Consults- Memorable/Dismal/Ridiculous/Unique

[Guile]

The moral of the story for me is that EMR and things such as phones for residents will play a large role in my evaluation of places for residency.

I'm not sure I saw one program that provided phones for its residents. Maybe a few places did and I just didn't know, but no one mentioned it. I wouldn't want one either. I don't want to be that easy to be reached. My pager works just fine, and we have phones literally everywhere.

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[SocialistMD]

We are switching to a cell-phone pager system. Some people get phone access. Others (residents) just get the ability to text message. It is how we will now receive pages; text messages. While I think it is kind of silly to deny phones to the people who would benefit most (residents), I also like that I am not 100% accessable and that I can still have a few minutes to reply (avoids the whole, "so, about your terminal cancer...<ring>...hang on a sec, this won't stop until I answer it. Sorry, be right back").

 

[45408]

I also like that I am not 100% accessable and that I can still have a few minutes to reply (avoids the whole, "so, about your terminal cancer...<ring>...hang on a sec, this won't stop until I answer it. Sorry, be right back").

Absolutely. People would call with more (and dumber) questions if they got an instant answer. Having to sit next to the phone for 1-5 minutes makes them think a little harder about how seriously they need to answer that question now, if at all.

Plus, if you're in the OR/clinic/middle of a consult, a ringing phone is really not necessary or appropriate.

 

[45408]

There was a boy who cried wolf, and there are way too many hospitalists that cry peritonitis. Two or three of them called us claiming their patients had peritonitis, come see them now, right away! Take them to the OR and off of my service!

None of them had peritonitis at all, and none of them had any acute surgical issue.

 

[SLUser11]

Absolutely. People would call with more (and dumber) questions if they got an instant answer. Having to sit next to the phone for 1-5 minutes makes them think a little harder about how seriously they need to answer that question now, if at all.

Plus, if you're in the OR/clinic/middle of a consult, a ringing phone is really not necessary or appropriate.

A major issue for me has always been cell phone reception. My pager always worked regardless of location, in a hospital dungeon or at home. My cell phone rarely worked in the hospital when I used Sprint. Attendings would text me or call, and I wouldn't see it for hours. The pager was always the most reliable way of contacting me, so I carried it 24/7, even when I was off.

Of course, now my new Houston pager has dead zones as well, and gets "no service" in several places, including some ORs and one of the doctor lounges. How scary is that?

 

[Buzz Me]

I'd rather carry a pager. You can return the page when you have a free moment...with a cell phone you have to answer right away. And no reception problems with a pager. Plus battery life is much better.

 

[dancinjenn]

So here in the "D" the second year interns get to be "Pit Boss." Essentially acting as first call for all ER consults and running the trauma codes. 24 hrs at a time Q3D. Needless to say I get some interesting stuff.

1) from the ED intern with a notorious ER attending...I have a pt with appendicitis. She has lower abdominal pain.
me: labs?
ER: I ordered them.
me: U/S? CT?
ER: I ordered them.
Final dx: 9 cm ovarian cyst compressing the bladder.

2) ER attending: consult for heel/knee/leg pain in a non-op hip fxr which was d/c to NH two weeks ago.
me: What's the exam like
ER attending: I didn't have time, I was with another pt.
Final dx: Pressure ulcer of the heel requiring better pt care.

3) ER resident - "my attending told me to call you stat" We have a medical code in the bay who we think has a ruptured AAA. We put an U/S on his abd and the AAA looks like it is over 8 cm. My attending says you have to bring a Sr. Resident with you. Taking the pt to the scanner now. he has great pulses.
ME: Ok, I'll meet you down there..(something seems fishy, but who am I to argue when I haven't seen the pt yet - it is a medical code)..I grab sr and we meet pt in CT
ER attending: looking at the prelim scan as it scrolls by: "There it is! It's huge! Oh- wait - that's the bladder"
Sr Resident and I just look at each other.... the R-U-SERIOUS look.
ER attending: looking at the delayed imaging as it scrolls by: "Look right there - oh - that's the bladder again.
Final dx: after am EGD-gastric ulcers, anemia, stable 4 cm AAA, and a foley catheter for retention.

 

[elr1983]

I'm only going to speak about my residency experience, as my current practice in Houston is variable, and the level of communication here leaves something to be desired.

As a surgical resident, I would routinely contact consulting teams to relay information. As I became more experienced, I would discriminate the level of needed feedback based on the content of the consult itself. Any time I wrote important orders, changed the level of care, or planned an operation, I would notify the primary team.

If it was a resident-run team, I would typically contact the resident that called me. Otherwise, I'd call the chief resident when appropriate. If it was an ER consult, I would already be down there, so I'd just talk to the ER doc about our plan briefly, and then let him know the patient's disposition.

There are three main reasons that I did this:

1. It enhances the level of communication, hence limiting misunderstandings and incorrect assumptions, and ultimately leading to better patient care.

2. It helps educate the consultant. Many of them have no idea that their consult is BS (or non-urgent). If they do know it's BS, and they call me at 2am anyway, then I spread the fun around a little.

3. If you treat consulting physicians poorly, it can reflect poorly on your service and your attending physician. Since I trained in a community hospital, those docs have a choice who they consult, and they simply won't use you (or your boss) if you're a jerk. Being nice and giving feedback is ultimately good for business.

