Consults- Memorable/Dismal/Ridiculous/Unique

[dpmd]

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)

---

Members don't see this ad.

 

[Apollyon]

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]

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]

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"!

 

[HighPriest]

My experience has always been that most people don't use their brain anyway. So what harm could it have if it's exposed?

 

[VA Hopeful Dr]

My experience has always been that most people don't use their brain anyway. So what harm could it have if it's exposed?

 

[HighPriest]

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.

 

[VA Hopeful Dr]

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.

 

[TraumaLlamaMD]

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.

ENT doesn’t stand for Ear Nose Tooth?

 

[HighPriest]

In my clinic, it stands for teeth, vertigo, and acid reflux.

 

[VA Hopeful Dr]

In my clinic, it stands for teeth, vertigo, and acid reflux.

At least nasolaryngoscopy pays well, right?

 

[HighPriest]

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.

 

[Wordead]

In my clinic, it stands for teeth, vertigo, and acid reflux.

Have you thought about hiring a NP/PA for those nonsense referrals? If not why not?

 

[HighPriest]

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]

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]

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]

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.

 

[swoopyswoop]

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]

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]

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]

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.

 

[nlax30]

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.

 

[dpmd]

Maybe they have only put dry gangrene patients to sleep and forgot there was a different kind?

 

[kitsunepixie]

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" 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 too 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.

 

[dpmd]

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" 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.

 

[HighPriest]

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.

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.

 

[HighPriest]

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.

 

[swoopyswoop]

Re-consulted to remove a non-tunneled HD line on a kid because the peds team and the dialysis nurses (who normally remove them) AND the peds nurses all felt "uncomfortable" doing so.

Also, consulted to evaluate a surgical wound on a patient re-admitted for completely separate reasons. On exam, I removed the bandage and the skin was 100% healed with barely evidence of there having been an incision. Turns out the primary team had not looked under the bandaid.

 

[dpmd]

Re-consulted to remove a non-tunneled HD line on a kid because the peds team and the dialysis nurses (who normally remove them) AND the peds nurses all felt "uncomfortable" doing so.

Also, consulted to evaluate a surgical wound on a patient re-admitted for completely separate reasons. On exam, I removed the bandage and the skin was 100% healed with barely evidence of there having been an incision. Turns out the primary team had not looked under the bandaid.

Silly rabbit, they never look underneath a dressing.

 

[HighPriest]

Silly rabbit, they never look underneath a dressing.

There be dragons

 

[MoMoGesiologist]

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.

Usually when anesthesia says “oh this patient is pretty sick,” we have some concerns we may not be able to get them off the table alive. Anesthetics and intubation on people with severe heart failure can be challenging. I’m sure your anesthesia team realizes all your patients are sick, but I feel they probably say it to remind you that these cases aren’t simple chip shots and these patients really can turn quickly. What may be a simple straightforward procedure for you, may be a nightmare anesthetic on someone with end stage organ failure. Just a perspective from the other side of the drape on why anesthesia would say something that is so obvious.

 

[nlax30]

Oh well aware they are being cautious and well aware these people have no reserve. But if I’m putting in an ICD or CRT then just the nature of the procedure means their EF is crappy. We know they are sick. For the most part we have great anesthesiologists and work well with them. The issue is when they play the CRNA rotation game and a CRNA is not familiar with our procedures comes to cover the lab then freaks out and we have to go this whole explanation again.

 

[BigRedBeta]

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" 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 too 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.

Uggh, story of my life in the PICU - everyone buries the lede. If I'm not busy I frequently stalk the ED board and have had times where a call about a cardiac arrest begins with the ED attending telling me about PCP visits from 3 weeks ago.

I absolutely stop them every single time to ask what their PICU need is, then if it's something routine, will ask if there is anything unusual about the patient I should know.

 

[VincentAdultman]

Uggh, story of my life in the PICU - everyone buries the lede. If I'm not busy I frequently stalk the ED board and have had times where a call about a cardiac arrest begins with the ED attending telling me about PCP visits from 3 weeks ago.

I absolutely stop them every single time to ask what their PICU need is, then if it's something routine, will ask if there is anything unusual about the patient I should know.

I’ve definitely interrupted the ER doc/PA during their spiel to ask them for the patients name so I can look up their xrs.

