Consults- Memorable/Dismal/Ridiculous/Unique

[HighPriest]

Call: elderly patient with GLF. Face is swollen. Got a CT which demonstrates facial fractures of unknown chronicity, minimally displaced. Can you see her?

Me: yep. Let me take a look at the scan.

Scan: no acute fracture. no blood in the sinuses, etc. But, the patient has multiple reconstructive plates of the frontal bone, temporal bone, zygomatic arch, and even some intracranial plates. definite facial deformity from the prior injury.

Call back: Hey, uh, I'm happy to see this person, but I'm not sure there's an acute trauma.
ER: (a little bashfully): Uh, yeah...she forgot to mention the prior car accident and reconstruction. and well...she did keep mentioning that her face didn't hurt....

At least there was some introspection, right?

Take home: sometimes they look funny just because they're funny looking.

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[HighPriest]

Referral from dentist.

patient with dental pain.

Had been to an orthodontist due to pain in one of her right molar teeth. He told her that for whatever reason he couldn't fix the tooth, better to pull it.

She went to her dentist. Dentist pulled the tooth 3 days ago. Patient woke up from anesthetic with pain in the area of the extraction. Pain has persisted for three days. Went back to her dentist, who told her that everything looks fine. She can't imagine why the patient is having pain. She thinks maybe there's an infection, but she doesn't know what kind of antibiotic to use. Send her to me.

I look at the extraction site. It looks like she had her tooth pulled three days ago. Still raw, fibrinous exudate. Question remains: why the pain.

Probably because you had a tooth pulled three days ago. Even if I saw inflammation in the maxillary sinus, after extracting a molar tooth this is not at all unusual. Dentist is actually a medical professional who is licensed to treat with antibiotics and control pain from the procedure she performed. Please follow up with dentist.

BLUF: Patient has dental procedure, dentist sends her to me to manage her post-procedural recovery.

 

[mestielest]

Call: no urine output

Actually, he was dead. He was an old and cachectic patient with several strokes previously and under palliative care.

 

[Jolie South]

Today, I get a call about a celiac artery aneurysm found on a PE study. "What do you do about this?"

Dude comes in with night sweats, headache, and urinary frequency. Naturally, first thought is PE. Shockingly, the PE study is negative.

I ask if the patient is symptomatic from his aneurysm. I get a long story that makes no sense from the ER.

Go see the patient and ask if he has abdominal pain. "Maybe if you push on my belly really hard"

Final diagnosis for this guy: hyperthyroidism.

 

[Raryn]

Today, I get a call about a celiac artery aneurysm found on a PE study. "What do you do about this?"

Dude comes in with night sweats, headache, and urinary frequency. Naturally, first thought is PE. Shockingly, the PE study is negative.

I ask if the patient is symptomatic from his aneurysm. I get a long story that makes no sense from the ER.

Go see the patient and ask if he has abdominal pain. "Maybe if you push on my belly really hard"

Final diagnosis for this guy: hyperthyroidism.

I'm sure the contrast he got for his PE study really helped his hyperthyroidism.

 

[dpmd]

Today, I get a call about a celiac artery aneurysm found on a PE study. "What do you do about this?"

Dude comes in with night sweats, headache, and urinary frequency. Naturally, first thought is PE. Shockingly, the PE study is negative.

I ask if the patient is symptomatic from his aneurysm. I get a long story that makes no sense from the ER.

Go see the patient and ask if he has abdominal pain. "Maybe if you push on my belly really hard"

Final diagnosis for this guy: hyperthyroidism.

Why weren't they all day sweats?

 

[doyouhaveaflag]

Got a call from peds ED that a 23 month old girl had an unwitnessed "dog bite" to the face and had been transferred here from a hospital two hours away for specialist care from plastic surgery.

When I go to see her, she has some scratches and abrasions but certainly nothing requiring closure. Which then puts me in the position of explaining that after this toddler's seven hour ordeal of two hospitals and a transfer, my move is to do nothing but put some ointment on her face.

 

[BigRedBeta]

Got a call from peds ED that a 23 month old girl had an unwitnessed "dog bite" to the face and had been transferred here from a hospital two hours away for specialist care from plastic surgery.

