Consults- Memorable/Dismal/Ridiculous/Unique

[dpmd]

I like the half somersault maneuver. Had my own bppv I went to my pcp for just because I have a migraine history that involved motor and sensory changes so the neurologist said likely migraine but can't rule out TIA so I figured getting an exam by someone else would be prudent. They did dix hallpike but no epley and gave me meclizine. Then my mom and my dad had separate occurrences of the same (again a doc did dix halpike but no eply and gave meclizine). I had Googled how to do my own crystal shifting and encountered the half somersault and it was so easy to do and immediately effective (though triggered such an intense vertigo I wanted to puke and fell over while on my knees, haven't felt anything quite so intense as that with the exception of when my ent suctioned the fungus out of my perforated TM and middle ear). So I taught my parents and they were able to do it and had good effectiveness too.

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[HighPriest]

I like the half somersault maneuver. Had my own bppv I went to my pcp for just because I have a migraine history that involved motor and sensory changes so the neurologist said likely migraine but can't rule out TIA so I figured getting an exam by someone else would be prudent. They did dix hallpike but no epley and gave me meclizine. Then my mom and my dad had separate occurrences of the same (again a doc did dix halpike but no eply and gave meclizine). I had Googled how to do my own crystal shifting and encountered the half somersault and it was so easy to do and immediately effective (though triggered such an intense vertigo I wanted to puke and fell over while on my knees, haven't felt anything quite so intense as that with the exception of when my ent suctioned the fungus out of my perforated TM and middle ear). So I taught my parents and they were able to do it and had good effectiveness too.

And this is the current experience of so many people. Primary care didn’t do anything, so let me try to figure this out on my own while I’m waiting to see a specialist. This is why I think we should replace urgent care centers with a referral dispensing machine. It could dispense meclizine too.

 

[dpmd]

And this is the current experience of so many people. Primary care didn’t do anything, so let me try to figure this out on my own while I’m waiting to see a specialist. This is why I think we should replace urgent care centers with a referral dispensing machine. It could dispense meclizine too.

I will say that none of us got a referral for this issue (not that we needed one)

 

[HighPriest]

I will say that none of us got a referral for this issue (not that we needed one)

So their answer was just to not do anything at all? Except meclizine, of course.

 

[dpmd]

So their answer was just to not do anything at all? Except meclizine, of course.

Kinda? I mean for this sort of issue the diagnosis is important enough that I don't see it as doing nothing (especially when talking about "dizziness" in elderly people with comorbidities that make scarier stuff a real possibility).

 

[HighPriest]

Kinda? I mean for this sort of issue the diagnosis is important enough that I don't see it as doing nothing (especially when talking about "dizziness" in elderly people with comorbidities that make scarier stuff a real possibility).

Well, put it another way: let’s say the diagnosis was cancer hey didn’t offer any treatment and didn’t refer you to anyone who could? Appropriate care?

In any case, it seems like the referral machine would be the superior option.

 

[longhaul3]

Cardiac surgery: Hello I have an urgent consult for you. Patient needs OR clearance.

Me: Go on

CTS: Patient has a structural heart lesion that is incompatible with life and needs surgery tonight. He is in multi organ failure from cardiogenic shock. His lactate is 15. He is seizing his bollocks off from anoxic brain injury. He has possible punctate intracranial hemorrhage. I need you to clear him for the OR.

Me: Sounds like this patient needs to go to the OR vs morgue

CTS: Yes. I need you to write a note clearing him for the OR now.

Me: Is there any possible circumstance under which you would not take this patient to the OR? Does it matter what I say?

CTS: No. The lesion is incompatible with life and he will die tomorrow without surgery. We are taking him whether you clear him or not. Therefore I need you to clear him.

Me: Thank you for this interesting consult.

 

[ThoracicGuy]

Cardiac surgery: Hello I have an urgent consult for you. Patient needs OR clearance.

Me: Go on

CTS: Patient has a structural heart lesion that is incompatible with life and needs surgery tonight. He is in multi organ failure from cardiogenic shock. His lactate is 15. He is seizing his bollocks off from anoxic brain injury. He has possible punctate intracranial hemorrhage. I need you to clear him for the OR.

Me: Sounds like this patient needs to go to the OR vs morgue

CTS: Yes. I need you to write a note clearing him for the OR now.

Me: Is there any possible circumstance under which you would not take this patient to the OR? Does it matter what I say?

CTS: No. The lesion is incompatible with life and he will die tomorrow without surgery. We are taking him whether you clear him or not. Therefore I need you to clear him.

Me: Thank you for this interesting consult.

So did you clear him?

 

[HighPriest]

Cardiac surgery: Hello I have an urgent consult for you. Patient needs OR clearance.

Me: Go on

CTS: Patient has a structural heart lesion that is incompatible with life and needs surgery tonight. He is in multi organ failure from cardiogenic shock. His lactate is 15. He is seizing his bollocks off from anoxic brain injury. He has possible punctate intracranial hemorrhage. I need you to clear him for the OR.

