Post your most ridiculous ER consults here!

[fiatslug]

My favorite: an "urgent" consult... at 8:30 on Saturday morning, with 15 cross cover notes to write on the unit... for INSOMNIA.

Then there was "homeless woman without shoes" at 3:30 am. Here's an idea: call a cobbler.

And are you with me, people: anyone who comes in after 2 am with "suicidality" is in fact (a) suffering from an acute housing crisis and (b) has already received some kind of opiate in the ED until proven otherwise?

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[MBK2003]

My favorite (oh there are SO MANY) of the last month was "Behavior problem" in schizophrenic on Haldol Dec (brought in note from outpt program with date of administration 1 week before), clean urine, with acute alcoholic pancreatitis who was howling in pain, curled up in fetal position sitting forward, and according to the admitting medicine intern "literally begging for pain meds" and the ER doctor thought should be seen by the psychiatrist for psychiatric clearance prior to giving pain meds. When I asked what the behavior problem specifically was, the ER doctor said, "he was rolling around in the stretcher, crying at times." No kidding, I would be too with a lipase of 10,000. Made my heart break standing there briefly interviewing a guy who was obviously in intense pain, saying "are you hearing any voices, are you thinking of hurting yourself or anyone else, do you want to kill yourself in the hospital?'

MBK2003

 

[Big Lebowski]

So many....it's hard to know where to start. I guess the most "ridiculous" consult that was a bit frightening:

Call from ER: "We have a patient here who is suicidal, can you see him?"

Of course, I did not ask much else and came to see him. Patient appears heavily sedated. Per ambulance transfer note, patient reportedly took an overdose of Darvocet. I ask the ER attending about this.

ER attending: "yeah, he said he overdosed, but I think he's lying".

Me: "why do you think he is lying"

ER attending: "we did a urine tox screen and it was negative"

Me: "did you check an acetaminophen level?"

ER attending: "no"

Me: "why not, he said he overdosed on Darvocet"

ER attending: "there's no acetaminophen in Darvocet"

Me: "I'm pretty sure there is" - in the most non-confrontational tone.

ER attending stands there looking at me quizzically

I ask the ER nurse to draw an acetaminophen level and to call me back afterwards.

Needless to say, the level was through the roof; patient admitted to ICU and started on n-acetylcysteine.

Incredible...."I think he's lying"!!!!

 

[OldPsychDoc]

Admitted to me this week for "anxiety"---

90 y/o male, 2 mo s/p stroke, dehydrated, MMSE of ~10.

🙄

 

[outofhere]

I was once asked to do a competency eval on a person (in process of getting conserved) in long term care. The patient was sedated and intubated. A few weeks later, I was asked to do the same eval on another patient, by the same attending, that patient was completely aphasic...

 

[fiatslug]

Big, I had a couple of similar "um... did you actually look at this pt?" moments with ED docs...

Ready to admit a pt for EtOH detox, I started my physical in the ED, rather than wait until he got onto the unit. Went to the ED doc and said, "Um... I think he's irregularly irregular." He kind of stares at me blankly for a second, then the nurse confirms he is, indeed, irregularly irregular. The guy ends up in CCU with Afib and delirium (b/c his detox was poorly managed--no CIWA on the medicine side of the house!) for 10 days.

Another pt came to our unit with SI, about 1 week s/p shoulder surgery. In spite of a white count (17), a fever, and a sick looking wound, the ED doc cleared him medically (though the admitting resident repeatedly asked him if he was sure he was stable). I see him on call the next night on the unit, fever, frank pus and now the wound is opening up--we called his orthopod, who admitted him to the OR of another hospital.

 

[Anasazi23]

There are so many I can't begin to recount them all...


"Doc, the patient in room XXX is acting up....he has somatic delusions. He keeps complaining stomach pain, but he ate all his dinner."

I talk to the patient a sec, as he projective vomits on the floor and wall (thankfully not on me). I touch his belly on the bed, and he goes through the roof.

I get a stat KUB.

Me: "Um, the somatic delusion needs to be transferred to the surgical service for SBO stat."

 

[Anasazi23]

*Beep! Beep! Beep!*

Me: Yes, this is Dr. Anasazi from psychiatry...I was paged.

