Consults- Memorable/Dismal/Ridiculous/Unique

[HighPriest]

Neurosurgery ICU called for a patient who had undergone angiography and IC aneurysm coiling, postop1, no urine output and hematoglob in USG. I tried to irrigate the foley. I could give fluid but the return was null. The foley was 22 fr. One colleague offered to place a cystostomy. Thank God we did not. We performed cystoscopy and saw a long and narrow bladder. We could not reach the end of the bladder. We performed a cystography and saw that the bladder dome is in the hypochondriac area. CT revealed a femoral pseudo-aneurysm that obstructed the bladder outlet and pushed the bladder up the upper abdomen.

Well, that falls under the “memorable” consult bracket.

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[HighPriest]

(Urgent cafe call at the end of clinic, 4:45, as usual):
“Hi, this is so-and-so from Urgent care. I have a patient (spells name three times). She’s 21. She has severe pain behind her ear. She jumps off the table when I touch her there. Although I question if it’s over-reacting, because she does the same thing when I touch her knee.
Her ear exam is totally normal. She’s had this for a couple months. She was in the ER last month for the same problem and she had a CT which was also totally normal. No infection, no mastoid fluid. They put her on antibiotics, but it didn’t help. (Shocking) I wanted to order another scan today, but she said she didn’t want to wait around, and she left. Do you think you could see her?”

My response: “of course.”

My thoughts:
I mean, yes. I can see anyone. You don’t actually need to call me to have me see her. Just place a consult. You’re not even asking for me to see her urgently, even though you’re implying that you would like that. But here we have a two month old problem with no concerning findings at all in a healthy patient for whom it wasn’t bad enough to stick around for an hour on a Wednesday afternoon to get it worked up. Which is good because somehow I don’t feel like yet another dose of radiation is going to crack this case. But I digress: how urgent do you think this is? And more importantly, what is it you think I do?

I can see anyone. But if the exam is normal and the CT is normal, there’s really nothing I can do. It’s a pain issue. It’s probably a headache or muscle tension or possibly a c-spine problem.

And I mention “yeah, we’ll take a look. Unless I find something unexpected on exam, I suspect it’s a c-spine issue or a headache or a musculoskeletal issue...maybe fibro...”

And she says “so, do you think I should put her on more antibiotics? Probably no, right?”


Yeah.....Probably not.....


Sometimes I think we could replace urgent care with the card dispensing soothsayer from the Tom Hanks classic “Big.”

 

[HighPriest]

Indications for antibiotics for a sinus infection:

Patient with 7-10 days of progressive and indicative symptoms.

Indications for topical antibiotics for otitis media:

Patient with discolored, painful, draining ear

Indications for antibiotics in urgent care:

Patient

 

[armybound]

I mean, you gotta give the patient what they want. Press-Ganey says so.

 

[ThoracicGuy]

(Urgent cafe call at the end of clinic, 4:45, as usual):
“Hi, this is so-and-so from Urgent care. I have a patient (spells name three times). She’s 21. She has severe pain behind her ear. She jumps off the table when I touch her there. Although I question if it’s over-reacting, because she does the same thing when I touch her knee.
Her ear exam is totally normal. She’s had this for a couple months. She was in the ER last month for the same problem and she had a CT which was also totally normal. No infection, no mastoid fluid. They put her on antibiotics, but it didn’t help. (Shocking) I wanted to order another scan today, but she said she didn’t want to wait around, and she left. Do you think you could see her?”

My response: “of course.”

My thoughts:
I mean, yes. I can see anyone. You don’t actually need to call me to have me see her. Just place a consult. You’re not even asking for me to see her urgently, even though you’re implying that you would like that. But here we have a two month old problem with no concerning findings at all in a healthy patient for whom it wasn’t bad enough to stick around for an hour on a Wednesday afternoon to get it worked up. Which is good because somehow I don’t feel like yet another dose of radiation is going to crack this case. But I digress: how urgent do you think this is? And more importantly, what is it you think I do?

I can see anyone. But if the exam is normal and the CT is normal, there’s really nothing I can do. It’s a pain issue. It’s probably a headache or muscle tension or possibly a c-spine problem.

And I mention “yeah, we’ll take a look. Unless I find something unexpected on exam, I suspect it’s a c-spine issue or a headache or a musculoskeletal issue...maybe fibro...”

