Night Float???

[jdh71]

Ironic. We usually get the late night consults from hospitalists just to get "surgery on board."

I feel your pain. As pulmonary, everyone (from the hospitalists to surgeons to the ob/gyns) with an in patient service gets us "on board" in cases where they aren't comfortable with resp. status.

Plus, given the acute nature of the most of the problems in your field that makes much more sense than other kinds of consults if you think about it.

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[jdh71]

I don't think L2D is in surgery anyway, jdh.

I thought he was. I stand corrected.

 

[jdh71]

Actually, I don't see it as ironic. The chances of me calling a consult in the middle of the night are proportional to 1/(my comfort or knowledge in that field). Hence, I'm unlikely to get a cards consult in the middle of the night, because I can manage afib or ischemia that doesn't need the cath lab myself. But, I'm not as comfortable with surgical stuff, and I hate being told "you should have called us earlier" which is exactly what you hear for the consult for the rigid abdomen.

It often kind of feels like "you're damned if you do and you're damned if you don't" calling surgery.

 

[Buzz Me]

It often kind of feels like "you're damned if you do and you're damned if you don't" calling surgery.

These consults are often painful because:

(1) A "rigid abdomen" usually isn't
(2) "Peritonitis" is usually just diffuse abdominal pain
(3) 90% of the consults are non-operative
(4) They're often for a symptom - i.e. "abdominal pain" (imagine calling Cardiology for a "chest pain" consult, or Pulmonology for a "shortness of breath" consult in the middle of the night)

 

[Mattchiavelli]

These consults are often painful because:

(1) A "rigid abdomen" usually isn't
(2) "Peritonitis" is usually just diffuse abdominal pain
(3) 90% of the consults are non-operative
(4) They're often for a symptom - i.e. "abdominal pain" (imagine calling Cardiology for a "chest pain" consult, or Pulmonology for a "shortness of breath" consult in the middle of the night)

The really unfortunate thing for surgeons is medicine docs can really only evaluate if surgery should be consulted, the surgeon really has to evaluate and determine if surgery is appropriate. When you consult to a medicine specialty overnight it's usually something procedural (interventional cards, scope, emergent dialysis, etc). I think if I consulted cardiology for new onset afib while on night float I would get laughed at if I was lucky, probably something worse. Depending on staff we might not even call cards for an NSTEMI til the AM.

 

[jdh71]

These consults are often painful because:

(1) A "rigid abdomen" usually isn't
(2) "Peritonitis" is usually just diffuse abdominal pain
(3) 90% of the consults are non-operative
(4) They're often for a symptom - i.e. "abdominal pain" (imagine calling Cardiology for a "chest pain" consult, or Pulmonology for a "shortness of breath" consult in the middle of the night)

For number 2 and 4, I don't think I'm ever guilty. When I think an abdomen is "rigid" (rarely happens), I usually try and grab a surgery senior and get their opinion first before putting in a consult. And number 3 . . . while I'm sure it's aggravating, to those of us who don't cut, we honestly don't know if you will cut, but think you might cut, and that's why we ask.

Most of it doesn't have to happen in the middle of the night.

FWIW, I have been consulted too many times for SOB in the middle of the night (almost always by young or lazy/old hospitalists["hey I know what I'll do so I don't have be bothered the rest of the night with this pesky patient, I'll consult pulm!"]). At least I can tell them that any pulmonary consult that can't wait until the morning, needs to go to the unit

 

[45408]

Actually, I don't see it as ironic. The chances of me calling a consult in the middle of the night are proportional to 1/(my comfort or knowledge in that field). Hence, I'm unlikely to get a cards consult in the middle of the night, because I can manage afib or ischemia that doesn't need the cath lab myself. But, I'm not as comfortable with surgical stuff, and I hate being told "you should have called us earlier" which is exactly what you hear for the consult for the rigid abdomen.

