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Oh I totally assumed.it was like a cast of the hearing aid in earwax
Consults- Memorable/Dismal/Ridiculous/Unique
Started by surgres88
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But did they try Ancef?
MRI report only mentioned that the mastoids were aerated. No mention of the EAC at all. I only had the report, not the images, so not sure how easy it was to see.
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MRI can be deceiving with non-organic obstructions cuz of artifact.
For us it would be Amoxicillin or if urgent care is feeling very feisty Augmentin.
Maybe a side order of ciprodex drops cause it has a super power of traversing an intact drum and fixing middle ear issues- which aren't actually present anyway.
But it's very clear someone is lost and throwing crap at the wall when patient comes in on oral antibiotics and drops. That combination just isn't needed. Or is very, very rarely needed. Good times
z-packs for us. I think they just keep a garbage bin full of z-packs and just hand you one when you check in at UC. And they would never give drops because they don’t know if there’s a hole in the eardrum!!!!
And also, you have to look in the ear to know, so that’s a non-starter.
And for the non-ENT, having a hole is not a contraindication, if anything it works better.
They’re usually silicone. But I suppose it might not visualize well.
The biggest “gotcha” a neurorad pulled on me was an MR Face that had what looked like clear sinuses. She pulled out the same day CT which had totally impacted hyperattenuating mucus. Some of the material in chronic inspissated mucus or fungal colonization can cause MR signal loss. Her lesson was “don’t call clear sinuses on MR. You can be faked out”.
Basically, unless it looks like soft tissue up in there, I’m not commenting on the absence of that kind of stuff in MR.
CT would more likely show.
So you’re saying the PcP should have ordered a CT and THAT is the only way to know there’s a FB in the ear canal. . I gotchu.
Ya man. Send em straight for the temporal bone CT (which I never read as I am not a neurorad 😂)
Classic. You look at T2 and it looks fine and never look at them on any other sequence. It's a great case conference case.
Weekend special:
Answering service: Hi, Outside Hospital in nearish city is calling you for a consult.
Me: …ok, why? Is it one of our patients?
AS: No, they have someone in their ICU with fungus in their blood they want you to see today. They say you’re on call.
Me: …let them know I don’t have privileges at their hospital and I can’t see the patient.
Never mind that the rate of ocular infection in fungemia is <1% even in an ICU setting and both national bodies of ophtho and ID have said there’s no reason to screen asymptomatic patients. I guess this particular hospital feels they can use Google as their call roster.
Answering service: Hi, Outside Hospital in nearish city is calling you for a consult.
Me: …ok, why? Is it one of our patients?
AS: No, they have someone in their ICU with fungus in their blood they want you to see today. They say you’re on call.
Me: …let them know I don’t have privileges at their hospital and I can’t see the patient.
Never mind that the rate of ocular infection in fungemia is <1% even in an ICU setting and both national bodies of ophtho and ID have said there’s no reason to screen asymptomatic patients. I guess this particular hospital feels they can use Google as their call roster.
Who should we consult about this patient?
Attending:
Although I know how this probably went:
Patient has been having some vision problems.
Ok. When did that start?
Four years ago.
Better call someone….you know, just to be sure.
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Weekend fun again. Got a text message from an area code that is an 11 hour drive away about a patient with an area code 14 hours away in a different direction.
Also, we don’t have a text service.
Good luck, friend. *shrug*
Also, we don’t have a text service.
Good luck, friend. *shrug*
Someone walked into our clinic on Friday off the street looking to be seen by a doctor. This is in a building attached to a hospital but not somewhere you wander into accidentally. You can’t get to it from the main hospital without a badge through a back door. And you pass other specialties on your way to our office from the patient entrance.
Patient “hit his hand with something a few days ago” and was in a lot of pain and hand bruised and swollen. Friend saw it and suggested patient get it looked at by a doctor. Somehow patient (never been seen in our office before) picked our office.
Please note our office is vascular surgery and general surgery. No trauma.
MAs came back asking if the vascular NP could fit a walk in onto her schedule. I was sitting nearby and asked questions.
