Post your bizarre consultant interactions

[johnny_bananas]

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, rights

Greatnt249 has the exact same question/issue, so my explanation might have been inadequate, I tried to go in depth with my reply to The Knife & Gun Club.

Polymyalgia rheumatica (PMR) is present in 40–60% of patients with giant-cell arteritis (GCA). The concern is not making a diagnosis of PMR (who cares about that), but making sure you have the correct diagnosis of GCA. Symptoms of PMR in someone with headache and inflammatory markers is supportive of a diagnosis of GCA. Other symptoms are important to ask as well (i.e jaw claudication). The absence of symptoms/signs cannot exclude the diagnosis of GCA, even normal inflammatory markers, but if there are multiple supporting symptoms/signs the probability this is GCA is higher. If it is a slam dunk diagnosis of GCA in a patient with isolated headache, you could put them on oral steroids with urgent outpatient follow up. So those questions over the phone are relevant in determining disposition and treatment.

However, if all that you have is a new headache and elevated inflammatory markers, this could still be GCA, but you are less confident. This could also be meningitis, intracranial infections, tumor etc. Differential is broad. I wouldn't feel comfortable sending that patient home without further investigations at the very least, and I would not start them on empiric steroids until I eliminate the possibility of infection. Does that make sense?

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[RustedFox]

Polymyalgia rheumatica (PMR) is present in 40–60% of patients with giant-cell arteritis (GCA).

I'm not involved in the fray. This is a generalized response and is not directed to johnny_bananas

It is textbook statements like these that puzzle the reader and make medical textbooks and articles sound silly.

"... present in 40-60% of patients with GCA."

So.... about fifty percent. Could they just have written 50%, or even 'about 50%'? That's one number and doesn't lend itself to the subconscious need to give a range in a situation where it doesn't quite fit the statement.

 

[johnny_bananas]

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.

I am confused because you were referring to the back and forth between EM and neurology on this tread, and there is only one neurologist. I didn't take it negatively, I think others have a similar view. Just thought maybe I said something rude and I didn't realize it. I will take you advice, thanks.

 

[Dr G Oogle]

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?

I mean for the most part they are appropriate, I am at 2 regional hospitals of a big health system and there are pretty seasoned attendants there. So I pretty much get reasonable consults, most of the time I can just curbside them. The few questionable consults have been from residents, but they are learners, getting upset with them is no more appropriate than yelling at an intern for not being able to tie a knot. I can only speak for myself and my specialty though, gyn and urogyn are very simple compared to neuro, our stuff is structural, there is no diagnostic dilemma, and I imagine neuro gets a lot more 💩 consults because of the huge overlap in medical presentations.

 

[Dr G Oogle]

@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.

I think the “I just need to help” from the ER and “happy to help” from consultants goes a long way.

 

[southerndoc]

Let's keep the thread related to discussion of bizarre consultant-interactions and not have one play out in real life in the forum.

Going forward, anything off-topic will be moved to the off-topic forum.

 

[Arcan57]

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.

I had a hypotensive patient with active vaginal bleeding and a Hb of 2.0 that a GYN attending at my first job told me to send home on iron.

 

[VisionaryTics]

I had a hypotensive patient with active vaginal bleeding and a Hb of 2.0 that a GYN attending at my first job told me to send home on iron.

I'm convinced every time I hear a story like this that the consultant is drunk on call. Explains the bizarre management and the refusal to come in.

 

[Dr G Oogle]

I'm convinced every time I hear a story like this that the consultant is drunk on call. Explains the bizarre management and the refusal to come in.

Alas, I have similar stories from my own colleagues. I’ve seen obvious torsions get admitted for observation, have seen the HB of 2-3 get admitted for IV iron which I guess is better than being sent home on PO, have seen septic patients with pyometra and DIC get admitted for IV abx, this is all at an academic center no less🤦‍♂️

I really feel for you ER peeps, sometimes when I get annoyed with a consult, I imagine what it would feel like to need help and have everyone tell me to handle it myself, and that is a real helpful way to get a clearer idea of what my role is in those situations

 

[Arcan57]

I'm convinced every time I hear a story like this that the consultant is drunk on call. Explains the bizarre management and the refusal to come in.

I think she hated her life and her patients. That’s the most egregious example of our interaction but I’m not sure I ever had her suggest a course of action consistent with the standard of care.

