Consults- Memorable/Dismal/Ridiculous/Unique

[TypeADissection]

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.

My wife is an otologist. Her practice is about 70/30 otology/general ENT. Just listening to her describe to me what it's like taking a history on a dizzy patient makes me want to stab myself. I don't have the patience for it nor the internal fortitude to listen for that long. I'll take a stank foot any day over a dizzy patient. Uh let me guess, you gots sugar-beetus, high blood pressure and smoke? Cool. So those piggies are going in a bucket.

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[longhaul3]

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.

Plot twist, she has invasive fungal infections of all her sinuses from snorting meth that are now communicating with the inner ear

 

[HighPriest]

Plot twist, she has invasive fungal infections of all her sinuses from snorting meth that are now communicating with the inner ear

If that’s the case, she needs a coffin catalogue not an ENT

 

[HighPriest]

My wife is an otologist. Her practice is about 70/30 otology/general ENT. Just listening to her describe to me what it's like taking a history on a dizzy patient makes me want to stab myself. I don't have the patience for it nor the internal fortitude to listen for that long. I'll take a stank foot any day over a dizzy patient. Uh let me guess, you gots sugar-beetus, high blood pressure and smoke? Cool. So those piggies are going in a bucket.

It really can be the worst. Incidentally, when they actually have an ear problem, it’s not so bad. The problem is most of them don’t. And I’ve found that one of the clearest signs of non-otogenic vertigo is the patient is entirely unable to answer a straightforward question with a straightforward answer.

“So how long have you felt dizzy?”

“Well when I was 15 I had a bad stomach ache and my doctor treated me with antibiotics and ever since then I’ve had bowel problems and so my son bought me some essential oils, lavender I think, no eucalyptus, no sage, no I think lavender, and ever since then I’ve noticed that my BMs are improved, but then I had a heart attack and I fell and hit my head and was in the hospital for a few days, and they told me I might need surgery for my heart.”

“Uh-huh...and this happened when?”

“1987.”

“Ok, so back to my question: for how long have you felt dizzy?”

Every @&$ing time.

 

[dpmd]

If that’s the case, she needs a coffin catalogue not an ENT

Costco has some very nice ones for a good deal.

 

[HighPriest]

Costco has some very nice ones for a good deal.

Always buy in bulk

 

[dpmd]

Always buy in bulk

Actually I didn't see any volume discount. Maybe you have to call and ask for one.

 

[HighPriest]

Actually I didn't see any volume discount. Maybe you have to call and ask for one.

You show up with enough bodies and they’ll give you one.

 

[I-dont-do-source-control]

Not me but my Fiance who is in GenSurg.
Between all the trauma activations at the regional Level 1at 3AM she gets an "urgent" floor consult for a choledocolithiasis, for eventual completion cholecystectomy. Patient just hit the floor and GI hasnt even seen the patient yet. The fun part was the past history of cholecystectomy

"Given patient has already had surgical cholecystectomy, there is no further role of surgical cholecystectomy
Thank you for involving us in the care of this patient
Surgery to sign off"

 

[Vandalia]

Not me but my Fiance who is in GenSurg.
Between all the trauma activations at the regional Level 1at 3AM she gets an "urgent" floor consult for a choledocolithiasis, for eventual completion cholecystectomy. Patient just hit the floor and GI hasnt even seen the patient yet. The fun part was the past history of cholecystectomy

"Given patient has already had surgical cholecystectomy, there is no further role of surgical cholecystectomy
Thank you for involving us in the care of this patient
Surgery to sign off"

Well, from EM, you would be surprised at the number of people who report having had an appendectomy or a cholecystectomy and who still have their appendix or gall-bladder. Doesn't excuse this, but it does actually happen. Not often, but n>0.

One example was a woman who after everything was figured out we realized she thought that removal of the gall-bladder was part of an EGD.

That is one of the advantages of EMR: I tend to consider a pathology report in the system fairly definitive.

