Unnecessary consults...

[Future DO]

---

Members don't see this ad.

I am really struggling with BS consults. I am a first year ophtho resident and cannot understand how to prevent bad calls. Not bashing all ER departments, but these are some of the things I have responded to:

1. Blurred vision - was actually 20/25
2. Eye pain with diplopia, possible mets. -was actually shingles with no hx of cancer.
3. Lid laceration per trauma team - was dried blood in the lid crease
4. Painful vision loss with hemianopia - pt had abrasion. She was also holding recurrent corneal erosion syndrome paperwork from her doctors office from prior issues. No VF defect.
5. Hand motion vision and bleeding from eye - 20/25 with subconj heme.

This is just a partial list. This happens nearly every shift. Don't get me wrong. We get legit consults often. I am trying to get all the correct history and triage appropriately, but often find myself feeling used and abused. Can anyone advise how to deal with these situations? I feel like if the word "eye" is mentioned in the ED, we wind up being consulted. It seems wasteful. Is this just the way medicine works? My co-residents make it seem easy to avoid going to the ED at 2 am without a true emergency, but I always find myself rushing in feeling only to feel duped. Do attending a fall for this when the ER calls? Do other residents ever feel this way?

 

[PBEA]

just my humble opinion but I've often felt ophtho's overestimate the skill and/or comfort level that their fellow non-ophtho MD's have with eye problems.

My feeling is that they are basically walking on the moon............

 

[deleted480308]

A blind plaintiff is an expensive plaintiff...you will get called in for anything that isn't ridiculously clear to a doctor with no experience in eyes

 

[Dusn]

It isn't just a problem for the ophtho residents. The ER residents may not realize it now but they will go out into the real world at community hospitals and not have ophtho (or a number of other specialties) readily available. Our ER program became more receptive to ophtho teaching them after they started getting calls from outside ERs about how their recent ER residency graduates were poorly trained in dealing with any of the surgical subspecialty issues (it's not just in ophtho...).

btw. you're doing the right thing by coming in to see the patient. I got called by the ER at 1AM for a corneal abrasion that turned out to be a full thickness corneal laceration. I was glad I came in at 1AM instead of having the patient follow up with me the next day.

As an aside, when you become an attending, many hospitals will act like it's your responsibility to take call for them for free. Insist on being paid what you're worth or don't take call for them (get privileges at different hospital if you need to). And then if you do sign up to take call make sure you do a good job evaluating the patients that you're called about (unlike many attendings who forget that they've signed up for call and don't even have their phones/pagers on...)

 

[DrZeke]

It isn't just a problem for the ophtho residents. The ER residents may not realize it now but they will go out into the real world at community hospitals and not have ophtho (or a number of other specialties) readily available. Our ER program became more receptive to ophtho teaching them after they started getting calls from outside ERs about how their recent ER residency graduates were poorly trained in dealing with any of the surgical subspecialty issues (it's not just in ophtho...).

btw. you're doing the right thing by coming in to see the patient. I got called by the ER at 1AM for a corneal abrasion that turned out to be a full thickness corneal laceration. I was glad I came in at 1AM instead of having the patient follow up with me the next day.

As an aside, when you become an attending, many hospitals will act like it's your responsibility to take call for them for free. Insist on being paid what you're worth or don't take call for them (get privileges at different hospital if you need to). And then if you do sign up to take call make sure you do a good job evaluating the patients that you're called about (unlike many attendings who forget that they've signed up for call and don't even have their phones/pagers on...)

I am a 1st year resident so I see almost everything I get called about. Some people in the ED know how to do an exam and that's awesome. I still think it's appropriate to ask people if they are uncomfortable and if they want me to come in.

I do ask that the ER give me a vision and a pressure...I have been woken up at 3am where the patient where eyes were not even assessed or examined and I thought that was kind of crappy.

Question....

How does your ED remove corneal foreign bodies? Sometimes we get called about foreign bodies they could not flick out with an 18 gauge needle and no slit lamp... That makes me cringe. Anyone else have experience with this ?

 

[Future DO]

That is exactly how our ER residents do it!!! Very stressful.

 

[MstaKing10]

I learned a lot on call, having to see patients on my own and managing them solo in the ER was a great experience. When I reflect on those consults now, as tired and frustrated as I was, it was a great opportunity to learn. In the academic setting you will get consulted a lot but in the private practice world it is rare to get called. Most patients will be seen in the office the following day.

While some consults are totally bogus, there are many that are worthwhile. You need to understands the limitations of you ER colleagues in terms of examining, assessing and treating these patients and both learn and teach. Take the opportunity to discuss the case with the consulting physician and write a thorough note that will be useful for them to learn from as well.

In the private sector, it is scary to see how some ER docs manage eye disease. A few weeks ago I saw a patient with and intraocular foreign body who had been prescribed topical steroids the day before by the ER then told to follow up with me the next day! No further assessment had been done. Scary.