 

[Matthew9Thirtyfive]

I think she hated her life and her patients. That’s the most egregious example of our interaction but I’m not sure I ever had her suggest a course of action consistent with the standard of care.

I’m convinced that for every dumb ER doc story I hear, you all have at least one insane or dumb consultant story.

 

[The Knife & Gun Club]

I’m convinced that for every dumb ER doc story I hear, you all have at least one insane or dumb consultant story.

Yea I could just as easily make a bizarre hand offs thread.

Our ED was one of the last to Transition from the old “medical and surgical” side model to a modern ED model. In those days there were some boarded ED docs and some non-ABEM boarded docs. A few of these dinosaurs still roam the county hospital halls, defiantly refusing to retire, consulting surgery for abscess I&Ds, calling anesthesia to intubate, and ordering plain film C spine X-rays for traumas.

In one particularly absurd handoff from an Gen surg prelim intern & a non-boarded doc, they signed out a patient pending “you just need to print the discharge papers.” The person had a knee lac they’d already repaired. She was an Olympic athlete who’d gotten drunk on vacation in South Beach and cut their knee breaking a glass table.

I thought I’d glance at the Knee xray they’d ordered only to see clear as day air in the joint. The rads read even mentioned free air in the joint! Called ortho who took one look at the films and rolled her straight to the OR for washout and reported a grossly contaminated knee joint with bits of wood and glass inside the capsule.

 

[Radetzky]

I had a hypotensive patient with active vaginal bleeding and a Hb of 2.0 that a GYN attending at my first job told me to send home on iron.

My enduring memory of OBGYN is them doing some elective operation on a patient with cirhosis without bothering to involve anyone who knew anything about livers, making a bunch of enterotomies, bailing, then a few days later trying to punt the patient to the medical team as a "fever of unknown origin"

 

[WilcoWorld]

Yea I could just as easily make a bizarre hand offs thread.

Our ED was one of the last to Transition from the old “medical and surgical” side model to a modern ED model. In those days there were some boarded ED docs and some non-ABEM boarded docs. A few of these dinosaurs still roam the county hospital halls, defiantly refusing to retire, consulting surgery for abscess I&Ds, calling anesthesia to intubate, and ordering plain film C spine X-rays for traumas.

In one particularly absurd handoff from an Gen surg prelim intern & a non-boarded doc, they signed out a patient pending “you just need to print the discharge papers.” The person had a knee lac they’d already repaired. She was an Olympic athlete who’d gotten drunk on vacation in South Beach and cut their knee breaking a glass table.

I thought I’d glance at the Knee xray they’d ordered only to see clear as day air in the joint. The rads read even mentioned free air in the joint! Called ortho who took one look at the films and rolled her straight to the OR for washout and reported a grossly contaminated knee joint with bits of wood and glass inside the capsule.

"Just print the discharge papers" is code for "just assume the liability"
Stupidest, most unnecessary and downright rude handoff one can give.

 

[DrSnips]

Got another one. I didn't personally interact with this consultant, but it's still note worthy:

So a 45 yo F with h/o HTN, iron def anemia looks at her most recent labs in the patient portal and sees that her ferritin is 300. She tries to call her hematologist to discuss, but can't get through. So then she comes to the ED because she's worried about the lab. They check CBC, BMP on her. Hgb is 10 ish, everything looks ok. Patient demands that her hematologist's group see her, so the ED calls the heme fellow. By this point it is nighttime. Heme fellow tells the ED over the phone to admit the patient to medicine so they can formally consult in the AM. So patient gets admitted to medicine. I see the patient the next day and explain that I don't think she needs to stay and can go home. She says she won't leave without seeing hematology. So I call the daytime heme fellow (different person than who was on last night) and they refuse the consult -- it's a ferritin of 300, big whoop. So I go back to the patient and tell her that heme refuses to see her and I'm discharging her. She got really mad, but eventually stormed off without things escalating to appeal of discharge.

In case you are wondering if the overnight heme fellow saw the patient or left a note ... they did not.

