Consults- Memorable/Dismal/Ridiculous/Unique

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dpmd said:
No but see when they can't consult a specialist they just consult one that is kinda sorta related to said specialty. You deal with the mouth hole right. Doesn't matter that you don't do teeth. You must become the specialty they lack.
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Yep.

I make the joke that we've become EENTT at one of our community hospitals (eyes, ears, nose, throat, and teeth).
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LucidSplash said:
ED consult for 15M walking around barefoot today with palpable pulses. Consult is for “cold feet.”

No not frostbite. Though it would serve him right.

I hate the peds ED. More than Tom Brady.

Edit: Turns out he has some toe-tip frostbite. But consult was literally worded “cold feet.” Definitely bounding palpable pulses. They asked if he needed a bypass. Yeah, no.

Told them to call the frostbite doctors, PRS & IR.
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Acute sockemia at it's most severe
 
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An outpatient consult.

I had a patient come to see me from India who had some nonoperative metatarsal base fractures. He got pinned in India and they pulled pins... at 12 days. (Normally should be 6 weeks if you’re gonna do it, which they didn’t. And he should have been nonweightbearing, which he wasn’t.) Lol, he’s a type 1 diabetic to boot. Despite their best attempts to murder him he healed, and was walking around in a wet pruny cast ...protected with a hairnet.

*facepalm*
 
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VisionaryTics said:
Yep.

I make the joke that we've become EENTT at one of our community hospitals (eyes, ears, nose, throat, and teeth).
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Heads, shoulders, knees and toes....sorry - I need to spend more time with adults....
 
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LucidSplash said:
Oh he’s an excellent football player. Not taking that away from him. I just think he’s pretty douchey from what I know of him as a person. A annoying rash would be good, but measles would definitely be better.
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If I had 6 rings I'd probably be a bit of a douche as well
 
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Not technically a consult, but an interesting story:

Off-service on Medicine :sleep:, am the one on call until night float comes in. Bounce back patient gets direct admitted from OSH. I only saw the patient on the last day of his previous admission and did his discharge. Saw on the OSH notes about "severe back pain," and I recall he had chronic back pain before, so this triggers an eye roll from me.

See the pt when he gets to the floor, see that he's laying comfortably in bed, triggering inner eye roll. I'm like "Hey, what's up?" Says he got a pop in his back earlier and then started getting numb and weak. Ok...when he left before he seemed like a reasonable guy who wanted to go home, so I didn't really see a reason for a faker angle. Go ahead and do my neuro exam. Lower extremities numb and maybe 4-/5. Go to do upper extremities: *profound* weakness. 2-3/5. Like, I'm thinking this would actually be hard to fake, and again, doesn't seem like the type.

Go ahead and place a stat neurosurg consult; they come evaluate, use some imaging from the prior admission plus their exam, and say, "yeah, we're taking him tonight." Gets posterior fusion, symptoms improved.

I took this as a reminder to try to not always be so cynical and immediately judgmental about the chief complaint: sometimes it's legitimate.
 
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Chillbo Baggins said:
Not technically a consult, but an interesting story:

Off-service on Medicine :sleep:, am the one on call until night float comes in. Bounce back patient gets direct admitted from OSH. I only saw the patient on the last day of his previous admission and did his discharge. Saw on the OSH notes about "severe back pain," and I recall he had chronic back pain before, so this triggers an eye roll from me.

See the pt when he gets to the floor, see that he's laying comfortably in bed, triggering inner eye roll. I'm like "Hey, what's up?" Says he got a pop in his back earlier and then started getting numb and weak. Ok...when he left before he seemed like a reasonable guy who wanted to go home, so I didn't really see a reason for a faker angle. Go ahead and do my neuro exam. Lower extremities numb and maybe 4-/5. Go to do upper extremities: *profound* weakness. 2-3/5. Like, I'm thinking this would actually be hard to fake, and again, doesn't seem like the type.

Go ahead and place a stat neurosurg consult; they come evaluate, use some imaging from the prior admission plus their exam, and say, "yeah, we're taking him tonight." Gets posterior fusion, symptoms improved.

I took this as a reminder to try to not always be so cynical and immediately judgmental about the chief complaint: sometimes it's legitimate.
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Sweet catch!
 
