Post your bizarre consultant interactions

[PianoMedic]

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.

If any visual symptoms my understanding is these people need pulse dose steroids at 1g solumedrol per day. I can’t arrange that either of my shops so these people would all get admitted. Getting the vascular follow up for biopsy at one shop would be easy and hard at the other.

---

Members don't see this ad.

 

[johnny_bananas]

If any visual symptoms my understanding is these people need pulse dose steroids at 1g solumedrol per day. I can’t arrange that either of my shops so these people would all get admitted. Getting the vascular follow up for biopsy at one shop would be easy and hard at the other.

I agree with you about visual symptoms, an emergency requiring admission and IV steroids, but there was no mention of visual symptoms in the case, that is why I am curious.

For patients without concerning symptoms (i.e. isolated headache), why not just send them with oral steroids, follow up for urgent biopsy, and rheumatology for long term follow-up. Not sure what an admission to hospital would provide.

 

[The Knife & Gun Club]

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.

So I adore our Neuro residents. We do a month in their Neuro ICU and they do a month with us in the ED. Being in the Neuro ICU We get to be the ones admitting the bad strokes overnight and experiencing what it’s like to have an hour to pick through an admission and think more like y’all think.

But as an ER person you’re just living in a totally different mindset. Neurologists play to win - the goal is to define the disorder, do the best possible management, determine what is most likely going on. In the ED we play not to lose - the stream of people doesn’t stop, and you’re asking pointed questions to rule in or rule out and treat life threatening pathology, and get that person to the doc who can ultimately decide what this most likely is.

So to me polymyalgia rheumatica is irrelevant. If they have it great. But my clinical suspicion for the disease is high enough to enlist a specialist without that piece of information is not useful. And every second I’m in there asking questions that don’t change dispo is a second someone is dying of a subarach in the waiting room who’s been triaged to level 4 as a “minor headache”.

In summary it’s funny because we get these questions all the time and it’s not that we don’t know the answer cuz we’re dumb, but more just that it doesn’t help me for my job so I don’t ask. Just like I don’t ask my patient what their tattoos mean.

 

[thegenius]

So I adore our Neuro residents. We do a month in their Neuro ICU and they do a month with us in the ED. Being in the Neuro ICU We get to be the ones admitting the bad strokes overnight and experiencing what it’s like to have an hour to pick through an admission and think more like y’all think.

But as an ER person you’re just living in a totally different mindset. Neurologists play to win - the goal is to define the disorder, do the best possible management, determine what is most likely going on. In the ED we play not to lose - the stream of people doesn’t stop, and you’re asking pointed questions to rule in or rule out and treat life threatening pathology, and get that person to the doc who can ultimately decide what this most likely is.

So to me polymyalgia rheumatica is irrelevant. If they have it great. But my clinical suspicion for the disease is high enough to enlist a specialist without that piece of information is not useful. And every second I’m in there asking questions that don’t change dispo is a second someone is dying of a subarach in the waiting room who’s been triaged to level 4 as a “minor headache”.

In summary it’s funny because we get these questions all the time and it’s not that we don’t know the answer cuz we’re dumb, but more just that it doesn’t help me for my job so I don’t ask. Just like I don’t ask my patient what their tattoos mean.

Why would someone think polymyalgia rheumatica when they present with a (unilateral) headache? And then you find out their ESR is elevated. It still doesn't bring PMR high on the differential.

 

[Zebra Hunter]

Why would someone think polymyalgia rheumatica when they present with a (unilateral) headache? And then you find out their ESR is elevated. It still doesn't bring PMR high on the differential.

Because it is highly associated with GCA.

 

[DocEspana]

So I adore our Neuro residents. We do a month in their Neuro ICU and they do a month with us in the ED. Being in the Neuro ICU We get to be the ones admitting the bad strokes overnight and experiencing what it’s like to have an hour to pick through an admission and think more like y’all think.

But as an ER person you’re just living in a totally different mindset. Neurologists play to win - the goal is to define the disorder, do the best possible management, determine what is most likely going on. In the ED we play not to lose - the stream of people doesn’t stop, and you’re asking pointed questions to rule in or rule out and treat life threatening pathology, and get that person to the doc who can ultimately decide what this most likely is.

So to me polymyalgia rheumatica is irrelevant. If they have it great. But my clinical suspicion for the disease is high enough to enlist a specialist without that piece of information is not useful. And every second I’m in there asking questions that don’t change dispo is a second someone is dying of a subarach in the waiting room who’s been triaged to level 4 as a “minor headache”.

In summary it’s funny because we get these questions all the time and it’s not that we don’t know the answer cuz we’re dumb, but more just that it doesn’t help me for my job so I don’t ask. Just like I don’t ask my patient what their tattoos mean.

I want to believe my conversations about patient's tattoos will prove medically relevant one day.

which is different than the "****ing funny sometimes" role they those answers currently occupy.

 

[thegenius]

Because it is highly associated with GCA.

I read the UTD article on this topic (PMR) and I didn’t read anything about that, unless you had a high spiking fever. Even then I wouldn’t consider both together due to lack of symptom overlap in this case.

 

[catnip12]

I read the UTD article on this topic (PMR) and I didn’t read anything about that, unless you had a high spiking fever. Even then I wouldn’t consider both together due to lack of symptom overlap in this case.