Patient redirected to the ED attached to the hospital for his broken hand. 🤷🏼♀️
Patient “hit his hand with something a few days ago” and was in a lot of pain and hand bruised and swollen. Friend saw it and suggested patient get it looked at by a doctor. Somehow patient (never been seen in our office before) picked our office.
Please note our office is vascular surgery and general surgery. No trauma.
MAs came back asking if the vascular NP could fit a walk in onto her schedule. I was sitting nearby and asked questions.
Patient redirected to the ED attached to the hospital for his broken hand. 🤷🏼♀️
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This was a long time ago, but my office once got a call at 4:55 pm on a Thursday from a Mom of a young adult son (never before seen by me). She stated that we had to see her son the next day and immediately take his tonsils out, because he was moving out of state on Saturday.
Man I get this kind of thing a lot.
Some of it’s military and I know that history - they’ve been trying to see a specialist for months and it took that long and now they’re on orders to PCS in a week. Sorry bro. Better luck at your next duty station.
But more often it’s this - we’re moving next Thursday can you work up and treat my sinuses before then? Also my PCP has done less than nothing. In fact they’ve somehow made it harder to work through if that’s possible.
Of course even more often I get: “it took so long to get in here that my problem went away!” And they’re angry about that. Because they need to have a problem.
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How'd the surgery go?
Lol
I'm truthfully amazed at patients / families on a daily basis. When you think you've seen or heard it all - you haven't.
OBGYN here. If I had a dollar for every time I got a consult for a woman of child bearing age with “vaginal bleeding” that ended up just being her period, I could afford my malpractice insurance for a year.
I mean, someone has to have “the talk.” Maybe you should charge for that.
I recall almost 20 years ago, a pt I saw in the ED 3 months in a row, for "abdominal pain and vaginal bleeding". Same time, 3 months in a row. Teenager in South Carolina, with her mother. First time, I did my due diligence, but found nothing wrong, and said it was normal menses (using the colloquial "it's your period"). Then I said it again, the next month. And then I said it again, the month after that. I don't know if it finally stuck, or they just saw someone else!
She got pregnant. Cleared right up for a while.
Great day in general surgery rounding.
Consult 1: "PEG tube falling out." Placed at OSH two months ago. The problem? The external bumper was pushed farther down the tube so it was slightly mobile and not snug against the abdominal wall. Tightened to 4 cm @ skin. Thank you for the interesting consult. ...Seen by no less than 3 nurses and an internal medicine doc...
Consult 2: "s/p CABG with ileus." Massively dilated. I recommend NGT. 7 (SEVEN!) unsuccessful RN attempts at placement. They consult IR to place (who refuse because its the weekend). I say eff it give me a tube. Goes right in. 2.6L out immediately. I don't think I've personally placed an NG in 2 years but I apparently I need to start doing it more often, which seems unfortunate.
Consult 1: "PEG tube falling out." Placed at OSH two months ago. The problem? The external bumper was pushed farther down the tube so it was slightly mobile and not snug against the abdominal wall. Tightened to 4 cm @ skin. Thank you for the interesting consult. ...Seen by no less than 3 nurses and an internal medicine doc...
Consult 2: "s/p CABG with ileus." Massively dilated. I recommend NGT. 7 (SEVEN!) unsuccessful RN attempts at placement. They consult IR to place (who refuse because its the weekend). I say eff it give me a tube. Goes right in. 2.6L out immediately. I don't think I've personally placed an NG in 2 years but I apparently I need to start doing it more often, which seems unfortunate.
Guy comes into ED with a headache. It so happens that he has had a surgery with our service for a pituitary tumor.
Immediate neurosurgery consult.
We get the call and start asking questions.
What's his status? Is he lethargic? Intubated?
- No, he's talking.
What's his headache like?
- *shrugs*
What does the imaging show?
- No imaging.
Any other medical history? When was the surgery?
- *shrugs*
Look him up in the EMR, can't find his surgery records.
