Consults- Memorable/Dismal/Ridiculous/Unique

[deleted50541]

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!

Just got a flashback to residency and the ED's ceaseless efforts to get us to admit absolute bottom of the barrel train wrecks.

ED: Hey is this surgery? Got a guy with a pretty bad decub that probably needs your attention. It smells horrible and he looks septic. Where do you want him to go?

Me: Hold up a minute. What's the story?

ED: Oh, well the patient is from a nursing home, bed ridden, morbidly obese, non-verbal, brittle diabetic, bilateral AKAs, h/o stroke, on ASA/Plavix/Coumadin for XYZ.

Me: . . .

ED: So you're gonna admit, right?

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[dpmd]

Just got a flashback to residency and the ED's ceaseless efforts to get us to admit absolute bottom of the barrel train wrecks.

ED: Hey is this surgery? Got a guy with a pretty bad decub that probably needs your attention. It smells horrible and he looks septic. Where do you want him to go?

Me: Hold up a minute. What's the story?

ED: Oh, well the patient is from a nursing home, bed ridden, morbidly obese, non-verbal, brittle diabetic, bilateral AKAs, h/o stroke, on ASA/Plavix/Coumadin for XYZ.

Me: . . .

ED: So you're gonna admit, right?

Is anyone ever actually septic from their decub and their decub alone? I haven't seen it but I don't see decubs (I thank flying spaghetti monster I trained in a place where plastics did all of them so I can honestly say I am not the appropriate person to manage it)

 

[Apollyon]

Is anyone ever actually septic from their decub and their decub alone? I haven't seen it but I don't see decubs (I thank flying spaghetti monster I trained in a place where plastics did all of them so I can honestly say I am not the appropriate person to manage it)

Saw it at Elmhurst, in Queens, almost 20 years ago. This is a true story: GSx consulted, they saw the pt, and called Ortho. It was that bad. And, pt still coded and died in the ED.

 

[Smurfette]

Is anyone ever actually septic from their decub and their decub alone? I haven't seen it but I don't see decubs (I thank flying spaghetti monster I trained in a place where plastics did all of them so I can honestly say I am not the appropriate person to manage it)

Not that I've seen either. One of my partners was just griping about how everyone always claims they are infected when most of the time they are "meh" at best.
Probably happens as often as you get a temporal artery biopsy that actually shows temporal arteritis.

 

[HighPriest]

Saw it at Elmhurst, in Queens, almost 20 years ago. This is a true story: GSx consulted, they saw the pt, and called Ortho. It was that bad. And, pt still coded and died in the ED.

So even then, gen surg didn’t have to admit.

 

[deleted50541]

Not that I've seen either. One of my partners was just griping about how everyone always claims they are infected when most of the time they are "meh" at best.
Probably happens as often as you get a temporal artery biopsy that actually shows temporal arteritis.

Exactly. It'd be the usual upsell by the ED to make it sound worse than it was. Little did they realize that only made us dig our heels in more.

There was always something else going on.

 

[Chillbo Baggins]

You’re going to need to admit them.

I hate this phrase the most. I think 95% of the time I've been told this, I send them out. I mean, I hate when they say "we just want you to take a look at it" because it's usually dumb, but this is where they're not only dumb, but doubling down on their incompetence and trying to make my assessment for me.

 

[dpmd]

I hate this phrase the most. I think 95% of the time I've been told this, I send them out. I mean, I hate when they say "we just want you to take a look at it" because it's usually dumb, but this is where they're not only dumb, but doubling down on their incompetence and trying to make my assessment for me.

Like you guys ever admit anyone anyway

 

[Chillbo Baggins]

Like you guys ever admit anyone anyway

 

[Chillbo Baggins]

Like you guys ever admit anyone anyway

Though I'm still amazed by the ER residents that are like, "are you going put in orders for the 94yo hip fx with CHF, afib, ESRD on dialysis?"

