Consults- Memorable/Dismal/Ridiculous/Unique

[futureapppsy2]

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.

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[Little Green Mensch]

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

Or the "I've got a kiddo with a shunt. And also hematemesis. Could this be shunt failure?" consults.

 

[dpmd]

Or the "I've got a kiddo with a shunt. And also hematemesis. Could this be shunt failure?" consults.

Unless they thought is was a portosytemic shunt they are barking up the wrong tree

 

[longhaul3]

Unless they thought is was a portosytemic shunt they are barking up the wrong tree

Try telling them that though.

 

[OrganRepo]

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

Dont engage with this nonsense get them both to agree to turf to podiatry

 

[dpmd]

Dont engage with this nonsense get them both to agree to turf to podiatry

Can I convince pod that a hand is just the foot of the arm?

 

[OrganRepo]

Can I convince pod that a hand is just the foot of the arm?

 

[longhaul3]

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

I hate to admit this but these are the cases where I'm in the CT control room praying to see some non-displaced rib or pelvic fracture so the patient will go to SICU. If it's going to be a garbage trauma I'd rather it be a garbage polytrauma.

 

[ThoracicGuy]

I hate to admit this but these are the cases where I'm in the CT control room praying to see some non-displaced rib or pelvic fracture so the patient will go to SICU. If it's going to be a garbage trauma I'd rather it be a garbage polytrauma.

And then it was a race to sign off... We hated those bogus polytraumas...

 

[WinslowPringle]

ED MD: “I got this guy here, has a history of dissection you guys repaired a couple of years ago, coming in with back pain.”
Me: “And...?”
ED: “Well, the CT is completely stable compared to all his previous post op scans. But he has bad back pain and it could be a dissection that the CTA doesn’t show.”
Me: “It was a CTA, right? And the attending radiologist has read it as stable to previous scans, yeah?”
ED:”Yeah. But it’s really bad back pain and I think it’s just something you guys should know about. I am consulting you to come see him.”
Me: “And his heart rate and blood pressure and troponin and EKG show...?”
ED: “All normal.”
Me: “.........”
Thus I got the distinct pleasure of seeing this fascinating consult at a particularly lovely time of night for back pain in an obese older gentleman with stone cold normal CTA, labs, vitals, EKG. Oh, his pain had resolved too by the time I saw him.

 

[longhaul3]

ED MD: “I got this guy here, has a history of dissection you guys repaired a couple of years ago, coming in with back pain.”
Me: “And...?”
ED: “Well, the CT is completely stable compared to all his previous post op scans. But he has bad back pain and it could be a dissection that the CTA doesn’t show.”
Me: “It was a CTA, right? And the attending radiologist has read it as stable to previous scans, yeah?”
ED:”Yeah. But it’s really bad back pain and I think it’s just something you guys should know about. I am consulting you to come see him.”
Me: “And his heart rate and blood pressure and troponin and EKG show...?”
ED: “All normal.”
Me: “.........”
Thus I got the distinct pleasure of seeing this fascinating consult at a particularly lovely time of night for back pain in an obese older gentleman with stone cold normal CTA, labs, vitals, EKG. Oh, his pain had resolved too by the time I saw him.

5 minutes later...

ED: Hi I've got this guy in the ED with back pain. What's your name doc?
Me: Is this a new consult?
ED: What imaging do you want?
Me:
ED: Just so I know so I can order it before I call you for the consult. What's your name doc?
Me:
ED: What's your name doc?
Me: As the primary you should order whatever imaging you need to do your back pain workup. Right now there is no indication for a neurosurgery consult.
ED: Ok I'll order a total spine ultrasound with PO contrast and skull xrays. BTW he's complaining because he's been in the ED for 13 hours. Will you be admitting the patient?

