Punked on call?

[SABRMan]

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Perhaps it would be entertaining to share some of the more unusual consult requests people have received. Today, I was called by surgery to see if I could help seal an anastomotic leak after a whipple. Apparently the pancreaticojejunal anastamosis has been leaking and they are desparately looking for a fix. "We heard that maybe a low dose of radiation might promote healing". Maybe this is sort-of a hormesis effect that has been seen in the lab...or not. I politely declined to intervene, however, I am naturally nervous that I missed the seminal paper on the paradoxical benefit of rt in just this scenario and I put my pride on the line if I need to be educated here. Anyone else have any fun consult stories?

 

[medgator]

Not too many other than prank beeping the resident on call at 5 PM on friday with the help of the neurosurg resident telling him about an inoperable symptomatic cord compression 🙂

After all, they do happen more often on fridays (or I should clarify, they are more often referred on fridays)

http://www.ncbi.nlm.nih.gov/pubmed/11321668

 

[RadOncDoc21]

Not too many other than prank beeping the resident on call at 5 PM on friday with the help of the neurosurg resident telling him about an inoperable symptomatic cord compression 🙂

After all, they do happen more often on fridays (or I should clarify, they are more often referred on fridays)

http://www.ncbi.nlm.nih.gov/pubmed/11321668

So true! Practically all of my spinal cord compression consults were done either on a Friday or Monday... I just thought that was really unusual, glad to see there is published data.

Thus far I have one call week under my belt with another one coming up next week. Other than calling in prescriptions, offering to see the patient during available clinical hours or referring them to the ER for emergencies. What else should one expect while on call?

Thanks.

-R

 

[Cancerdancer]

Today, I was called by surgery to see if I could help seal an anastomotic leak after a whipple. Apparently the pancreaticojejunal anastamosis has been leaking and they are desparately looking for a fix. "We heard that maybe a low dose of radiation might promote healing"

Often stated around my institution that rates of anastomotic leaks are lower in patients receiving postop RT, presumably due to fibrosis 'scarring in' the surgical bed...must admit haven't read thru the GITSG, EORTC, & ESPAC randomized trials to verify, but I bet if you do you'll find the data you're looking for. That said, hardly a justification for postop XRT...

 

[SABRMan]

Often stated around my institution that rates of anastomotic leaks are lower in patients receiving postop RT, presumably due to fibrosis 'scarring in' the surgical bed...QUOTE]

Thanks for the input. Interesting possibility. It makes sense that the more mechanical aspects of the anastanosis (clips or sutures) would get more bite into somewhat fibrotic tissues. I had not thought of that angle. If that mechanical connection is truly clinically beneficial in decreasing anastomotic leaks, then fibrosis could be seen as one potential benefit to preop xrt. Too late now.

 

[Cancerdancer]

Yeah, sorry wasn't really thinking there...obviously pertinent to preop RT for borderline resectable cases, not postop XRT. Brain flatulence.

 

[SABRMan]

What else should one expect while on call?

Thanks.

-R

You'll get a lot of common things like brain mets and potential/actual spinal cord compression. Less common but also areas where we can potentially help are things like bleeding tumors and tumor-related SVC and airway obstruction. I think there are some ASTRO lectures on rad onc emergencies that might make a good primer as you start your call duties--programs usually include something along those lines for the new residents (ask for it if your program doesn't have anything scheduled). Part of the fun and challenge of being a radiation oncologist is that our field is poorly understood by many of the players who consult us. Sometimes their requests are wildly off the mark (like my original post) and the challenge is tactfully redirecting/informing them. During residency this can be particularly challenging when you are in delicate heirarchical relationships complicated by the ubiquitous fragile academic ego. I once got a call from the ER, placed by a fellow, where the ER attending grabbed the phone and said: "we need some stat radiation...I'll put the fellow back on". That request/order was one of those moments when I sort-of wondered if I was being punked, so to speak. Anyway, if anyone else has any call anecdotes of xrt being misunderstood...and how you navigated it, I would enjoy hearing.

 

[Palex80]

First case:
I was called and asked if I could irradiate a patient with an infected hip prothesis. He was too ill to undergo major surgery to replace the prothesis and lots of different antibiotics had failed to control the infection.
The idea was to use radiation therapy, just like radiation is used to sterilize medical equipment & supplies.
I had to spend several minutes trying to make the fellow surgeon understand, that the dose needed to "sterilize" the prothesis would be of a whole different magnitude, than what the surrounding normal tissue (=the patient) would tolerate.