 

[Fox800]

Got another one. I didn't personally interact with this consultant, but it's still note worthy:

So a 45 yo F with h/o HTN, iron def anemia looks at her most recent labs in the patient portal and sees that her ferritin is 300. She tries to call her hematologist to discuss, but can't get through. So then she comes to the ED because she's worried about the lab. They check CBC, BMP on her. Hgb is 10 ish, everything looks ok. Patient demands that her hematologist's group see her, so the ED calls the heme fellow. By this point it is nighttime. Heme fellow tells the ED over the phone to admit the patient to medicine so they can formally consult in the AM. So patient gets admitted to medicine. I see the patient the next day and explain that I don't think she needs to stay and can go home. She says she won't leave without seeing hematology. So I call the daytime heme fellow (different person than who was on last night) and they refuse the consult -- it's a ferritin of 300, big whoop. So I go back to the patient and tell her that heme refuses to see her and I'm discharging her. She got really mad, but eventually stormed off without things escalating to appeal of discharge.

In case you are wondering if the overnight heme fellow saw the patient or left a note ... they did not.

#entitlement

 

[thegenius]

Got another one. I didn't personally interact with this consultant, but it's still note worthy:

So a 45 yo F with h/o HTN, iron def anemia looks at her most recent labs in the patient portal and sees that her ferritin is 300. She tries to call her hematologist to discuss, but can't get through. So then she comes to the ED because she's worried about the lab. They check CBC, BMP on her. Hgb is 10 ish, everything looks ok. Patient demands that her hematologist's group see her, so the ED calls the heme fellow. By this point it is nighttime. Heme fellow tells the ED over the phone to admit the patient to medicine so they can formally consult in the AM. So patient gets admitted to medicine. I see the patient the next day and explain that I don't think she needs to stay and can go home. She says she won't leave without seeing hematology. So I call the daytime heme fellow (different person than who was on last night) and they refuse the consult -- it's a ferritin of 300, big whoop. So I go back to the patient and tell her that heme refuses to see her and I'm discharging her. She got really mad, but eventually stormed off without things escalating to appeal of discharge.

In case you are wondering if the overnight heme fellow saw the patient or left a note ... they did not.

I would have discharged her from the ED and let her issue a formal complaint to the hospital, and then let admin deal with it.

There is not a single doctor in this Solar System that would suggest this is an appropriate use of hospital or ER resources.

And the nighttime Heme fellow should be spanked.

 

[Zebra Hunter]

I would have discharged her from the ED and let her issue a formal complaint to the hospital, and then let admin deal with it.

There is not a single doctor in this Solar System that would suggest this is an appropriate use of hospital or ER resources.

And the nighttime Heme fellow should be spanked.

Yup, I wouldn't have even checked labs on this patient unless she had an actual medical complaint. Just a "follow up with your hematologist" conversation.

 

[turkeyjerky]

I would have discharged her from the ED and let her issue a formal complaint to the hospital, and then let admin deal with it.

There is not a single doctor in this Solar System that would suggest this is an appropriate use of hospital or ER resources.

And the nighttime Heme fellow should be spanked.

My guess is that this ED doc had been previously involved in a complaint regarding failure to call a patient's specialist after they requested it, and likely wanted to head this off. Instead they get a ridiculous recommendation that they now feel they need to abide by. Had they just discharged the patient, they might've gotten a nastygram from an unsupportive medical director.

That said, it's a bizarre story and anyone w/ half a brain would agree that it was grossly inappropriate. Unfortunately too many people turn off their entire brain when going to work.

Put yourself in the patient's shoes. She probably googled "high ferritin" and saw this:

It says "Leukemia" right there (!). What kind of monster would send her home without seeing a specialist????

 

[Neopolymath]

It's always OB here. Patient with no medical problems in the ED with razor blades in her vagina. "Nah, we are too busy. Get medicine to admit them"

Ummmmmmmmmm.

 

[southerndoc]

It's always OB here. Patient with no medical problems in the ED with razor blades in her vagina. "Nah, we are too busy. Get medicine to admit them"

Ummmmmmmmmm.

Reminds me of one of the surgeons at a former site who told me to have a girl who shoved CT-confirmed broken glass in her rectum to follow up with colorectal surgery the following morning. Oddly enough, when I insisted that he come personally evaluate the patient, she was immediately booked for an exam under general anesthesia and admitted to their service.

It's always easy for them to say discharge someone when they can have plausible deniability, but when they have to write a note and put their name in the chart, they realize how wrong and legally indefensible it is.

Consultant shenanigans.

