Consults- Memorable/Dismal/Ridiculous/Unique

[deleted50541]

It's that magical time of year that brings the gift of esophageal perfs after stuffing one's face, Thanksgiving.

19 y/o guy with Down syndrome and pica (cat litter was his favorite treat) swallowed a turkey bone that got stuck in his cervical esophagus.

GI couldn't budge it with a scope. We gave it a go with a rigid scope. No luck. Left neck exploration with removal of the offending bone (it was rather sharp and pointy, mucosa shredded), repaired and muscle flapped the closure, and did a G-tube.

Guy had other serious behavioral issues and was a bear to manage post-op. Of course the repair leaked and took a month to heal. Thankfully he never ripped out his neck drain.

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[HighPriest]

It's that magical time of year that brings the gift of esophageal perfs after stuffing one's face, Thanksgiving.

19 y/o guy with Down syndrome and pica (cat litter was his favorite treat) swallowed a turkey bone that got stuck in his cervical esophagus.

GI couldn't budge it with a scope. We gave it a go with a rigid scope. No luck. Left neck exploration with removal of the offending bone (it was rather sharp and pointy, mucosa shredded), repaired and muscle flapped the closure, and did a G-tube.

Guy had other serious behavioral issues and was a bear to manage post-op. Of course the repair leaked and took a month to heal. Thankfully he never ripped out his neck drain.

I had almost the same scenario with a 23 year old meathead soldier. Except he didn’t have the excuse of having an extra chromosome. He was just a fool who didn’t know how to chew. The piece of chicken bone we took out was at least the size of a 50 cent piece. I don’t even know what part of the chicken it was. Some kind of mutant, big-boned chicken. And of course, “I don’t know how this could have happened, Sir!”

Well, considering the size, I’m going to assume you were just swallowing every bite you took without chewing at all. So that’s probably how it happened.

 

[LucidSplash]

Patient admitted to medicine with, in addition to multiple other issues, a toe wound, we get consulted. She has a toe ulcer needs an angio. Patient eats sandwich despite being told she is NPO for procedure. Patient is mad we can't do procedure today and insists she's "never needed to be NPO for a procedure before." Patient leaves AMA, walks downstairs to the ED and checks in saying she wants her angio. ED calls us, knowing the situation, asking if we want to admit this time.

NOPE.

Not the ED's fault really, just a troublesome, not very bright, patient. But yeah, no.

She's going back on the medicine service.

 

[HighPriest]

Patient admitted to medicine with, in addition to multiple other issues, a toe wound, we get consulted. She has a toe ulcer needs an angio. Patient eats sandwich despite being told she is NPO for procedure. Patient is mad we can't do procedure today and insists she's "never needed to be NPO for a procedure before." Patient leaves AMA, walks downstairs to the ED and checks in saying she wants her angio. ED calls us, knowing the situation, asking if we want to admit this time.

NOPE.

Not the ED's fault really, just a troublesome, not very bright, patient. But yeah, no.

She's going back on the medicine service.

She's like some kind of playground Machiavelli.

 

[dpmd]

Patient admitted to medicine with, in addition to multiple other issues, a toe wound, we get consulted. She has a toe ulcer needs an angio. Patient eats sandwich despite being told she is NPO for procedure. Patient is mad we can't do procedure today and insists she's "never needed to be NPO for a procedure before." Patient leaves AMA, walks downstairs to the ED and checks in saying she wants her angio. ED calls us, knowing the situation, asking if we want to admit this time.

NOPE.

Not the ED's fault really, just a troublesome, not very bright, patient. But yeah, no.

She's going back on the medicine service.

They should have just made her do an outpatient workup. Her walking downstairs implies she isn't sick enough to require admission.

 

[Jolie South]

They should have just made her do an outpatient workup. Her walking downstairs implies she isn't sick enough to require admission.

One of my attendings in particular has no patience for these inpatient but should be outpatient consults. They get one shot. If we schedule and they cancel, we sign off and you follow up in clinic.

 

[Arcan57]

They should have just made her do an outpatient workup. Her walking downstairs implies she isn't sick enough to require admission.

