kitsunepixie

Kunoichi Extraordinare
10+ Year Member
Jul 21, 2006
204
139
281
The Happiest Place on Earth
Status
Attending Physician
If it helps we get criticized mercilessly as surgical residents for the same thing and share your pain perhaps even equally. Why did you get a CT scan on this patient does that change operative management? *Show exact injury to another attending, "why didn't you get a CT scan on this, I always get CT scans on x injury."
Yep. So glad I'm an attending now and don't have to deal with that cray-cray. Seriously, that stressed me out more than receiving a herniating patient. At least with the herniating patient I knew what to do!

I got a panic call today on my ICU post-op "I think she's leaking CSF out of both of her ears!" While I'm thinking, "Okay, that's not physiologically possible since we were no where near any mastoid air cells," I had a good inkling what was going on since it's not an uncommon call that we get for this exact scenario while I sauntered over to the room as I was just down the hall. The "CSF" was actually tears...from her eyeballs...and it was tracking down her face and pooling in her ears. Cause...she was crying. ;) The family laughed. Mystery solved. Luckily they were tears of relief since her first surgery had to be aborted and we were able to fix her up this time.
 

Jolie South

is invoking Domo. . .
Moderator Emeritus
10+ Year Member
Jun 4, 2007
11,549
645
281
Deep in the Heart of Texas
Status
Resident [Any Field]
Yep. So glad I'm an attending now and don't have to deal with that cray-cray. Seriously, that stressed me out more than receiving a herniating patient. At least with the herniating patient I knew what to do!

I got a panic call today on my ICU post-op "I think she's leaking CSF out of both of her ears!" While I'm thinking, "Okay, that's not physiologically possible since we were no where near any mastoid air cells," I had a good inkling what was going on since it's not an uncommon call that we get for this exact scenario while I sauntered over to the room as I was just down the hall. The "CSF" was actually tears...from her eyeballs...and it was tracking down her face and pooling in her ears. Cause...she was crying. ;) The family laughed. Mystery solved. Luckily they were tears of relief since her first surgery had to be aborted and we were able to fix her up this time.
If I had a dollar for every time an EMT said "there is exposed brain matter" on a trauma, I could have retired from residency. Number of times it was actually exposed brain: zero.
 

dpmd

Relaxing
10+ Year Member
Sep 14, 2006
20,185
30,034
281
Lazytown
Status
Attending Physician
If I had a dollar for every time an EMT said "there is exposed brain matter" on a trauma, I could have retired from residency. Number of times it was actually exposed brain: zero.
Our medics were better. Anytime they said brain there really was brain. They weren't so great with skull fractures though (overcalling it is safer than undercalling at least)
 

Apollyon

Screw the GST
Lifetime Donor
15+ Year Member
Nov 24, 2002
20,066
4,813
381
SCREW IT!
If I had a dollar for every time an EMT said "there is exposed brain matter" on a trauma, I could have retired from residency. Number of times it was actually exposed brain: zero.
In NY state, exposed brain is enough to "black tag" (although, if that was the only patient, you wouldn't ACTUALLY "black tag", because it wasn't an MCI). In other words, "injuries incompatible with life". That's why I was a bit quizzical at Gabrielle Giffords, who, on-scene, had exposed brain. Maybe it's because she was a Member of Congress that they didn't just leave her to die. I don't know.

I DO know that I never called in exposed brain, because I didn't see it, and, to be brutally honest, I was told more than once that I was one of the best (out of about 2500 EMS providers).
 

kitsunepixie

Kunoichi Extraordinare
10+ Year Member
Jul 21, 2006
204
139
281
The Happiest Place on Earth
Status
Attending Physician
In NY state, exposed brain is enough to "black tag" (although, if that was the only patient, you wouldn't ACTUALLY "black tag", because it wasn't an MCI). In other words, "injuries incompatible with life". That's why I was a bit quizzical at Gabrielle Giffords, who, on-scene, had exposed brain. Maybe it's because she was a Member of Congress that they didn't just leave her to die. I don't know.

I DO know that I never called in exposed brain, because I didn't see it, and, to be brutally honest, I was told more than once that I was one of the best (out of about 2500 EMS providers).
I've had a number of patients with exposed brain who were talking to me and wound up doing surprisingly well. One was super sick and nearly died the night of a super publicized catastrophe but I follow her Youtube channel and she's now a very talented songstress. You'd never know.
 

