Consults- Memorable/Dismal/Ridiculous/Unique

[smq123]

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

My spouse told me that he saw a lot of GSWs to the legs/pelvis/hips when he was a med student on his EM and radiology rotations.

Apparently, the kids in that area had guns, but were trying to shoot them by holding the gun sideways, like they do in the movies:

It is, as you can imagine, not easy to hit your target when you're holding a gun that way. The effort to shoot the gun would usually propel the nozzle downwards, resulting in a lot of shots to the knees/shins/ankles.

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[Yankauer]

My spouse told me that he saw a lot of GSWs to the legs/pelvis/hips when he was a med student on his EM and radiology rotations.

Apparently, the kids in that area had guns, but were trying to shoot them by holding the gun sideways, like they do in the movies:

View attachment 306259

It is, as you can imagine, not easy to hit your target when you're holding a gun that way. The effort to shoot the gun would usually propel the nozzle downwards, resulting in a lot of shots to the knees/shins/ankles.

 

[Matthew9Thirtyfive]

My spouse told me that he saw a lot of GSWs to the legs/pelvis/hips when he was a med student on his EM and radiology rotations.

Apparently, the kids in that area had guns, but were trying to shoot them by holding the gun sideways, like they do in the movies:

View attachment 306259

It is, as you can imagine, not easy to hit your target when you're holding a gun that way. The effort to shoot the gun would usually propel the nozzle downwards, resulting in a lot of shots to the knees/shins/ankles.

Fingering the trigger is one of the most common pistol errors, so that totally makes sense.

 

[Smurfette]

My spouse told me that he saw a lot of GSWs to the legs/pelvis/hips when he was a med student on his EM and radiology rotations.

Apparently, the kids in that area had guns, but were trying to shoot them by holding the gun sideways, like they do in the movies:

View attachment 306259

It is, as you can imagine, not easy to hit your target when you're holding a gun that way. The effort to shoot the gun would usually propel the nozzle downwards, resulting in a lot of shots to the knees/shins/ankles.

That's what they do. Their aim is terrible even at close range.
I once had a patient come in who had 23 bullet holes (you read that right) and when the cops initially rolled up, they saw 4 guys standing right over him and shooting at him on the ground below with guns turned sideways. Not one was a kill shot. He absconded from the hospital 2 hours after we pulled his chest tube, maybe a week or 10 days after the incident. Presumably to seek revenge.

 

[JoaoMoutinho]

Turns out gang bangers dont care much for social distancing, lol.

Apparently a few do:

Gangs call curfews as coronavirus hits Rio favelas

The "baile funk" dance parties have been called off. Some open-air drug markets are closed for business. Gangs and militias have imposed strict curfews. Coronavirus is coming, and Rio de Janeiro's lawless favelas are gearing up for the onslaught.

www.reuters.com

In El Salvador, gangs are enforcing the coronavirus lockdown with baseball bats

Street gangs in El Salvador have turned from extortion and killing to enforcing social distancing restrictions, often with threats and baseball bats.

www.latimes.com

Although in that second article I'm not sure how socially distanced you can truly be while enforcing with a baseball bat...

 

[jw3600]

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.

Doubling down on pedanticism (is this a word?): isn't it technically Injured Extremity Index not ABI or BBI when discussing trauma?

 

[TraumaLlamaMD]

Doubling down on pedanticism (is this a word?): isn't it technically Injured Extremity Index not ABI or BBI when discussing trauma?

“Pedantry” if you want to be pedantic about it.

 

[WinslowPringle]

IM: “Requesting a consult for an art line on pt Thrombos in ICU.”
Me: “Ok, I’ll swing by.”
IM: “Thanks! It just needs to be done today, no rush. They’re having their PICC removed because there’s a blood clot, so we were hoping for an art line so it would clot less.”
Me: “.....So, uh. Why do you want an art line?”
IM (graciously speaking slowly so the stupid surgery resident understands): “They need access, because we have to pull the PICC. Because there is a blood clot. So we want an arterial line so it will clot less.”
Me: “You sure you want an arterial line? Not a central line?”
IM: “Well, we want it to clot less.”
Me: “Do you know the difference between an arterial line and a central line?”
IM (indignantly): “Yes.”
Me: “.....Sure. I’ll go see the patient and get back to you.”