 

[dpmd]

Reminds me of the consult I got for port a cath placement and when I got there the patient had an existing port a cath on his chest already.

 

[LucidSplash]

So my absolute favorite like this was the time I got a consult for foot pain in a patient with a history of PAD.

Get there, patient has bilateral AKA. Had phantom pain. But team asking for consult didn’t pull back the blanket to have a look at the “foot.”

 

[WheezyBaby]

So my absolute favorite like this was the time I got a consult for foot pain in a patient with a history of PAD.

Get there, patient has bilateral AKA. Had phantom pain. But team asking for consult didn’t pull back the blanket to have a look at the “foot.”

Prosthetic eyes look remarkably realistic nowadays. Love "catching" residents documenting eomi/perrl on them.

 

[TypeADissection]

"Given patient has already had surgical cholecystectomy, there is no further role of surgical cholecystectomy
Thank you for involving us in the care of this patient
Surgery to sign off"

Well, from EM, you would be surprised at the number of people who report having had an appendectomy or a cholecystectomy and who still have their appendix or gall-bladder. Doesn't excuse this, but it does actually happen. Not often, but n>0.

My N=3 during my general surgery years. All 3 times it was the ED asking to evaluate for appendicitis and every single time there was a big ole incision on the RLQ from an open appy decades prior. When the ED progress note says WNL, does that mean "we never looked?"

 

[akuko2]

As an off service surgical sub on General Surgery: Called by MICU for concern for pilonidal cyst in a 20ish YO M with catastrophic antiphospholipid syndrome. Waited to the end of the day to chart check and go see him and the patient was dead.

 

[TypeADissection]

As an off service surgical sub on General Surgery: Called by MICU for concern for pilonidal cyst in a 20ish YO M with catastrophic antiphospholipid syndrome. Waited to the end of the day to chart check and go see him and the patient was dead.

There’s an important lesson to be learned here. If you wait long enough, the problems usually sort themselves out...

 

[deleted50541]

There’s an important lesson to be learned here. If you wait long enough, the problems usually sort themselves out...

True enough. Can't count the number of times I was consulted in gen surg as a "load the boat" strategy for a patient spiraling into multi-organ failure. Then by the time we get there, which was usually fairly prompt, the patient is already coding or the family has chosen to withdraw care.

"Sorry, what did you need us for again?"

 

[HighPriest]

As an off service surgical sub on General Surgery: Called by MICU for concern for pilonidal cyst in a 20ish YO M with catastrophic antiphospholipid syndrome. Waited to the end of the day to chart check and go see him and the patient was dead.

So did he have a pilonidal cyst?

 

[dpmd]

So did he have a pilonidal cyst?

Probably what killed him

 

[HighPriest]

Probably what killed him

Gen surg should have gotten there faster. Could still be alive.

 

[Pir8DeacDoc]

Probably what killed him

Yeah, those things can be a real pain in the ass sometimes

 

[ThoracicGuy]

As an off service surgical sub on General Surgery: Called by MICU for concern for pilonidal cyst in a 20ish YO M with catastrophic antiphospholipid syndrome. Waited to the end of the day to chart check and go see him and the patient was dead.

If you had gotten there sooner, you could have done the procedure at bedside for some RVUs before he died.

 

[HighPriest]

If you had gotten there sooner, you could have done the procedure at bedside for some RVUs before he died.

.

 

[Jolie South]

Oh man I just remembered this gem from my chief year:

get a call from MICU about a patient with a “perirectal abscess on CT” admitted for CHF or liver failure or something.

I go ask the lady if she has any anal pain or drainage. She is like “ummm no”. I obviously do a rectal exam which is 100% normal with no abscess but do see a floridly prolapsed uterus. 🙄

“Perirectal abscess is prolapsed uterus. Please call gyn. Thank you for this interesting consult.”