I’m only a 3rd year med student so there’s so much I don’t know. However, we were taught that ~1/2 of GCA patients have PMR symptoms at diagnosis and similarly about 20% of patients with known PMR develop GCA

 

[sloh]

Exactly why ask about PMR when it doesn’t change management with that presentation and work-up—especially in the context of an EM physician and their practice environment/goals/competing factors

 

[thegenius]

I’m only a 3rd year med student so there’s so much I don’t know. However, we were taught that ~1/2 of GCA patients have PMR symptoms at diagnosis and similarly about 20% of patients with known PMR develop GCA

You know what? You probably know more about this than me. In fact, it’s not probably it’s assuredly. I believe you!

 

[johnny_bananas]

So I adore our Neuro residents. We do a month in their Neuro ICU and they do a month with us in the ED. Being in the Neuro ICU We get to be the ones admitting the bad strokes overnight and experiencing what it’s like to have an hour to pick through an admission and think more like y’all think.

But as an ER person you’re just living in a totally different mindset. Neurologists play to win - the goal is to define the disorder, do the best possible management, determine what is most likely going on. In the ED we play not to lose - the stream of people doesn’t stop, and you’re asking pointed questions to rule in or rule out and treat life threatening pathology, and get that person to the doc who can ultimately decide what this most likely is.

So to me polymyalgia rheumatica is irrelevant. If they have it great. But my clinical suspicion for the disease is high enough to enlist a specialist without that piece of information is not useful. And every second I’m in there asking questions that don’t change dispo is a second someone is dying of a subarach in the waiting room who’s been triaged to level 4 as a “minor headache”.

In summary it’s funny because we get these questions all the time and it’s not that we don’t know the answer cuz we’re dumb, but more just that it doesn’t help me for my job so I don’t ask. Just like I don’t ask my patient what their tattoos mean.

Thanks for your response and perspective.

When I discuss any consult I try to ask specific questions to obtain enough information to answer 2 general questions:
1. Is the question appropriate for neurology (can I help in any way)
2. Does the patient require being seen as an inpatient, or could they be safely sent for evaluation as an outpatient.

There was limited clinical information provided, but isolated headache and elevated inflammatory markers is non-specific, and obtaining more clinical information (i.e jaw claudication, symptoms of PMR, characterization of headache, scalp tenderness, neurological symptoms etc.) to be more confident in the diagnosis of GCA is relevant in answering both those general questions. For instance, if we were both confident in the diagnosis of GCA and they did not have concerning neurological symptoms (i.e. visual loss), I would recommend over the phone this patient be evaluated as an outpatient, I don’t see the benefit of any admission or from an inpatient consult, that is why I am surprised based on that story the patient was admitted if there was such confidence in the diagnosis of GCA with isolated headache.

On the other hand, if the case just involves a new headache with elevated inflammatory markers, and we are less confident in the diagnosis of GCA, there are other concerning causes to consider, and I would want to evaluate the patient. I would disagree with you that neurologists or any other medical specialities do not “play to loose”, everyone should consider emergencies in the top of their differential. As I mentioned, new headache and inflammatory markers the differential is broad, and meningitis (in elderly can present atypically), intracranial infection, intracranial tumor, cerebral venous sinus thrombosis, systemic infection are a few aetiologies that should also be considered in addition to GCA. I would certainly not recommend steroids over the phone, which was prescribed to the patient by the ED physician, until some of these considerations were excluded, and I would order some investigations to begin to rule out other considerations.

Just also wanted to say, I have the upmost respect for generalists and certainly do not want to make their lives more difficult, I am sure you all have plenty of frustrating stories, I just fail to see how asking questions about PMR would be a bizarre question to ask. Also, I agree with you that ED physicians are busy dealing with potentially serious emergencies, but the same can be said for other specialities, and when ED physicians ask me for a new consult I need to triage appropriately and make sure I get a sense that those 2 general questions are answered before I go on to do an entire new consult that depending on the complexity could take 0.5-2 hours, I certainly am not interested in making anyone feel “dumb” over the phone.

 

[johnny_bananas]

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?

Given the bilateral symmetrical leg weakness with loss of reflexes - conus medullaris syndrome would be the more likely localization than cauda equina syndrome.

The sudden onset suggests a spinal infarct. An important diagnosis to consider because MRI could be negative, and you need to ask for special DWI sequence in the region of interest, which is not typically done with routine spinal cord imaging.

 

[johnny_bananas]

You know what? You probably know more about this than me. In fact, it’s not probably it’s assuredly. I believe you!

This is really embarrassing, you are wrong, don't realize it, and worse you are trying to belittle a medical student.

@catnip12 ignore the comment by thegenius, you will realize throughout your training that when physicians attack your level of training and not arguments, it is a sign of insecurity and lack of humility.

​

 

[bravotwozero]

This is really embarrassing, you are wrong, don't realize it, and worse you are trying to belittle a medical student.

@catnip12 ignore the comment by thegenius, you will realize throughout your training that when physicians attack your level of training and not arguments, it is a sign of insecurity and lack of humility.

​

Pretty sure he was being serious.

Not too sure about your high horse though.

 

[VA Hopeful Dr]

This is really embarrassing, you are wrong, don't realize it, and worse you are trying to belittle a medical student.

@catnip12 ignore the comment by thegenius, you will realize throughout your training that when physicians attack your level of training and not arguments, it is a sign of insecurity and lack of humility.

​

I'm 99% sure he was being serious. Good medical students usually know minutia better than the rest of us since they are less than a year out from having to deal with step one, and getting close to step two.

