Post your bizarre consultant interactions

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Zebra Hunter

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Post your bizarre, funny, or facepalm inducing interactions you’ve had with consultants here. Non-EM folks, please refrain from posting your dumb ER doc stories, SDN is already filled with those threads.

I’ll post my story that made me think of making this thread.

Had a lady with significant CAD hx s/p 5 vessel bypass and numerous stents come in for epigastric pain. Initial ECG was completely normal. She is completely asymptomatic while in the ER. Her trop comes back mildly elevated, so I plan to admit but order a second ECG for completeness sake, and of course she has a damn inferior STEMI and intermittently going into complete heart block, all while swearing she has no symptoms (although finally admits she has a “twinge” in her chest after getting asked a million different ways).

I activate it and the STEMI cardiologist isn’t answering his phone, so we call his back up.

“Hey Dr. Backup, sorry to call you but we can’t get in touch with Dr. Firstcall. I got a lady with an inferior STEMI going in and out of complete heart block that needs to go to the cath lab ASAP. Came in with some epigastric pain, initial ECG normal, repeat is a clear cut inferior STEMI with reciprocal changes. Hs-Trop is 300. She has known significant CAD.”

“Sounds like an old MI, have you given nitro? I would give nitro and a beta blocker and get her admitted to the floor, I’ll see her in the morning.”

“I don’t think you heard me, I am not asking for recommendations, this patient has an acute inferior STEMI with intermittent CHB. I am not going to give her nitro or beta blockers, she needs to go to the cath lab now.”

“Her trop is 300, this happened likely 2-3 days ago. Just give her some plavix, nitro, and a BB. She doesn’t need to go to cath right now.”

“That is a HS-trop, and regardless, in 2021, this is not how we manage inferior STEMIs with CHB. Once again, I am asking you to take her to cath lab now.”

“Oh! High sensitivity, then I’m not worried about this at all, 300 is only a small elevation.”

*Me facepalming at this point and on the verge of yelling at him*

“The troponin level is clinically meaningless in an acute STEMI. I will repeat my question, will you be taking this patient to cath lab for her STEMI?”

“Well I don’t do STEMI call, I would maybe try to call Dr. Firstcall’s home phon….”

“Are you f***ing kidding me?”

“Sorry, but I still think you should give some nitro and a beta bl…”

*Aggressively hang up the phone*

Thankfully, the on-call cardiologist for the competing group happened to be an interventionalist and gladly took the patient to cath. The patient did well.

By far the most head scratching interaction I’ve ever had with a consultant.
 
Mbekweni said:
Document. Send to peer review.
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Eh, don’t know how I could have possibly documented that conversation without it looking like I’m bashing a consultant for a conversation that had ultimately nothing to do with the patient’s care other than delaying care by 3-4 minutes. I generally try to avoid making a consultant look bad in a chart unless there is no other option. Had he been my only option vs having to transfer, that’d be a different story.

Ultimately without documentation, peer review leads to a he said/she said headache that I didn’t feel like being a part of. I generally try to keep a low profile at work.
 
NSG refusing to even come in for a patient with a large intracranial epidural hematoma *who was still awake* because her platelets were too low so they wouldn't operate anyways. Recommended admission to neuro ICU and frequent neurochecks.
 
Zebra Hunter said:
Post your bizarre, funny, or facepalm inducing interactions you’ve had with consultants here. Non-EM folks, please refrain from posting your dumb ER doc stories, SDN is already filled with those threads.

I’ll post my story that made me think of making this thread.

Had a lady with significant CAD hx s/p 5 vessel bypass and numerous stents come in for epigastric pain. Initial ECG was completely normal. She is completely asymptomatic while in the ER. Her trop comes back mildly elevated, so I plan to admit but order a second ECG for completeness sake, and of course she has a damn inferior STEMI and intermittently going into complete heart block, all while swearing she has no symptoms (although finally admits she has a “twinge” in her chest after getting asked a million different ways).

I activate it and the STEMI cardiologist isn’t answering his phone, so we call his back up.

“Hey Dr. Backup, sorry to call you but we can’t get in touch with Dr. Firstcall. I got a lady with an inferior STEMI going in and out of complete heart block that needs to go to the cath lab ASAP. Came in with some epigastric pain, initial ECG normal, repeat is a clear cut inferior STEMI with reciprocal changes. Hs-Trop is 300. She has known significant CAD.”