When I go to see her, she has some scratches and abrasions but certainly nothing requiring closure. Which then puts me in the position of explaining that after this toddler's seven hour ordeal of two hospitals and a transfer, my move is to do nothing but put some ointment on her face.

Reminds me of the time as a resident that I took care of a kid who transferred from a rural urgent care to rural ED to children's hospital ED over the course of nearly 12 hours for chief complaint of "freaking out". 8 year old boy who saw a spider in the doorway of his house and refused to go into the house thereafter, grandma didn't know what to do so decided that he needed medical attention for some reason. UC made the family wait for at least 2 hours before bringing him back and the NP saying they didn't feel comfortable taking care of children, so transferred. Rural ED gave a dose of benadryl to get him to sleep, despite the family members telling them he has paradoxical reaction to it, and when that didn't work, they arranged transfer to the Children's ED 3 hours away. By the time I saw him at 2am he was of course asleep and the grandmother was now 3 hours away from home with no transportation. Let them all sleep in the ED room, and it was nearly noon before anyone came to get them.

 

[dpmd]

Got a call from peds ED that a 23 month old girl had an unwitnessed "dog bite" to the face and had been transferred here from a hospital two hours away for specialist care from plastic surgery.

When I go to see her, she has some scratches and abrasions but certainly nothing requiring closure. Which then puts me in the position of explaining that after this toddler's seven hour ordeal of two hospitals and a transfer, my move is to do nothing but put some ointment on her face.

If it makes it any better there is a decent chance the desire to see plastics was parent driven.

 

[TypeADissection]

...I get a long story that makes no sense from the ER...

We could probably start an entire thread that starts with this line...

 

[SouthernGent]

We could probably start an entire thread that starts with this line...

I am convinced that ERs exist solely to make surgery interns get their daily steps in by coming down to see at least two BS consults an hour.

My favorite from them this past block was "I don't know why, but we ordered a CT scan (The epitome of EM right there) and they've got gallstones. Can you come see them?" Completely asymptomatic...

 

[Apollyon]

I am convinced that ERs exist solely to make surgery interns get their daily steps in by coming down to see at least two BS consults an hour.

My favorite from them this past block was "I don't know why, but we ordered a CT scan (The epitome of EM right there and they've got gallstones. Can you come see them?" Completely asymptomatic...

"Surgery intern". In other words, academic hospital. In other words, not community hospital. In other words, the vast majority of hospitals.

In other words, it gets better.

Some animals have to live in the zoo, because they can't survive in the wild. (Some academic docs can't cut it without residents, and they consult for EVERYTHING, because everything is available.)

 

[SurgeDO]

Neurosurgery.

Call from the EM at 2 a.m.

EM: We got a GSW to the head. I need you to come see him STAT.

Me: are they alive? (I’ve been burned before)

EM: yea, they’re completely neuro intact and talking. Just not moving their left leg.

Me: what’s their name? I’ll look at their CT.

EM: you want a CT? You don’t want to just come down here and put in a burr hole?

Me: ... (I see where this is going)

—pt. goes to CT—

Me: (after looking at the CT, realizing this patient doesn’t have any intracranial pathology; realizing there is no sign of any gun shot wound; realizing there’s no skull fracture and maybe some sign of minor extracranial soft tissue damage)...uhh, this patient does not have any cranial pathology going on and certainly does not have a GSW to the dome.

EM: yea...it actually may have been blunt trauma and not a GSW. But he’s still not moving his leg very well.

Me: please cancel this consult.

Later found out this guy had a femur fracture. I don’t get where these ER people come from.

 

[WheezyBaby]

There's a point where buffing a consult becomes lying, and that point was waaaay before this

 

[kitsunepixie]

Neurosurgery.

—pt. goes to CT—

Me: (after looking at the CT, realizing this patient doesn’t have any intracranial pathology; realizing there is no sign of any gun shot wound; realizing there’s no skull fracture and maybe some sign of minor extracranial soft tissue damage)...uhh, this patient does not have any cranial pathology going on and certainly does not have a GSW to the dome.

EM: yea...it actually may have been blunt trauma and not a GSW. But he’s still not moving his leg very well.