 

[dpmd]

Oh man I just remembered this gem from my chief year:

get a call from MICU about a patient with a “perirectal abscess on CT” admitted for CHF or liver failure or something.

I go ask the lady if she has any anal pain or drainage. She is like “ummm no”. I obviously do a rectal exam which is 100% normal with no abscess but do see a floridly prolapsed uterus. 🙄

“Perirectal abscess is prolapsed uterus. Please call gyn. Thank you for this interesting consult.”

This reminds me of one where I was the *******. Got a call from the ER regarding small bowel prolapsed out the vagina and gyn says call general surgery. I was lucky in that it was daytime and I was not grumpy so I didn't say what I was thinking (which was you idiots don't know the difference between bowel and other parts, and why the **** can't gyn do anything themselves). Get there to discover this

Spoiler: Graphic pic

picture definite loop of small bowel coming out the vagina

And felt bad for doubting them. Ended up getting gyn onc to take care of the vaginal perf (hysterectomy was decades prior but the cuff was what opened) after I opened her up to resect that segment because it seemed healthiest to remove it.

 

[Smurfette]

This reminds me of one where I was the *******. Got a call from the ER regarding small bowel prolapsed out the vagina and gyn says call general surgery. I was lucky in that it was daytime and I was not grumpy so I didn't say what I was thinking (which was you idiots don't know the difference between bowel and other parts, and why the **** can't gyn do anything themselves). Get there to discover this
And felt bad for doubting them. Ended up getting gyn onc to take care of the vaginal perf (hysterectomy was decades prior but the cuff was what opened) after I opened her up to resect that segment because it seemed healthiest to remove it.

I don't know if we can post that image without getting flagged by google for explicit images even with the spoiler tag. Can you take it down?

I actually had a similar case when I was chief, except it was a loop of sigmoid and the ER, thinking it was prolapse, poured sugar on the colon to decrease the swelling and try to reduce. The intern saw the consult, and called me and said "there is something coming out. I don't know if it is bowel, but it's definitely not lady parts". Got there to find a very congested and large loop of sigmoid encrusted in sugar. My attending was not amused. We called the gyne in who recently did a sling on her, and he refused to help us. Literally came into the OR, took a look, turned around and walked out. We googled what suture to use on the vaginal cuff. We pexied the sigmoid and did not resect IIRC. 10 years later, I ran into that attending at a conference who introduced me to a colleague as a former resident who was responsible for the only case of "sugar colon" she'd ever seen.

 

[dpmd]

I don't know if we can post that image without getting flagged by google for explicit images even with the spoiler tag. Can you take it down?

I actually had a similar case when I was chief, except it was a loop of sigmoid and the ER, thinking it was prolapse, poured sugar on the colon to decrease the swelling and try to reduce. The intern saw the consult, and called me and said "there is something coming out. I don't know if it is bowel, but it's definitely not lady parts". Got there to find a very congested and large loop of sigmoid encrusted in sugar. My attending was not amused. We called the gyne in who recently did a sling on her, and he refused to help us. Literally came into the OR, took a look, turned around and walked out. We googled what suture to use on the vaginal cuff. We pexied the sigmoid and did not resect IIRC. 10 years later, I ran into that attending at a conference who introduced me to a colleague as a former resident who was responsible for the only case of "sugar colon" she'd ever seen.

Deleted the pic. I couldn't figure out if it was ok to reduce the eviscerated segment but what settled the issue is when it wouldn't budge at all and it got more purple as I worked. Plus who misses a small piece of small bowel right? A colon anastomosis would be harder to recover from in that setting.

 

[Jolie South]

Deleted the pic. I couldn't figure out if it was ok to reduce the eviscerated segment but what settled the issue is when it wouldn't budge at all and it got more purple as I worked. Plus who misses a small piece of small bowel right? A colon anastomosis would be harder to recover from in that setting.

I had one case of vaginal cuff rupture that I was consulted on as a chief for “appendicitis.” Appendix was gas filled to the tip and pristine. There was fluid surrounding the vaginal cuff and her pain started .....the first time she had sex after hysterectomy.