Turns out this surgery was over 12 years ago. He's been through the routine follow up since, imaging has remained pristine with no recurrence, most recently 5 years ago - earlier than the current EMR we're using, so the records are in a hidden tab.
We go and see the guy. Pleasant, AOx3 with zero outward indication that anything's wrong. We start asking him about his headaches. The "have you ever had this sort of thing before" question is asked, and he goes, "yeah, I have migraines."
"Does this feel like your other migraines, or much different?"
"Very similar, just worse this time."
Head CT perfectly normal. Migraine cocktail cures; he's happy.
He was already scheduled for a routine follow up with his surgeon the following month.
Immediate neurosurgery consult.
We get the call and start asking questions.
What's his status? Is he lethargic? Intubated?
- No, he's talking.
What's his headache like?
- *shrugs*
What does the imaging show?
- No imaging.
Any other medical history? When was the surgery?
- *shrugs*
Look him up in the EMR, can't find his surgery records.
Turns out this surgery was over 12 years ago. He's been through the routine follow up since, imaging has remained pristine with no recurrence, most recently 5 years ago - earlier than the current EMR we're using, so the records are in a hidden tab.
We go and see the guy. Pleasant, AOx3 with zero outward indication that anything's wrong. We start asking him about his headaches. The "have you ever had this sort of thing before" question is asked, and he goes, "yeah, I have migraines."
"Does this feel like your other migraines, or much different?"
"Very similar, just worse this time."
Head CT perfectly normal. Migraine cocktail cures; he's happy.
He was already scheduled for a routine follow up with his surgeon the following month.
Learned about meth induced mesenteric ischemia. Acute on chronic abdominal pain, aki, elevated lactic acid CT scan x3 in like 30 hours with really only showing non-specific findings (gastric distention initially, and 3rd one showed ileus). Had an ex lap on showed 90% small bowel necrosis and most of large bowel.
Ah yes. Good old meth-associated NOMI. Can happen with cocaine too. More commonly causes perforation though from localized ischemia.
Vasoconstrictors gonna vasoconstrict.
If you think meth and cocaine are dangerous, you should see minding your own business.
Forget ischemic bowel, very high likelihood you’ll get pistol whipped in my experience.
Forget ischemic bowel, very high likelihood you’ll get pistol whipped in my experience.
When I was a med student in Baltimore, I remember learning that you should always avoid anyone named “These Two Dudes” or “That B**ch” because they will mess you up usually while sitting on your front porch reading a Bible or walking your nana to church.
Once I moved to the south I learned all about the dangers associated with “My Buddy Said.”
How did we allow general surgery to become the disimpaction service? I don’t seem to recall an ABSITE question on the technique or double scrubbing a bedside disimpaction. The fact that it boils down to “ew gross I’m not doing it,” by anyone else in the hospital really gets me.
Why not GI?
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I trained as an LVN prior to becoming a doctor. This is 100% a nursing task and if you are getting pushback about it you need to take it up with the charge nurse or chief nursing officer. There is specific training for it during nursing school.
Unless there is a reason it needs to be done under anesthesia or there is some sort of anatomical issue in which case might as well make it into a sigmoidoscopy so you get paid
Yes. Why not GI? I often ponder this as it’s always a medical cause and rarely a surgical issue.
If they consistently access it to make a lot of green, they can access it for some brown too
My favorite one happens maybe once or twice a year. I get referred a patient for bypass or valvular surgery, and admitting medicine service consults the cardiologist (often times the one that has referred me the patient) for preoperative cardiac clearance.
Call service: Hi, we have a Dr. X who would like to speak to you about a retinal detachment.
*Don’t recognize the name, quick Google search*
Me: Ok.
Dr. X: *launches immediately into patient presentation without introducing themself* So you can get them taken care of?
Me: So… as a senior retina fellow, I think you and your attending can come up with your own plan here.
*Don’t recognize the name, quick Google search*
Me: Ok.
Dr. X: *launches immediately into patient presentation without introducing themself* So you can get them taken care of?
Me: So… as a senior retina fellow, I think you and your attending can come up with your own plan here.
Smurfette
Gargamel always had a thing for blondes.
