Consults- Memorable/Dismal/Ridiculous/Unique

[ThoracicGuy]

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?

Order some socks?

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[Raryn]

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

I think brachial-brachial is just comparing the one UE to the other.

 

[akwho]

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.

Brachial-brachial index isn't going to tell you much if it's the forearm that's injured as the brachial artery is proximal to the zone of injury. Additionally serial exams with pulses and a well perfused hand is more reassuring than a one time brachial-brachial index. The choice in this situation is put them in observation for serial examinations vs discharge with followup. CTA was never going to be a helpful part of the diagnostic algorithm - the odds of finding a vascular injury that would require intervention in a trunk closing on an arm type of situation is just so minisicule.

@Jolie South can pitch in and say what they think about utility of brachial-brachal index and CTA in this scenario.

 

[HighPriest]

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?

Reassure the patient and assume responsibility in the chance that something does go wrong, however unlikely.

 

[LucidSplash]

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.

To be clear, I’m not personally debating getting the CTA. The radial pulse was palpable and I personally wouldn’t have ordered it. I might have considered a PVR with WBI. I don’t think a brachial-brachial is at all useful in a forearm injury. But I’m the specialist not the ED doc and I get that they aren’t necessarily educated on the specialty-specific non-invasive testing and have easy access to a CT scanner at all hours.

But I truly have nothing to offer once you have The combination of a study showing no vascular injury and inline flow, a normal vascular exam (not terribly uncommon to have a non-palpable ulnar, lots of people are radial dominant), and a perfused hand.

 

[LucidSplash]

@Jolie South can pitch in and say what they think about utility of brachial-brachal index and CTA in this scenario.

You know, or me, who was the original person to post about it and is also a vascular surgeon like @Jolie South.

 

[dpmd]

You know, or me, who was the original person to post about it and is also a vascular surgeon like @Jolie South.

But you are just a girl

 

[akwho]

You know, or me, who was the original person to post about it and is also a vascular surgeon like @Jolie South.

Lol misremember'd who posted originally, sorry for not @'ing you in my post above.

Don't know or care about any of the poster's gender's here, hence the use of 'they' in my post above.

 

[Jolie South]

To be clear, I’m not personally debating getting the CTA. The radial pulse was palpable and I personally wouldn’t have ordered it. I might have considered a PVR with WBI. I don’t think a brachial-brachial is at all useful in a forearm injury. But I’m the specialist not the ED doc and I get that they aren’t necessarily educated on the specialty-specific non-invasive testing and have easy access to a CT scanner at all hours.

But I truly have nothing to offer once you have The combination of a study showing no vascular injury and inline flow, a normal vascular exam (not terribly uncommon to have a non-palpable ulnar, lots of people are radial dominant), and a perfused hand.

I don’t think a CTA was a bad idea. If I didn’t have a reliable vascular tech available, I would have done one too to look for an intimal flap.

I think it’s easier than several hours obs.

What I do disagree with is getting a normal study with a normal exam and you saying dc the patient, that the patient got admitted and you got consulted again.

A lot of times when ER/medicine orders CTA when I would have just gotten a duplex, I actually appreciate it bc I have anatomic information that can help me plan the case (stent sizing, exact location of stenosis in iliacs, bony landmarks in relation to injury, etc). Some people get really bent out of shape about “why did you order it? It’s unnecessary.” I am for reducing radiation/contrast but one CTA won’t kill anyone or push them into renal failure.

I think CTAs also give ER doctors peace of mind because the read doesn’t leave as much up to interpretation as an ultrasound does.

 

[Jolie South]

But you are just a girl

But I am also a girl.

 

[dpmd]

But I am also a girl.

Hah! We are taking over aren't we

 

[Dr.LeoSpaceman]

Brachial-brachial index isn't going to tell you much if it's the forearm that's injured as the brachial artery is proximal to the zone of injury. Additionally serial exams with pulses and a well perfused hand is more reassuring than a one time brachial-brachial index. The choice in this situation is put them in observation for serial examinations vs discharge with followup. CTA was never going to be a helpful part of the diagnostic algorithm - the odds of finding a vascular injury that would require intervention in a trunk closing on an arm type of situation is just so minisicule.

Well, considering BBI in this setting is, by definition, completed by taking the pressure below the site of injury, it certainly can be used.

