Consults- Memorable/Dismal/Ridiculous/Unique

[LucidSplash]

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.”

Yeah. I get “leg swelling and pain with walking” too. And then I’m trying to figure out if it is arterial claudication or venous claudication and then I see the patient and their BMI is 55 and it is clearly their knees about to give out “the orthopedic surgeon said he wouldn’t operate unless I lost some weight so my PCP said to see you because of the leg swelling.” News flash, RF ablation can’t magically fix leg edema due to being morbidly obese.

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[TypeADissection]

Exactly. When I get outside reads from East Jesus Hospital that describe a vague lesion I can't see...

Just like a high school girl, sometimes I just can't even. I've lost track of the number of times I've asked for films to be uploaded or send w/ CD. Instead what do I get? A huge stack of nursing notes. I can't think of anything more useless than 30 pages of nursing notes.

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.”

But that's why having pre-visit testing allows me to steer the conversation from the get go rather than trying to terse through a history where the answer to every question is going to be a yes. It keeps me sane and precipitously decreases the number of F-bombs that I drop in a day in my office while dictating.

 

[Dr.LeoSpaceman]

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.

Bonus points when this conversation follows one on difficulty getting patients in to clinic in a timely fashion. You know what makes scheduling easier? Not having patients in for unnecessary visits. The solution isn't just "Well, you can overbook."

 

[HighPriest]

So just today:

28 year old girl. Resting BP is 110/60. She says when she gets out of bed she’s lightheaded for a minute or so. No vertigo. One time she actually feinted.
Saw her PCP who did no exam and diagnosed her with positional vertigo. Did no treatment for this and referred her to me. Took her a month to see me. Of course her neuro exam is normal, Dix-Hallpike is normal, and by now she hasn’t had symptoms for three weeks. I told her I don’t think this has anything to do with her ear and that it’s probably a blood pressure issue and her response was “yeah, I thought it seemed like a blood pressure issue, but they told me I needed to come to see you.”

This is not an uncommon story. It isn’t always the patient demanding to see an ENT. Sometimes it’s just bad doctoring. And her PCP was an MD, not an NP or PA. And she’s not one of these patients who had 30 complaints. This was the only reason she went to see him that day. She takes no medication.

 

[Pir8DeacDoc]

So just today:

28 year old girl. Resting BP is 110/60. She says when she gets out of bed she’s lightheaded for a minute or so. No vertigo. One time she actually feinted.
Saw her PCP who did no exam and diagnosed her with positional vertigo. Did no treatment for this and referred her to me. Took her a month to see me. Of course her neuro exam is normal, Dix-Hallpike is normal, and by now she hasn’t had symptoms for three weeks. I told her I don’t think this has anything to do with her ear and that it’s probably a blood pressure issue and her response was “yeah, I thought it seemed like a blood pressure issue, but they told me I needed to come to see you.”

This is not an uncommon story. It isn’t always the patient demanding to see an ENT. Sometimes it’s just bad doctoring. And her PCP was an MD, not an NP or PA. And she’s not one of these patients who had 30 complaints. This was the only reason she went to see him that day. She takes no medication.

Very common story, unfortunately. I actually get excited to see true vertigo.
I don’t think everyone should know exactly what to send to me. But mercy. Give something a try. Geez

 

[HighPriest]

Very common story, unfortunately. I actually get excited to see true vertigo.
I don’t think everyone should know exactly what to send to me. By mercy. Give something a try. Geez

Yeah I don’t get upset when it’s actual vertigo, but unclear etiology. But when it’s obviously not an ear problem - or when I can read the PCP note end think “oh yeah, this isn’t an ear problem,” that’s frustrating.

 

[HighPriest]

.

 

[WinslowPringle]

Pt is about 4 months out now from a “big whack” surgery. Post op course was uneventful, discharged POD6 or so as is typical for someone of her age and comorbidities. Had been seen in our clinic for the last followup about 3 months ago. Had overall been doing very well.

PCP sends her back to see us in clinic as a “new consult” for hypoalbuminemia. Baseline albumin is like 2.5, after surgery it was 1.8, slowly recovered and is now like 2.3.

I got to write a very nice (imho) note on etiologies of hypoalbuminemia and the general effects of surgeries on lab values.