Fortunately patient needed neither a central line nor an arterial line. Also fortunately I didn’t tease that particular IM senior about getting a carotid arterial line....they might have found some way to do it!

 

[WheezyBaby]

IM: “Requesting a consult for an art line on pt Thrombos in ICU.”
Me: “Ok, I’ll swing by.”
IM: “Thanks! It just needs to be done today, no rush. They’re having their PICC removed because there’s a blood clot, so we were hoping for an art line so it would clot less.”
Me: “.....So, uh. Why do you want an art line?”
IM (graciously speaking slowly so the stupid surgery resident understands): “They need access, because we have to pull the PICC. Because there is a blood clot. So we want an arterial line so it will clot less.”
Me: “You sure you want an arterial line? Not a central line?”
IM: “Well, we want it to clot less.”
Me: “Do you know the difference between an arterial line and a central line?”
IM (indignantly): “Yes.”
Me: “.....Sure. I’ll go see the patient and get back to you.”

Fortunately patient needed neither a central line nor an arterial line. Also fortunately I didn’t tease that particular IM senior about getting a carotid arterial line....they might have found some way to do it!

ICU consulting for temporary lines? I'm still confused by what they were actually hoping to get. Did they cannulate the carotid and misunderstand why their staff wanted a vascular consult?

 

[MoMoGesiologist]

IM: “Requesting a consult for an art line on pt Thrombos in ICU.”
Me: “Ok, I’ll swing by.”
IM: “Thanks! It just needs to be done today, no rush. They’re having their PICC removed because there’s a blood clot, so we were hoping for an art line so it would clot less.”
Me: “.....So, uh. Why do you want an art line?”
IM (graciously speaking slowly so the stupid surgery resident understands): “They need access, because we have to pull the PICC. Because there is a blood clot. So we want an arterial line so it will clot less.”
Me: “You sure you want an arterial line? Not a central line?”
IM: “Well, we want it to clot less.”
Me: “Do you know the difference between an arterial line and a central line?”
IM (indignantly): “Yes.”
Me: “.....Sure. I’ll go see the patient and get back to you.”

Fortunately patient needed neither a central line nor an arterial line. Also fortunately I didn’t tease that particular IM senior about getting a carotid arterial line....they might have found some way to do it!

IM senior didn’t know difference between venous vs arterial access? This story is not making sense!

 

[WinslowPringle]

ICU consulting for temporary lines? I'm still confused by what they were actually hoping to get. Did they cannulate the carotid and misunderstand why their staff wanted a vascular consult?

Yes, ICU consult for an unneeded line and the wrong line. Patient already had a PICC but got a catheter associated thrombus. So they pulled the PICC. But IM physician 'wanted access' and so requested I place an arterial line. They wanted it in order to give medicine and thought that if the cannula was in the artery it might 'clot less'; they didn't want an art line for frequent lab draws/ABGs or for BP monitoring. I thought about joking with the person about putting in a carotid arterial line (you know, closer brain circulation of those pain meds), but thought better of it because 1) I didn't want to get written up and 2) I was concerned this person would find a way to actually get a carotid arterial line and that would be bad news for everyone.

IM senior didn’t know difference between venous vs arterial access? This story is not making sense!

Yeah, you got it. Was definitely a memorable consult for me.

 

[deleted50541]

IM senior didn’t know difference between venous vs arterial access? This story is not making sense!

Doesn't surprise me at all. At my training institution, the "IM senior" was usually a second-year resident. It was generally agreed upon that second years in any specialty were the most dangerous of all. They'd gotten through intern year and knew just enough to get the job done. But they still lacked the experience to sometimes know when they were in over their heads and make the right call.

It sounds like it was actually the attending passing on the request to their resident in this case. Not infrequently though, this IM attending could have been the same resident you interacted with just one or two years earlier when they were a "senior", calling with some nonsensical request.

 

[akuko2]

My spouse told me that he saw a lot of GSWs to the legs/pelvis/hips when he was a med student on his EM and radiology rotations.