And sure, the chance of finding injury is small. But that's not the point of a trauma evaluation. It's about ruling out the life/limb threatening injuries. A BBI has a specificity of 97% for vascular injuries detected on CTA, and is therefore the appropriate choice to exclude such injuries (in the setting of a trauma evaluation). So unless admission, observation, and serial exams is better than that, I disagree with you.

As for this situation, I make no comment on the appropriatness of the CTA. You presented a hypothetical. In said hypothetical ("Whats the indication for CTA in blunt trauma with perfused hand and dopplerable pulse?"), BBI is appropriate.

 

[dpmd]

Well, considering BBI in this setting is, by definition, completed by taking the pressure below the site of injury, it certainly can be used.

And sure, the chance of finding injury is small. But that's not the point of a trauma evaluation. It's about ruling out the life/limb threatening injuries. A BBI has a specificity of 97% for vascular injuries detected on CTA, and is therefore the appropriate choice to exclude such injuries (in the setting of a trauma evaluation). So unless admission, observation, and serial exams is better than that, I disagree with you.

As for this situation, I make no comment on the appropriatness of the CTA. You presented a hypothetical. In said hypothetical ("Whats the indication for CTA in blunt trauma with perfused hand and dopplerable pulse?"), BBI is appropriate.

Wouldn't it then be radial/radial index technically

 

[Dr.LeoSpaceman]

Wouldn't it then be radial/radial index technically

Radial Brachial Index is probably the right one (though not what's used, to my knowledge), or Arterial Pressure Index when using the Doppler. But I don't take responsibility for the naming convention.

 

[Jolie South]

Radial Brachial Index is probably the right one (though not what's used, to my knowledge), or Arterial Pressure Index when using the Doppler. But I don't take responsibility for the naming convention.

Taken from a 2017 BMJ article by Feliciano:
“Patients presenting with ‘soft’ signs of an arterial injury—history of bleeding at the scene or during transport, proximity of a penetrating wound or contusion/hematoma/fracture, a non-pulsatile hematoma or a neurologic deficit—underwent diagnostic imaging in the past. The historic yield on either emergency center arteriography performed by surgeons or formal arteriography performed in an interventional radiology suite for a ‘soft’ sign was under 4% to 5%.11 Various combinations of soft signs occasionally led to positive arteriograms in up to 13% to25% of patients, but the lesions diagnosed were non-occlusive, as expected, and were managed non-operatively over time as previously noted.2–4 12 13

The pitfall of overusing traditional imaging to rule out non-operative arterial injuries has been minimized in the past 25 years. This has been accomplished by the measurement of the ABI or BBI or arterial pressure index (API) in injured extremities for the past 25 years.14–16 Using the original cut-off of ≥0.9 as described by Johansen and Lynch, a patient with an ABI or API at this level is presumed to have a normal artery or one with a small non-occlusive lesion (intimal injury/intramural hematoma/small traumatic false aneurysm).14 Any lesion such as this is managed with observation and/or repeat imaging but not an operation.”

So, in essence, with brachial brachial index we rule out immediately operable lesions, but not intimal injury.

I would obs someone with intimal injury vs send someone without it home. So doing the extra imaging does have value to me.

I would rather completely see what is going on than have a patient go home with an intimal injury and later thrombose the artery and lose a limb, especially in the case of a young healthy person.

As a trauma surgeon who is a taking care of a multi system trauma patient who is likely going to be in house anyways, I think a non invasive index is a great way to triage your care.

As a vascular surgeon, I want to know about the intimal injury and ensure obs and close follow up if the mechanism is worrisome.

 

[WinslowPringle]

ED NP: “I got this guy you operated on a few days ago. He fell and has a bruise on his side...”
Me: “Ok...”
NP: “So, I got a CT, and the radiologist read out “post operative changes with ileo-colonic anastomosis.” “
Me: “Ok...?”
NP: “I was just calling to see what that meant. I mean, is that normal?”
Me: “He had a hemicolectomy 10years ago. I did an inguinal hernia. Typically “post operative changes” just refers to there being surgically altered anatomy. If you have concerns about the wording of the read, you need to call the radiologist.”
NP: “Well, I just wanted to know what it meant.”
Me: “It’s 0300, I’m at home and don’t have access to his images right now. I suggest that if you have concerns or questions about what the radiologist wrote, that you call the radiologist.”

