Consults- Memorable/Dismal/Ridiculous/Unique

[Fah-Q]

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You are paid for both codes, but not as much as if you do them on separate days. This is especially true when you consider the reduction for multiple procedures. I see this every day in my office - I make less if I do a consult and a biopsy on the same day than if I do the consult and then bring them back another day for the biopsy.

YMMV depending on your insurers.

I've never noticed a reduction for E&M code + procedure code on the same day as long as -25 is used. Honestly, I've never heard of this. I've only seen the reduction for 2 or more procedure codes on the same day.

It is very common in an ENT practice to do a scope during a patient encounter. I always bill this as a "separately identifiable procedure" linked to a different ICD-9. I'll have to look at my EOB's more closely and see if I'm getting paid less than the allowable.

I know it is unwise to doubt someone so wise, but...

 

[45408]

I think you're putting a little too much stock into the accuracy of your clinical exam. There are plenty of patients with ischemia/perforation who don't manifest a perfect combination of fever/leukocytosis/acidosis with signs of peritonitis.

I've now seen this on a few occasions. It's kind of unsettling.

 

[OtoHNS]

I recently got paged by an pedi ER attending on a patient without a surgical problem because "I saw in the computer that you guys saw her last time"

Reminds me of this. It's funny because it's true...

http://www.youtube.com/watch?v=g658mbtMOTI&playnext=1&list=PL59347BA2ECAD6CE7

 

[balaguru]

I think you're putting a little too much stock into the accuracy of your clinical exam. There are plenty of patients with ischemia/perforation who don't manifest a perfect combination of fever/leukocytosis/acidosis with signs of peritonitis.

Don't need a perfect combination in the garden variety SBO patient. There are populations where the exam is challenging: obese (as you mentioned), demented/elderly, the intubated, psych patients, the immunosuppressed, etc. You always have the CT scanner if you're not sure. I'm not against it, I just don't think it should be the default.

You say mass and intussusception are too rare to matter, but I put etc etc because there are a million things you can find in there you weren't expecting....when you add them all together, they're more common than you think. Perfect example: Abscess and associated ileus, no SBO.

A million things? Come on, man. We're going to have to agree to disagree on that point. Abscess is a special case. You should have some suspicion without a CT scan...and if I did, I'd get a scan because it might be perc drainable--perfed appy being the most likely culprit.

As for microperforation, I've seen it several times, but I guess since I get CT scans and you don't, that difference in experience can be easily explained. Plain films are just not good for identifying free fluid or small to moderate amounts of air.

We unfortunately get scans routinely as they are ordered before we are consulted and some of my colleagues insist on them, further perpetuating the problem. I'm sure there were some rare instances that the scan changed management but on the whole they didn't.

Different patients and different pathologies require individualized therapy.

Couldn't agree more. That's why I'm against the notion of scanning all SBO's.

I'm not sure I can subscribe to the simplistic, cookbook approach of "NGT x 48 hours, then OR if they don't progress." Since I want to operate on some right away, and I want to sit on some other ones for as long as humanly possible, I use the CT to guide my therapy.

Actually, I'm advocating the opposite of a cookbook approach--evaluation of the clinical information at hand, NGT, observation and if indicated selective use of CT.

...I've found that there's not always a great relationship between the physical exam and degree/severity of underlying pathology. Often times, the hands and the CT disagree.

We'll have to agree to disagree on that point. When the clinical picture and CT disagree I go with the clinical picture. I've been consulted for ominous findings on CT on more than one occasion in a patient with no complaints or clinical abnormalities. Hard to make a well patient better with an operation.

Anyway, I think it's okay to have differing opinions. My opinion is that it's $2,000 well spent, since it guides my therapy...and I think it can ultimately lead to a cheaper hospital stay for a good portion of patients.

Agree with it being ok to have differing opinions. However, cost isn't the only concern: radiation and contrast exposure are getting more attention.

 

[SLUser11]

We'll have to agree to disagree on that point. When the clinical picture and CT disagree I go with the clinical picture. I've been consulted for ominous findings on CT on more than one occasion in a patient with no complaints or clinical abnormalities. Hard to make a well patient better with an operation.

Agree. We're unlikely to come to a consensus on this.

I'm going to keep ordering CTs on most SBOs. I like having the info (proximal/distal/partial/complete/ischemic/necrotic).