“Sounds like an old MI, have you given nitro? I would give nitro and a beta blocker and get her admitted to the floor, I’ll see her in the morning.”

“I don’t think you heard me, I am not asking for recommendations, this patient has an acute inferior STEMI with intermittent CHB. I am not going to give her nitro or beta blockers, she needs to go to the cath lab now.”

“Her trop is 300, this happened likely 2-3 days ago. Just give her some plavix, nitro, and a BB. She doesn’t need to go to cath right now.”

“That is a HS-trop, and regardless, in 2021, this is not how we manage inferior STEMIs with CHB. Once again, I am asking you to take her to cath lab now.”

“Oh! High sensitivity, then I’m not worried about this at all, 300 is only a small elevation.”

*Me facepalming at this point and on the verge of yelling at him*

“The troponin level is clinically meaningless in an acute STEMI. I will repeat my question, will you be taking this patient to cath lab for her STEMI?”

“Well I don’t do STEMI call, I would maybe try to call Dr. Firstcall’s home phon….”

“Are you f***ing kidding me?”

“Sorry, but I still think you should give some nitro and a beta bl…”

*Aggressively hang up the phone*

Thankfully, the on-call cardiologist for the competing group happened to be an interventionalist and gladly took the patient to cath. The patient did well.

By far the most head scratching interaction I’ve ever had with a consultant.
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Very bizarre recommendations, one for the calling it an old MI when troponin was rising (I'm assuming when you said the first set was mildly elevated it was not the 300), and two to give beta blockers to a patient you mentioned several times was having intermittent complete heart block.

Do you have the ability to transmit the EKG to the cardiologist where you're at?
 
Jabbed said:
NSG refusing to even come in for a patient with a large intracranial epidural hematoma *who was still awake* because her platelets were too low so they wouldn't operate anyways. Recommended admission to neuro ICU and frequent neurochecks.
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I can probably count on one hand the number of times NSGY have emergently taken anyone to the OR
 
Zebra Hunter said:
Post your bizarre, funny, or facepalm inducing interactions you’ve had with consultants here. Non-EM folks, please refrain from posting your dumb ER doc stories, SDN is already filled with those threads.

I’ll post my story that made me think of making this thread.

Had a lady with significant CAD hx s/p 5 vessel bypass and numerous stents come in for epigastric pain. Initial ECG was completely normal. She is completely asymptomatic while in the ER. Her trop comes back mildly elevated, so I plan to admit but order a second ECG for completeness sake, and of course she has a damn inferior STEMI and intermittently going into complete heart block, all while swearing she has no symptoms (although finally admits she has a “twinge” in her chest after getting asked a million different ways).

I activate it and the STEMI cardiologist isn’t answering his phone, so we call his back up.

“Hey Dr. Backup, sorry to call you but we can’t get in touch with Dr. Firstcall. I got a lady with an inferior STEMI going in and out of complete heart block that needs to go to the cath lab ASAP. Came in with some epigastric pain, initial ECG normal, repeat is a clear cut inferior STEMI with reciprocal changes. Hs-Trop is 300. She has known significant CAD.”

“Sounds like an old MI, have you given nitro? I would give nitro and a beta blocker and get her admitted to the floor, I’ll see her in the morning.”

“I don’t think you heard me, I am not asking for recommendations, this patient has an acute inferior STEMI with intermittent CHB. I am not going to give her nitro or beta blockers, she needs to go to the cath lab now.”

“Her trop is 300, this happened likely 2-3 days ago. Just give her some plavix, nitro, and a BB. She doesn’t need to go to cath right now.”

“That is a HS-trop, and regardless, in 2021, this is not how we manage inferior STEMIs with CHB. Once again, I am asking you to take her to cath lab now.”

“Oh! High sensitivity, then I’m not worried about this at all, 300 is only a small elevation.”

*Me facepalming at this point and on the verge of yelling at him*

“The troponin level is clinically meaningless in an acute STEMI. I will repeat my question, will you be taking this patient to cath lab for her STEMI?”