Me: Sounds like this patient needs to go to the OR vs morgue

CTS: Yes. I need you to write a note clearing him for the OR now.

Me: Is there any possible circumstance under which you would not take this patient to the OR? Does it matter what I say?

CTS: No. The lesion is incompatible with life and he will die tomorrow without surgery. We are taking him whether you clear him or not. Therefore I need you to clear him.

Me: Thank you for this interesting consult.

We just want someone to take some of the heat if something goes wrong. Although this guys going to die for sure if we don’t go, so really we just want to waste your time.

 

[Wordead]

Cardiac surgery: Hello I have an urgent consult for you. Patient needs OR clearance.

Me: Go on

CTS: Patient has a structural heart lesion that is incompatible with life and needs surgery tonight. He is in multi organ failure from cardiogenic shock. His lactate is 15. He is seizing his bollocks off from anoxic brain injury. He has possible punctate intracranial hemorrhage. I need you to clear him for the OR.

Me: Sounds like this patient needs to go to the OR vs morgue

CTS: Yes. I need you to write a note clearing him for the OR now.

Me: Is there any possible circumstance under which you would not take this patient to the OR? Does it matter what I say?

CTS: No. The lesion is incompatible with life and he will die tomorrow without surgery. We are taking him whether you clear him or not. Therefore I need you to clear him.

Me: Thank you for this interesting consult.

Patient died? Probably the hypokalemia of 3.4 medicine missed. Obviously.

 

[deleted50541]

I don't recall ever asking someone for "OR clearance" on cardiac surgery, which are inherently high-risk procedures. We typically did our own risk assessments and counseled the patient/family on their risk of perioperative complications.

If a patient was that sick, we'd have a frank discussion with the family/next of kin regarding their chances of survival and anticipated long-term recovery. If there was a head bleed involved, neurology and/or neurosurg might be consulted to get their opinion on the risks with cardiopulmonary bypass. But we didn't ask for their blessing to operate.

Maybe this is more in academic institutions from my general surgery days, but we really didn't talk about getting "OR clearance" in fellowship and it's not something I routinely do in practice now.

 

[dpmd]

I can't imagine a scenario where a moribund emergency surgery patient that you have decided to proceed to the OR with would require "clearance" of any sort.

 

[HighPriest]

It does seem weird. No. Dumb. It seems dumb. But based upon the rest of this thread anything is possible.

 

[akwho]

Sometimes in residency we would get cards/medicine consult pre-emptively if a certain anesthesia attending was running the board. One of his favorite delay tactics for horrible operative candidates that needed urgent surgery irregardless of their medical comorbidities was to ask for various things he knew would delay their surgery until someone else's shift (echo, cards consult, medicine risk stratification).

Not saying that's what happened here, but I wouldn't be surprised if something similar was at play. Sometimes it's more politics than anything else.

 

[Apollyon]

Sometimes in residency we would get cards/medicine consult pre-emptively if a certain anesthesia attending was running the board. One of his favorite delay tactics for horrible operative candidates that needed urgent surgery irregardless of their medical comorbidities was to ask for various things he knew would delay their surgery until someone else's shift (echo, cards consult, medicine risk stratification).

Not saying that's what happened here, but I wouldn't be surprised if something similar was at play. Sometimes it's more politics than anything else.

That reminds me of a story: in the distant past, I did a prelim IM year at Elmhurst, in Queens. There was something called the "social pool", which was for pts that only had a social issue, but, not a legit medical issue to be admitted. If you ever were house staff in NYC, you know what I mean. To keep IM from becoming completely obstructed by these pts, the social pool arose. This was any service that admitted pts took a day on the schedule. I recall one admit done by OMFS which was, actually, remarkable; I was amazed (in the single free minute I had) by how efficient, quick, and "clean" that these dentists did with it (at the time, Mt. Sinai had a thing that dentists in the OMFS program could earn an MD; don't know if it's still a thing). Anyways, the point: there was a Friday afternoon, and, that day, neurosurgery was on for the social pool. The resident on, a lot of people didn't like, but, I got along well with him. Well, he thinks he'll be slick: he asks for this, that, and the other thing, figuring that these things couldn't get completed, and, he'd be off the hook. Well, the IM resident, I respected the hell out of her. Like a crusader, she hit it like a truck, and got every single thing done on the list. The NSx resident was gobsmacked, but, he admitted the patient!

 

[dpmd]

Sometimes in residency we would get cards/medicine consult pre-emptively if a certain anesthesia attending was running the board. One of his favorite delay tactics for horrible operative candidates that needed urgent surgery irregardless of their medical comorbidities was to ask for various things he knew would delay their surgery until someone else's shift (echo, cards consult, medicine risk stratification).

Not saying that's what happened here, but I wouldn't be surprised if something similar was at play. Sometimes it's more politics than anything else.