 

[Radetzky]

ED MD: “I got this guy here, has a history of dissection you guys repaired a couple of years ago, coming in with back pain.”
Me: “And...?”
ED: “Well, the CT is completely stable compared to all his previous post op scans. But he has bad back pain and it could be a dissection that the CTA doesn’t show.”
Me: “It was a CTA, right? And the attending radiologist has read it as stable to previous scans, yeah?”
ED:”Yeah. But it’s really bad back pain and I think it’s just something you guys should know about. I am consulting you to come see him.”
Me: “And his heart rate and blood pressure and troponin and EKG show...?”
ED: “All normal.”
Me: “.........”
Thus I got the distinct pleasure of seeing this fascinating consult at a particularly lovely time of night for back pain in an obese older gentleman with stone cold normal CTA, labs, vitals, EKG. Oh, his pain had resolved too by the time I saw him.

not saying that the consult was justified ... but false negative CTAs can occur

 

[LucidSplash]

not saying that the consult was justified ... but false negative CTAs can occur

Sure, but exceedingly rare, and in a patient with otherwise stone-cold normal vitals and labs, there is essentially zero chance of a hemodynamically significant dissection. Especially in the setting of a previous repair.

 

[TypeADissection]

Thus I got the distinct pleasure of seeing this fascinating consult at a particularly lovely time of night for back pain in an obese older gentleman with stone cold normal CTA, labs, vitals, EKG. Oh, his pain had resolved too by the time I saw him.

BTW he's complaining because he's been in the ED for 13 hours. Will you be admitting the patient?

What is it called when while reading this I began to become very angry?

But in all fairness, working in a primarily non-teaching hospital, the staff all around from primary teams to ED has been pretty outstanding. Very collegial. There are some curbsides here and there that I've been called for, but not really a consult that I've seen where I thought it was a waste of time. From my perspective, leaving academia has been very therapeutic for me, especially in dealing with the ED.

 

[nlax30]

See it, sign off, bill it and move on.

 

[TypeADissection]

See it, sign off, bill it and move on.

Pretty sure these are the words to the Kanye West song Stronger:

"See it, sign off, bill it, move on, see the next one, do it faster..."

 

[Matthew9Thirtyfive]

Pretty sure these are the words to the Kanye West song Stronger:

"See it, sign off, bill it, move on, see the next one, do it faster..."

You mean the Daft Punk song.

 

[nlax30]

You mean the Daft Punk song.

Harder, better, faster, stronger

 

[deleted547339]

5 minutes later...

ED: Hi I've got this guy in the ED with back pain. What's your name doc?
Me: Is this a new consult?
ED: What imaging do you want?
Me:
ED: Just so I know so I can order it before I call you for the consult. What's your name doc?
Me:
ED: What's your name doc?
Me: As the primary you should order whatever imaging you need to do your back pain workup. Right now there is no indication for a neurosurgery consult.
ED: Ok I'll order a total spine ultrasound with PO contrast and skull xrays. BTW he's complaining because he's been in the ED for 13 hours. Will you be admitting the patient?

I see you and raise you:
Neurosurgery to OSH on recorded line: Sounds good, we should lay hands on them. Send them to our ER and we’ll take care of it.
ER: Hey, this transfer with a SDH you accepted is here.
Nsgy: Oh, we’re not going to operate, admit to medicine or DC.
ER: Don’t you want to come see him? He just got transferred 3 hours for your evaluation.
Nsgy: His CT looks fine, we’re not going to operate.
ER: Don’t you want to come examine him, or at least hear what my exam was?
Nsgy: Nah, scan looks good.
ER: Then why did you have him shipped a long way from him when you already reviewed his scans and aren’t planning on operating?
Nsgy: Just admit to medicine. <click>

 

[longhaul3]

I see you and raise you:
Neurosurgery to OSH on recorded line: Sounds good, we should lay hands on them. Send them to our ER and we’ll take care of it.
ER: Hey, this transfer with a SDH you accepted is here.
Nsgy: Oh, we’re not going to operate, admit to medicine or DC.
ER: Don’t you want to come see him? He just got transferred 3 hours for your evaluation.
Nsgy: His CT looks fine, we’re not going to operate.
ER: Don’t you want to come examine him, or at least hear what my exam was?
Nsgy: Nah, scan looks good.
ER: Then why did you have him shipped a long way from him when you already reviewed his scans and aren’t planning on operating?
Nsgy: Just admit to medicine. <click>

Guilty as charged. I could never be a medicine resident, too much of a dumping ground for trash consults. For every interesting diagnostic mystery that got us all excited as med students they must have 50 social admits and dispo disasters.

