Consults- Memorable/Dismal/Ridiculous/Unique

[ThoracicGuy]

I got one of those appy consults in a guy with crohns and a history of an ileocolic resection.

I was at a salty point in my residency then and wrote in my note that "appendicitis was low on my differential given the surgical absence of an appendix"

I have to say I rather enjoyed telling this ER doc that I did not think he had appendicitis as his appendix was already gone. The look on her face made up for the lousy consult.

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[deleted547339]

I got one of those appy consults in a guy with crohns and a history of an ileocolic resection.

I was at a salty point in my residency then and wrote in my note that "appendicitis was low on my differential given the surgical absence of an appendix"

I like that, "a salty point in my residency" - mind if I use that for "a salty point in my fellowship?"

 

[Winged Scapula]

I think I'm having a salty point in my attending hood.

7 AM and Saturday with five new cancer consults that my staff couldn't figure out anywhere else to put them.

Then going to see the consult I should have gotten. A long-term patient of mine, who told the ER that I was her patient gets admitted but for some reason the Hospitalist decides to consult general surgery. Fortunately the general surgeon is a former medical student of mine Who called me on my cell after he saw her to let me know.

I mean it's not like I want more consults but if the alert and oriented patient tells you that Dr. Ex is their Dr. isn't that the person that should be called?

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[Winged Scapula]

I saw a patient once in the ED for a consult for wound infection after operation done at an outside hospital.

The patient told us they went back to the ED at the hospital where they'd had their operation and were told this was just bruising and the patient was discharged with a narcotic script. They were still in pain and started having fevers so they came to our ED.

When I talked to him I asked who had done his operation...turns out it's a former resident at our program who went into private practice. So I just called him as an FYI to let him know. Turns out the ED at his own hospital hadn't ever consulted or called him. He was like WTF and set up a direct admission for the patient.

Not surprised.

I know we're bitching about the ridiculous consults we get because in residency we think we see it all but frankly there's probably just as many consults we don't get that we should. I think this is especially prevalent in private practice where it's not so easy to get a hold of a resident on the spur of the moment.

I just finished seeing my patient and when I asked her if she knew why I wasn't consulted she said she was just as confused. She said that she always asks the ambulance or family bringing her in to bring her to a certain hospital, bypassing the one near her house, because this is where her surgeon and her oncologist are. She said that when she told the hospitalist who her surgeon was, they replied, "I don't know who that is". :|

Now while I like keeping a low profile in the ED, I'm sorry that the Hospitalist who's been in practice for a whole two years doesn't know who I am and seemingly doesn't know how to work the damn computer charting system. It's pretty darn easy in Power Chart to type in the last name of the consultant and since I'm the only surgeon with my last name here, it's pretty easy to find me. She's either stupid or lazy. I mean really. Another thought would be how about asking the nurses or the oncologist or even the infectious disease consultant…they all know who I am.

It's bad enough to be consulted when it's a non-surgical problem but it's entirely different when they don't call and they should've called yesterday.


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[dpmd]

Not surprised.

I know we're bitching about the ridiculous consults we get because in residency we think we see it all but frankly there's probably just as many consults we don't get that we should. I think this is especially prevalent in private practice where it's not so easy to get a hold of a resident on the spur of the moment.

I just finished seeing my patient and when I asked her if she knew why I wasn't consulted she said she was just as confused. She said that she always asks the ambulance or family bringing her in to bring her to a certain hospital, bypassing the one near her house, because this is where her surgeon and her oncologist are. She said that when she told the hospitalist who her surgeon was, they replied, "I don't know who that is". :|

Now while I like keeping a low profile, I'm sorry that the Hospitalist whose in practice for a whole two years doesn't know who I am and seemingly doesn't know how to work the damn computer charting system. It's pretty darn easy in Power Chart to type in the last name of the consultant and since I'm the only surgeon with my last name here, it's pretty easy to find me. She's either stupid or lazy. I mean really. Another thought would be how about asking the nurses or the oncologist or even the infectious disease consultant…they all know who I am.

It's bad enough to be consulted when it's a non-surgical problem but it's entirely different when they don't call and they should've called yesterday.


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They are pretty good about calling me for patients admitted for issues, but they never call about the ones that go home. I try to push the idea of calling my office 24-7 rather than just going direct to er because some of the ER visits could be avoided and some unnecessary imaging would also be avoided but not sure why only some patients take advantage. Even if I send them to the ER it means I don't have to worry about whether or not I am going to be called (or if they are going to go the a hospital I go to)

 

[dpmd]

Speaking of consults that should have been called yesterday, got called in the evening (so I had to go back to that hospital I had already rounded at earlier in the day) for free air on a CT scan. Check the computer and it turns out the CT last evening showed the same thing and this repeat with IV and PO contrast was ordered the following day. Story was abd pain after difficult ercp initially thought to just be pancreatitis (which she also has) but then ct showed some free air (pattern is consistent with retroperitoneal duodenal perf and repeat CT suggests it is sealed) but no one thought to call a surgeon for 24hrs. She is so lucky she sealed it off or I would probably be trying to keep her from dying right now.