No! We've never done this! As soon as you get the radiology read (because you don't look at the films yourself), you should be calling medicine!

 

[LucidSplash]

Is anyone ever actually septic from their decub and their decub alone? I haven't seen it but I don't see decubs (I thank flying spaghetti monster I trained in a place where plastics did all of them so I can honestly say I am not the appropriate person to manage it)

I mean yes I have seen them horribly purulent but yes when they are that bad it is usually with concomitant bacteremia +/- osteo. Which all came from the decub but you’re right that the average decub doesn’t make anyone septic. But if you have true ass rot it can be as bad as a diabetic foot infection/wet gangrene like.

But I also literally did a 2 year fellowship just to avoid decubs and enterocutaneous fistulas. I actually really liked general surgery for the most part otherwise. 😂

 

[Matthew9Thirtyfive]

Like you guys ever admit anyone anyway

When I was on IM, ortho asked us to be primary on a patient because she was on one BP med. Her pressures were completely normal. Gotta respect that.

 

[HighPriest]

When I was on IM, ortho asked us to be primary on a patient because she was on one BP med. Her pressures were completely normal. Gotta respect that.

I have also seen that happen. So there is another side to the coin. Although I think they were referring to the ED.

 

[WheezyBaby]

Ortho tried to admit a kid with a fracture to me because they had a syndrome, but their syndrome was exclusively skeletal abnormalities. Nah bro

 

[HemeOncHopeful19]

When I was on IM, ortho asked us to be primary on a patient because she was on one BP med. Her pressures were completely normal. Gotta respect that.

I once had them try to get me to admit because “patient is old” (direct quote)

When we discovered the patient, despite being old, had no medical conditions and took no medications we were asked “but can’t you do a DEXA scan and find something?” (direct quote)

 

[dpmd]

I make fun, but I actually don't admit anyone except for my elective hospital surgeries. But that is because it was the established deal when I began working here so why rock the boat. The hospitalists like the easy rvus and I like not having to get out of bed for most overnight admits (the hospitalists have 12 hour shifts) and getting no calls about tylenol at random hours.

 

[HighPriest]

There is a balance, I suppose. I try to manage everything I can as some kind of (probably foolish) point of pride, but if the patient is on 15 meds and has labile BP, I do call the hospitalists. I realize that the “this is what they get paid to do” argument could be used to justify every patient that gets sent to me for a sinus workup who has no symptoms of sinusitis other than forehead pain. I’m sure that some hospitalists look at “admit and manage” requests like I do those patients “why can’t you figure it his out?” But there’s another side to that coin as well: I don’t get paid to stay in the hospital, I don’t have 40 partners with whom I share coverage, and there’s one of me to every 10 of them. So from a resource management standpoint it does make sense to let them handle a lot of it.
But I certainly wouldn’t @&$king ask them to admit for a DEXA. That’s just horse$#!ttery. That’s just like the patient with obvious headaches who is sent for “the sinus.” Get a CT. If it’s normal, don’t send them.

 

[DoctwoB]

I make fun, but I actually don't admit anyone except for my elective hospital surgeries. But that is because it was the established deal when I began working here so why rock the boat. The hospitalists like the easy rvus and I like not having to get out of bed for most overnight admits (the hospitalists have 12 hour shifts) and getting no calls about tylenol at random hours.

This. It's one of the best parts of being in the community. The hospitalists would love my admissions (They're a bit overstaffed in the area and want the easy RVUs). I like not managing inpatient issues while I'm in clinic or the OR or driving in in the middle of the night for someone who doesn't need an urgent procedure. Not to mention they're better at inpatient management of medical issues. Win Win.

 

[longhaul3]

Just got a flashback to residency and the ED's ceaseless efforts to get us to admit absolute bottom of the barrel train wrecks.

ED: Hey is this surgery? Got a guy with a pretty bad decub that probably needs your attention. It smells horrible and he looks septic. Where do you want him to go?