 

[longhaul3]

Referral for "abnormal MRI lumbar spine" with no further comment, submitted as urgent

MRI lumbar spine demonstrates large partially imaged pelvic mass

Thank you for allowing us to participate in the care of this patient
RTC prn

 

[dpmd]

Referral for "abnormal MRI lumbar spine" with no further comment, submitted as urgent

MRI lumbar spine demonstrates large partially imaged pelvic mass

Thank you for allowing us to participate in the care of this patient
RTC prn

Im assuming you are a spine surgeon. How frustrating.

 

[longhaul3]

Im assuming you are a spine surgeon. How frustrating.

Yeah. Also one from the same day "patient states she has a brain tumor, evaluate and treat." No imaging. Patient shows up and has no idea why she's in our office.

Clinic is the worst. I know some of you ENT/urology folks do a lot of office procedures, some of which sound pretty interesting, but I can't imagine being an outpatient doctor and doing clinic all day every day.

 

[Pir8DeacDoc]

Called to the ICU on Friday afternoon for brisk left sided epistaxis. Ok so not abnormal consult. I review the chart. INR is 16. So I mention to hospitalist that's not compatible with me stopping the bleeding. But....cardiology has insisted we not reverse or attempt to reverse as pt could develop thrombus on their mechanical mitral valve. I place nasal packing. Nose improves but still bleeding. I tell cards "sir he may develop thrombus but without ffp he's going to bleed to death and that thrombus won't be a huge concern." I mean there are a lot of INR values between 16 and 3 that are more compatible with controlling his epistaxis and keeping his valve happy. Common sense doesn't seem so common sometimes

 

[LucidSplash]

Called to the ICU on Friday afternoon for brisk left sides epistaxis. Ok so not abnormal consult. I review the chart. INR is 16. So I mention to hospitalist that's not compatible with me stopping the bleeding. But....cardiology has insisted we not reverse or attempt to reverse as pt Could develop thrombus on their machanical mitral valve. I place nasal packing. Nose improves but still bleeding. I tell cards "sir he may develop thrombus but without ffp he's going to bleed to death and that thrombus won't be a huge concern." I mean there are a lot of INR values between 16 and 3 that are more compatible with controlling his epistaxis and keeping his valve happy. Common sense doesn't seem so common sometimes

Gotta love the “make the bleeding stop without making the blood clot” consults. 🤦🏼‍♀️

 

[HemeOncHopeful19]

Called to the ICU on Friday afternoon for brisk left sides epistaxis. Ok so not abnormal consult. I review the chart. INR is 16. So I mention to hospitalist that's not compatible with me stopping the bleeding. But....cardiology has insisted we not reverse or attempt to reverse as pt Could develop thrombus on their machanical mitral valve. I place nasal packing. Nose improves but still bleeding. I tell cards "sir he may develop thrombus but without ffp he's going to bleed to death and that thrombus won't be a huge concern." I mean there are a lot of INR values between 16 and 3 that are more compatible with controlling his epistaxis and keeping his valve happy. Common sense doesn't seem so common sometimes

Sounds like a consult to Heme incoming for “anticoagulation recs”

 

[VA Hopeful Dr]

Called to the ICU on Friday afternoon for brisk left sides epistaxis. Ok so not abnormal consult. I review the chart. INR is 16. So I mention to hospitalist that's not compatible with me stopping the bleeding. But....cardiology has insisted we not reverse or attempt to reverse as pt Could develop thrombus on their machanical mitral valve. I place nasal packing. Nose improves but still bleeding. I tell cards "sir he may develop thrombus but without ffp he's going to bleed to death and that thrombus won't be a huge concern." I mean there are a lot of INR values between 16 and 3 that are more compatible with controlling his epistaxis and keeping his valve happy. Common sense doesn't seem so common sometimes

Can't develop a thrombus if all the thrombocytes escaped out the nose

 

[Suture15]

Called to the ICU on Friday afternoon for brisk left sided epistaxis. Ok so not abnormal consult. I review the chart. INR is 16. So I mention to hospitalist that's not compatible with me stopping the bleeding. But....cardiology has insisted we not reverse or attempt to reverse as pt could develop thrombus on their mechanical mitral valve. I place nasal packing. Nose improves but still bleeding. I tell cards "sir he may develop thrombus but without ffp he's going to bleed to death and that thrombus won't be a huge concern." I mean there are a lot of INR values between 16 and 3 that are more compatible with controlling his epistaxis and keeping his valve happy. Common sense doesn't seem so common sometimes

As a hospitalist myself, I'll be honest. It is more likely the hospitalist took cardiology's "not to reverse" very strictly despite an INR of 16. I mean, anyone who thinks there is no room for some reversal with active bleeding is either lazy or relying too much on consultants. Realistically, cardiology obviously must've meant avoid reversal UNLESS necessary...which in this case... it is...