 

[kitsunepixie]

In my short career in neurosurg, this is probably my most memorable consult:

Hem-Onc consulted me because they had a patient with known leptomeningeal carcinomatosis from a PNET tumor for lower extremity weakness. While on the phone with the resident, I reviewed her latest scans/notes from a month ago and saw that she had an inoperable spinal cord tumor that was believed to be her primary and that she already had lower extremity weakness noted from prior admissions. He also went on to mention that she had an "altered mental status," and I saw from her scans that she had a shunt, which he didnt' realize until I told him.

Me: Any nausea, vomiting, or headaches?

Hem-Onc: Yeah, all of those. But we got a shunt series and it looks like the shunt is working.

Me: A shunt series is a series of x-rays that we use only to look for disconnections/placement of the tubing...it cannot tell us whether the shunt is actually working or not. You guys going to scan her head??

Hem-Onc: Oh...well, we ordered an MRI of her entire neuraxis, but it won't be done until 8 PM (4 hours from now).

Me: Okay, she needs a HCT STAT. I'll be right there.

HCT showed massive ventriculomegaly with transependymal flow, while she had slit-like vents on her last scan. On exam she was obtunded and she was on a regular Hem-Onc floor, not even hooked up to any monitoring. I performed a bedside shunt tap that confirmed a high-grade distal obstruction and therapeutically removed about 20 cc of CSF and she perked up a bit, and we then did an emergent shunt revision and she woke up as her normal self--pleasantly confused but not near death like she was! Her prognosis still sucks, but she still has some time left to spend with her family.

So, this time it WAS the shunt, but no one seriously considered it enough or worked it up before neurosurgery stepped in! And they wonder why we can be a grouchy lot at times. 🙄

 

[SLUser11]

So, this time it WAS the shunt, but no one seriously considered it enough or worked it up before neurosurgery stepped in! And they wonder why we can be a grouchy lot at times. 🙄

So, you're grouchy at times because you have to step in and save the patient?

I don't know if that's fair. Should a heme/onc fellow really know the intricacies of a VP shunt?

It sounds like the consult was appropriate, albeit for the wrong reasons....I think the most important thing is that the heme/onc fellow realized he was in over his head, and knew to consult an expert when the patient wasn't doing well....as for the under-triage, that's pretty standard for medicine patients in my experience.

 

[kitsunepixie]

So, you're grouchy at times because you have to step in and save the patient?

I don't know if that's fair. Should a heme/onc fellow really know the intricacies of a VP shunt?

It sounds like the consult was appropriate, albeit for the wrong reasons....I think the most important thing is that the heme/onc fellow realized he was in over his head, and knew to consult an expert when the patient wasn't doing well....as for the under-triage, that's pretty standard for medicine patients in my experience.

I never said that the consult was inappropriate, but the person who consulted me didn't know his patient well enough to know that she was unstable...she had been in the hospital over 24 hours and they didn't have enough a sense of urgency to consult us sooner or do order more appropriate imaging within a timely time frame. I'm always polite to consults and I don't expect them to be shuntmasters, but I am allowed to feel outraged for the poor patient or at least find this case memorable, like the thunderclap headaches who aren't properly worked up and rerupture a berry aneurysm who present to us at death's door. At least the hem-onc floor all got to learn something from this case before she herniated and died. Plus all the consults we get for patients who happen to have shunts and we get asked to see them when they're being evaluated for something like an uri and have no sx of shunt malfunctions...it just gets a little tiresome is all.

 

[Winged Scapula]

I've never noticed a reduction for E&M code + procedure code on the same day as long as -25 is used. Honestly, I've never heard of this. I've only seen the reduction for 2 or more procedure codes on the same day.

It is very common in an ENT practice to do a scope during a patient encounter. I always bill this as a "separately identifiable procedure" linked to a different ICD-9. I'll have to look at my EOB's more closely and see if I'm getting paid less than the allowable.

Ahh...that may be the difference. I do MULTIPLE procedures in the office on the same day. I imagine if it were a single one there may not be a reduction.

I know it is unwise to doubt someone so wise, but...

Thanks for the kind words, but you are welcome to doubt me or tell me I'm wrong! I can always learn from everyone here.

 

[45408]

I never said that the consult was inappropriate, but the person who consulted me didn't know his patient well enough to know that she was unstable...she had been in the hospital over 24 hours and they didn't have enough a sense of urgency to consult us sooner or do order more appropriate imaging within a timely time frame. I'm always polite to consults and I don't expect them to be shuntmasters, but I am allowed to feel outraged for the poor patient or at least find this case memorable, like the thunderclap headaches who aren't properly worked up and rerupture a berry aneurysm who present to us at death's door. At least the hem-onc floor all got to learn something from this case before she herniated and died. Plus all the consults we get for patients who happen to have shunts and we get asked to see them when they're being evaluated for something like an uri and have no sx of shunt malfunctions...it just gets a little tiresome is all.