 

[TraumaLlamaMD]

Speaking of consults that should have been called yesterday, got called in the evening (so I had to go back to that hospital I had already rounded at earlier in the day) for free air on a CT scan. Check the computer and it turns out the CT last evening showed the same thing and this repeat with IV and PO contrast was ordered the following day. Story was abd pain after difficult ercp initially thought to just be pancreatitis (which she also has) but then ct showed some free air (pattern is consistent with retroperitoneal duodenal perf and repeat CT suggests it is sealed) but no one thought to call a surgeon for 24hrs. She is so lucky she sealed it off or I would probably be trying to keep her from dying right now.

I don't know which instance is sadder - nobody thought to call surgery, or nobody bothered to look at the CT read until days down the line! I get multiple consults a year for "small bowel obstruction" when the patient may have been obstructed at the time of CT, but is eating and pooping three days later when someone bothers to call us.

 

[Winged Scapula]

They are pretty good about calling me for patients admitted for issues, but they never call about the ones that go home. I try to push the idea of calling my office 24-7 rather than just going direct to er because some of the ER visits could be avoided and some unnecessary imaging would also be avoided but not sure why only some patients take advantage. Even if I send them to the ER it means I don't have to worry about whether or not I am going to be called (or if they are going to go the a hospital I go to)

I do the same - tell them to call me first, so I can make sure they're going to someplace I go and then I can triage/faciliate the ED visit (if necessary).

 

[dpmd]

I don't know which instance is sadder - nobody thought to call surgery, or nobody bothered to look at the CT read until days down the line! I get multiple consults a year for "small bowel obstruction" when the patient may have been obstructed at the time of CT, but is eating and pooping three days later when someone bothers to call us.

No, no. The free air was seen and the phrase "perfect viscus" was used when rads called with a critical finding. GI knew about it. Hospitalist knew at some point because he ordered the scan. They knew and chose not to call evidently

 

[dpmd]

Though I have had the consult for a patient who was in the ER a few days ago and comes back sicker who was dced with diagnosis of PID because rads failed to read the free air and evidently gun was cool with sending a patient with peritonitis from "PID" home. She hung out on the brink of death postop for a bit but I pulled her back.

 

[armybound]

It's bad enough to be consulted when it's a non-surgical problem but it's entirely different when they don't call and they should've called yesterday.

I stalk the ED list sometimes to see if there are any potential calls. Some people get sent home very inappropriately.

We got a consult for a septic stone well after it was admitted. The IM resident's note specifically says obstructing stone, UTI, pyelo, sepsis -> no indication for urgent urologic evaluation, will call in the morning. Not sure where they got that from because that's a prime urologic emergency. Thankfully the patient did alright after emergent stenting.

 

[dpmd]

I stalk the ED list sometimes to see if there are any potential calls. Some people get sent home very inappropriately.

We got a consult for a septic stone well after it was admitted. The IM resident's note specifically says obstructing stone, UTI, pyelo, sepsis -> no indication for urgent urologic evaluation, will call in the morning. Not sure where they got that from because that's a prime urologic emergency. Thankfully the patient did alright after emergent stenting.

It is like they don't learn that any pus in a body cavity or tube that can't come out needs to be drained asap so badness doesn't happen (that is a really good way of it being conveyed because that then covers septic joints, cholangitis, spetic stones, and whatever else they might encounter).

 

[deleted547339]

I stalk the ED list sometimes to see if there are any potential calls. Some people get sent home very inappropriately.

We got a consult for a septic stone well after it was admitted. The IM resident's note specifically says obstructing stone, UTI, pyelo, sepsis -> no indication for urgent urologic evaluation, will call in the morning. Not sure where they got that from because that's a prime urologic emergency. Thankfully the patient did alright after emergent stenting.

The funny thing about that is where I trained, you couldn't convince a urologist anything needed to go to the OR. Septic from pyelo with an impacted stone? Too sick. Normal vitals? Sit them on the floor and we may add them on for the next day....

Thankfully, uro at my current hospital is phenomenal.

 

[deleted547339]

Not surprised.

I know we're bitching about the ridiculous consults we get because in residency we think we see it all but frankly there's probably just as many consults we don't get that we should. I think this is especially prevalent in private practice where it's not so easy to get a hold of a resident on the spur of the moment.