.........

ED NP: “I need you to come take a look at this guy.He has gallstones and I can’t get his pain under control.”
Me: (Quick chart review...) “So, his labs and vitals are [perfectly normal]. There are zero signs of cholecystitis on the US. You have given 2mg morphine and his pain in chart is last listed as a five. This sounds like symptomatic cholelithiasis and I recommend he follow up in our clinic.”
NP: “But his pain isn’t controlled. I need you to see him.“
Me: “I can see him, but it will be a wait and I won’t tell you anything different.
NP: “You won’t admit and operate?”
Me: “Not emergently. He can follow up outpatient.”
NP:”So, basically you are just going to do nothing right now but wait for him to get sicker before you do something.”
Me: ......... “I recommend you give him toradol. And have him follow up outpatient.”

 

[LucidSplash]

ED NP: “I got this guy you operated on a few days ago. He fell and has a bruise on his side...”
Me: “Ok...”
NP: “So, I got a CT, and the radiologist read out “post operative changes with ileo-colonic anastomosis.” “
Me: “Ok...?”
NP: “I was just calling to see what that meant. I mean, is that normal?”
Me: “He had a hemicolectomy 10years ago. I did an inguinal hernia. Typically “post operative changes” just refers to there being surgically altered anatomy. If you have concerns about the wording of the read, you need to call the radiologist.”
NP: “Well, I just wanted to know what it meant.”
Me: “It’s 0300, I’m at home and don’t have access to his images right now. I suggest that if you have concerns or questions about what the radiologist wrote, that you call the radiologist.”

.........

ED NP: “I need you to come take a look at this guy.He has gallstones and I can’t get his pain under control.”
Me: (Quick chart review...) “So, his labs and vitals are [perfectly normal]. There are zero signs of cholecystitis on the US. You have given 2mg morphine and his pain in chart is last listed as a five. This sounds like symptomatic cholelithiasis and I recommend he follow up in our clinic.”
NP: “But his pain isn’t controlled. I need you to see him.“
Me: “I can see him, but it will be a wait and I won’t tell you anything different.
NP: “You won’t admit and operate?”
Me: “Not emergently. He can follow up outpatient.”
NP:”So, basically you are just going to do nothing right now but wait for him to get sicker before you do something.”
Me: ......... “I recommend you give him toradol. And have him follow up outpatient.”

It is frequently hard to convince non-surgeons that “pain under control” does not mean “zero pain.”

 

[dpmd]

ED NP: “I got this guy you operated on a few days ago. He fell and has a bruise on his side...”
Me: “Ok...”
NP: “So, I got a CT, and the radiologist read out “post operative changes with ileo-colonic anastomosis.” “
Me: “Ok...?”
NP: “I was just calling to see what that meant. I mean, is that normal?”
Me: “He had a hemicolectomy 10years ago. I did an inguinal hernia. Typically “post operative changes” just refers to there being surgically altered anatomy. If you have concerns about the wording of the read, you need to call the radiologist.”
NP: “Well, I just wanted to know what it meant.”
Me: “It’s 0300, I’m at home and don’t have access to his images right now. I suggest that if you have concerns or questions about what the radiologist wrote, that you call the radiologist.”

.........

ED NP: “I need you to come take a look at this guy.He has gallstones and I can’t get his pain under control.”
Me: (Quick chart review...) “So, his labs and vitals are [perfectly normal]. There are zero signs of cholecystitis on the US. You have given 2mg morphine and his pain in chart is last listed as a five. This sounds like symptomatic cholelithiasis and I recommend he follow up in our clinic.”
NP: “But his pain isn’t controlled. I need you to see him.“
Me: “I can see him, but it will be a wait and I won’t tell you anything different.
NP: “You won’t admit and operate?”
Me: “Not emergently. He can follow up outpatient.”
NP:”So, basically you are just going to do nothing right now but wait for him to get sicker before you do something.”
Me: ......... “I recommend you give him toradol. And have him follow up outpatient.”

If they hurt bad and long enough to come to the er about it i prefer to just get their gallbladder out. Plus, most of the time the ultrasound says normal wall thickness I find an inflamed gallbladder so I don't really trust our ultrasonagraphers here.