Not sure but this case could be a liability thing, if there is no nsg at the OSH the patient needs at least a perfunctory neurosurgery "evaluation." Happens at our hospitals all the time, although it's poor form not to actually see the patient in person.

 

[deleted547339]

Guilty as charged. I could never be a medicine resident, too much of a dumping ground for trash consults. For every interesting diagnostic mystery that got us all excited as med students they must have 50 social admits and dispo disasters.

Not sure but this case could be a liability thing, if there is no nsg at the OSH the patient needs at least a perfunctory neurosurgery "evaluation." Happens at our hospitals all the time, although it's poor form not to actually see the patient in person.

No, it’s a nsgy thing. Literally no other service tried this nonsense.

If one of my colleagues from vascular or trauma or any other surgical service found out their chief residents were doing this, there would be blood.

 

[longhaul3]

No, it’s a nsgy thing. Literally no other service tried this nonsense.

If one of my colleagues from vascular or trauma or any other surgical service found out their chief residents were doing this, there would be blood.

I believe you that it's a nsg thing. At our hospitals we basically always have to accept people for "neurosurgical evaluation" when the outlying hospital doesn't have in-house neurosurgery no matter how insignificant the bleed. It's mostly a matter of liability.

I can't speak for vascular or trauma surgery, but most of this story sounds like a typical nonoperative subdural that I see 5-10 times a week. What is unusual and I would say inappropriate is if neurosurgery declined to actually see the patient face to face. So if that's what you mean, then yes, there would be blood on my service too.

 

[dpmd]

I believe you that it's a nsg thing. At our hospitals we basically always have to accept people for "neurosurgical evaluation" when the outlying hospital doesn't have in-house neurosurgery no matter how insignificant the bleed. It's mostly a matter of liability.

I can't speak for vascular or trauma surgery, but most of this story sounds like a typical nonoperative subdural that I see 5-10 times a week. What is unusual and I would say inappropriate is if neurosurgery declined to actually see the patient face to face. So if that's what you mean, then yes, there would be blood on my service too.

I interpreted it as they didn't want to sdmit them but perhaps would drop a consult at some point which would be reasonable.

 

[deleted547339]

I interpreted it as they didn't want to sdmit them but perhaps would drop a consult at some point which would be reasonable.

It’s gone both ways....

 

[deleted547339]

Oh, I got another good one. Patient on surgical floor, pending lap chole, IIRC had a perc drain. Had klebsiella in blood. Started having rigors. RN called rapid response team for “seizures” while the patient kept saying “I’m.......soooo......cold.......”

 

[longhaul3]

Oh, I got another good one. Patient on surgical floor, pending lap chole, IIRC had a perc drain. Had klebsiella in blood. Started having rigors. RN called rapid response team for “seizures” while the patient kept saying “I’m.......soooo......cold.......”

No joke, I've been stat paged for a patient rigoring in the MICU. Nevermind that there is an entire separate specialty that deals with seizures; the patient was in a cooling blanket sandwich.

Recommendations
-remove head from rectum
-consult neurology if concern persists

thank you for this interesting consult.

 

[IMGASMD]

It’s gone both ways....

I’ve heard it both ways....

 

[WinslowPringle]

I’ve heard it both ways....

...but have you heard about Pluto? That’s messed up, right?

Also messed up:
Medicine sub specialist admits patient directly from clinic; has CT finding they think needs surgical biopsy. Does not consult or curbside with surgical specialty prior to admission. Pt admitted and made NPO for his “planned surgery” the following day, and is told surgery will see him and do this surgical biopsy stat. I am then called the following day (no, wasn’t consulted on day of admission....) to see this patient. Had the pleasure of informing them we would not be doing surgery....at all. Fortunately IR is much nicer than we are and he was able to get the appropriate type of biopsy during his (unnecessary) hospital stay in the midst of a pandemic.

 

[TypeADissection]

“The single biggest problem in communication is the illusion that it has taken place.” - George Bernard Shaw.

If there is anything that I have learned through residency and fellowship is that, a lot bickering and strife can be avoided if we just talked to each other like adults. One of my pet peeves was when attendings would communicate with other attendings (sometimes in the same division) through the residents. Uh...you know this is way more efficient if you just talked to them yourself right?