 

[johnny_bananas]

I'm 99% sure he was being serious. Good medical students usually know minutia better than the rest of us since they are less than a year out from having to deal with step one, and getting close to step two.

To me that sound like obvious sarcasm. They stated they read an article on PMR, and after catnip12 responded wrote the comment:

"You know what? You probably know more about this than me. In fact, it’s not probably it’s assuredly. I believe you!"

How does that not sound like sarcasm? They could have just wrote, you are correct.

If that wasn't sarcasm, I misunderstood and retract my comment.

 

[thegenius]

This is really embarrassing, you are wrong, don't realize it, and worse you are trying to belittle a medical student.

@catnip12 ignore the comment by thegenius, you will realize throughout your training that when physicians attack your level of training and not arguments, it is a sign of insecurity and lack of humility.

​

Johnny bananas, you are wrong. I was being 100% serious. I was not trying to be facetious or back handed. At one point 10 years ago I probably knew this about PMR and GCA. But I have since forgot.

Man…I don’t know what it is about you. I haven’t had much real issue about your comments, except your last one, but you sure have ruffled a lot of feathers among us.

 

[thegenius]

To me that sound like obvious sarcasm. They stated they read an article on PMR, and after catnip12 responded wrote the comment:

"You know what? You probably know more about this than me. In fact, it’s not probably it’s assuredly. I believe you!"

How does that not sound like sarcasm? They could have just wrote, you are correct.

If that wasn't sarcasm, I misunderstood and retract my comment.

It was not meant as sarcasm at all. But I can see how you took it like that given my choice of words or sentence construction.

 

[johnny_bananas]

Johnny bananas, you are wrong. I was being 100% serious. I was not trying to be facetious or back handed. At one point 10 years ago I probably knew this about PMR and GCA. But I have since forgot.

Man…I don’t know what it is about you. I haven’t had much real issue about your comments, except your last one, but you sure have ruffled a lot of feathers among us.

Accept my sincere apologies thegenius, I honestly thought you were being sarcastic. A lesson for me to not attempt to read sarcasm in other peoples writing, and I should have asked you instead of making that assumption.

 

[VA Hopeful Dr]

Accept my sincere apologies thegenius, I honestly thought you were being sarcastic. A lesson for me to not attempt to read sarcasm in other peoples writing, and I should have asked you instead of making that assumption.

Its tough when you're new to a place. Give it another 17 years (turns out @thegenius @bravotwozero and I all joined within 2 months of each other 17 years ago).

 

[deleted836128]

I am sure I have a lot of 'em but a more recent one that comes to mind is a 20 year old woman with a ruptured ovarian cyst. A lot of these go home, but this one passed out in the ER - twice - with a heart rate in the 110s and slightly hypotensive. Oh, and intractable pain. No improvement in the ER. Repeat H+H (don't hang my hat on this but I thought it would help my case to admit this girl) worsened; hemoglobin went from 11.2 to 8.0 in five hours. Freaking GYN would not take the admission! I decided to watch the patient a little more and she passed out a third time on the way to the bathroom. When I called the GYN she STILL said she thought the patient could go home. It was SUPER frustrating.

 

[greatnt249]

Thanks for your response and perspective.

When I discuss any consult I try to ask specific questions to obtain enough information to answer 2 general questions:
1. Is the question appropriate for neurology (can I help in any way)
2. Does the patient require being seen as an inpatient, or could they be safely sent for evaluation as an outpatient.

There was limited clinical information provided, but isolated headache and elevated inflammatory markers is non-specific, and obtaining more clinical information (i.e jaw claudication, symptoms of PMR, characterization of headache, scalp tenderness, neurological symptoms etc.) to be more confident in the diagnosis of GCA is relevant in answering both those general questions. For instance, if we were both confident in the diagnosis of GCA and they did not have concerning neurological symptoms (i.e. visual loss), I would recommend over the phone this patient be evaluated as an outpatient, I don’t see the benefit of any admission or from an inpatient consult, that is why I am surprised based on that story the patient was admitted if there was such confidence in the diagnosis of GCA with isolated headache.

On the other hand, if the case just involves a new headache with elevated inflammatory markers, and we are less confident in the diagnosis of GCA, there are other concerning causes to consider, and I would want to evaluate the patient. I would disagree with you that neurologists or any other medical specialities do not “play to loose”, everyone should consider emergencies in the top of their differential. As I mentioned, new headache and inflammatory markers the differential is broad, and meningitis (in elderly can present atypically), intracranial infection, intracranial tumor, cerebral venous sinus thrombosis, systemic infection are a few aetiologies that should also be considered in addition to GCA. I would certainly not recommend steroids over the phone, which was prescribed to the patient by the ED physician, until some of these considerations were excluded, and I would order some investigations to begin to rule out other considerations.

Just also wanted to say, I have the upmost respect for generalists and certainly do not want to make their lives more difficult, I am sure you all have plenty of frustrating stories, I just fail to see how asking questions about PMR would be a bizarre question to ask. Also, I agree with you that ED physicians are busy dealing with potentially serious emergencies, but the same can be said for other specialities, and when ED physicians ask me for a new consult I need to triage appropriately and make sure I get a sense that those 2 general questions are answered before I go on to do an entire new consult that depending on the complexity could take 0.5-2 hours, I certainly am not interested in making anyone feel “dumb” over the phone.

