Consults- Memorable/Dismal/Ridiculous/Unique

[45408]

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Consult for 82F r/o acute appy. No labs, no studies, sigh...
Go see the patient, healthy, pleasant, old lady.

We don't see those consults, honestly. Basically, our senior residents (who have to accept all consults) will tell the ED/urgent care docs to work it up if they try to give us that crap. And they do.

 

[DoctorDoom]

We don't see those consults, honestly. Basically, our senior residents (who have to accept all consults) will tell the ED/urgent care docs to work it up if they try to give us that crap. And they do.

Yeah, I tried that, both as a senior resident and as a policy when I was Chief. I also tried to make it a policy that my service did not accept consults from medical students (mostly because their residents were hanging them out to dry, so I was trying to force the Medicine and OB services to actually work up their patients) or unit clerks. That lasted 2 weeks before my PD told me that we should "do the right thing and just see the patient." My question as to why we should do the right thing when no other service in my training institution needed to, and doesn't our behavior suborn laziness and poor patient care, was met with attacks against my character delivered at a loud volume. I was told that as a trainee I was not qualified to decide which consults were inappropriate.

My program graduated good residents despite the staff.

When your staff don't give a **** about you and just want the ED staff to be nice to them at barbecues, you have no choice but see everyone. I got chewed out once for telling the ER to call the IR call person to look at a drain that the IR service put in earlier that day...

 

[dpmd]

At my institution the department chair requests us to keep a list of inappropriate consults and takes that info to the departments where it is coming from. She doesn't want the interns turning them away (the junior is the person who gets the consult), but allows a bit of latitude to the chief (she doesn't want the patient to suffer from another service's ineptitude, but is fine with us forcing the other service to do their own work). It hasn't eliminated the stupidity because there is always someone new getting involved, but at least it is getting acknowledged.

 

[sphincter tone]

2 am
ER: Hi i have a lady down here with chronic back pain x 2 years!
me: does she have a neuro deficit, bowel or bladder dysfunction?
ER: no
me: she appears to have no imagaing
ER: that's right
me: what exactly are you expecting us to operate on?
ER: uhhhhh..... her back?

 

[Ronin2258]

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

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

I only wish to be this acerbic in real life with the people I encountered as lazy.

 

[skiz knot]

I'll play!

I'm ortho, so the flavor is a little different...

Was on call at the local children's hospital when I got a call from the ER asking me to come see a 9 or 10 year old "kiddo" with "refusal to bear weight" on whom they wanted me to "rule out septic hip." After asking them to draw a CBC, CRP and ESR and an get an xray (it still boggles my mind that he had been in the ER upwards of 4 hours at that point and none of this had been done yet). I came to see him after labs had been drawn (mildly elevated everything but not exciting, normal xrays).

I go to examine him and he isn't really having hip pain. Never did. He is laying on the bed right hip flexed, holding his RLQ. He describes classic pain started in the "middle of (his) stomach" and had "moved" to the RLQ over the last several hours. +rebound/guarding, psoas sign, and the only +Rovsing sign I've actually seen.

I found the off service intern that consulted me and diplomatically told her of my findings. I told her to consult Pediatric surgery and she quizzically replied "but I thought ortho took care of septic hips."



Patient was up in the OR within an hour having his (fortunately non-ruptured) appendix removed.

 

[Smurfette]

For some reason, that reminds me of the time I got call by the ER attending for a 10 yo kid with "some intraabdominal catastrophe" necessitating him to call me (peds surg chief at the time) and skip calling my intern who was first call. He tells me the patient has vague abdominal pain that was clearly surgical because the labs were "really messed up and his bicarb is 8". He figured we'd take him straight to the OR and was "getting him ready" for us. So I go down there, take a look at the lab printout, and find the ER attending. "so....I think he just needs the ICU and an insulin drip". ER attending: "what?!". Me: "Yep, I'm pretty sure his labs are messed up because he's in DKA and his glucose is 750. DKA can cause abdominal pain. Do you still want me to do the consult?". Sad thing is, the glucose level was right underneath that bicarb of 9 on the lab printout.

Another one:
ER calls for a r/o appendicitis in a 10 weeks pregnant 17 yo. It's the same 17 yo who was discharged the day before after being admitted to OB after a negative MRI AND negative US for appendicitis, and with a story that isn't classic for appendicitis. We ask "isn't this the same patient who was discharged yesterday from OB after the work up was negative?". Answer: yes, but OB says appendicitis is a surgery issue. "But her MRI and US were negative for an appy. We're not going to operate on a pregnant woman who doesn't need it". Answer: OB says she's thinking about terminating the pregnancy anyways, so it would be ok to operate since if she loses the baby, she probably won't care. Me (horrified): "umm...no. It doesn't work that way. If she doesn't have appendicitis, she's not getting an operation". Unbelievable that OB said that. So OB insists it's appendicitis and gets a SECOND MRI which shows....nothing. Can't believe radiology repeated the MRI.