 

[Jolie South]

If they hurt bad and long enough to come to the er about it i prefer to just get their gallbladder out. Plus, most of the time the ultrasound says normal wall thickness I find an inflamed gallbladder so I don't really trust our ultrasonagraphers here.

That was my philosophy in residency. Take it out and can’t get calls about it again. The times we tried to manage with pain control, they would just come back again. Waste of everyone’s time.

 

[dpmd]

That was my philosophy in residency. Take it out and can’t get calls about it again. The times we tried to manage with pain control, they would just come back again. Waste of everyone’s time.

Not to mention how many times I get called a couple days after a patient like described above (though sometimes they also have a mildly elevated WBC that was blown off) was sent home because they are back in the er but now with gallstone pancreatitis, choledocholithiasis, or a gangrenous gallbladder.

 

[WinslowPringle]

If they hurt bad and long enough to come to the er about it i prefer to just get their gallbladder out. Plus, most of the time the ultrasound says normal wall thickness I find an inflamed gallbladder so I don't really trust our ultrasonagraphers here.

If only there were ORs enough and time.....
this particular call came on Charity Coverage - one resident, two hospitals and all the EMTALA/no insurance or no PCP or no prior surgeon call for the city in addition to clinic and scheduled outpatient cases. To do this gallbladder the patient would have been admitted for minimum two days prior to surgery. That really would have been a waste of everyone’s time. I reviewed the labs and imaging and labs were probably more normal than mine and the US was technically adequate with a nice thin wall, no fluid, etc. I wish I could’ve taken it out same or next day - a nice outpatient gallbladder would’ve been much more fun than the dead bowel ex laps and the sick geriatrics that family wants everything done for I was dealing with.

Good news is the pt did fine - toradol helped, the biliary colic was just biliary colic and the pt was able to follow up later for a nice outpatient surgery. The consult was mainly memorable bc the NP was insistent that a pain of “five” after a touch or morphine was uncontrolled pain; and she was snippy about not getting an easy admit. (She had talked to me several times that morning and I had already straight-up admitted 3 patients for legit cholecystitis so she probably thought this would be another easy dispo.)

 

[dpmd]

If only there were ORs enough and time.....
this particular call came on Charity Coverage - one resident, two hospitals and all the EMTALA/no insurance or no PCP or no prior surgeon call for the city in addition to clinic and scheduled outpatient cases. To do this gallbladder the patient would have been admitted for minimum two days prior to surgery. That really would have been a waste of everyone’s time. I reviewed the labs and imaging and labs were probably more normal than mine and the US was technically adequate with a nice thin wall, no fluid, etc. I wish I could’ve taken it out same or next day - a nice outpatient gallbladder would’ve been much more fun than the dead bowel ex laps and the sick geriatrics that family wants everything done for I was dealing with.

Good news is the pt did fine - toradol helped, the biliary colic was just biliary colic and the pt was able to follow up later for a nice outpatient surgery. The consult was mainly memorable bc the NP was insistent that a pain of “five” after a touch or morphine was uncontrolled pain; and she was snippy about not getting an easy admit. (She had talked to me several times that morning and I had already straight-up admitted 3 patients for legit cholecystitis so she probably thought this would be another easy dispo.)

In med school the list for elective procedures was very long and so few got done any given operative day that in all likelihood that two days of sitting there would be less than how many times they would be in the er (assuming no more complicated episode brought them in) so the waste of time for patient and er would be less by wasting a bed on them on our service. But if you guys are actually able to get the elective stuff done then that is great. Luckily I can get people on the next day pretty easily (i don't do them same day unless I get the call early enough) so I am pretty generous with who I will let come in though I will tell the er when I am slammed and it will likely have to wait an extra day so they can give the patient the option if insured.

 

[deleted50541]

NP:”So, basically you are just going to do nothing right now but wait for him to get sicker before you do something.”
Me: ......... “I recommend you give him toradol. And have him follow up outpatient.”

I absolutely cringe when I hear something like that over the phone. That's when I know I need to choose my next words carefully or they'll end up dictating something like "spoke to on-call surgeon and expressed concerns about current patient's condition...surgeon not concerned." Completely missed the point of probably the 10-15 minutes I just spent talking with them.