I'm saying it's ironic that I don't feel like we ever call someone "just to get them on board" in the middle of the night, but our hospitalists do that with surgery periodically. There's no need to "have us on board" as a precaution. The situation that comes to mind as the most egregious example was a GI bleed (that was more of a trickle) being admitted to the CCU. GI had been consulted and said they'd see the patient in the morning. We were consulted by the night hospitalist "to have on board" (per his note). It was purely so that he could sign it out to the person who was going to take over and say that GI and surgery and a partridge in a pear tree were following. A bleed so slow that you're not transfusing and not scoping until the morning doesn't need a surgeon.

If there's an actual question that the person asking thinks might need to be answered in the middle of the night, then a consult is appropriate. If you think that your patient might need cardioversion/dialysis/temporary pacing/laparotomy in the next hour, then a call is warranted.

 

[45408]

It often kind of feels like "you're damned if you do and you're damned if you don't" calling surgery.

I feel like we have a few very intelligent hospitalists who rarely call us unless the patient will be going to the operating room in short order. We have quite a few other ones who seem to have no desire to learn the basic medical management of surgical issues. Not every patient with diverticulitis needs an inpatient surgery consult.

These consults are often painful because:

(1) A "rigid abdomen" usually isn't
(2) "Peritonitis" is usually just diffuse abdominal pain
(3) 90% of the consults are non-operative
(4) They're often for a symptom - i.e. "abdominal pain" (imagine calling Cardiology for a "chest pain" consult, or Pulmonology for a "shortness of breath" consult in the middle of the night)

There's the boy who cried wolf, and there's the hospitalist who cried peritonitis. It's a critical descriptive term, and if I called cardiology saying it was a STEMI, and there was nothing more than an old inverted T wave seen on previous EKGs, they'd be furious too.

I feel like some people pull that card just so that we come running to see the patient. I also think your other points are spot on.

 

[Winged Scapula]

In the classic experience of "I'm an attending so I have a different perspective on these types of consults now", I would venture that I have had the same experience as the surgical residents here and spent a lot of time being pissed about them.

However, to be fair guys, non-surgeons are just not as experienced at examining the abdomen as we are. They just don't know what a rigid abdomen really feels like or what peritonitis looks like. In addition to lack of experience, is the training of the abdominal exam which may have been faulty. As I've noted here previously, I have had more than 1 patient complain of, and watched a non-surgical colleague "examine" the abdomen with rigid pointy fingers jabbing swiftly and sharply into some poor Joe's doughy belly. No wonder some of these patients seem rigid, tensing themselves against ongoing assault.

And they are right: you *are* damned if you do, damned if you don't. You just can't please us.

 

[koc123]

When I was an obgyn resident, I rarely ever consulted anyone overnight. I transferred a few patients who crashed to the SICU or MICU. I guess the advantage of being a gyn is that we are pretty comfortable taking someone to the OR. I honestly think most consults can wait until the morning. Most of my overnight consults I got were from the ER. My least favorite part of residency was working with the ER.

 

[Law2Doc]

Actually, I don't see it as ironic. The chances of me calling a consult in the middle of the night are proportional to 1/(my comfort or knowledge in that field). Hence, I'm unlikely to get a cards consult in the middle of the night, because I can manage afib or ischemia that doesn't need the cath lab myself. But, I'm not as comfortable with surgical stuff, and I hate being told "you should have called us earlier" which is exactly what you hear for the consult for the rigid abdomen.

Sure. Medicine will consult on surgical things in the middle of the night, surgery will consult on certain medical things in the middle of the night. The milder psych and derm and endocrine issues etc can wait until morning. My own experience is that the chief or attending is going to ask you what you did about it overnight and you aren't going to get any kudos for saying you decided to leave it to the day team to handle. That's the whole point of having a doctor on call overnight and not a PA. A surgery resident is going to be facile in managing blood pressure and diabetes, but perhaps isn't going to do a late night cardioversion on his own without cardiology on board. A medicine resident isn't going to sit on a rigid abdomen, or a lot of blood/pus oozing out of a patient someplace. The point is that the night float person is going to get that ball rolling in the middle of the night, and that often involves calling a consult.

 

[Law2Doc]

When I was an obgyn resident, I rarely ever consulted anyone overnight. I transferred a few patients who crashed to the SICU or MICU. I guess the advantage of being a gyn is that we are pretty comfortable taking someone to the OR. ...

bear in mind that the OB portion of your patient population was far younger and healthier than the average hospital patient, who on some services is a 70 year old obese chain smoking diabetic status post CABG.