 

[PianoMedic]

"Just print the discharge papers" is code for "just assume the liability"
Stupidest, most unnecessary and downright rude handoff one can give.

… If someone gave me that handoff I would have asked them to take the five minutes to print the papers and go discharge the patient. I did that for two of my own patients tonight instead of handing them off. Granted, in this case mentioned that would have been a terrible outcome for the patient, but otherwise that’s demanding someone else take on your medicolegal liability for you.

 

[HemeOncHopeful19]

I would have discharged her from the ED and let her issue a formal complaint to the hospital, and then let admin deal with it.

There is not a single doctor in this Solar System that would suggest this is an appropriate use of hospital or ER resources.

And the nighttime Heme fellow should be spanked.

What would y’all want the PM heme fellow to do? I would’ve never been called tbh, but if I did I would’ve said admit to medicine and we’ll see in the AM but no way am I coming in overnight for crap like that.

If anything the day time fellow would’ve been reamed here for refusing any consult, especially if y’all said the patient was demanding to be seen by Heme.

Agreed it is a big waste of everybody’s time and a good example of the harms of releasing labs to patients early.

 

[bravotwozero]

What would y’all want the PM heme fellow to do? I would’ve never been called tbh, but if I did I would’ve said admit to medicine and we’ll see in the AM but no way am I coming in overnight for crap like that.

If anything the day time fellow would’ve been reamed here for refusing any consult, especially if y’all said the patient was demanding to be seen by Heme.

Agreed it is a big waste of everybody’s time and a good example of the harms of releasing labs to patients early.

The night heme fellow should have had the cajones to say she can follow up with us in clinic.

 

[HemeOncHopeful19]

The night heme fellow should have had the cajones to say she can follow up with us in clinic.

Ah yeah my bad, I assumed that was offered and patient was refusing it. I would’ve said “you can tell patient that we’ll work them into clinic earlier than their next appointment but if you really need us to see her we’ll be happy to come by in the morning”

 

[WorkNoteEmergency]

Both of mine involve vascular surgery calls at the academic tertiary care center. The first one I was working at a busy suburban ER. Lady comes in with a ruptured AAA, hypotensive. It’s 5:05 pm and the local vascular surgeon went off call at 5 pm and refused to come see her. I call the academic referral center (always hit or miss if you talk to resident, fellow or attending), talk to the chief surgery resident, a guy I happened to know, who says “send her up, we’ll be waiting”. I call the helicopter and then get a call back from the vascular surgery fellow who tells me to stabilize her before transfer. I asked him how he expected me to do that and he didn’t have an answer. I called my local general surgeon who was in the middle of another surgery and told me he hadn’t done a AAA since he was an intern. Meanwhile helicopter arrives. I tell the family she might die on the helo, would definitely die here without transfer, and might survive if she makes it to the transfer hospital. They told me to send her, so we loaded her up and I called the referral center back and said she’s on her way. I heard she made it to the OR But no news beyond that.

More recently, working in a rural ER with almost no specialist coverage I get a guy with BP 230 and horrible flank pain. CTA shoes an endoleak from his previous AAA repair. The vascular fellow at the same academic center asks me if there are any other findings to explain the guys pain. I asked him if I needed another reason and if he had, say, a kidney stone (he didn’t) would you not need to see him. He also got a helicopter ride.

 

[thegenius]

More recently, working in a rural ER with almost no specialist coverage I get a guy with BP 230 and horrible flank pain. CTA shoes an endoleak from his previous AAA repair. The vascular fellow at the same academic center asks me if there are any other findings to explain the guys pain. I asked him if I needed another reason and if he had, say, a kidney stone (he didn’t) would you not need to see him. He also got a helicopter ride.

Sometimes you can't make this stuff up.

Is there anything else that needs to be addressed before blood leaking out of a major artery?

 

[Neopolymath]

Sometimes you can't make this stuff up.

Is there anything else that needs to be addressed before blood leaking out of a major artery?

Did you get a good social history?

 

[NITRAS]

My guess is that this ED doc had been previously involved in a complaint regarding failure to call a patient's specialist after they requested it, and likely wanted to head this off. Instead they get a ridiculous recommendation that they now feel they need to abide by. Had they just discharged the patient, they might've gotten a nastygram from an unsupportive medical director.