I'm familiar with this tactic but for an emergency surgery I tell them no we are doing it now and they either get on board or I find someone who will do it (unless I didn't actually want to do it and just wanted someone else to share the blame for why the surgery was being refused and the patient was going to be allowed to die, but in that case there is no ordering of bull****, just a statement that the patient is too unstable to benefit from surgery)

 

[HighPriest]

I'm familiar with this tactic but for an emergency surgery I tell them no we are doing it now and they either get on board or I find someone who will do it (unless I didn't actually want to do it and just wanted someone else to share the blame for why the surgery was being refused and the patient was going to be allowed to die, but in that case there is no ordering of bull****, just a statement that the patient is too unstable to benefit from surgery)

I have a lot of patients who are too unstable to benefit from surgery, but they usually need a psychiatric not an anesthesia clearance.

 

[longhaul3]

So did you clear him?

I have a dot phrase that says there is a risk to anticoagulating the patient but the primary team should discuss this possibility with the family when they discuss the proposed surgery and it's up to them to weigh the risks and benefits.

I don't recall ever asking someone for "OR clearance" on cardiac surgery, which are inherently high-risk procedures. We typically did our own risk assessments and counseled the patient/family on their risk of perioperative complications.

If a patient was that sick, we'd have a frank discussion with the family/next of kin regarding their chances of survival and anticipated long-term recovery. If there was a head bleed involved, neurology and/or neurosurg might be consulted to get their opinion on the risks with cardiopulmonary bypass. But we didn't ask for their blessing to operate.

Maybe this is more in academic institutions from my general surgery days, but we really didn't talk about getting "OR clearance" in fellowship and it's not something I routinely do in practice now.

Thank you! We rarely get garbage consults like this from other surgeons, especially services like CT or GS who deal with similarly invasive and morbid surgeries and have a good understanding of severe complications. They said it was part of some protocol where these cardiac surgeons require clearance from every service that could be consulted for the patient's comorbidities. They have a PA who just shotgun consults the entire pager directory the day before surgery.

For some reason they also consulted neurology, who provided different (less conservative) recommendations. Would love to see the neurologist take the patient for a craniectomy and EVD at 2am.

I can't imagine a scenario where a moribund emergency surgery patient that you have decided to proceed to the OR with would require "clearance" of any sort.

Consider it imagined and manifested. Patient actually ended up doing pretty well.

 

[dpmd]

I have a dot phrase that says there is a risk to anticoagulating the patient but the primary team should discuss this possibility with the family when they discuss the proposed surgery and it's up to them to weigh the risks and benefits.


Thank you! We rarely get garbage consults like this from other surgeons, especially services like CT or GS who deal with similarly invasive and morbid surgeries and have a good understanding of severe complications. They said it was part of some protocol where these cardiac surgeons require clearance from every service that could be consulted for the patient's comorbidities. They have a PA who just shotgun consults the entire pager directory the day before surgery.

For some reason they also consulted neurology, who provided different (less conservative) recommendations. Would love to see the neurologist take the patient for a craniectomy and EVD at 2am.


Consider it imagined and manifested. Patient actually ended up doing pretty well.

Oh I believe stupid **** gets asked for all the time. I just meant I can't imagine a scenario where it was actually necessary and not stupid ****

 

[Wordead]

I have a dot phrase that says there is a risk to anticoagulating the patient but the primary team should discuss this possibility with the family when they discuss the proposed surgery and it's up to them to weigh the risks and benefits.


Thank you! We rarely get garbage consults like this from other surgeons, especially services like CT or GS who deal with similarly invasive and morbid surgeries and have a good understanding of severe complications. They said it was part of some protocol where these cardiac surgeons require clearance from every service that could be consulted for the patient's comorbidities. They have a PA who just shotgun consults the entire pager directory the day before surgery.

For some reason they also consulted neurology, who provided different (less conservative) recommendations. Would love to see the neurologist take the patient for a craniectomy and EVD at 2am.


Consider it imagined and manifested. Patient actually ended up doing pretty well.

I get consults from CT for patients with sinus or mastoid opacification for people undergoing heart valve work intermittently and did as well in residency. I guess I just assumed this was normal.

 

[deleted50541]

Thank you! We rarely get garbage consults like this from other surgeons, especially services like CT or GS who deal with similarly invasive and morbid surgeries and have a good understanding of severe complications. They said it was part of some protocol where these cardiac surgeons require clearance from every service that could be consulted for the patient's comorbidities. They have a PA who just shotgun consults the entire pager directory the day before surgery.

That's awful and a waste of other people's time. I smell a prior lawsuit in the background driving that kind of behavior.

 

[DocSurgeon]

Get paged from ER. Get put on hold. Pull up chart on patient - Middle aged female with a good amount of free air on CXR and CT. We're talking clearly see on CXR from across the room, 3-4cm over the liver on CT good. Radiology calling colon perf but there's absolutely no inflammation and without oral contrast so its a reach. There's actually no inflammation anywhere... Labs and vitals normal too. Only surgery was a lap hysterectomy months ago. Healthy with no major risk factors. Doc picks up. Tells me everything I've already gleaned from the chart.

