Inpatient consults

[hfzballer11]

Hey everyone,

I'm currently an intern planning to go the PMR-->pain route. Initially I thought I would love the typical outpatient clinic and fluoro suite type practice. However doing my intern year I am finding that I also enjoy inpatient work as well. This past week we admitted a rib fracture s/p fall and got a pain consult for possible thoracic epidural injection. This was an anesthesia based group that covers our hospital. My question is if it is possible for PMR-trained pain doctors to do inpatient consults as well, as I have heard that this is an area typically dominated by anesthesia-pain. Thanks!

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[Aether2000]

An epidural injection for rib fractures has extremely limited utility since the pain will return when the local anesthesia wears off. An epidural infusion may be useful, but in general, inpatient consults are extremely time intensive, low paying, and have a tendency to disrupt a clinic practice or your life. Also not all hospitals are set up for catheter infusions in the epidural, paravertebral, plexus, or nerves, therefore one may have to develop the paperwork and staff education for these low occurrence consults.

 

[willabeast]

Of course it is possible. Think for a second - inpatient consults mean (often and in this case) trauma. Trauma happens at all hours but especially weekends after 9 PM. Everyone will be more than happy to have the ER etc. call anyone willing to be on call 24/7 for trauma pain referrals. To facilitate this suggest living across the street from the hospital

 

[lobelsteve]

Let them have it. Low reimbursement, probably a nurse doing the work of the doc (CRNA), and trauma patients more likely to have psychosocial issues making them uninsured, more likely to have substance abuse issues.

No thanks.

 

[kstarm]

My practice is about 50% inpatient pain and I am PMR then pain fellowship trained. No call, no weekends or holidays. I am not trained in all the regional stuff so don't manage epidurals/catheters etc. Have a good relationship with Anethesia and most of the surgery groups. See a lot of trauma and post op pain but also psych, and general medicine patients. With all the of the Joint Commission changes most hospitals are looking to establish inpatient pain programs. I started the one at the hospital I am at and have basically been able to tell them this is how I am going to practice which so far they have been fine with and have provided a lot of institutional support. We will see how it goes going forward, but with the opioid epidemic where it is at, and again the pressure to meet the new Joint Commission standards I think you will be able to have a fair amount of influence and say in what you would like your job to be if you decide to do inpatient. It is a different skill set and you will want good training if you are planning on doing some. It would be very unlikely for you to make what the straight interventionist make with the current reimbursement system the way that it is, and compared to the high volume needle jockeys you will make significantly less.

 

[hfzballer11]

An epidural injection for rib fractures has extremely limited utility since the pain will return when the local anesthesia wears off. An epidural infusion may be useful, but in general, inpatient consults are extremely time intensive, low paying, and have a tendency to disrupt a clinic practice or your life. Also not all hospitals are set up for catheter infusions in the epidural, paravertebral, plexus, or nerves, therefore one may have to develop the paperwork and staff education for these low occurrence consults.

An epidural injection for rib fractures has extremely limited utility since the pain will return when the local anesthesia wears off. An epidural infusion may be useful, but in general, inpatient consults are extremely time intensive, low paying, and have a tendency to disrupt a clinic practice or your life. Also not all hospitals are set up for catheter infusions in the epidural, paravertebral, plexus, or nerves, therefore one may have to develop the paperwork and staff education for these low occurrence consults.

My apologies. It was actually a intercostal nerve block, not a thoracic epidural.

 

[Ducttape]

the best situation for this kind of work is probably an inpatient acute pain consult program at a level 1 trauma center or at a teaching hospital. you would probably be salaried. i would hazard that having some experience or actual certification as a palliative physician would be helpful.

the run of the mill anesthesiologist does not want to do this work - it takes a lot of time out of their OR work and pay.


a thoracic epidural with a short term catheter is the best option for the acute rib fracture pain, allowing some to avoid the vent or get off the vent sooner. epidural comes out in 6 days, when pain can be controlled orally. would be better than an intercostal nerve block. ive tried both. other option is paravertebral catheters.