That said, it's a bizarre story and anyone w/ half a brain would agree that it was grossly inappropriate. Unfortunately too many people turn off their entire brain when going to work.

Put yourself in the patient's shoes. She probably googled "high ferritin" and saw this:

View attachment 347392

It says "Leukemia" right there (!). What kind of monster would send her home without seeing a specialist????

Some of our fellows are told they will only give official recommendations by official consult, and they don’t come to the ED. Endocrinology is one, even for incredibly stupid ****. You ask them or recommendations to send them home, and they request admission for a consult.

Stupid waste of everyone’s time, but that is how it is in places with fellows who aren’t given the leeway to practice and/or lazy arses. I however wouldn’t have accepted a fellow refusing to see a patient.

 

[HemeOncHopeful19]

Some of our fellows are told they will only give official recommendations by official consult, and they don’t come to the ED. Endocrinology is one, even for incredibly stupid ****. You ask them or recommendations to send them home, and they request admission for a consult.

Stupid waste of everyone’s time, but that is how it is in places with fellows who aren’t given the leeway to practice and/or lazy arses. I however wouldn’t have accepted a fellow refusing to see a patient.

My personal policy is if you call me and say hey this patient can go home I just want to make sure y’all get them follow-up then I’ll gladly arrange it.

If I get called and you’re asking me to bless a discharge then I should see the patient so an attending can be involved. If it’s not urgent and it’s 1am I might triage that to the morning (which I realize can be a pain in the ass for the ER) but I would never just say no to a consult.

 

[Matthew9Thirtyfive]

Did you get a good social history?

Does he have sex with men, women, or both?

 

[Captain_Falcon]

Does he have sex with men, women, or both?

Has he ever done the marijuana "just once or twice" in college many blue moons ago?

 

[rokshana]

Some of our fellows are told they will only give official recommendations by official consult, and they don’t come to the ED. Endocrinology is one, even for incredibly stupid ****. You ask them or recommendations to send them home, and they request admission for a consult.

Stupid waste of everyone’s time, but that is how it is in places with fellows who aren’t given the leeway to practice and/or lazy arses. I however wouldn’t have accepted a fellow refusing to see a patient.

There are a grand total of 4-5 endocrine emergencies that would require me to say admit… and even then, the intensivist is the one that will make the call for the icu or the ED:hospitalist for less severe issues…it’s one of the reason people go into endocrinology…it’s overall an outpt specialty…and less and less endos do inpt consults.
I’ll certainly write a brief note stating what I told the ED … that’s as an attending…as a fellow, if I got called for a consult, I went to see the consult…period. As a fellow, was not allowed to refuse a consult, no matter how eye rolling they may have been. Generally, they are signed off after rounds with the attending.

 

[RustedFox]

Hmmm... What are the 4-5 endocrine emergencies?

1. DKA.
2. Acute adrenal crisis.
3. Thyroid storm.
4. Myxedema Coma.
5. ...

 

[Lexdiamondz]

Hmmm... What are the 4-5 endocrine emergencies?

1. DKA.
2. Acute adrenal crisis.
3. Thyroid storm.
4. Myxedema Coma.
5. ...

and of those 4, I don't think any actually require an endocrinologist to be at the bedside.


Now that I think of it, I've never seen an endo in an adult ED. Peds on the other hand...

 

[RustedFox]

and of those 4, I don't think any actually require an endocrinologist to be at the bedside.


Now that I think of it, I've never seen an endo in an adult ED. Peds on the other hand...

True: academic exercise in differential diagnosis only.

Anyone got another?

 

[BoardingDoc]

True: academic exercise in differential diagnosis only.

Anyone got another?

HHS, though that's basically a different flavor of DKA.

 

[rokshana]

Hmmm... What are the 4-5 endocrine emergencies?

1. DKA.
2. Acute adrenal crisis.
3. Thyroid storm.
4. Myxedema Coma.
5. ...

Hypercalcemic crisis

 

[rokshana]

and of those 4, I don't think any actually require an endocrinologist to be at the bedside.


Now that I think of it, I've never seen an endo in an adult ED. Peds on the other hand...

Like I said… it’s not me that is making the recs for admission for an endocrine emergency…practically any other endocrine issue can be seen as outpt.