 

[SLUser11]

Another one:
ER calls for a r/o appendicitis in a 10 weeks pregnant 17 yo. It's the same 17 yo who was discharged the day before after being admitted to OB after a negative MRI AND negative US for appendicitis, and with a story that isn't classic for appendicitis. We ask "isn't this the same patient who was discharged yesterday from OB after the work up was negative?". Answer: yes, but OB says appendicitis is a surgery issue. "But her MRI and US were negative for an appy. We're not going to operate on a pregnant woman who doesn't need it". Answer: OB says she's thinking about terminating the pregnancy anyways, so it would be ok to operate since if she loses the baby, she probably won't care. Me (horrified): "umm...no. It doesn't work that way. If she doesn't have appendicitis, she's not getting an operation". Unbelievable that OB said that. So OB insists it's appendicitis and gets a SECOND MRI which shows....nothing. Can't believe radiology repeated the MRI.

I don't know...for that case, maybe a surgical consult wasn't such a horrible idea. Abdominal ultrasound isn't perfect, nor is MRI, and an early appendicitis could be easily missed, especially if the symptoms weren't classic (as they frequently are not in preggos).

It would be different if a week had passed, but persistent pain 24 hours later may possibly warrant another educated abdominal exam (educated=surgical), as it could be a developing diagnosis....assuming all the other gyn-ey things were ruled out.

With fetal demise being so high for perforated appendicitis, I've always been relatively aggressive in the workup of pregnant RLQ (or RUQ) pain. That doesn't mean that every patient gets a laparoscopy, but they all get a serious look.

 

[Smurfette]

I don't know...for that case, maybe a surgical consult wasn't such a horrible idea. Abdominal ultrasound isn't perfect, nor is MRI, and an early appendicitis could be easily missed, especially if the symptoms weren't classic (as they frequently are not in preggos).

It would be different if a week had passed, but persistent pain 24 hours later may possibly warrant another educated abdominal exam (educated=surgical), as it could be a developing diagnosis....assuming all the other gyn-ey things were ruled out.

With fetal demise being so high for perforated appendicitis, I've always been relatively aggressive in the workup of pregnant RLQ (or RUQ) pain. That doesn't mean that every patient gets a laparoscopy, but they all get a serious look.

I agree with being careful in pregnant patients. However, she had been admitted to OB for three days and got serial exams with us on consult, was tolerating a diet and was discharged home the day prior to her ER return. Her exam was never all that impressive and she didn't look like an appy; we were being paranoid in the first place because she was pregnant (hence the MRI). IIRC, she had pain for a day or two prior to admission as well. It wasn't an "early appy" situation after this amount of time; she had been thoroughly worked up and watched. I should've made it more clear that it wasn't a "sent home from ER and came right back" patient.

However, as a teaching point, MRI *is* very specific (I've seen 97-99%) for appendicitis, and ~94%+ sensitive for appendicitis; it's better than CT scans in pregnancy (not that you'd CT a pregnant woman). There are several studies that give MRI a 100% NPV.

 

[45408]

I thought laparoscopy was relatively contraindicated during pregnancy, or is it reasonable during the first trimester?

 

[SLUser11]

I thought laparoscopy was relatively contraindicated during pregnancy, or is it reasonable during the first trimester?

That's a common misconception. Laparoscopy is safe in pregnancy and often the preferred approach. If you tried to offer an elective open chole to a patient in her second trimester I would have a heart attack.

 

[anonperson]

I thought laparoscopy was relatively contraindicated during pregnancy, or is it reasonable during the first trimester?

Second trimester is generally considered the optimal time. Laparoscopy is a reasonable and safe approach.

However, as a teaching point, MRI *is* very specific (I've seen 97-99%) for appendicitis, and ~94%+ sensitive for appendicitis; it's better than CT scans in pregnancy (not that you'd CT a pregnant woman). There are several studies that give MRI a 100% NPV.

We run into this a lot. If a pregnant woman needs a CT, then she needs a CT. We get a lot of push back in the hospital due to the concern for radiation exposure. While this is legitimate, if a CT gives the quickest and most effective answer, the radiation dose from a CT is going to provide minimal adverse effects, especially after organogenesis/1st trimester.

 

[45408]

However, as a teaching point, MRI *is* very specific (I've seen 97-99%) for appendicitis, and ~94%+ sensitive for appendicitis; it's better than CT scans in pregnancy (not that you'd CT a pregnant woman). There are several studies that give MRI a 100% NPV.

