i am sorry

[Incandescent]

The other day, 40 something y/o woman admitted to the medicine service for severe RUQ pain. I am an intern on the service (though I am not going into medicine).

Basically, we find no reason for her pain. It doesn't radiate anywhere. No abnormal labs. No pregnancy. No free air. No CT findings. No ultrasound findings. We even resorted to a physical. No radiation of the pain. No rebound, no guarding, no rigidity. Beautiful bowel sounds.

And yet, we consulted you. Why? I still have no idea. She had NO significant gyn history. Her gyn history is completely appropriate for her age. I did what my senior and attending wanted. And I called the consult...

OBGYN Resident: "So, why are you calling this consult? Do you think she has any OBGYN pathology?"
Me: "Um, she has RUQ pain that we can't explain...and...um..."
OBGYN Resident: "Basically you need me to do a pelvic."

I'm so sorry.

---

Members don't see this ad.

 

[Trillgirl]

You reminded me of when I was the OB/Gyn intern and got called down to the ED because a woman in her early 60's was having heavy bleeding.

I ran down there and took her history, which apparently they seemed to skip over in the ED. She had a hysterectomy (TAH/BSO) years ago, but had had some recent uro problems and recently had stents placed.

I did a SSE... her cervix had been removed and there was a nice cuff with NO bleeding anywhere in the vault. I asked the ED resident if she had seen a cervix on her exam. She swore she had... and then I told her the patient had a total hysterectomy, that there was no cervix, no blood in the vault, and that maybe... just maybe they should address her hematuria.

 

[minime]

Not that I condone your actions, but at least you called the consult. Many times at our hospital we get these BS consults and no one even calls. You typically get a call from the nurse who has no idea why you are being consulted.

 

[rayofdiana]

On my OB/GYN AI, we received a consult from the MICU for vaginal bleeding. Since we're used to services calling suspect gyn consults, I asked the resident, "How do you know it's vaginal? Did you examine her?" He said that, yes, he did. I then asked if he placed a spec and saw blood coming from the cervical os. Again, he stated that, yes, he did. Okay. Fine. We'll see the patient.

Turns out she had a total hyst. No cervical os. We did a spec exam for completeness, which was 100% normal. What was not normal was the huge clots of blood at her urethra surrounding her Foley. You didn't even have to actually examine the patient to see this. If the resident had so much as actually lifted her gown, he would have seen the obvious problem. What really got me was that he straight out lied to me. Arrrrghh...

 

[Global Disrobal]

We've all had our fair share of bogus consults. Having the luxury of being finished with residency, let me give a couple of PEARLS:

1. No matter how bogus, perform the consult and try not to punt it on the phone. First of all, it will make the primary team feel worse when you make your assessment of "vaginal bleeding secondary to monthly menstruation" and more importantly you protect yourself from having missed something serious on the patient's end. Often time (as in the case of the hematuria/foley trauma above), the consult may not have been warranted, but from a patient's angle, "you" having laid a hand on her, helped her care in the long run.

2. Go easy on interns from other services. What may seem like a clear cut pelvic exam (i.e. well healed cuff, no cervix, no mass, atrophic vaginitis), may not be as obvious to someone who does not do pelvics on a daily basis. Amuse yourself and make the assumption that he/she did not lie, but rather did not know what they were looking at.

3. Again, go easy on the interns from other services. Often time, even they know the consult is bogus, but happen to be the messenger for an upper-level resident or attending who had the epiphany of calling GYN for a RUQ pain.

4. Don't take any consult lightly. I can tell you a number of stories in residency where I got a consult, thought it was pure BS, huffed and puffed my way to the ER, only to get humbled with a case of ruptured ectopic, mass at the cuff in a woman s/p TAH, mass in a recurrent Bartholin's, fulminant pancreatitis in a HEG patient...

Anyhow, enough preaching! Have a great weekend everyone!

 

[fuzzyerin]

I don't really expect primary services to do pelvic exams - I don't think anyone in the hospital outside of ER residents and OB/Gyn residents know where the speculums can be found. But I do expect them to LOOK and TAKE A HISTORY.

For example, the consult we got recently on the gyn onc service was for our patient with known endometrial cancer scheduled for surgery the following week who had gotten admitted to medicine for "r/o GI bleed" because of her anemia. They got neurology, pulmonology, cardiology, and gastroenterology to see her for her multiple medical problems. They scoped her, and the end result of all of their hard work was to call us on hospital day number 4 to say "we think she has vaginal bleeding and that may be why she's anemic."

Duh. She's got endometrial cancer. If you had ASKED the patient, she would tell you that her gyn oncologist told her she was anemic with a Hct of 28 and she may require a transfusion during her surgery. She'd also tell you she'd been bleeding vaginally for "a really long time."

But I didn't really mind. The medicine team got me all the clearances the patient needed for surgery!

 

[shamrock13]

Honestly, I used to get upset with BS consults being called because they take time in our busy schedule, add to our day, etc etc. Finally... (and it took until my second year to have this epiphany!) I realized that the consult isn't about a stressed out resident, or someone being too lazy to do a speculum exam. It is about a patient with a problem and me as her physician having the expertise to do something about it. Also, as a resident, consults are learning opportunities for when you're the attending and EXPECTED to know all the answers!

As far as potentially lying about doing an exam, now that's just plain stupid. I have taken interns from the ED through exams when they said they didn't know what they were doing. And when someone says "I didn't do a speculum exam to confirm that the bleeding is from the vagina, that's what I'm calling you for", I do respond in kind with "would you call a pulmonologist to do a lung exam?"

 

[pruritis_ani]

Getting a consult to do a pelvic is BS, plain and simple. If you work in a hospital as a physician and care for female patients, you need to be able to ascertain whether bleeding below the umbilicus requires a urologist, gastroenterologist, general surgeon or a gynecologist.

Example 1: I was paged to the ED stat for a women with "massive vaginal bleeding". Nobody had examined the pt, she was in bed and had bloody pants and panties. By simply having her spread her legs, you could clearly see blood pouring from her anus. Additionally, she was s/p a TAH/BSO. That, my freinds, is piss poor care in the ED. Not to mention a waste of my time. Do the exam, so you can get the appropriate care for your patient, and not waste your consultants time.

Example 2: Paged by Medicine to "rule out vaginal bleeding". Per my conversation with the resident, they really didn't think she was bleeding from her vagina, as she had a lesion on her urethra that was obviously bleeding. They consulted urology (appropriately) who then refused to see the patient until a gyn bleed had been excluded (which is an a-hole move all by itself). Now, logic would dictate that you could look at the urethra, see the bleeding, and just to be thorough, do a pelvic exam. Zero need for a gyn, unless your findings were equivocal, or you actually found blood in the vagina.

Now, we should all do these consults. I never refuse, and always say "happy to help out". But, I ALWAYS ask if a pelvic was done. And if not, I ask why. I make it clear that I will see the patient, but that they have done a sub optimal work up. IMHO, if you ask for a consultant, you need to perform a minimal amount of due diligence simply to consult the correct service. I would never consult a pulmonologist to do a lung exam, a cardiologist to listen to heart sounds, or neurology to do a basic neuro exam. Other specialities should have the same courtesy.