Thanks for your response. I always appreciate hearing from consultants for all of your stated reasons, especially #1 and 2!

 

[Dirt]

I would also say that, regardless of Dirt's preference of pager vs phone, I'd recommend making that an extremely LOW priority in your evaluation of a program. That is a matter of minor convenience and you will find yourself getting comfortable with either system after a short time. The nuances of the paging system really won't impact your training in a meaningful way

I see that I didn't really specify, but it is the EMR/computer systems that is far more important to me than the phone vs. pager. The place I am at now has 4 different systems, one for orders/labs, one for rads, one for prior inpatient d/c summaries/op reports and such, and one for the o/p records. None of these systems communicate at all. There are no systems for vitals/nursing and if you want vitals, you have to call the nurse and track them down because they keep the flow sheets on them.

It absolutely affects not only patient care, but the education of the residents. It makes for so much scut that there is a decreased emphasis on education. It also makes every person who has to use these systems irrationally angry. I am not joking when I say that interns have to come in an hour earlier than they would have to every day if they didn't have to chase down nurses for vitals.

Now, obviously this will not be the number one, two or three factor in my decision, but it will definitely be a factor.

The phone vs pager thing is far less important.

 

[skiz knot]

...if you want vitals, you have to call the nurse and track them down because they keep the flow sheets on them.

One day you'll discover talking for 30 seconds with the nurse that is taking care of your patient is more valuable than the perceived time saved on a computer system.

 

[Buzz Me]

So here in the "D" the second year interns get to be "Pit Boss."...
3) ER resident - "my attending told me to call you stat" We have a medical code in the bay who we think has a ruptured AAA. We put an U/S on his abd and the AAA looks like it is over 8 cm. My attending says you have to bring a Sr. Resident with you. Taking the pt to the scanner now.

(1) What's a "second year intern"?

(2) Why would you bring a "medical code" pt with a "ruptured AAA" to the CT scanner?

 

[dancinjenn]

(1) What's a "second year intern"?

(2) Why would you bring a "medical code" pt with a "ruptured AAA" to the CT scanner?

I meant 2nd year resident...

"Well the pt was stable. Had great pulses." remember this is the attending/resident combo who diagnosed a distended bladder as a ruptured AAA.

 

[45408]

One day you'll discover talking for 30 seconds with the nurse that is taking care of your patient is more valuable than the perceived time saved on a computer system.

For ICU patients with a nurse with no other patients and who has been with them for 12 hours, I certainly agree.

For floor patients, when they change shifts so often, have 6-7 other patients (when we round, it's still the night nurses working), and aren't the ones taking the vitals (the CNA does), then I definitely disagree. In addition, the ICU nurses are usually pretty good, but a few of the floor nurses are actually pretty incompetent.

I meant 2nd year resident...

"Well the pt was stable. Had great pulses." remember this is the attending/resident combo who diagnosed a distended bladder as a ruptured AAA.

I'm pretty sure most ruptured AAAs don't have great pulses...(I'm sure you realize this)

 

[Winged Scapula]

There was a boy who cried wolf, and there are way too many hospitalists that cry peritonitis. Two or three of them called us claiming their patients had peritonitis, come see them now, right away! Take them to the OR and off of my service!

None of them had peritonitis at all, and none of them had any acute surgical issue.

Have you seen how many non-surgeons examine the belly? I've seen, more times than I can count, practically a karate chop to the abdomen as way of demonstrating pain.

"Uh, yeah...if you poked me that hard with the pointy end of your hand, I'd have pain too."

 

[filter07]

When there is an acute abdomen and the most likely source is gynecological, is it standard practice to still consult both gyn and gen surg? I had a few of these recently. Tense abdomen, free fluid in the belly.

I can sort of see the reasoning in consulting general surgery. I guess in case it's a perforated peptic ulcer or something, we would be able to guide workup and treatment. One problem is that GS might get into the belly and find a GYN problem.

The other issue is that in a non-pregnant patient the work up would pretty much be the same (CT +/- V US), and in a pregnant patient the GS work up would follow the V US.

So do you think the ED should consult only after a gyn rule out in patients whose history and physical point towards gyn as the top ddx, or is it acceptable for the ED to double consult out of the urgent nature of an acute abdomen and free fluid (which could potentially be blood)?

 

[basupran]

Yes, exactly. I am an ortho resident and don't have much experience beyond medical school when it comes to MEDICALLY managing a patient. I am instead learning how to treat a reverse obliquity intertrochanteric hip fracture in an 85 year old, how to operate on a pediatric grade 3 supracondylar fracture, how to fix curves in a 14 year old kid with a spine that looks like a snake, how to transfer a big toe to hand and make it functional, how to remove half of a pelvis (osteosarcoma) in the hopes of keeping a semi-functional patient, etc...

You do not want me medically managing patients, trust me on this. I have little experience when it comes to this. It is not that I am dumping. It is not that I am stupid or lazy. I am running around like a headless chicken in the ER reducing hips, wrists, ankles, shoulders, etc.. And while that medicine resident is getting to bed at midnight to get 3-4 hours of sleep, I am in the trauma bay figuring out what arteries and nerves that axillary bullet went through.