We just CT'd a woman who was 16-20 weeks pregnant a few weeks ago. She had some very iffy looking small bowel on imaging that turned out to be completely dead on ex lap. The fetus looks pretty sweet on CT.

She has Crohn's, but this problem was due to adhesions. To be honest, I really don't know if an MRI would have been a better choice, although it certainly would have taken longer to obtain at night, and she definitely would have died without the operation.

 

[45408]

That's a common misconception. Laparoscopy is safe in pregnancy and often the preferred approach. If you tried to offer an elective open chole to a patient in her second trimester I would have a heart attack.

Perhaps I'm about to walk into your second common misconception, but I also thought that elective abdominal cases are verboten in pregnancy.

 

[Buzz Me]

Answer: OB says she's thinking about terminating the pregnancy anyways, so it would be ok to operate since if she loses the baby, she probably won't care. Me (horrified): "umm...no. It doesn't work that way. If she doesn't have appendicitis, she's not getting an operation". Unbelievable that OB said that. So OB insists it's appendicitis and gets a SECOND MRI which shows....nothing. Can't believe radiology repeated the MRI.

Holy crap...I've had the EXACT SAME consult before! 😱 Same situation and everything.

 

[SLUser11]

Perhaps I'm about to walk into your second common misconception, but I also thought that elective abdominal cases are verboten in pregnancy.

I think that sort of depends on your definition of "elective." I wouldn't recommend breast augmentation during pregnancy, but if a patient has symptomatic cholelithiasis that is bothersome, I'd put the gallbladder in a bucket. There are plenty of non-emergent cases that can be done safely in a pregnant patient.

There have been multiple studies that show abdominal surgery is relatively safe during pregnancy, including laparoscopy. When possible, it's recommended that patients wait until the second trimester because it's still a stress on the body and fetus, and the miscarriage rate is lower during that time period.

However, there are plenty of situations where the risk of non-operative management is equal to or greater than the risk of surgery. As surgeons get more experienced, they are becoming increasingly aggressive with the surgical treatment of pregnant patients.

Examples:
1. Hyperthyroidism refractory to PTU- Thyroidectomy regardless of trimester.
2. Symptomatic cholelithiasis- Probably wait until 2nd trimester if symptoms controlled with narcs.
3. Cholecystitis- Lap chole regardless of trimester, 3rd included. The recurrence rate is prett high.
4. Gallstone pancreatitis- Lap chole regardless of trimester, again based on the possible effects of a severe pancreatitis and the likelihood of recurrence prior to delivery.
5. Breast cancer- Oh boy this is a whole hour-long lecture in itself, and I'll defer to WS, but lumpectomy is still an option, chemo is still an option (2nd trimester and beyond), and sentinel lymph node with radioactive colloid (but not lymphazurin blue) is still an option.


I keep going back to biliary disease because it's common in pregnancy, and you're likely to see it a lot during residency. There are a couple good articles that I'll post later when I have pubmed access that will help a lot.

 

[Smurfette]

Perhaps I'm about to walk into your second common misconception, but I also thought that elective abdominal cases are verboten in pregnancy.

Truly elective things that can wait until after pregnancy should wait.

If something is legitimately life threatening (trauma, SBO, etc.) I'll get a CT scan on a pregnant patient. Radiology freaks out. Multiple times (the tech, the resident, the attending), every time. But I will try other imaging first if clinically reasonable given the history and exam.

Second trimester is best for reasons SLU said, as well as the fact that since organogenesis is done, there are less chances of causing congenital sequelae along those lines (from anesthetics, meds, etc.).

Symptomatic cholelithiasis should be taken care of, because it normally worsens throughout pregnancy, and a bad attack in the third trimester can cause premature labor.

SAGES guidelines are for lap choles/appys being safe until AT LEAST 28 weeks, can go later if adequate visualization. There's papers stating good results at 34 weeks. Just stay away from the uterus (I had a friend who saw a fetus injured from a gen surg trocar during her OB residency).

SLU's summary is nice and succinct. Thankfully most pregnant women are young and healthy, so gallbladders, appys and breast complaints are the most common scenarios of things that can't wait until they deliver.

I've had 3 pregnant patient consults recently: pilonidal cyst (can wait unless gets infected) and 2 umbilical hernias (waiting until post partum as they are reducible and their expanding bellies are not going to allow for adequate repair now anyhow).

 

[45408]

I've had 3 pregnant patient consults recently: pilonidal cyst (can wait unless gets infected) and 2 umbilical hernias (waiting until post partum as they are reducible and their expanding bellies are not going to allow for adequate repair now anyhow).

Can't you just filet a pilonidal wide open with some local if it's a problem?