 

[deleted547339]

“The single biggest problem in communication is the illusion that it has taken place.” - George Bernard Shaw.

If there is anything that I have learned through residency and fellowship is that, a lot bickering and strife can be avoided if we just talked to each other like adults. One of my pet peeves was when attendings would communicate with other attendings (sometimes in the same division) through the residents. Uh...you know this is way more efficient if you just talked to them yourself right?

So true. The number of times I’ve had some absurd rec from an resident of fellow that got passed down the chain which subsequently were either 1) entirely reversed or 2) actually appropriate when explained correctly is nearly 100%.

 

[WheezyBaby]

So true. The number of times I’ve had some absurd rec from an resident of fellow that got passed down the chain which subsequently were either 1) entirely reversed or 2) actually appropriate when explained correctly is nearly 100%.

Or when the staff just drops different recs in their attestation and that isn't relayed to anyone by any other medium.

 

[akwho]

95% of problems in the hospital can be solved by picking up the phone and dialing the offending party directly.

The other 5% can't be solved with any number of phone calls.

 

[TypeADissection]

For me, leaving academia was a great thing. I don’t miss it. I don’t know anything other than seeing consults, writing my own notes, doing my own dressing changes, and directly talking with other physicians about the management of a patient. It’s efficient, cordial and much more stress free. I’ve had too many attendings in training who would piss themselves if they didn’t have residents to lower their zippers. They were so proud of how helpless they were and how they didn’t even know how to do orders. Yeah f*ck that mentality.

 

[longhaul3]

For me, leaving academia was a great thing. I don’t miss it. I don’t know anything other than seeing consults, writing my own notes, doing my own dressing changes, and directly talking with other physicians about the management of a patient. It’s efficient, cordial and much more stress free. I’ve had too many attendings in training who would piss themselves if they didn’t have residents to lower their zippers. They were so proud of how helpless they were and how they didn’t even know how to do orders. Yeah f*ck that mentality.

My chairman had a VIP patient from far away seek him out for treatment of a complex aneurysm. Arranged for him to be pre-admitted, had the patient come to the ED, etc. Asked me to call when the patient got to the ED so we could see him together.

Chairman couldn't find the ED. Had to meet him at the front door of the hospital.

Edit: Also regarding above subdural scenario, right after I posted about the rigors consult I got paged for a nonoperative subdural. Went in to see it. Admitted to medicine.

 

[deleted547339]

My chairman had a VIP patient from far away seek him out for treatment of a complex aneurysm. Arranged for him to be pre-admitted, had the patient come to the ED, etc. Asked me to call when the patient got to the ED so we could see him together.

Chairman couldn't find the ED. Had to meet him at the front door of the hospital.

Edit: Also regarding above subdural scenario, right after I posted about the rigors consult I got paged for a nonoperative subdural. Went in to see it. Admitted to medicine.

It isn’t the admit to medicine that upset me. It’s the fact that neurosurgery routinely accepts outside hospital transfers, then says “not my problem, admit them to someone else” dumping the patient on the ER, occasionally without even seeing the patient.

I have no opinion on the management of subdurals, which I presume they are competent on.

 

[Little Green Mensch]

It isn’t the admit to medicine that upset me. It’s the fact that neurosurgery routinely accepts outside hospital transfers, then says “not my problem, admit them to someone else” dumping the patient on the ER, occasionally without even seeing the patient.

I have no opinion on the management of subdurals, which I presume they are competent on.

At my institution, transfers can either be accepted, and admitted directly onto the accepting service, or sent to the E.D. for evaluation. There are a lot of "little bit of blood in the head" consults that should be seen by a neurosurgeon, because occasionally a small hemorrhage does get big enough to warrant doing something about, but the vast majority of those mild TBI cases really only need a 6-hour CT and/or overnight observation. Where I am, they are typically sent to the E.D., and usually admitted to either Neurology or Medicine.