To be fair, there are a lot of things that cause altered mental status. They may have been barking up the wrong tree.

It is a fairly big lapse to not notice your patient has a VP shunt...

 

[Pir8DeacDoc]

You might as well just accept that almost no consultants will know the patient they are calling you about. I find that a good percentage of the time my consult reveals information that the primary team would have known what to do with, if they had taken the time to find it. Similarly when we call medicine they dig up all sorts of information about our patients.
Often finding and putting the information together is the entire consult, without really doing anything terribly creative or new for the patient. The information is easy to find and put together in a usable way as a specialist whereby the generalist might not be able to do that.

 

[DrCG20]

Good stories everyone, but I think I got you beat.

This is a true consult, no BSing.

So I was on my Vascular surgery rotation and got a STAT consult for gangrene of the index finger, right hand. Patient was on the gastroenterology floor, getting worked up for melena.

I go to the patient's room and the Gastroenterologist is right there with his patient, checking up his brachial pulse. I look at the finger in question (without touching it), look back at his doc, look again the finger and understand everything. Poor patient was so confused that he has been scratching and cleaning his butthole with the finger in question.

I grabbed a towel and some alcohol and saved the gangrene'd index finger.
The look of the gastroenterologist was priceless.

And yes, I wrote the consult down for my attending 🙂

 

[Smurfette]

😱 😱 Really, a GI guy?

And here I thought the maggot consults from my vascular rotations were memorable.

 

[Pir8DeacDoc]

The other universal truism is that non-surgeons have no idea what stat means.

In ENT, stat means someone is actively losing their airway and needs an emergency procedure. I can't tell you how many times we get called stat for goofy stuff. I guess when your goal is to prevent a bad outcome thirty years from now with a medication something that may happen in 12 or 24 hours is considered stat.

 

[LucidSplash]

The other universal truism is that non-surgeons have no idea what stat means. ... I can't tell you how many times we get called stat for goofy stuff.

I've also had the other end of the spectrum. NON-stat (in fact stated "take your time/don't rush") consults for "rule out compartment syndrome vs nec fasc" (floor patient with cellulitis) and "peritonitis" (ED patient, NOT peritonitis). Of course we always come running and I've yet to have one of these "no hurry" consults turn out to be anything big, but it scares me sometimes to think what if they had waited to call the consult because it wasn't concerning enough for a stat consult and it WAS compartment syndrome, nec fasc, peritonitis, etc.

 

[Miami_med]

I've also had the other end of the spectrum. NON-stat (in fact stated "take your time/don't rush") consults for "rule out compartment syndrome vs nec fasc" (floor patient with cellulitis) and "peritonitis" (ED patient, NOT peritonitis). Of course we always come running and I've yet to have one of these "no hurry" consults turn out to be anything big, but it scares me sometimes to think what if they had waited to call the consult because it wasn't concerning enough for a stat consult and it WAS compartment syndrome, nec fasc, peritonitis, etc.

I think that a rapid "drive-by" on these patients at the very least is a good idea. I've had a couple that turned out to be very sick. Most recently, I had patient with a cholecystojejunostomy present with an obstructed cystic duct. The consult was for "jaundice after biliary surgery." I found a hypotensive patient in acute renal failure suffering from untreated cholangitis. It never hurts to look.

Probably one of the weirder consults that I remember was actually a trauma activation for an individual who "jumped out a second story window and now has altered mental status." It turned out to be a suicidal drunk guy who attempted to jump out a closed window and simply bounced off. He had no signs of trauma and kept repeating "I wanna die man," over and over again.

 

[Dr.LeoSpaceman]

I've also had the other end of the spectrum. NON-stat (in fact stated "take your time/don't rush") consults for "rule out compartment syndrome vs nec fasc" (floor patient with cellulitis) and "peritonitis" (ED patient, NOT peritonitis). Of course we always come running and I've yet to have one of these "no hurry" consults turn out to be anything big, but it scares me sometimes to think what if they had waited to call the consult because it wasn't concerning enough for a stat consult and it WAS compartment syndrome, nec fasc, peritonitis, etc.

Just like there shouldn't be tests medicine teams shouldn't order (e.g. lactate, as discussed above), there's diagnoses/exam findings they shouldn't be allowed to use. Those include cold leg, peritonitis, nec fasc, and compartment syndrome. Unless you know what they are, you shouldn't be calling someone and using those terms.