 

[Smurfette]

Can't you just filet a pilonidal wide open with some local if it's a problem?

Yep. Sometimes pilonidals are really problematic though. Or maybe that was my residency experience...this is the first patient I've had who hasn't previously had a pilonidal cyst procedure of some kind (one of our colorectal guys got referrals all the time for recurrent ones that community guys were sick of dealing with. So my view is admittedly skewed). A regular I&D is fine with local, but if it doesn't heal well and keeps on getting reinfected, and it needs to be completely excised, I'd do it under a spinal (or something other than local alone) for her. She is *not* a gal who can tolerate much of anything, and quite a drama queen. The exam alone was "excruciatingly painful" and it wasn't that bad compared to most. I think going into labor will put things into perspective for her.

In random consults, I got a patient sent to see me by gyne last month because "her adhesions are back". How did she know? Well, she has had 2 previously ex lap/LOAs before that presented as SBOs, so when she started having dyspareunia she "just knew" the pain was being caused by intraabdominal adhesions. Sent her back to gyne for work up of pelvic pain and dyspareunia.

 

[45408]

Last night's ridiculous consult by a new medicine intern: newly discovered incarcerated R inguinal hernia. The medicine guy said "I couldn't find any previous documentation about it."

It wasn't new ("I've had this damn thing for years!")
It also wasn't incarcerated (reduced in <1 minute of trying)

It was also in a patient who is being treated palliatively and is a DNR, and they didn't bother calling us until 8pm for an issue that had to have been known about for a while. Not only that, the patient correctly diagnosed the problem: "They put me on these pain medications, and when I get constipated, my hernia sticks out!"

 

[LucidSplash]

2:30am call to surgical critical care resident (me) from hospitalist regarding patient on the floor who they are "thinking of consulting SCC on" but "not certain he needs to be in the ICU":

Hospitalist: "Blah blah blah patient history. Hemodynamically and neuro stable. My question for you is should I give FFP?"
Me: What are the patient's coags?
Hospitalist: I don't know.
Me: Then I don't either.

 

[45408]

2:30am call to surgical critical care resident (me) from hospitalist regarding patient on the floor who they are "thinking of consulting SCC on" but "not certain he needs to be in the ICU":

Hospitalist: "Blah blah blah patient history. Hemodynamically and neuro stable. My question for you is should I give FFP?"
Me: What are the patient's coags?
Hospitalist: I don't know.
Me: Then I don't either.

I'm pleased that the hospitalist had at least formulated a specific question, but the logical disconnect there is incredible.

 

[McGillGrad]

ED consult for 6m old baby with abdominal mass.

Arrive to find happy, well nourished baby with no mass and not a care in the world. I asked the ED resident where he felt the mass. He said he wasn't comfortable examining a baby and took the mother's word that there was a left sided mass that "appeared over night".

The kicker: the frequent flyer mother asked for a prescription for diapers and formula. Oh the joys of medicaid patients.

 

[SLUser11]

I'm not sure when it changed, but I just noticed today that when you're not logged in, people are listed as "Member ____" instead of their traditional screen names.

Lee is Member 1, so I'm guessing it's chronological.....WS is member 4288, I'm Member 62744.....

Has this been going on for a while? Is it permanent?

 

[Smurfette]

I'm not sure when it changed, but I just noticed today that when you're not logged in, people are listed as "Member ____" instead of their traditional screen names.

Lee is Member 1, so I'm guessing it's chronological.....WS is member 4288, I'm Member 62744.....

Has this been going on for a while? Is it permanent?

SLU,
This has been changed to protect member identities. There are programs that try to match screennames to other sites in order to gain more information about the individual. So only SDN members can see screen names now; when logged out, you'll just be able to see the member number (which is indeed chronological). This is new. I believe there will be an announcement posted about this soon.

 

[filter07]

ED consult for 6m old baby with abdominal mass.

Arrive to find happy, well nourished baby with no mass and not a care in the world. I asked the ED resident where he felt the mass. He said he wasn't comfortable examining a baby and took the mother's word that there was a left sided mass that "appeared over night".

The kicker: the frequent flyer mother asked for a prescription for diapers and formula. Oh the joys of medicaid patients.

"Not comfortable" is one of my biggest hospital pet peeves. I so sick of hearing weak students, residents, and attendings use that line to justify their laziness and irrational fear. They're not comfortable doing a whole host of things. Well guess what, learning isn't supposed to be comfortable. Taking care of patients is not comfortable. It's hard work and that's what we signed up for.

