Post your bizarre consultant interactions

[bingbongbink]

Hypercalcemic crisis

At some sites i’ve seen them call the nephrologist for hypercalcemic issues, not endo, since it falls under ‘electrolyte’ abnormality

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[rokshana]

At some sites i’ve seen them call the nephrologist for hypercalcemic issues, not endo, since it falls under ‘electrolyte’ abnormality

It varies… nephro and endo get called for hypo/hyper natremia , hypo/hypercalcemia…sometimes one or the other… annoying when it’s both of us…

Occasionally get called for hypo/hypokalemia, but usually if they are suspecting adrenal insufficiency or hyper aldo…

 

[rokshana]

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

Technically true… sheehan’s is the eponym for pituitary apoplexy seen peri/post partum whereas you can have apoplexy from tumor hemorrhage/necrosis… end result is the same, mechanism is a little different…both can be an emergency…mostly due to the potential for adrenal crisis or severe hypothyroidism…other pituitary issues not usually emergent. So would be emergency #2 and/or 4.

 

[Rendar5]

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.

Am I out of date because I thought there wasn’t any benefit for emergent vs delayed cath in an NSTEMI? Though with a typical story I usually get repeat ekgs to check for dynamic changes.

 

[RustedFox]

Technically true… sheehan’s is the eponym for pituitary apoplexy seen peri/post partum whereas you can have apoplexy from tumor hemorrhage/necrosis… end result is the same, mechanism is a little different…both can be an emergency…mostly due to the potential for adrenal crisis or severe hypothyroidism…other pituitary issues not usually emergent. So would be emergency #2 and/or 4.

I still remember learning this as a question on USMLEWorld. Had never heard of it prior to that.

USMLEWorld was THE bomb.

 

[thegenius]

Am I out of date because I thought there wasn’t any benefit for emergent vs delayed cath in an NSTEMI? Though with a typical story I usually get repeat ekgs to check for dynamic changes.

That’s my understanding as well. But one would think a trop of 0.1 -> 40 in 12 hours would merit intervention now, not tomorrow

 

[lucid_leprechaun]

That’s my understanding as well. But one would think a trop of 0.1 -> 40 in 12 hours would merit intervention now, not tomorrow

Yeah if he’s having pain refractory to vasodilator therapy that’s an indication for emergent cath. Especially with a troponin suggesting a large infarct.

 

[thegenius]

Yeah if he’s having pain refractory to vasodilator therapy that’s an indication for emergent cath. Especially with a troponin suggesting a large infarct.

Yup.
Occasionally you get these weirdo patients who certify they are having NO SYMPTOMS AT ALL...and their troponin goes from 0.1 to 40. How on earth does that happen. no symptoms at all. Like 1/4 of their heart is dying, how can that not lead to a single symptom?

 

[NITRAS]

Yup.
Occasionally you get these weirdo patients who certify they are having NO SYMPTOMS AT ALL...and their troponin goes from 0.1 to 40. How on earth does that happen. no symptoms at all. Like 1/4 of their heart is dying, how can that not lead to a single symptom?

Our cardiac icu docs wouldn’t cath them urgently. No STEMI, no refractory pain. Angiogram on Monday. And please only use unfractionated heparin. No LMH.

 

[WilcoWorld]

Yup.
Occasionally you get these weirdo patients who certify they are having NO SYMPTOMS AT ALL...and their troponin goes from 0.1 to 40. How on earth does that happen. no symptoms at all. Like 1/4 of their heart is dying, how can that not lead to a single symptom?

Autonomic neuropathy from the diabetes that led to the CAD?

 

[DrSnips]

Am I out of date because I thought there wasn’t any benefit for emergent vs delayed cath in an NSTEMI? Though with a typical story I usually get repeat ekgs to check for dynamic changes.

He was having ongoing chest pain with his ACS though. At bare minimum that needs CCU medical mgmt, not sit and do nothing as the first cards fellow recommended. As for whether or not to cath him, that's above my pay grade.

 

[rokshana]

Autonomic neuropathy from the diabetes that led to the CAD?

Lol…that was my thought too!

 

[nimbus]

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.

To be fair, if that heme fellow wanted to see patients at night, they would have done EM. There’s no actual need for an urgent consult or an inpatient consult, more an issue of poor communication between the patient and her private doctor. Even going to the ER is questionable. She should just have called the next day.