 

[kitsunepixie]

To be fair, there are a lot of things that cause altered mental status. They may have been barking up the wrong tree.

It is a fairly big lapse to not notice your patient has a VP shunt...

Yeah, and they weren't really consulting me about the AMS...it was first all about the lower extremity weakness that wasn't even new, and then when he mentioned the AMS I got concerned since I was reviewing her images and saw that someone (not the person calling me) had ordered a shunt series and that she had a shunt on her recent HCT...

I agree about always eyeballing the "non-urgent" consults...especially after this case.

 

[maxheadroom]

Just like there shouldn't be tests medicine teams shouldn't order (e.g. lactate, as discussed above), there's diagnoses/exam findings they shouldn't be allowed to use. Those include cold leg, peritonitis, nec fasc, and compartment syndrome. Unless you know what they are, you shouldn't be calling someone and using those terms.

So how are they supposed to communicate what they think is going on with the patient when they call you? I want them to tell me, "I think this patient has nec fasc," if that's a possibility. That tells me that I need to see the patient immediately. There are certainly times when they're way off, but that's why they're calling the expert (you).

Also, take those patients (who either have the scary diagnosis or don't) and use that to teach the providers who are calling you about what they're seeing. Every time I have a patient in house with an important finding (in Plastics it's usually a flap that's compromised) I want all of my residents to see it so they know it next time they see it. Similarly, I routinely look at wounds on in-patients with the medicine teams that consult me. I take the whole group of Medicine residents into the room and have them look at the wound with me so they can actually see what I want them to see. Once they have that education, they can communicate more effectively when consulting me (and I can communicate more effectively when consulting them).

 

[Fah-Q]

I got called STAT to the MICU once to intubate a patient. Rare for the ENT resident to get that call and it usually means you are going to walk into a total disaster.

So I changed my shorts and ran upstairs to see a room full of fleas in 2 groups. One group is convened around the "difficult airway cart." The other is standing with folded arms around the terrified patient. He's got a 100% non-re-breather mask on and mouthing and gesturing frantically. I get close enough to notice that this patient has had a laryngectomy and we make eye contact and recognize each other from his frequent visits to our clinic. I give him a smile and he starts laughing.

I calmly walk over to the "difficult airway cart" and pull out a 6.5 ETT. I gently place this in the patient's wide open stoma, inflate the balloon, and tape the tube down to his chest. I walk out of the room to stunned silence which is broken when the head clipboard nurse declares that I must better secure the ETT..."what are we supposed to do if it comes out?"

True story.

 

[Fah-Q]

Ahh...that may be the difference. I do MULTIPLE procedures in the office on the same day. I imagine if it were a single one there may not be a reduction.

What procedures do you do in the office?

 

[ZagDoc]

He's got a 100% non-re-breather mask on and mouthing and gesturing frantically. I get close enough to notice that this patient has had a laryngectomy and we make eye contact and recognize each other from his frequent visits to our clinic. I give him a smile and he starts laughing.

Golden.

Patient must have a shunt! Sats not responding to 100% O2!

 

[Maybeknot]

So I changed my shorts

I know I shouldn't ask, but.....

 

[Dr.LeoSpaceman]

So how are they supposed to communicate what they think is going on with the patient when they call you? I want them to tell me, "I think this patient has nec fasc," if that's a possibility. That tells me that I need to see the patient immediately. There are certainly times when they're way off, but that's why they're calling the expert (you).

Also, take those patients (who either have the scary diagnosis or don't) and use that to teach the providers who are calling you about what they're seeing. Every time I have a patient in house with an important finding (in Plastics it's usually a flap that's compromised) I want all of my residents to see it so they know it next time they see it. Similarly, I routinely look at wounds on in-patients with the medicine teams that consult me. I take the whole group of Medicine residents into the room and have them look at the wound with me so they can actually see what I want them to see. Once they have that education, they can communicate more effectively when consulting me (and I can communicate more effectively when consulting them).

Well, teaching would be nice, but I've been called about erroneous "nec fasc" and "peritonitis" by the same people on multiple occasions (and the "cold leg" with palpable pulses), so obviously they aren't learning. Or, more likely, they know by throwing out those terms it will get me to come running and speed up their turnover (if it's the ED).

I don't need them to tell me they think it's something for it to be on my radar. If they give me the antecedent history with accurate physical exam findings (severe belly pain, leukocytosis, fever, etc.) I'll make the connection on my own. I don't need them to tell me it sounds like peritonitis. More often than not, you get there on a "peritonitis" call to find the person's legs crossed, reading the paper and an empty jello cup on the bedside tray.