 

[Jolie South]

In med school the list for elective procedures was very long and so few got done any given operative day that in all likelihood that two days of sitting there would be less than how many times they would be in the er (assuming no more complicated episode brought them in) so the waste of time for patient and er would be less by wasting a bed on them on our service. But if you guys are actually able to get the elective stuff done then that is great. Luckily I can get people on the next day pretty easily (i don't do them same day unless I get the call early enough) so I am pretty generous with who I will let come in though I will tell the er when I am slammed and it will likely have to wait an extra day so they can give the patient the option if insured.

I did residency at a county facility so a lot of patients were uninsured. All call general surgeons got a post call block so there was always OR time available to add them on.

However, I did my intern year at a different program and people would be waiting a week+ sometimes for their chole. Would make them all NPO every morning just in case. But if they got discharged no way they would ever have surgery.

 

[LucidSplash]

Speaking of gallbags, one of my best friends is having attacks again. She has stones but modified her diet before and hasn’t had an attack in months. She had another ultrasound today.

We have a girls trip planned (cruise) in March and I’m screaming “get it out so you can eat all the food and drink all the booze!” I told her it belonged in a bucket no matter what the ultrasound said.

 

[WinslowPringle]

I did residency at a county facility so a lot of patients were uninsured. All call general surgeons got a post call block so there was always OR time available to add them on.

However, I did my intern year at a different program and people would be waiting a week+ sometimes for their chole. Would make them all NPO every morning just in case. But if they got discharged no way they would ever have surgery.

A post-call block is a really good idea...

 

[doyouhaveaflag]

Got a call from one of the ED NPs at about 2am recently. Patient had an abdominoplasty in Miami (nowhere near where I'm in residency) five days ago and had come in to get her drains pulled. Apparently she had experimented in medical tourism and her surgeon there had literally told her that her follow up plan should be to present to whatever ED was near her home to get her drains pulled when the output was low. Appalling! I asked, as a matter of interest, how much her drains had been putting out and apparently she hadn't been recording it.

I told them to have her follow up in our cosmetic clinic during the daytime and to please record how much her drains are actually putting out. Someone should have words with her surgeon about appropriate surgical aftercare.

 

[dpmd]

Got a call from one of the ED NPs at about 2am recently. Patient had an abdominoplasty in Miami (nowhere near where I'm in residency) five days ago and had come in to get her drains pulled. Apparently she had experimented in medical tourism and her surgeon there had literally told her that her follow up plan should be to present to whatever ED was near her home to get her drains pulled when the output was low. Appalling! I asked, as a matter of interest, how much her drains had been putting out and apparently she hadn't been recording it.

I told them to have her follow up in our cosmetic clinic during the daytime and to please record how much her drains are actually putting out. Someone should have words with her surgeon about appropriate surgical aftercare.

I would say there is a greater than 50% chance that is not actually what she was told to do by the surgeon. I get misquoted by patients who go to the er more often than they give the real story (usually that I reassured them over the phone and recommended that they come to clinic unless x, y, z occurs in which case then they can go to the er, but they weren't convinced so decided to come to the er even though x,y,z did not occur)

 

[TraumaLlamaMD]

I would say there is a greater than 50% chance that is not actually what she was told to do by the surgeon. I get misquoted by patients who go to the er more often than they give the real story (usually that I reassured them over the phone and recommended that they come to clinic unless x, y, z occurs in which case then they can go to the er, but they weren't convinced so decided to come to the er even though x,y,z did not occur)

I have had multiple versions of this patient where cosmetic surgery was done in Mexico (Miami is also a big one), and the patient showed up to our ER for drain care/suture removal/infection. I do think when the patient obviously lives somewhere far away from the surgeon, unless you explicitly confirm with them that they’ll be staying in town for their followup care, or make an arrangement with a local doctor back home, you should expect this is what’s going to happen. And apparently there are a lot of surgeons out there who are just fine with this arrangement.

 

[dpmd]

I have had multiple versions of this patient where cosmetic surgery was done in Mexico (Miami is also a big one), and the patient showed up to our ER for drain care/suture removal/infection. I do think when the patient obviously lives somewhere far away from the surgeon, unless you explicitly confirm with them that they’ll be staying in town for their followup care, or make an arrangement with a local doctor back home, you should expect this is what’s going to happen. And apparently there are a lot of surgeons out there who are just fine with this arrangement.