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Chillbo Baggins said:
See the pt when he gets to the floor, see that he's laying comfortably in bed, triggering inner eye roll. I'm like "Hey, what's up?" Says he got a pop in his back earlier and then started getting numb and weak. Ok...when he left before he seemed like a reasonable guy who wanted to go home, so I didn't really see a reason for a faker angle. Go ahead and do my neuro exam. Lower extremities numb and maybe 4-/5. Go to do upper extremities: *profound* weakness. 2-3/5. Like, I'm thinking this would actually be hard to fake, and again, doesn't seem like the type.

Go ahead and place a stat neurosurg consult; they come evaluate, use some imaging from the prior admission plus their exam, and say, "yeah, we're taking him tonight." Gets posterior fusion, symptoms improved.

I took this as a reminder to try to not always be so cynical and immediately judgmental about the chief complaint: sometimes it's legitimate.
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Story of my life. We recently had a patient transferred to our rehab unit from another hospital for "conversion disorder" causing paraparesis. Our rehab doctors did a spinal MRI with multiple emboliform spinal cord infarcts. Definitely not conversion disorder.
 
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TimesNewRoman said:
Not infrequently that is a hospitalist requiring a silly admission prior to accepting a patient. I don’t know your ER staff, but I’m pretty upfront about it when I go. E.g. Hey Dr. cards, I have a patient here with fatigue. I think it’s because their hemoglobin is 5 and they have melena, but the hospitalist wants you to see the patient because they have some ST depression and their trop is 0 point something. I don’t think this is ACS, but the hospitalist says you need to say so before they accept the patient.
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Assessment: demand ischemia
Recommendations: hospitalist should request a refund from his medical school .

Thank you for this interesting consult...
 
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Call from the ER:
"Hey, uh, I got this guy. 46. He came in about 6 days ago with a sore throat. We did a strep swab, which was negative, so we sent him home. He comes back today and it's worse. It's been 8 days now since it started. So, I think it's time he see an ENT."

"So, you think he has an abscess?"

"Oh, no. No abscess."

"So, can he drink fluids? Is his airway ok?"

"Oh, yeah, I'm not worried about that. He could be seen as an outpatient."

"So...have you treated him? Has he been on antibiotics or steroids or something?"

"No. No antibiotics. His strep was negative. But it's been 8 days. Do you think he needs steroids?"

'........yeah. why don't you put him on an antibiotic and some steroids, and we'll schedule him an appointment for next week if he's not better..."


I mean....I got information that's going to blow your mind into oblivion: Strep isn't the only thing that causes tonsillitis, and 8 days of sore throat doesn't indicate a tonsillectomy. Pull out some of that medicine you learned, big dog.
 
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There's another one that I blame myself for:

Had a guy come in with a very aggressive cancer. Imaging looked suspicious for esophageal invasion. So I wanted to do an esophagoscopy, but the hospital somehow managed to lose our rigid set. We don't have a flex or nasal esophagoscope. Didn't have time to wait for them to find it, so I asked my referral coordinator to send him somewhere for an esophagoscopy. She writes me back, stating that the local big-hospital head ad neck oncologist doesn't do those procedures. Which is weird because I remember doing them with him as a resident, but that was a while back so who knows. So I told her to try a local GI doc. Again she comes back stating that they don't do those procedures. Well, that's....really odd. Maybe they just don't feel comfortable because it might be a cancer? So I say try a general surgeon. She comes back again, flustered, saying that they don't do it either.

So I say "I just can't believe this. You're saying that none of these places do esophagoscopy?" She says "No, none of them. I've talked to all of the schedulers over the phone." and I say "The GI docs and the general surgeons, who I have sent patients to before for EGD can't do that now?"

And she says "Yeah, they do EGD, but they don't do esophagoscopy."

.....Call any one of them back and tell them I need someone to look in his throat and do a biopsy if necessary.....

He had an appointment with the first guy the next day.

Take home point: do not assume that your staff knows what you're talking about, or that your colleagues staff knows any better. It was the blind leading the blind.
 
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HighPriest said:
Call from the ER:
"Hey, uh, I got this guy. 46. He came in about 6 days ago with a sore throat. We did a strep swab, which was negative, so we sent him home. He comes back today and it's worse. It's been 8 days now since it started. So, I think it's time he see an ENT."

