Consults- Memorable/Dismal/Ridiculous/Unique

[Lem0nz]

I'm an ENT and I've only done three. Good /bad for you, I suppose.

My mortality rate is 60%. :\ It is what it is I guess.

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[dpmd]

My mortality rate is 60%. :\ It is what it is I guess.

The very first one I did as a second year resident about 6 months in I did a technically flawless performance and the patient lived without any complications. Then a few months later he killed his wife and mother in law in front of their children. I kinda wished I had ****ed up and given him brain damage or killed him.

 

[deleted50541]

I basically did this case except there was no chest tube present and no one ever considered asking thoracic to do it. I did call thoracic when I could not for the life of me reduce the stomach out of the chest but they were reluctant to get involved. I ended up making the gastric perforation bigger within the chest (from below of course because I wasn't about to open the chest) so I could empty the stomach out at which point I finally got it to fit through the opening in the diaphragm but was left with a question of what to do with the chest that had all that vegetative gastric contents evacuated into it. I washed out from below as best as I could but she ended up needing a VATS later to clean it out some more. Not sure that would have been avoided had they done something at my surgery though.

As others said, I don't hesitate to come and help if someone calls for it. I helped MIS out at 2AM with a similar case that was about a week out from a lap fundoplication and HH repair. Elderly lady who was vomiting at home and had the repair fail, leading to gastric incarceration and perforation into both pleural spaces. I did a thoracotomy with the MIS attending, repaired the perf and hiatus, then washed her out well. MIS then did a lap gastropexy.

I did two more cases like this in the last two months. I'm becoming the regional expert on perforated intra-thoracic fundoplications.

In your case dpmd, did you consider dividing the left crus to help reduce the stomach? I know it can sometimes be a tight space to work in with incarcerated viscera, but that's what I would've tried if I wasn't making any headway. It's easy to repair and is unlikely to impact diaphragm function. Gastric decompression is a good last resort measure if all else fails.

If you didn't feel like you'd washed out the pleural space well enough either, thoracic could've at least helped ensure adequate chest drainage or even done a quick look with a scope. Better than coming back for her decort a week or two later.

 

[Lem0nz]

As others said, I don't hesitate to come and help if someone calls for it. I helped MIS out at 2AM with a similar case that was about a week out from a lap fundoplication and HH repair. Elderly lady who was vomiting at home and had the repair fail, leading to gastric incarceration and perforation into both pleural spaces. I did a thoracotomy with the MIS attending, repaired the perf and hiatus, then washed her out well. MIS then did a lap gastropexy.

I did two more cases like this in the last two months. I'm becoming the regional expert on perforated intra-thoracic fundoplications.

In your case dpmd, did you consider dividing the left crus to help reduce the stomach? I know it can sometimes be a tight space to work in with incarcerated viscera, but that's what I would've tried if I wasn't making any headway. It's easy to repair and is unlikely to impact diaphragm function. Gastric decompression is a good last resort measure if all else fails.

If you didn't feel like you'd washed out the pleural space well enough either, thoracic could've at least helped ensure adequate chest drainage or even done a quick look with a scope. Better than coming back for her decort a week or two later.

What might work really well for that is divide the crus with a reinforced staple load and then you can use the seamguard reinforcement to hold stitches instead of pledgets. I do that for the SCM in the neck when I need to get much larger exposure. Doesn't shred the muscle.

Also googled the staple load because I couldn't remember the word seamguard from a TIA but when I did I found this little beast. Didn't even know this thing existed. What a weird stapler. Endo GIA™ Radial Reload with Tri-Staple™ Technology | Medtronic

Has anyone used this thing?

 

[dpmd]

As others said, I don't hesitate to come and help if someone calls for it. I helped MIS out at 2AM with a similar case that was about a week out from a lap fundoplication and HH repair. Elderly lady who was vomiting at home and had the repair fail, leading to gastric incarceration and perforation into both pleural spaces. I did a thoracotomy with the MIS attending, repaired the perf and hiatus, then washed her out well. MIS then did a lap gastropexy.

I did two more cases like this in the last two months. I'm becoming the regional expert on perforated intra-thoracic fundoplications.

In your case dpmd, did you consider dividing the left crus to help reduce the stomach? I know it can sometimes be a tight space to work in with incarcerated viscera, but that's what I would've tried if I wasn't making any headway. It's easy to repair and is unlikely to impact diaphragm function. Gastric decompression is a good last resort measure if all else fails.

If you didn't feel like you'd washed out the pleural space well enough either, thoracic could've at least helped ensure adequate chest drainage or even done a quick look with a scope. Better than coming back for her decort a week or two later.

I opened the prior repair which let me get my hand up into the chest but was reluctant to make the opening any bigger. However this sounds like when I had a rectally inserted foreign body that I couldn't get out from below and also couldn't move it proximal to remove through sigmoid and I phoned a friend who had me divide the rectovesical fascia and then was able to move it. Once you learn it the trick sounds easy but if you don't know about it you don't think of it.

As for the washout I irrigated a ton and even used laps to make sure I cleaned out all the debris (and it was really easy to do so with the stomach out of the way and with the giant defect open) then left a big chest tube positioned by my hand from within the chest which is why I don't know what more could have been done at the time.