I told them to call gyn. I was on nights. Left in the morning. Come back at night to the ER reconsulting me bc gyn says it’s not their problem. Just because gyn does not want to deal with this does not mean the vagina is my territory now.

you can’t make this stuff up.

 

[HighPriest]

I don't know if we can post that image without getting flagged by google for explicit images even with the spoiler tag. Can you take it down?

I actually had a similar case when I was chief, except it was a loop of sigmoid and the ER, thinking it was prolapse, poured sugar on the colon to decrease the swelling and try to reduce. The intern saw the consult, and called me and said "there is something coming out. I don't know if it is bowel, but it's definitely not lady parts". Got there to find a very congested and large loop of sigmoid encrusted in sugar. My attending was not amused. We called the gyne in who recently did a sling on her, and he refused to help us. Literally came into the OR, took a look, turned around and walked out. We googled what suture to use on the vaginal cuff. We pexied the sigmoid and did not resect IIRC. 10 years later, I ran into that attending at a conference who introduced me to a colleague as a former resident who was responsible for the only case of "sugar colon" she'd ever seen.

Sweet

 

[deleted50541]

We really struggled with gyn support at our county hospital where we did trauma. They didn't routinely operate there, so it took an act of congress to get them involved and keep them invested in *their* patients.

I was covering our trauma ICU when a young woman was admitted after a massive hemorrhage from a ruptured ovarian cyst. Gyn did operate on her and dropped her off in our trauma/surgery unit post-op. It was a closed unit, so we managed her post-op care. But I do recall the gyn attending seeing her in the unit and the plan of care was discussed with him. She did well and we sent her to the floor on POD#2. Two days later, one of the surgical ICU attendings who had seen her in the unit happened to stop by and see how she was doing. The patient said he was the first doctor she'd seen since transfer.

To say he was livid would be an understatement. This attending, who also happened to be the chief of surgery, got on the phone with the gyn attending and ripped him a new one for patient abandonment and negligence. Gyn promptly came to see the patient shortly after this tongue lashing and fortunately no harm came to the patient.

 

[WinslowPringle]

I had one case of vaginal cuff rupture that I was consulted on as a chief for “appendicitis.” Appendix was gas filled to the tip and pristine. There was fluid surrounding the vaginal cuff and her pain started .....the first time she had sex after hysterectomy.

I told them to call gyn. I was on nights. Left in the morning. Come back at night to the ER reconsulting me bc gyn says it’s not their problem. Just because gyn does not want to deal with this does not mean the vagina is my territory now.

you can’t make this stuff up.

Classic. Had the exact same presentation x2 in residency, as well.

One of them gyn refused to operate on, pt was peritoneal, etc so we took her to the OR anyway telling Gyn we’d call them in when we found their dehiscence.....which, yep, there it was.

 

[dpmd]

Why does gyn always think it isn't their organ system with a problem

 

[WheezyBaby]

Why does gyn always think it isn't their organ system with a problem

 

[TypeADissection]

Why does gyn always think it isn't their organ system with a problem

I used to ask this exact question every time I got called to the ED for a labial abscess. The amount of F-words that I dropped between PGY-2 and 3 probably surpasses all the years since then combined.

 

[dpmd]

I used to ask this exact question every time I got called to the ED for a labial abscess. The amount of F-words that I dropped between PGY-2 and 3 probably surpasses all the years since then combined.

Omg yes. Why am I the one draining these things?

 

[GassYous]

As a medicine intern doing a month in the ed we were having a quiet weekend morning shift when we get a patient with previous section who was brought in by ambulance tachycardic and hypotensive. Duri g resuscitation, free fluid was noted in the abdomen. Of note she was third trimester. Ob refused to come down to the ed to see her despite strong suspicion for uterine rupture and the on call trauma attending took her to the or. Ob finally showed up to see the patient in the or when the trauma attending called them intraop.