Cosmetics people seem shadier than the rest of us which was why I didn't say 80% chance that wasn't what they said. I was just factoring in people misrepresenting stuff. Maybe to the surgeon (sure doc I will come to you for follow up) or to you guys. Don't know if it is intentional or if they just don't understand what we say sometimes..

 

[Smurfette]

Got a call from one of the ED NPs at about 2am recently. Patient had an abdominoplasty in Miami (nowhere near where I'm in residency) five days ago and had come in to get her drains pulled. Apparently she had experimented in medical tourism and her surgeon there had literally told her that her follow up plan should be to present to whatever ED was near her home to get her drains pulled when the output was low. Appalling! I asked, as a matter of interest, how much her drains had been putting out and apparently she hadn't been recording it.

I told them to have her follow up in our cosmetic clinic during the daytime and to please record how much her drains are actually putting out. Someone should have words with her surgeon about appropriate surgical aftercare.

I have had multiple versions of this patient where cosmetic surgery was done in Mexico (Miami is also a big one), and the patient showed up to our ER for drain care/suture removal/infection. I do think when the patient obviously lives somewhere far away from the surgeon, unless you explicitly confirm with them that they’ll be staying in town for their followup care, or make an arrangement with a local doctor back home, you should expect this is what’s going to happen. And apparently there are a lot of surgeons out there who are just fine with this arrangement.

I recently had a patient call my office for drain removal after having a butt lift procedure in Mexico. She was told to see a surgeon back home for drain removal.
My office staff thankfully checked with me before putting her in my schedule; I refused to see her. Unless it's an emergency, I'm not willing to deal with sketchy surgeon clean-up aftermath.

When I have a patient from out of town who needs follow up in their home town, I'm always willing to talk to the local surgeon and send any relevant documentation to ensure the patient gets care.

 

[Dr.LeoSpaceman]

Unless it's an emergency, I'm not willing to deal with sketchy surgeon clean-up aftermath.

I find "Don't make someone else's problem your problem." to be axiomatic. It fits in any number of situations.

 

[HighPriest]

So this kind of thing actually happens to me a lot, seeing as we do some cosmetics (I personally don't do much. maybe an otoplasty here and there).

I get patients in the ER or just walking in to clinic asking to be seen for post op care, or because they're unhappy with their results (when they had surgery, say, three days ago in some other city.)

I find this happens for a number of reasons.

Definitely there are shady-@$$ cosmetic surgeons out there. Some of them frankly don't care what happens after patients leave their office. I think there are guys out there who bank on the idea that if a patient isn't happy they just don't come back. Of course, there's some risk therein legally, but it's hard to sue for a poor cosmetic result unless the surgeon just totally botches things.

When I lived in El Paso, we would see tons of people who were treated in Mexico and then came up for aftercare. I'd actually have guys show up after dental work to see me for follow up (because their insurance would pay to see an ENT, but not for a dentist). So they'd get their molars pulled in Juarez, dodge a few bullets, and see me for follow up so that I could tell them that I have no idea how to treat a dry socket.

A lot of cosmetic patients are (*&king crazy. That's the primary reason why I don't do cosmetics, even though I did a ton in residency. I feel totally comfortable doing cosmetic rhinoplasty, I did something like 170 in residency, but I don't do them because there are only three kinds of patients: normal people wanting a reasonable result, people who are never going to be happy no matter what you do, and absolutely bat$#!t, thermonuclear crazy. And I know that cosmetic surgeons will tell you that you "just have to avoid" the latter patients, but I would argue that your ability to do so depends upon your personal threshold for what is or isn't bat$#!t crazy. And I have found there to be a relative paucity of people in group 1. Also, I don't like feeling like a used car salesman, but that's another thing entirely.

So, no matter what you tell those patients, they'll do whatever insane thing crosses their mind whenever it crosses their mind. This is often the patient showing up in the ER and demanding post-op care. I had a woman not 6 months ago show up at my office demanding to be seen. She had a facelift literally 72 hours ago by a surgeon no more than 45 minutes away, but she didn't want to drive to his office for follow up. She told us that he was refusing to see her. He wasn't. We called and asked him if this was normal post op care, and he wasn't aware that she wanted to be seen at all. It is possible someone in his office other than the surgeon had told her she couldn't be seen. But I have within the last year had a different facelift patient show up in the ER just to have her incisions checked. At 3am.