I had a student on surgery tell me s/he wasn't comfortable putting in a foley catheter in the OR. Well yeah, that's the whole point of putting one in, so you're comfortable doing it the next time. Durr

Another phrase that gets thrown around way too often these days is "That's malpractice". I used to only hear that one every few months and now I hear it at least once a week (not to me, fwiw). That kind of language is pretty unprofessional IMO unless something is really egregious. Nowadays it's used without much discretion.

 

[LucidSplash]

"Not comfortable" is one of my biggest hospital pet peeves. I so sick of hearing weak students, residents, and attendings use that line to justify their laziness and irrational fear. They're not comfortable doing a whole host of things. Well guess what, learning isn't supposed to be comfortable. Taking care of patients is not comfortable. It's hard work and that's what we signed up for.

I had a student on surgery tell me s/he wasn't comfortable putting in a foley catheter in the OR. Well yeah, that's the whole point of putting one in, so you're comfortable doing it the next time. Durr

THIS. I have heard this a couple times myself and it makes my skin creepy crawly because, holy crap, I am almost NEVER comfortable. I was more confident in handling small problems as the year went on last year but still always aware of how much I didn't know and how much I could NOT handle on my own. Now I'm a newly-minted PGY-2 and I'm in the ICU and it feels like July of intern year all over again. I'm at a program with supportive culture where you are encouraged to try to figure out problems yourself but NEVER tells you that you are "weak" when you make a phone call. Even so, being on call as the only surgery resident in the ICUs is slightly easier now (Day 24) than Day 1 but I'm definitely not comfortable - these are MY patients and they are MY responsibility no matter who I call to back me up. If I had to wait until I felt "comfortable" I would never be on call and I would never progress.

 

[Dr.LeoSpaceman]

THIS. I have heard this a couple times myself and it makes my skin creepy crawly because, holy crap, I am almost NEVER comfortable. I was more confident in handling small problems as the year went on last year but still always aware of how much I didn't know and how much I could NOT handle on my own. Now I'm a newly-minted PGY-2 and I'm in the ICU and it feels like July of intern year all over again. I'm at a program with supportive culture where you are encouraged to try to figure out problems yourself but NEVER tells you that you are "weak" when you make a phone call. Even so, being on call as the only surgery resident in the ICUs is slightly easier now (Day 24) than Day 1 but I'm definitely not comfortable - these are MY patients and they are MY responsibility no matter who I call to back me up. If I had to wait until I felt "comfortable" I would never be on call and I would never progress.

I think saying "not comfortable" is ok as long as it's a way of saying "Hey, I've never done this and need some help", especially in situations where a mistake could cause a problem . Now if you try and use the same line the next time the situation comes up...

It's also a bush league maneuver when used on something we all should have learned in medical school. A surgery intern saying they "aren't comfortable" pulling a chest tube alone if they've never done it (yes, sadly they exist) is much different than an IM PGY2 saying they deferred the rectal because they weren't comfortable.

 

[45408]

ED consult for 6m old baby with abdominal mass.

Arrive to find happy, well nourished baby with no mass and not a care in the world. I asked the ED resident where he felt the mass. He said he wasn't comfortable examining a baby and took the mother's word that there was a left sided mass that "appeared over night".

The kicker: the frequent flyer mother asked for a prescription for diapers and formula. Oh the joys of medicaid patients.

In that case, me neither!

 

[45408]

If it were on the chest, would it go to cardiothoracic surgery?

 

[Thanatos]

If it were on the chest, would it go to cardiothoracic surgery?

It should probably go to cardiology first. If they want first bid on everything procedural, maybe we should make sure to run this past them as well.

 

[DD214_DOC]

You surgery guys aren't immune, either. My "best" consult came from surgery.


Surgery: "Yeah, I got this XX year old guy who is POD #something s/p partial colectomy for colon cancer. He hasn't been eating in a couple days. I think it may have something to do with depression. Could you come check him out?"

Me: "Any other signs or symptoms of depression you're aware of? Any safety risks?"

Surgery: "Uhhhh [meaning he didn't ask any other questions] I don't think so"

Knowing that we end up seeing everything anyway, I tell them I'll come see the patient.

Me: Introduce myself and where I'm from. Patient states he didn't know psychiatry was asked to see him. "How are you feeling today?"

Patient: "I feel great, I'm not sure why you were called"

Me: "They tell me you haven't been eating for the past couple of days. Tell me more about that"

Patient: "That's because they took my dentures before surgery and lost the damn thing! I'm starving!"

I know most specialties think psychiatry is a joke (until they need us) but please provide proper consults to us as well.

 

[DoctaJay]

lol, Tired I love it!

 

[McGillGrad]

Called surgery to consult on 16 year old with abdominal pain, fever, elevated RBCs. White as a ghost and obviously unwell.