So go down and do the consult yourself then if these details are that relevant to your disposition, instead of arguing with the ED doc about whether they asked these questions. Asking whether they could have PMR when the concern is whether or not they have temporal arteritis is like the cardiologist asking whether they could be having pericarditis when the concern is if the patient is having ACS.

 

[thegenius]

I am sure I have a lot of 'em but a more recent one that comes to mind is a 20 year old woman with a ruptured ovarian cyst. A lot of these go home, but this one passed out in the ER - twice - with a heart rate in the 110s and slightly hypotensive. Oh, and intractable pain. No improvement in the ER. Repeat H+H (don't hang my hat on this but I thought it would help my case to admit this girl) worsened; hemoglobin went from 11.2 to 8.0 in five hours. Freaking GYN would not take the admission! I decided to watch the patient a little more and she passed out a third time on the way to the bathroom. When I called the GYN she STILL said she thought the patient could go home. It was SUPER frustrating.

Yea that sure is. I’ve had that happen before too. I can’t remember what happened I think I pleaded with them and they finally obs’ed her in the hospital for a day. How much blood does one need to lose before you get admitted? Or how many times do you have to faint? Is 8 times the margin number?

 

[johnny_bananas]

So go down and do the consult yourself then if these details are that relevant to your disposition, instead of arguing with the ED doc about whether they asked these questions. Asking whether they could have PMR when the concern is whether or not they have temporal arteritis is like the cardiologist asking whether they could be having pericarditis when the concern is if the patient is having ACS.

Why is 5 minutes of your time that is required to ask a couple more questions, worth more than 0.5-1 hour of my time that would be required to do a new consult? Again, if the pretest probability is high this is GCA, why do I need to do a consult in the first place, when all of this can be dealt with as an outpatient.

If I am suppose to see every single patient with a neurological complaint that walks into the emergency department what exactly is your role? Why not just have a triage nurse page neurology whenever there is a "brain" problem.

Edit: I just wanted to say, hopefully this interaction over the phone would not be an argument, and if the ED physician expresses any concern or doubt and requires assistance I would be more than happy to help out, but I do ask for some reciprocity in return, medicine is a team sport.

 

[greatnt249]

Why is 5 minutes of your time that is required to ask a couple more questions, worth more than 0.5-1 hour of my time that would be required to do a new consult? Again, if the pretest probability is high this is GCA, why do I need to do a consult in the first place, when all of this can be dealt with as an outpatient.

If I am suppose to see every single patient with a neurological complaint that walks into the emergency department what exactly is your role? Why not just have a triage nurse page neurology whenever there is a "brain" problem.

Edit: I just wanted to say, hopefully this interaction over the phone would not be an argument, and if the ED physician expresses any concern or doubt and requires assistance I would be more than happy to help out, but I do ask for some reciprocity in return, medicine is a team sport.

Yes, it is a team sport. However, you're doing it wrong if you're wasting your time on the phone berating the ED doctor for not asking questions about the potential for nonurgent conditions to be present when evidence exists to suggest that a more urgent condition is present.

You sound like that teacher who overwhelms their students with homework without regard to the students having assignments for other classes as well. If you, as an expert consultant, are looking down on other specialties for not having the expertise you carry, you're doing it wrong.

 

[Jabbed]

Why is 5 minutes of your time that is required to ask a couple more questions, worth more than 0.5-1 hour of my time that would be required to do a new consult? Again, if the pretest probability is high this is GCA, why do I need to do a consult in the first place, when all of this can be dealt with as an outpatient.

If I am suppose to see every single patient with a neurological complaint that walks into the emergency department what exactly is your role? Why not just have a triage nurse page neurology whenever there is a "brain" problem.

Edit: I just wanted to say, hopefully this interaction over the phone would not be an argument, and if the ED physician expresses any concern or doubt and requires assistance I would be more than happy to help out, but I do ask for some reciprocity in return, medicine is a team sport.

Well that was moderately offensive.

How does a past history of PMR affect the disposition of a GCA patient with vision loss? I'm not going to discharge them regardless of how closely you promise to follow up with them outpatient. You can ask that yourself when you come to take a history.

We literally have more important things to do.

 

[Apollyon]

I am sure I have a lot of 'em but a more recent one that comes to mind is a 20 year old woman with a ruptured ovarian cyst. A lot of these go home, but this one passed out in the ER - twice - with a heart rate in the 110s and slightly hypotensive. Oh, and intractable pain. No improvement in the ER. Repeat H+H (don't hang my hat on this but I thought it would help my case to admit this girl) worsened; hemoglobin went from 11.2 to 8.0 in five hours. Freaking GYN would not take the admission! I decided to watch the patient a little more and she passed out a third time on the way to the bathroom. When I called the GYN she STILL said she thought the patient could go home. It was SUPER frustrating.

That reminds me of an OB/GYN over ten years ago that did a hysto on a pt, I don't recall when (day before, or what), but comes to the ED on Saturday with vag bleeding. The case goes to the PA in Fast Track. Very soon, the PA calls me in, because bleeding is picking up. I call the OB. He is beyond dismissive. I talk to him twice more, and I end up packing the vag vault, trying to tamponade it. The OB was STILL saying to send her home. I had no idea why he was being so obstinate; I mean, of ALL hills to die on, this wasn't it. Coincidentally on call that weekend for surgery was the chief of sx (he ran the Dept, for the admin side of anyone who did sx at the hospital, including OB, GenSx, Ortho, ENT, and ophtho). I called him, exasperated. He calls the OB, and tells him to get his head out of his a$$ (I don't recall, but, that might be an exact quote).