Apparently, the kids in that area had guns, but were trying to shoot them by holding the gun sideways, like they do in the movies:

View attachment 306259

It is, as you can imagine, not easy to hit your target when you're holding a gun that way. The effort to shoot the gun would usually propel the nozzle downwards, resulting in a lot of shots to the knees/shins/ankles.

I rotated onto a trauma service in a location where 'giving someone a bag' was something that gang members tried to do rivals. So lots of GSW to abdomen/pelvis.

 

[aSagacious]

You should've given them an a-line. Let the MICU administer TPN through the line and then wonder why the a-line surprisingly didn't "clot less".

 

[kitsunepixie]

I rotated onto a trauma service in a location where 'giving someone a bag' was something that gang members tried to do rivals. So lots of GSW to abdomen/pelvis.

You and I must have trained at the same location. I remember a lot of that on my Trauma rotation as an intern. Women also liked to target the scrotum when their men cheated on them. A certain Trauma attending would have trouble stepping into the room and would appear visibly distressed by that particular injury. Everything else? Total cowboy

 

[deleted50541]

You and I must have trained at the same location. I remember a lot of that on my Trauma rotation as an intern. Women also liked to target the scrotum when their men cheated on them. A certain Trauma attending would have trouble stepping into the room and would appear visibly distressed by that particular injury. Everything else? Total cowboy

We had this too where I trained. I don't recall women specifically doing this, but I definitively noticed an uptick in targeted belly and groin shots over my 5 years on trauma. It didn't click right away until I asked someone about this and was educated on "giving someone a bag".

I'm sure a deep sigh followed as I learned another awesome fact about life in the inner city. I don't miss trauma...

 

[HighPriest]

"32 yo female with cough, fevers, malaise, and nasal congestion for five days. Recent contact with COVID positive patient. Please evaluate and treat."

Keep in mind I'm an ENT.

 

[dpmd]

"32 yo female with cough, fevers, malaise, and nasal congestion for five days. Recent contact with COVID positive patient. Please evaluate and treat."

Keep in mind I'm an ENT.

You can try removing the nose and throat and seeing that fixes things I guess

 

[dpmd]

Though hopefully this never got as far as getting scheduled for you.

 

[HighPriest]

It didn't get scheduled. My front desk staff came and asked me if that seemed weird, and I gave them a belly rub and a treat.

 

[HighPriest]

It's fine anyway. I called the patient and told her that maybe she should try going to the beach or a restaurant to see if the fresh air will help. Don't wear a mask. All that CO2 will make things worse.

 

[Pir8DeacDoc]

For interest sake, she test positive?
I'm ent too and worry about one slipping into my schedule. Uggh

 

[HighPriest]

I honestly don't know. We called the PCP office and suggested that she be testing, and that she self-isolate regardless, and that was the last I heard. I'm just fortunate that the referring provider was so blissfully and ignorantly honest. They could have said "patient with the sinus" like they usually do.

 

[HighPriest]

You can try removing the nose and throat and seeing that fixes things I guess

It's amazing how often people stop getting sick when you do this.

 

[evilbooyaa]

"32 yo female with cough, fevers, malaise, and nasal congestion for five days. Recent contact with COVID positive patient. Please evaluate and treat."

Keep in mind I'm an ENT.

From a physician? Or a NP/PA?

 

[HighPriest]

From a physician? Or a NP/PA?

You know, I usually look at that, but I didn't this time simply because someone on my staff brought it to me and I was wrapped up doing other things (and it was obviously something that shouldn't come in).

 

[deleted50541]

For interest sake, she test positive?
I'm ent too and worry about one slipping into my schedule. Uggh

We had a patient like that get to our office a few weeks ago. I don't recall what she was seeing us for, but she managed to get by the crack team of elderly volunteer screeners in the lobby and made it to our front desk with a nasty cough and fever of 38.3. She was promptly turned away by our staff and directed to get a COVID test.

 

[LucidSplash]

We had a patient like that get to our office a few weeks ago. I don't recall what she was seeing us for, but she managed to get by the crack team of elderly volunteer screeners in the lobby and made it to our front desk with a nasty cough and fever of 38.3. She was promptly turned away by our staff and directed to get a COVID test.