There have been times when I’ve had to ask them like 3-5 times s

 

[HighPriest]

I always get a chuckle when I get a call (usually from a PA or NP) and they have this long, dramatic story to tell me leading up to the patient having something really simple, like maybe a PTA, and yet when I ask for the name and DOB they're stumped. I can just picture the mental exercise before they call, trying to make sure that their story makes sense, that it leads up to the diagnosis and that it gives me an idea as to why they worked up the patient the way they did (like you're supposed to do in training), and they've memorized it to an extent that the patient's name is just popped out of their head, when really all I want is the guy's name and his diagnosis.

 

[EMDOC17]

I always get a chuckle when I get a call (usually from a PA or NP) and they have this long, dramatic story to tell me leading up to the patient having something really simple, like maybe a PTA, and yet when I ask for the name and DOB they're stumped. I can just picture the mental exercise before they call, trying to make sure that their story makes sense, that it leads up to the diagnosis and that it gives me an idea as to why they worked up the patient the way they did (like you're supposed to do in training), and they've memorized it to an extent that the patient's name is just popped out of their head, when really all I want is the guy's name and his diagnosis.

As an ED doc I will tell you that I never remember names. I mostly remember patients by "bed 5 with abdominal pain." Usually we are managing multiple patients at a time and even if you think you call back timely most likely I have moved on to another task. Like putting in orders in on the next patient or reviewing labs. When you do call back the EMR loves to freeze or take forever to pull the patient back up so if you ask for name/DOB I usually am needing to pull the patient back up to tell you.

I don't get why ER docs don't get to the point though. I think I learned this right away in residency. "Pt x has a 9mm stone at the UVJ with UTI and are septic WBC X, Lactic X, Gave rocephin". "Jim is 9 and has a PTA that I have been unable to drain". I figure if the consultant wants more info than that they will ask. On some of the not clear cases I may expand after I give the pertinent details.

 

[dpmd]

As an ED doc I will tell you that I never remember names. I mostly remember patients by "bed 5 with abdominal pain." Usually we are managing multiple patients at a time and even if you think you call back timely most likely I have moved on to another task. Like putting in orders in on the next patient or reviewing labs. When you do call back the EMR loves to freeze or take forever to pull the patient back up so if you ask for name/DOB I usually am needing to pull the patient back up to tell you.

I don't get why ER docs don't get to the point though. I think I learned this right away in residency. "Pt x has a 9mm stone at the UVJ with UTI and are septic WBC X, Lactic X, Gave rocephin". "Jim is 9 and has a PTA that I have been unable to drain". I figure if the consultant wants more info than that they will ask. On some of the not clear cases I may expand after I give the pertinent details.

I like that the folks I get called by most frequently will get to the point on the straightforward stuff and preface the weird or unclear stuff with a line like can you give me some advice on this one, or I have this strange one so i know to pay attention when they get into details because otherwise i am probably not processing all the stuff they are saying. Not all of them are like that though.

 

[doyouhaveaflag]

I’ve definitely interrupted the ER doc/PA during their spiel to ask them for the patients name so I can look up their xrs.

Agree. I ask for MRN and/or room number at their first pause then look up information and imaging at my leisure and zone out while they continue with the rest of the story.

I think I have trust issues. I prefer to just look up everything on my own and/or ask the patient because I don't trust people to tell me correct information. I really just want to know where the person is, some identifying piece of info so I can look them up, and what I'm being consulted for/mechanism of injury. I know others though who really do want the whole story.

 

[HighPriest]

Agree. I ask for MRN and/or room number at their first pause then look up information and imaging at my leisure and zone out while they continue with the rest of the story.

I think I have trust issues. I prefer to just look up everything on my own and/or ask the patient because I don't trust people to tell me correct information. I really just want to know where the person is, some identifying piece of info so I can look them up, and what I'm being consulted for/mechanism of injury. I know others though who really do want the whole story.

That’s not a trust issue, that’s good medicine. If the NP were able to interpret the information as well as me, they wouldn’t have consulted me in the first place. Outside of the “bleeding or not bleeding” patients, it’s very frequently that I disagree with a radiology interpretation or that the lab values taken in whole mean something different.

 

[kitsunepixie]

Agree. I ask for MRN and/or room number at their first pause then look up information and imaging at my leisure and zone out while they continue with the rest of the story.