The OB finally relents to admit (but, didn't come in or book an OR at that time). I, honestly, don't recall if she lived or died.

I don't get that small subset of OBs that are beyond resistant, to the point of killing the pt. When I was a med student, the OB residents were given a lot of latitude. One of the chiefs let a pt bleed to death, due to hubris.

And, the coda to the OB I mentioned above? Months later, criminally charged with sexual assault for other pts.

 

[johnny_bananas]

Yes, it is a team sport. However, you're doing it wrong if you're wasting your time on the phone berating the ED doctor for not asking questions about the potential for nonurgent conditions to be present when evidence exists to suggest that a more urgent condition is present.

You sound like that teacher who overwhelms their students with homework without regard to the students having assignments for other classes as well. If you, as an expert consultant, are looking down on other specialties for not having the expertise you carry, you're doing it wrong.

You acknowledge that medicine is a team sport, but you suggest it is “berating the ED doctor” to ask for several questions and answers that would help determine whether a consult is even required.

Having an attitude like that in my opinion would not lead to collegial interactions with consultants. Your view is that I am “looking down” at you for asking questions that as a consultant I may feel are important in deciding how I can help. You view it as I am wasting your time, but how I would view it is that you care so little about my time that you wouldn’t even try to answer those questions for me, and again may prevent an unnecessary consult and get the patient out from the ED quicker.

I am sympathetic about where this attitude arrises, because I do think as ED physicians you may deal with unnecessary abuse from consultants when you are trying to advocate for your patients, but I would not let those experiences cloud your judgement that all consultants are trying to behave in that way.

 

[johnny_bananas]

Well that was moderately offensive.

How does a past history of PMR affect the disposition of a GCA patient with vision loss? I'm not going to discharge them regardless of how closely you promise to follow up with them outpatient. You can ask that yourself when you come to take a history.

We literally have more important things to do.

Why was that offensive?

I think you have a misunderstanding of the case, where in the description was it stated that the patient had vision loss?

 

[The Knife & Gun Club]

That reminds me of an OB/GYN over ten years ago that did a hysto on a pt, I don't recall when (day before, or what), but comes to the ED on Saturday with vag bleeding. The case goes to the PA in Fast Track. Very soon, the PA calls me in, because bleeding is picking up. I call the OB. He is beyond dismissive. I talk to him twice more, and I end up packing the vag vault, trying to tamponade it. The OB was STILL saying to send her home. I had no idea why he was being so obstinate; I mean, of ALL hills to die on, this wasn't it. Coincidentally on call that weekend for surgery was the chief of sx (he ran the Dept, for the admin side of anyone who did sx at the hospital, including OB, GenSx, Ortho, ENT, and ophtho). I called him, exasperated. He calls the OB, and tells him to get his head out of his a$$ (I don't recall, but, that might be an exact quote).

The OB finally relents to admit (but, didn't come in or book an OR at that time). I, honestly, don't recall if she lived or died.

I don't get that small subset of OBs that are beyond resistant, to the point of killing the pt. When I was a med student, the OB residents were given a lot of latitude. One of the chiefs let a pt bleed to death, due to hubris.

And, the coda to the OB I mentioned above? Months later, criminally charged with sexual assault for other pts.

I have had similar discussions with OB.

“Hey I think the person you did a D&C on the other day has endometritis. They’re tachy, febrile, hypotensive and there’s green goop coming from the is.”

- Nah they have a UTI. It’s clear as day on their labs, leuk esterase and WBCs. You can manage that and send her home

Umm are you sure? Because there is pus pouring from their vagina and her lactic is 4.

- maybe urosepsis, admit to medicine and they can consult if they feel it’s warranted.

*performs ct*

The CT AP has a loculated fluid collection in the uterus. I really think this needs OR.

- did they never teach you in medical school that CT is not the perfered imaging for the pelvic organs? Are you a physician?

*Attending steps in* threatens to wake up the attending on home call.

The patient spent like 4 days languishing on the floor before someone finally called a rapid, tubed her and took her to the SICU where gen surg drained the abscess.

 

[southerndoc]

You acknowledge that medicine is a team sport, but you suggest it is “berating the ED doctor” to ask for several questions and answers that would help determine whether a consult is even required.

Having an attitude like that in my opinion would not lead to collegial interactions with consultants. Your view is that I am “looking down” at you for asking questions that as a consultant I may feel are important in deciding how I can help. You view it as I am wasting your time, but how I would view it is that you care so little about my time that you wouldn’t even try to answer those questions for me, and again may prevent an unnecessary consult and get the patient out from the ED quicker.

I am sympathetic about where this attitude arrises, because I do think as ED physicians you may deal with unnecessary abuse from consultants when you are trying to advocate for your patients, but I would not let those experiences cloud your judgement that all consultants are trying to behave in that way.

Luckily in the US we don't have to answer your questions. We can simply say "I would like for you to see this patient," and per EMTALA, you're required to see the patient within the time frame defined by your hospital bylaws. Failure to do so can result in a $50,00 fine levied against the consultant (not the hospital) by CMS.

 

[Phantom Spike]

Given the bilateral symmetrical leg weakness with loss of reflexes - conus medullaris syndrome would be the more likely localization than cauda equina syndrome.