I’m super skeptical of the no touch thermometers they are using at the doors of my institution. Had a patient come for HBO therapy last week who somehow didn’t have a fever at the door but then did in clinic. Asked if he had any sick contacts and he said yes that both of his parents had “the flu.” Made him go get Covid test and of course he is pos.

 

[Wordead]

I’m super skeptical of the no touch thermometers they are using at the doors of my institution. Had a patient come for HBO therapy last week who somehow didn’t have a fever at the door but then did in clinic. Asked if he had any sick contacts and he said yes that both of his parents had “the flu.” Made him go get Covid test and of course he is pos.

Every time I get screened Im at like 34-35 degrees. Like sure this seems accurate.

 

[LucidSplash]

Every time I get screened Im at like 34-35 degrees. Like sure this seems accurate.

In general I have been very pleased by the way my institution has handled the last several months.

This particular part seems more like security theater. Like the TSA. It makes people feel better but doesn’t actually make you any safer.

 

[nlax30]

Yea I think screening here is being used very loosely. At least at my main hospital just forehead non-invasive temp checks and a brief "feeling ok?". At our clinic much more in depth questions though certainly relies on the person being truthful.

Actually current recovering from COVID19 myself and based on my own symptoms I can very easily see these screening protocols not being very efficient or accurate. Looking back I was already likely a couple days into symptoms before I every had a low grade fever and that was only transient fever. Never had high or sustained fevers. Literally started as just "allergies" with some nasal congestion and I would think very easy for anyone to initially not give much thought to.

 

[akwho]

In general I have been very pleased by the way my institution has handled the last several months.

This particular part seems more like security theater. Like the TSA. It makes people feel better but doesn’t actually make you any safer.

It's not security theater. It's risk mitigation in case any employee comes to work COVID + and infects patients or other staff. The hospital admin can say we screened their temperature and asked if they had any symptoms -- we couldn't have known they would infect X number of people.

The hospitals are doing this to prevent lawsuits regardless of how effective or ineffective it may be. Morning temp/symptoms screenings are just another part of the game.

 

[ThoracicGuy]

It's not security theater. It's risk mitigation in case any employee comes to work COVID + and infects patients or other staff. The hospital admin can say we screened their temperature and asked if they had any symptoms -- we couldn't have known they would infect X number of people.

The hospitals are doing this to prevent lawsuits regardless of how effective or ineffective it may be. Morning temp/symptoms screenings are just another part of the game.

That's basically security theater. It's unlikely to protect anything except CYA.

 

[VA Hopeful Dr]

That's basically security theater. It's unlikely to protect anything except CYA.

Thought we had some convincing data that said otherwise...

 

[LucidSplash]

Thought we had some convincing data that said otherwise...

Do we? I’m only talking about the temperature checks with these no-touch infrared thermometers. I’m not sure they are accurate since my temp seems to come back at 95-96F most of the time. After walking in from the Houston heat.

 

[ThoracicGuy]

Thought we had some convincing data that said otherwise...

As @LucidSplash mentioned, these thermometers are horribly inaccurate. Our hospital uses them and when I get scanned, I'm usually around 95-97F. That's just not correct. When you have something like that, is it really helping anything or just making it seem like we're doing something?

 

[VA Hopeful Dr]

Ah, my mistake. I thought y'all were referring to everything involved.

 

[LucidSplash]

Ah, my mistake. I thought y'all were referring to everything involved.

Oh no, definitely not. As I stated above I’m pretty pleased with how my institution has handled things. I’m happy to mask up at work, etc. Not allowing visitors, etc has been smart. But these temperature check are ridiculous. Apparently we are going to be moving to some kind of self-service iPad-esque kiosks for employees that will scan your face and turn red if >99.6F.I’m obviously skeptical.

 

[310prolene]

It's not security theater. It's risk mitigation in case any employee comes to work COVID + and infects patients or other staff. The hospital admin can say we screened their temperature and asked if they had any symptoms -- we couldn't have known they would infect X number of people.

The hospitals are doing this to prevent lawsuits regardless of how effective or ineffective it may be. Morning temp/symptoms screenings are just another part of the game.