“Well I don’t do STEMI call, I would maybe try to call Dr. Firstcall’s home phon….”

“Are you f***ing kidding me?”

“Sorry, but I still think you should give some nitro and a beta bl…”

*Aggressively hang up the phone*

Thankfully, the on-call cardiologist for the competing group happened to be an interventionalist and gladly took the patient to cath. The patient did well.

By far the most head scratching interaction I’ve ever had with a consultant.
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I would consider calling them back on transfer center recorded line in this scenario. Clearly state your concern for stemi and that you’ll be transferring them to another center for cards eval/cath if he refuses to evaluate the patient.

Of course that’s the nuclear option but it sounds like this person may have been just dense enough to reach critical mass. :bang:
 
Zebra Hunter said:
Post your bizarre, funny, or facepalm inducing interactions you’ve had with consultants here. Non-EM folks, please refrain from posting your dumb ER doc stories, SDN is already filled with those threads.

I’ll post my story that made me think of making this thread.

Had a lady with significant CAD hx s/p 5 vessel bypass and numerous stents come in for epigastric pain. Initial ECG was completely normal. She is completely asymptomatic while in the ER. Her trop comes back mildly elevated, so I plan to admit but order a second ECG for completeness sake, and of course she has a damn inferior STEMI and intermittently going into complete heart block, all while swearing she has no symptoms (although finally admits she has a “twinge” in her chest after getting asked a million different ways).

I activate it and the STEMI cardiologist isn’t answering his phone, so we call his back up.

“Hey Dr. Backup, sorry to call you but we can’t get in touch with Dr. Firstcall. I got a lady with an inferior STEMI going in and out of complete heart block that needs to go to the cath lab ASAP. Came in with some epigastric pain, initial ECG normal, repeat is a clear cut inferior STEMI with reciprocal changes. Hs-Trop is 300. She has known significant CAD.”

“Sounds like an old MI, have you given nitro? I would give nitro and a beta blocker and get her admitted to the floor, I’ll see her in the morning.”

“I don’t think you heard me, I am not asking for recommendations, this patient has an acute inferior STEMI with intermittent CHB. I am not going to give her nitro or beta blockers, she needs to go to the cath lab now.”

“Her trop is 300, this happened likely 2-3 days ago. Just give her some plavix, nitro, and a BB. She doesn’t need to go to cath right now.”

“That is a HS-trop, and regardless, in 2021, this is not how we manage inferior STEMIs with CHB. Once again, I am asking you to take her to cath lab now.”

“Oh! High sensitivity, then I’m not worried about this at all, 300 is only a small elevation.”

*Me facepalming at this point and on the verge of yelling at him*

“The troponin level is clinically meaningless in an acute STEMI. I will repeat my question, will you be taking this patient to cath lab for her STEMI?”

“Well I don’t do STEMI call, I would maybe try to call Dr. Firstcall’s home phon….”

“Are you f***ing kidding me?”

“Sorry, but I still think you should give some nitro and a beta bl…”

*Aggressively hang up the phone*

Thankfully, the on-call cardiologist for the competing group happened to be an interventionalist and gladly took the patient to cath. The patient did well.

By far the most head scratching interaction I’ve ever had with a consultant.
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What was the conversation like with the competing group?
 
Lexdiamondz said:
I can probably count on one hand the number of times NSGY have emergently taken anyone to the OR
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Seriously? Our neurosurgeons are highly activate (both with our patients and transfers) and are in the OR all the time when they're on call.
 
southerndoc said:
Seriously? Our neurosurgeons are highly activate (both with our patients and transfers) and are in the OR all the time when they're on call.
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Yeah, not the typical case out in the community, from what I’ve seen. I had one neurosurgeon demand I transfer a pt with a shunt malfunction who had new hydrocephalus on CT with significant n/v and headaches because the hospital down the street performed a shunt revision on her 3 months prior…on a shunt a doc from his group originally placed. He kept hanging up on me and refusing to see the patient. I eventually got to the point that I asked on a recorded line if he was currently intoxicated or was in some sort impaired state that he couldn’t fulfill his job as the on-call neurosurgeon for a case that even a 2nd year NSGY resident could handle. He of course hung up again and I had to get admin involved, my medical director, his chief of staff, and finally they ended up convincing one of his colleagues to come in and perform the shunt revision. Of course nothing happened to this guy, although he finally left this year, 3 years after this incident.
 