ER nurse: Yes, doctor, the patient in bed 8 wants to know how to stop smoking. Can you come do a consult?

Me: No. *Click*

 

[MBK2003]

*Beep! Beep! Beep!*

Me: Yes, this is Dr. Anasazi from psychiatry...I was paged.

ER nurse: Yes, doctor, the patient in bed 8 wants to know how to stop smoking. Can you come do a consult?

Me: No. *Click*

Let me guess, that call came in at 11:30pm on a Saturday night when you had nothing else to do, right?

MBK2003

 

[Anasazi23]

Let me guess, that call came in at 11:30pm on a Saturday night when you had nothing else to do, right?

MBK2003

Don't they all?

There's some rule about that in the bible...house of God.

 

[Apollyon]

Thanks for yet another specialty MFing EM docs.

I can tell you that a lot of these screwups came from people that were not EM-trained - although it sounds VERY suspect that one doc would tell the psychiatrist that the patient was having "somatic complaints" (in those words) without working it up better.

And, as for the doc who didn't know that Darvocet had APAP in it (and the heroic pshyciatrist "cracked the case"), I don't have "countless" stories, but just one: our psychiatry program is supposedly one of the strongest in the country (I don't know, and I don't care to look it up), but, for medical clearance, although the psychiatrists are MDs (no DOs here, although they are welcome), the EM residents do the medical clearance before patients are cleared for disposition. Why? Because a psych resident medically cleared a patient for inpatient psych treatment at an off-site service that decompensated (just slightly, mind you) at the other hospital - the patient was returned to ours, and part of the re-evaluation was a gait evaluation (which was not done), and, that being off, pt got a CT-brain - showing a subdural (acute) bleed. The patient's psych problems were the result of an organic process.

Someone on SDN said that (I'm paraphrasing) "doctors that insult other doctors are dinguses".

Funny stories are one thing - but, as far as criticizing other doctors go, if anyone lives in a glass house, it's psychiatry.

 

[Anasazi23]

Needless to say, the level was through the roof; patient admitted to ICU and started on n-acetylcysteine.

Incredible...."I think he's lying"!!!!

Long time, no see, Lebowski....

I've had similar things happen in the ER and on the medical floors. Simple and somewhat basic medical info glossed over.

It seems like our ER sometimes looks for almost any excuse to 'turf to psych.' It gets pretty aggravating at times. Though I certainly understand they can get overwhelmed.

 

[Anasazi23]

Thanks for yet another specialty MFing EM docs.

I can tell you that a lot of these screwups came from people that were not EM-trained - although it sounds VERY suspect that one doc would tell the psychiatrist that the patient was having "somatic complaints" (in those words) without working it up better.

And, as for the doc who didn't know that Darvocet had APAP in it (and the heroic pshyciatrist "cracked the case"), I don't have "countless" stories, but just one: our psychiatry program is supposedly one of the strongest in the country (I don't know, and I don't care to look it up), but, for medical clearance, although the psychiatrists are MDs (no DOs here, although they are welcome), the EM residents do the medical clearance before patients are cleared for disposition. Why? Because a psych resident medically cleared a patient for inpatient psych treatment at an off-site service that decompensated (just slightly, mind you) at the other hospital - the patient was returned to ours, and part of the re-evaluation was a gait evaluation (which was not done), and, that being off, pt got a CT-brain - showing a subdural (acute) bleed. The patient's psych problems were the result of an organic process.

Someone on SDN said that (I'm paraphrasing) "doctors that insult other doctors are dinguses".

Funny stories are one thing - but, as far as criticizing other doctors go, if anyone lives in a glass house, it's psychiatry.

I can see where you'd be insulted at our perceived comments directed at EM docs. And you're definately right that nobody should criticise other specialties. At least in my case, the venting is more the frustration of other specialties not knowing how or what we do, or routinely minimizing psychiatric patients in general, or discounting our medical knowledge, etc....more than bashing another specialty.

Just as you folks get frustrated at the homeless drunk dumps in the ER, we get just as frustrated at the likely psych consult that results from that dump onto you. In actuality, I think most psychiatrists work very well with their ERs that are not psych-ER based. I do also in general. Also, a few of these stories I think come from the medical floors...not the ER even. At least, a large portion of my silly consults come from the floors.