Another thing: don't be the guy/gal that chews out ER residents constantly or refuses to see consults. Worse yet, don't be the one that doesn't see a consult because it sounds like BS and it turns out to be a true emergency. If your attendings catch wind of this...you are hosed! It happened to one of our 1st year residents when I was a 3rd year. Wasn't pretty!

Last point: seeing a lot of patients on call will teach you what is a true emergency and what is not. You can learn this in books but nothing beats experience. This is imperative, as those in private practice know. You will receive many calls when on call and knowing which patients need to be seen and which can wait for the following day and which don't even need to be seen is an important skill. The ER experience helps you to formulate that algorithm.

Still, sometimes it just plain sucks!! We've all been there.

 

[Slide]

To the OP, just keep in mind that overall, this is temporary. As a senior resident, I still get called down on consults to see ridiculous ER consults. If the official consult is in, however, I'll see it even if it's inappropriate. The one time you refuse a consult that sounds inappropriate always seems to be the time when it's something vision threatening. On the bright side, a silly consult will usually be quick and simple.

That said, I do feel ER staff do need to learn the basics of managing and working up eye issues. Like other posters have said, when these ER residents or attendings get out into the real world, they won't have a consultant on hand 24/7 to bail them out of any eye issue (or anything that requires a surgical subspecialist). We don't ask them to be on par as an ophthalmology resident, but being able to do something as basic as take vision, pressure, or even open an eye with swollen lids should be something any staff member in an ER should be able to do. We had a patient come into our ER with an open globe that had been there for 3 days from an ATV accident! The ER physician that saw him at his local hospital didn't bother opening his eye because it was too swollen shut, and just told him the swelling would go down and he'd be fine. You can infer from there how he turned up ultimately...

Also, just blindly (no pun intended) consulting someone to take care of someone with an eye issue doesn't really help their argument that MDs should be the ones running ERs.

 

[LightBox]

I am really struggling with BS consults. I am a first year ophtho resident and cannot understand how to prevent bad calls. Not bashing all ER departments, but these are some of the things I have responded to:

1. Blurred vision - was actually 20/25
2. Eye pain with diplopia, possible mets. -was actually shingles with no hx of cancer.
3. Lid laceration per trauma team - was dried blood in the lid crease
4. Painful vision loss with hemianopia - pt had abrasion. She was also holding recurrent corneal erosion syndrome paperwork from her doctors office from prior issues. No VF defect.
5. Hand motion vision and bleeding from eye - 20/25 with subconj heme.

This is just a partial list. This happens nearly every shift. Don't get me wrong. We get legit consults often. I am trying to get all the correct history and triage appropriately, but often find myself feeling used and abused. Can anyone advise how to deal with these situations? I feel like if the word "eye" is mentioned in the ED, we wind up being consulted. It seems wasteful. Is this just the way medicine works? My co-residents make it seem easy to avoid going to the ED at 2 am without a true emergency, but I always find myself rushing in feeling only to feel duped. Do attending a fall for this when the ER calls? Do other residents ever feel this way?

You are a first year Ophtho resident -- just get through with it. We all had to go through a similar experience. Like the above poster said, this experience will help you later down the road when you are trying to triage "emergencies" who call your office to be seen.

 

[eye love lamp]

I am really struggling with BS consults. I am a first year ophtho resident and cannot understand how to prevent bad calls. Not bashing all ER departments, but these are some of the things I have responded to:

1. Blurred vision - was actually 20/25
2. Eye pain with diplopia, possible mets. -was actually shingles with no hx of cancer.
3. Lid laceration per trauma team - was dried blood in the lid crease
4. Painful vision loss with hemianopia - pt had abrasion. She was also holding recurrent corneal erosion syndrome paperwork from her doctors office from prior issues. No VF defect.
5. Hand motion vision and bleeding from eye - 20/25 with subconj heme.

This is just a partial list. This happens nearly every shift. Don't get me wrong. We get legit consults often. I am trying to get all the correct history and triage appropriately, but often find myself feeling used and abused. Can anyone advise how to deal with these situations? I feel like if the word "eye" is mentioned in the ED, we wind up being consulted. It seems wasteful. Is this just the way medicine works? My co-residents make it seem easy to avoid going to the ED at 2 am without a true emergency, but I always find myself rushing in feeling only to feel duped. Do attending a fall for this when the ER calls? Do other residents ever feel this way?

I'm ok with any consults that consist of the primary team asking for your help because they're unsure/uneasy with the patient. What seems trivial to you (eg subconj heme) can really worry other docs because they have zero experience in eyes (remember how much ophtho you had in med school outside of your fourth year electives?) What you can do in the above situations is ask the ER doc to repeat the vision in the "hand motion" patient - and then teach them a few pearls about the exam, slit lamp exam, or just general knowledge. They usually appreciate this and should make them better for next time. Don't just write the consult note and leave.

The consults that infuriate me are "The patient has an eye complaint and I haven't had a chance to go ask them what's wrong - do you mind just coming in and taking care of this for me?" and "I haven't evaluated the patient yet, but they might have a facial burn so we're going to need ophtho clearance of the eye" - that person didn't have any involvement of their head/face. These are just pure laziness and are the ones you should be fighting.