It’s unusual within the same institution, but I get ~1-2 pts per month that left AMA from an ICU just prior to their presentation to my ED. They’re about a 50/50 mix of Axis II rage quits and backdoor transfers where the fact that we didn’t have capacity wasn’t seen as a barrier to encouraging the patient to leave and show up where “[we’d] take care of things”.

 

[dpmd]

It’s unusual within the same institution, but I get ~1-2 pts per month that left AMA from an ICU just prior to their presentation to my ED. They’re about a 50/50 mix of Axis II rage quits and backdoor transfers where the fact that we didn’t have capacity wasn’t seen as a barrier to encouraging the patient to leave and show up where “[we’d] take care of things”.

On occasion I want to do that backdoor transfer but mostly when it is a patient of that hospital that they still won't accept. I still can't bring myself to actually do it.

 

[Jolie South]

On occasion I want to do that backdoor transfer but mostly when it is a patient of that hospital that they still won't accept. I still can't bring myself to actually do it.

Nothing fires me up more than when we get backdoor transfers.

Or other shady transfers, you know like on Thanksgiving when you get a patient with acute limb ischemia because the on call staff vascular surgeon at another hospital is “unavailable”. Like how is that crap legal?

 

[Gastrapathy]

She's like some kind of playground Machiavelli.

On the overnight IM calls in residency, I used to fantasize about what I will do when it’s my turn to be a gomer. Pull IVs and bleed everywhere. Slide onto the floor and put ketchup in my hair while telling them I hit my head. Change my code status at 3 am to the most impossibly detailed Burger King style code status, repeat. Switch wristbands, rooms, etc. order a keg to the ward.

 

[HighPriest]

On the overnight IM calls in residency, I used to fantasize about what I will do when it’s my turn to be a gomer. Pull IVs and bleed everywhere. Slide onto the floor and put ketchup in my hair while telling them I hit my head. Change my code status at 3 am to the most impossibly detailed Burger King style code status, repeat. Switch wristbands, rooms, etc. order a keg to the ward.

I’ll always remember the day I really knew I could never be a nurse. I was working on the CCU as a medical student at a VA. We were rounding. I dunno, like hour 15 or whatever on our fourth patient. We’re standing outside his room talking about his case when he stands up out of bed, takes three steps, pulls out his picc and starts hemorrhaging all over his gown, the bed, the floor. Then he takes two more steps and drops deuce. From a standing position. I’m the middle of his two-man room. And not a clean deuce, if there ever were such a thing. The cardiologist glances at the room as the guy starts yelling incoherently and says “let’s move on. We’ll come back and evaluate him after the nurses take care of this.”

I think you’ll have a lot of work to do to really get under their skin.

 

[Apollyon]

On the overnight IM calls in residency, I used to fantasize about what I will do when it’s my turn to be a gomer. Pull IVs and bleed everywhere. Slide onto the floor and put ketchup in my hair while telling them I hit my head. Change my code status at 3 am to the most impossibly detailed Burger King style code status, repeat. Switch wristbands, rooms, etc. order a keg to the ward.

A guy with whom I worked on the ambulance had this ALL planned out. He said that he'd tell the paramedics that "I used to be one of you guys", and EMS would just blow him off. Pinch all of the nurses' butts. Every time someone touched him - "ow!" "Ow!!" Always have something that just HAS to go with you, like a TV or a puppy. Go nuts and start yelling, "Where's my gold ring? Where's my gold ring??" And, finally, when they pick you up - pee all over the floor (hat tip @HighPriest ).

 

[WheezyBaby]

I’ll always remember the day I really knew I could never be a nurse. I was working on the CCU as a medical student at a VA. We were rounding. I dunno, like hour 15 or whatever on our fourth patient. We’re standing outside his room talking about his case when he stands up out of bed, takes three steps, pulls out his picc and starts hemorrhaging all over his gown, the bed, the floor. Then he takes two more steps and drops deuce. From a standing position. I’m the middle of his two-man room. And not a clean deuce, if there ever were such a thing. The cardiologist glances at the room as the guy starts yelling incoherently and says “let’s move on. We’ll come back and evaluate him after the nurses take care of this.”