 

[Aether2000]

We rarely do inpatient consults, but today we did have one, and I relate it to show what kind of crap you see. 32 Year old patient, 6 days s/p tricuspid valve replacement due to vegetations from repeated IV drug usage with multiple infections and non compliance, having checked out AMA several times from hospitals trying to institute or finish IV antibiotics. He as given IV MS the first two days, taking 32mg a day, still complaining of pain 10/10. For the past 2 days he is taking 500mg a day tramadol that he says is ineffective and continues to complain of anterior incisional pain 10/10. I enter his room- he is playing video games on his phone, and I tell him I am a doctor consulted to see him. He says "wait a minute" as he continues playing video games for another minute. No grimaces, no pain behaviors, he is focused and alert so just for fun I go fishing. I mention buprenorphine IV and he states any form of buprenorphine causes headaches. I mention nucynta- he has never heard of it but does not want to try it. He states high dose methadone works for pain in the past and has acquired it from the street. I leave the room, dictate a consult note stating this guy is at extremely high risk of continuing IV drug abuse, amplified by mu agonists- suggest getting him off the opioids within a day and not return to opioids in this patient again, esp. since he does not appear to be in any pain at all, moves comfortably from lying to sitting, and has a profoundly strong IV drug abuse history. The patient has of course- no insurance. We will receive nothing.

 

[Timeoutofmind]

We rarely do inpatient consults, but today we did have one, and I relate it to show what kind of crap you see. 32 Year old patient, 6 days s/p tricuspid valve replacement due to vegetations from repeated IV drug usage with multiple infections and non compliance, having checked out AMA several times from hospitals trying to institute or finish IV antibiotics. He as given IV MS the first two days, taking 32mg a day, still complaining of pain 10/10. For the past 2 days he is taking 500mg a day tramadol that he says is ineffective and continues to complain of anterior incisional pain 10/10. I enter his room- he is playing video games on his phone, and I tell him I am a doctor consulted to see him. He says "wait a minute" as he continues playing video games for another minute. No grimaces, no pain behaviors, he is focused and alert so just for fun I go fishing. I mention buprenorphine IV and he states any form of buprenorphine causes headaches. I mention nucynta- he has never heard of it but does not want to try it. He states high dose methadone works for pain in the past and has acquired it from the street. I leave the room, dictate a consult note stating this guy is at extremely high risk of continuing IV drug abuse, amplified by mu agonists- suggest getting him off the opioids within a day and not return to opioids in this patient again, esp. since he does not appear to be in any pain at all, moves comfortably from lying to sitting, and has a profoundly strong IV drug abuse history. The patient has of course- no insurance. We will receive nothing.

Unless your inpatient pain consults are basically in the context of an anesthesia based regional acute post op pain service… it is basically just negotiating with drug addicts in a situation where you have zero leverage

 

[SeniorWrangler]

To the OP: The most practical way to combine inpatient postoperative pain and outpatient pain is to be a salaried physician at a big hospital, probably an academic hospital. At most hospitals, this will be tightly associated with anesthesia and it may or may not be possible to get involved as a PM&R guy. In many health care systems, there are "silos" for each specialty and you will be fighting an uphill battle to do this.

 

[clubdeac]

sounds like hell.....

 

[BobBarker]

I got an inpatient consult on a 91 year old for epidural injection last week. She was being treated for cellulitis/bacteremia and on IV abx. Last year I got one, same scenario and the hospitalitist wanted me to do a kypho. I just look at the chart and punch in a note saying not a candidate for my services from my clinic. No charge for that one.

 

[NJPAIN]

When I first started on hospital staff they would try to call me in in two scenarios:
1. Patient with chronic LBP on tons of opioids prescribed by PCP found unconscious or nearly unconscious. My job would be to find a miracle cure for the chronic LBP and then fight with patient to come off of the opioids they received for 25 years. Essentially, tag I'm IT.
2. Patient admitted with a painful condition, managed by PCP or hospitalist. Patient's pain not well controlled as the WEEKEND approaches. My job is to deal with the belly aching all weekend so the PCP and hospital can enjoy the weekend.

In patient pain consultant is the most thankless job on planet earth.