 

[dpmd]

What might work really well for that is divide the crus with a reinforced staple load and then you can use the seamguard reinforcement to hold stitches really well instead of pledgets. I do that for the SCM in the neck when I need to get much larger exposure. Doesn't shred the muscle.

Also googled the staple load because I couldn't remember the word seamguard from a TIA but when I did I found this little beast. Didn't even know this thing existed. What a weird stapler. Endo GIA™ Radial Reload with Tri-Staple™ Technology | Medtronic

Has anyone used this thing?

I had no idea that existed but I could see where it would come in handy especially in a narrow male pelvis

 

[Lem0nz]

I had no idea that existed but I could see where it would come in handy especially in a narrow male pelvis

I was thinking it might be nice through a gelport to divide the distal esophagus on a total gastrectomy.

 

[dpmd]

I was thinking it might be nice through a gelport to divide the distal esophagus on a total gastrectomy.

I don't do those but yeah

 

[Dr.LeoSpaceman]

I was thinking it might be nice through a gelport to divide the distal esophagus on a total gastrectomy.

This is what I've used them for, as well as the pelvis. That being said, I've mostly done hand-assist LARs where the Echelon Contour works just as well.

Don't quote me on it, but I thought some of the thoracic guys would use them on VATS lung resections.

 

[ThoracicGuy]

This is what I've used them for, as well as the pelvis. That being said, I've mostly done hand-assist LARs where the Echelon Contour works just as well.

Don't quote me on it, but I thought some of the thoracic guys would use them on VATS lung resections.

It is generally marketed for that. I've never actually used that load before, though.

 

[deleted50541]

It is generally marketed for that. I've never actually used that load before, though.

Same. Never used it and I'm not sure we even stock it since we mostly use Covidien staplers.

I did use a linear 30 mm TX stapler that other day to divide the BI on a bi-lobectomy for a metastatic melanoma. Tried it VATS, but immunotherapy/radiation had made a mess of things and had to open. Hadn't used that stapler in a while, but I still love the weight of it and the satisfying "chunk" it makes when you fire it.

 

[WinslowPringle]

ED at 0300: “So I wanted to give you a heads up on this guy. I think he has a type B or maybe a rupture or something. I think you’ll have to take him to the OR. He looks really sick.”
Me: “What’s going on?”
ED: “He’s having pain and just looks sick. He’s on his way to the scanner. Labs are pending. But he has abdominal pain.”
Me: “What are his vitals? Pulses? Exam?”
ED: “BP 150s, HR 70s. I didn’t get a chance to check pulses. But he’s had prior vascular stents, and with all this pain he’s having, I think it could be something big, maybe his aorta. He’s grey and sweaty.”
Me: “Ok......”
ED: “You don’t have to see him yet! I’m not putting in for a consult now; he’ll be done with the scan in a sec. This is just a heads up call in case the CT scan does show something.”
Me: .....”Ok. Please call me when he’s back.”

.....CT and labs were stone cold normal. He normal pulses. Acute case of dilaulipenia.

 

[Neopolymath]

ED at 0300: “So I wanted to give you a heads up on this guy. I think he has a type B or maybe a rupture or something. I think you’ll have to take him to the OR. He looks really sick.”
Me: “What’s going on?”
ED: “He’s having pain and just looks sick. He’s on his way to the scanner. Labs are pending. But he has abdominal pain.”
Me: “What are his vitals? Pulses? Exam?”
ED: “BP 150s, HR 70s. I didn’t get a chance to check pulses. But he’s had prior vascular stents, and with all this pain he’s having, I think it could be something big, maybe his aorta. He’s grey and sweaty.”
Me: “Ok......”
ED: “You don’t have to see him yet! I’m not putting in for a consult now; he’ll be done with the scan in a sec. This is just a heads up call in case the CT scan does show something.”
Me: .....”Ok. Please call me when he’s back.”

.....CT and labs were stone cold normal. He normal pulses. Acute case of dilaulipenia.

Heads up call should be a fireable offense. Don't do that **** to your colleagues!

 

[Apollyon]

ED at 0300: “So I wanted to give you a heads up on this guy. I think he has a type B or maybe a rupture or something. I think you’ll have to take him to the OR. He looks really sick.”
Me: “What’s going on?”
ED: “He’s having pain and just looks sick. He’s on his way to the scanner. Labs are pending. But he has abdominal pain.”
Me: “What are his vitals? Pulses? Exam?”
ED: “BP 150s, HR 70s. I didn’t get a chance to check pulses. But he’s had prior vascular stents, and with all this pain he’s having, I think it could be something big, maybe his aorta. He’s grey and sweaty.”
Me: “Ok......”
ED: “You don’t have to see him yet! I’m not putting in for a consult now; he’ll be done with the scan in a sec. This is just a heads up call in case the CT scan does show something.”
Me: .....”Ok. Please call me when he’s back.”

.....CT and labs were stone cold normal. He normal pulses. Acute case of dilaulipenia.

Alcohol residents - the cause and solution to all life's hospital problems.

 

[deleted50541]

Sounds like a consult I had recently.