 

[dpmd]

Or they meant don't reverse to normal while not minding reducing the excessive anticoagulation

 

[Pir8DeacDoc]

Or they meant don't reverse to normal while not minding reducing the excessive anticoagulation

I mentioned that I'd settle for 4-5. But that 16 just wasn't going to work. He seemed befuddled by my request. 🤣🤣

 

[OtoHNS]

Seen in clinic this morning:

Adult patient went snorkeling on vacation 2 weeks ago and her right ear has felt clogged since then. No pain, drainage, dizziness, etc. Her hearing is muffled.

Saw her PCP (an actual MD) a few days after that. He told her the right ear was "really infected bad" and the asymptomatic left ear was "a little infected". He prescribed abx and oral steroids. Pt had no improvement in her symptoms and decided to come see me.

On exam, her right ear is full of wax. I cleaned it out, and voila she is cured!

I get it that otoscopy is tricky, but come on!

 

[HighPriest]

Seen in clinic this morning:

Adult patient went snorkeling on vacation 2 weeks ago and her right ear has felt clogged since then. No pain, drainage, dizziness, etc. Her hearing is muffled.

Saw her PCP (an actual MD) a few days after that. He told her the right ear was "really infected bad" and the asymptomatic left ear was "a little infected". He prescribed abx and oral steroids. Pt had no improvement in her symptoms and decided to come see me.

On exam, her right ear is full of wax. I cleaned it out, and voila she is cured!

I get it that otoscopy is tricky, but come on!

Preach.

This has happened to me twice already this morning and it’s only 9:30. “My doctor said my eardrum looks really infected.” I look: completely full of wax.

Why? Why not just say that? I’m happy to see them anyway and take care of it.

The second one was a 14 year old kid who says he’s getting ear infections all of the time. I ask how he knows he has an ear infection (I always ask that now because the answers can be really surprising) and he says “I don’t know. They just look in my ear and tell me. I don’t even feel them anymore.”

And then, there you have it, they either didn’t look in his ear or are just incapable of doing an ear exam. And they’re putting him on antibiotics for this, three times this year. While here’s the literature clearly indicating that most real infections get better without treatment. So why treat a totally asymptomatic person?

 

[VisionaryTics]

I don't remember the last time I saw a patient with an even remotely accurate ear exam from a non ENT. Calling perforations that don't exist, missing perforations, "fluid", "bulging" TMs, missed foreign bodies etc etc etc. I really think it would help primary doctors to do a month in a general ENT clinic and just get practice seeing lots of ears. Ear issues have to be some of the most common chief complaints in medicine.

 

[LucidSplash]

I don't remember the last time I saw a patient with an even remotely accurate ear exam from a non ENT. Calling perforations that don't exist, missing perforations, "fluid", "bulging" TMs, missed foreign bodies etc etc etc. I really think it would help primary doctors to do a month in a general ENT clinic and just get practice seeing lots of ears. Ear issues have to be some of the most common chief complaints in medicine.

I’m not primary care, but I do occasionally send to ENT because I cover hyperbaric oxygen therapy as part of my wound care responsibilities. Every once in a while we get a patient who has difficulty clearing their ears either on descent or ascent and that can be a pretty bad problem so we send them to ENT for tubes. What kind of tips can you give me for a referral like that? Anything that would make your life easier?

 

[HighPriest]

I’m not primary care, but I do occasionally send to ENT because I cover hyperbaric oxygen therapy as part of my wound care responsibilities. Every once in a while we get a patient who has difficulty clearing their ears either on descent or ascent and that can be a pretty bad problem so we send them to ENT for tubes. What kind of tips can you give me for a referral like that? Anything that would make your life easier?

Tubes for HBO is pretty standard: They need tubes. Easy peasy. We send patients for osteo(radio)necrosis of the jaw and poorly healing post-rad necks, etc. we get it. I assume.
The thing is: the ear exam matters less for that specific patient. And, if a vascular surgeon has trouble with an ear exam I cut them some slack. Ear exams aren’t a routine part of their job. They should be for primary care.