Me: How's her exam?
ER: Actually not too impressive. Pains manageable. She hasn't gotten anything for pain since she's been here.
Me: This is weird... Do me a favor. Go ask her a very personal question for me. Has she had any vigorous sex recently?
ER: Sure no problem. BRB ::time passes:: She says she had sex late last night, nothing particularly crazy.
Me: When did her pain start again?
ER: Early this morning.
Me: Ah...I'm on my way in but I'm pretty sure she has a vaginal cuff dehiscence... she needs Gyn.

Get to the hospital and evaluate the patient. She's completely nontoxic, sitting playing on her phone, begging for a cheeseburger. Abdomen completely normal. Think about doing a speculum exam but think better of it as I haven't done one of those since medical school. Tell ER they definitely need to call Gyn, though. Gyn skeptical. Makes ER do a speculum exam. Sure enough, he see's stitches and a hole. Goes back to OR that night and Gyn fixes it.

But holy cow, that was a LOT of free air.

 

[dpmd]

Get paged from ER. Get put on hold. Pull up chart on patient - Middle aged female with a good amount of free air on CXR and CT. We're talking clearly see on CXR from across the room, 3-4cm over the liver on CT good. Radiology calling colon perf but there's absolutely no inflammation and without oral contrast so its a reach. There's actually no inflammation anywhere... Labs and vitals normal too. Only surgery was a lap hysterectomy months ago. Healthy with no major risk factors. Doc picks up. Tells me everything I've already gleaned from the chart.

Me: How's her exam?
ER: Actually not too impressive. Pains manageable. She hasn't gotten anything for pain since she's been here.
Me: This is weird... Do me a favor. Go ask her a very personal question for me. Has she had any vigorous sex recently?
ER: Sure no problem. BRB ::time passes:: She says she had sex late last night, nothing particularly crazy.
Me: When did her pain start again?
ER: Early this morning.
Me: Ah...I'm on my way in but I'm pretty sure she has a vaginal cuff dehiscence... she needs Gyn.

Get to the hospital and evaluate the patient. She's completely nontoxic, sitting playing on her phone, begging for a cheeseburger. Abdomen completely normal. Think about doing a speculum exam but think better of it as I haven't done one of those since medical school. Tell ER they definitely need to call Gyn, though. Gyn skeptical. Makes ER do a speculum exam. Sure enough, he see's stitches and a hole. Goes back to OR that night and Gyn fixes it.

But holy cow, that was a LOT of free air.

Had one of these before too. Husband was polite enough to feel bad about it rather than just proud of being too big or vigorous.

 

[Smurfette]

Had one of these before too. Husband was polite enough to feel bad about it rather than just proud of being too big or vigorous.

I haven't seen free air from it, but I did have someone who incarcerated a good 8 inch loop of sigmoid through their vagina. It had been stuck a while and just to get more exciting, the ER thought it was a prolapse and put a crap ton of sugar on it to "decrease the edema", plus the patient had an INR of 4 and was in rapid afib that had to be dealt with too. Gyne refused to help and told us we were capable of fixing the vaginal cuff after we reduced the sigmoid. Which I guess is true since it's not difficult, but it was HIS complication as her surgery was just a few weeks prior.

 

[dpmd]

I haven't seen free air from it, but I did have someone who incarcerated a good 8 inch loop of sigmoid through their vagina. It had been stuck a while and just to get more exciting, the ER thought it was a prolapse and put a crap ton of sugar on it to "decrease the edema", plus the patient had an INR of 4 and was in rapid afib that had to be dealt with too. Gyne refused to help and told us we were capable of fixing the vaginal cuff after we reduced the sigmoid. Which I guess is true since it's not difficult, but it was HIS complication as her surgery was just a few weeks prior.

I had something similar except it was like 20 yrs post hyster and I thought the er doc was full of **** when they said small bowel was coming out the vagina. My lady was otherwise stable for OR but gyn refused to help at first. Finally got gyn onc to come fix the bottom after I cut the small bowel out and reanastomosed (even once I opened I couldn't get the bowel to budge and it looked pretty ischemic by the time we were in the OR messing with it). I actually apologized to the er doc for thinking he was wrong.

 

[deleted50541]

I had something similar except it was like 20 yrs post hyster and I thought the er doc was full of **** when they said small bowel was coming out the vagina. My lady was otherwise stable for OR but gyn refused to help at first. Finally got gyn onc to come fix the bottom after I cut the small bowel out and reanastomosed (even once I opened I couldn't get the bowel to budge and it looked pretty ischemic by the time we were in the OR messing with it). I actually apologized to the er doc for thinking he was wrong.

I've tried to really temper my foul mood against the ED since finishing training and even apologized to an ED doc recently after getting awoken by a late night call. The ED now has our direct cell numbers when before we would just get a text page from the answering service. But apparently some of my colleagues weren't calling back in a timely fashion (or at all), so the ED requested direct numbers for all providers.