Junior Surgery resident: He looks a bit off but not for surgery. He might just be anemic.
Me: Are you sure, he looks like a prime candidate for surgery. Could you call your attending?
Junior Surgery resident: Listen, I don't tell you how to do our consults...
Me: Ok, thanks.

*2 hours later on rounds with my attending
Me: Surgery said he didn't need their help.
Attending (after a quick physical exam): Send him to the OR right now. He is about to perforate.

Kid had a nasty inflamed appendix that burst during surgery, took him a week to recover. I called to thank the junior surgical resident myself, right before my attending called his attending.

 

[SLUser11]

You surgery guys aren't immune, either. My "best" consult came from surgery.

I agree that inpatient consults to psychiatry for depression are silly. The surgery team says "we think the patient is depressed," then psych comes and sees the patient a day or two later and writes, "we agree, this patient is depressed. Thank you for the consult. Please follow up in the office." Or maybe they start an SSRI....not really necessary.

I only consult psychiatry if a patient is actively psychotic or actively suicidal. I think my psych colleagues appreciate it.

Kid had a nasty inflamed appendix that burst during surgery, took him a week to recover. I called to thank the junior surgical resident myself, right before my attending called his attending.

That's a big miss considering how easy it is to diagnose appendicitis. There's nothing worse than a junior resident with a crapload of attitude. Unfortunately, we're trained to condescend to certain specialties starting in med school. How many times as students did we hear medicine and surgery residents complain about the ER? When we make the transition to residency, we immediately regurgitate the ER insults without any true experience to back it up....we're breeding bad behavior.

 

[DD214_DOC]

I agree that inpatient consults to psychiatry for depression are silly. The surgery team says "we think the patient is depressed," then psych comes and sees the patient a day or two later and writes, "we agree, this patient is depressed. Thank you for the consult. Please follow up in the office." Or maybe they start an SSRI....not really necessary.

I only consult psychiatry if a patient is actively psychotic or actively suicidal. I think my psych colleagues appreciate it.

It is appreciated. There's really no reason to consult psychiatry for something a FP or any other primary care doc can take care of. Surgery usually doesn't consult us very often anyway, but I think this consult was mainly because the attendings didn't want to actually talk to the patient more than 30 seconds, or it was initiated by the intern/resident without speaking to staff first.

The consults from other services tend to be a lot worse. Medicine isn't too bad as they try to handle things on their own (which is sometimes bad, since one IM attending wanted to give a delirious patient haldol decanoate for "psychosis"). The OB dept seems to be really bad at pointless CYA consults. Typically, it's a patient with a history of depression previously treated on X prior to pregnancy, has been off but doing well mood-wise and completely stable. The patient delivers and the day prior to discharge they consult us. Typically, there isn't even a consult question. It's usually, "Patient with history of depression, previously treated with X, please eval and make reccs prior to discharge". We see the patient, then inevitably they are discharged before we put the recs on the chart. It's really annoying, and it tempts me to start consulting OB for my patients who, "have a history of being pregnant, previously treated with delivery. Not currently pregnant, please eval and make recs".

 

[ZagDoc]

It's really annoying, and it tempts me to start consulting OB for my patients who, "have a history of being pregnant, previously treated with delivery. Not currently pregnant, please eval and make recs".

Totally appropriate consult. Pregnancy has a high rate of recurrence.

 

[filter07]

Just letting psych be aware of the patient in case she has post partum depression. That way, psychiatrists can act right away without all the paperwork that gets in the way of emergency treatment. Sort of like how surgeons who do a consult note can just walk into a patient's room and start cutting on their belly at any moment.

 

[dpmd]

We rarely consult psych, but that is mostly because the only thing that typically gets us is recs for RPR, TSH, head CT, etc. It is usually because a patient has something complex (psych history plus head injury and now dangerous behavior), or because we want some documentation on competence and aren't sure enough about it to do it ourselves (one that comes to mind is a guy with an open tib fib fracture with multiple other injuries including pneumothorax who was refusing any treatment for any of the issues-attending refused to believe he wasn't crazy and I had to get psych to see him not once, but five times before I was finally allowed to follow his wishes and get him out on hospice)

 

[SLUser11]

When we call you, what we're really saying is this: I have a patient with a mental health issue, and I don't have time to deal with it. You're the expert, we just want to know what to do about it....

While that makes sense, if an ER doc called you to take care of a problem, and his explanation was "yes I know what to do, but I just don't have time right now to do it," you would be extremely unhappy. For surgery, it might be a laceration repair or an abscess drainage...or even worse a "trauma" activation. For ortho, it could be a splint or a joint issue. Either way, we routinely get pissed at ER docs for a similar train of thought.

Once we get into deciding whose time is more important than others, there's going to be a justified disagreement.