 

[Pir8DeacDoc]

I’m not primary care, but I do occasionally send to ENT because I cover hyperbaric oxygen therapy as part of my wound care responsibilities. Every once in a while we get a patient who has difficulty clearing their ears either on descent or ascent and that can be a pretty bad problem so we send them to ENT for tubes. What kind of tips can you give me for a referral like that? Anything that would make your life easier?

If it hurts when they "dive" then send them over. I don't expect you to know a thing about their ear. Not within your scope. And it's not uncommon to need a tube for HBO. My beef is with pcp, urgent care, etc. Like have some clue about common diagnosis folks. Subtle findings I get. Clearly normal with a history that doesn't fit - that's incompetence

 

[LucidSplash]

If it hurts when they "dive" then send them over. I don't expect you to know a thing about their ear. Not within your scope. And it's not uncommon to need a tube for HBO. My beef is with pcp, urgent care, etc. Like have some clue about common diagnosis folks. Subtle findings I get. Clearly normal with a history that doesn't fit - that's incompetence

Ok. No problem. I get you. What you are describing is how I feel when I get sent patients for “chronic leg pain/pvd” who have bounding palpable pulses that can be seen from the doorway but clearly no one ever bothered to do a basic “touch the foot” exam. I have diagnosed gout, diabetic neuropathy, and most recently ankle osteoarthritis and really in general I accept that no one understands a thing about blood vessels outside of vascular but I agree that I wish the some of the PCP/urgent care peeps would try a little bit harder to do a basic vascular exam. And maybe learn the pleotrophic effects of statins in patients with CAD/PAD and stop taking people off their high-intensity statins just because their LDL isn’t elevated. This goes triple for NPs.

So I just wanted to make sure that there wasn’t something I could learn from/improve based on your above conversation.

 

[WinslowPringle]

In medical school, the Welch Allyn people came and tried to sell us M1s a bunch of stuff - I got the mandatory reflex hammer and none of the fancy otoscopes and ophthalmoscopes. Over the next 10 years of training I had no reason to regret that….until this year I had to make an ENT consult for an ear exam.

Medically complex guy admitted to my surgical subspecialty service. Has ear complaints that could have caused his primary reason for surgical admit, not something that if present can just be followed up outpatient. No working otoscopes on the floor. Check three different ICUs, no otoscopes there the nurses or I can find floating around (we don’t have a dedicated head and neck unit, they go to SICU and ENT brings their own equipment it seems. The otoscopes in the ED are in the wall so I can’t remove them.) Have spent legit two hours of my day trying to see this guys tympanic membrane, finally just call ENT. The disdain from the intern as she asks “Did you even look in his ear?” haunts me to this day….🤣

If only I had listened to the Welch Allyn salesman!

 

[dpmd]

In medical school, the Welch Allyn people came and tried to sell us M1s a bunch of stuff - I got the mandatory reflex hammer and none of the fancy otoscopes and ophthalmoscopes. Over the next 10 years of training I had no reason to regret that….until this year I had to make an ENT consult for an ear exam.

Medically complex guy admitted to my surgical subspecialty service. Has ear complaints that could have caused his primary reason for surgical admit, not something that if present can just be followed up outpatient. No working otoscopes on the floor. Check three different ICUs, no otoscopes there the nurses or I can find floating around (we don’t have a dedicated head and neck unit, they go to SICU and ENT brings their own equipment it seems. The otoscopes in the ED are in the wall so I can’t remove them.) Have spent legit two hours of my day trying to see this guys tympanic membrane, finally just call ENT. The disdain from the intern as she asks “Did you even look in his ear?” haunts me to this day….🤣

If only I had listened to the Welch Allyn salesman!

By then yours would likely no longer even work though.

 

[OtoHNS]

Preach.

This has happened to me twice already this morning and it’s only 9:30. “My doctor said my eardrum looks really infected.” I look: completely full of wax.

Why? Why not just say that? I’m happy to see them anyway and take care of it.

The second one was a 14 year old kid who says he’s getting ear infections all of the time. I ask how he knows he has an ear infection (I always ask that now because the answers can be really surprising) and he says “I don’t know. They just look in my ear and tell me. I don’t even feel them anymore.”