In this instance, the change was fairly new and I was used to having a moment to get my brain back online before returning the page. I'd just fallen asleep when I got called about possible nec fasc in the chest wall of an obese diabetic lady. My initial response was "WTF are you talking about?" and got the details while I muttered under my breath. I told the ED doc I'd call back in a few minutes after I'd had a chance to review the chart and imaging. WBC up a little, sodium on the low side of normal, abscess/gas just under the pec muscle. She wasn't particularly toxic looking by the ED's account though.

I called back and told the ED doc to ship her on up to the mothership (she was at a smaller hospital about 30 miles away). I apologized for being so cranky and he just laughed it off. Turned out not to be nec fasc, just a nasty staph infection with bacteremia in a poorly-controlled diabetic who was a picker. Did an I&D at 3AM, washed it out and left drains. Fortunately, it'd stopped at the pleura and didn't have an associated empyema or lung abscess. She did fine.

 

[HighPriest]

I have definitely try to be better, especially over the last couple of years. I do realize that, at least in our ER, they have a full waiting room, full beds, and people in the hallways almost every day. I’ve seen it. So sometimes they really do just need to unload a patient. If it’s actually something I can help with, I don’t ask too many questions. I’m just hoping they don’t get too used to that. At some point we have to try appropriately diagnosing problems again.

 

[BigRedBeta]

Get paged from ER. Get put on hold. Pull up chart on patient - Middle aged female with a good amount of free air on CXR and CT. We're talking clearly see on CXR from across the room, 3-4cm over the liver on CT good. Radiology calling colon perf but there's absolutely no inflammation and without oral contrast so its a reach. There's actually no inflammation anywhere... Labs and vitals normal too. Only surgery was a lap hysterectomy months ago. Healthy with no major risk factors. Doc picks up. Tells me everything I've already gleaned from the chart.

Me: How's her exam?
ER: Actually not too impressive. Pains manageable. She hasn't gotten anything for pain since she's been here.
Me: This is weird... Do me a favor. Go ask her a very personal question for me. Has she had any vigorous sex recently?
ER: Sure no problem. BRB ::time passes:: She says she had sex late last night, nothing particularly crazy.
Me: When did her pain start again?
ER: Early this morning.
Me: Ah...I'm on my way in but I'm pretty sure she has a vaginal cuff dehiscence... she needs Gyn.

Get to the hospital and evaluate the patient. She's completely nontoxic, sitting playing on her phone, begging for a cheeseburger. Abdomen completely normal. Think about doing a speculum exam but think better of it as I haven't done one of those since medical school. Tell ER they definitely need to call Gyn, though. Gyn skeptical. Makes ER do a speculum exam. Sure enough, he see's stitches and a hole. Goes back to OR that night and Gyn fixes it.

But holy cow, that was a LOT of free air.

One of the stories from the IM clerkship director where I was a student is along these lines. After residency had joined a practice in a college town that helped cover the University Health Clinic. Student came in with pain but not terribly crazy. KUB with free air...turned out the patient's boyfriend had a unique method of oral sex that involved blowing a lot of air

 

[TypeADissection]

And this is the current experience of so many people. Primary care didn’t do anything, so let me try to figure this out on my own while I’m waiting to see a specialist. This is why I think we should replace urgent care centers with a referral dispensing machine. It could dispense meclizine too.

Before landing into the hospital that I am currently in, I would have said we should just do this with the ED where I did my residency. Have a touch screen where patients input their symptoms and then it recommends imaging and labs then consults a specialist, because there was very little doctoring provided by those EM residents and attendings from what I could see other than picking up a phone with a half-assed workup, minimal H&P and then calling someone else. And then I got to my current job and am surrounded by unbelievably industrious ER docs that are cordial, take pride in their work and make it quite pleasant to work with on a daily basis. My wife and I both commented that we feel like we've landed in Shangri-La.

 

[DOVinciRobot]

Before landing into the hospital that I am currently in, I would have said we should just do this with the ED where I did my residency. Have a touch screen where patients input their symptoms and then it recommends imaging and labs then consults a specialist, because there was very little doctoring provided by those EM residents and attendings from what I could see other than picking up a phone with a half-assed workup, minimal H&P and then calling someone else. And then I got to my current job and am surrounded by unbelievably industrious ER docs that are cordial, take pride in their work and make it quite pleasant to work with on a daily basis. My wife and I both commented that we feel like we've landed in Shangri-La.

On vascular currently, the ED dropped us a 5 pm consult the other day to show them how a femoral chemo port worked that we had put in a week before. That was the consult. Worked perfectly, “we just have never seen this before and think y’all should be on board after medicine admits.”

 

[Wordead]

On vascular currently, the ED dropped us a 5 pm consult the other day to show them how a femoral chemo port worked that we had put in a week before. That was the consult. Worked perfectly, “we just have never seen this before and think y’all should be on board after medicine admits.”

I had a consult for "we cant find our trachs, can you help us" like Im a ****ing trach store and have a bag of goodies Im carrying around.

