Questionable Advice from Consultants

[WerdSalid]

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We all know that as ER docs our decisions and practices are often questioned and second-guessed through the lens of the retrospectoscope. This is not an attempt to bash consultants and specialists, but let's hear some examples of questionable advice we have received from the various services. As an example, a few nights back I had a 40 yr old previously healthy female who presented with 15 mins of substernal chest heavyness while cleaning a swimming pool. First ECG, troponin, labs all normal. The story was good enough that the previous doc signed her out to me pending a repeat 6 hr troponin. I was planning to admit her for serial enzymes and possibly a provocative test anyways when the 2nd troponin came back elevated. We don't have in-house cardiologists nor a cath lab in our rural small-community ED so I called the cardiologist for transfer. His response......"15 minutes of chest pain is not enough to infarct" as he sandbagged on the transfer. What???? Last time I checked one could infarct without pain at all. Needless to say she was eventually transferred. Let's hear some more.....

 

[txterp98]

I'm with you...this isn't to trash talk on the consultants...this was a learning point I had a few years back that I actually posted about here.

I made the diagnosis of a penile fracture. I talked to the on-call urologist and he said to have the patient come to the office in the morning. It was 3am at the time....he wanted to see him at 9am...I figured no problem. The guy wasn't in excessive pain and was able to void without difficulty.

The guy follows up at 9am but ends up seeing a different urologist in the group. This guy was pissed. His premise was that the patient should've been admitted for an urgent surgery...not follow-up in the office. He then had to admit him to the hospital from the office and perform surgery around noon.

Ultimately, I learned the 2nd urologist was correct. Apparently the longer time that elapses, the more clotting and fibrosis that ensues which potentially leads to long-term complications.

The 2nd urologist complained to my medical director. After my medical director reviewed my documentation that I was acting on the advice of his partner, he let it go. I'm pretty sure a major double standard ensued and he did not chastise his partner for faulty advice.

 

[Rendar5]

had a seizure patient who had a breakthrough seizure for no good reason (adequate meds, no signs of infection, nothing on history) and then a second in the ED. neuro said "get CT. if normal nothing to do". came back from the waiting room while awaiting a ride out with a 3rd and admitted for status.

Lesson, ultimately these are our patients and if we feel that something shouldn't be dismissed, then we can't; whether our consultants want to or not.

 

[WilcoWorld]

deleted

 

[EMDoc0411]

I was fresh off the boat of residency and had to deal with a surgeon whe literally felt he was God. Pt. was a 65 year old male who had fallen 8 ft. off of a ladder onto this side. He subsequently broke three ribs, minimal displacement. I wanted to admit the guy for pain control and pulmonary toilet. However, the surgeon said this was no criteria to admit. When I responded that at my Level I where I trained this guy woud have met our standard trauma/admit protocols. To that he responded that he went to U Penn. I could see I wasn't going to win this one, so I gave the guy pain meds and strong directions to come back if worse.
Guess who came back the next day with a ptx. The surgeon never discussed this issue with me, but I did get away a nice smile in his direction. Gotta love medicine.

 

[la gringa]

another doc in my group called GI for esophageal food impaction. on call, old school sort of GI doc refused to come in until the pt failed meat tenderizer and papain. war ensued b/c another guy had to be called in... it's often tough getting the right thing done for the pt.

 

[gman33]

I was in a surgery m&m conference this morning, where the surgeons where complaining about not getting called sooner about a potential AAA. In the back of my mind I was just laughing about all the extra work they would be bitching about if they got called in for every questionable situation. It's so easy to say what should have been done after you have a full diagnosis, etc, after the fact.

 

[n2b8me]

😉

 

[quinsy]

why didn't you say "hey, I hear the bill is pretty high when you violate EMTALA, too?"

 

[dr. maybe]

Anyone feel good about sending home a cerebral contusion (18yo male with normal MS) without a written note from a neurosurgeon? A chat over a cell phone just isn't reassuring.

 

[deleted65604]

I've been in the boat of tiny traumatic SAH before with current normal neuro exam. I called the trauma center to transfer and the general surgeon said,

"If he comes down here, we will repeat a head CT at 4 hours after the first and if no change, we will send him home. I'll take him if the patient wants to come down here and get a massive ER bill from us in addition to yours and the ambulance transport, or you can do the same thing there."

Patient opted for staying at my facility, had no change on repeat CT and I sent him home under the care of parents with REALLY GOOD discharge instructions and a tutorial on complete neuro exam for the parents.

 

[tkim]

I've had it go either way during residency. They usually get shipped to us from Outside Hospital for faint or ? (+) read on CT. Speaking of Outside Hospital:

[YOUTUBE]http://www.youtube.com/watch?v=xskFo75Wdhs[/YOUTUBE]

I consult nsx and admission to obs is +/- depending on LOC, LOC, and symptoms.

 

[Arcan57]

I've been in the boat of tiny traumatic SAH before with current normal neuro exam. I called the trauma center to transfer and the general surgeon said,

"If he comes down here, we will repeat a head CT at 4 hours after the first and if no change, we will send him home. I'll take him if the patient wants to come down here and get a massive ER bill from us in addition to yours and the ambulance transport, or you can do the same thing there."

Patient opted for staying at my facility, had no change on repeat CT and I sent him home under the care of parents with REALLY GOOD discharge instructions and a tutorial on complete neuro exam for the parents.

We sent home small traumatic SAHs with a 6 hr repeat head CT all the time in residency. It creeped me out initially, but in four years we didn't have any M&Ms related to return admits. I would document talking to neurosurgery before I did that, however.