Apollyon

Screw the GST
Lifetime Donor
15+ Year Member
Nov 24, 2002
20,066
4,813
381
SCREW IT!
I've had a number of patients with exposed brain who were talking to me and wound up doing surprisingly well. One was super sick and nearly died the night of a super publicized catastrophe but I follow her Youtube channel and she's now a very talented songstress. You'd never know.
What do I know? I'm just a dumb ER doc! And, what was the phrase (or was it a song)? "You're never the same once the air hits your brain"!
 
  • Like
Reactions: kitsunepixie

HighPriest

Specialized in diseases of the head holes
10+ Year Member
Jan 1, 2008
1,951
2,232
281
Status
Attending Physician
Here's my current PITA consult, which I see probably at least once/month:

Guy shows up with jaw pain/maxillary pain/or just mush mouth, NOS. No imaging, no medications tried, nothing. He opens his mouth and it's like someone jammed burned macaroni into his gingiva. Sometimes there's literal pus rolling out of a tooth. Entire rest of the exam is normal. And I'm like
"Uh, hey buddy, I think you would probably feel better if you saw a dentist."

"Yeah, I did, but they told me I needed a bunch of teeth pulled, and I can't afford it, so i went to my PCP and they suggested I come to see you."

Why? Why did they suggest that? I'm not a dentist. If i was a dentist, I'd be quitting my job to do something else right now. What could your PCP possibly think I could do for you, other than tell you to go to a dentist? I realize that I will see your horrible insurance whereas the dentist will not, but that doesn't change the fact that you need a dentist.

If I had sewage leaking out of my showerhead, I wouldn't call an HVAC guy just because the pipes all run under the house and I can get one cheaper per hour.

Had another guy come in recently - pain and swelling in the face. Had a tooth extracted from that area 48 hours beforehand. His dentist told him he didn't think it was related. Saw his PCP who did a scan that showed an abscess near the empty socket. Sent him to me. Now, I don't mind draining an abscess, but common' man. Where's the integrity? That kind of thing, btw, happens all of the time.
 
Last edited:

VA Hopeful Dr

Senior Member
10+ Year Member
Jul 28, 2004
19,569
24,056
281
Status
Attending Physician
Here's my current PITA consult, which I see probably at least once/month:

Guy shows up with jaw pain/maxillary pain/or just mush mouth, NOS. No imaging, no medications tried, nothing. He opens his mouth and it's like someone jammed burned macaroni into his gingiva. Sometimes there's literal pus rolling out of a tooth. Entire rest of the exam is normal. And I'm like
"Uh, hey buddy, I think you would probably feel better if you saw a dentist."

"Yeah, I did, but they told me I needed a bunch of teeth pulled, and I can't afford it, so i went to my PCP and they suggested I come to see you."

Why? Why did they suggest that? I'm not a dentist. If i was a dentist, I'd be quitting my job to do something else right now. What could your PCP possibly think I could do for you, other than tell you to go to a dentist? I realize that I will see your horrible insurance whereas the dentist will not, but that doesn't change the fact that you need a dentist.

If I had sewage leaking out of my showerhead, I wouldn't call an HVAC guy just because the pipes all run under the house and I can get one cheaper per hour.

Had another guy come in recently - pain and swelling in the face. Had a tooth extracted from that area 48 hours beforehand. His dentist told him he didn't think it was related. Saw his PCP who did a scan that showed an abscess near the empty socket. Sent him to me. Now, I don't mind draining an abscess, but common' man. Where's the integrity? That kind of thing, btw, happens all of the time.
Yeah that doesn't make sense. As an FP I hate dental stuff as much as anyone but I've never sent someone to ENT for anything teeth related.
 

HighPriest

Specialized in diseases of the head holes
10+ Year Member
Jan 1, 2008
1,951
2,232
281
Status
Attending Physician
At least nasolaryngoscopy pays well, right?
Yep. If only it were commonly abnormal. Most studies indicate that physical findings do not correlate with LPR any more than they do anything else. But I can rule out a mass, which is nice. Plus, most patients point to their sternal notch when they describe their globus, and I can't see that far with NP scope. I don't do flex esophagoscopy or TNE, so...they go see a GI anyway.
 