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Have to ask...what was that about? Their attending unavailable?
*heavy shrug*
When I called them out, it was a weird combination of they’re from xyz and you’re closer (narrator: we’re not) and oh there’s this insurance thing, which it’s not like I can check and see if I’m any better off. Then the exam magically changed to something more urgent, so I reminded them of an in office temporizing measure.
May have been an unavailable attending - that center has a reputation for tough call and I wouldn’t be surprised if there’s some “suck it up” directed at the fellows. Unfortunate, but
This also wasn’t one of our patients, and I can’t remember the last time we sent something their way/dumped on them, so it’s not like there’s some big confounder either. I could see them going after the solo guy in that area who lists everybody under the sun on his website as alternatives if he’s out (narrator again: he often is, and we had to send a cease and desist).
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I would not feel bad. Some of the people in the system already understand that midlevels do not actually save money, but we need more people to understand that. Only then can we possibly get the medical field back on track.
Smurfette
Gargamel always had a thing for blondes.
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Administrator
Volunteer Staff
20+ Year Member
I recently had a pt referred to me that had seen both their PCP and dermatology for an "umbilical mass".
It was a black stone of belly button lint that I removed in 30 seconds and advised pt to clean her belly button on a regular basis to prevent more.
The patient was convinced prior to seeing me that it was cancer and thought I was fantastic.
Both PCP and dermatology were midlevels.
Easy consult indeed.
It was a black stone of belly button lint that I removed in 30 seconds and advised pt to clean her belly button on a regular basis to prevent more.
The patient was convinced prior to seeing me that it was cancer and thought I was fantastic.
Both PCP and dermatology were midlevels.
Easy consult indeed.
LOL! I had the same thing happen to me only they saw their primary NP, went to an urgent care NP who sent to the ER NP, got a million dollar work up (CT included) and finally sent to me for umbilical mass where I had the exact same 30 second interaction. The patient recently tried to follow up with me because it recurred. I caught it looking ahead on my clinic schedule and told my office manager absolutely not.
I’m not a surgeon but I had a Derm NP refer a T4 melanoma (reported as “pT4” on the path report from a shave biopsy or whatever) to my office the other day after telling a patient they had stage IV dz and less than a year to live. I kept thinking the patient MUST have been confused or misheard but the more they told the story the more I believed them.
Not technically a consult, but my practice recently found out that a solo doc a couple hours away has us, on their website, in an extensive list of groups of who to call when they’re “unavailable,” which I’ll assume is whenever they want. Probably time for a cease and desist.
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It's already September and we haven't had any good consults to enjoy. Anything amusing happening out there?
Got a consult from ED for “highly vascularized liver tumor” read on CT. Get one of these at least once a year. ED PA got indignant when I said vascular consult not indicated, because “it says vascularized, how can that not be your responsibility?”
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Well, at least their brain surgery wouldn't need vascular...
But, but - it's got VESSELS!!
Got a self referral from a patient whose doc did an eye injection for edema after cataract surgery. Vision worsening with pain, doc couldn’t be bothered.
Florid infection, which happens, part of the ball game. What doesn’t usually happen (when I saw the records) is to use a drug that I literally can’t think of anybody using in the last 20 years given its black box warning.
Gets better. Said class of med is useless for the actual, very common, diagnosis they were “treating”.
Had the cojones to ask if I really thought it was an infection. Glad the doc to doc was over the phone so I didn’t have to bandage my knuckles afterward.
Florid infection, which happens, part of the ball game. What doesn’t usually happen (when I saw the records) is to use a drug that I literally can’t think of anybody using in the last 20 years given its black box warning.
Gets better. Said class of med is useless for the actual, very common, diagnosis they were “treating”.
Had the cojones to ask if I really thought it was an infection. Glad the doc to doc was over the phone so I didn’t have to bandage my knuckles afterward.
Was the doc another ophtho, or an FM type?
I’m sure this dude was a fool but you do know black box warnings aren’t like a ban on the medication right?
I usually see them as a lawyer’s label TBH