 

[deleted547339]

At my institution, transfers can either be accepted, and admitted directly onto the accepting service, or sent to the E.D. for evaluation. There are a lot of "little bit of blood in the head" consults that should be seen by a neurosurgeon, because occasionally a small hemorrhage does get big enough to warrant doing something about, but the vast majority of those mild TBI cases really only need a 6-hour CT and/or overnight observation. Where I am, they are typically sent to the E.D., and usually admitted to either Neurology or Medicine.

That’s where you’re wrong. There’s no such thing as “accepted to the ED.” It’s not a thing. If you accept a transfer, you are the attending of record whether you tell them to go to the Er, the ICU or the floor. You can’t accept a patient on someone else’s behalf, and when people say “no, I just accepted them to the ER,” that is effectively what you are doing. You’re saying “the Er will accept this patient and I will consult.” You essentially signing the ER doc up for extra work and then saying you’ll be hands off. And a patient can’t get billed for two ER visits in the same day - so you’re forcing us to evaluate and disposition a patient, take up a room in my ER, exposing me to liability and ensuring I don’t get paid a dime.

For unclear reasons, neurosurgery is the only service that does this. When every other service in the hospital accepts a transfer that they don’t admit, they arrange admission. Neurosurgery basically just flips us the bird and says “ha, tag you’re it.”

 

[TypeADissection]

Neurosurgery basically just flips us the bird and says “ha, tag you’re it.”

As Anakin Skywalker once said, "Is it possible to learn this power?"

 

[WheezyBaby]

That’s where you’re wrong. There’s no such thing as “accepted to the ED.” It’s not a thing. If you accept a transfer, you are the attending of record whether you tell them to go to the Er, the ICU or the floor. You can’t accept a patient on someone else’s behalf, and when people say “no, I just accepted them to the ER,” that is effectively what you are doing. You’re saying “the Er will accept this patient and I will consult.” You essentially signing the ER doc up for extra work and then saying you’ll be hands off. And a patient can’t get billed for two ER visits in the same day - so you’re forcing us to evaluate and disposition a patient, take up a room in my ER, exposing me to liability and ensuring I don’t get paid a dime.

For unclear reasons, neurosurgery is the only service that does this. When every other service in the hospital accepts a transfer that they don’t admit, they arrange admission. Neurosurgery basically just flips us the bird and says “ha, tag you’re it.”

I will occasionally send a transfer to the ED, but its when they're in a gray zone where it's unclear if they'll need floor or cc level care, and I communicate with the ED physician about the patient. If they're clearly just in need of admission to a service other than mine I will arrange that with who I think the accepting service should be. Have a good relationship with our EM group and have not had any pushback with doing this. I was not aware of inability to bill a 2nd ED visit, though I'm honestly not sure if our EM physicians are salaried or RVU. Regardless, accepting someone and being unwilling to evaluate the patient is unacceptable imo

 

[Pir8DeacDoc]

Patients aren't always easily triaged. Especially when the outside hospital may have a variable amount of resources /skill. I'm not accepting a potentially unstable patient to the floor. Unless it's a clear chipshot it's coming in through the ER. Often I'll be the only person to see them which is how the ER guys must overcome this?

 

[LucidSplash]

That’s where you’re wrong. There’s no such thing as “accepted to the ED.” It’s not a thing. If you accept a transfer, you are the attending of record whether you tell them to go to the Er, the ICU or the floor. You can’t accept a patient on someone else’s behalf, and when people say “no, I just accepted them to the ER,” that is effectively what you are doing. You’re saying “the Er will accept this patient and I will consult.” You essentially signing the ER doc up for extra work and then saying you’ll be hands off. And a patient can’t get billed for two ER visits in the same day - so you’re forcing us to evaluate and disposition a patient, take up a room in my ER, exposing me to liability and ensuring I don’t get paid a dime.

For unclear reasons, neurosurgery is the only service that does this. When every other service in the hospital accepts a transfer that they don’t admit, they arrange admission. Neurosurgery basically just flips us the bird and says “ha, tag you’re it.”

While I generally agree with everything you’ve said, I will say that some places have arrangements with the ED, where things that aren’t clearly in need of trauma surgery service but are coming from a OSH ED that “doesn’t feel comfortable” discharging the patient, are ok’d to be sent to the ED for higher level evaluation.