Me: please cancel this consult.

Later found out this guy had a femur fracture. I don’t get where these ER people come from.

I've had that happen before too. I've also been consulted on a kindergartner after the ER found a bullet in her brain on MRI (yes...she had an MRI). She was sent to the ER by her dentist who evaluated her for "bleeding gums." Family "forgot to mention" that the child had found a gun and put it in her mouth and it went off 3 days prior. She was running around and tried to play hide and seek with me. You can't make this stuff up.

 

[Crabbygas]

One night I got a call from my favorite surgery resident. "Patient in the ER with 3 GSW to the head and one to the abdomen. I want to bring him up for an ex-lap."

When he got to the OR he did indeed have 3 small caliber holes in his head but none had gone through bone and the patient was awake and talking. So we did the ex-lap. A .22 had gone right through his pancreas. Had a post op MI and died a few weeks later.

 

[HighPriest]

One night I got a call from my favorite surgery resident. "Patient in the ER with 3 GSW to the head and one to the abdomen. I want to bring him up for an ex-lap."

When he got to the OR he did indeed have 3 small caliber holes in his head but none had gone through bone and the patient was awake and talking. So we did the ex-lap. A .22 had gone right through his pancreas. Had a post op MI and died a few weeks later.

I love it when all the loose ends are tied up when someone finishes a story.

 

[OrthoTraumaMD]

I've had that happen before too. I've also been consulted on a kindergartner after the ER found a bullet in her brain on MRI (yes...she had an MRI). She was sent to the ER by her dentist who evaluated her for "bleeding gums." Family "forgot to mention" that the child had found a gun and put it in her mouth and it went off 3 days prior. She was running around and tried to play hide and seek with me. You can't make this stuff up.

I hope the family got CPS called on them.

 

[kitsunepixie]

I hope the family got CPS called on them.

Ah yes. I followed her in clinic afterward and she was back in the custody of her loving prostitute mum

 

[HighPriest]

I recall a situation in medical school: 20-something-year-old parent, delivering her third kid. Long history of meth and cocaine abuse, multiple stints in the clink. Her two older toddlers were both in the custody of her parents due to abuse and neglect. Third kid (not even born yet) is slated to also go directly into the custody of her parents. But the icing on the cake is that she (drug addict Mom) was living with her parents. So, essentially, the kids were in the same situation they would have been in without CPS, except the Mom isn't financially responsible for them in any way.

The system works.

 

[dpmd]

I recall a situation in medical school: 20-something-year-old parent, delivering her third kid. Long history of meth and cocaine abuse, multiple stints in the clink. Her two older toddlers were both in the custody of her parents due to abuse and neglect. Third kid (not even born yet) is slated to also go directly into the custody of her parents. But the icing on the cake is that she (drug addict Mom) was living with her parents. So, essentially, the kids were in the same situation they would have been in without CPS, except the Mom isn't financially responsible for them in any way.

The system works.

I don't think there are foster care payments when are placed with family members. Not sure though.

 

[HighPriest]

I don't think there are foster care payments when are placed with family members. Not sure though.

I don't know that it was foster care or custody. Maybe the blame isn't on CPS if they filed for custody, but rather the court system. In any case, my point is that the children would have been in the same situation either way. Mom would be living with GPs no matter what. She's unfit either way. She gets all the benefits, and can still shoot coke on the reg.

 

[dpmd]

I don't know that it was foster care or custody. Maybe the blame isn't on CPS if they filed for custody, but rather the court system. In any case, my point is that the children would have been in the same situation either way. Mom would be living with GPs no matter what. She's unfit either way. She gets all the benefits, and can still shoot coke on the reg.

All what benefits though? She doesn't have custody so she isn't getting welfare payments for them. Like what outcome are you wishing had happened instead?

 

[HighPriest]

All what benefits though? She doesn't have custody so she isn't getting welfare payments for them. Like what outcome are you wishing had happened instead?