And she says “so, do you think I should put her on more antibiotics? Probably no, right?”


Yeah.....Probably not.....


Sometimes I think we could replace urgent care with the card dispensing soothsayer from the Tom Hanks classic “Big.”

Was this from a NP?

 

[VA Hopeful Dr]

I mean, you gotta give the patient what they want. Press-Ganey says so.

We could save the country a lot of money by just replacing urgent cares with an antibiotic dispensing machine. No reason to pay a doctor to act in that role.

 

[HighPriest]

Was this from a NP?

Yes. I hope you were sitting down for that news.

 

[ThoracicGuy]

Yes. I hope you were sitting down for that news.

 

[HighPriest]

We could save the country a lot of money by just replacing urgent cares with an antibiotic dispensing machine. No reason to pay a doctor to act in that role.

We can be jealous all we want, but I almost wish I could go back and go the NP/Urgent care route. How great would it be to have a patient come in, tell you their issues, and then be able to say ".....(concerned and interested look) what you YOU think is going on?" Then you just diagnose them with that, call a sub-specialty consult, and put them on a z-pack. No matter what they say. The hardest part is just picking which specialist to call at 0300. If it's above the collar bone - ENT. If it's their johnson - Uro. Lady parts? - GYN. If it seems like they're actually sick right now - ambulance to the ER.

If there's any job that we could replace with very basic AI, it's that one.

 

[VA Hopeful Dr]

We can be jealous all we want, but I almost wish I could go back and go the NP/Urgent care route. How great would it be to have a patient come in, tell you their issues, and then be able to say ".....(concerned and interested look) what you YOU think is going on?" Then you just diagnose them with that, call a sub-specialty consult, and put them on a z-pack. No matter what they say. The hardest part is just picking which specialist to call at 0300. If it's above the collar bone - ENT. If it's their johnson - Uro. Lady parts? - GYN. If it seems like they're actually sick right now - ambulance to the ER.

If there's any job that we could replace with very basic AI, it's that one.

I did urgent care for a year.

I went from having a glass of wine on Friday night to drinking several every night after I had to work.

My wife actually said "you seemed happier in residency".

 

[HighPriest]

I did urgent care for a year.

I went from having a glass of wine on Friday night to drinking several every night after I had to work.

My wife actually said "you seemed happier in residency".

That's what you get for taking your job seriously.

 

[VA Hopeful Dr]

That's what you get for taking your job seriously.

That's pretty much what I learned from that actually. My last month I mostly gave up and it was great:

You've had a sore throat for 3 hours, sure you can have a z-pack.

You have arthritis that you're seeing an orthopedist for but you just know it's more than that? Sure you can get an MRI.

You've clearly got poison ivy but you don't trust me and want to see a dermatologist? Sure!

 

[Jolie South]

We can be jealous all we want, but I almost wish I could go back and go the NP/Urgent care route. How great would it be to have a patient come in, tell you their issues, and then be able to say ".....(concerned and interested look) what you YOU think is going on?" Then you just diagnose them with that, call a sub-specialty consult, and put them on a z-pack. No matter what they say. The hardest part is just picking which specialist to call at 0300. If it's above the collar bone - ENT. If it's their johnson - Uro. Lady parts? - GYN. If it seems like they're actually sick right now - ambulance to the ER.

If there's any job that we could replace with very basic AI, it's that one.

Any kind of pain from sternum to pubis? Call general surgery for “appendicitis” or “cholecystitis.”

 

[Synchronous]

Any kind of pain from sternum to pubis? Call general surgery for “appendicitis” or “cholecystitis.”

Bonus points if the consult is called with a negative CT and US....

 

[LucidSplash]

Bonus points if the consult is called with a negative CT and US....

Or my favorite, CT showing obvious pathology not managed by gen surg, but which was not reviewed by the person calling the consult. I diagnosed severe bladder outlet obstructions multiple times in residency by phone/reviewing CT.

Them: "Hey there's someone here with severe abdominal pain, I got a CT but radiology hasn't read it yet, but they are in a lot of pain I think you're going to want to lap them."
Me, reviewing CT while they are talking: "Do they have a foley yet to help out with the bladder that is so distended it is touching the liver?"
Them: "..."
Me: "I'll come see them, but you're probably gonna want to call urology and get the foley in ASAP."