I think you’re both describing the same intention of the hospital whether you call it security theater or risk mitigation.

 

[dpmd]

I think you’re both describing the same intention of the hospital whether you call it security theater or risk mitigation.

Not really. TSA knows it isn't really effective and isn't afraid to get sued. Hospitals may think it is effective but mostly.they don't want to be sued.

 

[longhaul3]

I recently got an urgent inpatient consult for lumbar stenosis due to L5-L6 disc herniation.

Thankfully ortho was on spine call so I was able to turf this stat anatomy lesson.

 

[HighPriest]

I recently got an urgent inpatient consult for lumbar stenosis due to L5-L6 disc herniation.

Thankfully ortho was on spine call so I was able to turf this stat anatomy lesson.

Tell them they’re creating pain in your S5 dermatome.

 

[kitsunepixie]

I recently got an urgent inpatient consult for lumbar stenosis due to L5-L6 disc herniation.

Thankfully ortho was on spine call so I was able to turf this stat anatomy lesson.

One of my spine trauma attending's hills he liked to die on was when people said "spinal cord compression" in reference to nerve root or cauda equina compression. He'd get hilariously and dramatically worked up, but somehow not in a mean way.

 

[longhaul3]

Tell them they’re creating pain in your S5 dermatome.

It hurts from tectum to rectum when we're on spine call.

One of my spine trauma attending's hills he liked to die on was when people said "spinal cord compression" in reference to nerve root or cauda equina compression. He'd get hilariously and dramatically worked up, but somehow not in a mean way.

That's why I hedge with "neural elements" which is fancy enough to satisfy the medicine resident calling the consult but vague enough not to get chewed out by the attending.

 

[akwho]

I recently got an urgent inpatient consult for lumbar stenosis due to L5-L6 disc herniation.

Thankfully ortho was on spine call so I was able to turf this stat anatomy lesson.

I want to like this but as an ortho I can't. Our call schedule doesn't specify if ortho spine or neuro spine is on call at our private hospital. Shortly thereafter each spine consult commences the eternal game of spine call chicken between the on call ortho and neurosurgery resident until one or the other caves.

 

[dpmd]

I want to like this but as an ortho I can't. Our call schedule doesn't specify if ortho spine or neuro spine is on call at our private hospital. Shortly thereafter each spine consult commences the eternal game of spine call chicken between the on call ortho and neurosurgery resident until one or the other caves.

Must be similar to when vascular and ortho play not it with amputations

 

[longhaul3]

I want to like this but as an ortho I can't. Our call schedule doesn't specify if ortho spine or neuro spine is on call at our private hospital. Shortly thereafter each spine consult commences the eternal game of spine call chicken between the on call ortho and neurosurgery resident until one or the other caves.

That is brutal. We love our ortho bros but we know they would dump 110% of them on us if they weren't officially assigned to spine call.

"It looks like it might involve the dura"

"You guys saw this patient's stepfather in 1977"

Maybe I'm just bitter because we always cave and ortho holds their ground.

 

[WheezyBaby]

I want to like this but as an ortho I can't. Our call schedule doesn't specify if ortho spine or neuro spine is on call at our private hospital. Shortly thereafter each spine consult commences the eternal game of spine call chicken between the on call ortho and neurosurgery resident until one or the other caves.

Must be similar to when vascular and ortho play not it with amputations

Add on the plastics / ortho fight for hand coverage. Ok no more I'm getting PTSD

 

[kitsunepixie]

Don't you guys get excited though when it's a nice juicy disc with cauda equina? I can get the transverse process fracture consults. I just remember the poor trauma residents calling me and being so very apologetic: "we know you're busy; our attending is making us consult you."

 

[WedgeDawg]

Don't you guys get excited though when it's a nice juicy disc with cauda equina? I can get the transverse process fracture consults. I just remember the poor trauma residents calling me and being so very apologetic: "we know you're busy; our attending is making us consult you."

No because then my chief gets to do the case while I get to move onto the next “MVC with possible trace SAH, GCS 15, no other injuries, do you want to admit to neuro ICU or step down” ED consult