Medicine resident: "Hi, we need a thoracic consult for a possible SC joint infection."
Me: "Ok"...*sighs* (the memory of prior SC joints and the patients attached to them coming back to haunt me).
Resident: "This is an IV drug abuser with cirrhosis c/o severe arm and shoulder pain. We think he has endocarditis too and his SC joint does not look good."
Me: *Scrolling through CT, labs and TTE* "I'm not seeing anything concerning so far."
Resident: "The joint looks pretty swollen and bad. We'd really appreciate it if you'd see him. Our attending said he's never seen an SC joint infection before and doesn't know how to manage it."
Me: "Sure thing. Get some IV antibiotics going and I'll see him in the morning." (It's already past 1900. I ain't coming in for this.)
Resident: "Great, thank you."

Sure enough, joint is totally unremarkable on exam and imaging. He's got cellulitis in the attached arm up to his deltoid and track marks/sores everywhere. He's also doped out of his gourd on all the Dilaudid/Ativan they gave him to sit through an MRI of his spine. Nothing to support endocarditis either.

I write my note ("thank you for this interesting consult") and sign off. Turns out he left AMA later that day and then promptly came back to the ED demanding more Dilaudid. He was quickly escorted back out of the hospital after refusing any kind of exam.

 

[HighPriest]

Got a call for epiglottitis. 22 year old. The ED doc is “really worried about her.” She has a “hot potato voice and everything.” He had a plain film. Looked normal to me, but the radiologist thinks maybe the epiglottis looks a little bigger than it should. So I came in. At night. Patient is 22, 350 lbs. she’s laying supine, texting on her phone, laughing at something her mother said. She’s not even on pulse oximetry. She’s not short of air, she’s not in a sniffer position, she’s tolerating her secretions. She’s had a sore throat for three days. I asked her if her voice sounded different and both she and her Mom said it did not.

Normal exam. Normal NP scope.

Told the ER doc it isn’t epiglottitis because she has none of the clinical symptoms of epiglottitis. He asked about her voice and I told him that isn’t a hot potato voice. She’s just fat.

 

[robellis]

Got a call for epiglottitis. 22 year old. The ED doc is “really worried about her.” She has a “hot potato voice and everything.” He had a plain film. Looked normal to me, but the radiologist thinks maybe the epiglottis looks a little bigger than it should. So I came in. At night. Patient is 22, 350 lbs. she’s laying supine, texting on her phone, laughing at something her mother said. She’s not even on pulse oximetry. She’s not short of air, she’s not in a sniffer position, she’s tolerating her secretions. She’s had a sore throat for three days. I asked her if her voice sounded different and both she and her Mom said it did not.

Normal exam. Normal NP scope.

Told the ER doc it isn’t epiglottitis because she has none of the clinical symptoms of epiglottitis. He asked about her voice and I told him that isn’t a hot potato voice. She’s just fat.

Hahhahahaha

 

[LucidSplash]

It is possible that once in residency, after a string of “heads up” late night calls from a certain ED resident who was notorious for them and also for whatever they called about to be a big nothingburger, that one day (during the actual daytime) there was a minor car accident in front of the hospital. Which we could see from our surgery residents lounge. And I may have called the ED specifically to give that resident a “heads up” that there was a car accident near the hospital and that they might or might not see some patients from it because from up here it looks like the wheel and the bumper are pretty messed up and it could be a high velocity situation but I wasn’t sure but wanted to be sure they were aware as early as possible.

Said resident did not understand the joke.

Hypothetically speaking - can not confirm I actually did this because even though I graduated at least 4 years ago I can’t swear I wouldn’t still get called into the PD’s office for it.

 

[deleted50541]

As a fellow, my PD called me that he'd received a complaint from a nurse in the ED about me. The patient she was treating had a type A dissection.

Of course, I get the page at quarter to 5PM, right as we're finishing our second cardiac case of the day and anesthesia/staff are looking to bounce. I scramble to tell the staff to prep a room for an emergent dissection and I grab an anesthesia resident to come with me to get the patient from the ED. I get down there and see his BP his sky high with no nurse in site. I start explaining the situation to the patient as anesthesia starts packing the guy up to move. The patient is not looking good and says do whatever we have to.

So we start moving the guy and his nurse suddenly appears and asks what's happening. I said, probably curtly given my chronic sleep deprivation, that this guy has a dissection and we need to move now. She starts going off on me that she hasn't done a full assessment and knows nothing about surgery. Not in the mood to argue, I tell her to get out of our way as anesthesia and I keep rolling with the patient to the OR. Straight forward case and patient does well.

PD tells me about the complaint that I was rude to the nurse and says he has to provide a response. Then he asks, "so, did the patient live?". "Yes, sir" (he was the attending actually, but we did so many dissections that it was hard to keep track sometimes). "Great", he said and gave me a big smile. "Don't worry about it, this makes my job much easier then".

I don't know what he said exactly or to whom, but I could tell he loved to pick fights with administration, especially if he felt we were in the right.

 

[TypeADissection]

"...I can’t swear I wouldn’t still get called into the PD’s office for it."