 

[HighPriest]

Or my favorite, CT showing obvious pathology not managed by gen surg, but which was not reviewed by the person calling the consult. I diagnosed severe bladder outlet obstructions multiple times in residency by phone/reviewing CT.

Them: "Hey there's someone here with severe abdominal pain, I got a CT but radiology hasn't read it yet, but they are in a lot of pain I think you're going to want to lap them."
Me, reviewing CT while they are talking: "Do they have a foley yet to help out with the bladder that is so distended it is touching the liver?"
Them: "..."
Me: "I'll come see them, but you're probably gonna want to call urology and get the foley in ASAP."

Yeah. Been there too. “Waiting for radiology, but I think this guy has sinusitis”

Have you looked at the scan?

“No, you know, we’re swamped. I haven’t had the chance to do it.”

(Me, having pulled up the scan at home at 0300 while fielding the call I’m currently on because it doesn’t take that long)
Is...is his brain supposed to be that shape?

 

[dpmd]

Or my favorite, CT showing obvious pathology not managed by gen surg, but which was not reviewed by the person calling the consult. I diagnosed severe bladder outlet obstructions multiple times in residency by phone/reviewing CT.

Them: "Hey there's someone here with severe abdominal pain, I got a CT but radiology hasn't read it yet, but they are in a lot of pain I think you're going to want to lap them."
Me, reviewing CT while they are talking: "Do they have a foley yet to help out with the bladder that is so distended it is touching the liver?"
Them: "..."
Me: "I'll come see them, but you're probably gonna want to call urology and get the foley in ASAP."

I get these on occasion where there is a read but it doesn't address the thing that is likely causing the symptoms. Like the "dilated" appendix with no stranding because evidently some rads feel 7mm in an adult isn't normal meanwhile the colon is stuffed with stool. Or the slightly dilated small bowel "can't rule out sbo" again with a colon stuffed with stool.

 

[HighPriest]

I get these on occasion where there is a read but it doesn't address the thing that is likely causing the symptoms. Like the "dilated" appendix with no stranding because evidently some rads feel 7mm in an adult isn't normal meanwhile the colon is stuffed with stool. Or the slightly dilated small bowel "can't rule out sbo" again with a colon stuffed with stool.

yeah, those guys are full of $#!t

 

[WinslowPringle]

ED NP: "I had a question....there's this guy that came in with belly pain. I got a CTA. Radiology is calling the appendix 1cm but no fat stranding. His white count is normal, no localized tenderness, vitals are normal."
Me: "What's the question?"
ED NP: "The patient says he's had an appendectomy. What could it be?"
Me: "Does he have a scar?"
ED NP:".......Let me go check."......"Yes."
Me: "Weird. Well, a differential maybe might include lymphadenopathy, neoplasm, Meckel's, maybe he didn't actually have an appendectomy and the scar is from something else...What did the scan actually look like?"
ED NP: "I don't know, I don't read them. What do you want me to do with him?"
Me: ".......Are you asking me for a consult, then?"
ED NP: "I guess so. I'd appreciate if you'd see him."
Me: "Fine."

Reviewed CT and found.....

..... a completely normal TI. No appendix. Confirmed with a second radiologist. Saw the patient, in no way, shape, or form was the story consistent with appendicitis. He did have a symptomatic, easily reducible inguinal hernia I booked for elective repair though. Fun, fun.

 

[swoopyswoop]

ED NP: "I had a question....there's this guy that came in with belly pain. I got a CTA. Radiology is calling the appendix 1cm but no fat stranding. His white count is normal, no localized tenderness, vitals are normal."
Me: "What's the question?"
ED NP: "The patient says he's had an appendectomy. What could it be?"
Me: "Does he have a scar?"
ED NP:".......Let me go check."......"Yes."
Me: "Weird. Well, a differential maybe might include lymphadenopathy, neoplasm, Meckel's, maybe he didn't actually have an appendectomy and the scar is from something else...What did the scan actually look like?"
ED NP: "I don't know, I don't read them. What do you want me to do with him?"
Me: ".......Are you asking me for a consult, then?"
ED NP: "I guess so. I'd appreciate if you'd see him."
Me: "Fine."

Reviewed CT and found.....

..... a completely normal TI. No appendix. Confirmed with a second radiologist. Saw the patient, in no way, shape, or form was the story consistent with appendicitis. He did have a symptomatic, easily reducible inguinal hernia I booked for elective repair though. Fun, fun.