The benefits in question would be continuing to care for her kids on a daily basis, and continuing to influence their lives. (which, I see as a benefit)

What'd I'd like to see is the un-salavgable, drug addict mother out of the picture. Or at least a situation wherein the kids aren't exposed to her poison on a daily basis. You're looking at the financial side of it exclusively. I'm looking at the well-being of the kids. I can't see a situation where living with their mother is the best thing for them (in this case). What you have now is the state and her parents enabling her to continue to be an addict without any real consequences. I mean, the point of taking the kids away from her is that she wasn't able to take care of them and/or that she might be a danger to them. I find it hard to believe that situation is better because her elderly parents were around. I mean....they already failed once...If they weren't all co-habitating, maybe the situation would make more sense. This is basically the state, coming in to a home and saying "yeah, it isn't safe for these kids here. So...ah....(picks someone in the room) you guys. you guys are now responsible..."

 

[dpmd]

The benefits in question would be continuing to care for her kids on a daily basis, and continuing to influence their lives. (which, I see as a benefit)

What'd I'd like to see is the un-salavgable, drug addict mother out of the picture. Or at least a situation wherein the kids aren't exposed to her poison on a daily basis. You're looking at the financial side of it exclusively. I'm looking at the well-being of the kids. I can't see a situation where living with their mother is the best thing for them (in this case). What you have now is the state and her parents enabling her to continue to be an addict without any real consequences. I mean, the point of taking the kids away from her is that she wasn't able to take care of them and/or that she might be a danger to them. I find it hard to believe that situation is better because her elderly parents were around. I mean....they already failed once...If they weren't all co-habitating, maybe the situation would make more sense. This is basically the state, coming in to a home and saying "yeah, it isn't safe for these kids here. So...ah....(picks someone in the room) you guys. you guys are now responsible...)

You had me confused because you talked about her not being financially responsible for them. So I was only considering that side. You are also assuming foster care would be a better situation but the unfortunate reality is that kids can be abused in that system too so if the parents are willing to take on the job and they are assessed as being ok to take custody then at least that way if I am correct then we aren't paying for their foster care while they get bounced around and hopefully don't get molested or neglected. The daughter being a drug addict doesn't automatically mean the parents failed and doesn't mean they won't be able to raise the grandkids well. The issue isn't so much that the home is unsafe, just that the mom can't be a good mom and someone else needs to be making decisions about the kids. If she is abusing them that would be different.

 

[HighPriest]

You had me confused because you talked about her not being financially responsible for them. So I was only considering that side. You are also assuming foster care would be a better situation but the unfortunate reality is that kids can be abused in that system too so if the parents are willing to take on the job and they are assessed as being ok to take custody then at least that way if I am correct then we aren't paying for their foster care while they get bounced around and hopefully don't get molested or neglected. The daughter being a drug addict doesn't automatically mean the parents failed and doesn't mean they won't be able to raise the grandkids well. The issue isn't so much that the home is unsafe, just that the mom can't be a good mom and someone else needs to be making decisions about the kids. If she is abusing them that would be different.

If you say so. In my book, keeping the kids in the same house as her isn’t very different from keeping the kid above who shot herself in the mouth in that same environment. It’s also worse for the mother, as she has no motivation whatsoever to change. They could have tacked on a restraining order for the mother if they wanted a better situation, but wanted to keep it in house.

 

[WinslowPringle]

Zero-dark thirty, on “home call” for chief service for multiple hospitals. One of the hospitals I’m sometimes on for has an attending doing call this night who doesn’t work with residents, so the calls should be going to him.

Hospitalist: “Yes, I’m calling you to come put an art line in my patient. “
Me: “I don’t have an attending to staff it, you’ll have to call Dr Nores tonight.”
Hospitalist: “He doesn’t have residents, I can’t call and wake him up. He won’t come in for an art line.”
Me: “...... I don’t have staff there. You can call Nores or another private attending or the in house anesthesiologist, or do it yourself.”
Hospitalist: Proceeds to argue that he can’t call anyone else because they are attendings and asleep. (Doesn’t tell me why he can’t do it himself tho...In my opinion, if you’re the in house ICU coverage you should probably be able to do your own lines.)

Memorable because I guess residents don’t need sleep. True dat.

 

[swoopyswoop]

Zero-dark thirty, on “home call” for chief service for multiple hospitals. One of the hospitals I’m sometimes on for has an attending doing call this night who doesn’t work with residents, so the calls should be going to him.