And then, there you have it, they either didn’t look in his ear or are just incapable of doing an ear exam. And they’re putting him on antibiotics for this, three times this year. While here’s the literature clearly indicating that most real infections get better without treatment. So why treat a totally asymptomatic person?

Oof, I guess my referring docs are at least marginally better. This is the first time in recent memory that an obvious wax plug was misdiagnosed.

Usually it's the TMJ patients that keep getting antibiotics over and over again in my area.

 

[Wordead]

Oof, I guess my referring docs are at least marginally better. This is the first time in recent memory that an obvious wax plug was misdiagnosed.

Usually it's the TMJ patients that keep getting antibiotics over and over again in my area.

Yeah everyone has a "bulging" TM on both sides as the cause of the ear pain but somehow has a normal exam even if I see them the next day. Really the bane of my existence. And I have to try and explain why they've been diagnosed over and over with an ear infection without just coming out and saying their PCP has no idea what they're looking at.

At least the steady stream of "TM perfs" with monomeric membranes and perfect hearing once in awhile have an actual perf that I can surgerize....

 

[TypeADissection]

I showed these posts to my wife and she just nodded her head in agreement and said, “It’s everywhere. Apparently no one looks in the ears and just sends people over to ENT.”

I also do wound care and HBO and have the advantage of phoning my wife when someone couldn’t dive and needed tubes placed. Thankfully that’s only happened once.

 

[HighPriest]

Yeah everyone has a "bulging" TM on both sides as the cause of the ear pain but somehow has a normal exam even if I see them the next day. Really the bane of my existence. And I have to try and explain why they've been diagnosed over and over with an ear infection without just coming out and saying their PCP has no idea what they're looking at.

At least the steady stream of "TM perfs" with monomeric membranes and perfect hearing once in awhile have an actual perf that I can surgerize....

Honestly, what you said here is the hardest part. My average ear complain patient is a guy with a plugged ear, no hearing troubles and a normal exam. He’s been told 500 times he has fluid and he’s been treated with 50 quarts of Flonase in the absence of nasal symptoms, and maybe four z-packs.

He’s super pissed now because nothing has worked, and he wants me to fix him. Like, today.

So I spend 5 minutes unwiring the idea that he’s got an ear problem and defending his PCP’s honor as to why he would be told all those times his ear looks bad.

I wish making excuses for the referring doc generated RVUs, I’d be able to retire next year.

 

[HighPriest]

In medical school, the Welch Allyn people came and tried to sell us M1s a bunch of stuff - I got the mandatory reflex hammer and none of the fancy otoscopes and ophthalmoscopes. Over the next 10 years of training I had no reason to regret that….until this year I had to make an ENT consult for an ear exam.

Medically complex guy admitted to my surgical subspecialty service. Has ear complaints that could have caused his primary reason for surgical admit, not something that if present can just be followed up outpatient. No working otoscopes on the floor. Check three different ICUs, no otoscopes there the nurses or I can find floating around (we don’t have a dedicated head and neck unit, they go to SICU and ENT brings their own equipment it seems. The otoscopes in the ED are in the wall so I can’t remove them.) Have spent legit two hours of my day trying to see this guys tympanic membrane, finally just call ENT. The disdain from the intern as she asks “Did you even look in his ear?” haunts me to this day….🤣

If only I had listened to the Welch Allyn salesman!

This actually is often a problem on inpatient wards. Inpatient consults can be a PITA because you can’t find equipment and to be honest I can bring an otoscope over, but I can’t really do any ENT-type treatment with it (not well anyway).

Nowadays you can buy endoscopic cameras that hook right to your phone to do an ear exam and take photos, upload to epic, all that jazz. I wouldn’t expect a surgeon to have one, but I kind of do expect the medicine wards to be able to do an ear exam and tuning forks. They don’t. But I expect them to.

 

[dpmd]

Honestly, what you said here is the hardest part. My average ear complain patient is a guy with a plugged ear, no hearing troubles and a normal exam. He’s been told 500 times he has fluid and he’s been treated with 50 quarts of Flonase in the absence of nasal symptoms, and maybe four z-packs.

He’s super pissed now because nothing has worked, and he wants me to fix him. Like, today.

So I spend 5 minutes unwiring the idea that he’s got an ear problem and defending his PCP’s honor as to why he would be told all those times his ear looks bad.

I wish making excuses for the referring doc generated RVUs, I’d be able to retire next year.

I frequently say something along the lines of they don't know because they haven't had the training I have. Haven't lost any referral sources over that yet.