"So, you think he has an abscess?"

"Oh, no. No abscess."

"So, can he drink fluids? Is his airway ok?"

"Oh, yeah, I'm not worried about that. He could be seen as an outpatient."

"So...have you treated him? Has he been on antibiotics or steroids or something?"

"No. No antibiotics. His strep was negative. But it's been 8 days. Do you think he needs steroids?"

'........yeah. why don't you put him on an antibiotic and some steroids, and we'll schedule him an appointment for next week if he's not better..."


I mean....I got information that's going to blow your mind into oblivion: Strep isn't the only thing that causes tonsillitis, and 8 days of sore throat doesn't indicate a tonsillectomy. Pull out some of that medicine you learned, big dog.
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Plot twist. His throat is sore from all the reflux or postnasal drip that they didn't mention in his history.
 
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dpmd said:
Plot twist. His throat is sore from all the reflux or postnasal drip that they didn't mention in his history.
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About 60% of the time they end up with an enormous hiatal hernia and Brundle-fly level acid reflux.
 
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TimesNewRoman said:
For....ECMO?
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Ha no, it was slightly more legit than it sounds on first blush. They wanted to do activated charcoal lavage, but couldn't get the OG down. Eventually got an xray to figure out why and saw she had a lap band. Then realized they dont know how to deflate a lap band so consulted me.

I deflated the band but that wasnt the issue, I ended up having to endoscopically place the tube because it just absolutely would not pass GEJ blindly
 
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vhawk said:
Ha no, it was slightly more legit than it sounds on first blush. They wanted to do activated charcoal lavage, but couldn't get the OG down. Eventually got an xray to figure out why and saw she had a lap band. Then realized they dont know how to deflate a lap band so consulted me.

I deflated the band but that wasnt the issue, I ended up having to endoscopically place the tube because it just absolutely would not pass GEJ blindly
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I am guessing you are saying this was memorable or maybe unique....because it's not that dismal or ridiculous...it doesn't fit with the character of the rest of the thread

HH

Consults - Memorable/Dismal/Ridiculous/Unique (from OP title)
 
vhawk said:
Ha no, it was slightly more legit than it sounds on first blush. They wanted to do activated charcoal lavage, but couldn't get the OG down. Eventually got an xray to figure out why and saw she had a lap band. Then realized they dont know how to deflate a lap band so consulted me.

I deflated the band but that wasnt the issue, I ended up having to endoscopically place the tube because it just absolutely would not pass GEJ blindly
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That’s silly. By the time they consulted you, charcoal wasn’t indicated.
 
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vhawk said:
Ha no, it was slightly more legit than it sounds on first blush. They wanted to do activated charcoal lavage, but couldn't get the OG down. Eventually got an xray to figure out why and saw she had a lap band. Then realized they dont know how to deflate a lap band so consulted me.

I deflated the band but that wasnt the issue, I ended up having to endoscopically place the tube because it just absolutely would not pass GEJ blindly
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And she wouldn’t drink it but was compliant with NGT placement??
 
Hamhock said:
I am guessing you are saying this was memorable or maybe unique....because it's not that dismal or ridiculous...it doesn't fit with the character of the rest of the thread

HH

Consults - Memorable/Dismal/Ridiculous/Unique (from OP title)
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Never once been consulted for a TCA overdose, fits my definition of unique, thanks
 
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vhawk said:
Never once been consulted for a TCA overdose, fits my definition of unique, thanks
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Yeah, it does seem unique; that's what I guessed.
I don't really remember why I wrote that first post. The ideas entered my mind and my fingers just started typing.
(self eye roll).

HH
 
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Consulted for "bump on sternum"... It was the patient's sternal wires/chronic deformity from his sternotomy.

Also consulted to evaluate a patient for surgical intervention for an unresectable cancer invading into the adjacent structures, which we evaluated months ago and stated no surgical intervention is possible, care per heme/onc/palliative/etc.
 
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Consulted for an infected sebaceous cyst on someone's back. The NP in the ER insisted she was not comfortable lancing it because she was highly concerned it involved the spine in this very stable, well-appearing gentleman with no neurologic symptoms.
 