I think it's just venting of the frustrations mentioned. In some ways, I feel that the psych docs here and the ER folks are sort of in the same boat...that there are often amorphous, chronically crazy patients who have problems, often not medical or even psychiatric per se, and we're both responsible for them.

It's good to see you have an appreciation of psychiatry, based on your signature.
👍

 

[Apollyon]

It's good to see you have an appreciation of psychiatry, based on your signature.
👍

I completely and totally believe this. Two anecdotes: 1. there is a guy I was a firefighter with; I cannot ****ing stand his wife - at all, AT ALL - and he and she are "peas in a pod" - and, if they can find each other, there's hope for me and 2. my best friend - his wife is his complement, whereas I am his congruent. Once again, I know that there is hope for me somewhere.

 

[Anasazi23]

I completely and totally believe this. Two anecdotes: 1. there is a guy I was a firefighter with; I cannot ****ing stand his wife - at all, AT ALL - and he and she are "peas in a pod" - and, if they can find each other, there's hope for me and 2. my best friend - his wife is his complement, whereas I am his congruent. Once again, I know that there is hope for me somewhere.

There is someone out there for each of us to revel in our shared psychosis.
😍

 

[Triathlon]

I personally didn't really see any EM doc bashing (in general). Specific cases yes, which we all could do, about every specialty, even our own, if not more so in our own. These are funny stories and I assume they all really happened. If we were to get a fair amount of consults from say, the surgical floor, I bet you would see even more missed obviousness there. And I agree with you and the psych docs clearing a pt. medically for admit. That is probably not always a good scenario, unfortunately we are not all going to be as medically savvy as EM or IM specialties. Such is life. So as an observer and enjoyer of these posts I say keep em coming and if you have crazy psych doc stories tell them also its good to learn from the mistakes of others.

 

[Anasazi23]

I find that in my hospital, when a case is a 'mess' or a social trainwreck, or if the case if very refractory and there are complications, psych invariably gets involved somehow.

You know the cases...the ones where for whatever existential reason, nobody seems to have a good grip on - for no good reason. The interns don't fully know all the diseases and pathology of the patient, the notes are amorphous, the residents are only slightly less confused, and the medical attending is frustrated and cranky.

Our psychiatry department (c/l) has a way of doing a consult in a way that summarizes the problems, the treatments rendered thus far, documents a relevant lab history, and gets some more info out of the patient and sometimes families, to sort of "bring together" the case. It's usually some sort of 'non-question' for which the consult is called. I guess they figure the more hands in the pot, the better.

 

[MBK2003]

I know that in our ER, when I get a "bad" ER consult it will invariably come from one of 2 attendings, who also call for "bad" consults from Ob-Gyn, Surgery, Ortho, etc. It's not specific to EM attendings in general, and in fact, EM residents are great to work with on consults, they actually ask for your recommendations on management and there's a real give and take of information both ways. I have had excellent experiences with 90-95% of the EM faculty in our ER, and 2 bad apples really stand out in my experience. Unfortunately, two to three turf fights during each of their 10 hour shifts makes for an awful week on nightfloat.

MBK2003

 

[fiatslug]

I concur--my ED colleagues are my favorites. There are a couple of people who notoriously call unnecessary consults, but that happens in all disciplines.

Psych often gets called in hopes of a "dispo dump" for difficult patients, many of whom are having acute housing (rather than psychiatric) crises.

 

[signomi]

I witnessed an awesome one a few years ago. I was doing my night float month as an internal medicine resident and the ER attending (known to every dept as being clueless - every dept has one) called psych down for a "psychosis" admission. I overheard the exchange and it was brilliant.
ER: "He is psychotic. He ate a spoon."
Psych: "He ate a spoon?"
ER: "Oh and a toothbrush. Psychotic."
Psych: "...."
ER: "I booked him a room with you."
Psych: "And where's the spoon and the toothbrush?"
ER (looks at psych like he is "touched"): "He...ATE...them."
Me: "So I'm thinking this is my admission with a GI consult for EGD, no?"
Psych: 😍