Similarly, if you consult me on an '85 y/o F s/p mechanical fall, xray shows r hip fx, per radiology garden iii hip fx'. You expect me to effectively surgically fix the patient. Not just put in a consult saying 'pt needs hemi-arthroplasty' and tape a hip to the chart. I expect you to medically manage this patient who likely has 10,000 medical problems much more efficiently than I ever will; similarly, I will get get that hip back into that firefighter who fell down a flight of stairs.

People that "(come) in with a femur fracture after a fall" aren't healthy individuals, period. That is why they, one, fell, and two, broke their femur (you probably are referring to a hip fracture). They have a multitude of comorbid medical conditions and a low physiolgic reserve. 25% percent will be dead in a year, and 1/3 of those within 30 days. They will undergo a major orthopaedic surgery associated with a fair amount of blood loss and will be (relatively) immobile for some time afterwards. "giving insulin and antibiotics" isn't going to fix the leg, but it will keep the patient healthy. Frankly, in orthopaedics, we are not trained to necessarily recognize or appropriately treat medical conditions. We focus our training on disorders of the peripheral nervous and musculoskeletal systems. That keeps us plenty busy. We can not be efficient if we have to manage issues outside of our specialty. Would you want your parent managed medically by an orthopod?

J Bone Joint Surg Am. 2010 Apr;92(4):807-13.
Use of medical comorbidities to predict complications after hip fracture surgery in the elderly.
Donegan DJ, Gay AN, Baldwin K, Morales EE, Esterhai JL Jr, Mehta S.
Source
Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 2 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA.
Abstract
BACKGROUND:
Comorbidities before and complications following hip fracture surgery can impact the return of function. We hypothesized that the American Society of Anesthesiologists (ASA) classification of medical comorbidities is a useful surrogate variable for the patient's general medical condition and would be a strong predictor of perioperative medical complications following hip fracture surgery.

METHODS:
A retrospective review of the cases of 197 elderly patients who had undergone operative management of a hip fracture was performed. The ASA class, data regarding perioperative medical and surgical complications, and demographic data were obtained. Medical complications were defined as those requiring intervention by an internist or medical specialist. Differences in complication rates among the ASA classes were determined.

RESULTS:
Medical complications were more common in patients in ASA class 3 (p < 0.001) and those in class 4 (p = 0.001) than in those in class 2. Patients in ASA class 3 had a 3.78 times greater chance of having a medical complication than did those in class 2 (p < 0.001). Patients in ASA class 4 had a 7.39 times greater chance of having medical complications than did those in class 2 (p = 0.001). No significant relationship was identified between the ASA class and surgical complications.

CONCLUSIONS:
The ASA class is strongly associated with medical problems in the perioperative period following hip fracture surgery in the elderly. Patients identified as being at higher risk (in ASA class 3 or 4) preoperatively should be closely managed medically so that perioperative medical complications can be managed and evolving medical issues can be addressed in a timely fashion.

 

[Dirt]

One day you'll discover talking for 30 seconds with the nurse that is taking care of your patient is more valuable than the perceived time saved on a computer system.

Thank you for being snide.

Talking to the nurse about what is going on with the patient is mutually exclusive of tracking down vitals.

Maybe if you rotated at the hospital to which I am referring you would discover that seeing the patient is more valuable then spending 30 minutes tracking down the nurse, who is in the break room with his/her buds talking about the latest issue of us weekly. Then being rudely referred to the CNA who has the vitals written on a post-it in their pocket but is in some patient's room arm deep in $hit and piss.

Me wanting a better computer system is truly not about being lazy as people responding to me must think, it is about being accurate, complete, and efficient.

 

[Pir8DeacDoc]

I love the responses from the orthpods. It's like the rest of us aren't trying to learn how to operate too- yet we find time to manage basic medical problems.

 

[LucidSplash]

I love the responses from the orthpods. It's like the rest of us aren't trying to learn how to operate too- yet we find time to manage basic medical problems.

Yep. Nothing complex about abdominal surgery.

Though in fairness to the orthopods, I recognize that they have no one to teach them these medical management skills beyond what they learn in medical school and as interns. This has been going on so long that none of their attendings have these skills either. So a change would require a major shift in the education of orthopods requiring multiple years of training in general surgery/basic medical management in addition to orthopedic residency (and a requirement for this knowledge in their board exams) and that's not going to happen. The horse is out of the barn on this one, and as much as we like to complain about it, it won't change.

However, that doesn't mean its ok for them to pretend that the only reason they don't have these basic skills is that their specialty education is so complex as to preclude the time for learning it while general surgeons have an equally varied and complex caseload requirements to be board-eligible. Blame it on the system and the loss of this fund of knowledge within your own field but don't minimize the difficulty and complexity of my operative training in that fashion. Its rather gauche to do so.

 

[TysonCook]

WTF does that rationale for the consult have to do with anything? By that logic, that pedi ED may as well consult the physcian who delivered her at birth since they too saw her last name. Would not be surprised if that attending would try to consult ENT for a pt with a sore throat that just had their tonsils removed in the last couple days....

I'm a lurker (yes from the fishbowl), but I will say, that if you know your ENT, the above isn't the best example

....without much ado, I sincerely appreciate all the surgeons that I work with, and appreciate the work that you as surgeons do. If it needs cutting "now" I call you, if it isn't surgical, you don't hear from me.

...that is what I teach the residents

In the end, our surgery staff state it pretty eloquently in that their best surgeons don't have to operate, but if they need to, please call.