 

[DrSnips]

To be fair, if that heme fellow wanted to see patients at night, they would have done EM. There’s no actual need for an urgent consult or an inpatient consult, more an issue of poor communication between the patient and her private doctor. Even going to the ER is questionable. She should just have called the next day.

Yeah, that would have been ideal. I think as others pointed out we have a bunch of factors that lead to this scenario -- auto-released lab results to the patient portal, then the patient uses Dr. Google, thinks they have leukemia and off to the ED they go. Just kind of an unfortunate side effect of the information age.

 

[nimbus]

Yeah, that would have been ideal. I think as others pointed out we have a bunch of factors that lead to this scenario -- auto-released lab results to the patient portal, then the patient uses Dr. Google, thinks they have leukemia and off to the ED they go. Just kind of an unfortunate side effect of the information age.

Even dr Google would tell her it’s not an urgent matter. The patient sounds whack.

 

[WilcoWorld]

Even dr Google would tell her it’s not an urgent matter. The patient sounds whack.

I don't think you've met my patient population...😉

 

[thegenius]

Autonomic neuropathy from the diabetes that led to the CAD?

That’s a common response. But only in the terrible diabetics could this be possibly true…but even then there are numerous problems with this theory:

diabetes doesn’t distinguish what kind of nerve to damage. Say nerve X and Y are close to each other in the body and are of similar caliber and cellular makup. It's not like diabetes decides to damage nerve X and avoid Y. It likes the real long nerves first. We have all met neuropathic patients who can’t feel their toes. But they can feel noxious stimuli in their mid foot, or their ankles and legs. They can feel it all the up to their nipples.

I find it odd that all of the somatosensory nerves around a heart are active and fire appropriately, but the sensory nerves innervating the heart close to (or literally) dead and the patient feels nothing. I bet if I could magically stab their heart with a knife, alst the while avoiding the skin, they would feel pain.

This is my opinion...I think there is something else going on to explain why people can have NSTEMIs or major heart attacks...and one person feels severe pain and the other doesn't. It can't all be diabetic neuropathy.

 

[nimbus]

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.

He didn’t suggest X-clamp or REBOA?😉

Sometimes patients just die if the ducks aren’t already lined up. Strange there’s no local vascular coverage after 5pm.

 

[thegenius]

Sometimes patients just die if the ducks aren’t already lined up. Strange there’s no local vascular coverage after 5pm.

Of course! But you know who doesn't believe this?

Lawyers.

If someone dies, it's someone else's fault.

Plain and simple. Every death in the world is caused by someone else's negligence.


EDIT: I'm willing to bet 33% of our health care premiums are due directly to the existence of lawyers. Another 33% are due to health care administrators. The last 33% actually goes to the doctors, nurses, and hospitals that exist to actually try to help people who are sick.

 

[RustedFox]

Of course! But you know who doesn't believe this?

Lawyers.

If someone dies, it's someone else's fault.

Plain and simple. Every death in the world is caused by someone else's negligence.


EDIT: I'm willing to bet 33% of our health care premiums are due directly to the existence of lawyers. Another 33% are due to health care administrators. The last 33% actually goes to the doctors, nurses, and hospitals that exist to actually try to help people who are sick.

Send lawyers, guns, and money.

 

[rokshana]

That’s a common response. But only in the terrible diabetics could this be possibly true…but even then there are numerous problems with this theory:

diabetes doesn’t distinguish what kind of nerve to damage. Say nerve X and Y are close to each other in the body and are of similar caliber and cellular makup. It's not like diabetes decides to damage nerve X and avoid Y. It likes the real long nerves first. We have all met neuropathic patients who can’t feel their toes. But they can feel noxious stimuli in their mid foot, or their ankles and legs. They can feel it all the up to their nipples.

I find it odd that all of the somatosensory nerves around a heart are active and fire appropriately, but the sensory nerves innervating the heart close to (or literally) dead and the patient feels nothing. I bet if I could magically stab their heart with a knife, alst the while avoiding the skin, they would feel pain.

This is my opinion...I think there is something else going on to explain why people can have NSTEMIs or major heart attacks...and one person feels severe pain and the other doesn't. It can't all be diabetic neuropathy.

Yet dead in bed and the silent MI are real things with pts with diabetes…my population is a bit skewed though…