HighPriest

Specialized in diseases of the head holes
10+ Year Member
Jan 1, 2008
1,951
2,232
281
Status
Attending Physician
Have you thought about hiring a NP/PA for those nonsense referrals? If not why not?
Definitely. But, they’re still nonsense referrals even if someone else is seeing them.
 

WinslowPringle

2+ Year Member
Sep 29, 2014
328
441
81
Status
Resident [Any Field]
Medicine doctor (MD) requesting consult 10pm: "I'm admitting this 80 yo male with abdominal pain. [6 minute digression - I timed it - on something about patient shopping with his wife, milkshakes, and his hypertension meds none of which I could discern had anything to do with abdominal pain and could not tell where the information was going. I couldn't interrupt the stream of consciousness....]..."
Me: "...he got a CT scan in the ED, did I hear that right?"
MD: "Yes. The CT didn't show an umbilical hernia, but he was tender at his umbilicus and I think he has a hernia. He also had gallstones on the CT."
Me: "So, is this a consult for evaluation for an umbilical hernia?"
MD: "No, this is a consult for abdominal pain. It's your job to see the patient and figure out where the pain is coming from."
Hangs up on me.
I drive in (home call), see the patient. Pain has resolved. Afebrile, labs WNL; on CT stable gallstones for which he had been seen in clinic a month ago and declined surgery at the time, no CT-evident pericholecystic fluid or GB wall thickening, no umbilical, ventral or inguinal hernia.No pain or umbilical hernia on exam. No anemia, no NSAID use, no history of gastritis or GERD. Troponin is elevated tho...
Me: "Saw [abdominal pain patient]. He has a history of symptomatic cholelithiasis, but his troponin is elevated tonight; I'm concerned this could be an anginal equivalent. I reviewed the CT report and images, no hernia. He didn't have reproducible abdominal pain on my exam though; no physical evidence of umbilical hernia."
MD: "Are you sure he doesn't have a hernia? He was really tender there and the umbilicus felt full, I think he has a hernia."
Me: ....................

.............................................................................................
ED NP: "I got a guy here, he has an inguinal hernia. I can't reduce it. Can he follow-up in your clinic?"
Me: "Wait. What?"
NP: "Yeah, he has a huge inguinal hernia, I saw it on the CT scan. He came in because he is having increasing pain. I'd like to send him home, but want to make sure he has followup in your clinic."
Me: "You said you can't reduce it - so, does he have an incarcerated hernia?"
NP: "Well, I don't know...."
Me: "Does the hernia go back in when you try to reduce it?"
NP: "No, it was too sore."
Me: "So, he has an incarcerated hernia then, is that right?"
NP: "Well, I don't know...."
Me: "How long has it been like this?"
NP: "I don't know...."
Me: "Has he ever been able to reduce it?"
NP: "I don't know..."
Me: "Any obstructive symptoms? What about his white count and vitals?"
NP: "I haven't asked about obstructive symptoms. WBC and vitals are [normal]."
Me: "Well, sure, anyone can followup in my clinic, but if you're saying he has a maybe acutely incarcerated hernia, I don't think he should just be allowed to leave at this point....."
NP: "Oh, would you be willing to see him? That would be great. He's in room [9]."
I see the patient. Minimal pain, no incarceration, easily reducible. Per patient, no one had tried to reduce it yet. No obstructive symptoms. He came in because he decided it was time he have someone pay attention to this hernia after >5 years. NP was right about one thing, though, I set him up for outpatient followup and repair...
........................................................

And I'm about 50/50 on EMS reports of 'It's braaaainnns....' Either it's super obvious, or it's vomit. ;-)
 