Me: Hold up a minute. What's the story?

ED: Oh, well the patient is from a nursing home, bed ridden, morbidly obese, non-verbal, brittle diabetic, bilateral AKAs, h/o stroke, on ASA/Plavix/Coumadin for XYZ.

Me: . . .

ED: So you're gonna admit, right?

ED: hey there's this guy who's nonverbal down here, what imaging do you want?

Me:

ED: also he's septic from a decub ulcer which is near the spine. you guys are icu doctors so should be fine right

Me:

ED: also I'm highly concerned for cord compression and acute intracranial hemorrhage

 

[Chillbo Baggins]

I once had them try to get me to admit because “patient is old” (direct quote)

I mean, if a 80+ patient comes in with a hip fracture or distal femur fracture or whatever, and they somehow don't have any (known) comorbidities, I'm still going to have the hospitalist admit because I don't believe healthy people get these fractures, and more so, they're liable to have issues develop in the periop period that they're much better equipped to handle. Also because they'll probably be rocks waiting for SNF approval and my usefulness/interest drops dramatically after POD2

 

[Chillbo Baggins]

Not a consult, but today there was a distal radius ORIF of a known clinic patient that had been scheduled based on outside ED xrays. Attending saw them preop while I was knocking out some other stuff.

Patient rolls into the OR and I go in. What do I see winking at me from in between the ortho-glass splint? A freaking thick ring!

The ED had one job! I can ignore their terrible reduction attempt, but getting jewelry off ASAP is like ED 101. Then we had to spend 10 minutes with the ridiculously dull ring cutters.

 

[Apollyon]

The ED had one job! I can ignore their terrible reduction attempt, but getting jewelry off ASAP is like ED 101. Then we had to spend 10 minutes with the ridiculously dull ring cutters.

With respect, first, that is two jobs. Second, God's honest truth, it's not "like ED 101". Maybe it's just my luck, but, I never had a written or oral board question about it, and I never got chewed out by Ortho for that. We ARE taught to look for constrictive signs, though. Maybe, again, I just, as a matter of rote, told pts to remove their rings.

Also, it's interesting you say your ring cutters are dull - one of the hallmarks is that the ED has the dull cutters, and Ortho has the good ones that they keep to themselves.

 

[dpmd]

With respect, first, that is two jobs. Second, God's honest truth, it's not "like ED 101". Maybe it's just my luck, but, I never had a written or oral board question about it, and I never got chewed out by Ortho for that. We ARE taught to look for constrictive signs, though. Maybe, again, I just, as a matter of rote, told pts to remove their rings.

Also, it's interesting you say your ring cutters are dull - one of the hallmarks is that the ED has the dull cutters, and Ortho has the good ones that they keep to themselves.

Any person with an injury or infection anywhere on an upper extremity no matter how proximal needs ipsilateral rings off stat. Hands love to swell and if you are lucky and get to it quickly enough it will slip off instead of needing to be cut. That is nursing 101 so maybe your nurses have been having your back and keeping it from being an issue. Honestly, whoever is working triage should have the patient remove the ring to make it earlier in the process.

 

[Miles Gloriosus]

With respect, first, that is two jobs. Second, God's honest truth, it's not "like ED 101". Maybe it's just my luck, but, I never had a written or oral board question about it, and I never got chewed out by Ortho for that. We ARE taught to look for constrictive signs, though. Maybe, again, I just, as a matter of rote, told pts to remove their rings.

Also, it's interesting you say your ring cutters are dull - one of the hallmarks is that the ED has the dull cutters, and Ortho has the good ones that they keep to themselves.

As a hand surgeon, rest assured, our ring cutters are just as dull as yours.
If it’s not ED 101, then it should be. It’s not a board question because it’s such a fundamental concept.
Its like if you had a EM board question asking about a GSW trauma and the correct answer was getting vitals and removing patients clothes before sending to CT scan.
The reasons your Ortho colleagues don’t chew you out is they don’t want to lose your referrals and have to be nice to you or don’t have the time/energy to figure out who to chew out.