And btw, I was in the ED today… concerns for adrenal insufficiency in a persistently hypotensive pt…mind you, started HD in October and had lost 30-40 lbs since starting HD…how much you want to bet it’s more an overestimated dry weight and not AI?

 

[Jabbed]

Hmmm... What are the 4-5 endocrine emergencies?

1. DKA.
2. Acute adrenal crisis.
3. Thyroid storm.
4. Myxedema Coma.
5. ...

Let's go for zebras:

5. Pituitary apoplexy
6. Sheehan's syndrome.

 

[WilcoWorld]

Sometimes you can't make this stuff up.

Is there anything else that needs to be addressed before blood leaking out of a major artery?

Did you check for a UTI?
-It's negative
What's the lipase?
-Normal
What's the amylase?!?

 

[WilcoWorld]

True: academic exercise in differential diagnosis only.

Anyone got another?

Hypophytis (arguably it's usually an ONC emergency since it's usually an ONC treatment complication).

 

[DrSnips]

True: academic exercise in differential diagnosis only.

Anyone got another?

HTN emergency is debatably one, though honestly cards, renal and endo could all point the finger at each other as the appropriate specialist.

 

[deleted1114045]

Patient on Coumadin who fell with a clear acute large white subdural. Neurosurgeon tells my partner to send her home, and to not reverse her, that it’s just an old subdural. My partner gets off the phone kind of mystified and I tell him, “Dude, don’t send that patient home. That is clearly acute.” Neurosurgeon has second thoughts and calls back 5 minutes later and decides to have her transferred over to his hospital. Of course, the head bleed gets worse. Really strange.

I had a female with a classic anginal chest pain story who was very healthy and in her 40s. Normal EKG, with an elevated troponin. Cardiology acted mystified that I had gotten a troponins on a patient with chest pain. Refuse to be primary and insisted that internal medicine be the accepting physician.

 

[BoardingDoc]

Patient on Coumadin who fell with a clear acute large white subdural. Neurosurgeon tells my partner to send her home, and to not reverse her, that it’s just an old subdural. My partner gets off the phone kind of mystified and I tell him, “Dude, don’t send that patient home. That is clearly acute.” Neurosurgeon has second thoughts and calls back 5 minutes later and decides to have her transferred over to his hospital. Of course, the head bleed gets worse. Really strange.

Was the neurosurgeon Chris Duntsch?

 

[DrSnips]

Patient on Coumadin who fell with a clear acute large white subdural. Neurosurgeon tells my partner to send her home, and to not reverse her, that it’s just an old subdural. My partner gets off the phone kind of mystified and I tell him, “Dude, don’t send that patient home. That is clearly acute.” Neurosurgeon has second thoughts and calls back 5 minutes later and decides to have her transferred over to his hospital. Of course, the head bleed gets worse. Really strange.

I had a female with a classic anginal chest pain story who was very healthy and in her 40s. Normal EKG, with an elevated troponin. Cardiology acted mystified that I had gotten a troponins on a patient with chest pain. Refuse to be primary and insisted that internal medicine be the accepting physician.

This reminds me of one:

70 yo M h/o CAD s/p CABG, DM, multiple stents within the grafts p/w abdominal pain. ED workup includes trop (which is 0.1) and CT is c/w pancreatitis. Patient is admitted to medicine. About 12 hours later he's c/o typical chest pain. I check a repeat trop and EKG. Trop is now 40.0. EKG without acute ST changes. I call the intervention cards fellow who says because the EKG doesn't show acute changes they aren't taking him to the cath lab. I then call the gen cards fellow because that plan sounds pretty bad. He tells me to start wheeling the guy to the cath lab and he'll meet us there. They ended up popping in yet another stent in the LAD.

 

[rokshana]

Let's go for zebras:

5. Pituitary apoplexy
6. Sheehan's syndrome.

Those are the same things…

 

[rokshana]

Hypophytis (arguably it's usually an ONC emergency since it's usually an ONC treatment complication).

But they usually say consult endocrine… they monitor with treatment and if changes, we see them… usually outpt though.

There are places that have oncological endocrinologist… there is actually a sub fellowship for that.

 

[WilcoWorld]

Those are the same things…

Technically Sheehan's is just one cause of apoplexy though, would you agree?

 

[Matthew9Thirtyfive]

Those are the same things…

Arent most cases of pituitary apoplexy caused by adenomas?