Got consulted intraop once for a "gastric mass."

It was the pylorus.

 

[HighPriest]

ED NP: "I had a question....there's this guy that came in with belly pain. I got a CTA. Radiology is calling the appendix 1cm but no fat stranding. His white count is normal, no localized tenderness, vitals are normal."
Me: "What's the question?"
ED NP: "The patient says he's had an appendectomy. What could it be?"
Me: "Does he have a scar?"
ED NP:".......Let me go check."......"Yes."
Me: "Weird. Well, a differential maybe might include lymphadenopathy, neoplasm, Meckel's, maybe he didn't actually have an appendectomy and the scar is from something else...What did the scan actually look like?"
ED NP: "I don't know, I don't read them. What do you want me to do with him?"
Me: ".......Are you asking me for a consult, then?"
ED NP: "I guess so. I'd appreciate if you'd see him."
Me: "Fine."

Reviewed CT and found.....

..... a completely normal TI. No appendix. Confirmed with a second radiologist. Saw the patient, in no way, shape, or form was the story consistent with appendicitis. He did have a symptomatic, easily reducible inguinal hernia I booked for elective repair though. Fun, fun.

Thank God she caught that. I understand there’s some inherent bias in my saying this, but it irritates me to no end when I ask a resident if they look at the films they’ve ordered and they look at me like I have two heads.

 

[You shall know the Truth]

Thank God she caught that. I understand there’s some inherent bias in my saying this, but it irritates me to no end when I ask a resident if they look at the films they’ve ordered and they look at me like I have two heads.

Possibly diplopia from the aforementioned appendicitis that was a hernia?

 

[AsianPersuasion]

I'm only a PGY-1, but what is up with paging surgery for something that isn't my specialty related? For example, got paged from the ER about a gyn problem, told the PA I'm vascular intern, she told me, "Well, gyn said they don't feel comfortable doing it..."
I told her I'd be happy to assess the pt, but again, I'm vascular and I know jacksh8t about that gyn pathology. She huffed and puffed and told me to just ask my senior to come down to look at the pt....

 

[TraumaLlamaMD]

I'm only a PGY-1, but what is up with paging surgery for something that isn't my specialty related? For example, got paged from the ER about a gyn problem, told the PA I'm vascular intern, she told me, "Well, gyn said they don't feel comfortable doing it..."
I told her I'd be happy to assess the pt, but again, I'm vascular and I know jacksh8t about that gyn pathology. She huffed and puffed and told me to just ask my senior to come down to look at the pt....

If I had business cards -
“Dr. Llama
Chief Resident, General Surgery
Secretary, IR and GI”

 

[dpmd]

I'm only a PGY-1, but what is up with paging surgery for something that isn't my specialty related? For example, got paged from the ER about a gyn problem, told the PA I'm vascular intern, she told me, "Well, gyn said they don't feel comfortable doing it..."
I told her I'd be happy to assess the pt, but again, I'm vascular and I know jacksh8t about that gyn pathology. She huffed and puffed and told me to just ask my senior to come down to look at the pt....

Gyn where I am at will not drain any vulvar abscess so I can either do it (and bill for it which is much better than in residency where any extra work is just free) and help the patient or say no only for it to eventually work it's way back to me when it gets worse.

 

[dpmd]

Same goes for ortho and extremity pus or extremity necrotizing fasciitis. Not sure why they think I am better at fasciotomy and fasciectomy but it is what it is.

 

[HighPriest]

I'm only a PGY-1, but what is up with paging surgery for something that isn't my specialty related? For example, got paged from the ER about a gyn problem, told the PA I'm vascular intern, she told me, "Well, gyn said they don't feel comfortable doing it..."
I told her I'd be happy to assess the pt, but again, I'm vascular and I know jacksh8t about that gyn pathology. She huffed and puffed and told me to just ask my senior to come down to look at the pt....

Get used to this, man. If I had a nickel for every dental abscess I was called about....
But I don’t because none of those people pay their bills.
I’ve been called in to deal with post op infections caused by oral surgeons who are in our community. Like three blocks away.

 

[dpmd]

Get used to this, man. If I had a nickel for every dental abscess I was called about....
But I don’t because none of those people pay their bills.
I’ve been called in to deal with post op infections caused by oral surgeons who are in our community. Like three blocks away.