I have been called into the principal's Program Director's office 3 times as a general surgery resident and told, "TAD, you can't call people stupid." This is actually a direct quote and even as I write this, I can see his face and hear his voice. My reply was usually, "But Dr. PD, I didn't tell the EM Resident/Attending that they were stupid, I just said that their plan was stupid." Man oh man, those PGY-2 & 3 years took me to some really dark places. I'm a socially adaptable curmudgeon, but the crucible of junior residency just cranked my baseline levels of snark to an 11.

 

[deleted50541]

Man oh man, those PGY-2 & 3 years took me to some really dark places. I'm a socially adaptable curmudgeon, but the crucible of junior residency just cranked my baseline levels of snark to an 11.

This hits me right in the feels as a former CT surg fellow. I'm usually pretty quiet and reserved, but fellowship really tried my patience some days. The OR staff couldn't wait to hear my next rant whenever my pager went off with the newest disaster.

 

[Chillbo Baggins]

I have been called into the principal's Program Director's office 3 times as a general surgery resident and told, "TAD, you can't call people stupid." This is actually a direct quote and even as I write this, I can see his face and hear his voice. My reply was usually, "But Dr. PD, I didn't tell the EM Resident/Attending that they were stupid, I just said that their plan was stupid." Man oh man, those PGY-2 & 3 years took me to some really dark places. I'm a socially adaptable curmudgeon, but the crucible of junior residency just cranked my baseline levels of snark to an 11.

A resident in our program was off service on gen surg trauma first thing intern year: I can't remember the exact details, but at one point just a week or two into July he was dealing with simultaneous traumas and this notoriously bad ED attending was causing flak while he was trying to take care of the patients. Eventually they got into a spat and he told the ED attending she "wasn't a real doctor."

The next day he was rounding with one of the trauma attendings and was recounting the story to get ahead of any trouble. After he finished, the trauma attending looked at him and said simply, "Oh no, you're totally right: she's not a real doctor, she's terrible." Resident never got in trouble and that ED attending has since been banished to the graveyard shift.

 

[Chillbo Baggins]

So there's 2 main hospitals in town and while residents from all other specialties have all moved over to the big one, ortho's main operation is still out of the other. Unfortunately, this kind of screws us at the little hospital because the ED and nurses and everyone know that we're the only residents in house at night, so they'll bother us with stuff that they wouldn't for any other service. Sometimes they'll even call about patients that other teams are primary on because they know we'll answer and they don't have to page an attending. To help circumvent the BS, we started taking a harder stance on things we really don't need to see and that they can temporize and send to clinic. It hasn't always gone as planned.

*early on in a night float shift, trolling the ED board

*sees patient with c/o GSW to leg

*ED documentation says fully NV intact, pain with plantarflexion

*XR negative

*knows no ortho intervention necessary, goes on with reading ESPN or whatever

*ED page

"Hey, yeah, got this guy down here, shot himself in the leg-"

"Oh yeah, I took a look at the XRs, didn't see anythi-"

"Are you gonna come see him?"

"...well, there's no bony involvement. (playing dumb that I didn't already read their note) What's his exam like? Any active bleeding?"

"All his muscles seem to be working, no bleeding, and he's got 2+ DP and PT."

"What about sensation?"

"Intact in the whole foot."

'Ok, so what's the concern?"

"Can you just come see him?"

"I'm just trying to figure out what the orthopedic concern is, since you just said he's completely NV intact. What do you want me to evaluate?"

"I don't know, the nerves, muscles, tendons?"

"So you're saying you don't trust your own exam? I'm confused."

"ARE YOU GONNA SEE THE PATIENT OR NOT"

"Yeah yeah, I'll come see him, but it'll be a bit." (I always dragged my feet with anything to help perpetuate the idea we weren't in house)

"Ok. *click*"


In the resident's defense, it was a decent size whack that I threw a WTD on and would probably benefit from a STSG down the road, but still something that didn't actually require me to lay eyes on it.

 

[DOVinciRobot]

At our facility there is a group of trauma NPs that cover trauma patients that don’t require SICU level of care. They are notorious for pan-scanning people once they hit the floor and blasting out consults for every incidental finding. This week alone I got a consult for “incidental SMA stenosis, please provide recs” (40% stenosis and completely asymptomatic) and on Friday at about 5:45 PM got this little number.

NP: so we got this guy up here with a GSW to the leg. We want you to come take a look at him.

Me, thinking it’s for vascular compromise of the leg: oh dang ok I’ll grab my chief and we’ll be right up. What’s his NV exam like?

NP: oh it’s normal, he’s been up here for a few days and he’s fine, probably will be discharged soon. We want you to come evaluate his aorta though.

Me: oh ok, what’s going on?

NP: well we were reading the report of the CTA we did when he got here and they comment that he has an AAA. We just noticed it now. They say his aorta is dilated to 26 mm, can you come evaluate?

me: ……….

My chief was thrilled when I called to inform her we had one more patient to see before we could sign out.

 

[Matthew9Thirtyfive]

At our facility there is a group of trauma NPs that cover trauma patients that don’t require SICU level of care. They are notorious for pan-scanning people once they hit the floor and blasting out consults for every incidental finding. This week alone I got a consult for “incidental SMA stenosis, please provide recs” (40% stenosis and completely asymptomatic) and on Friday at about 5:45 PM got this little number.