More power to you guys who stay cordial but I can't help but be rude these days.

 

[HighPriest]

I had a consult for "we cant find our trachs, can you help us" like Im a ****ing trach store and have a bag of goodies Im carrying around.

More power to you guys who stay cordial but I can't help but be rude these days.

I’ve had that one too. We don’t carry trachs in our clinic. Hospital called us because they couldn’t find one. I was like “well…that sucks man…”

 

[VA Hopeful Dr]

So what I'm hearing is that if I run out of otoscope covers in my office I should page the on-call ENT and ask them to bring me some.

 

[Wordead]

So what I'm hearing is that if I run out of otoscope covers in my office I should page the on-call ENT and ask them to bring me some.

Only if you put in a consult so I can get those sweet sweet rvus

 

[botansurge2]

Cardiac surgery: Hello I have an urgent consult for you. Patient needs OR clearance.

Me: Go on

CTS: Patient has a structural heart lesion that is incompatible with life and needs surgery tonight. He is in multi organ failure from cardiogenic shock. His lactate is 15. He is seizing his bollocks off from anoxic brain injury. He has possible punctate intracranial hemorrhage. I need you to clear him for the OR.

Me: Sounds like this patient needs to go to the OR vs morgue

CTS: Yes. I need you to write a note clearing him for the OR now.

Me: Is there any possible circumstance under which you would not take this patient to the OR? Does it matter what I say?

CTS: No. The lesion is incompatible with life and he will die tomorrow without surgery. We are taking him whether you clear him or not. Therefore I need you to clear him.

Me: Thank you for this interesting consult.

LOL - this happens daily im sure!

 

[BigRedBeta]

Before landing into the hospital that I am currently in, I would have said we should just do this with the ED where I did my residency. Have a touch screen where patients input their symptoms and then it recommends imaging and labs then consults a specialist, because there was very little doctoring provided by those EM residents and attendings from what I could see other than picking up a phone with a half-assed workup, minimal H&P and then calling someone else. And then I got to my current job and am surrounded by unbelievably industrious ER docs that are cordial, take pride in their work and make it quite pleasant to work with on a daily basis. My wife and I both commented that we feel like we've landed in Shangri-La.

Amazing how big an impact a functional ED can be.
As a peds resident, we did a ton of ED shifts, but since didn't really know any different and seemed like a lot of workups were done when I was in the ICU, couldn't really tell if it was good or bad.
As a PICU fellow, went to a children's hospital that had just moved into a new facility. Old ED was woefully undersized so there had developed a very strong "figure out a dispo ASAP" mentality and none of the workups were anywhere close to complete. So many patients would hit the floors and need immediate ICU transfer or vice versa, make it to the unit and not meet ICU criteria.
As an attending, in a place where the ED docs generally really are going to do the work, and try to get the patient into some semblance of stability for sending them to the PICU and it's such a huge difference to have workups done, consultants notified and plans from them received.

 

[WheezyBaby]

Amazing how big an impact a functional ED can be.
As a peds resident, we did a ton of ED shifts, but since didn't really know any different and seemed like a lot of workups were done when I was in the ICU, couldn't really tell if it was good or bad.
As a PICU fellow, went to a children's hospital that had just moved into a new facility. Old ED was woefully undersized so there had developed a very strong "figure out a dispo ASAP" mentality and none of the workups were anywhere close to complete. So many patients would hit the floors and need immediate ICU transfer or vice versa, make it to the unit and not meet ICU criteria.
As an attending, in a place where the ED docs generally really are going to do the work, and try to get the patient into some semblance of stability for sending them to the PICU and it's such a huge difference to have workups done, consultants notified and plans from them received.

The ED called me once when I was a resident and tried to admit a patient to me on whom they were actively doing compressions.

Like, ???

They did not end up needing admission

But in general that group was phenomenal and agree, it makes a huge quality of life difference and dramatically improves patient care. In peds land, the difference between PEM and nonPEM trained is significant

 

[mmmcdowe]

I think I posted this somewhere deep in these pages years ago, but this is my favorite consult ever:

Young boy with a ventriculoperitoneal shunt and a testicular hydrocele. Consult asking if hydrocele could be a sign of shunt failure.

Explained that a hydrocele could only be caused by a shunt producing fluid, so no.

Also explained that the patient didn't even have a shunt.

 

[BigRedBeta]

The ED called me once when I was a resident and tried to admit a patient to me on whom they were actively doing compressions.

Like, ???

They did not end up needing admission

Yeah...still occasionally get those "well if they make it, they're going to need you" sort of calls.