 

[Winged Scapula]

What procedures do you do in the office?

Small punch/excisional biopsies (skin only), ultrasound guided core needle biopsies, placement of brachytherapy catheters for delivery of partial breast irradiation, drain seromas.

Good times.

 

[Winged Scapula]

Well, teaching would be nice, but I've been called about erroneous "nec fasc" and "peritonitis" by the same people on multiple occasions (and the "cold leg" with palpable pulses), so obviously they aren't learning. Or, more likely, they know by throwing out those terms it will get me to come running and speed up their turnover (if it's the ED).

I don't need them to tell me they think it's something for it to be on my radar. If they give me the antecedent history with accurate physical exam findings (severe belly pain, leukocytosis, fever, etc.) I'll make the connection on my own. I don't need them to tell me it sounds like peritonitis. More often than not, you get there on a "peritonitis" call to find the person's legs crossed, reading the paper and an empty jello cup on the bedside tray.

Ya see, I always figured it was because they didn't understand that surgeons and surgery residents respond to consults much much more quickly then medicine teams.

Our medicine teams typically saw consults, IF seen on the day called, at 500 pm (ie, end of daily rounds). It didn't matter when you called.

OTOH, our asses were handed to us if someone didn't at least eyeball ANY consult and write a quick note within 30 minutes of the call.

So perhaps they figure they need to tell you "nec fasc" because of the typical delay they give to consults coming their way.

 

[Pir8DeacDoc]

I got called STAT to the MICU once to intubate a patient. Rare for the ENT resident to get that call and it usually means you are going to walk into a total disaster.


I calmly walk over to the "difficult airway cart" and pull out a 6.5 ETT. I gently place this in the patient's wide open stoma, inflate the balloon, and tape the tube down to his chest. I walk out of the room to stunned silence which is broken when the head clipboard nurse declares that I must better secure the ETT..."what are we supposed to do if it comes out?"

True story.

This sort of stuff happens too often. I make it a life mission to educate people on the difference between a trach and a laryngectomy stoma. Doesn't seem to help. We even put "neck breather" signs over the bed and it doesn't help.

I will say that I've had anesthesiologists pre-oxygenate the mouth/nose of my total laryngectomy patients before. To which I contained my laughter and told them it probably wouldn't help and that the need for pre-oxygentation is none. Oh well, that's why there are different specialities.

 

[Winged Scapula]

This sort of stuff happens too often. I make it a life mission to educate people on the difference between a trach and a laryngectomy stoma. Doesn't seem to help. We even put "neck breather" signs over the bed and it doesn't help.

I will say that I've had anesthesiologists pre-oxygenate the mouth/nose of my total laryngectomy patients before. To which I contained my laughter and told them it probably wouldn't help and that the need for pre-oxygentation is none. Oh well, that's why there are different specialities.

Glad to hear that all specialties have their face palm moments.

 

[45408]

by the same people on multiple occasions (and the "cold leg" with palpable pulses).

Man, that merits a slap upside the head.

I don't think our medicine teams even know how to run a Doppler to check for signals...

 

[Buzz Me]

I also try to grab nearby students/Medicine residents/ER residents whenever I actually find a patient with true peritonitis - and try to impress upon them that it's not the PAIN I'm worried about, but the RIGIDITY.

 

[dpmd]

I have been assigned to teach the incoming interns about "the acute abdomen". It will be interesting to see how long it takes for the first intern outside of surgery to completely forget everything I teach.

 

[LucidSplash]

I really do not mind doing non-urgent line consults. Typically they are easy, require very little paperwork and can be signed off on immediately. On busy days (most days are busy) it can be a bit tough to find time to do them, but in general they do not annoy me as much as they seem to annoy others.

However, when you are a medicine resident seeing a patient admitted to ortho and you consult me for a patient with a legitimate need for a line and I ask why surgery is being consulted for the line (expecting some info on difficult stick, previous issues with line placement, wonky post-surgical anatomy, etc), please please please do not ever tell me "I'm too busy to do it today." At least sell it a little better.

Then, when I am guiding my medical student through the femoral line placement on your very skinny and easy to stick patient and your team walks into the room to round on the patient (despite my "we're doing a procedure please come back" reply to your knock on the door) and your attending inquires what procedure I am doing on his patient, please do not act surprised when I reply "the line you asked us to place because you were too busy." Also do not change your answer to "well if it makes you feel any better I'm not signed off to do lines either."

