, this brings on a disconnect that I'm pointing out. Well, which one was it - needed labs and imaging or didn't?

It's the double-edged sword of calling consultants - why did you/didn't you - order these labs - order that imaging - call me sooner/now/at all.

As I've said in probably every reply to my first reply, I get that this was a poorly initiated consult and probably not necessary. Could've stopped there. But the part about them not ordering labs or imaging, that's weak sauce, and saying that had she seen that patient, would not have needed those things, drops the grousing about it as unnecessary.

The post is pretty clear that labs and imaging (in the poster's opinion) are not necessary to rule out that specific concern (vascular disease) but are reasonable to evaluate for other possible concerns related to that chief complaint. Or perhaps you can interpret it to say that even if the ED doc felt that they couldn't adequately rule out vascular disease with their physical exam, the next step is labs/imaging rather than calling a different physician in to evaluate the question. Or maybe you can interpret it to say "before you call another physician, do *something* to show you at least thought about the problem first". Regardless of how you interpret it, it's a reasonable statement - though I suppose the last one might be less palatable to a referring physician (inpatient or outpatient).

 

[Jolie South]

I had the same thought, which was why I asked why they still ordered all that stuff. Answer to that is her attendings are the weak sauce. I don't think you crossed any line but I think you could have approached it differently and not triggered the defensiveness. Should you have to? No. But we are supposed to be in the kinder gentler sdn so I guess it would be helpful.

Maybe it’s just me, but when I get consulted by an ED or any specialty physician that is not vascular I have a lot of skepticism about their physical exam findings. I trust my hands and eyes to see things that you in your scope of practice aren’t trained to see or do. That is not a knock against you as an emergency medicine physician. It’s just that you aren’t trained to do what I do. You don’t critically examine legs and wounds on the daily like I do.

If you call me with some irrefutable objective evidence, instead of “there is some leg swelling and I think the patient has a DVT” that gives us somewhere to start from in terms of prioritizing seeing consults between the OR, ones I can send the intern to see, and ones that can wait until morning rounds. And for a lot of things I can’t even give you a dispo (which is your bottom line) until I get the needed study.

 

[dpmd]

Maybe it’s just me, but when I get consulted by an ED or any specialty physician that is not vascular I have a lot of skepticism about their physical exam findings. I trust my hands and eyes to see things that you in your scope of practice aren’t trained to see or do. That is not a knock against you as an emergency medicine physician. It’s just that you aren’t trained to do what I do. You don’t critically examine legs and wounds on the daily like I do.

If you call me with some irrefutable objective evidence, instead of “there is some leg swelling and I think the patient has a DVT” that gives us somewhere to start from in terms of prioritizing seeing consults between the OR, ones I can send the intern to see, and ones that can wait until morning rounds. And for a lot of things I can’t even give you a dispo (which is your bottom line) until I get the needed study.

Hey, I'm a surgeon! But I do get your point about the questionable nature of the exams coming from the ED. However, that doesn't mean that they should skip the exam part or that every finding needs an objective test to prove it. Like I may not believe someone that the patient has peritonitis on exam but that doesn't mean they should delay consultation for someone with a bowel perf until they get the labs and imaging back.

 

[tkim]

I had the same thought, which was why I asked why they still ordered all that stuff. Answer to that is her attendings are the weak sauce. I don't think you crossed any line but I think you could have approached it differently and not triggered the defensiveness. Should you have to? No. But we are supposed to be in the kinder gentler sdn so I guess it would be helpful.

What's telling is that you ask essentially the same question, you get 'because my attending told me to'. I get 'piss off'. Nice.

 

[dpmd]

What's telling is that you ask essentially the same question, you get 'because my attending told me to'. I get 'piss off'. Nice.

Yeah but I asked nicely. Sort of my point. Like when I noticed something that our EM guys kept on doing that bugged me, instead of saying I hate how you guys keep doing x because it is a bunch of crap I asked one guy who I know pretty well "hey why do you guys all seem to do x when it doesn't seem needed all the time". The answer was that other surgeons yell at them if x isn't done. Boom we all are on the same page, I can ask then to try not to do x if they know I am on call, talk to my colleagues about why they want x done all the time, or if it isn't that big a deal I can just go with x being done.

 

[tkim]

So, I agree with what everyone else has said and if I responded strongly, I apologize. But truthfully, this is the Surgery forum. This is a thread for surgeons to post consult experiences. I don’t hang out in the EM forum looking for complaints about surgeons to respond to with the surgery perspective; I’m sure there are a few but I see that as your space and respect it.

I see, I didn't realize that this thread was for surgeons only, so that surgeons could, in a clubby fashion, throw shade on other physicians. My bad. Or, non-surgeons can post only if the don't piss off the regulars in the thread. Again, my bad.

didn’t make a generalized ad hominem attack against the ED. That’s not my style anyway if you want to review my post history but whatever. You may have thought my response was snarky as depicted but it was about a specific incident as you already pointed out. You took that opportunity to voice a broader complaint about consultants to the ED which is frankly not the topic of this thread.

Others seemed to have gotten yet, but you seem stuck on my posts being some screed on all consultants. Once again. I asked you what labs, you answer X labs. You say you don't need X labs to determine not a vascular problem, but complain that X labs weren't ordered by the ED. Are you seeing the disconnect I'm trying to figure out?

I post here I post for surgeons. It isn’t against TOS for you to add your 2 cents but to me it seems out of place, because I would consider it rude to come into your space and do something similar.

I see, I didn't realize that this thread was for surgeons only, so that surgeons could, in a clubby fashion, throw shade on other physicians. My bad. Or, non-surgeons can post only if the don't piss off the regulars in the thread. Again, my bad.

I’m the only one who feels this way. But that’s my personal opinion and I in no way am intending to speak for all the surgeons here. We have plenty of good collegial interspecialty conversations in this forum, I’m just not interested in that in this thread unless a surgeon specifically reaches out and asks for another specialty’s opinion. So I took your post as a rude unwanted intrusion and still see it that way. I likely reacted mostly to that. I apologize for coming off strongly because of that but my opinion otherwise stands.

I see, I didn't realize that this thread was for surgeons only, so that surgeons could, in a clubby fashion, throw shade on other physicians. My bad. Or, non-surgeons can post only if the don't piss off the regulars in the thread. Again, my bad.

 

[tkim]

Yeah but I asked nicely. Sort of my point. Like when I noticed something that our EM guys kept on doing that bugged me, instead of saying I hate how you guys keep doing x because it is a bunch of crap I asked one guy who I know pretty well "hey why do you guys all seem to do x when it doesn't seem needed all the time". The answer was that other surgeons yell at them if x isn't done. Boom we all are on the same page, I can ask then to try not to do x if they know I am on call, talk to my colleagues about why they want x done all the time, or if it isn't that big a deal I can just go with x being done.

I've reread my posts, and I'm trying to see where I didn't ask nicely. I'm asking sincerely for you point out what's different between how I asked and how you did:

Me: "Educate me - what labs and what would they do to help to determine the problem being/not being vascular.

Imaging - downthread you mention that imaging could not be done overnight and was done the next day. Were those studies available to order at the time of the consult? I'm assuming the it would be ultrasound because IV contrast on a kidney transplant is probably a no-no, but what information would a US give that a palpable thrill and bruit not give?

I don't have vascular at my small community hospital, nor overnight imaging. Doubtful that I would immediately leap to a vascular or fistula problem with a complaint of of tingly arm but hey, it's all in the presentation."

You: "Why not stand by your exam and not order unnecessary studies then?"