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swoopyswoop said:
Consulted for an infected sebaceous cyst on someone's back. The NP in the ER insisted she was not comfortable lancing it because she was highly concerned it involved the spine in this very stable, well-appearing gentleman with no neurologic symptoms.
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I would say if you think it really involves the spine then perhaps you should get some imaging and call neurosurgery. That is out of my wheelhouse. :smuggrin:

I have gotten this same consult except with in IVDA abscess over the delt. “I was concerned about the structures underneath”. Oh you mean like the deltoid muscle?

I i&d’d it and the PA was like omg how did you do it? I said the same way you would have. I put a knife in there and cut till I got pus. :rolleyes: Thank you for this interesting consult.
 
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Jolie South said:
I would say if you think it really involves the spine then perhaps you should get some imaging and call neurosurgery. That is out of my wheelhouse. :smuggrin:

I have gotten this same consult except with in IVDA abscess over the delt. “I was concerned about the structures underneath”. Oh you mean like the deltoid muscle?

I i&d’d it and the PA was like omg how did you do it? I said the same way you would have. I put a knife in there and cut till I got pus. :rolleyes: Thank you for this interesting consult.
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Did this PA image first, looking for needle fragments? There is a good, but old, picture in the Roberts and Hedges procedure book showing these.

And, I recall a case from residency - a groin abscess, but it overlied the R femoral artery and vein (visualized by ultrasound). The attending was worried (I wasn't), so we called surgery, and they, of course, masterfully and meticulously took care of it, and didn't exsanguinate the pt. However, where I was a resident, it was constantly beaten into the surgery residents (and subspecialists - the notable outliers were urology, who were absolute *******s every chance they could be) that they would be gracious and polite and thankful.
 
Apollyon said:
Did this PA image first, looking for needle fragments? There is a good, but old, picture in the Roberts and Hedges procedure book showing these.

And, I recall a case from residency - a groin abscess, but it overlied the R femoral artery and vein (visualized by ultrasound). The attending was worried (I wasn't), so we called surgery, and they, of course, masterfully and meticulously took care of it, and didn't exsanguinate the pt. However, where I was a resident, it was constantly beaten into the surgery residents (and subspecialists - the notable outliers were urology, who were absolute *******s every chance they could be) that they would be gracious and polite and thankful.
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This patient had a plain film that was negative for foreign bodies. Because I always check them myself on these patients. I think the arm just looked "scary," but it was just a subcutaneous abscess overlying the delt on the lateral arm. Nothing more.

One of my attendings, who takes call at an outlying facility, told me about a "hernia" the ER reduced, which in reality was a pseudo aneurysm of an aortobifem anastomosis. Needless to say, the patient died before my attending could get there to see the patient.
 
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Jolie South said:
One of my attendings, who takes call at an outlying facility, told me about a "hernia" the ER reduced, which in reality was a pseudo aneurysm of an aortobifem anastomosis. Needless to say, the patient died before my attending could get there to see the patient.
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Yeah, as a dumb ER doc, I stop right there, at the bolded.
 
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Jolie South said:
One of my attendings, who takes call at an outlying facility, told me about a "hernia" the ER reduced, which in reality was a pseudo aneurysm of an aortobifem anastomosis. Needless to say, the patient died before my attending could get there to see the patient.
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Ah yes, we also had an ER doc reduce "99%" of a groin hernia only to find it was a femoral artery pseudoaneurysm. Patient survived.
 
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Jolie South said:
This patient had a plain film that was negative for foreign bodies. Because I always check them myself on these patients. I think the arm just looked "scary," but it was just a subcutaneous abscess overlying the delt on the lateral arm. Nothing more.

One of my attendings, who takes call at an outlying facility, told me about a "hernia" the ER reduced, which in reality was a pseudo aneurysm of an aortobifem anastomosis. Needless to say, the patient died before my attending could get there to see the patient.
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I just threw up in my mouth.
 
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Been a good weekend, I guess.

Got a call from the ER:

“I got this girl. She’s been in the ER four time in the last four days. The first time she came in, she said she had been stung by a bee and had started having symptoms of anaphylaxis. Took an epipen. (sounds legit), we treated her and discharged her. Second day she came back. Stung by another bee. Took another epipen. Still asymptomatic, so we discharged her. Third day she came in and said she had swallowed a bee. She demanded that someone go in and remove it from her stomach. She was asymptomatic, so we discharged her. Today she comes back in and says that the bee sting from the first day is still effecting her. She's breathing fine, swallowing her secretions, no in any distress, but she won't speak to us. She's communicating via texts. Looks normal. Could you come and scope her? We just want to help prove that there's nothing wrong with her."