I got called for a recalcitrant neck abscess in a guy whose exuberant facial abscess in response to his multiple dental abscesses was likely his bigger issue. Er had already drained the posterior neck abscess but because the skin is so thick there and the pus likes to dissect within it rather than make a nice cavity i had to resect a nice chunk of skin. Patient had already been getting dental care but claimed it was because the er let the pus drain onto his face when they drained it that his face and jaw was full of pus. Whatever. Quick debridement and get the **** out of here to a dentist for you buddy.

 

[You shall know the Truth]

If I had business cards -
“Dr. Llama
Chief Resident, General Surgery
Secretary, IR and GI”

And OB

 

[AsianPersuasion]

I can see if it's acute, sh8t hit the fan in the OR and need back up but this was not the case and that particular complaint fell perfectly into the realm of OB/GYN nor was it emergent. I barely remember anything from OB/GYN rotation. The past months I did GS, Plastic, SICU and now VS. Literally, don't know what I'm doing half the time.

And dear lord, the entitlement from other attendings, fellow and resident!! You don't realized how bad it is until you're truly in it. For example, emergent situation, pt is circling the drain, the consulting attending is yelling at you and your chief to fix the problem that you literally just showed up to the scene, cause what the hell are you there for other than clean up the mess?! everyone and their mother skedaddled out...bad outcome takes place but your team was to blame?!

I feel like 98% of the time some "interventionist" like to explore and get in over their head and we look like geek squad to them or something.

 

[LucidSplash]

As a chief once, while leading our chief service, I took a morbidly obese lady to the OR emergently for Fournier’s/nec fasc/whatever you want to call it in a woman. After I was done, I was sitting in the surgeon’s lounge dictating, and the PD of the OB/Gyn program came up to me. He was always kinda pompous but otherwise a pretty nice guy. He gently took me to task for “stealing” cases that would benefit his residents, though he congratulated me on “being aggressive for my own learning and education” and asked how I’d come to be taking this lady with an “obvious” gyn issue to the OR and why wasn’t his service consulted?

I admit I was pretty flabbergasted. I told him that the ED had consulted me, and it never occurred to me to call his service because somehow this kind of thing always ended up being punted to gen surg and is never heard of gyn taking this patient. I did however assure him that I had no intention of stealing cases from his residents and I would be happy to call them directly the next time we were consulted before them on this kind of patient.

Totally tried it the next time. As you can probably guess, another gyn attending was on service and said he “wasn’t comfortable” with this kind of case.

 

[dpmd]

As a chief once, while leading our chief service, I took a morbidly obese lady to the OR emergently for Fournier’s/nec fasc/whatever you want to call it in a woman. After I was done, I was sitting in the surgeon’s lounge dictating, and the PD of the OB/Gyn program came up to me. He was always kinda pompous but otherwise a pretty nice guy. He gently took me to task for “stealing” cases that would benefit his residents, though he congratulated me on “being aggressive for my own learning and education” and asked how I’d come to be taking this lady with an “obvious” gyn issue to the OR and why wasn’t his service consulted?

I admit I was pretty flabbergasted. I told him that the ED had consulted me, and it never occurred to me to call his service because somehow this kind of thing always ended up being punted to gen surg and is never heard of gyn taking this patient. I did however assure him that I had no intention of stealing cases from his residents and I would be happy to call them directly the next time we were consulted before them on this kind of patient.

Totally tried it the next time. As you can probably guess, another gyn attending was on service and said he “wasn’t comfortable” with this kind of case.

This was the kind of case I first learned that gyn where I am is "uncomfortable" with ***** pus. Where I trained between urology and gyn I never dealt with that stuff so when i got consulted I said call gyn thinking the er doc had just made a mistake. So then later i got the call that gyn said transfer the patient but it had been a few hours, there was no accepting hospital, and the patient was not doing well could I please help. As it turned out it didn't require any specialized knowledge more than try not to make any of the preexisting holes connect to each other.

I have also become pretty good at draining tuboovarian abscesses that gyn insists are appys and I can't convince them otherwise.

 

[WheezyBaby]

As a chief once, while leading our chief service, I took a morbidly obese lady to the OR emergently for Fournier’s/nec fasc/whatever you want to call it in a woman. After I was done, I was sitting in the surgeon’s lounge dictating, and the PD of the OB/Gyn program came up to me. He was always kinda pompous but otherwise a pretty nice guy. He gently took me to task for “stealing” cases that would benefit his residents, though he congratulated me on “being aggressive for my own learning and education” and asked how I’d come to be taking this lady with an “obvious” gyn issue to the OR and why wasn’t his service consulted?