 

[HighPriest]

I’ve been called - multiple times, mind you- for “airway emergencies” where the ER provider has specifically mentioned “possible trach” where the patient has been alone in a dark room with no telemetry. I can think of three times specifically, and in at least one they didn’t even have supplemental O2, and there are probably more I’m forgetting. And this is despite my requesting that they “have a trach set in the room, and consider calling the on-call trauma surgeon because I’m 15 minutes away.”

Sometimes “101” goes out the window.

 

[deleted50541]

I mean, if a 80+ patient comes in with a hip fracture or distal femur fracture or whatever, and they somehow don't have any (known) comorbidities, I'm still going to have the hospitalist admit because I don't believe healthy people get these fractures, and more so, they're liable to have issues develop in the periop period that they're much better equipped to handle. Also because they'll probably be rocks waiting for SNF approval and my usefulness/interest drops dramatically after POD2

We had a geriatric medicine service at the trauma center I trained at for exactly these patients. Once their acute surgical needs were addressed, they were much better off in the hands of a geriatrician. Ortho and neuro were heavy users of this service.

 

[VisionaryTics]

I’ve been called - multiple times, mind you- for “airway emergencies” where the ER provider has specifically mentioned “possible trach” where the patient has been alone in a dark room with no telemetry. I can think of three times specifically, and in at least one they didn’t even have supplemental O2, and there are probably more I’m forgetting. And this is despite my requesting that they “have a trach set in the room, and consider calling the on-call trauma surgeon because I’m 15 minutes away.”

Sometimes “101” goes out the window.

Invariably the urgent airway consult is sitting in a dark, unmonitored room in the observation unit as far away from the nursing station as possible, while the non-bleeding epistaxis is sitting in the resuscitation bay surrounded by staff panicking.

 

[TypeADissection]

Just got a flashback to residency and the ED's ceaseless efforts to get us to admit absolute bottom of the barrel train wrecks.

ED: Hey is this surgery? Got a guy with a pretty bad decub that probably needs your attention. It smells horrible and he looks septic. Where do you want him to go?

Me: Hold up a minute. What's the story?

ED: Oh, well the patient is from a nursing home, bed ridden, morbidly obese, non-verbal, brittle diabetic, bilateral AKAs, h/o stroke, on ASA/Plavix/Coumadin for XYZ.

Me: . . .

ED: So you're gonna admit, right?

Me: So what's the ICD-10 code for "F*ck off?"

Not that I've seen either. One of my partners was just griping about how everyone always claims they are infected when most of the time they are "meh" at best.
Probably happens as often as you get a temporal artery biopsy that actually shows temporal arteritis.

I kid you not. I actually got my first positive TAB. After I don't know how many negatives, I finally got one on the person I had the lowest index of suspicion for. So anyway, I figured if I can do 437,876 more TABs, I can probably retire. Not comfortably, but definitely calling it quits.

 

[Smurfette]

Me: So what's the ICD-10 code for "F*ck off?"



I kid you not. I actually got my first positive TAB. After I don't know how many negatives, I finally got one on the person I had the lowest index of suspicion for. So anyway, I figured if I can do 437,876 more TABs, I can probably retire. Not comfortably, but definitely calling it quits.

It'll be the only one in your career, but that one positive is going to motivate the referring doc to send you everyone with a headache for years to come!
If I had to do 437,876 TABs, I'd quit, because that is just torture.

 

[HighPriest]

Eh. Takes 10 min in clinic for 3 RVUs. I’d take it over a dizzy patient any day of the week. But it would take you 3,000 years even if you worked constantly.

 

[TypeADissection]

It'll be the only one in your career, but that one positive is going to motivate the referring doc to send you everyone with a headache for years to come!
If I had to do 437,876 TABs, I'd quit, because that is just torture.