The sudden onset suggests a spinal infarct. An important diagnosis to consider because MRI could be negative, and you need to ask for special DWI sequence in the region of interest, which is not typically done with routine spinal cord imaging.

To your first point; reflexes can be diminished in the acute phase of a spinal injury ("spinal shock"), so it doesn't rule out a myelopathy (conus medullaris or higher). We were not given additional details such as presence or absence of a spinal level, rectal tone, loss of perineal sensation, etc. Also, cauda equina is usually due to structural lesion (and indeed, we were subsequently told that a herniated disc was apparently the cause), but in a young patient who bent over to pick up a bottle and suddenly couldn't walk, the story was unusual.

To your second point; yes, spinal cord infarct could fit the picture nicely, but the setting for that is usually periprocedural during aortic surgery and very rarely spontaneous, and again, this is a very young patient. Not to mention, untreatable, so not an emergency as such. Inflammatory causes (MS, NMO, anti-MOG, transverse myelitis) don't present instantaneously the way this case apparently did, but can be rather rapidly progressive.

 

[turkeyjerky]

Does this whole thread count as a bizaare consultant interaction? I can't tell if it's culture differences (doubt it cause I've never met a canadian IRL that I didn't like), trolling or autism.

 

[Dr G Oogle]

So I adore our Neuro residents. We do a month in their Neuro ICU and they do a month with us in the ED. Being in the Neuro ICU We get to be the ones admitting the bad strokes overnight and experiencing what it’s like to have an hour to pick through an admission and think more like y’all think.

But as an ER person you’re just living in a totally different mindset. Neurologists play to win - the goal is to define the disorder, do the best possible management, determine what is most likely going on. In the ED we play not to lose - the stream of people doesn’t stop, and you’re asking pointed questions to rule in or rule out and treat life threatening pathology, and get that person to the doc who can ultimately decide what this most likely is.

So to me polymyalgia rheumatica is irrelevant. If they have it great. But my clinical suspicion for the disease is high enough to enlist a specialist without that piece of information is not useful. And every second I’m in there asking questions that don’t change dispo is a second someone is dying of a subarach in the waiting room who’s been triaged to level 4 as a “minor headache”.

In summary it’s funny because we get these questions all the time and it’s not that we don’t know the answer cuz we’re dumb, but more just that it doesn’t help me for my job so I don’t ask. Just like I don’t ask my patient what their tattoos mean.

Not an ER doc, and this took me a long time to understand unfortunately. I would always ask these types of questions I think this should be drilled into every med stud and resident. I think people sometimes forget that we also get paid to see those consults.

As an OB, who’s fellowship trained, I completely agree with the generalists being very obstinate to deal with anything remotely surgical. We even did a QI project because so many torsions, ruptured cysts and ectopics were being admitted for Observation and nearly 90% of generalists did non surgical management for a clearly surgical problem

 

[johnny_bananas]

To your first point; reflexes can be diminished in the acute phase of a spinal injury ("spinal shock"), so it doesn't rule out a myelopathy (conus medullaris or higher). We were not given additional details such as presence or absence of a spinal level, rectal tone, loss of perineal sensation, etc. Also, cauda equina is usually due to structural lesion (and indeed, we were subsequently told that a herniated disc was apparently the cause), but in a young patient who bent over to pick up a bottle and suddenly couldn't walk, the story was unusual.

To your second point; yes, spinal cord infarct could fit the picture nicely, but the setting for that is usually periprocedural during aortic surgery and very rarely spontaneous, and again, this is a very young patient. Not to mention, untreatable, so not an emergency as such. Inflammatory causes (MS, NMO, anti-MOG, transverse myelitis) don't present instantaneously the way this case apparently did, but can be rather rapidly progressive.

I completely agree with you that areflexia doesn’t rule out a myelopathy, as you mentioned the phenomenon of spinal shock exists. Also conus medullaris synndrome is a myelopathy (inferior cord). Localization is similar to a differential, there are typically multiple possible areas that you rank based on likelihood. As you also mentioned, very little detail was given, so it is a somewhat silly exercise because we are making a lot of assumptions. To be honest when someone says a patient is areflexic based on using their stethoscope it makes harder to believe that is even accurate, you should really optimize the ability to obtain reflexes if you are reporting someone is areflexic, but I digress.

Others mentioned cauda equina syndrome as a localization, which is a possibility, my only point regarding localization was that conus medullaris syndrome was more likely given the symmetry of weakness, cauda equina typically presents in an asymmetrical fashion. The “intense pain shooting down the bilateral legs” would fit well with conus medularis syndrome, and the fact that the region is susceptible to ischemia.

Spontaneous spinal cord infarct (SCI), is rare, like many neurological disorders, but studies suggest that 16% of patients referred for transverse myelitis ultimately are diagnosed with SCI. There is a wide range of effected age groups, possibly due to the fact that fibrocartilaginous embolism, which is thought to be a common cause of SCI, has a bimodal age distribution.

I agree SCI is untreatable, the reason why it is important to consider is protocoling the correct sequences on MRI, without a diagnosis for the patient this may often lead to further unnecessary tests or worse incorrect treatment.

As you mentioned, inflammatory causes typically reach a nadir over several days, would be very unusual to present abruptly and would virtually exclude the diagnosis.

You may find this case report interesting:
Fibrocartilaginous embolism: a cause of acute ischemic myelopathy - Spinal Cord

The patient was inappropriately treated for GBS as SCI was not considered.