I think you’ll have a lot of work to do to really get under their skin.

I got an overnight page from a nurse at our children's hospital. Called her back and she sounded like she'd just stopped crying. Night shift there is a large percent new nurses, so I thought I was going to be hearing about some mandatory report error thatd happened on the alaris pump or something. She struggled to get her words out. "There's... There's.. it's all.. there's poop all over the walls!!" School aged kid with constipation we'd fleets'ed and apparently finally unleashed the beast. I asked her if there was anything she needed from me and she just kind of despondently said no then hung up. At our county hospital, prerounding on patients for the day to find one of my postarrest patients whod been improving had been moved to the psych floor. Went to her bedside and she was there pleasantly smiling sitting Indian style butt naked in a soma bed still covered in dried blood from her self d/c'd aline and IJ. Cant even get started on how much crap the ed nurses have to deal with. Not. The job. For me

 

[deleted547339]

I got an overnight page from a nurse at our children's hospital. Called her back and she sounded like she'd just stopped crying. Night shift there is a large percent new nurses, so I thought I was going to be hearing about some mandatory report error thatd happened on the alaris pump or something. She struggled to get her words out. "There's... There's.. it's all.. there's poop all over the walls!!" School aged kid with constipation we'd fleets'ed and apparently finally unleashed the beast. I asked her if there was anything she needed from me and she just kind of despondently said no then hung up. At our county hospital, prerounding on patients for the day to find one of my postarrest patients whod been improving had been moved to the psych floor. Went to her bedside and she was there pleasantly smiling sitting Indian style butt naked in a soma bed still covered in dried blood from her self d/c'd aline and IJ. Cant even get started on how much crap the ed nurses have to deal with. Not. The job. For me

That’s nothing. I was almost expecting you to say the blood calms from.....somewhere else.

 

[HighPriest]

I got an overnight page from a nurse at our children's hospital. Called her back and she sounded like she'd just stopped crying. Night shift there is a large percent new nurses, so I thought I was going to be hearing about some mandatory report error thatd happened on the alaris pump or something. She struggled to get her words out. "There's... There's.. it's all.. there's poop all over the walls!!" School aged kid with constipation we'd fleets'ed and apparently finally unleashed the beast. I asked her if there was anything she needed from me and she just kind of despondently said no then hung up.

I really hope you had the time to grab a coffee and stroll by the room to poke your head in and ask that nurse how everything was going with the clean up?

 

[smq123]

I got an overnight page from a nurse at our children's hospital. Called her back and she sounded like she'd just stopped crying. Night shift there is a large percent new nurses, so I thought I was going to be hearing about some mandatory report error thatd happened on the alaris pump or something. She struggled to get her words out. "There's... There's.. it's all.. there's poop all over the walls!!" School aged kid with constipation we'd fleets'ed and apparently finally unleashed the beast. I asked her if there was anything she needed from me and she just kind of despondently said no then hung up.

I'm a terrible person, I know, but this line made me laugh the most.

 

[WheezyBaby]

I really hope you had the time to grab a coffee and stroll by the room to poke your head in and ask that nurse how everything was going with the clean up?

I stopped by about an hour afterward. She had recovered

 

[BigRedBeta]

Med student on IM at the VA, we're standing there talking to one of our patients when he promptly craps his pants. Our team is all men (students, interns, senior resident, attending). We sit there in disbelief and my intern goes "dude, what the hell? Why did you do that?", patient says "wait till you see hot my nurse is...I just want her to stare at my junk for a minute and this is how I get her in here".

Kicker is, of course, that his nurse was a typical VA med/surg nurse - on the far side of 50, overweight, no makeup, clearly had a significant pack-year history that had aged her even further. Hot is probably the last word anyone had used to describe her in quite some time. She comes in, starts yelling at him about how she's going to have to clean him up now, and as we leave he give us the biggest smile and a thumbs up.