 

[dpmd]

(3) And while we're on it, psychiatry is hardly blameless in this whole game. Tell me the last time you saw a psychiatrist (ie - a fellow MD) perform or document a physical exam? When you rotated as a student in IM, how many consults did you see for "r/o gen med condition as cause of psych symptoms"? How many psych admissions get turned down because "patient has medical conditions that cannot be managed on psych ward"? It cuts both ways; you can't blame a surgical specialist for not doing generalist work, then turn around and say you can't do generalist work because you're a mental health specialist.

I am particularly fond of the consults from psych to remove sutures placed by the ED (for patients we never saw).

 

[DD214_DOC]

but seriously, if they're not on the inpatient consult service to handle these kinds of issues, what the hell else do they have to do?

I'm not sure if this is a legitimate question or condescension, or both.

Patients admitted for medical reasons who have severe, uncontrolled psychiatric comorbidities or who have to be taken off of their current rx regimen for some medical reason (Recently had a surg consult for a bipolar patient on multiple meds who had to be taken to the OR for an eviscerated bowel, decompensated and surgical team had no idea how to manage given he was NPO.)

Delirium that the med team can't fix/figure out, delirium in dementia patients, psychosis and its various etiologies (have been consulted for "psychosis" which turned out to be seizure activity, anti-NMDA-receptor encephalopathy, PRES, and other things that were actually neurological), s/p suicide attempts, combative and aggressive behavior in hospitalized patients, severe depression not responsive to treatment, acute safety issues in patients, etc.

We usually recommend imaging studies in psychotic patients and other disorders because of the huge overlap in symptoms with neurological disorders, especially things like PRES where you can see white-matter changes and edema on MRI.

I'm not saying psychiatry isn't guilty, either. Unfortunately we do our fair share of simple consults for things we *should* be able to manage. We asked medicine a lot to do something that, "can't be managed on the psych ward". They get pissed and think it's a dump, but it's actually true -- we cannot give ANYTHING IV, including fluids, on a psychiatric ward because of the safety risk of having plastic tubing and such around. There's also a ton of other things we simply cannot do because of regulations about what is allowed to be on a psychiatric ward.

Having said that, I have never seen anyone consult to, "rule out medical condition". That's part of our job in psychiatry.

 

[Hamhock]

While that makes sense, if an ER doc called you to take care of a problem, and his explanation was "yes I know what to do, but I just don't have time right now to do it," you would be extremely unhappy. For surgery, it might be a laceration repair or an abscess drainage...or even worse a "trauma" activation. For ortho, it could be a splint or a joint issue. Either way, we routinely get pissed at ER docs for a similar train of thought.

Once we get into deciding whose time is more important than others, there's going to be a justified disagreement.

I'll admit, as an EM doc, that I have been guilty of this a few times. However, these "infractions" have been in a busy county yet academic ED when we (the ED) have been getting crushed and I am stuck with three or four patients who are truly crashing at the same time as an intern from OB-Gyn or psychiatry is trying to get me to teach how to repair a fairly complex facial laceration or Bartholin's.

Each time (twice within the last few months) I have called for assistance from surgical subspecialties (GYN and OMFS)...however, I have explained the situation on the phone (once on a portable phone while pushing sux and etomidate).

...and there are equivalent times when surgery asks for our help...difficulty reductions that should go to the OR but ortho doesn't want to wait for anesthesia/OR, so we help in the ED...trauma team is getting killed in the OR/SICU and we "help out" on patients admitted long ago and need CCM intervention/procedures/etc...

In the community, it is a different story...but there folks get pretty good money...when I was in residency and rotating in a community ED, there was a plastics guy who would love to come in for the simplest lacs because they were big money for him.

HH

 

[SLUser11]

In the community, it is a different story...but there folks get pretty good money...when I was in residency and rotating in a community ED, there was a plastics guy who would love to come in for the simplest lacs because they were big money for him.

HH

I don't know if that's necessarily true. Sure, some people get paid for ER call, but actually going in and draining an abscess or sewing up a laceration rarely pays well, especially considering how many ER patients don't have insurance.

A lot of community surgeons actually loathe the ER, and would do anything to get out of ER call....they don't have resident buffers, so they're going in on their own at 2am to drain butt pus. Also, if they already have a busy clinic or elective OR day, ER calls can be very disruptive.

I will say, however, that some plastics guys seem to be very fascile with creative coding, which surely helps with reimbursement.


However, otherwise I'm in agreement with your statements. As surgeons, we often make decisions to consult someone because we simply don't have time to complete the task, or we don't want to be responsible for the follow up....however, we vilify EM docs for the same behavior.