Really, I do not mind the line consult. But I mind the implication that your time is more valuable than mine and I am less busy than you and I mind that your attending doesn't seem to know that his intern passed up a perfectly easy stick and chance to get closer to being signed off on lines by consulting surgery to do it.

 

[Apollyon]

But I mind the implication that your time is more valuable than mine

Bingo!

 

[Raygun77]

I recently had a jaw dropping moment with our cardiology folk

Guy came through ER with "epigastric pain", 40 y/o
Got admitted to cardiology and Cathed!!
Findings: none ... shocking

STAT consult at MN to gen surg to workup abdominal pain, and oh by the way would you take the pat on your service ... ummm no

CT and RUQ u/s and LFTs normal
Wanted to do an EGD, endo could not accomodate me in the am the next day when we were post call, so we booked it for the following day.

Cardiology comes by to round on their patient, dosent like the fact that he cant get his scope done tomm, so consults GI to see the pt and scope them tomm. The GI doc bumps his own 8am case (which is why we wouldne get in) to do the pt when we wanted to do him

my head almost exploded 😡

oh man don't they do ECGs before cathing :O

kinda reminds me of this:
http://www.youtube.com/watch?v=xskFo75Wdhs

 

[dynx]

Got a good one the other day. I'm not sure if the medicine attendings teach the residents to just make up any reason for a surgical consult if they cant come up with a good one themselves but it seems to be the case.
Paged at 2 am. And I'm allready pissed off they passed up the intern and the junior on call.
me: "you paged?"
med res: "yeah I just wanted to run something by you (DANGER!) when do you start to worry about abdominal compartment syndrome? we've got a guy we gave a lot of fluid too...etc etc BS BS"
me: (edited out stability questions etc....)"have you checked a bladder pressure?"
med res: "what?"
me: "a bladder pressure, have you checked one?"
med res: "I'm not sure, my attending wanted us to ask you guys"
me: "well, look up abdominal compartment syndrome find out what a bladder pressure is and check one, then page the SICU resident"
med res: "I don't know how to do that"
me: "the ICU nurse does" (hang up)
Paged 10 minutes later
med res: "the bladder pressure is 17"
me: "great"
med res: "so....."
me: "yeah?"
med res: "is that okay?"
me" what did you read? what did the SICU resident tell you?"
med res: "the attending wanted me to page the senior"
me: "Page the SICU resident. We worry about pressures in the mid to high 20s go look up abdominal comp syndrome and if you're worried check the bladder pressures every 4-6 hours"
med res: "okay" (hang up)
Paged 10 minutes later
my wife "what the f*ck"
me "what the f*ck"
med res: "sorry, I just checked again and now the bladder pressure is 28"
me: "it changed in 2 minutes?!?
lots of swearing slam down the phone, call the SIC res myself and drag my ass in to see the non-surgical patient myself.
This kind of lie to get surgery to see the patient is stupid, lazy and dangerous.
just had to vent.

 

[Ronin2258]

Got a good one the other day. I'm not sure if the medicine attendings teach the residents to just make up any reason for a surgical consult if they cant come up with a good one themselves but it seems to be the case.
Paged at 2 am. And I'm allready pissed off they passed up the intern and the junior on call.
me: "you paged?"
med res: "yeah I just wanted to run something by you (DANGER!) when do you start to worry about abdominal compartment syndrome? we've got a guy we gave a lot of fluid too...etc etc BS BS"
me: (edited out stability questions etc....)"have you checked a bladder pressure?"
med res: "what?"
me: "a bladder pressure, have you checked one?"
med res: "I'm not sure, my attending wanted us to ask you guys"
me: "well, look up abdominal compartment syndrome find out what a bladder pressure is and check one, then page the SICU resident"
med res: "I don't know how to do that"
me: "the ICU nurse does" (hang up)
Paged 10 minutes later
med res: "the bladder pressure is 17"
me: "great"
med res: "so....."
me: "yeah?"
med res: "is that okay?"
me" what did you read? what did the SICU resident tell you?"
med res: "the attending wanted me to page the senior"
me: "Page the SICU resident. We worry about pressures in the mid to high 20s go look up abdominal comp syndrome and if you're worried check the bladder pressures every 4-6 hours"
med res: "okay" (hang up)
Paged 10 minutes later
my wife "what the f*ck"
me "what the f*ck"
med res: "sorry, I just checked again and now the bladder pressure is 28"
me: "it changed in 2 minutes?!?
lots of swearing slam down the phone, call the SIC res myself and drag my ass in to see the non-surgical patient myself.
This kind of lie to get surgery to see the patient is stupid, lazy and dangerous.
just had to vent.