 

[OrthoTraumaMD]

Med student on IM at the VA, we're standing there talking to one of our patients when he promptly craps his pants

For just a moment there, I thought you were talking about the med student.


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[coldleg]

They should have just made her do an outpatient workup. Her walking downstairs implies she isn't sick enough to require admission.

Had the exact same patient in training who withdrew consent for the angio. That evening, eloped on to a busy city street to smoke crack, stumbled back in the ED an hour later wanting to return to her room. Yeah, uh, sounds like she can follow up as an outpatient....

 

[swoopyswoop]

Consult for possible intussusception in a child on OSH US. Repeat US normal. Pain resolved. ???

 

[HighPriest]

Consult for possible intussusception in a child on OSH US. Repeat US normal. Pain resolved. ???

The intussusception completed. His colon is inside out and backwards now. Like that Christopher Nolan movie of the same name.

 

[mimelim]

"I just want to confirm, you want 3 type and screens?" - 2:30am floor nurse

 

[LucidSplash]

Must be something about 230am.

Friday 230am, transfer center calls an urgent consult directly to me. Apparently ortho direct admitted some 71 y/o with a toe ulcer and want us to “begin the workup immediately.” Transfer center guy apologizes.

Immediately consisted of me texting the intern to see the consult and order non-invasive testing for when the vascular lab is actually open. And rolling over and going back to sleep.

 

[ThoracicGuy]

Must be something about 230am.

Friday 230am, transfer center calls an urgent consult directly to me. Apparently ortho direct admitted some 71 y/o with a toe ulcer and want us to “begin the workup immediately.” Transfer center guy apologizes.

Immediately consisted of me texting the intern to see the consult and order non-invasive testing for when the vascular lab is actually open. And rolling over and going back to sleep.

I've yet to see a toe ulcer that was an overnight emergency...

 

[Apollyon]

I've yet to see a toe ulcer that was an overnight emergency...

"When in doubt, cut it out (or off)!"

 

[OrthoTraumaMD]

Yeah. Not sure why Ortho consulted you. I would’ve just chopped it off. He’s got nine more… LOL



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[LucidSplash]

Yeah. Not sure why Ortho consulted you. I would’ve just chopped it off. He’s got nine more… LOL



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Well he’s a diabetic with non palpable pulses. And just an ulcer not a nonsalvageable toe. So the consult was the right thing to do, just not necessary to do it at 230am. Likely wouldn’t have healed if they had just cut it off. Not enough blood flow.

We can definitely ask why they admitted the patient for a non-infected toe ulcer though, instead of sending them to the office for outpt workup. Who knows.

 

[OrthoTraumaMD]

Well he’s a diabetic with non palpable pulses. And just an ulcer not a nonsalvageable toe. So the consult was the right thing to do, just not necessary to do it at 230am. Likely wouldn’t have healed if they had just cut it off. Not enough blood flow.

Ah... where I’m at they don’t even call vascular. Those guys aren’t interested in seeing diabetics in house. So I try to treat nonop and then start cutting...

Can you intervene to revascularize a toe? I thought it was a lost cause that far down...or do you just do the foot and rely on collaterals?

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[Jolie South]

Ah... where I’m at they don’t even call vascular. Those guys aren’t interested in seeing diabetics in house. So I try to treat nonop and then start cutting...

Can you intervene to revascularize a toe? I thought it was a lost cause that far down...or do you just do the foot and rely on collaterals?

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You don’t revascularize just the toe. You look for general strategies to improve the overall flow to the foot depending on where the disease is. Then, amputate the toe if not healing after the fact. Or do BKA if revascularization is not possible.

 

[LucidSplash]

Ah... where I’m at they don’t even call vascular. Those guys aren’t interested in seeing diabetics in house. So I try to treat nonop and then start cutting...

Can you intervene to revascularize a toe? I thought it was a lost cause that far down...or do you just do the foot and rely on collaterals?

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In a diabetic the issue is usually tibial disease. I would start with noninvasive testing and then get an angio to see what the issue is. Start with some endovascular intervention if amenable or you can bypass to the distal tibials. A few places (including where I train) will even bypass to the DP or plantar for limb salvage.