 

[Matthew9Thirtyfive]

As a medicine intern doing a month in the ed we were having a quiet weekend morning shift when we get a patient with previous section who was brought in by ambulance tachycardic and hypotensive. Duri g resuscitation, free fluid was noted in the abdomen. Of note she was third trimester. Ob refused to come down to the ed to see her despite strong suspicion for uterine rupture and the on call trauma attending took her to the or. Ob finally showed up to see the patient in the or when the trauma attending called them intraop.

How do they get away with that?

 

[HighPriest]

Omg yes. Why am I the one draining these things?

I drain them too, but we’re probably talking about different things.

 

[dpmd]

I drain them too, but we’re probably talking about different things.

The other labia lol. Though I have been called for various facial abscesses because we have no on call ent. I mostly won't **** with those. The hospital's lack of funding a call schedule for those specialties does not turn me into one.

 

[heybrother]

My last day of my general surgery rotation I'm with this lady general surgeon who was considered to be the best/fastest (and nicest!?!?) surgeon at the hospital. She's scheduled for 4 cases and she's known for like a consistent 25 minute lap chole. However, everytime she leaves the OR between cases she comes back with another case. Farewell being done before noon. Anyway, 8th case.

Drug addict with multiple kids already taken away by CPS. Went clean for pregnancy. Uneventful c-section. Back on the rock. "Hi, I have green drainage." Dehisces the c-section. Obgyn says it could be an abdominal wall abscess or something and ...refuses to see it. CPS takes just delivered child away. Patient is balling while being sedated.

So the general surgeon is cleaning it out.

Anyway. There's a medical student in the room doing like an anesthesia rotation but they just matched to obgyn.

The entire case the general surgeon just keeps saying variations of the medical students name and the following (name changed).

Johnny, Johnny, Johnny. You would never do this to me. No, no, no. You would see your patient.
Student: No, I would not.
No, no, no, you would not do this to me.

 

[HighPriest]

Patient with “frontal sinus headache” (one of the most abused diagnoses in primary care). No sinus symptoms other than transient pain in the forehead. Primary actually got a CT, which is amazing. CT demonstrated not only no sinusitis, but no frontal sinuses (10% of the population doesn’t have one or both. It’s not even that uncommon). Note says the PCP is concerned that the lack of frontal sinuses may be the cause of the headache, see ENT for recommendations.

Like...what? You want me to drill her some frontal sinuses? Is there a possibility her headache isn’t a sinus issue?

 

[VA Hopeful Dr]

Patient with “frontal sinus headache” (one of the most abused diagnoses in primary care). No sinus symptoms other than transient pain in the forehead. Primary actually got a CT, which is amazing. CT demonstrated not only no sinusitis, but no frontal sinuses (10% of the population doesn’t have one or both. It’s not even that uncommon). Note says the PCP is concerned that the lack of frontal sinuses may be the cause of the headache, see ENT for recommendations.

Like...what? You want me to drill her some frontal sinuses? Is there a possibility her headache isn’t a sinus issue?

She doesn't have sinuses you heartless jerk, how could that not cause terrible headaches? Make her some with a 3D printer and implant them so then she'll have no reason to ever have a headache again for the rest of her life!

Sarcasm aside, do y'all want CTs before we send chronic/recurrent sinus people to you? I haven't been doing that since I had thought the ENTs liked to do their own since from what I remember you focus much more on the actual anatomy. If I'm mistaken I'll need to adjust how I do things.

 

[HighPriest]

She doesn't have sinuses you heartless jerk, how could that not cause terrible headaches? Make her some with a 3D printer and implant them so then she'll have no reason to ever have a headache again for the rest of her life!

Sarcasm aside, do y'all want CTs before we send chronic/recurrent sinus people to you? I haven't been doing that since I had thought the ENTs liked to do their own since from what I remember you focus much more on the actual anatomy. If I'm mistaken I'll need to adjust how I do things.