It's not at all uncommon to have a patient come in stating that they just want to breathe better through their nose. And they'll deny that they've ever had surgery. And when you do an exam, there's a rhinoplasty scar. And when you ask them about it, they'll say "oh, yeah, I forgot. I had nasal surgery in Toledo, OH about 15 years ago after I broke my nose." You ask for the doc's name in Toledo, and they'll forget what it was. Then you tell them that you might not want to operate on them without a surgical history, and they'll suddenly remember. Then you'll get those records and find out they had a purely cosmetic procedure, and that it wasn't the first one. And the Toledo doc has records from a guy in New York and the New York guy has records from a guy in San Francisco. And you realize that she's only in to see you because she's already had surgery by the top ten list all across the country, and you're her backup fix. And BTW, she thinks she'll breathe better if you could just reduce the size of her nose a little more.....

 

[armybound]

Got a call from one of the ED NPs at about 2am recently. Patient had an abdominoplasty in Miami (nowhere near where I'm in residency) five days ago and had come in to get her drains pulled. Apparently she had experimented in medical tourism and her surgeon there had literally told her that her follow up plan should be to present to whatever ED was near her home to get her drains pulled when the output was low. Appalling! I asked, as a matter of interest, how much her drains had been putting out and apparently she hadn't been recording it.

I told them to have her follow up in our cosmetic clinic during the daytime and to please record how much her drains are actually putting out. Someone should have words with her surgeon about appropriate surgical aftercare.

there was a "men's clinic" where I did residency who had a very lucrative cash-pay business for erectile dysfunction injections. the risk of priapism isn't terribly high, but is very real with these injections.

their instructions to the patients were to show up at our hospital if they had priapism, because we had residents and we knew how to take care of it. we were told this by several patients. guess they ddin't have time to deal with their own complications.

 

[HighPriest]

there was a "men's clinic" where I did residency who had a very lucrative cash-pay business for erectile dysfunction injections. the risk of priapism isn't terribly high, but is very real with these injections.

their instructions to the patients were to show up at our hospital if they had priapism, because we had residents and we knew how to take care of it. we were told this by several patients. guess they ddin't have time to deal with their own complications.

Too busy counting money. No time.

 

[DoctwoB]

there was a "men's clinic" where I did residency who had a very lucrative cash-pay business for erectile dysfunction injections. the risk of priapism isn't terribly high, but is very real with these injections.

their instructions to the patients were to show up at our hospital if they had priapism, because we had residents and we knew how to take care of it. we were told this by several patients. guess they ddin't have time to deal with their own complications.

In my city too. And they never seemed to take the time to titrate up their dose.

 

[Apollyon]

In my city too. And they never seemed to take the time to titrate up their dose.

Dude, when Viagra came out, guys on NTG were told there was a 1 in 3 chance of having a fatal MI. Literal millions of guys took that chance. When a man is looking to "get some", that titration is zero to 100.

 

[MediCane2006]

Cosmetics people seem shadier than the rest of us which was why I didn't say 80% chance that wasn't what they said. I was just factoring in people misrepresenting stuff. Maybe to the surgeon (sure doc I will come to you for follow up) or to you guys. Don't know if it is intentional or if they just don't understand what we say sometimes..

I can imagine it's probably a decent percentage of patients who just don't have the desire or ability to follow up with their surgeons when they have gone far from home to have surgery. I always got the "my doc said to just go to a local surgeon" excuse as well but I would like to believe that most surgeons are better than that.

The "severe complication after a discount breast aug/tummy tuck/butt lift in a foreign country in a completely uninsured patient" was distressingly common when I had my adult practice at the university hospital...

 

[cpants]

In my city too. And they never seemed to take the time to titrate up their dose.

+1. Happened in my city too. Report them to the medical board every time this happens. Made our "Men's clinic" staffed by a non-board certified (in anything) doc go away pretty fast.