A diabetic with an ABI below 0.7 is likely not going to heal a toe ulcer or a toe amp without some kind of vascular intervention to get inline flow.

 

[ThoracicGuy]

In a diabetic the issue is usually tibial disease. I would start with noninvasive testing and then get an angio to see what the issue is. Start with some endovascular intervention if amenable or you can bypass to the distal tibials. A few places (including where I train) will even bypass to the DP or plantar for limb salvage.

A diabetic with an ABI below 0.7 is likely not going to heal a toe ulcer or a toe amp without some kind of vascular intervention to get inline flow.

How many of these distal bypasses actually provide much benefit... I don't really see much in distal tibial bypass for the most part. Bypassing to the DP just seems a bit silly.

 

[dpmd]

How many of these distal bypasses actually provide much benefit... I don't really see much in distal tibial bypass for the most part. Bypassing to the DP just seems a bit silly.

Just adding steps to the old fem-pop, fem-clot, fem-chop sequence.

 

[ThoracicGuy]

Just adding steps to the old fem-pop, fem-clot, fem-chop sequence.

I mean, sometimes the kids need some new shoes...

 

[LucidSplash]

If you’re interested in limb salvage it’s not at all silly. Also would likely be less silly if it was your leg. This kind of thing is typical pursued for tissue loss and isn’t generally necessary for rest pain. As a fellow I do 5-10 on a typical week.

This was one of the first papers, and we have an additional 25 years of experience here now beyond this that says it works.

Fempop femclot femchop is an antiquated way of thinking about peripheral vascular disease and does a disservice to our patients.

 

[dpmd]

I was mostly teasing. I have no idea what the patency rates are for the distal stuff or how the amputation rates have changed. I am wholeheartedly grateful for those who choose to do vascular because I would hate for it to be any part of my practice.

 

[Psai]

If you’re interested in limb salvage it’s not at all silly. Also would likely be less silly if it was your leg. This kind of thing is typical pursued for tissue loss and isn’t generally necessary for rest pain. As a fellow I do 5-10 on a typical week.

This was one of the first papers, and we have an additional 25 years of experience here now beyond this that says it works.

Fempop femclot femchop is an antiquated way of thinking about peripheral vascular disease and does a disservice to our patients.

If it was my leg, I'd be doing something about it before it turned black and dead. Let the toe fall off by itself no biggie.

 

[ThoracicGuy]

If you’re interested in limb salvage it’s not at all silly. Also would likely be less silly if it was your leg. This kind of thing is typical pursued for tissue loss and isn’t generally necessary for rest pain. As a fellow I do 5-10 on a typical week.

This was one of the first papers, and we have an additional 25 years of experience here now beyond this that says it works.

Fempop femclot femchop is an antiquated way of thinking about peripheral vascular disease and does a disservice to our patients.

I've not seen that great of outcomes with bypassing to these small vessels. It usually seems a long shot for long term patency. I would worry about the size mismatch from the larger vein to the small vessel (usually). As always, I'm sure patient selection plays into this.

 

[LucidSplash]

If it was my leg, I'd be doing something about it before it turned black and dead. Let the toe fall off by itself no biggie.

Sure. But not all toe ulcers are black gangrene. And even if they are, that gangrene tends not to stop at the toe if you don’t do anything.

I’m not debating that vascular patients are a difficult population both medically and socially. And I know everyone is being somewhat fascetious. But limb salvage is kinda my jam and I’m happy to engage in discussion about it if people are interested.

 

[LucidSplash]

I've not seen that great of outcomes with bypassing to these small vessels. It usually seems a long shot for long term patency. I would worry about the size mismatch from the larger vein to the small vessel (usually). As always, I'm sure patient selection plays into this.

Size mismatch isn’t an issue if you know what you’re doing from a technical standpoint and you’re used to doing it. Orthograde rather than reverses helps. Doing your own vein harvest instead of endoscopic by a PA is best for these IMHO. There are a lot of factors including patient selection, for example ESRD much worse outcomes than non ESRD. But I can tell you our data going on 35 years here is about what is in the paper I linked to which details the first 10 years.