 

[HighPriest]

I frequently say something along the lines of they don't know because they haven't had the training I have. Haven't lost any referral sources over that yet.

That’s what I say. And if it were something more complicated than an ear exam I would mean it, too.

 

[VA Hopeful Dr]

OK I felt really good about myself for catching a perforated TM on Friday and now y'all have me wanting to call the patient back in Monday to make sure...

But seriously, ear wax doesn't really look like anything else that I'm familiar with. How do you screw that one up?

 

[TypeADissection]

OK I felt really good about myself for catching a perforated TM on Friday and now y'all have me wanting to call the patient back in Monday to make sure...

But seriously, ear wax doesn't really look like anything else that I'm familiar with. How do you screw that one up?

If it makes you feel any better, in the private practice my wife was in while I was finishing general surgery residency, the senior partner sent her cholesteatoma referral and it turned out to be bad ear wax. That's it. Having met the guy he's in and out of each room in 15 minutes tops and rarely ever talks to patients. Just kind of barks what's going on and then moves on. Wife lost a lot of respect for the guy after that because he of all people should know how to do an ear exam.

 

[Pir8DeacDoc]

If it makes you feel any better, in the private practice my wife was in while I was finishing general surgery residency, the senior partner sent her cholesteatoma referral and it turned out to be bad ear wax. That's it. Having met the guy he's in and out of each room in 15 minutes tops and rarely ever talks to patients. Just kind of barks what's going on and then moves on. Wife lost a lot of respect for the guy after that because he of all people should know how to do an ear exam.

Ouch. That's no Bueno. And the more I do this the more I'm surprised that patients continue to see docs with such horrible interpersonal skills. I mean yeesh. If you're a bad clinician you should at least be pleasant 🤣🤣

 

[Wordead]

OK I felt really good about myself for catching a perforated TM on Friday and now y'all have me wanting to call the patient back in Monday to make sure...

But seriously, ear wax doesn't really look like anything else that I'm familiar with. How do you screw that one up?

For perfs it is what it is. You dont have a microscope with magnification and sometimes it's hard to tell even for ENTs with an otoscope. I dont mind those.

But adults with recurrent ear infections especially bilateral is rare so if theres a stone cold normal ear and one course of antibiotics doesnt help then more antibiotics probably isnt going to help either. Just push on their masseters, ask about grinding or clenching, send them off to dentist/oral surgeon/physical therapy if needed.

 

[HighPriest]

Some of those monomeric TMs are almost impossible to differentiate from a perf without either tympanometry or a microscope or both. That's different from "infection." Also, usually the "not-a-perf" patients are happy they don't have a perf and that's that. The "not-an-effusion" patients are all symptomatic from their TMJ or cervical neck disease or whatever, and they want answers. Like, now. Because it's already been 8 weeks, why can't anyone figure this out?

 

[TypeADissection]

"...monomeric TMs are almost impossible to differentiate from a perf without either tympanometry or a microscope or both."

"Well, 'aight, check this out, dawg. First of all, you throwin' too many big words at me, and because I don't understand them, I'm gonna take 'em as disrespect."

- Kevin Hart, 40-Year-Old Virgin

 

[HighPriest]

"Well, 'aight, check this out, dawg. First of all, you throwin' too many big words at me, and because I don't understand them, I'm gonna take 'em as disrespect."

- Kevin Hart, 40-Year-Old Virgin

I made all that up just to draw you out.

 

[Dr G Oogle]

Long time listener first time poster.

Consult from bariatric surgeon for hematuria after gastric ulcer cauterization surgery, foley placed in OR, hematuria already resolved.

Have to vent because surgeon requested immediate consult at the end of my 37 patient clinic 🤦‍♂️. I wish I could say this was the first time…

 

[HighPriest]

Call at 11:58
-Hey this is (redacted) at (redacted) ER. I have this lady who came in tonight for nasal congestion.

-ok…

-she says she thinks she broke her nose 3 weeks ago.

-has she been congested since then?

-no, just started today.

-…ok…

-so I got a CT and it shows maybe some compression of the maxillary spine, but that’s about all. No other abnormalities noted.

-ok.

-so should she come to see you tomorrow?

-I mean…I’m happy to see her. I’m not sure what the emergency is, other than that she came to the ER for one day of stuffy nose.

-yeah..so…should I put her on anything?