Zebra Hunter said:
Yeah, not the typical case out in the community, from what I’ve seen. I had one neurosurgeon demand I transfer a pt with a shunt malfunction who had new hydrocephalus on CT with significant n/v and headaches because the hospital down the street performed a shunt revision on her 3 months prior…on a shunt a doc from his group originally placed. He kept hanging up on me and refusing to see the patient. I eventually got to the point that I asked on a recorded line if he was currently intoxicated or was in some sort impaired state that he couldn’t fulfill his job as the on-call neurosurgeon for a case that even a 2nd year NSGY resident could handle. He of course hung up again and I had to get admin involved, my medical director, his chief of staff, and finally they ended up convincing one of his colleagues to come in and perform the shunt revision. Of course nothing happened to this guy, although he finally left this year, 3 years after this incident.
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That's an EMTALA violation. Even if the surgery was performed elsewhere and even if it's best to transfer the patient to the surgeon who did the case, if your facility has the specialty and capacity available, any transfer to another facility is an EMTALA violation unless the patient requests the transfer.
 
One of my shops has a diagnostic only cath lab. We transfer our stemis to a facility 20 mins up the freeway.
Had a inferior stemi. Their cardiologist disagreed it was a stemi.
Called the other stemi facility in the area 10 mins further up the road. Spoke to their cardiologist whom agreed it was a stemi and accepted after a 2 min conversation.
 
Fart Daddy Smooth said:
How/why would a Cath Lab be diagnostic only? Is it a credentialing thing?
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Yes. There's a lot to get a CON from the state (backup cardiovascular services within so many minutes, on-call agreements with them, number of procedures performed, etc.).
 
23 yo F with no PMHx reaches down to pick up a soda bottle and feels a "pop" in her back along with intense pain shooting down the bilateral legs. Gets brought to ED where she says she can't move her legs. The EM doc calls NSGY. NSGY resident says NTD, likely MSK etiology, admit to medicine for PT eval if she really can't walk. Patient gets admitted by our nocturnist (who basically just places admit orders) and I (daytime hospitalist) see her the following day. She still says she can't move her legs at all. I whack at her knees with my stethoscope -- no reflexes. I STAT page the NSGY attending and they whisk her off to the OR.

Not sure what that NSGY resident was smoking, but I don't want any. It is fortunately rare that someone with acute SCI gets admitted to me, and when they do there's usually a compelling reason for them not to be on NSGY primary.
 
How about the consultants that use midlevels to screen their consult calls and refuse to tall to you? I had that recently. Orthopod refused to talk to me despite me asking the midlevel to connect us so we can talk doc-to-doc. I definitely documented that in the chart.
 
EMhawkeye said:
One of my shops has a diagnostic only cath lab. We transfer our stemis to a facility 20 mins up the freeway.
Had a inferior stemi. Their cardiologist disagreed it was a stemi.
Called the other stemi facility in the area 10 mins further up the road. Spoke to their cardiologist whom agreed it was a stemi and accepted after a 2 min conversation.
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So was that an EMTALA violation?
You are trying to transfer a patient for a specific intervention and the receiving doctor felt it was a wrong diagnosis.
 
DrSnips said:
23 yo F with no PMHx reaches down to pick up a soda bottle and feels a "pop" in her back along with intense pain shooting down the bilateral legs. Gets brought to ED where she says she can't move her legs. The EM doc calls NSGY. NSGY resident says NTD, likely MSK etiology, admit to medicine for PT eval if she really can't walk. Patient gets admitted by our nocturnist (who basically just places admit orders) and I (daytime hospitalist) see her the following day. She still says she can't move her legs at all. I whack at her knees with my stethoscope -- no reflexes. I STAT page the NSGY attending and they whisk her off to the OR.

Not sure what that NSGY resident was smoking, but I don't want any. It is fortunately rare that someone with acute SCI gets admitted to me, and when they do there's usually a compelling reason for them not to be on NSGY primary.
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No advanced imaging was done?
 