Kudos to you guys, its a long road (regardless of what field of surgery), but it isn't ignored by a lot of us.

 

[45408]

Have you seen how many non-surgeons examine the belly? I've seen, more times than I can count, practically a karate chop to the abdomen as way of demonstrating pain.

"Uh, yeah...if you poked me that hard with the pointy end of your hand, I'd have pain too."

Either that, or their abdominal exam consists of "bowel sounds present."

 

[45408]

Yes, exactly. I am an ortho resident and don't have much experience beyond medical school when it comes to MEDICALLY managing a patient. I am instead learning how to treat a reverse obliquity intertrochanteric hip fracture in an 85 year old, how to operate on a pediatric grade 3 supracondylar fracture, how to fix curves in a 14 year old kid with a spine that looks like a snake, how to transfer a big toe to hand and make it functional, how to remove half of a pelvis (osteosarcoma) in the hopes of keeping a semi-functional patient, etc...

What about those of us learning how to do the hepaticojejunostomy in a pylorus-preserving pancreaticoduodenectomy? Or a femoral-tibial artery bypass with contralateral greater saphenous vein?


The rest of us aren't just doing lap choles and tonsillectomies.

 

[LucidSplash]

You guys don't utilize medicine because you don't want to, it's some weird point of pride for you. But that's a choice, not a necessity.

Actually, I have repeatedly seen medicine services, when left unscrutinized, mismanage medical issues when found in the setting of surgical disease or post-operative care. Frequently they simply don't understand the physical demands of an open abdomen and they certainly don't learn to read their own imaging like all surgical services do. I've seen free air missed on x-rays, huge pneumothoraces called to surgery 12 hours after the chest xray was taken because, according to the note they were "waiting on the read." I wouldn't let them near a trauma patient with multiple co-morbidities. Similarly I don't think they'd want me handling things in someone who's main issue is DKA rather than the abscess I drained. Medicine is great for handling a lot of complex medical issues and we DO sometimes ask them for help but I think its a mistake to think they know what to look for most of the time in peri-operative patients.

 

[LucidSplash]

The better question is this: when you take out a gallbladder of a 60yo diabetic, why don't you admit them to medicine?

Because its either an outpatient procedure or they leave the next morning and its a better use of resources for me to write the following at the bottom of their other post-op orders:

Accuchecks QAC + QHS
Sliding scale insulin: (Blood glucose - 100)/20 = # of units of regular insulin.

Short-term diabetic management in the post-operative patient done!

 

[filter07]

Medicine does not understand post surgical patients. It's not part of their training. If ortho patients routinely get better care under the medicine service, that is a sad statement about ortho.

 

[jdh71]

Medicine does not understand post surgical patients. It's not part of their training.

Maybe it should be a part of our training. I admit what I know about post-surgical patients I picked up in medical school, and the occasional patient we were asked to see to help with in the ICU, which amounts to not much. One of the things that has always bothered me about the ENT and Urology drop off's we sometimes get into the MICU on a Friday afternoon.

Here's an interesting question should post-op management be a part of IM training? Assuming of course we move towards a sort of single service admission to the hospital (ie. medicine admits everyone and everyone else consults). Maybe it's a horrible idea.

 

[jdh71]

There's nothing magical about it. It's certainly something they should remember from their MS3 rotations and time they spent on surgical rotations as interns.

OH the I - RON - EEEEE!

 

[LucidSplash]

There's nothing magical about it. It's certainly something they should remember from their MS3 rotations and time they spent on surgical rotations as interns.

So wait... now your argument is that medicine isn't the best service to be taking care of surgical patients?

Oh nevermind, I see what you did there.

 

[jdh71]

See, I knew you would enjoy that, even if the Gen Surg boys didn't get it.

I like you man. If we ever meet IRL, I'm buying you a beer.

[/moment]

 

[45408]

These are not the majority of your patients as a resident, and unless you end up in a very niche position as a trauma surgeon at a Level I facility, it will not be the majority of your patients as an attending.

You guys always throw out the ICU-level trauma cases or Whipples like those are your typical patients. That's no more true than Ortho arguing that hemipelvectomies for sarcoma are our typical patients.

I admitted several trauma patients to the ICU the last time I was on call. Our vascular patients have MIs on what seems like a regular basis. These are routine scenarios for us.

The better question is this: when you take out a gallbladder of a 60yo diabetic, why don't you admit them to medicine?

Why would we admit them? That's an outpatient procedure. If it were an open chole, the medicine team would probably try to give them a cheeseburger and a mouthful of horse pills as soon as they got to the floor. Plus, it's really just easier to do it yourself. Fewer cooks in the kitchen.

Maybe you'd turn out a better surgeon if you spent more time doing pylorojejustomapancreotoectomies, or whatever you just said there, instead of calculating insulin drips and reading JAMA?

You guys don't utilize medicine because you don't want to, it's some weird point of pride for you. But that's a choice, not a necessity.

Just sayin'

No, we don't utilize the medicine service to manage surgical patients, because they're not as good at it as we are. On a routine basis, when we take one of their patients from their ICU to the OR (because the "urosepsis" turned out to be dead gut or something), they're severely under-resuscitated.

PS: you don't calculate an insulin drip. The nurse does. All I have to do is write "insulin gtt, titrate to BS 90-140" and I'm done.