NP: so we got this guy up here with a GSW to the leg. We want you to come take a look at him.

Me, thinking it’s for vascular compromise of the leg: oh dang ok I’ll grab my chief and we’ll be right up. What’s his NV exam like?

NP: oh it’s normal, he’s been up here for a few days and he’s fine, probably will be discharged soon. We want you to come evaluate his aorta though.

Me: oh ok, what’s going on?

NP: well we were reading the report of the CTA we did when he got here and they comment that he has an AAA. We just noticed it now. They say his aorta is dilated to 26 mm, can you come evaluate?

me: ……….

My chief was thrilled when I called to inform her we had one more patient to see before we could sign out.

EqUaL oR bEtTeR cARe

 

[HighPriest]

EqUaL oR bEtTeR cARe

Well, to be fair, if your metric for care is that the patient has his medical concerns addressed, then it’s equal. Because they’re just going to call you down for every medical concern, and then let you manage it on their behalf.

 

[Matthew9Thirtyfive]

Well, to be fair, if your metric for care is that the patient has his medical concerns addressed, then it’s equal. Because they’re just going to call you down for every medical concern, and then let you manage it on their behalf.

Don’t give them any ideas for a new study.

 

[HighPriest]

I’m just saying: let’s say you have a diner, and the restaurant across the street sells the best soup in town. It’s not that hard for you to sell the best soup in town, you just buy all of their soup and resell it. Business 101.

 

[DocSurgeon]

Started a new job this month. Really loving it so far but noticed a number of referrals from corporate satellite urgent cares, some same day, for abscess I&D’s. These aren’t brain busters, I’m talking throw a dart from the other side of the room drainage. Now this is fine with me. Easy money. But I can’t help but feel like the Bob’s looking at these urgent care docs’ charts wondering, “What would you say you do here.”

 

[HighPriest]

Started a new job this month. Really loving it so far but noticed a number of referrals from corporate satellite urgent cares, some same day, for abscess I&D’s. These aren’t brain busters, I’m talking throw a dart from the other side of the room drainage. Now this is fine with me. Easy money. But I can’t help but feel like the Bob’s looking at these urgent care docs’ charts wondering, “What would you say you do here.”

$&@t, that’s half my referrals. I had a patient come in the other day for a 2 year cough. PCP had done literally nothing. No CxR, no abx, no steroids, not even an inhaler. I asked her what her PCP had done for her, and her response was matter-of-fact: “Oh, nothing. She doesn’t do anything. She just refers me places.”

So…why not just have, like, a vending machine for referrals?

Like in Japan, you can order Ramen some places by just clicking buttons to indicate what you want in it, you hit enter, you pay, and it provides you a receipt to go get your Ramen.

Why not just have primary/urgent care replaced by these? You enter you symptoms, pay, hit enter, and it spits out a referral and a z-pack. Why pay people to do this?

 

[VA Hopeful Dr]

$&@t, that’s half my referrals. I had a patient come in the other day for a 2 year cough. PCP had done literally nothing. No CxR, no abx, no steroids, not even an inhaler. I asked her what her PCP had done for her, and her response was matter-of-fact: “Oh, nothing. She doesn’t do anything. She just refers me places.”

So…why not just have, like, a vending machine for referrals?

Like in Japan, you can order Ramen some places by just clicking buttons to indicate what you want in it, you hit enter, you pay, and it provides you a receipt to go get your Ramen.

Why not just have primary/urgent care replaced by these? You enter you symptoms, pay, hit enter, and it spits out a referral and a z-pack. Why pay people to do this?

From the primary care side, ENT referrals are the most frustrating. Yesterday I had a patient call demanding an ENT referral for a hoarse voice. She has never seen me about this before and its only been going on for about 2-3 weeks. Offered her an appointment which she refused and said if I didn't place the referral she'd find a doctor who would. I think you can guess what I did.

I wish I had a way to pre-warn our ENTs about patients like this as this is not a rare occurrence and I'd rather not be thought of as either lazy or incompetent.

 

[HighPriest]

From the primary care side, ENT referrals are the most frustrating. Yesterday I had a patient call demanding an ENT referral for a hoarse voice. She has never seen me about this before and its only been going on for about 2-3 weeks. Offered her an appointment which she refused and said if I didn't place the referral she'd find a doctor who would. I think you can guess what I did.

I wish I had a way to pre-warn our ENTs about patients like this as this is not a rare occurrence and I'd rather not be thought of as either lazy or incompetent.

I realize this happens. I see it mentioned in notes (patient demanded referral). I don’t blame PCPs for this. I also know it doesn’t account for every completely unworked up patient that I see.

More often than not, either the patient was seen at urgent care and just sent straight to us, no questions asked and really no history taken, or they were seen by their PCP with four medical issues, three of which are clearly documented and detailed in their note with appropriate medical planning, and then there’s the ENT problem for which it just says “refer to ENT.”

But a very large number read like this:
S:
Patient presents with: “sinus” “HTN” “constipation” “rash” (more often than not no symptoms are mentioned)

O: completely normal, boilerplate exam

A: Sinus, HTN, Constipation, Rash

P:
Sinus: REFER TO ENT
HTN: refill medicine
Constipation: REFER TO GI
Rash: REFER TO DERMATOLOGY

I wish that only happened sometimes, but it does not. And to be fair 9/10 it’s an NP or PA.