If it didn't mean I would have to call a trauma code and ENT to correct the crushed windpipes of the medicine attending and team...

Let's just say I have low tolerance for lying, especially when patient safety is is concerned. Military Code of Honor thingy: "I will not lie, steal or cheat, nor tolerate I anyone who does."

Did you ever find out the reason that they wanted an overnight consult on someone with a non-surgical abdomen?

 

[Pir8DeacDoc]

I try and respect all consultants. I hope that they know I will help them if needed and therefore won't call me unnecessarily. Unfortunately you got a total bs story. I have low threshold for that crap. Don't dump on me, just be honest. I'll help you if you need it

 

[dynx]

If it didn't mean I would have to call a trauma code and ENT to correct the crushed windpipes of the medicine attending and team...

Let's just say I have low tolerance for lying, especially when patient safety is is concerned. Military Code of Honor thingy: "I will not lie, steal or cheat, nor tolerate I anyone who does."

Did you ever find out the reason that they wanted an overnight consult on someone with a non-surgical abdomen?

To be fair the guy was pretty sick, ETOH panc. It was a new IM attending, and the patient started to look bad and needed a lot of fluid over night.

 

[Buzz Me]

To be fair the guy was pretty sick, ETOH panc. It was a new IM attending, and the patient started to look bad and needed a lot of fluid over night.

Surprised they didn't call an early surgery consult for the diagnosis of pancreatitis - this is usually wrapped up as a consult for "peritonitis" (no, just very tender) or "necrotizing pancreatitis" (where's the air?) or "surgical abdomen with hypotension" (needs more fluid).

 

[dpmd]

My night team got consulted recently for a splenectomy for hypersplenism. Checked the chart out and platelets are fine, Hg is 7 ish, and the patient has a bunch of blasts on the diff. Called the primary team the next morning to discuss. They thought the patient might need emergent splenectomy for her anemia while they work her up for possible leukemia.

 

[Dr.LeoSpaceman]

Surprised they didn't call an early surgery consult for the diagnosis of pancreatitis - this is usually wrapped up as a consult for "peritonitis" (no, just very tender) or "necrotizing pancreatitis" (where's the air?) or "surgical abdomen with hypotension" (needs more fluid).

I think pancreatitis is one of those "medical" conditions that actually does warrant a surgical consult, if only to ensure appropriate management. Similar to some SBOs. Though I did go to a med school where the institutional culture was to treat pancreatitis as a surgical disease, and the place I'm in residency with HPB guys that feel the same and want the consults.

Of course, the irritating thing is when you make recommendations, they aren't followed, and then the patient (predictably) deteriorates.

 

[MediCane2006]

I'm moonlighting at a small community hospital where we cover all the surgical specialties (gen, ortho, ENT, uro). Got a call from the ED...."we have an elderly lady with multiple medical problems and a humerus fracture, nondisplaced, neurovascularly intact"

ED resident was vague on whether there was any trauma involved.

So I go down, and there's this very nice lady with a nice-looking cast on her arm. Two minutes of questioning revealed that she'd broken the arm two weeks ago and had it fixed by ortho. She had come to the ER this time because her primary doc wanted her admitted to work up her new-onset renal failure.

The thing that infuriated me the most was that the ED resident was totally surprised when I informed her that the patient's fracture had, in fact been fixed. Apparently she'd gotten the patient signed out to her with films pending, got back a film read that said "fracture" and automatically called a consult. Honestly...

 

[45408]

I'm moonlighting at a small community hospital where we cover all the surgical specialties (gen, ortho, ENT, uro). Got a call from the ED...."we have an elderly lady with multiple medical problems and a humerus fracture, nondisplaced, neurovascularly intact"

ED resident was vague on whether there was any trauma involved.

So I go down, and there's this very nice lady with a nice-looking cast on her arm. Two minutes of questioning revealed that she'd broken the arm two weeks ago and had it fixed by ortho. She had come to the ER this time because her primary doc wanted her admitted to work up her new-onset renal failure.

The thing that infuriated me the most was that the ED resident was totally surprised when I informed her that the patient's fracture had, in fact been fixed. Apparently she'd gotten the patient signed out to her with films pending, got back a film read that said "fracture" and automatically called a consult. Honestly...

Man, this makes me glad we don't have problems with our ER "signing" things out to the guy coming on. That's insane.

 

[Buzz Me]

Of course, the irritating thing is when you make recommendations, they aren't followed, and then the patient (predictably) deteriorates.

Happens the majority of the time, unfortunately.