 

[LucidSplash]

Just finished up a consult in the NICU for a neonate with abdominal distention. Was called by the very apologetic NICU staff because the night radiologist was refusing to do a contrast enema ordered by the on-site senior attending neonatologist until a surgery consult was obtained. Despite explaining that said consult would be done by the PGY-2 resident who not for any reason make any recommendations other than to proceed with work-up as ordered by an attending neonatologist, the radiologist required it.

I went, waved my hand in the sign of the cross over the baby, and wrote the (totally useless) consult note. NICU staff and neonatologist aware and completely comfortable that I am not calling the attending at home about the consult until there is information to give him beyond "totally stable term neonate with abdominal distension but no work up."

<facepalm>

 

[SocialistMD]

...the night radiologist was refusing to do a contrast enema ordered by the on-site senior attending neonatologist until a surgery consult was obtained.

That's a children's hospital. The radiologists don't typically do overnight procedures unless a surgical consult has been obtained, and their argument makes some sense. If you, the surgeon, aren't planning on doing anything in the middle of the night to intervene on any finding, then why should they call in their staff to do what you have effectively deemed a non-emergent procedure?

They also will not do an enema to r/o intussusception until surgery is on board, should a perforation occur. It is what it is.

 

[LucidSplash]

That's a children's hospital. The radiologists don't typically do overnight procedures unless a surgical consult has been obtained, and their argument makes some sense. If you, the surgeon, aren't planning on doing anything in the middle of the night to intervene on any finding, then why should they call in their staff to do what you have effectively deemed a non-emergent procedure?

They also will not do an enema to r/o intussusception until surgery is on board, should a perforation occur. It is what it is.

Our "Children's Hospital" is two floors on one end of the hospital complex plus the NICU which adjoins the L&D floor. There is an in-house rads team (serves both adult and kids) to do procedures during the night. Additionally, at least at my facility, the neonatology team in the NICU routinely works up these patients prior to consulting surgery - they only call if they have findings. True, I do not know what the procedures are elsewhere, but this was definitely irregular for our institution.

 

[Winged Scapula]

This one a standard "breast mass" consult.

Only memorable because it came from "Dr. X, hospitalist".

Only significant because "Dr. X" is a nurse practitioner. Apparently the DNP has infiltrated even the backwoods of Arizona (this was a small town about an hour outside of PHX).

 

[DHT]

This one a standard "breast mass" consult.

Only memorable because it came from "Dr. X, hospitalist".

Only significant because "Dr. X" is a nurse practitioner. Apparently the DNP has infiltrated even the backwoods of Arizona (this was a small town about an hour outside of PHX).

This literally makes me sick.

 

[Instatewaiter]

The difference, at least in my mind, is that:

(1) The consults for minor surgical issues are mixed into the context of larger surgical issues. Every splint for an ankle sprain done by Ortho in the ER is time not spent on the septic joint in the ICU. Ortho's job is not to do splints for the ER, but everywhere I have been, the kinds of issues I'm discussing are exactly what the inpatient psych consult service is for.

(2) Splinting and I&D'ing abscesses is firmly within the realm of what ER doctors do. Managing outpatient psych issues in the setting of a surgical admission is not within the routine scope of a surgeon. Can they do it? Probably. Should they do it? Questionable.

(3) And while we're on it, psychiatry is hardly blameless in this whole game. Tell me the last time you saw a psychiatrist (ie - a fellow MD) perform or document a physical exam? When you rotated as a student in IM, how many consults did you see for "r/o gen med condition as cause of psych symptoms"? How many psych admissions get turned down because "patient has medical conditions that cannot be managed on psych ward"? It cuts both ways; you can't blame a surgical specialist for not doing generalist work, then turn around and say you can't do generalist work because you're a mental health specialist.

No one is blameless in this whole thing. Usually the consult is coming because the other team just doesn't know what to do. I can't count how many times medicine's been consulted for BS by surgery (or by psych) but we tend to be happy to see them because you guys need the help. Honestly, surgery should probably consult us more than they already do for normal inpatient management. You say you can deal with medical issues but in my experience it often isnt the case. Surgeons know the surgical stuff, medicine knows the medicine stuff, psych knows the psych stuff.

I think my biggest beef is the BS dumps. Patient comes in with a femur fracture after a fall and their normal, stable medical issues- how does that come to medicine? I'm pretty sure giving insulin and antibiotics isn't going to fix the leg. I really would love to meet the first person to do the first successful dump. They must have been a genius.

I get the psych dumps because their nurses can do basically nothing and do vitals like once a week. The patients are safer on medicine if they have active medical problems and psych tends to take them back after the issue is resolved. Getting a true surgical patient back onto a surgical team is like pulling teeth.