But when a patient frustratedly tells me their PCP doesn’t do anything for them and just refers them all over the place, that’s not a glowing recommendation. And that happens fairly often as well. Again, usually with an NP or PA. But not entirely.

I saw a guy yesterday (and this is also a common scenario): he saw his NP for sinusitis. She took a (weird) history, sent him for a CT, saw him back after the CT, CT showed sinusitis, and she then sent him to me. Didn’t even try an antibiotic or rinse or anything. I can’t seem to figure a good reason for not at least trying to treat him once you’ve seen him three or four times for a basic problem. So I see him, put him on an antibiotic, and that’s it. 80% of the time he’s done. And yet I’m booked out 6 weeks. Which means two things: 1-it took this guy 6 more weeks of having a sinus infection to get treatment he could have had at his first appointment, and 2-the guy who actually needs sinus surgery is still waiting another 5 weeks. And then he’s pissed when he sees me.

 

[TypeADissection]

But I can’t help but feel like the Bob’s looking at these urgent care docs’ charts wondering, “What would you say you do here.”

Urgent Care Provider: Well look I already told you! I deal with the gosh darn patients so that the ER doesn't have to. I have people skills! I am good at dealing with patients! Can't you understand that?!?! WHAT THE HELL IS WRONG WITH YOU PEOPLE?!?!

 

[Wordead]

$&@t, that’s half my referrals. I had a patient come in the other day for a 2 year cough. PCP had done literally nothing. No CxR, no abx, no steroids, not even an inhaler. I asked her what her PCP had done for her, and her response was matter-of-fact: “Oh, nothing. She doesn’t do anything. She just refers me places.”

So…why not just have, like, a vending machine for referrals?

Like in Japan, you can order Ramen some places by just clicking buttons to indicate what you want in it, you hit enter, you pay, and it provides you a receipt to go get your Ramen.

Why not just have primary/urgent care replaced by these? You enter you symptoms, pay, hit enter, and it spits out a referral and a z-pack. Why pay people to do this?

I have the same experience and find it bewildering. And with the rise in telemedicine it's gotten even worse. PCPs will see people with ear pain and refer. "cannot assess will refer to ENT" like you're too good to see the ****ing patient in person but I can? It's such a waste of everyone's time and money.

From the primary care side, ENT referrals are the most frustrating. Yesterday I had a patient call demanding an ENT referral for a hoarse voice. She has never seen me about this before and its only been going on for about 2-3 weeks. Offered her an appointment which she refused and said if I didn't place the referral she'd find a doctor who would. I think you can guess what I did.

I wish I had a way to pre-warn our ENTs about patients like this as this is not a rare occurrence and I'd rather not be thought of as either lazy or incompetent.

I think we all know that these patients come through your offices and they're pretty obvious when we see them. I doubt any ENT would blame a referral doctor for those. I think there's a clear delineation of PCPs - I see half that have thoughtful notes and attempted treatments (this is how I picked out my PCP actually) and half that clearly put zero thought and are referral machines with dog**** notes. And i wish I could blame it on NPs/PAs but the worst offenders are a select few MDs.

 

[VA Hopeful Dr]

I have the same experience and find it bewildering. And with the rise in telemedicine it's gotten even worse. PCPs will see people with ear pain and refer. "cannot assess will refer to ENT" like you're too good to see the ****ing patient in person but I can? It's such a waste of everyone's time and money.



I think we all know that these patients come through your offices and they're pretty obvious when we see them. I doubt any ENT would blame a referral doctor for those. I think there's a clear delineation of PCPs - I see half that have thoughtful notes and attempted treatments (this is how I picked out my PCP actually) and half that clearly put zero thought and are referral machines with dog**** notes. And i wish I could blame it on NPs/PAs but the worst offenders are a select few MDs.

Can I be a decent PCP but still have dog**** notes?

 

[LucidSplash]

Can I be a decent PCP but still have dog**** notes?

Yes but it is difficult to determine that from a specialist standpoint if it is difficult to tell why you have referred a patient to me, especially when the patient themself isn’t sure. I get a ton of referrals for “PVD” and it can be miserable trying to suss out from the patient what the concern is.

 

[Wordead]

Can I be a decent PCP but still have dog**** notes?

Sometimes. If your notes suck and I ask the patient why they're there and they go "My doctor said to come here and have no idea" then probably not

 

[ThoracicGuy]

Yes but it is difficult to determine that from a specialist standpoint if it is difficult to tell why you have referred a patient to me, especially when the patient themself isn’t sure. I get a ton of referrals for “PVD” and it can be miserable trying to suss out from the patient what the concern is.

Some of the notes I get say almost nothing in the HPI and I just see a one line in the assessment/plan section that says something like PVD and there is nothing elsewhere to suggest what is going on. It's really annoying to see that. Sometimes its something, sometimes its ridiculous.

 

[LucidSplash]

Some of the notes I get say almost nothing in the HPI and I just see a one line in the assessment/plan section that says something like PVD and there is nothing elsewhere to suggest what is going on. It's really annoying to see that. Sometimes its something, sometimes its ridiculous.