Hospitalist: “Yes, I’m calling you to come put an art line in my patient. “
Me: “I don’t have an attending to staff it, you’ll have to call Dr Nores tonight.”
Hospitalist: “He doesn’t have residents, I can’t call and wake him up. He won’t come in for an art line.”
Me: “...... I don’t have staff there. You can call Nores or another private attending or the in house anesthesiologist, or do it yourself.”
Hospitalist: Proceeds to argue that he can’t call anyone else because they are attendings and asleep. (Doesn’t tell me why he can’t do it himself tho...In my opinion, if you’re the in house ICU coverage you should probably be able to do your own lines.)

Memorable because I guess residents don’t need sleep. True dat.

That's embarrassing. Anyone covering the ICU should know how to put in an a-line and a central line. We rotated at a hospital with hospitalists covering the ICU in house while the intensivist took home call (and did not come in, ever), and there was an attending who said they couldn't place central lines other than femoral lines. Mind boggling.

 

[ThoracicGuy]

Zero-dark thirty, on “home call” for chief service for multiple hospitals. One of the hospitals I’m sometimes on for has an attending doing call this night who doesn’t work with residents, so the calls should be going to him.

Hospitalist: “Yes, I’m calling you to come put an art line in my patient. “
Me: “I don’t have an attending to staff it, you’ll have to call Dr Nores tonight.”
Hospitalist: “He doesn’t have residents, I can’t call and wake him up. He won’t come in for an art line.”
Me: “...... I don’t have staff there. You can call Nores or another private attending or the in house anesthesiologist, or do it yourself.”
Hospitalist: Proceeds to argue that he can’t call anyone else because they are attendings and asleep. (Doesn’t tell me why he can’t do it himself tho...In my opinion, if you’re the in house ICU coverage you should probably be able to do your own lines.)

Memorable because I guess residents don’t need sleep. True dat.

Unfortunately, it's part of the academic center mentality... They don't want to call the attendings, but will call residents on the most inane questions sometimes. I don't know how many of these I've gotten on call that started with, "I was just looking through the chart...".

 

[Jolie South]

Unfortunately, it's part of the academic center mentality... They don't want to call the attendings, but will call residents on the most inane questions sometimes. I don't know how many of these I've gotten on call that started with, "I was just looking through the chart...".

Or at 2 am:

“I was just cleaning up the orders...”

 

[HighPriest]

Zero-dark thirty, on “home call” for chief service for multiple hospitals. One of the hospitals I’m sometimes on for has an attending doing call this night who doesn’t work with residents, so the calls should be going to him.

Hospitalist: “Yes, I’m calling you to come put an art line in my patient. “
Me: “I don’t have an attending to staff it, you’ll have to call Dr Nores tonight.”
Hospitalist: “He doesn’t have residents, I can’t call and wake him up. He won’t come in for an art line.”
Me: “...... I don’t have staff there. You can call Nores or another private attending or the in house anesthesiologist, or do it yourself.”
Hospitalist: Proceeds to argue that he can’t call anyone else because they are attendings and asleep. (Doesn’t tell me why he can’t do it himself tho...In my opinion, if you’re the in house ICU coverage you should probably be able to do your own lines.)

Memorable because I guess residents don’t need sleep. True dat.

The best part about it is that he new dang well the private doc wouldn’t come in and do it. Which means there have been times where he or someone in his situation had to do it themselves. But it was just easier for him to try to pressure you in to it. Because I guess there wasn’t anything else going on.
In later years, I may have been know to say “hey, don’t worry, I’ll walk you through how to do one over the phone. It’s not that hard.”

 

[Radetzky]

Zero-dark thirty, on “home call” for chief service for multiple hospitals. One of the hospitals I’m sometimes on for has an attending doing call this night who doesn’t work with residents, so the calls should be going to him.