DrSnips said:
23 yo F with no PMHx reaches down to pick up a soda bottle and feels a "pop" in her back along with intense pain shooting down the bilateral legs. Gets brought to ED where she says she can't move her legs. The EM doc calls NSGY. NSGY resident says NTD, likely MSK etiology, admit to medicine for PT eval if she really can't walk. Patient gets admitted by our nocturnist (who basically just places admit orders) and I (daytime hospitalist) see her the following day. She still says she can't move her legs at all. I whack at her knees with my stethoscope -- no reflexes. I STAT page the NSGY attending and they whisk her off to the OR.

Not sure what that NSGY resident was smoking, but I don't want any. It is fortunately rare that someone with acute SCI gets admitted to me, and when they do there's usually a compelling reason for them not to be on NSGY primary.
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Great job as the hospitalist. But wouldn't your user name be more appropriate for a Urologist?
 
If SDN is looking for money they could have a pay-per-view showdown with this thread, the surgery consults thread, and add in FM/IM/Specialties as well.

Each tries to top the other's story. Last specialty standing wins.

Have a panel of celebrity administrators as the scoring panel.
 
thegenius said:
So was that an EMTALA violation?
You are trying to transfer a patient for a specific intervention and the receiving doctor felt it was a wrong diagnosis.
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No. They didn't have the services the patient needed (intervention; they were diagnostic only which would delay care) and the receiving physician saw the EKG and agreed to accept the patient. At least that's what was reported by the OP. That's not an EMTALA violation if you have an accepting physician and you don't have the services available. Now if the transferring facility could do interventional cath instead of diagnostic, then this would be an EMTALA violation for the transferring facility to not do the cath and instead transfer the patient.
 
southerndoc said:
No. They didn't have the services the patient needed (intervention; they were diagnostic only which would delay care) and the receiving physician saw the EKG and agreed to accept the patient. At least that's what was reported by the OP. That's not an EMTALA violation if you have an accepting physician and you don't have the services available. Now if the transferring facility could do interventional cath instead of diagnostic, then this would be an EMTALA violation for the transferring facility to not do the cath and instead transfer the patient.
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I think they were asking if it was a violation for the first physician to not accept because they “disagreed” that it was a STEMI
 
This happened last night and is pretty normal for me. We had one bed and multiple admits.

*Hospitalist enters my hole in the wall office thing*
Hospitalist: who do you want me to admit? This Covid guy?
Me: no, this person with all these electrolyte abnormalities (this case is a train wreck btw)
H: *opens epic* wth is this?
Me: it’s your next patient
H: this person is on 40 meds. I don’t want this.
Me: this is literally why you went into IM.
H: I want the Covid guy.
Me: no, you can’t have him.
H: please?
Me: no.
H: I hate you.
Me: I love you.

And scene.
 
thegenius said:
No advanced imaging was done?
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I agree, I am intrigued by this case. What spinal cord trauma could have occurred in an otherwise healthy 23-year-old who bent down to pick up a soda bottle? If it weren't so sudden, at this age and in this scenario I would think inflammatory (transverse myelitis) rather than something surgical. Is there any further information available?
 
HemeOncHopeful19 said:
I think they were asking if it was a violation for the first physician to not accept because they “disagreed” that it was a STEMI
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Depends on how it was asked. If he said "I would like for you to come evaluate the patient" and the doc said no, then yes, it's an EMTALA violation. If he said "what do you think of this EKG?" then it's not asking him to see the patient. If it's a diagnostic only cath lab, then he can't activate for a STEMI to be treated.
 
southerndoc said:
Depends on how it was asked. If he said "I would like for you to come evaluate the patient" and the doc said no, then yes, it's an EMTALA violation. If he said "what do you think of this EKG?" then it's not asking him to see the patient. If it's a diagnostic only cath lab, then he can't activate for a STEMI to be treated.
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My impression from reading it was that he called the closest interventional cath lab who said “nah I disagree that is not a STEMI we won’t accept don’t send him” followed by immediately calling the second closest cath lab who accepted.

I’m guessing it’s not a violation but monumentally dumb to refuse a transfer in that scenario however I concede maybe they get a lot of stupid “STEMI” transfers that turn out to be nothing.
 