Yes. And even the ones that have an HPI, the ones that rely only on NoteWriter in Epic are useless. I use macros for parts of my note but I always dictate the HPI and the A/P part so it is absolutely clear what is going on. If I sent back notes to referring physicians like the ones I receive, no one would have any idea WTF is going on. I completely recognize that PCP see a billion more patients per clinic than I do and spend a lot more time in charting but it is really frustrating to have nothing to go on.

It is especially difficult because I have told my staff to limit the number of vein/leg swelling patients to 2 per clinic because you really have to spend a lot of time with those patients and I can only give my vein/leg edema/lymphedema spiel so many times in a day before I hate the sound of my own voice. (I have considered recording a video and making patients watch it before I come into the room but I’m pretty sure they would hate that). But when the referral and office notes don’t give any clues, it is hard for my staff to follow my instructions.

 

[HighPriest]

Yep. On a good day, at least 10-15% of my patients just need reassurance and usually they need me to tactfully explain why they didn’t actually have the problem for which they were sent to see me. And that’s a good day. Everyone with pain on the side of the head has a middle ear effusion, even if they have no hearing loss or any other clinical signs of effusion. I have gotten in to the habit of asking if the PCP looked in the patient’s ear. Cynical, I know, but I ask it matter-of-factly, and mixed with my routine questions, and I do it because I bet at least 1/3 they’ll say that the PCP never looked. Which, frankly, is skirting fraud.
Everyone with any balance problem whatsoever has vertigo, gets meclizine, and I see them. Including the guy who’s 95, has a bad hip, two knee replacements, complete anesthesia below his knees, three prior strokes, paroxysmal afib, and says he just feels off balance when he tries to go to the bathroom when it’s dark. Vertigo. See the ENT. Take meclizine. That’ll help.

 

[HighPriest]

I know it’s b@&$tching, but at the same time: at some point this stuff HAS to be handled at the PCP level. Because, frankly, there are hundreds of times more of them than there are of us. And you can train more PCPs as long as you have more PATIENTS, but you need real, clinical problems that require an ENT in order to train more ENT docs.
If we decided tomorrow that PCPs we’re just going to be referral machines (and for many they’re not far off already), and that we were going to just have the specialists take care of the issues, you would find the specialty clinics inundated with nonsense. On my bad days up to 80% of the patients in my clinic don’t need a specialist. And we could try to train more ENT docs, but then you need more residency spots. And if you have more residency spots, then you need more patients. And you think: hey, problem solved! There’s a ton more patients because the PCPs are just sending everything along! But no. In order to be an ENT your training needs to be filled with actual ENT issues that you can learn from so that you can do parotids and neck dissections and ear surgeries and sinus surgery. But the volume of these things hasn’t changed because those were always coming in to see us. The upswing is mostly crap the PCP could have managed. So either you don’t get more ENT docs, or you get a bunch of poorly trained ENT docs, or you extend residency to like 9 years.

Filling your garbage disposal with ALL of your garbage doesn’t mean another garbage disposal will fix the problem. It’s meant for kitchen scraps. Not tin cans. Stop putting tin cans in there.

/rant

 

[deleted50541]

Some of the notes I get say almost nothing in the HPI and I just see a one line in the assessment/plan section that says something like PVD and there is nothing elsewhere to suggest what is going on. It's really annoying to see that. Sometimes its something, sometimes its ridiculous.

Drives me nuts. I've noticed that a lot of referral notes recently are literally just the diagnosis codes with "referral to CT surgery" underneath. No HPI, no impression of what might be going on. If I'm lucky, there will be a radiology report along with it. And maybe, just maybe, the actual imaging.

The icing on the cake is when the patient isn't quite sure either why they're seeing me and we have to play 20 questions to suss this mystery out together. Wastes so much time.

 

[WinslowPringle]

Drives me nuts. I've noticed that a lot of referral notes recently are literally just the diagnosis codes with "referral to CT surgery" underneath. No HPI, no impression of what might be going on. If I'm lucky, there will be a radiology report along with it. And maybe, just maybe, the actual imaging.

The icing on the cake is when the patient isn't quite sure either why they're seeing me and we have to play 20 questions to suss this mystery out together. Wastes so much time.

I’m curious - what kind of PCP referrals are you getting in CT surg without imaging being done or sent over? (In GS residency, I didn’t see a ton of CT clinic but enjoyed what I saw; it seemed much less vague not worked up stuff than GS. The cardiac stuff come from the cardiologists pretty much wrapped up w/ cath+ echo at minimum; the thoracic was usually an oncology referral already discussed at tumor board except for the random annoying decort type consult or rare TOS/thymoma/sympathectomy.)

 

[deleted50541]

I’m curious - what kind of PCP referrals are you getting in CT surg without imaging being done or sent over? (In GS residency, I didn’t see a ton of CT clinic but enjoyed what I saw; it seemed much less vague not worked up stuff than GS. The cardiac stuff come from the cardiologists pretty much wrapped up w/ cath+ echo at minimum; the thoracic was usually an oncology referral already discussed at tumor board except for the random annoying decort type consult or rare TOS/thymoma/sympathectomy.)