Most people who haven’t been affiliated with a limb salvage program are skeptical, I get it. The patency with these is obviously lower than with a proximal tibial or a pop, but it isn’t anywhere near zero. I know a lot of vascular surgeons don’t want to deal with this and that’s fine, but they should be willing to refer their patients to eval in a limb salvage center before proceeding to a major amp if that’s the case.

 

[LucidSplash]

So is this is bad time to make the joke that vascular patients don’t get better, they just get shorter? (I got that from one of my mentors in med school, who was a vascular surgeon.)


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It’s not untrue. I do my fair share of amps trust me. I’m just willing to go the extra mile first. When I first got to my fellowship I was really skeptical of this stuff. But I’m a believer now both data-wise and anecdotally.

 

[dpmd]

So is this is bad time to make the joke that vascular patients don’t get better, they just get shorter? (I got that from one of my mentors in med school, who was a vascular surgeon.)


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Nah sometime they die from the cardiovascular disease or other comorbidities before having to become shorter.

 

[LucidSplash]

I've not seen that great of outcomes with bypassing to these small vessels. It usually seems a long shot for long term patency. I would worry about the size mismatch from the larger vein to the small vessel (usually). As always, I'm sure patient selection plays into this.

With limb salvage, long-term patency is a goal but not the only one. Sometimes you just need it open long enough for a wound to heal. I have a lot of patients who have asymptomatic occlusion of their bypasses months to years out. They have enough collaterals to prevent rest pain, they don’t walk far enough to have claudication and if their wounds healed before the bypass went down that’s a win. And they don’t piss themselves in the middle of the night when they can’t get to the bathroom in time because it takes them too long on one leg.

I’m just saying the algorithm isn’t as straight forward as in the days of yore. It isn’t for the impatient or faint of heart, that’s for sure. But it is definitely worth doing if you are willing to commit to it.

 

[HighPriest]

Sure. But not all toe ulcers are black gangrene. And even if they are, that gangrene tends not to stop at the toe if you don’t do anything.

I’m not debating that vascular patients are a difficult population both medically and socially. And I know everyone is being somewhat fascetious. But limb salvage is kinda my jam and I’m happy to engage in discussion about it if people are interested.

You just don’t inject anything with epi and you’ll be fine. Right?

 

[HighPriest]

You should challenge the hospitalists more on that issue when they call you about ulcerated toes.

“Did you inject epi in to this, MF??!”

 

[Chillbo Baggins]

So is this is bad time to make the joke that vascular patients don’t get better, they just get shorter? (I got that from one of my mentors in med school, who was a vascular surgeon.)


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Definitely an interesting population to work with. I essentially had 2 months of it this year, and when rounding it seemed like it was about a 20% chance they were at dialysis, 10% chance they'd be out smoking, and 5% chance I could get palpable pulses.

 

[Chillbo Baggins]

Simultaneous traumas roll in: what are the odds that a 3.5x limit drunk driver heads into oncoming traffic and hits a coked up driver at 4 in the afternoon??

 

[HighPriest]

Simultaneous traumas roll in: what are the odds that a 3.5x limit drunk driver heads into oncoming traffic and hits a coked up driver at 4 in the afternoon??

He got his chocolate in the other guy’s peanut butter.

 

[TraumaLlamaMD]

Must be something about 230am.

Friday 230am, transfer center calls an urgent consult directly to me. Apparently ortho direct admitted some 71 y/o with a toe ulcer and want us to “begin the workup immediately.” Transfer center guy apologizes.

Immediately consisted of me texting the intern to see the consult and order non-invasive testing for when the vascular lab is actually open. And rolling over and going back to sleep.

Wait, can we back up to the part where Ortho is the willing primary on a septuagenarian vasculopath? I gotta move to wherever you are.

 

[LucidSplash]

Wait, can we back up to the part where Ortho is the willing primary on a septuagenarian vasculopath? I gotta move to wherever you are.

Yeah this is not the norm. I think that’s why I got a 230am urgent consult. Someone realized “oh ****, we dun effed up.”