 

[johnny_bananas]

Luckily in the US we don't have to answer your questions. We can simply say "I would like for you to see this patient," and per EMTALA, you're required to see the patient within the time frame defined by your hospital bylaws. Failure to do so can result in a $50,00 fine levied against the consultant (not the hospital) by CMS.

That is interesting, I didn't know that. I am sure there were likely reasons for that implementation, but if there is a culture of accepting all consults regardless of need, that would lead to a lot of unnecessary consults and increased cost to the medical system.

In Canada, we don’t have that. In my experience, around 50% of phone calls with ED physicians is just giving advise over the phone, and not doing a full consult. To be honest, I can't remember a single interaction with an ED physician where we disagreed on the need to see a patient in the ER or if they were more appropriate to be evaluated as an outpatient.

 

[Matthew9Thirtyfive]

I have had similar discussions with OB.

“Hey I think the person you did a D&C on the other day has endometritis. They’re tachy, febrile, hypotensive and there’s green goop coming from the is.”

- Nah they have a UTI. It’s clear as day on their labs, leuk esterase and WBCs. You can manage that and send her home

Umm are you sure? Because there is pus pouring from their vagina and her lactic is 4.

- maybe urosepsis, admit to medicine and they can consult if they feel it’s warranted.

*performs ct*

The CT AP has a loculated fluid collection in the uterus. I really think this needs OR.

- did they never teach you in medical school that CT is not the perfered imaging for the pelvic organs? Are you a physician?

*Attending steps in* threatens to wake up the attending on home call.

The patient spent like 4 days languishing on the floor before someone finally called a rapid, tubed her and took her to the SICU where gen surg drained the abscess.

That’s horrible. As someone who will be applying to OB next year, that embarrasses me.

 

[johnny_bananas]

Does this whole thread count as a bizaare consultant interaction? I can't tell if it's culture differences (doubt it cause I've never met a canadian IRL that I didn't like), trolling or autism.

Are you using "autism" as a pejorative?

And if you say no, then why is it right after "trolling"?

 

[Matthew9Thirtyfive]

Are you using "autism" as a pejorative?

And if you say no, then why is it right after "trolling"?

That’s usually how lists work. Cultural differences probably isn’t a pejorative and it’s in the same list. You are being extremely argumentative and bothering a lot of people on this forum though.

 

[johnny_bananas]

That’s usually how lists work. Cultural differences probably isn’t a pejorative and it’s in the same list. You are being extremely argumentative and bothering a lot of people on this forum though.

Let me get this straight, I respectively disagree with posters on issues and this is considered "extremely argumentative" and "bothering" people, but you think it is okay to use the word autism as an insult? You realize that there are families on this forum who have children with autism, I am sure they would not take lightly using that word as an insult. And no, the list included either troll or autism. Are you not a moderator?


Please let me know where I was disrespectful? I try to engage with issues and topics not ad hominem attacks.

 

[johnny_bananas]

Not an ER doc, and this took me a long time to understand unfortunately. I would always ask these types of questions I think this should be drilled into every med stud and resident. I think people sometimes forget that we also get paid to see those consults.

As an OB, who’s fellowship trained, I completely agree with the generalists being very obstinate to deal with anything remotely surgical. We even did a QI project because so many torsions, ruptured cysts and ectopics were being admitted for Observation and nearly 90% of generalists did non surgical management for a clearly surgical problem

Are all consults that you receive from the ER appropriate? What I mean by that is are there consults that you receive over the phone that could be dealt with as an outpatient. Should the fact that we get paid for consults factor in to the question of the appropriateness of consults? For instance, should the fact we get paid for consults mean it doesn't matter how appropriate the consult is?

 

[thegenius]

Does this whole thread count as a bizaare consultant interaction? I can't tell if it's culture differences (doubt it cause I've never met a canadian IRL that I didn't like), trolling or autism.

Yes I’m getting tired of reading the recent back-and-forth between EM and Neuro. I think both sides are making some reasonable points but there isn’t a lot of good listening and nice manners. I feel like saying “will you kids stop arguing!!!! Now sit down and eat your vegetables”

 

[Matthew9Thirtyfive]

You realize that there are families on this forum who have children with autism, I am sure they would not take lightly using that word as an insult.

I am on the spectrum and so is my daughter. I didn’t think it was meant as an insult. But sure, please tell me how I’m supposed to feel.

 

[The Knife & Gun Club]

That’s horrible. As someone who will be applying to OB next year, that embarrasses me.

@Dr G Oogle

My wife is OB so I’ve heard second hand of the crap y’all have to deal with. Our OBs do some great work and the residency is insane so cudos to you for signing up for that, lord knows good OBs can do a lot of good in this world.

What’s interesting is of the 2 places we cover (one is just attendings one is academic) both seem to respond well to the “hey this doesn’t need to be an official consult, I just need your help” Type call. Then I tell them the case and half the time they end up actually interested and want to see the case, other half the time they give me some useful dispo advice or get the patient set up in their clinic.

I think it may be the result of me treating them like a specialist consultant rather than them feeling like I’m dumping on them for just for a dispo.

 

[rokshana]

To me that sound like obvious sarcasm. They stated they read an article on PMR, and after catnip12 responded wrote the comment:

"You know what? You probably know more about this than me. In fact, it’s not probably it’s assuredly. I believe you!"

How does that not sound like sarcasm? They could have just wrote, you are correct.