These are referrals that come outside our system and the pattern seems to be chest wall lesions/injuries. Just yesterday, I saw a referral in clinic that was literally what I described: referral from family practice for rib fractures, brief HPI, A/P listed CPT code for rib fractures and "referral to CT surgery". No report or outside images. Fortunately, the patient brought the disc. But it was just a CXR with limited views. Symptomatic non-union 8 weeks after a fall. Getting a CT for operative planning.

I always look ahead to see what's coming up and tell my office to get the images beforehand so we don't waste time. But there's always some excuse about incompatibility, the patient has the disc, or it's the wrong study I'd want. Happens at least once a week.

I agree though, it's usually pretty straight forward particularly when it comes to cancers that have been thoroughly worked over before getting to me.

 

[HighPriest]

I always look ahead to see what's coming up and tell my office to get the images beforehand so we don't waste time. But there's always some excuse about incompatibility, the patient has the disc, or it's the wrong study I'd want. Happens at least once a week.

Oh yeah. Or you get no images, but a report that is highly dubious in the extent of it vagueness.

 

[TypeADissection]

I recently got a new clinic manager and told him that I've been eating a lot of ass recently with some really bullsh*t referrals. To help sift through the enormous amounts of **** I have been requesting an ABI/PVR because the PCP's note will only say "leg pain" or "leg swelling."

His reply was, "Why is it important to have this testing prior to seeing you? You can see them, then order the test, then see them again and bill for two clinic notes." My reply was something like, "Because that is wildly inefficient, I don't want to listen to sob stories if they have normal perfusion, some of these people drive from a long distance away, and my time is more valuable than billing peanuts for second clinic visit."

It's actually quite gratifying when I have ABI/PVRs that are stone cold normal and I can palpate pulses, because it allows me to shift the entire conversation. It's like having an UNO Reverse card.

 

[HighPriest]

I recently got a new clinic manager and told him that I've been eating a lot of ass recently with some really bullsh*t referrals. To help sift through the enormous amounts of **** I have been requesting an ABI/PVR because the PCP's note will only say "leg pain" or "leg swelling."

His reply was, "Why is it important to have this testing prior to seeing you? You can see them, then order the test, then see them again and bill for two clinic notes." My reply was something like, "Because that is wildly inefficient, I don't want to listen to sob stories if they have normal perfusion, some of these people drive from a long distance away, and my time is more valuable than billing peanuts for second clinic visit."

It's actually quite gratifying when I have ABI/PVRs that are stone cold normal and I can palpate pulses, because it allows me to shift the entire conversation. It's like having an UNO Reverse card.

This is a hill I climb up frequently as well.

“You can bill twice!”

That shouldn’t be the @&$king goal, man. I appreciate getting paid. A lot. But the point here is to get people back to their lives ASAP. Not to waste their time and eat in to the time I could be spending seeing people I can actually help. It’s the point where the business of medicine really cuts in to the ethics or medicine (and increases burnout). Yep. It’s more billing. That doesn’t make it a good thing.

 

[deleted50541]

Oh yeah. Or you get no images, but a report that is highly dubious in the extent of it vagueness.

Exactly. When I get outside reads from East Jesus Hospital that describe a vague lesion I can't see, the first thing I do is have our radiologists review the films. They're usual response is, "I wouldn't have called that". I all also bug my ortho onc colleagues to look at the bones just to affirm I'm not crazy and missing something.

 

[DOVinciRobot]

I recently got a new clinic manager and told him that I've been eating a lot of ass recently with some really bullsh*t referrals. To help sift through the enormous amounts of **** I have been requesting an ABI/PVR because the PCP's note will only say "leg pain" or "leg swelling."

His reply was, "Why is it important to have this testing prior to seeing you? You can see them, then order the test, then see them again and bill for two clinic notes." My reply was something like, "Because that is wildly inefficient, I don't want to listen to sob stories if they have normal perfusion, some of these people drive from a long distance away, and my time is more valuable than billing peanuts for second clinic visit."

It's actually quite gratifying when I have ABI/PVRs that are stone cold normal and I can palpate pulses, because it allows me to shift the entire conversation. It's like having an UNO Reverse card.

In vascular clinic this week I saw two referrals from the same PCP office come for “leg pain with walking.” Pulses easily palpable and the first thing they did when I asked them about it was start grabbing their knee and talking about how hard it is to walk on their knee that “feels like it’s grinding.”

 

[VA Hopeful Dr]

I recently got a new clinic manager and told him that I've been eating a lot of ass recently with some really bullsh*t referrals. To help sift through the enormous amounts of **** I have been requesting an ABI/PVR because the PCP's note will only say "leg pain" or "leg swelling."

His reply was, "Why is it important to have this testing prior to seeing you? You can see them, then order the test, then see them again and bill for two clinic notes." My reply was something like, "Because that is wildly inefficient, I don't want to listen to sob stories if they have normal perfusion, some of these people drive from a long distance away, and my time is more valuable than billing peanuts for second clinic visit."

It's actually quite gratifying when I have ABI/PVRs that are stone cold normal and I can palpate pulses, because it allows me to shift the entire conversation. It's like having an UNO Reverse card.

Our local vascular surgeons require ABIs at minimum as well. That's not unreasonable to my mind.