The funniest part was the pathologist paged me to tell me that she finally found a positive TAB. She was even more pumped than me.

 

[TypeADissection]

Eh. Takes 10 min in clinic for 3 RVUs. I’d take it over a dizzy patient any day of the week. But it would take you 3,000 years even if you worked constantly.

Bc my wife is an otologist, ALL the dizzy patients in the practice end up going to her. Listening to her describe taking a history from these patients is enough to convince me that it is a form of torture.

 

[Wordead]

Bc my wife is an otologist, ALL the dizzy patients in the practice end up going to her. Listening to her describe taking a history from these patients is enough to convince me that it is a form of torture.

She is getting a hilariously raw deal. I cant imagine. We spread that pain with everyone and/or dump it on the midlevels.

 

[Pir8DeacDoc]

They all have migraine. Or anxiety. Or orthostasis. But nearly none of them have a real ear problem. Ever

 

[deleted50541]

The funniest part was the pathologist paged me to tell me that she finally found a positive TAB. She was even more pumped than me.

I love the "stoked pathologist" phone call. At my old job back east, the pathologist called me all excited about finding Cocci in a nodule I'd wedged out. It was an unexpected finding, but when I called the patient with the results, they confirmed they'd been in the Southwest and had symptoms that sounded like valley fever.

When I called the pathologist back to confirm the history, he was even more thrilled. We both laughed the like nerds we are.

 

[Neopolymath]

I love the "stoked pathologist" phone call. At my old job back east, the pathologist called me all excited about finding Cocci in a nodule I'd wedged out. It was an unexpected finding, but when I called the patient with the results, they confirmed they'd been in the Southwest and had symptoms that sounded like valley fever.

When I called the pathologist back to confirm the history, he was even more thrilled. We both laughed the like nerds we are.

I get excited when they get amped up at tumor conference. It's so wholesome.

 

[HighPriest]

Had that same phone call just this week because of a mucosal melanoma. Weird thing to get pumped up about considering the overall survival rate, but it is rare.

 

[Pir8DeacDoc]

Had that same phone call just this week because of a mucosal melanoma. Weird thing to get pumped up about considering the overall survival rate, but it is rare.

Reminds me of a "chronic sinusitis" patient a few months back. Many, many abx at urgent care. Finally in to see us. Obvious nasal mass. Melanoma. Went to the Ivory Tower for big operation. During post op therapy he died. Uggh. Brutal diagnosis.

 

[TypeADissection]

I get excited when they get amped up at tumor conference. It's so wholesome.

This was the highlight of tumor board. They’d run through slide after slide of purple and pink and just be so amped to discuss how it’s so obvious that there is invasion into the muscularis. I’m like Werd? I just want someone to look at me the way they look at those slides. Pound sign squad goals.

 

[doyouhaveaflag]

Is anyone ever actually septic from their decub and their decub alone? I haven't seen it but I don't see decubs (I thank flying spaghetti monster I trained in a place where plastics did all of them so I can honestly say I am not the appropriate person to manage it)

No definitely not!

When I get called to evaluate the butt sore that's "causing septic shock" I tell them to wait for the urine and CXR results that they surely must have ordered already.

9 times out of 10 it's the urine
0.9 times out of 10 its pneumonia
One time, in all the butt sore consults I've gotten, it was the source of sepsis. And in that case it was nec fasc so....call gen surg not me.

 

[OtoHNS]

They all have migraine. Or anxiety. Or orthostasis. But nearly none of them have a real ear problem. Ever

A lot of mine actually have BPPV. They even get diagnosed by the ED with a Hallpike maneuver. But then instead of just taking 1 minute to do an Epley and fix the problem, they get sent home with a prescription for meclizine and told to go see ENT. 2-3 weeks later, I get to do the Epley after they've been suffering the whole time.