 

[SLUser11]

Accuchecks QAC + QHS
Sliding scale insulin: (Blood glucose - 100)/20 = # of units of regular insulin.

Short-term diabetic management in the post-operative patient done!

PS: you don't calculate an insulin drip. The nurse does. All I have to do is write "insulin gtt, titrate to BS 90-140" and I'm done.

I feel like we might be reinforcing Tired's point with these statements. There is much more to good perioperative glucose control than writing a simple sliding scale.....also, I feel like this insulin gtt order might be a little too aggressive.

If we aim for a BS of 90-140, the patient has more hypoglycemic episodes, and if you believe in the NICE-SUGAR Trial, this will actually increase mortality compared to a less aggressive approach.

I think a target of 140-180 may be more appropriate for insulin drips...

As for accuchecks, I also want to recommend that if a patient is being started on a long acting insulin (Levemir or Lantus), you may want to add an 0200 accucheck as well, as these patients can bottom out in the middle of the night, and nobody knows it until it's too late.

 

[dpmd]

If we aim for a BS of 90-140, the patient has more hypoglycemic episodes, and if you believe in the NICE-SUGAR Trial, this will actually increase mortality compared to a less aggressive approach.

I have seen insulin drips calculated a variety of ways at different institutions, and I wonder how much of a role that plays in the hypoglycemic episode rate. If you target 90-one something and actually stay close to that, perhaps that is better than a higher target but wide variations in actual levels. Don't know how you would test for that though.

As for sliding scale only, our endocrinologist has done a good job at teaching all residents that this really isn't the best way to deal with blood glucose. Basal prandial (or basal plus correction if not taking po) actually controls sugar instead of letting it go wherever and just reacting to it.

 

[Arcan57]

When there is an acute abdomen and the most likely source is gynecological, is it standard practice to still consult both gyn and gen surg? I had a few of these recently. Tense abdomen, free fluid in the belly.

I can sort of see the reasoning in consulting general surgery. I guess in case it's a perforated peptic ulcer or something, we would be able to guide workup and treatment. One problem is that GS might get into the belly and find a GYN problem.

The other issue is that in a non-pregnant patient the work up would pretty much be the same (CT +/- V US), and in a pregnant patient the GS work up would follow the V US.

So do you think the ED should consult only after a gyn rule out in patients whose history and physical point towards gyn as the top ddx, or is it acceptable for the ED to double consult out of the urgent nature of an acute abdomen and free fluid (which could potentially be blood)?

It sounds like you already some understanding of the thought process behind the double consult. The only cases I've seen of the double barrel has been on hemodynamically unstable patients with a peritoneal abdomen and without a clear-cut source.

The problem with the sequential consults is that in most hospitals (academic or community) running a patient through the consult process twice is usually a 4-5+ hour process. That's annoying when the patient is stable, but is sometimes a necessary evil. When the patient is unstable, I've seen patients crash and die while Gyn and G. Surg argued (both at resident and attending level) about who needed to take the patient to the OR.

As an ED doc, I can resuscitate the patient and recognize intra-abdominal catastrophes but I can't take the patient to the OR. Furthermore, if a patient is crashing, they don't have the time for me to play messenger boy between the operative specialties as surgery and OB/GYN fight about who has to step up. Getting both services in front of the patient to directly discuss and decide on a plan of care is inconvenient for the docs but can be life-saving to the patient.

From past experience with a small n, patients seem to do better if they went to the OR with a surgeon and are discovered to have a gyn issue than vice-versa.

The patients that need the double consult are quite rare, and if this is a routine practice for female lower abd/pelvic pain NOS then that is a problem.

 

[sirenomelia]

Several years ago about this time of year an outside hospital called to transfer a 7 year-old who was on a hayride and fell off the wagon and the wagon wheel rolled over him- somehow missing all of him except his weiner and partially avulsed/ transected the glans only. What are the odds!?

When I was a resident our department came up with an money making scheme using us on the trauma service to make money for the dept by offering "critical care" services to all the surgical specialty patients. Ofcourse they didnt ask us first. Left and right we were getting calls all day and night for craniotomy patients landing in the unit and the only order the neursurgeons had written was "Admit to SICU, page trauma for orders." It got so out of hand one night a sickly ortho hip replacement guy had chest pain on the night of surgery and when the attending was called all he told the nurse was "call a trauma consult".

 

[LucidSplash]

16F no prior history except acute on chronic pelvic pain. Peds surg consulted by admitting peds team at the recommendation of the consulting OB/Gyn service for diagnostic laparoscopy to rule out endometriosis vs menorrhagia.

OB/Gyn actually wrote in their note "defer procedure to peds/peds surg."

 

[PostCall]

I've always wondered can an attending refuse to see a consult if they determine it is BS? I realize a private practice attending runs the risk of not getting anymore consults from that particular doctor if they refuse the consult. But what about a salaried attending at an institution where it doesn't matter if they see 1 consult or a 100 consults. If you get the typical 3AM BS consult from the ER or other service can you flat out tell them you're not going to take the consult?

 

[turkeyjerky]

I've always wondered can an attending refuse to see a consult if they determine it is BS? I realize a private practice attending runs the risk of not getting anymore consults from that particular doctor if they refuse the consult. But what about a salaried attending at an institution where it doesn't matter if they see 1 consult or a 100 consults. If you get the typical 3AM BS consult from the ER or other service can you flat out tell them you're not going to take the consult?