swoopyswoop

5+ Year Member
Dec 23, 2013
321
294
131
Status
Resident [Any Field]
ED NP: "I got a guy here, he has an inguinal hernia. I can't reduce it. Can he follow-up in your clinic?"
Me: "Wait. What?"
NP: "Yeah, he has a huge inguinal hernia, I saw it on the CT scan. He came in because he is having increasing pain. I'd like to send him home, but want to make sure he has followup in your clinic."
Me: "You said you can't reduce it - so, does he have an incarcerated hernia?"
NP: "Well, I don't know...."
Me: "Does the hernia go back in when you try to reduce it?"
NP: "No, it was too sore."
Me: "So, he has an incarcerated hernia then, is that right?"
NP: "Well, I don't know...."
Me: "How long has it been like this?"
NP: "I don't know...."
Me: "Has he ever been able to reduce it?"
NP: "I don't know..."
Me: "Any obstructive symptoms? What about his white count and vitals?"
NP: "I haven't asked about obstructive symptoms. WBC and vitals are [normal]."
Me: "Well, sure, anyone can followup in my clinic, but if you're saying he has a maybe acutely incarcerated hernia, I don't think he should just be allowed to leave at this point....."
NP: "Oh, would you be willing to see him? That would be great. He's in room [9]."
I see the patient. Minimal pain, no incarceration, easily reducible. Per patient, no one had tried to reduce it yet. No obstructive symptoms. He came in because he decided it was time he have someone pay attention to this hernia after >5 years. NP was right about one thing, though, I set him up for outpatient followup and repair...
........................................................

And I'm about 50/50 on EMS reports of 'It's braaaainnns....' Either it's super obvious, or it's vomit. ;-)
I'm at the point where if an NP is going to consult me on something dumb I ask them to staff it with their supervising ER physician first and call back if the consult is still needed.
 

dpmd

Relaxing
10+ Year Member
Sep 14, 2006
20,185
30,034
281
Lazytown
Status
Attending Physician
I'm at the point where if an NP is going to consult me on something dumb I ask them to staff it with their supervising ER physician first and call back if the consult is still needed.
I have only done that once and it was because I couldn't understand what the clinical question was and I wasn't convinced I could trust any of their exam because the history was so disjointed. Had it been something simple like gallstones or appy I wouldn't have cared much but this was somewhat was either going to be a complete nothing or a bad problem. Since it was night and I didn't want to get out of bed needlessly I made them discuss it with their staff and have them see the patient and call me back if they needed to.
 
  • Like
Reactions: kitsunepixie

swoopyswoop

5+ Year Member
Dec 23, 2013
321
294
131
Status
Resident [Any Field]
I have only done that once and it was because I couldn't understand what the clinical question was and I wasn't convinced I could trust any of their exam because the history was so disjointed. Had it been something simple like gallstones or appy I wouldn't have cared much but this was somewhat was either going to be a complete nothing or a bad problem. Since it was night and I didn't want to get out of bed needlessly I made them discuss it with their staff and have them see the patient and call me back if they needed to.
Yea, this is only if it seems like a very odd consult and it's at night and I know they have an ER doc 5 feet away from them to help out. I think of it as a resident calling a consult without staffing it with their ER attending. For obvious, straightforward stuff - sure. For weird stuff? Please go through the appropriate channels before calling in new teams from home.
 

WinslowPringle

2+ Year Member
Sep 29, 2014
328
441
81
Status
Resident [Any Field]
I'm at the point where if an NP is going to consult me on something dumb I ask them to staff it with their supervising ER physician first and call back if the consult is still needed.
I think it's a good idea and have done it occasionally, but I try to stay out of my PDs office ;-) In this particular case there was no supervising/"collaborating" physician, just this ED "provider".
 

HighPriest

Specialized in diseases of the head holes
10+ Year Member
Jan 1, 2008
1,951
2,232
281
Status
Attending Physician
Most of the NPs I take consults from currently are actually pretty good. I don't know if that's because they're staffing things or not.

But I have definitely worked with the ones you're talking about. I always ride the line between irritated and terrified that we accept that level of incompetence (or ignorance) as acceptable for patient care. I would feel the same way about a doc who routinely called with ridiculous questions, but that happens much, much less frequently.
 

LucidSplash

Bloody Plumber
10+ Year Member
Feb 27, 2005
2,800
2,682
281
Status
Fellow [Any Field]
Just did a guillotine AKA for gas gangrene. Pretty standard stuff, Type I diabetic, dripping pus from a huge ulcer behind his knee that he ignored. But had the strangest conversation with the cardiac anesthesia attending, the kind that is so odd you start to doubt yourself and wonder if you’re the crazy one.

Anes: (as pt rolling into room) Hey did you see this guy in the ED?
Me: Yah. What’s up?
Anes: He looks pretty sick. Tachy to the 120s. What else do you think could be going on with him?
Me: (blank stare) He has gas gangrene.
Anes: Yeah but do you think he could be septic or something?
Me: (still blank stare) He has gas gangrene.
Anes: Yeah, but are all patients with gas gangrene septic?
Me: Pretty much by definition. That’s why we are here at midnight.
Anes: Ok, if you say so, I’ve never heard that before.