 

[WinslowPringle]

ED: “Yeah, gotta guy for ya down here in muh shop….He just had surgery with your service. He’s having some shortness of breath. CXR looks bad. He needs an admit, what floor do you want him sent to?”
Me: “I’ll come down and see him.”
…..Two months out from an ax-fem. Bilateral pleural effusions and kicker is he’s in complete heart block with a rate in the 40s clearly evident on the tele monitor (miracle he was even attached to it). No EKG obtained.
Me: “I saw Mr Axfem. He has bilateral pleural effusions and is in heart block. Looks like he needs an EKG and you should call cardiology or medicine for the admit. He’s two months out, his incisions look great and he has good pulses. I don’t think this is from his surgery.”
ED: “So, you did surgery on his chest and you don’t think the fluid in his lungs is from that, you don’t think it’s surgical?
Me:”No. No, I don’t.”
ED: (Skeptically) “Hmm. You operated on him and you don’t think it’s surgical?”
Me. “….I talked to my attending Dr Departmentchair and he doesn’t want to admit him. Please call medicine.”
ED: “I just think you operate on someone’s chest and they have problems breathing, you know, it’s probably surgical….”
Me: (thinking of my most recent write ups. Pretty sure any attempts at explaining anything will just get me in trouble) “…..I talked to my attending Dr Departmentchair and he doesn’t want to admit him. Please call medicine. Thanks.”

 

[dpmd]

ED: “Yeah, gotta guy for ya down here in muh shop….He just had surgery with your service. He’s having some shortness of breath. CXR looks bad. He needs an admit, what floor do you want him sent to?”
Me: “I’ll come down and see him.”
…..Two months out from an ax-fem. Bilateral pleural effusions and kicker is he’s in complete heart block with a rate in the 40s clearly evident on the tele monitor (miracle he was even attached to it). No EKG obtained.
Me: “I saw Mr Axfem. He has bilateral pleural effusions and is in heart block. Looks like he needs an EKG and you should call cardiology or medicine for the admit. He’s two months out, his incisions look great and he has good pulses. I don’t think this is from his surgery.”
ED: “So, you did surgery on his chest and you don’t think the fluid in his lungs is from that, you don’t think it’s surgical?
Me:”No. No, I don’t.”
ED: (Skeptically) “Hmm. You operated on him and you don’t think it’s surgical?”
Me. “….I talked to my attending Dr Departmentchair and he doesn’t want to admit him. Please call medicine.”
ED: “I just think you operate on someone’s chest and they have problems breathing, you know, it’s probably surgical….”
Me: (thinking of my most recent write ups. Pretty sure any attempts at explaining anything will just get me in trouble) “…..I talked to my attending Dr Departmentchair and he doesn’t want to admit him. Please call medicine. Thanks.”

Aren't you pretty much outside the chest for an ax fem?

 

[WinslowPringle]

Aren't you pretty much outside the chest for an ax fem?

Yes. Exactly.

 

[akwho]

Surgical anatomy and the ER, never shall the twain meet.

About 3 weeks into my consult year, I gave up trying to explain to the E.R. that a dorsal hand abscess was not and could not be FTS (flexor tenosynovitis) as the flexor tendons are located on the volar surface of the hand.

About 8 out of 10 hand abscess consults were on the dorsal hand, and maybe 1 of the remaining 2 on the volar hand was actually "FTS." But you can be sure 10 out of 10 were called FTS when the consult was called.

 

[TypeADissection]

ED: “Yeah, gotta guy for ya down here in muh shop….He just had surgery with your service. He’s having some shortness of breath. CXR looks bad. He needs an admit, what floor do you want him sent to?”
Me: “I’ll come down and see him.”
…..Two months out from an ax-fem. Bilateral pleural effusions and kicker is he’s in complete heart block with a rate in the 40s clearly evident on the tele monitor (miracle he was even attached to it). No EKG obtained.
Me: “I saw Mr Axfem. He has bilateral pleural effusions and is in heart block. Looks like he needs an EKG and you should call cardiology or medicine for the admit. He’s two months out, his incisions look great and he has good pulses. I don’t think this is from his surgery.”
ED: “So, you did surgery on his chest and you don’t think the fluid in his lungs is from that, you don’t think it’s surgical?
Me:”No. No, I don’t.”
ED: (Skeptically) “Hmm. You operated on him and you don’t think it’s surgical?”
Me. “….I talked to my attending Dr Departmentchair and he doesn’t want to admit him. Please call medicine.”
ED: “I just think you operate on someone’s chest and they have problems breathing, you know, it’s probably surgical….”
Me: (thinking of my most recent write ups. Pretty sure any attempts at explaining anything will just get me in trouble) “…..I talked to my attending Dr Departmentchair and he doesn’t want to admit him. Please call medicine. Thanks.”

I can already feel my blood pressure rising and thinking back to my training days. Next time this happens, just give me call. I'll help get rid of the body. Cheers.

 

[FindersFee5]

Surgical anatomy and the ER, never shall the twain meet.

About 3 weeks into my consult year, I gave up trying to explain to the E.R. that a dorsal hand abscess was not and could not be FTS (flexor tenosynovitis) as the flexor tendons are located on the volar surface of the hand.

About 8 out of 10 hand abscess consults were on the dorsal hand, and maybe 1 of the remaining 2 on the volar hand was actually "FTS." But you can be sure 10 out of 10 were called FTS when the consult was called.