Again this is location dependent and there has to be an agreement between trauma and the ED ahead of time. Where I did residency, we had this. Fired on level I & level II trauma would get trauma team to respond. Level III would get eval by the ED and then decide if it needed trauma. Things that fell into this category were like isolated extremity fractures and lacerations and such. And yeah in theory most of these things maybe should have been able to be cared for at “OSH” ED but there were a lot of standalone places that were glorified urgent cares.

Again, agree with what you say in principle, but that some places have a prior arrangement where the trauma service can agree that something can be “accepted to the ED for evaluation” and trauma isn’t auto consulted.

 

[deleted547339]

While I generally agree with everything you’ve said, I will say that some places have arrangements with the ED, where things that aren’t clearly in need of trauma surgery service but are coming from a OSH ED that “doesn’t feel comfortable” discharging the patient, are ok’d to be sent to the ED for higher level evaluation.

Again this is location dependent and there has to be an agreement between trauma and the ED ahead of time. Where I did residency, we had this. Fired on level I & level II trauma would get trauma team to respond. Level III would get eval by the ED and then decide if it needed trauma. Things that fell into this category were like isolated extremity fractures and lacerations and such. And yeah in theory most of these things maybe should have been able to be cared for at “OSH” ED but there were a lot of standalone places that were glorified urgent cares.

Again, agree with what you say in principle, but that some places have a prior arrangement where the trauma service can agree that something can be “accepted to the ED for evaluation” and trauma isn’t auto consulted.

Sure. That’s not what I’m referring to. Also, our trauma surgeons bend over backwards to be helpful. The literally bought all the ER nurses and residents meals and snacks a couple times during covid just because of all the insanity we had to deal with (like consultants refusing to see patients and us intubating folks having no idea if we’d get sick) and now everyone has to deal with.

I think, as above, most of this would be resolved if there was a human interaction between attending every now and then. For whatever reason, the neurosurgeons never speak to or make eye contact with us. All the other surgeons that come through regularly are always cordial.

 

[kitsunepixie]

For unclear reasons, neurosurgery is the only service that does this. When every other service in the hospital accepts a transfer that they don’t admit, they arrange admission. Neurosurgery basically just flips us the bird and says “ha, tag you’re it.”

The children's hospital where I am at, Neurosurgery is consult only and we admit to either Pediatrics or more commonly, to PICU. That is how the hospital was set up and after being opened, it has since started a pediatric residency (still no neurosurgery residents yet) and the residents are actually requesting to admit other surgical patients to their service for education purposes. Thus, when called by hospitals requesting transfer, we have our PICU or Peds attendings on the line as well. Very rarely do we do ED-ED transfers unless the patient needs one simple thing done that only can be done at our hospital before they can go home, and when we do, the ED attending is on the transfer line.

I think, as above, most of this would be resolved if there was a human interaction between attending every now and then. For whatever reason, the neurosurgeons never speak to or make eye contact with us. All the other surgeons that come through regularly are always cordial.

That sounds like a bummer. Maybe after the COVID outbreak, there could be some medical staff rapport building event. Or maybe they're just miserable human beings who regret their life choices

 

[Wordead]

That’s where you’re wrong. There’s no such thing as “accepted to the ED.” It’s not a thing. If you accept a transfer, you are the attending of record whether you tell them to go to the Er, the ICU or the floor. You can’t accept a patient on someone else’s behalf, and when people say “no, I just accepted them to the ER,” that is effectively what you are doing. You’re saying “the Er will accept this patient and I will consult.” You essentially signing the ER doc up for extra work and then saying you’ll be hands off. And a patient can’t get billed for two ER visits in the same day - so you’re forcing us to evaluate and disposition a patient, take up a room in my ER, exposing me to liability and ensuring I don’t get paid a dime.

For unclear reasons, neurosurgery is the only service that does this. When every other service in the hospital accepts a transfer that they don’t admit, they arrange admission. Neurosurgery basically just flips us the bird and says “ha, tag you’re it.”

Interesting, didn't know any of that. I wonder though if that part of it isn't miscommunication whether willful or otherwise. We routinely would say "not sure what's happening with that patient" because the outside ED would have a nonsense story, and say it'll have to be a ED to ED transfer and we can assess the patient when they arrive and inevitably the patient would show up and the ED would say "hey, we were told this was accepted for ENT admission" and it would be a fight with medicine ED and us.