 

[BlondeDocteur]

I'm just dipping my toe into the pool of being a consult resident...

I was consulted by the MICU intern for "a line problem."

Me: "What's the problem?"
MICU: "The line has become unsecured."
Me: "Did Surgery place the line?" (which would be extremely odd in our MICU, but perhaps it was a post-op who was transferred...)
MICU: "No, my senior resident did."
Me: "Do you have a CXR confirming the line is still in place?"
MICU: "Yes, it's still blahblah cm from the cavoatrial junction."
Me: "So what is the consult for?"
MICU: "The stitch came loose."
Me: "So you want Surgery to come place a stitch? A single stitch, around your line?"
MICU: "Yes."

And I did.

 

[DoctorDoom]

I never minded doing even the silly stuff, even in residency, if the consultant is ignorant of surgical disease or procedure. You aren't good with lines? Ok, I'm stuck here anyways, and if I'm not getting killed I'll walk you through it. You don't know what you're looking at on the CT? Ok, let's check it out, no problem. It's the lies and laziness and clear punts that make me insane. At least see the patient. I mean for crying out loud put in a minimum of effort.

Consult for 82F r/o acute appy. No labs, no studies, sigh...
Go see the patient, healthy, pleasant, old lady.
History: "...I had a hip replacement, and my appendix taken out."
"When?"
"I was about 20 yrs old, it was a long time ago." No kidding.
Exam: benign exam, no hernias, a VERY old scar in the RLQ, no TTP.
ER doc: "So you gonna take her?"
"I don't think she has appendicitis. She had an appendectomy. Have you seen her?"
"Not yet, I was waiting for you, but I'm gonna order a CT, just to be sure."
"She's not a f**king starfish, she can't regrow parts."

I lose my temper with those who seem to celebrate their laziness.

 

[DoctorDoom]

ER resident: We have a cold extremity from a trauma. You guys need to see her.
Me: Sure, be right down. (I double time it down to ED.)

Lady sitting up, one sock off, fully clothed.

History: Tripped and fell three weeks ago. Came in for f/u in clinic.
Exam: Benign. Normal DP pulses. Both feet same temp.

Me: Did you examine both feet?
ER resident: Um... no.
Me: Did you do a pulse exam?
ER resident: She's a trauma. That's your job.
Me: Where's your staff?

That didn't go well for him. Plus when he consulted trauma again for a foreign body in the rectum, I retrieved it during my rectal and put it on his desk.

 

[DoctorDoom]

ER Attending: You need to see this woman, she swallowed a pin and it's in her rectum.
Me: She's stable? No pain no bleeding?
ER A: Totally, but you might need to take her to the OR stat. You can see it on the plain film!
Me: Really? Ok, let me look at the film because I'm at the PACS machine, I'll see her right afterwards.

Films shows IUD in place, no other foreign objects. Radiologist read: "No acute pathologic findings. No foreign objects noted, previously noted IUD in normal position, unchanged in 24 hours since previous study."

Previously noted? 24 hours? Look at film from ED from the day before. Same IUD, same read.

Chief Complaint: Patient with extensive psych history claiming to have swallowed pin.

Me: Does this patient have an IUD?
ER A: What? An IUD? I don't know.
Me: Have you seen this patient?
ER A: No, the medical student did though and saw the pin in her rectum.
Me: Please go look at the film, and then ask her if she has an IUD. Then let me know if you still want the consult.
(5mins later)
ER A: Uh, I'll call you if I need you.

That was a bad Christmas night.

 

[dpmd]

Can't remember if I posted this one yet.

Get a call to evaluate lower abdominal mass on a medicine patient. Since part of the story I heard from my junior was that the CT showed a large mass I decide to cheat and look at the film first. Open the scan and see a very large, very abnormal appearing uterus. My junior has just gotten to the family history section of his (overly long) presentation and is describing about 4 different family members of this lady with uterine cancer. I stop her and ask if the medicine team had checked the CT before they called us (it was from a day or so prior-no official read yet as is typical for our facility, but they already waited a few days since admit so I was curious). She said they were just about to talk to the radiologist about it but that since they saw her they figured they would just give her the consult now. I was pissed, but went up to see the patient (mostly because there was a history of peritonitis from a peritoneal dialysis cath so I just wanted to make sure she didn't have something going on still since there was some free fluid in the pelvis). I tried to be diplomatic as I told her that she would be best served by having the gyn folks evaluate her mass. I was less diplomatic when I told the medicine resident the same thing.

 

[ZagDoc]

"She's not a f**king starfish, she can't regrow parts."

Awesome.