I think I have trust issues. I prefer to just look up everything on my own and/or ask the patient because I don't trust people to tell me correct information. I really just want to know where the person is, some identifying piece of info so I can look them up, and what I'm being consulted for/mechanism of injury. I know others though who really do want the whole story.

Yep. One of my jrs got consulted on a guy who was found down with a spinal fracture. He was told that the patient was "neuro intact" by the ED resident. I guess the ED resident meant that he was GCS 15...he forgot to mention that he was paraplegic

 

[HighPriest]

Yep. One of my jrs got consulted on a guy who was found down with a spinal fracture. He was told that the patient was "neuro intact" by the ED resident. I guess the ED resident meant that he was GCS 15...he forgot to mention that he was paraplegic

The resident wasn't sure if he was like that before, and its an awkward conversation to have...

 

[akwho]

Yep. One of my jrs got consulted on a guy who was found down with a spinal fracture. He was told that the patient was "neuro intact" by the ED resident. I guess the ED resident meant that he was GCS 15...he forgot to mention that he was paraplegic

I got one of those from the medicine service last year. Some incidental ortho finding on CT. Get consulted -> ticked off about getting consulted on an old fracture at 11pm. Go see the patient anyways and this poor old lady can't lift her BLE off the bed, 1.5 days of worsening saddle anesthesia, and incontinence of urine. Nobody on medicine had noticed she hadn't been able to lift her legs off the bed in the past day. She's in the OR within 6 hours for cauda equina syndrome.

Moral of the story. Even if the consulting service doesn't know what the heck they are doing you can still help a patient.

 

[Synchronous]

I like the saying ‘trust but verify.’ It also doesn’t help that it’s july and all the new interns don’t have a clue what they are doing and some new seniors don’t oversee them as well as they should. I got a call the other night from the ED for “cellulitis of the RLE, maybe might need debridement.” I get down there and the guys leg looks awful, his foot is visibly deformed and puffy, like everything inside has just liquified. On top of that he has maggots in the space between his big toe and the next digit munching away. Apparently dude has had an issue for the past 5 years with his leg and his family member in Guatemala who is a doctor has been sending him pills and creams to take care of it. I leave the room and think ‘oh s***t’ this guys gonna need an amputation’ I just needed to figure out how much first. Run into the medicine team that has already admitted him. Tell them what I think and the the first thing the intern says is “oh so you’re not going to do the debridement? What about all the maggots in the wound? “I honestly didn’t know what to say to that, I had just told them that the guy was going to lose his leg and he was super fixated on these maggots.

 

[Daisy_Buchanan]

As a general surgery intern on vascular, I once got a call for "sepsis due to a foot infection." 20-something IV drug user w/ palpable pedal pulses, h/o multiple episodes of endocarditis, found down, septic as a goat. Some scholar noticed that he had janky feet (I bet!) and called us because they were concerned that his "foot infection" was causing his sepsis. He did indeed have a bad case of athlete's foot, but then, my middle school gym teacher could have picked that one out. I prescribed some life-saving Lotrimin- thank God they called me in time. I recommended extensive patient education on sock safety- when he got off levophed and the vent, of course- and prepared 5 mg of IM Haldol for when I had to explain the situation to my chronically angry attending.

Those were the days.

 

[You shall know the Truth]

As a general surgery intern on vascular, I once got a call for "sepsis due to a foot infection." 20-something IV drug user w/ palpable pedal pulses, h/o multiple episodes of endocarditis, found down, septic as a goat. Some scholar noticed that he had janky feet (I bet!) and called us because they were concerned that his "foot infection" was causing his sepsis. He did indeed have a bad case of athlete's foot, but then, my middle school gym teacher could have picked that one out. I prescribed some life-saving Lotrimin- thank God they called me in time. I recommended extensive patient education on sock safety- when he got off levophed and the vent, of course- and prepared 5 mg of IM Haldol for when I had to explain the situation to my chronically angry attending.

Those were the days.