-….Flonase? Maybe a decongestant? You could try Afrin in a pinch if you just want her to feel better today.

-oh yeah! afrin. I’ll give that a try. Thanks.

-uh-huh….

12:08am call
-oh, hey, it’s (redacted) again. Hey, so sorry to call you again. So I looked in her nose and it’s like, REALLY congested. Like I’ve never seen a nose so congested before.

-(so…you didn’t look in her nose before you, you know, called me or got a CT?)

-do you think maybe it’s a septal hematoma? I’ve never seen one before.

-is it the septum swollen or the turbinates?

-…….

-is there a hematoma on the CT?

-no. No hematoma mentioned on the CT.

-did you try some afrin?

-not yet, I just wanted to make sure it was ok because it’s really congested.

-it’s ok

-ok, so can she see you tomorrow if it doesn’t work?

-(ffs.) yeah. Sure. If it doesn’t work she can see me.

 

[Miles Gloriosus]

Call at 11:58
-Hey this is (redacted) at (redacted) ER. I have this lady who came in tonight for nasal congestion.

-ok…

-she says she thinks she broke her nose 3 weeks ago.

-has she been congested since then?

-no, just started today.

-…ok…

-so I got a CT and it shows maybe some compression of the maxillary spine, but that’s about all. No other abnormalities noted.

-ok.

-so should she come to see you tomorrow?

-I mean…I’m happy to see her. I’m not sure what the emergency is, other than that she came to the ER for one day of stuffy nose.

-yeah..so…should I put her on anything?

-….Flonase? Maybe a decongestant? You could try Afrin in a pinch if you just want her to feel better today.

-oh yeah! afrin. I’ll give that a try. Thanks.

-uh-huh….

12:08am call
-oh, hey, it’s (redacted) again. Hey, so sorry to call you again. So I looked in her nose and it’s like, REALLY congested. Like I’ve never seen a nose so congested before.

-(so…you didn’t look in her nose before you, you know, called me or got a CT?)

-do you think maybe it’s a septal hematoma? I’ve never seen one before.

-is it the septum swollen or the turbinates?

-…….

-is there a hematoma on the CT?

-no. No hematoma mentioned on the CT.

-did you try some afrin?

-not yet, I just wanted to make sure it was ok because it’s really congested.

-it’s ok

-ok, so can she see you tomorrow if it doesn’t work?

-(ffs.) yeah. Sure. If it doesn’t work she can see me.

This smells of an NP or PA consult.

 

[TypeADissection]

Call at 11:58
-Hey this is (redacted) at (redacted) ER. I have this lady who came in tonight for nasal congestion.

-ok…

-she says she thinks she broke her nose 3 weeks ago.

-has she been congested since then?

-no, just started today.

-…ok…

-so I got a CT and it shows maybe some compression of the maxillary spine, but that’s about all. No other abnormalities noted.

-ok.

-so should she come to see you tomorrow?

-I mean…I’m happy to see her. I’m not sure what the emergency is, other than that she came to the ER for one day of stuffy nose.

-yeah..so…should I put her on anything?

-….Flonase? Maybe a decongestant? You could try Afrin in a pinch if you just want her to feel better today.

-oh yeah! afrin. I’ll give that a try. Thanks.

-uh-huh….

12:08am call
-oh, hey, it’s (redacted) again. Hey, so sorry to call you again. So I looked in her nose and it’s like, REALLY congested. Like I’ve never seen a nose so congested before.

-(so…you didn’t look in her nose before you, you know, called me or got a CT?)

-do you think maybe it’s a septal hematoma? I’ve never seen one before.

-is it the septum swollen or the turbinates?

-…….

-is there a hematoma on the CT?

-no. No hematoma mentioned on the CT.

-did you try some afrin?

-not yet, I just wanted to make sure it was ok because it’s really congested.

-it’s ok

-ok, so can she see you tomorrow if it doesn’t work?

-(ffs.) yeah. Sure. If it doesn’t work she can see me.

Showed this to the wife. She rolled her eyes. "This **** is everywhere." Our residencies and fellowships have taken us across the country, and this really is everywhere. Although we both have been absolutely floored by how strong the ER at our current institution is. Our docs genuinely give a ****, are talented and caring, and actually try to do everything within their scope before they call. It's also a pleasure because they're all so cordial as well. I would use a whole different set of adjectives to describe the ED attendings and residents where I did my general surgery training. We've found the rare unicorn in our current gigs and have zero complaints.