If it's from the ED, then it would be an EMTALA violation and that attending would get his ass canned.

 

[45408]

If it's from the ED, then it would be an EMTALA violation and that attending would get his ass canned.

I agree, but depending on the situation, they could convince the ED attending that it was simply not a necessary consult. However, if the ED doc said "I still want the consult," and then they refused, that would be a big problem. At my hospital, it's a very large fine, and you'd probably be open to malpractice suits if something bad happened.

 

[cpants]

I agree, but depending on the situation, they could convince the ED attending that it was simply not a necessary consult. However, if the ED doc said "I still want the consult," and then they refused, that would be a big problem. At my hospital, it's a very large fine, and you'd probably be open to malpractice suits if something bad happened.

I obviously don't speak from experience, but I think it's less of a problem for attendings. For one thing, you get paid just as much for BS consults as you do for good ones. So if you have to come in and spend 15 minutes writing 'no surgical intervention warranted, please call with questions', at least you aren't doing it for free. Plus it's usually just not worth the bad will. In most hospitals the ED and medicine docs have a choice of who they throw the consult to. The next call for something legitimate will just go to your competition. Better to be pleasant at all times and take an opportunity to educate if possible.

 

[45408]

I obviously don't speak from experience, but I think it's less of a problem for attendings. For one thing, you get paid just as much for BS consults as you do for good ones. So if you have to come in and spend 15 minutes writing 'no surgical intervention warranted, please call with questions', at least you aren't doing it for free. Plus it's usually just not worth the bad will. In most hospitals the ED and medicine docs have a choice of who they throw the consult to. The next call for something legitimate will just go to your competition. Better to be pleasant at all times and take an opportunity to educate if possible.

True, but a 3am consult will suck even more for an attending who has a full day of clinic/cases the next day, rather than being post-call like I am right now.

 

[Apollyon]

In most hospitals the ED and medicine docs have a choice of who they throw the consult to.

If it is someone on the call list, in the ED, I don't have that option - if the patient is unassigned, and I call someone else when there is a doctor on call for that specialty, I WOULD affirmatively go up against the medical staff board, and would probably lose my privileges (and, as such, my job). It's right there in the bylaws. The only way around is if the on-call doctor is unreachable (which will get that doc in BIG trouble).

The IM docs on the floor, I think they have free reign.

However, also, think of it from the consultant side - if you, surgeon X, are on call, and are required by the hospital to take call in order to maintain your operative privileges, how would you feel if I cut into your business by calling another surgeon?

edit: and I realize (having just come home from 12 hours overnight) that I am reiterating that which turkeyjerky stated (correctly).

 

[DD214_DOC]

If it's from the ED, then it would be an EMTALA violation and that attending would get his ass canned.

Could someone explain this? I'm not in a civilian system so these things do not really come up.

How is a consultant refusing to see a bogus consult an EMTALA violation?

 

[Xerxes1729]

Under the EMTALA statute, once the ED physician requests that you consult on a patient you have a legal duty to do so. It is non-negotiable. If you do not, you can be fined something like $50,000 and lose your ability to bill Medicare and Medicaid. You are also liable if an adverse outcome results in a malpractice suit.

 

[Winged Scapula]

Under the EMTALA statute, once the ED physician requests that you consult on a patient you have a legal duty to do so. It is non-negotiable. If you do not, you can be fined something like $50,000 and lose your ability to bill Medicare and Medicaid. You are also liable if an adverse outcome results in a malpractice suit.

Some clarification is in order.

EMTALA is only in effect for a consultant if that person is actually on call FOR THE HOSPITAL. Therefore, only physicians who are employed by the hospital or who are required to take call as part of hospital privileges and are on call that night for their specialty are affected by EMTALA.

"Physicians are often told by hospitals that they are "required by EMTALA" to serve on a call schedule. The truth is that EMTALA does not impose any requirement on physicians that they serve on a call schedule. It is the hospital which imposes an obligation on physicians in order to meet the obligation imposed upon it by the Medicare statute. The obligation of a physician to serve on a call schedule is legally based on state law governing contracts, derived from the agreements attendant to medical staff membership, rather than an obligation placed on the physician by Federal law.

As noted above, Section 1395dd(d)(1)(C) imposes a penalty on a physician who fails to respond to an emergency situation when he is assigned as the on-call physician. This is the only obligation placed on physicians governing the obligation to respond to an emergency situation. This provision does not require that a particular physician or particular specialty provide coverage on a call basis."

The responses above affect the blinders that medical students and residents training in academic hospitals have. Most surgeons and other specialists are not hospital employees out in the real world. Many hospitals in the community setting do not require private practice physicians to take call as part of hospital privileging. Those that have tried to enforce such requirements, especially in large cities, find that they no longer have certain specialties available to them (i.e., a certain local hospital here in town lost plastics, ENT and Neurosx in droves when they tried to enforce an ER call schedule. There's another hospital in town that requires *me* to take General Surgery call...LOL. I rescinded my privileges there.)

So EMTALA does not apply to most of the surgical specialists in this country (who are largely in private practice and not employed by hospitals or in academic institutions).