Hospitalist: “Yes, I’m calling you to come put an art line in my patient. “
Me: “I don’t have an attending to staff it, you’ll have to call Dr Nores tonight.”
Hospitalist: “He doesn’t have residents, I can’t call and wake him up. He won’t come in for an art line.”
Me: “...... I don’t have staff there. You can call Nores or another private attending or the in house anesthesiologist, or do it yourself.”
Hospitalist: Proceeds to argue that he can’t call anyone else because they are attendings and asleep. (Doesn’t tell me why he can’t do it himself tho...In my opinion, if you’re the in house ICU coverage you should probably be able to do your own lines.)

Memorable because I guess residents don’t need sleep. True dat.

so what happens if the art line craps out? Does he call you back to come and replace it? Embarrassing.

 

[WinslowPringle]

The best part about it is that he new dang well the private doc wouldn’t come in and do it. Which means there have been times where he or someone in his situation had to do it themselves. But it was just easier for him to try to pressure you in to it. Because I guess there wasn’t anything else going on.
In later years, I may have been know to say “hey, don’t worry, I’ll walk you through how to do one over the phone. It’s not that hard.”

Exactly.
I like your approach, will have to try it....

so what happens if the art line craps out? Does he call you back to come and replace it? Embarrassing.

Yes. I’d be the one to replace or manipulate it as needed any time of day or night.
.....Upside is, I’ve gotten good and fast at any sort of line...

 

[aSagacious]

Not exactly a consult, but in the spirit of the thread...

For the lulz I often enjoy reading the medicine progress notes for mutual patients.

Patient with a newly diagnosed endobronchial carcinoid presenting with hemoptysis. Goes to IR for empiric bronchial artery embolization (palliation prior to return for elective surgery). Medicine note (MICU attending) reads, "underwent catheter directed thrombolysis of the tumor's feeding pulmonary artery." Yuuuup something like that. And that's probably gonna make it to the d/c summary.

 

[LucidSplash]

ED: Hi I have a consult for you.
Me: Ok.
ED: I have a Middle-aged woman that had the hood of car fall on the dorsal aspect of her arm. She has an abrasion and a bruise. She is complaining of Some numbness in the forearm. I have Xrays that are negative. She has a palpable radial pulse, I couldn’t feel an ulnar but she has a Doppler signal. She says her hand feels a little cool so I got a CTA.
Me: <Reviewed CTA before calling back> All the vessels are intact with inline flow. There’s no extravasation. And you have a palpable pulse. Is her hand pink?
ED: Yes. But I can only Doppler the ulnar and she says her hand is cold.
Me: Yes but you have a study that shows that her flow is inline to the hand, all the vessels are intact, you have a palpable pulse, her hand is pink, you are telling me she does not have a crush injury to the hand, only a bruise on the forearm, and her only symptom is numbness. As vascular I don’t have any skills that will assist you.
ED: Ok, any ideas of who else I should call?
Me: Not my area.

 

[dpmd]

ED: Hi I have a consult for you.
Me: Ok.
ED: I have a Middle-aged woman that had the hood of car fall on the dorsal aspect of her arm. She has an abrasion and a bruise. She is complaining of Some numbness in the forearm. I have Xrays that are negative. She has a palpable radial pulse, I couldn’t feel an ulnar but she has a Doppler signal. She says her hand feels a little cool so I got a CTA.
Me: <Reviewed CTA before calling back> All the vessels are intact with inline flow. There’s no extravasation. And you have a palpable pulse. Is her hand pink?
ED: Yes. But I can only Doppler the ulnar and she says her hand is cold.
Me: Yes but you have a study that shows that her flow is inline to the hand, all the vessels are intact, you have a palpable pulse, her hand is pink, you are telling me she does not have a crush injury to the hand, only a bruise on the forearm, and her only symptom is numbness. As vascular I don’t have any skills that will assist you.
ED: Ok, any ideas of who else I should call?
Me: Not my area.

Outpatient hand if her numbness fails to improve in 6 weeks? And give the poor lady a warm blanket for her hand.

 

[OnePunchBiopsy]

General Surgery

Got a page from a medicine PA (bypassing my intern) to assess a patient's neck after central line placement.

**Goes to bedside, scared of neck hematoma**

Patient is sitting up, eating.
Neck looks great.
Sterile line (placed by Radiology 1 hour ago) running well. Literally nothing wrong with it.
No one from the IM team around.