I admit I was pretty flabbergasted. I told him that the ED had consulted me, and it never occurred to me to call his service because somehow this kind of thing always ended up being punted to gen surg and is never heard of gyn taking this patient. I did however assure him that I had no intention of stealing cases from his residents and I would be happy to call them directly the next time we were consulted before them on this kind of patient.

Totally tried it the next time. As you can probably guess, another gyn attending was on service and said he “wasn’t comfortable” with this kind of case.

Yeah I'm not consulting gyn for next fasc

 

[LucidSplash]

Yeah I'm not consulting gyn for next fasc

I know, right? Like I said, it had literally never occurred to me that anyone would until that PD accuses me of stealing a good learning case from his residents.

 

[ThoracicGuy]

I know, right? Like I said, it had literally never occurred to me that anyone would until that PD accuses me of stealing a good learning case from his residents.

You mean learning how to call a general surgery consult?

 

[SurgeDO]

Neurosurgery

ED NP at 3 am: we got a guy down here in the ED with a fever and back pain. We think he might have an epidural abscess and wanted you to come see him STAT.

Me: where does the MRI show the abscess at?

ED NP: do you want us to order an MRI?

Me:...where does the CT show the abscess is at?

ED NP: do you want us to order a CT?

Me: !$$&!&@$&!!!?$&$


I will honestly never understand the ED and its purpose.

 

[fleetfox]

Neurosurgery

ED NP at 3 am: we got a guy down here in the ED with a fever and back pain. We think he might have an epidural abscess and wanted you to come see him STAT.

Me: where does the MRI show the abscess at?

ED NP: do you want us to order an MRI?

Me:...where does the CT show the abscess is at?

ED NP: do you want us to order a CT?

Me: !$$&!&@$&!!!?$&$


I will honestly never understand the ED and its purpose.

We have no idea what we're doing BUT WE'RE VERY CONCERNED!!!

 

[WinslowPringle]

I hate it when ED providers (or anyone really, but recently it's been the ED) put words in my mouth. Worse than lawyers.
Consult for "necrotizing" pancreatitis
Me: "I will not perform surgery on this patient. She needs fluid resuscitation, alcohol cessation, and long-term nutrition. The radiologist is right that it's pancreatitis, but there is nothing to drain and operative intervention is definitely not indicated in this case"
ED MD in accusatory tone: "So, you aren't concerned about the necrotizing pancreatitis?"

Consult for perforated diverticulitis (microperforation, nothing to drain)
Me: "So, we will give her fluids and antibiotics, put her in the ICU, closely monitor her exam, make sure she's comfortable, keep her NPO..."
ED PA: "So, you aren't going to do anything?"
Me: "We are going to give her fluids and antibiotics, put her in the ICU, closely monitor her, and provide bowel rest. I wouldn't characterize that as not doing anything..."

Consult for 'cholecystitis'
Me: "I'm concerned that, given the labs, it's consistent with an hepatocellular process and I think the patient needs further workup; certainly right now I won't be operating until we have some answers and, also, she's a terrible operative candidate."
ED NP: "So, you don't think the elevated bilirubin means anything?"

 

[evilbooyaa]

I hate it when ED providers (or anyone really, but recently it's been the ED) put words in my mouth. Worse than lawyers.
Consult for "necrotizing" pancreatitis
Me: "I will not perform surgery on this patient. She needs fluid resuscitation, alcohol cessation, and long-term nutrition. The radiologist is right that it's pancreatitis, but there is nothing to drain and operative intervention is definitely not indicated in this case"
ED MD in accusatory tone: "So, you aren't concerned about the necrotizing pancreatitis?"

Where I did my intern year, about a quarter of the way through, the surgery leadership got so sick of IM/MICU mismanaging pancreatitis and getting a few consults when these patients were on death's door that they just decided that all pancreatitis diagnoses MUST be admitted to the general surgery service.

That sucked. Anyone with an elevated lipase and any other diagnosis ended up as a surgery admit.

 

[HighPriest]

Where I did my intern year, about a quarter of the way through, the surgery leadership got so sick of IM/MICU mismanaging pancreatitis and getting a few consults when these patients were on death's door that they just decided that all pancreatitis diagnoses MUST be admitted to the general surgery service.