 

[Maybeknot]

Under the EMTALA statute, once the ED physician requests that you consult on a patient you have a legal duty to do so. It is non-negotiable. If you do not, you can be fined something like $50,000 and lose your ability to bill Medicare and Medicaid. You are also liable if an adverse outcome results in a malpractice suit.

As noted above, Section 1395dd(d)(1)(C) imposes a penalty on a physician who fails to respond to an emergency situation when he is assigned as the on-call physician. This is the only obligation placed on physicians governing the obligation to respond to an emergency situation.

How is "emergency situation" defined? If I'm call for the hospital and the ER wants to call me in, for, say, tonsillitis or eval of a 3 yr old thyroid mass, is that an emergency situation under EMTALA?

 

[Winged Scapula]

How is "emergency situation" defined? If I'm call for the hospital and the ER wants to call me in, for, say, tonsillitis or eval of a 3 yr old thyroid mass, is that an emergency situation under EMTALA?

From EMTALA.com:

An attempt is made by the statute to provide a definition, but as usually happens, the legal definition leaves much to be desired. The determination is ultimately a medical one rather than a legal one. That is not to say that it is sheltered from review. As is the case with any medical decision, it must often be made quickly, with such information as is available, and is subject to critical retrospective review by physicians testifying as expert witnesses in the alien setting of the courtroom, in the event of litigation.

The definition provided under the statute is:

"A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in --
placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
serious impairment to bodily functions, or
serious dysfunction of any bodily organ or part, or

"With respect to a pregnant woman who is having contractions --
that there is inadequate time to effect a safe transfer to another hospital before delivery, or
that the transfer may pose a threat to the health or safety of the woman or her unborn child."


In my experience, ED physicians aren't trying to get consultants to come in for non-emergent things like chronic neck masses (unless the patient in question has an airway issue). If yours are, that sounds like a system issue where they are having trouble getting appropriate follow-up for non-emergent, non-admitted patients.

If you're on call and the ED physician thinks the patient needs specialist evaluation and/or admission and you refuse AND there's litigation (because it really was an emergency and the patient had a bad outcome), then you're hosed.

 

[Xerxes1729]

Some clarification is in order.

EMTALA is only in effect for a consultant if that person is actually on call FOR THE HOSPITAL. Therefore, only physicians who are employed by the hospital or who are required to take call as part of hospital privileges and are on call that night for their specialty are affected by EMTALA.

That's true. I should have been more clear. However, if you agree to be on call, then you're obligated.

 

[kitsunepixie]

I very recently saw a lady with SEVERE cervical myelopathy who had progressive arm weakness, paresthesias in her fingertips, and gait abnormality since July who was refused an MRI of her c-spine due to lack of insurance and who wasn't taken seriously by her PCP or local ER because of a history of fibromyalgia and chronic pain. She had lost her job because she couldn't file paperwork due to profound instrinsic hand weakness. She started having urinary incontinence 3 weeks prior to my seeing her and she told me she was turned away again from her local ER when she sought medical attention for it, so she and her one-armed ex-husband who was helping her with ADLs came up to my hospital for a second opinion. MRI showed an enormous herniated disc compressing her spinal cord with myelomalacia. Took the disc out and she's doing much better with her strength and gait, but I don't know if her bladder is going to improve or not. Obviously, I don't know the full story, but it's a bummer she didn't get diagnosed sooner to have given her a better chance for full recovery...

 

[AJSmith]

I wanna play too [CT surgery, so be prepared for that flavor]

Call from the oncology service:
Them: Hello, are you the person for cardiac surgery?
Me: Yes. What's on your mind?
Them: I have a patient with widely metastatic pancratic cancer s/p prior bleeds from brain mets and a lot of clot in her LV on her last echo.
Me: That's horrible. Have you called cardiology? They usually do LV clot... it's not really something to operate on.
Them: Yes, they recommended anticoagulation. But we can't anticoagulate her because we're afraid she'll bleed into her head.
Me: So.... what do you want me to do?
Them: [without missing a beat] Take the clot out.
I go through a very long discussion of the fact that we don't cut into people's left ventricles to take clot out, and that it would involve a lot of anticoagulation to go on bypass.
Them: So, will you leave a note?

-Overhead page
*Perfusion STAT to L&D*Perfusion STAT to L&D*
Me (scratching my head, as I'm the only person allowed to call perfusion since I'm the one who would go on CPS): I guess I better go up there.
Me (after arriving): So, I heard a page for perfusion over head. I'm the CT surgery fellow. Can I help you guys?
Them: This patient needs an emergent C section.
Me: On bypass?
Them: She's anticoagulated.
Me: I guess that makes it easier to go on bypass, but why do you want us to do that?
Them: We need to know how to reverse her. So we figured we'd call perfusion.
Me: *palm to forhead* Just give 25 of protamine.
Of course, by that time my charge nurse was running up from the CT SICU with our sternotomy/ECMO cart and perfusion was there with a pump.

- While acting as a 'fellow' on cardiology, I sometimes hear consults. This one from gen surg to cardiology about a patient I knew well.

Them: So, we want to know when you are going to take the stents out.
Me: The ones "we" put in for her STEMI?
Them: Yes.
Me: What's your name?
Them: You mean the patient?
Me: No, yours. I want to keep an eye out for you when you do your CT SICU rotation.
Them: Uhhh... okay. I'm Dr X [love it when the interns use the Dr thing]. Well, what should I tell my chief.
Me: If I were you, nothing about this particular call. My guess is she wanted you to call urology about the stents placed for her colectomy.