Ahh, the old fainting goat syndrome

 

[doyouhaveaflag]

Two memorable ones in the last month:

First was a consult from the VA (which we cover in addition to our main hospital on call) from a frantic ED resident with a "septic" patient with tachycardia and HYPERtension (afebrile, normal labs). They had done a CT face because he had some unilateral cheek swelling and noted two pinpoint sized foreign bodies in the cheek. He had no recent trauma or mechanism for the foreign bodies to get there. They had already consulted ENT to manage his parotitis, but decided that plastic surgery was definitely needed for a STAT consult because the foreign bodies were making him septic. I told the resident I was seeing three actually urgent consults at the main hospital then I would head over to the VA (comments from him ensued about me being irresponsible and killing this patient). When I went two hours later, patient was completely stable and stated he was previously a welder 20 years ago, which was why he had metal in his face. He was totally unbothered by it and it was nowhere near the area of swelling.

Second one was a consult from the ED for a guy who's only injury after an MCC was miraculously a thumb nail bent back at the distal tip. He had been transferred from OSH for specialist management of this injury. I offered to trim the nail for him so it didn't catch on things, which he declined.

 

[HighPriest]

Two memorable ones in the last month:

First was a consult from the VA (which we cover in addition to our main hospital on call) from a frantic ED resident with a "septic" patient with tachycardia and HYPERtension (afebrile, normal labs). They had done a CT face because he had some unilateral cheek swelling and noted two pinpoint sized foreign bodies in the cheek. He had no recent trauma or mechanism for the foreign bodies to get there. They had already consulted ENT to manage his parotitis, but decided that plastic surgery was definitely needed for a STAT consult because the foreign bodies were making him septic. I told the resident I was seeing three actually urgent consults at the main hospital then I would head over to the VA (comments from him ensued about me being irresponsible and killing this patient). When I went two hours later, patient was completely stable and stated he was previously a welder 20 years ago, which was why he had metal in his face. He was totally unbothered by it and it was nowhere near the area of swelling.

Second one was a consult from the ED for a guy who's only injury after an MCC was miraculously a thumb nail bent back at the distal tip. He had been transferred from OSH for specialist management of this injury. I offered to trim the nail for him so it didn't catch on things, which he declined.

Is there some reason the ENT guy who they already called, and who already agreed to see the patient couldn't manage a FB in the face? I mean: "please come see this guy for parotitis, and manage the infection or drain an abscess or stent a duct, or open his face and dissect the facial nerve to get the gland out....but a FB in the cheek? I think we need plastics for this..."

the thumbnail thing I get. You definitely need a fellowship trained surgeon for that. Think of the implications...

 

[swoopyswoop]

Is there some reason the ENT guy who they already called, and who already agreed to see the patient couldn't manage a FB in the face? I mean: "please come see this guy for parotitis, and manage the infection or drain an abscess or stent a duct, or open his face and dissect the facial nerve to get the gland out....but a FB in the cheek? I think we need plastics for this..."

the thumbnail thing I get. You definitely need a fellowship trained surgeon for that. Think of the implications...

I got consulted once for a "vascular tumor of the head" by an ER NP... I was in the middle of a nightmare gallbladder so told them to call ENT if they think there is a vascular head/neck tumor. I go down to see the patient after, who has had a CT of the head, for an infected sebaceous cyst. After I come back from seeing the patient, I find the NP on the phone with the confused ENT residents trying to explain the consult (he knew I was seeing the patient). I took the phone and thanked them for their time and told them the consult was no longer necessary.

 

[HighPriest]

I got consulted once for a "vascular tumor of the head" by an ER NP... I was in the middle of a nightmare gallbladder so told them to call ENT if they think there is a vascular head/neck tumor. I go down to see the patient after, who has had a CT of the head, for an infected sebaceous cyst. After I come back from seeing the patient, I find the NP on the phone with the confused ENT residents trying to explain the consult (he knew I was seeing the patient). I took the phone and thanked them for their time and told them the consult was no longer necessary.

How many vessels does a tumor have to have before it’s technically vascular?

 

[doyouhaveaflag]

Is there some reason the ENT guy who they already called, and who already agreed to see the patient couldn't manage a FB in the face? I mean: "please come see this guy for parotitis, and manage the infection or drain an abscess or stent a duct, or open his face and dissect the facial nerve to get the gland out....but a FB in the cheek? I think we need plastics for this..."

the thumbnail thing I get. You definitely need a fellowship trained surgeon for that. Think of the implications...

I asked the ED resident the same thing. He said the ENT resident had put "consult plastics" in his note. I'm giving him the benefit of the doubt and think the ENT resident meant follow up outpatient in the future for this totally non-urgent issue. The ENT residents have never punted dumb stuff to us.