 

[45408]

However, to be fair guys, non-surgeons are just not as experienced at examining the abdomen as we are. They just don't know what a rigid abdomen really feels like or what peritonitis looks like. In addition to lack of experience, is the training of the abdominal exam which may have been faulty. As I've noted here previously, I have had more than 1 patient complain of, and watched a non-surgical colleague "examine" the abdomen with rigid pointy fingers jabbing swiftly and sharply into some poor Joe's doughy belly. No wonder some of these patients seem rigid, tensing themselves against ongoing assault.

My favorite abdominal exam is when it reads "Abdomen: bowel sounds present."

But yeah, the ol' karate chop to the belly will elicit some tenderness.

 

[koc123]

bear in mind that the OB portion of your patient population was far younger and healthier than the average hospital patient, who on some services is a 70 year old obese chain smoking diabetic status post CABG.

True, I also did my residency in west philly where our average BMI was 30 and quite a number of patients with major commorbidities. Also I took care of my fair share of sick elderly gynonc patient who underwent major debulking.

 

[Law2Doc]

True, I also did my residency in west philly where our average BMI was 30 and quite a number of patients with major commorbidities. Also I took care of my fair share of sick elderly gynonc patient who underwent major debulking.

Yes but there's a difference between a "fair share" and "the vast majority" of your patients being old and comorbid when it comes to how often you need to call a consult in the middle of the night. I'm just saying in OB you perhaps had nights where the average age of your census was under 30 and nobody was threatening to die.

 

[koc123]

Yes but there's a difference between a "fair share" and "the vast majority" of your patients being old and comorbid when it comes to how often you need to call a consult in the middle of the night. I'm just saying in OB you perhaps had nights where the average age of your census was under 30 and nobody was threatening to die.

Fair. I especially like your line about being under 30 and "nobody was threatening to die." That's so cute. I guess you think dealing with shoulder dystocia in a 300# "healthy" patient is a walk in the park. You are so cute.

 

[45408]

Fair. I especially like your line about being under 30 and "nobody was threatening to die." That's so cute. I guess you think dealing with shoulder dystocia in a 300# "healthy" patient is a walk in the park. You are so cute.

Seems like he was referring to cross-coverage and floor calls, not delivering babies and operating.

 

[Law2Doc]

Seems like he was referring to cross-coverage and floor calls, not delivering babies and operating.

Yeah, I was referring to the likelihood of needing to call a consult in the middle of the night, which is what i thought we were talking about. Obviously every field has their own difficult patients. But some fields have a patient base that is less likely to be another specialties difficult patient. An OBGYN isn't going to call another specialty for shoulder dystocia and a surgeon isn't going to call another specialty for a consult on a ruptured appendicitis. Thats your own problem. But a surgeon may call a medicine subspecialty for a consult outside of their scope, and a medicine doc is likely to consult surgery for potential surgical issues. If the patient base is old and comorbid, there are going to be more of these calls than if the patient base is generally young and healthy. Which is why I suspect you "rarely" consulted people overnight as an OB resident. For other fields, overnight consults aren't so rare. I suspect it has everything to do with the patient base, and the fact that most of your patients issues are issues relating to your specialty. You dont consult people on the complicated OB cases because thats what YOU do. That's all I'm saying. Not a pissing match on whose patients are riskier. Just a pissing match on whose patients generally need more consults.

 

[Buzz Me]

Most of it doesn't have to happen in the middle of the night.

And that's the painful part. We have to see consults right away - none of this "we'll see him/her in the morning" business.

 

[Dral]

False. Our night floats are expected to stay for rounds...they are also the ONLY ones doing the majority of the pre-rounding work (i.e. they are expected to print the lists and vitals before the day team shows up)

Ouch, sucks to be you guys. Our nightfloat people give a 2 minute sign out at most. If nothing happens with your patients, the nightfloat just throws the original signout paper at you and says 'nothing happened with your ppl' and leaves. heheh.

No problems have arisen from it and it works really well. Different places have different methods that work I guess.