Small Bowel Obstruction - how long until you see?

[Jolie South]

So my dad is in what I can only presume is a crappy community hospital with a “partial small bowel obstruction.” He has been in house over 24 hours. I call up today to find out about his status and if the surgeon has seen him and >24 hours after admission, still yet to set foot to see my dad.

So maybe I’m being an overly concerned daughter who knows too much, but like really, >24 hours to see a consult for a small bowel obstruction? I am not out in practice but even as a chief resident, I never trusted the ER and would always see those sooner rather than later to rule out badness. Because to me either it’s not concerning at all or needs an operation and ER docs frequently don’t know the difference or miss an important point in the H&P or on the scan.

What time frame do you feel comfortable sitting on a small bowel obstruction consult?

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[Winged Scapula]

Not sure if I'm at a crappy community hospital or not but all have staff rules about consults which state patients must be seen within 24 hrs.

I do raise the possibility that the surgeon was never actually notified. All of my partners and I have that happen from time to time.

But Im with you on both fronts: consults especially possibly operative ones need to be seen ASAP and I wouldn't trust the EP to make that decision. How long? Depends on lots of factors including whether I can " see" patient from home by reviewing imaging. Etc, would

 

[SpecializedSurgeon]

So my dad is in what I can only presume is a crappy community hospital with a “partial small bowel obstruction.” He has been in house over 24 hours. I call up today to find out about his status and if the surgeon has seen him and >24 hours after admission, still yet to set foot to see my dad.

So maybe I’m being an overly concerned daughter who knows too much, but like really, >24 hours to see a consult for a small bowel obstruction? I am not out in practice but even as a chief resident, I never trusted the ER and would always see those sooner rather than later to rule out badness. Because to me either it’s not concerning at all or needs an operation and ER docs frequently don’t know the difference or miss an important point in the H&P or on the scan.

What time frame do you feel comfortable sitting on a small bowel obstruction consult?

Even at a community hospital, a surgeon should be seeing this no later than the next morning after being called, assuming you trust the ED doc (or whoever) that called you.

 

[Jolie South]

Also, want to point out that I am in no way insulting all community hospitals. I mean I technically am doing my fellowship at one. I think there is a wide range of quality that depends on a million factors.

In an update on my dad, surgeon finally saw him. We think that he wasn’t notified of the consult. He doesn’t think my dad has an obstruction. It’s hard to parse that out over the phone when you can’t look at the objective data.

 

[SLUser11]

Also, want to point out that I am in no way insulting all community hospitals. I mean I technically am doing my fellowship at one. I think there is a wide range of quality that depends on a million factors.

In an update on my dad, surgeon finally saw him. We think that he wasn’t notified of the consult. He doesn’t think my dad has an obstruction. It’s hard to parse that out over the phone when you can’t look at the objective data.

Nothing worse than feeling helpless when your loved ones are sick, especially when you add in the ambiguity that comes from their partial understanding of the situation.

We have the burden of knowledge, so we can envision all the things that can go wrong. We are also hyper-aware of how incompetent outside hospitals can be, thanks to our countless late consults/transfers.

I've been on the giving and receiving end, on several occasions, of those awkward surgeon-to-surgeon phone calls about a loved one. Never easy for either side.

I'm glad your dad is doing ok. I think it's important to remember how you feel, as eventually you will be the annoyed practitioner dealing with an unreasonable medical family member who questions your competence/expertise. You are not this thing, so please don't misunderstand my comment, but it's a spectrum.

 

[kemper6036]

I know things are different in the community world but >24 hrs seems problematic for nearly any inpatient consult. I would echo the others that maybe the surgeon wasn’t notified - it still amazes me how often that happens to us.

As a more general medical discussion topic - I looked through some other threads on the topic of SBO which were and interesting glimpse through the way back machine. Some great posts like “why would you get a CT for an SBO?? It’s a clinical diagnosis!”

My approach to SBO (obviously a bit more algorithmic than applicable to your personal situation) is to try and figure out who is going to need an operation sooner rather than later.

Any high risk features on CT - closed loop, significant free fluid, mesenteric edema, etc - those patients need to prove to me that they DONT need an operation.

Other patients I really like the gastrografin challenge - give concentrated gastrografin and then take a series of X-rays at 1, 8, and 24 hrs. Contrast in the colon by 8 hours has like a 98% NPV and some studies would say if you see contrast in the colon by then you should just take out the NG and feed them.

diagnostic and therapeutic

 

[balaguru]

I take call at a few community hospitals. Anybody can apply for privileges and get on the call schedule so the call pool may run the gamut from excellent to dangerous surgeons. Sometimes the competent surgeons have to take over the care of patients from the less than good surgeons who might have been on call when the patient came in. All the hospitals that I work at have the 24 hr rule mentioned above but it appears to me at least that violations of the bylaws are rarely acted upon by hospitals in any meaningful way especially if those surgeons bring elective cases to the hospital.

 

[Apollyon]

I'm in a "crappy community hospital" without 24/7 surgical coverage. If the doc in the ED didn't personally speak with the on call surgeon, that is bogus. If the pt was not admitted by the surgeon, but the hospitalist, or the PMD, and that admitting doc took the patient without speaking to the surgeon themselves (and just left it to the unit clerk to make the call), well, that's a ballsy move, and, remember, there's a fine line between balls and stupidity.

 

[Jolie South]

I take call at a few community hospitals. Anybody can apply for privileges and get on the call schedule so the call pool may run the gamut from excellent to dangerous surgeons. Sometimes the competent surgeons have to take over the care of patients from the less than good surgeons who might have been on call when the patient came in. All the hospitals that I work at have the 24 hr rule mentioned above but it appears to me at least that violations of the bylaws are rarely acted upon by hospitals in any meaningful way especially if those surgeons bring elective cases to the hospital.

In looking back, this is what happened. Apparently, a surgeon literally pulled back the curtain, didn’t examine my dad or talk to him, made recs and left. Another surgeon was called and came and saw him late at night after OR cases were done.

 

[vhawk]

I've been burned so many times by ed docs or hospitalists or even junior senior residents saying "non op sho, I'll tuck him in and you can see him in the AM" that I basically never let it go without at LEAST looking at the labs and scans. If any worrisome signs I'm pushing on that belly within an hr or two.