If that wasn't sarcasm, I misunderstood and retract my comment.

Didn’t read that as sarcasm at all…thought he was being sincere

 

[greatnt249]

You acknowledge that medicine is a team sport, but you suggest it is “berating the ED doctor” to ask for several questions and answers that would help determine whether a consult is even required.

Having an attitude like that in my opinion would not lead to collegial interactions with consultants. Your view is that I am “looking down” at you for asking questions that as a consultant I may feel are important in deciding how I can help. You view it as I am wasting your time, but how I would view it is that you care so little about my time that you wouldn’t even try to answer those questions for me, and again may prevent an unnecessary consult and get the patient out from the ED quicker.

I am sympathetic about where this attitude arrises, because I do think as ED physicians you may deal with unnecessary abuse from consultants when you are trying to advocate for your patients, but I would not let those experiences cloud your judgement that all consultants are trying to behave in that way.

1. Asking about PMR in a patient presenting to the ED with temporal arteritis symptoms is irrelevant to the ED doctor, as temporal arteritis is a more urgent condition. You can figure out if the patient has PMR when you come do the consult if you so choose, but it's quite frankly not the ED's job to make every diagnosis for you before calling. That's not to say a basic work-up shouldn't be done beforehand. If that was the case, what's the point of your role as a consultant?

2. I'm not an emergency medicine physician.

3. You say you're sympathetic to the plight of the ED doctor, but what you write and how you write it suggests otherwise, such as when you jumped down the other poster's throat and apologized for them for "talking down" to the medical student who posted when it was pretty apparent that there was no ill intent.

 

[johnny_bananas]

I am on the spectrum and so is my daughter. I didn’t think it was meant as an insult. But sure, please tell me how I’m supposed to feel.

And I too have family members, neither of us represent or speak for the entire community, so yours or my personal life means very little in the conversation. What matters is the facts of what was said:

"Does this whole thread count as a bizaare consultant interaction? I can't tell if it's culture differences (doubt it cause I've never met a canadian IRL that I didn't like), trolling or autism."

They label my interaction as "bizarre", and they don't think it is related to cultural differences because they like all Canadians, so they conclude it must be trolling or autism. Do you think that was meant as a compliment?

The fact is it was meant to be an insult, they associated the word trolling, which is a negative term with autism, regardless of how much you try to distort the truth by telling us about your personal life and that you are not offended, and therefore it is okay.

Look, I really don't care if I was insulted, some have an inability to follow arguments so they resort to personal attacks. I could care less. This is not about me, but I do find it disrespectful to individuals with autism, more so coming from a physician who should know better, to use the word 'autism' to try to insult someone or be "funny", and this comment was 'liked' by other physicians. They should all be embarrassed.

I am really astonished by your lack of objectivity in this as someone who is a "moderator", you jump in and try to speak for the poster and you accuse me of "bothering" people without ever highlighting how I was rude, but you condone language that demeans a group of people. Do people with autism act like trolls? Like I say, I am not for putting people in "timeout", but if anything should be moderated is speech like this.

 

[johnny_bananas]

Yes I’m getting tired of reading the recent back-and-forth between EM and Neuro. I think both sides are making some reasonable points but there isn’t a lot of good listening and nice manners. I feel like saying “will you kids stop arguing!!!! Now sit down and eat your vegetables”

I respect your opinion as a veteran on this forum and as someone who accepted my apology when I was wrong and made an assumption.

Can you tell me where I am not "listening" or not displaying "nice manners"? If I am wrong, I have no issue to correct myself, you know that. I try to answer peoples posts with in depth replies and arguments, sure I provide a contrary opinion and I am not sure what is wrong with that, but I try to do it in a respectful manner for the most part. This results in ad hominem attacks (i.e. trolling, autism), and people not reading posts and making accusations based on incorrect information(i.e. the case had visual loss).

I honestly don't get it. I like talking to EM or other physicians outside of neurology as I think they provide a valuable different perspective, it just doesn't seem reciprocated, and I feel some take offence to the slightest difference in opinion, which results in ad hominem attacks, and then I am grouped with those that don't have "nice manners".

 

[thegenius]

I still don't understand why I should think of PMR when someone comes in with a unilateral HA and elevated inflammatory markers. Where do those symptoms fit in with PMR? Don't you need some sort of girdle weakness?

This entire thing doesn't make sense.

It's not good enough to have overlap between the two. You have to have a least one symptom of PMR to have PMR, right

 

[thegenius]

I respect your opinion as a veteran on this forum and as someone who accepted my apology when I was wrong and made an assumption.

Can you tell me where I am not "listening" or not displaying "nice manners"? If I am wrong, I have no issue to correct myself, you know that. I try to answer peoples posts with in depth replies and arguments, sure I provide a contrary opinion and I am not sure what is wrong with that, but I try to do it in a respectful manner for the most part. This results in ad hominem attacks (i.e. trolling, autism), and people not reading posts and making accusations based on incorrect information(i.e. the case had visual loss).

I honestly don't get it. I like talking to EM or other physicians outside of neurology as I think they provide a valuable different perspective, it just doesn't seem reciprocated, and I feel some take offence to the slightest difference in opinion, which results in ad hominem attacks, and then I am grouped with those that don't have "nice manners".

I never wrote "YOU DO NOT HAVE NICE MANNERS."

Johnny, sometimes it's best to just walk away. Even if you are right.

Just walk away. Honestly. It's the best advice I can give you.