HemeOncHopeful19 said:
My impression from reading it was that he called the closest interventional cath lab who said “nah I disagree that is not a STEMI we won’t accept don’t send him” followed by immediately calling the second closest cath lab who accepted.

I’m guessing it’s not a violation but monumentally dumb to refuse a transfer in that scenario however I concede maybe they get a lot of stupid “STEMI” transfers that turn out to be nothing.
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Maybe you're right regarding it being another facility that was diagnostic only. Why in the world would you call a STEMI to a diagnostic only lab? There's a high chance there would be an occlusion, which would mean the patient would have to be transferred twice and would have a delay in definitive care.
 
southerndoc said:
No. They didn't have the services the patient needed (intervention; they were diagnostic only which would delay care) and the receiving physician saw the EKG and agreed to accept the patient. At least that's what was reported by the OP. That's not an EMTALA violation if you have an accepting physician and you don't have the services available. Now if the transferring facility could do interventional cath instead of diagnostic, then this would be an EMTALA violation for the transferring facility to not do the cath and instead transfer the patient.
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Ok. Let's do a generic situation. You have a pt with CP at your facility and you (as an ER physician) read the EKG as a STEMI. Your facility cannot perform a cath. Let's say you can't get in touch with your own cardiologist at your own institution to review the EKG.

So you call "BlockingAllTransfers Hospital" that is 1 minute from your facility. This facility is a STEMI center. They can perform emergent PCI. You talk to the STEMI doctor over the phone there and you agree to text or fax him the EKG. He looks at it and says "it's not a STEMI."

Can the receiving facility legally block this transfer under the EMTALA statute?

Next...let's say you show your own cardiologist the EKG and he agrees it's a STEMI. The receiving facility cardiologist says it's not a STEMI.

What now?
 
Phantom Spike said:
I agree, I am intrigued by this case. What spinal cord trauma could have occurred in an otherwise healthy 23-year-old who bent down to pick up a soda bottle? If it weren't so sudden, at this age and in this scenario I would think inflammatory (transverse myelitis) rather than something surgical. Is there any further information available?
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There is something missing in this case. No way some dude with LBP is admitted to the hospital...there for 24 hours or more...and is whisked to the OR by NSG without confirmatory imaging. Not in my universe.

In my universe this pt can't be admitted without an MRI to begin with.

But I just can't see NSGY emergently taking any LBP for any reason what-so-ever to the OR without MRI.
 
thegenius said:
Ok. Let's do a generic situation. You have a pt with CP at your facility and you (as an ER physician) read the EKG as a STEMI. Your facility cannot perform a cath. Let's say you can't get in touch with your own cardiologist at your own institution to review the EKG.

So you call "BlockingAllTransfers Hospital" that is 1 minute from your facility. This facility is a STEMI center. They can perform emergent PCI. You talk to the STEMI doctor over the phone there and you agree to text or fax him the EKG. He looks at it and says "it's not a STEMI."

Can the receiving facility legally block this transfer under the EMTALA statute?

Next...let's say you show your own cardiologist the EKG and he agrees it's a STEMI. The receiving facility cardiologist says it's not a STEMI.

What now?
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For the most part, most CMS investigators will go with what you believe at the time: you thought the patient had an emergency medical condition and requested to transfer the patient. Usually they care nothing about what the accepting physician's interpretation of the situation is. (This is why EMTALA violations occur when a specialist is requested to evaluate the patient in the ER when it's something the specialist feels can go home.)

The only acceptable response for the receiving facility is:
  • Yes, we will take the patient.
  • No, we cannot accept the patient because we currently do not have the needed services available (i.e., in another cardiac cath, a surgeon who is tied up with a prolonged case, etc.)
  • No, we cannot accept the patient because we do not have the capacity to do so (all beds are full, ER is oversaturated, etc.) -- note that saturation does not require you to be on diversion (diversion is a prehospital notification and has nothing to do with a transfer)
Any response other than one of the above 3 is most likely an EMTALA violation. CMS investigators do not consider your call requesting a transfer as a call for advice, and any way to block the transfer is an EMTALA violation for a patient with a non-resolved EMC (I mention non-resolved because I hate their interpretation of stable vs unstable). If you receive a call for transfer and tell the transferring facility that you would normally discharge this type of patient, their hospitalist can admit the patient there, etc., then it's an EMTALA violation unless one of the 2 conditions above applies (i.e., you can say you don't have capacity or surgeon is unavailable and then tell them that this is something that doesn't need surgery, can be admitted at their facility, etc.).