So, lots of factors there:

If your ENT owns a scanner, he will want to do it himself.

If the patient has atypical symptoms (meaning not: stuffy nose, PND, Rhinorrhea, facial pain and pressure, etc), then I like a CT but ONLY if you’re going to look at it and not send the patient to me for sinusitis if it’s normal. Meaning: if it’s just headache and the Ct is normal, and the patient is symptomatic, congrats, you have ruled out sinusitis. No need to make the patient pay a copay for me to tell them that).

There is data showing that the most COST EFFECTIVE time to do a sinus CT is before ENT referral, but that assumes you will act upon the results before the patient gets here.

If the patient has chronic symptoms (3 months duration) a CT is nice up front.
If the patient has recurrent symptoms, ththe CT is nice when symptomatic.

I definitely read 100% of my scans personally. Radio graphic “polyps” and “sinusitis” frequently do not correlate to actual sinus problems (just like all fluid in the mastoid is “mastoiditis,” but 99.9% of it doesn’t matter. So if your ENT doesn’t have access to your system, then I would hold on a scan.
Ive worked with really amazing, Head and Neck Fellowship trained radiologists who could read a scan and basically highlight everything I could care about, and I’ve worked with guys who I’m pretty sure are drunk and looking at the scan in a mirror without their glasses. But I read all of them myself anyway.

 

[HighPriest]

Make her some with a 3D printer and implant them so then she'll have no reason to ever have a headache again for the rest of her life!

We’ll just order a frontal lobectomy to make some room and pop a hole up through the skull base. BAM - no more headache complaints.

 

[doyouhaveaflag]

My colleague on ACS got a ridiculous one from the ED today.

Patient came in with abdominal pain and CT A/P was obtained. ED resident called ACS to evaluate the "entrapped bowel" she saw on the CT. Turns out that "entrapped bowel" was patient's stoma, which appeared to be just fine and with normal output.

 

[TypeADissection]

My colleague on ACS got a ridiculous one from the ED today.

Patient came in with abdominal pain and CT A/P was obtained. ED resident called ACS to evaluate the "entrapped bowel" she saw on the CT. Turns out that "entrapped bowel" was patient's stoma, which appeared to be just fine and with normal output.

I have lost count if I could recall the number of times I have seen a consult for absolutely nothing, where I also knew for a fact that the EM resident/attending never even really examined the patient and just ordered a scan; and then called me usually after a Radiologist said they couldn't rule something out. So at least the ED resident in this case looked at the scan, so many during my residency wouldn't even do that.

ED Places CT Scanners at Entrance | GomerBlog

A fun ride to start your ED experience!

gomerblog.com

 

[longhaul3]

I respect radiologists' expertise but radiology reports are the bane of my existence. At one of my hospitals I'd say 50% of the consults I get from the ED are patients who had an outpatient CT or MRI for any number of unrelated indications and were told to report immediately to the ED for "cord compression" or "compression fracture."

Also, how about ridiculous non-consults? Last year there was a code 1, GCS 3 with obviously mangled face; nobody paged neurosurgery, trauma surgeon calls 15 minutes later asking if we know about this patient...who has already been paralyzed, intubated, and scanned with a huge operative bleed and blown pupils.

 

[HighPriest]

I got called to evaluate dysphonia on a guy who was trached and sedated and on a ventilator for a massive base of tongue tumor. He was on palliative care.

But he died a couple hours later so I didn’t have to write a note.

Now we’ll never know for sure why he couldn’t speak.

 

[LucidSplash]

Consult from ED for an 80yo patient who came in w/chest pain. Had a history of AAA repaired by EVAR a few years ago. Got a CTA TAP for ?? Indication. Everything looked great no endoleak. Consulted because there was still an aneurysm sac and “shouldn’t that be gone?”

Not with an EVAR friend.

 

[HighPriest]