I page the PA for explanation
No Answer
Pages IM attending (no residents for this particular patient)

IM Attending: "Oh yeah, my PA said the nurse saw that the line was crooked, so I had her page surgery to put a stitch in it."

Never assessed the line themselves, never told the patient she was calling surgery, never called Radiology (who placed the line), and expected me to takedown a sterile dressing to throw in a stitch for a line that was working and looked fine.

 

[HighPriest]

ED: Hi I have a consult for you.
Me: Ok.
ED: I have a Middle-aged woman that had the hood of car fall on the dorsal aspect of her arm. She has an abrasion and a bruise. She is complaining of Some numbness in the forearm. I have Xrays that are negative. She has a palpable radial pulse, I couldn’t feel an ulnar but she has a Doppler signal. She says her hand feels a little cool so I got a CTA.
Me: <Reviewed CTA before calling back> All the vessels are intact with inline flow. There’s no extravasation. And you have a palpable pulse. Is her hand pink?
ED: Yes. But I can only Doppler the ulnar and she says her hand is cold.
Me: Yes but you have a study that shows that her flow is inline to the hand, all the vessels are intact, you have a palpable pulse, her hand is pink, you are telling me she does not have a crush injury to the hand, only a bruise on the forearm, and her only symptom is numbness. As vascular I don’t have any skills that will assist you.
ED: Ok, any ideas of who else I should call?
Me: Not my area.

You should call no one. Put on your big boy pants and tell the patient they're fine. Liability is not a hot potato. And in any case, you can now say in your note that a vascular surgeon told you they wouldn't see this poor patient even though you tried to be her advocate.

 

[LucidSplash]

They admitted her and the hospitalist consulted me this am.

 

[HighPriest]

They admitted her and the hospitalist consulted me this am.

Of course they did.

 

[TraumaLlamaMD]

They admitted her and the hospitalist consulted me this am.

I suggest neurology consult for a stat EMG

 

[Jolie South]

I have a patient in house for a few things that general surgery and I have operated on, including cancer. Patient develops a brachial DVT from a PICC line. I suggest he be anticoagulated and that we can choose between lovenox or DOAC.

Patient says outright he will not do lovenox and I think DOAC is reasonable.

Get a call from a medicine intern saying “DOACs have no proven efficacy in brachial DVT. We need to use lovenox.”

You know what has low efficacy? The patient not taking the lovenox he was prescribed.

He then documents being forced to prescribe DOAC against his will.

 

[Raryn]

I have a patient in house for a few things that general surgery and I have operated on, including cancer. Patient develops a brachial DVT from a PICC line. I suggest he be anticoagulated and that we can choose between lovenox or DOAC.

Patient says outright he will not do lovenox and I think DOAC is reasonable.

Get a call from a medicine intern saying “DOACs have no proven efficacy in brachial DVT. We need to use lovenox.”

You know what has low efficacy? The patient not taking the lovenox he was prescribed.

He then documents being forced to prescribe DOAC against his will.

There are two kinds of people on this planet

1) Those who can extrapolate from incomplete data
2)

 

[akwho]

ED: Hi I have a consult for you.
Me: Ok.
ED: I have a Middle-aged woman that had the hood of car fall on the dorsal aspect of her arm. She has an abrasion and a bruise. She is complaining of Some numbness in the forearm. I have Xrays that are negative. She has a palpable radial pulse, I couldn’t feel an ulnar but she has a Doppler signal. She says her hand feels a little cool so I got a CTA.
Me: <Reviewed CTA before calling back> All the vessels are intact with inline flow. There’s no extravasation. And you have a palpable pulse. Is her hand pink?
ED: Yes. But I can only Doppler the ulnar and she says her hand is cold.
Me: Yes but you have a study that shows that her flow is inline to the hand, all the vessels are intact, you have a palpable pulse, her hand is pink, you are telling me she does not have a crush injury to the hand, only a bruise on the forearm, and her only symptom is numbness. As vascular I don’t have any skills that will assist you.
ED: Ok, any ideas of who else I should call?
Me: Not my area.