This smells of an NP or PA consult.

Nice pun yo.

 

[Pir8DeacDoc]

Showed this to the wife. She rolled her eyes. "This **** is everywhere." Our residencies and fellowships have taken us across the country, and this really is everywhere. Although we both have been absolutely floored by how strong the ER at our current institution is. Our docs genuinely give a ****, are talented and caring, and actually try to do everything within their scope before they call. It's also a pleasure because they're all so cordial as well. I would use a whole different set of adjectives to describe the ED attendings and residents where I did my general surgery training. We've found the rare unicorn in our current gigs and have zero complaints.


Nice pun yo.

My first job was an all physician ER- all EM trained. That place was rock solid. If they called, there was an issue that needed attention. But of course with time the mid-level creep happened. And the docs were less happy and the care got worse. A real night and day situation. A lot of the docs have since left. But the bean counters are happy. 🤷🏻‍♂️🤷🏻‍♂️

 

[longhaul3]

Me: Neurosurgery

ER: Hey buddy how's it going?

Me:

ER: Anyway I've got one for ya, 80 year old with advanced myeloma coming in with knee pain. Want you to take a look at him.

Me:

ER: The other thing is he's complaining of chest pain and shortness of breath and his leg is real swollen. His O2 sat is 85.

Me: You should work that up

ER: Yeah yeah we plan to, before we do that I just want to get you on board to know what imaging you want so our workup doesn't interfere with your evaluation

Me:

ER: We were thinking of a stat MRI brain and total spine with and without contrast, I'm really concerned about acute spinal cord compression

Me: Oh I'm concerned all right

 

[deleted50541]

Me:

Me: You should work that up

Me: Oh I'm concerned all right

Pretty much my boilerplate responses to most ED consults.

And I'm not your "buddy", guy.

 

[DOVinciRobot]

Seeing as we’re focused on the ED at the moment.

Me: hey this is DOVinci Robot with burns

ED PA: Yeah we got a burn down here for you. Bed 16.

Me: Ok…… Can you tell me anything about the patient?

ED PA: Threw gasoline on a fire. Torched their entire arm. It’s really bad. You’re going to need to admit them.

Me: Ok…. How come this didn’t come in as a trauma? Are they stable? What does it look like?

ED PA: Vitals are stable. It happened 3 days ago. Arm is very badly burned.

Me:………. 3 days ago?………

ED PA: yeah. Pain is really bad so they came in.

Me:

ED PA: so will you come admit them?

Me: I’ll come see them.

Patients arm had some flash burn to the forearm and back of the hand, largely first degree with some small areas of superficial 2nd degree with small bullae. Didn’t even have any areas to put silvadene on. No evidence of infection. Told them to wash it with soap and water daily and made a burn clinic appointment for them they never even came to. They called and said it had pretty much healed and felt they didn’t need to be seen. My staff saw the pic I sent them and didn’t even want to me to make a clinic appointment.

 

[HighPriest]

Seeing as we’re focused on the ED at the moment.

Me: hey this is DOVinci Robot with burns

ED PA: Yeah we got a burn down here for you. Bed 16.

Me: Ok…… Can you tell me anything about the patient?

ED PA: Threw gasoline on a fire. Torched their entire arm. It’s really bad. You’re going to need to admit them.

Me: Ok…. How come this didn’t come in as a trauma? Are they stable? What does it look like?

ED PA: Vitals are stable. It happened 3 days ago. Arm is very badly burned.

Me:………. 3 days ago?………

ED PA: yeah. Pain is really bad so they came in.

Me:

ED PA: so will you come admit them?

Me: I’ll come see them.

Patients arm had some flash burn to the forearm and back of the hand, largely first degree with some small areas of superficial 2nd degree with small bullae. Didn’t even have any areas to put silvadene on. No evidence of infection. Told them to wash it with soap and water daily and made a burn clinic appointment for them they never even came to. They called and said it had pretty much healed and felt they didn’t need to be seen. My staff saw the pic I sent them and didn’t even want to me to make a clinic appointment.

ED: But….it’s a burn. And…you’re a burn guy. Don’t you care about this patient??

We can’t send him to Family medicine. It’s a guy, not a family. And it’s not on the inside, so it can’t go to IM…we gotta send it somewhere!