:shrug:
 
Last edited:

nlax30

Fellow
10+ Year Member
Oct 4, 2006
4,007
709
281
Status
Fellow [Any Field]
Sounds like several conversations I’ve had with anesthesia at times in the EP lab before putting in an ICD/CRT or doing a VT ablation when they tell me the guy is pretty sick, his EF is 15%. Yea.... that’s like most of these patients.
 

kitsunepixie

Kunoichi Extraordinare
10+ Year Member
Jul 21, 2006
204
139
281
The Happiest Place on Earth
Status
Attending Physician
I love our ER docs, but I wish they knew what goes on when they call us during the middle of a surgery and kept things short and to the point. I don't want to be rude and say "STOP" :stop: but I'd love it if they just said as briefly as possible why they are calling. Just tell me "I have a kid with a couple of small bleeds in his head, GCS 15." Our team stops what they're doing and stares at the phone when they give us a long introduction ("Oh, he was at camp going about his business when this or that happened and at first he didn't think to much about it but then when he started throwing up they figured he should come on in to get checked out.") It's like the longest game of...anticipation.
 
  • Like
Reactions: HighPriest

dpmd

Relaxing
10+ Year Member
Sep 14, 2006
20,185
30,034
281
Lazytown
Status
Attending Physician
I love our ER docs, but I wish they knew what goes on when they call us during the middle of a surgery and kept things short and to the point. I don't want to be rude and say "STOP" :stop: but I'd love it if they just said as briefly as possible why they are calling. Just tell me "I have a kid with a couple of small bleeds in his head, GCS 15." Our team stops what they're doing and stares at the phone when they give us a long introduction ("Oh, he was at camp going about his business when this or that happened and at first he didn't think to much about it but then when he started throwing up they figured he should come on in to get checked out.") It's like the longest game of...anticipation.
I hate when they start with the name then give the whole story and end with the problem. More at night than during surgery because I don't answer until after since mine are mostly short. Give me the problem first, then supporting story if you must and and with the name so I don't have to ask for it again because I have already forgotten it.
 
  • Like
Reactions: HighPriest

HighPriest

Specialized in diseases of the head holes
10+ Year Member
Jan 1, 2008
1,951
2,232
281
Status
Attending Physician
Just did a guillotine AKA for gas gangrene. Pretty standard stuff, Type I diabetic, dripping pus from a huge ulcer behind his knee that he ignored. But had the strangest conversation with the cardiac anesthesia attending, the kind that is so odd you start to doubt yourself and wonder if you’re the crazy one.

Anes: (as pt rolling into room) Hey did you see this guy in the ED?
Me: Yah. What’s up?
Anes: He looks pretty sick. Tachy to the 120s. What else do you think could be going on with him?
Me: (blank stare) He has gas gangrene.
Anes: Yeah but do you think he could be septic or something?
Me: (still blank stare) He has gas gangrene.
Anes: Yeah, but are all patients with gas gangrene septic?
Me: Pretty much by definition. That’s why we are here at midnight.
Anes: Ok, if you say so, I’ve never heard that before.

:shrug:
Pretty sure you're just making that up on the spot, but whatever.

You should have told him it's possible the guy did a bunch of coke before he came to the ER.
 
Last edited:
  • Haha
Reactions: LucidSplash

HighPriest

Specialized in diseases of the head holes
10+ Year Member
Jan 1, 2008
1,951
2,232
281
Status
Attending Physician
The storytime consults are the worst. I can never tell if they just don't know what they're looking at and they don't want to leave anything out, or if they're just afraid that if they're straightforward I won't take them seriously, or if they're just &*(king with me. Ultimately, if the guy has an orbital fracture, I don't actually care how it happened.
1 - why are you calling? (facial fracture)
2 - Did you do any relevant labs/imaging (hint; I'll ask about this anyway, so don't stress it)
3 - Is the guy sick enough that I'm going to end up not treating him tonight anyway (does he have the aforementioned exposed brain, but you're just giving me a "heads up" before you transfer him out anyway).

Actually, start with 3. Or just don't call if possible.