The ER should need to have CTA's approved by a higher power prior to ordering them. Whats the indication for CTA in blunt trauma with perfused hand and dopplerable pulse? Crazy to irradiate patient and expose their kidneys to contrast for info that can be gained on physical exam.

Our ER orders CTA's on legs where the femur or tibia look like an "L." Of course you can't feel a pulse, the vessels are occluded since the leg is sideways. We always ask them to page ortho prior to CTA. Yet time and time again we get paged after a worthless pre-reduction CTA is obtained.

Ddx for forearm numbness after blunt trauma = contusion or compartment syndrome, only one of them is an emergency and neither need CTA or vascular consult.

 

[HighPriest]

The ER should need to have CTA's approved by a higher power prior to ordering them. Whats the indication for CTA in blunt trauma with perfused hand and dopplerable pulse? Crazy to irradiate patient and expose their kidneys to contrast for info that can be gained on physical exam.

Our ER orders CTA's on legs where the femur or tibia look like an "L." Of course you can't feel a pulse, the vessels are occluded since the leg is sideways. We always ask them to page ortho prior to CTA. Yet time and time again we get paged after a worthless pre-reduction CTA is obtained.

Ddx for forearm numbness after blunt trauma = contusion or compartment syndrome, only one of them is an emergency and neither need CTA or vascular consult.

Almost like getting called to come do a "slash trach" on an unconscious MI patient they can't seem to intubate orally and you get there and he's had a laryngectomy. It's somewhat surprising how often that sort of thing comes up.

I mean, I guess its good that they don't try to trach him themselves. Silver lining.

When I was a med student, a guy came in to the ER having been between two traincars when they were linking. He was knocked over and the train ran over both legs. His legs were twisted around at least 1.5 times just below the knees. His co-workers actually brought his kneecaps in with them in their Gatorade cooler. The ER staff spent at least 20 minutes looking for pedal pulses. Got a doppler. Everything. Now that you mention it (I haven't thought about it in years) that seems pretty dumb. I mean, if you feel them you're probably wrong. If you don't, you know why. And either way it probably doesn't matter. I don't think they did an angio, however. Can't recall for sure.

 

[ThoracicGuy]

Almost like getting called to come do a "slash trach" on an unconscious MI patient they can't seem to intubate orally and you get there and he's had a laryngectomy. It's somewhat surprising how often that sort of thing comes up.

I mean, I guess its good that they don't try to trach him themselves. Silver lining.

When I was a med student, a guy came in to the ER having been between two traincars when they were linking. He was knocked over and the train ran over both legs. His legs were twisted around at least 1.5 times just below the knees. His co-workers actually brought his kneecaps in with them in their Gatorade cooler. The ER staff spent at least 20 minutes looking for pedal pulses. Got a doppler. Everything. Now that you mention it (I haven't thought about it in years) that seems pretty dumb. I mean, if you feel them you're probably wrong. If you don't, you know why. And either way it probably doesn't matter. I don't think they did an angio, however. Can't recall for sure.

So did they save the legs?

 

[HighPriest]

So did they save the legs?

Nossir. Unless you mean "as a memento" and then I don't know.

 

[Dr.LeoSpaceman]

Whats the indication for CTA in blunt trauma with perfused hand and dopplerable pulse?

Not to be pedantic, but it's brachial/brachial index <= 0.9. Though your point stands in that there's actually evidence-based approaches to ordering diagnostic imaging. On the flip side if there was a true traumatic injury and the intern only told me it looked perfused and had a signal, I wouldn't consider that to be sufficient information.

 

[Apollyon]

Not to be pedantic, but it's brachial/brachial index <= 0.9. Though your point stands in that there's actually evidence-based approaches to ordering diagnostic imaging. On the flip side if there was a true traumatic injury and the intern only told me it looked perfused and had a signal, I wouldn't consider that to be sufficient information.

Isn't it "ankle brachial index"? Or is brachial brachial something different? (Sincere, not trolling)

 

[Jolie South]

Got a consult this morning for “cold leg, pedal pulses less strong than contraleral with leg pain”

Pt has cold legs. But has bounding pulses. Never had leg pain before and describes sciatica/lumbar spine disease type pain. CTA not perfect but shows perfusion. Wtf do you want me to do?