It's all in how you word it. If you call and say "can I get your advice on this EKG, CT scan, etc." then it's OK to give advice. However, if the patient has a bad outcome and someone files an EMTALA complaint, it's likely the CMS investigator will just consider a simple phone call as a request for transfer regardless if the transferring facility actually requested it. Also, keep in mind that you as a physician have no privy to the conversation that occurred before you. When I get on the line to accept a transfer, the transfer center staff that has fielded the call before me may have already been requested to transfer the patient and then the transferring facility may only ask you for advice. CMS will definitely consider this a request for transfer even though the transfer request wasn't made to the accepting physician (it was only made to the call center staff).
 
sloh said:
Yeah stat MRI is indicated in this case. I'm thinking Cauda Equina Syndrome. Also curious about perineal sensory symptoms as well as bowel and bladder dysfunction.
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This case was a couple years back, but I'm pretty sure the ED had done spinal imaging of some sort (can't recall if MRI or CT). There was a herniated disc, but radiographic e/o cord compression was equivocal. The radiologist basically dropped their usual correlate with exam phrase.
 
Tenk said:
This happened last night and is pretty normal for me. We had one bed and multiple admits.

*Hospitalist enters my hole in the wall office thing*
Hospitalist: who do you want me to admit? This Covid guy?
Me: no, this person with all these electrolyte abnormalities (this case is a train wreck btw)
H: *opens epic* wth is this?
Me: it’s your next patient
H: this person is on 40 meds. I don’t want this.
Me: this is literally why you went into IM.
H: I want the Covid guy.
Me: no, you can’t have him.
H: please?
Me: no.
H: I hate you.
Me: I love you.

And scene.
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I'd be the exact opposite. Covid is boring at this point. I can probably help train wreck guy at least a bit.
 
Tiger26 said:
Had a cardiologist tell me once that it couldn't be a STEMI because he already had one that day. Thought it was a joke. Nope. Didn't take the patient to the cath lab.
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Whaaaaaat lol
 
Tiger26 said:
Had a cardiologist tell me once that it couldn't be a STEMI because he already had one that day. Thought it was a joke. Nope. Didn't take the patient to the cath lab.
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I mean, that's just science.
 
80s year old lady with right temporal headache and tenderness, ESR and CRP >3x upper limit of normal. Gave steroids and called neuro for consult for temporal arteritis. Neuro resident takes a brief pause and asks, "Well, did you ask about history of polymylagia rheumatica?"
 
EthylMethylMan said:
80s year old lady with right temporal headache and tenderness, ESR and CRP >3x upper limit of normal. Gave steroids and called neuro for consult for temporal arteritis. Neuro resident takes a brief pause and asks, "Well, did you ask about history of polymylagia rheumatica?"
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Why were you consulting neurology for suspected temporal arteritis?
 
EthylMethylMan said:
80s year old lady with right temporal headache and tenderness, ESR and CRP >3x upper limit of normal. Gave steroids and called neuro for consult for temporal arteritis. Neuro resident takes a brief pause and asks, "Well, did you ask about history of polymylagia rheumatica?"
Click to expand...
Neuro. Resident.
 
EthylMethylMan said:
80s year old lady with right temporal headache and tenderness, ESR and CRP >3x upper limit of normal. Gave steroids and called neuro for consult for temporal arteritis. Neuro resident takes a brief pause and asks, "Well, did you ask about history of polymylagia rheumatica?"
Click to expand...
Just curious why you felt that was an inappropriate question? Headache and elevated inflammatory markers is not very specific and there would be a differential to consider, and jaw claudication is the single best finding on history suggesting the presence of temporal arteritis. Don't get me wrong, we would likely agree that efficiency is important, and if you are going to see the patient anyways why ask the ED physician 50 questions, but out of all the questions that could be asked, this one was not inappropriate in my opinion.

Also, do you know why the patient was admitted? It is odd to admit a patient with only headache and GCA, when that could be dealt with as an outpatient.
 
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