Second case:
A medical oncologist kept asking me, why we could't irradiate his patient, which had a developing spinal cord compression, after suffering a pathological fracture in the mid spine.
"This is a classic indication for radiation therapy" was his favorite quote.
He didn't find my argument amusing, that we would need 50.000 Gy to melt down the bone fragment (and not tumor) that had detached itself from the spine and was compressing the spinal cord, a dose that I would not like to give to the patient (not only because the LINAC might overheat).

 

[deleted4401]

Always get asked to radiate compression fractures. I don't think it should work. I mean, it's a broken bone. But, I think there must be some placebo effect or something else going on, b/c it does seem to work.
S

 

[Gfunk6]

This is not quite what the OP had in mind, but I believe is in the spirit of this thread. For the last few years we have had a tradition of the senior residents sending out a "joke" or "punk'd" email to all the residents, siting back, and reveling in the hilarity that followed. I've pasted a few of these below with names redacted.

Guys,
[Program Director] just paged me (and [another resident]). I guess some stuff is coming down from ACGME, affecting our schedules for the rest of the year. Probably losing all electives. She has been trying to fight it, but for now, she asked that you page (XXX-XXX) or call [other resident cited above] ASAP to discuss your schedule/electives. Please don't plan to have elective time off. Please do not email around or mention to non-residents, attendings, or admin people yet. She said can not address further right now as she is at a meeting, we'll have a meeting as soon as she's back.

Needless to say, the poor [another resident] was relentlessly slammed with pages, emails, and phone calls trying to figure out what the hell was going on. I was totally suckered in as well and actually asked our PD what the deal was. The "WTF are you talking about" look she gave me was classic . . .

Hey guys I just came back to [the resident room] and found this sitting in my Inbox . . . WTF?

[PD] is out of town, does anybody know anything about this?

[Prankster Resident]

-----Original Message-----
From: [Dean of GME]
Sent: Thursday, April 1, 2010 11:56 AM
To: [PD]; [Chair]
Cc: [Program Coordinator]; [Prankster Resident]
Subject: Academic misrepresentation

[Chair] and [PD],

As you all know, the GME has recently mandated a review of all current residents including checking the veracity of CVs. A couple of years ago, we had a serious incident with a resident who actually forged her medical school credentials and was only found out fortuitously during her application for [State] medical licensure.

We have therefore, starting this year, begun to enforce a zero tolerance policy for academic misrepresentation. I'm sorry to say that two of your current residents have fraudulently reported publications/work history on their CVs. We at the GME are taking this very seriously and would like to meet with all of the residents on Monday, April 5th at your [department] conference room.

If you could also distribute the attached publication to your residents, I believe it will help with this difficult discussion.

Best,

[Dean of GME]

Attached to this email was a genuine publication from SUNY-Buffalo (aka. Roswell Park) stating how Rad Onc applicants sometimes misrepresent their publications on the ERAS CV. The freakout that commenced was quite epic . . .

Hey guys, somebody blind cc'd me on this email chain. WTF?!


________________________________________
From: [Chair]
Sent: April 1, 2011 06:28 AM
To: [Dean of GME]; [PD]; [PC]
Subject: RE: FW: Meeting and Survey Results

Yes

I completely agree

[Chair]

________________________________________
From: [Dean of GME]
Sent: April 1, 2011 06:28 AM
To: [PD]; [Chair]; [PC]
Subject: RE: FW: Meeting and Survey Results


In the short term, I think that resident electives should be temporarily suspended. This has worked in the past for other residency programs as a transient measure while they analyze the problem and implement corrective changes.

Best,

[Dean of GME]

________________________________________
From: [PD]
Sent: Tuesday, March 31, 2011 12:28 PM
To: [Dean of GME]; [Chair]; [PC]
Subject: FW: Meeting and Survey Results

I am genuinely concerned about the results of this survey and I think it warrants quick corrective action on our part. I will, of course, meet with the residents, but I wanted your take on it as well.

Thanks, [PD]

Sadly, the reaction to this last prank was less than inspiring. Probably because it was so similar to the first two!

 

[Seldon1985]

Haha, nice stories.

But for some reason, every time I see the name of this thread, I feel like it says, "Puked on call?" Didn't realize rad onc call was that rough 👍

 

[Palex80]

Haha, nice stories.

But for some reason, every time I see the name of this thread, I feel like it says, "Puked on call?" Didn't realize rad onc call was that rough 👍

Too much alchohol...