-While on gen surg:
Them: Hi, this is the MICU resident. I'm just calling to let you know that IR is placing a chest tube.
Me: Okay. What can I help you with?
Them: Nothing. Just wanted you to be aware.

-Call from MICU
*CT SURGERY STAT TO THE MICU*CT SURGERY STAT TO THE MICU* [overhead]
I go up and they're all in a room with nurses swarming and a very sweaty MICU resident looking like he had just attempted a subclavian line.
Me: What's on your mind?
Them: This patient has a TENSION PNEUMOTHORAX!!! We need a chest tube?
Me: [looking at vitals] Looks pretty stable to me. What happened?
Them: I NEED A CHEST TUBE RIGHT NOW!!!
Me: I'm here. Tell me the story.
Them: I WAS PUTTING IN A SUBCLAVIAN LINE AND THE PATIENT GOT HYPERTENSIVE AND TACHYCARDIC AND THE PULSE OX WENT TO UNREADABLE!!! SHE NEEDS A CHEST TUBE NOW!!!
Me: Ahhh -- HYPOtensive or HYPER?
Them: Hyper. But every tension pneumo I've ever caused was hypertension.
Me: [with admirable restraint] That's very interesting. When you had an unreadable pulseox, was there a pleth?
Them: A what?
Me: Okay. Do we have bilateral breath sounds.
Them: Yes. But every tension pneumo I've ever caused has bilateral breath sounds.
Me: Let's get a CXR first.
Them: BUT YOU DON'T GET A CXR FOR TENSION. You're just supposed to put in the tube.
Me: Honestly, I don't think this is a tension. I'll stand here, but we're getting an x ray first.
Me to RN: Could you please get a chest tube tray and some gowns and drapes please?
RN: I CAN'T DO THAT RIGHT NOW! I'M ADVOCATING FOR MY PATIENT!!!
Me: [feeling like I'm in the twilight zone] Okay. I guess we'll wait until you're done advocating to relieve the tension pneumothorax. [yes, I resisted air quotes]
CXR comes, no pneumothorax.
Me: Okay, there's no pneumothorax. See you later.
Them: YOU HAVE TO PUT IN A CHEST TUBE!!!
Me: Look. I've been pretty tolerant. But I don't have to do anything. So tell me why you think this patient needs a chest tube.
Them: I already needle decompressed her.
Me: [cringing] did you leave the needle in?
Them: Yes, it's right here.
Points to a 25 guage local needle which is all of 1 1/2 cm long, stuck into her breast next to the areola and no where near her chest wall.
Me: That doesn't count. It's not in her chest. Get another CXR in 6 hours if you're worried.

And I fled. Fast.

 

[45408]

-Call from MICU
*CT SURGERY STAT TO THE MICU*CT SURGERY STAT TO THE MICU* [overhead]
I go up and they're all in a room with nurses swarming and a very sweaty MICU resident looking like he had just attempted a subclavian line.
Me: What's on your mind?
Them: This patient has a TENSION PNEUMOTHORAX!!! We need a chest tube?
Me: [looking at vitals] Looks pretty stable to me. What happened?
Them: I NEED A CHEST TUBE RIGHT NOW!!!
Me: I'm here. Tell me the story.
Them: I WAS PUTTING IN A SUBCLAVIAN LINE AND THE PATIENT GOT HYPERTENSIVE AND TACHYCARDIC AND THE PULSE OX WENT TO UNREADABLE!!! SHE NEEDS A CHEST TUBE NOW!!!
Me: Ahhh -- HYPOtensive or HYPER?
Them: Hyper. But every tension pneumo I've ever caused was hypertension.
Me: [with admirable restraint] That's very interesting. When you had an unreadable pulseox, was there a pleth?
Them: A what?
Me: Okay. Do we have bilateral breath sounds.
Them: Yes. But every tension pneumo I've ever caused has bilateral breath sounds.
Me: Let's get a CXR first.
Them: BUT YOU DON'T GET A CXR FOR TENSION. You're just supposed to put in the tube.
Me: Honestly, I don't think this is a tension. I'll stand here, but we're getting an x ray first.
Me to RN: Could you please get a chest tube tray and some gowns and drapes please?
RN: I CAN'T DO THAT RIGHT NOW! I'M ADVOCATING FOR MY PATIENT!!!
Me: [feeling like I'm in the twilight zone] Okay. I guess we'll wait until you're done advocating to relieve the tension pneumothorax. [yes, I resisted air quotes]
CXR comes, no pneumothorax.
Me: Okay, there's no pneumothorax. See you later.
Them: YOU HAVE TO PUT IN A CHEST TUBE!!!
Me: Look. I've been pretty tolerant. But I don't have to do anything. So tell me why you think this patient needs a chest tube.
Them: I already needle decompressed her.
Me: [cringing] did you leave the needle in?
Them: Yes, it's right here.
Points to a 25 guage local needle which is all of 1 1/2 cm long, stuck into her breast next to the areola and no where near her chest wall.
Me: That doesn't count. It's not in her chest. Get another CXR in 6 hours if you're worried.

And I fled. Fast.

Good God almighty, that's horrific.