I almost got in trouble with this once - guy with a delayed presentation, only external injury was a small healing lac to the dorsal MCP (think fight bite but he swore up and down he hadn't been in a fight in weeks ), but had all Kanavel's signs so we ended up taking him to the OR and opening him up with purulence down to the flexor sheaths in the palm. Still not totally sure how that happened.

 

[HighPriest]

Had a dude sent to me for dysphagia. Admittedly, the issue here is the patient, not the referral, but it’s classic. He was diagnosed with eosinophilic esophagitis about three months ago by GI. They made recommendations which he promptly ignored. He went to another ENT where they told him his dysphagia is probably due to his known diagnosis of EE. He didn’t like that, so he came to see me. He said he wanted a second opinion, so I requested his notes from the other ENT, and the patient got riled up about that, so that’s already a major red flag.

Dude is 40’s, mildly overweight. Looks like anxiety and ADHD with a bronze tan. Chief complaint is “things stick sometimes when I swallow.” The exam otherwise normal. Swallow study shows slow esophageal transit and reflux.

So I tell him I think his EE has something to do with it. He angrily tells me he can’t believe that because he never had that problem before (my favorite denial statement). I explain that most people aren’t born with all of the medical problems they’ll eventually get.

He asks what to do about it. I tell him dietary restrictions. He tells me he’d “rather die” than cut anything from his diet.

I offered steroids. He said he tried that already and it helped but he doesn’t want to “depend on medication.”

I offer reflux treatment. Obviously he won’t take medicine and he won’t make dietary changes. I tell him he could sleep with his head elevated and he says he can’t sleep that way and he won’t even try. I tell him he could split up his meals and he says “I have a friend that did that and it worked, but I can’t. I eat one big meal a day, at night when I get home. It’s usually pretty late and that’s when it’s convenient. I can’t eat breakfast. I just can’t do it.” I explain that’s one of the worst things you can do for reflux. He says we’ll have to find another treatment because he can’t change that.

I tell him to could cut back on alcohol. He says he can’t do that either.

This goes on.

So I tell him we’re kind of at an impasse. He tells me he doesn’t think I’m listening to him, and he wants another opinion.

…cool…bon voyage.

It’s like he was reading from a book of things not to do when you have reflux and EE, and specifically doing those things out of spite.

 

[VA Hopeful Dr]

Had a dude sent to me for dysphagia. Admittedly, the issue here is the patient, not the referral, but it’s classic. He was diagnosed with eosinophilic esophagitis about three months ago by GI. They made recommendations which he promptly ignored. He went to another ENT where they told him his dysphagia is probably due to his known diagnosis of EE. He didn’t like that, so he came to see me. He said he wanted a second opinion, so I requested his notes from the other ENT, and the patient got riled up about that, so that’s already a major red flag.

Dude is 40’s, mildly overweight. Looks like anxiety and ADHD with a bronze tan. Chief complaint is “things stick sometimes when I swallow.” The exam otherwise normal. Swallow study shows slow esophageal transit and reflux.

So I tell him I think his EE has something to do with it. He angrily tells me he can’t believe that because he never had that problem before (my favorite denial statement). I explain that most people aren’t born with all of the medical problems they’ll eventually get.

He asks what to do about it. I tell him dietary restrictions. He tells me he’d “rather die” than cut anything from his diet.

I offered steroids. He said he tried that already and it helped but he doesn’t want to “depend on medication.”

I offer reflux treatment. Obviously he won’t take medicine and he won’t make dietary changes. I tell him he could sleep with his head elevated and he says he can’t sleep that way and he won’t even try. I tell him he could split up his meals and he says “I have a friend that did that and it worked, but I can’t. I eat one big meal a day, at night when I get home. It’s usually pretty late and that’s when it’s convenient. I can’t eat breakfast. I just can’t do it.” I explain that’s one of the worst things you can do for reflux. He says we’ll have to find another treatment because he can’t change that.

I tell him to could cut back on alcohol. He says he can’t do that either.

This goes on.

So I tell him we’re kind of at an impasse. He tells me he doesn’t think I’m listening to him, and he wants another opinion.

…cool…bon voyage.

It’s like he was reading from a book of things not to do when you have reflux and EE, and specifically doing those things out of spite.

You were way more patient than I would have been. Its rare but in situations like this I pull out the old "these are my recommendations, you can do whatever you want with them. I'll show you how to get to the check out desk".

 

[HighPriest]

You were way more patient than I would have been. Its rare but in situations like this I pull out the old "these are my recommendations, you can do whatever you want with them. I'll show you how to get to the check out desk".

I’m sure that’s what the last two guys told him. And probably the next one if they know what’s good for them.

 

[ThoracicGuy]

I’m sure that’s what the last two guys told him. And probably the next one if they know what’s good for them.

Can't you just operate and fix him????

 

[Raryn]

Can't you just operate and fix him????

I'm sure a roux-en-y would fix most of his issues. He sounds like the perfect candidate to be perfectly compliant post-op.