 

[HighPriest]

I don't mind following up on someone else's patient if there's a good reason to do so. If someone comes to see you in another city, but they want to see me in post op, great. But it warrants a phone call at least to make sure I'm aware of it, that I get some information as to what was done and how it went, and so that I can respectfully decline to see the patient if I choose to do so. If you can't find anyone to take care of your patient post op, and you can't do it yourself, you probably shouldn't do the surgery - for anything routine at least.

 

[Dr.LeoSpaceman]

This one never gets old:

"Consult for suspected EC fistula". Go see the patient, they have a known mucous fistula.

 

[deleted50541]

With all the goings-on of this pandemic, trauma has definitely slowed down. But that hasn't stopped everyone from finding something stupid to do.

ED: "Hey, we got a guy here with a massive hemothorax. He's got some busted ribs and we think he lacerated an intercostal"
Me: "What happened?"
ED: "He mixed up and smoked his own concoction of meth/heroin/window caulking"
Me: "That's a new one. How'd he get the busted ribs?"
ED: "He fought the cops and lost. We've got him tubed and heavily sedated now, BP stable."
Me: "Perfect, I'll be right in."

Bleeding already stopped by the time I got to him. Quick VATS to wash out the retained clot and clip the offending vessel. He went off to jail yesterday.

 

[smq123]

With all the goings-on of this pandemic, trauma has definitely slowed down. But that hasn't stopped everyone from finding something stupid to do.

ED: "Hey, we got a guy here with a massive hemothorax. He's got some busted ribs and we think he lacerated an intercostal"
Me: "What happened?"
ED: "He mixed up and smoked his own concoction of meth/heroin/window caulking"
Me: "That's a new one. How'd he get the busted ribs?"
ED: "He fought the cops and lost. We've got him tubed and heavily sedated now, BP stable."
Me: "Perfect, I'll be right in."

Bleeding already stopped by the time I got to him. Quick VATS to wash out the retained clot and clip the offending vessel. He went off to jail yesterday.

Window caulking? That IS a new one....

 

[deleted547339]

With all the goings-on of this pandemic, trauma has definitely slowed down. But that hasn't stopped everyone from finding something stupid to do.

ED: "Hey, we got a guy here with a massive hemothorax. He's got some busted ribs and we think he lacerated an intercostal"
Me: "What happened?"
ED: "He mixed up and smoked his own concoction of meth/heroin/window caulking"
Me: "That's a new one. How'd he get the busted ribs?"
ED: "He fought the cops and lost. We've got him tubed and heavily sedated now, BP stable."
Me: "Perfect, I'll be right in."

Bleeding already stopped by the time I got to him. Quick VATS to wash out the retained clot and clip the offending vessel. He went off to jail yesterday.

Must be nice. People in my neck or the woods have gone on a stabbing spree. Also think there’s a gang way a la 1990s.

 

[doyouhaveaflag]

Must be nice. People in my neck or the woods have gone on a stabbing spree. Also think there’s a gang way a la 1990s.

Interesting there seem to be regional trends. People in my neck of the woods have gone on a do some PCP and break their face by jumping out a window/falling off a ladder/falling while evading cops/etc spree.

 

[deleted50541]

Must be nice. People in my neck or the woods have gone on a stabbing spree. Also think there’s a gang way a la 1990s.

Nice. Yeah, I was expecting more of an uptick from the combination alone of alcohol/drugs, boredom, and DIY home projects requiring power tools and step ladders.

 

[deleted547339]

Nice. Yeah, I was expecting more of an uptick from the combination alone of alcohol/drugs, boredom, and DIY home projects requiring power tools and step ladders.

Turns out gang bangers dont care much for social distancing, lol. Although I suppose you can shoot someone from more than 6 feet away.

 

[dpmd]

Turns out gang bangers dont care much for social distancing, lol. Although I suppose you can shoot someone from more than 6 feet away.

I would think that is the best way to do it.

 

[smq123]

I would think that is the best way to do it.

Is it? I mean, the average gang banger probably doesn’t have much gun training - not like he’s getting lessons at a shooting range from a professional. I imagine that the average gang banger’s aim gets exponentially worse with every foot of distance from his target.

 

[dpmd]

Is it? I mean, the average gang banger probably doesn’t have much gun training - not like he’s getting lessons at a shooting range from a professional. I imagine that the average gang banger’s aim gets exponentially worse with every foot of distance from his target.

Now I am imagining a gang program where they take new folks to the range and go over principles of firing.