Well, I mean....there's something wrong with her. It's just not an acute airway. I don't think we need a nasopharyngoscopy to prove that.
 
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HighPriest said:
Been a good weekend, I guess.

Got a call from the ER:

“I got this girl. She’s been in the ER four time in the last four days. The first time she came in, she said she had been stung by a bee and had started having symptoms of anaphylaxis. Took an epipen. (sounds legit), we treated her and discharged her. Second day she came back. Stung by another bee. Took another epipen. Still asymptomatic, so we discharged her. Third day she came in and said she had swallowed a bee. She demanded that someone go in and remove it from her stomach. She was asymptomatic, so we discharged her. Today she comes back in and says that the bee sting from the first day is still effecting her. She's breathing fine, swallowing her secretions, no in any distress, but she won't speak to us. She's communicating via texts. Looks normal. Could you come and scope her? We just want to help prove that there's nothing wrong with her."

Well, I mean....there's something wrong with her. It's just not an acute airway. I don't think we need a nasopharyngoscopy to prove that.
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Maybe a colonoscopy would convince her?
 
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Got a 'consult' from the ED to perform a neuro exam.

Yep, the general surgery resident is definitely the expert in appropriate neuro exams.

Thank you for the interesting consult.

Hey, if you're going to ask me to do your job, can you at least split the cut with me?
 
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WinslowPringle said:
Got a 'consult' from the ED to perform a neuro exam.

Yep, the general surgery resident is definitely the expert in appropriate neuro exams.

Thank you for the interesting consult.

Hey, if you're going to ask me to do your job, can you at least split the cut with me?
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$#!t, man, that's like at least 20% of my job.

"Hey, sorry I know it's 3am. The hospitalists just admitted a 36 year old patient with a right facial cellulitis. We did a CT, MRI, PET-CT, US, and slaughtered a chicken to read the guts, and there's no sign of abscess and it's never happened before and the patient hasn't been on any antibiotics yet. In fact, they've just been rubbing compost on their face to see if that helps. They're not septic and their WBC is normal and they don't have any fevers, but they're really unhappy that they can't smoke in here. They had a third molar pulled 6 hours ago and the dentist slapped them full-on in the cheek twice when they refused to pay their bill. Not sure if that's part of the problem. We consulted ID and rheumatology and pediatric retinal surgery and they're all on board, but we were wondering if you would be willing to come see the patient and make antibiotic recommendations."

Maybe you could scope them too? Just to make sure their airway is ok.
 
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One of my post op patients that we bypassed is doing great. Just need to watch her dry gangrene demarcate. Get a call from the medicine attending we transferred her to for some other issues.

“The nurse says the patient’s foot looks worse and doesn’t have Doppler pulses.”

Me: “well what did you find on your exam?”

Medicine: ummmmm

Me: *in my mind* GTFO

My resident goes by and everything looks better than it did. Positive Doppler signals.
 
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Jolie South said:
One of my post op patients that we bypassed is doing great. Just need to watch her dry gangrene demarcate. Get a call from the medicine attending we transferred her to for some other issues.

“The nurse says the patient’s foot looks worse and doesn’t have Doppler pulses.”

Me: “well what did you find on your exam?”

Medicine: ummmmm

Me: *in my mind* GTFO

My resident goes by and everything looks better than it did. Positive Doppler signals.
Click to expand...

I have gotten many phone calls from medicine attendings reporting to me nursing findings without actually seeing the patients themselves. Even worse, sometimes I get nursing calls from medicine patients because the nurse thought the surgeon needed to assess the issue and just bypassed the medicine team.
 
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swoopyswoop said:
I have gotten many phone calls from medicine attendings reporting to me nursing findings without actually seeing the patients themselves. Even worse, sometimes I get nursing calls from medicine patients because the nurse thought the surgeon needed to assess the issue and just bypassed the medicine team.
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I would flip if a nurse tried to call a consult on my patient.
 
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