 

[HighPriest]

A lot of mine actually have BPPV. They even get diagnosed by the ED with a Hallpike maneuver. But then instead of just taking 1 minute to do an Epley and fix the problem, they get sent home with a prescription for meclizine and told to go see ENT. 2-3 weeks later, I get to do the Epley after they've been suffering the whole time.

Yeah I got a nice mix between “non-otogenic” and BPPV that could have been fixed at step 1 but now the patient has been snowed on Q6H meclizine for a month. Honestly, half the presumably BPPV patient haven’t been able to see me for 2 months and by the time I see them they have just resolved spontaneously, or found Brandt-Daroff online and self-treated. I’m just amazed your ER does Dix Hallpike. There are like 2 providers in my community who document that. I assume the rest aren’t doing it, and everyone who feels wobbly get meclizine and a diagnosis of either “vertigo” or “BPPV.” The diagnosis of balance disorders are as easy as hitting the referral button.

 

[VisionaryTics]

Meclizine should be a controlled drug like methadone, needs to be taken out of the hands of ER and primary care doctors.

 

[VA Hopeful Dr]

Meclizine should be a controlled drug like methadone, needs to be taken out of the hands of ER and primary care doctors.

I'd be OK with that

 

[Raryn]

Meclizine should be a controlled drug like methadone, needs to be taken out of the hands of ER and primary care doctors.

Then they'll just use benadryl or something equally dumb.

 

[HighPriest]

Then they'll just use benadryl or something equally dumb.

He’s right. Let’s not blame the meclizine here.

 

[VisionaryTics]

Amusingly, in Canada, Serc (betahistine) is the most commonly prescribed drug for dizziness while meclizine is not available. So, south of the border, we're giving histamine antagonists with no effect, and north of the border they're giving histamine agonists with no effect.

 

[OtoHNS]

Yeah I got a nice mix between “non-otogenic” and BPPV that could have been fixed at step 1 but now the patient has been snowed on Q6H meclizine for a month. Honestly, half the presumably BPPV patient haven’t been able to see me for 2 months and by the time I see them they have just resolved spontaneously, or found Brandt-Daroff online and self-treated. I’m just amazed your ER does Dix Hallpike. There are like 2 providers in my community who document that. I assume the rest aren’t doing it, and everyone who feels wobbly get meclizine and a diagnosis of either “vertigo” or “BPPV.” The diagnosis of balance disorders are as easy as hitting the referral button.

Now "documenting it" might be a step too far. I never get any notes from the ED anyway (I don't take any official call there). Sometimes the patient brings a stack of paperwork, which usually consists of a medication list and a generic vertigo informational handout.

But, I frequently get a reliable-sounding story from the patient that the ED provider turned their head, laid them back, and then they got dizzy. They even get told "it's the crystals in your ear." But then the providers don't do the Epley!

 

[OtoHNS]

Amusingly, in Canada, Serc (betahistine) is the most commonly prescribed drug for dizziness while meclizine is not available. So, south of the border, we're giving histamine antagonists with no effect, and north of the border they're giving histamine agonists with no effect.

Obviously, this is all Canada's fault then.

 

[HighPriest]

Now "documenting it" might be a step too far. I never get any notes from the ED anyway (I don't take any official call there). Sometimes the patient brings a stack of paperwork, which usually consists of a medication list and a generic vertigo informational handout.

But, I frequently get a reliable-sounding story from the patient that the ED provider turned their head, laid them back, and then they got dizzy. They even get told "it's the crystals in your ear." But then the providers don't do the Epley!

But, I frequently get a reliable-sounding story from the patient that the ED provider turned their head, laid them back, and then they got dizzy. They even get told "it's the crystals in your ear." But then the providers don't do the Epley!

Epley is a lot harder. They don’t have the special equipment that we do. Can’t remember how to do it. They should invent some sort of video database on your computer that would show you how to do things like that.