That sucked. Anyone with an elevated lipase and any other diagnosis ended up as a surgery admit.

That is the great thing about being an attending physician with residents. I always loved policies that made the resident’s lives living hell and really didn’t help educate them, but it made things marginally easier for the staff (in this case in lieu of actually talking to the MICU staff).
I recall a staff doc who used to give CME lectures on epistaxis. He would tell people, straight faced, that he hadn’t had to pack a nose in years because this new $400 gel he published on could stop any nosebleed. You just squirt it up in there and all is well. And I, the resident listening to him on his service, had packed like three noses that week in his name when the patient just immediately blew the gel right out of their nose and resumed bleeding (at a cost of $400, of course).
I mean, technically he hadn’t packed any noses, so it’s not -really- bull$#!t.

 

[dpmd]

Where I did my intern year, about a quarter of the way through, the surgery leadership got so sick of IM/MICU mismanaging pancreatitis and getting a few consults when these patients were on death's door that they just decided that all pancreatitis diagnoses MUST be admitted to the general surgery service.

That sucked. Anyone with an elevated lipase and any other diagnosis ended up as a surgery admit.

We had this policy plus one that every gi bleeder got an immediate surgery consult (due to some not getting managed well).

 

[Dr.LeoSpaceman]

We had this policy plus one that every gi bleeder got an immediate surgery consult (due to some not getting managed well).

We didn't have such a policy, though the "just want to get you onboard" consult is no less inevitable. However I will say that while I've only operated on a handful, it is more frequent that I've had to play the heavy with recalcitrant GI teams when they're giving the IM teams a hard time.

 

[ThoracicGuy]

Where I did my intern year, about a quarter of the way through, the surgery leadership got so sick of IM/MICU mismanaging pancreatitis and getting a few consults when these patients were on death's door that they just decided that all pancreatitis diagnoses MUST be admitted to the general surgery service.

That sucked. Anyone with an elevated lipase and any other diagnosis ended up as a surgery admit.

Did we train at the same place??? That was a terrible policy.

 

[LucidSplash]

Did we train at the same place??? That was a terrible policy.

Saaaaamsies. Annoying as crap for surgery residents but honestly like three times in a month I got consulted for a line on a pancreatitis patient admitted to medicine and found them to be profoundly hypotensive, tachycardic, not on IVF, anuric with AKI being given lasix... and it kinda made sense to me after that. One was being encouraged by the GI doc to eat. We took her to the OR about an hour after I found her dying on the floor from her infected pancreatitis.

 

[dpmd]

It is like medicine folks are allergic to fluid resuscitation.

 

[deleted50541]

It is like medicine folks are allergic to fluid resuscitation.

"Gotta swell to get well"

 

[HighPriest]

It is like medicine folks are allergic to fluid resuscitation.

I’ve had patients tells they were allergic to saline. I’m sure I’m not alone there. Makes me wonder if the Hippocratic Oath should contain a part about Darwin.

 

[Jolie South]

It is like medicine folks are allergic to fluid resuscitation.

Levo at 30, zero urine output. How much fluids did they get? “The patient is saline locked.”

 

[TraumaLlamaMD]

Levo at 30, zero urine output. How much fluids did they get? “The patient is saline locked.”

This is funny to me given how aggressive my hospital is with its “CODE SEPSIS” triggers - I’m pretty sure I’d get a 30cc/kg bolus right now if someone here took my vitals and labs!

 

[dpmd]

Levo at 30, zero urine output. How much fluids did they get? “The patient is saline locked.”

I deal with a lot of necrotizing fasciitis and the ICU is supposedly staffed 24 hrs and closed now so I am not supposed to be in charge. I sometimes have to make an open wound that occupies half of their extremity and therefore there is fluid losses ongoing with that. If is visible on the dressing or once it gets there in the wound vac. But if I don't do my own fluid orders the patient will get 100ml an hour and have orders for levo, vasopressin, and phenylephrine with no boluses. And I had a patient once who had bright red blood coming from her gi tract (400 ml in an hour) who got orders for one unit prbcs and the same three pressors. I told the nurses to have the blood bank get 6 units ready and keep transfusing instead of adding pressors while they waited for the guy to show up and do some lines (I offered and he declined claiming he would be there soon, but wasn't there soon) and while arrangements for angioembolization were made.