Though I agree not evaluating the patient at all is pretty unreasonable.

 

[deleted547339]

Interesting, didn't know any of that. I wonder though if that part of it isn't miscommunication whether willful or otherwise. We routinely would say "not sure what's happening with that patient" because the outside ED would have a nonsense story, and say it'll have to be a ED to ED transfer and we can assess the patient when they arrive and inevitably the patient would show up and the ED would say "hey, we were told this was accepted for ENT admission" and it would be a fight with medicine ED and us.

Though I agree not evaluating the patient at all is pretty unreasonable.

Yea. Unless you get the ER doc on the phone and they accept them, you are the attending of record. Same as if you accepted to your floor or the ICU, you are welcome to have another service take over and sign off, but until they do you’re on the hook.

Another relatively little known fact about patient transfers is that you aren’t liable until they hit the stretcher in your hospital, unless you start giving recs. Courts have found that if you start giving medical advice, you are assuming (to some extent) care for the patient and opening yourself up to liability. If I’m ever accepting a transfer (I also work in the ICU), I always try to avoid any firm recs beyond general recommendations, and with major caveats and on a recorded line.

 

[Wordead]

Yea. Unless you get the ER doc on the phone and they accept them, you are the attending of record. Same as if you accepted to your floor or the ICU, you are welcome to have another service take over and sign off, but until they do you’re on the hook.

Another relatively little known fact about patient transfers is that you aren’t liable until they hit the stretcher in your hospital, unless you start giving recs. Courts have found that if you start giving medical advice, you are assuming (to some extent) care for the patient and opening yourself up to liability. If I’m ever accepting a transfer (I also work in the ICU), I always try to avoid any firm recs beyond general recommendations, and with major caveats and on a recorded line.

That's what I'm saying. We never accepted them (the attending literally never spoke to anyone, it was just the chief resident) and told the ED they need to arrange a ED-ED transfer and the patient would show up as a transfer under ENT. I dont know if our ED didn't care or it was accepted practice or what.

 

[turkeyjerky]

Yea. Unless you get the ER doc on the phone and they accept them, you are the attending of record. Same as if you accepted to your floor or the ICU, you are welcome to have another service take over and sign off, but until they do you’re on the hook.

Are you sure about this? I'm EM and everytime I've ever transferred someone or accepted someone, it's always been the EM doc being the accepting doc of record. I don't think anyone else can "accept" a patient to the ED. They can refuse to accept the patient directly to the floor (or unit) and recommend they go through the ER, but I'm pretty sure hospitals require that the ED doctor be the attending of record. It's a 'closed unit'.

 

[deleted547339]

Are you sure about this? I'm EM and everytime I've ever transferred someone or accepted someone, it's always been the EM doc being the accepting doc of record. I don't think anyone else can "accept" a patient to the ED. They can refuse to accept the patient directly to the floor (or unit) and recommend they go through the ER, but I'm pretty sure hospitals require that the ED doctor be the attending of record. It's a 'closed unit'.

It could technically be you, but only if you 1) accept the patient or 2) have auto-accept agreements already in place. That’s insane if you’re considered the accepting patient on someone you didn’t accept.

If you have patients that are transferred to your ED and you didnt talk to the sending physician, you should get your medical director on the phone ASAP.

 

[turkeyjerky]

It could technically be you, but only if you 1) accept the patient or 2) have auto-accept agreements already in place. That’s insane if you’re considered the accepting patient on someone you didn’t accept.

If you have patients that are transferred to your ED and you didnt talk to the sending physician, you should get your medical director on the phone ASAP.

yeah, of course. That's exactly what I was saying (that another doctor cannot accept a patient to the ED).

 

[HighPriest]

Consult for a 28 year old methamphetamine addict with acute pyelonephritis, fairly severe iron deficiency anemia, and a necrotic foot. Says when she stands up and tries to move quickly she feels dizzy and has balance issues that resolve quickly.

I'm going to be a real big help for this one. Luckily she's a meth addict so there's a good chance she'll no show.