I just finished seeing my patient and when I asked her if she knew why I wasn't consulted she said she was just as confused. She said that she always asks the ambulance or family bringing her in to bring her to a certain hospital, bypassing the one near her house, because this is where her surgeon and her oncologist are. She said that when she told the hospitalist who her surgeon was, they replied, "I don't know who that is". :|

Now while I like keeping a low profile in the ED, I'm sorry that the Hospitalist who's been in practice for a whole two years doesn't know who I am and seemingly doesn't know how to work the damn computer charting system. It's pretty darn easy in Power Chart to type in the last name of the consultant and since I'm the only surgeon with my last name here, it's pretty easy to find me. She's either stupid or lazy. I mean really. Another thought would be how about asking the nurses or the oncologist or even the infectious disease consultant…they all know who I am.

It's bad enough to be consulted when it's a non-surgical problem but it's entirely different when they don't call and they should've called yesterday.


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Yea, I think this is a big problem in learning EM in an academic center. Every surgical intern (I.e the one who first answers your page) pitches a fit when you call to let them know a post-op patient is back in the ER if the complaint isn't 1) surgical or 2) a direct complication of surgery. I vividly remember as a resident having an immediate post-op nsgy patient who fell and broke a hip a few days after being discharged from their service because they over narc'ed her, started her on a muscle relaxer, a massive dose of gabapentin, etc and messed with her meds making her hyponatremic. He pitched a fit about having him come see the patient for a nonsurgical issue. No amount of explanation made him understand the many reasons he should be seeing her. This negative feedback loop ends up hurting patients in the long run once we transition to "the real world."

Obviously, as surgeons get more senior, this perspective drastically changes. I always page any surgeon who has operated in the recent past when a patient shows up, regardless of the complaint. Often, it's an "FYI your post op patient has an unrelated complaint, planning on admitting to medicine if you'd like to see them in he morning." Frequently, I find they'd rather just admit. This is one thing I really like about surgeons; they are some of the few docs that still take pride in taking care of their patients.

It's funny, as an ER doc (now doing CCM fellowship), senior/chief surgical residents and attending surgeons are some of my favorite people in the hospital. Surgical interns and junior residents I avoid like the plague.

 

[vhawk]

Yea, I think this is a big problem in learning EM in an academic center. Every surgical intern (I.e the one who first answers your page) pitches a fit when you call to let them know a post-op patient is back in the ER if the complaint isn't 1) surgical or 2) a direct complication of surgery. I vividly remember as a resident having an immediate post-op nsgy patient who fell and broke a hip a few days after being discharged from their service because they over narc'ed her, started her on a muscle relaxer, a massive dose of gabapentin, etc and messed with her meds making her hyponatremic. He pitched a fit about having him come see the patient for a nonsurgical issue. No amount of explanation made him understand the many reasons he should be seeing her. This negative feedback loop ends up hurting patients in the long run once we transition to "the real world."

Obviously, as surgeons get more senior, this perspective drastically changes. I always page any surgeon who has operated in the recent past when a patient shows up, regardless of the complaint. Often, it's an "FYI your post op patient has an unrelated complaint, planning on admitting to medicine if you'd like to see them in he morning." Frequently, I find they'd rather just admit. This is one thing I really like about surgeons; they are some of the few docs that still take pride in taking care of their patients.

It's funny, as an ER doc (now doing CCM fellowship), senior/chief surgical residents and attending surgeons are some of my favorite people in the hospital. Surgical interns and junior residents I avoid like the plague.

I think this is a really good point. There is a whole other side to the practice of surgery that involves all of these sorts of things, the taking care of your patients even outside the periop period, the being the contact person for that patient, making things happen for them and making sure they get treated approrpriately. Residents are often overworked but more I think its just that they have no concept of that at all. THEY dont wanna see this little old lady who had her GB out and now had a fall, so why would her SURGEON want to see her? I dont really know how to go about teaching them that though. If they spent time in a private model I think they'd get it, but even more junior academic attendings dont really practice or preach the "affable, available, able" mantra. Its definitely unfair to the ED residents calling consults. The further I get from intern year the more dismayed I am by the nasty tone and condescension I see from the junior surgery residents when dealing with consults. At the VERY least, you need to realize why you even exist in the first place. And you should be a lot less smug that you know what is and isnt an appropriate call.

 

[armybound]

The funny thing about that is where I trained, you couldn't convince a urologist anything needed to go to the OR. Septic from pyelo with an impacted stone? Too sick. Normal vitals? Sit them on the floor and we may add them on for the next day....

Thankfully, uro at my current hospital is phenomenal.

Everyone is different with their interpretation of the "septic stone = nephrostomy tube" mantra. Some of my staff say we shouldn't call IR unless we've already tried, others will go straight to IR if it's between certain hours and they don't feel like getting out of bed. And of course there's the "well if the patient had come in 12 hours later they'd be in the same position as if we just let them sit on the floor until the morning" excuse.

The further I get from intern year the more dismayed I am by the nasty tone and condescension I see from the junior surgery residents when dealing with consults. At the VERY least, you need to realize why you even exist in the first place. And you should be a lot less smug that you know what is and isnt an appropriate call.

I agree. My approach toward my consults has changed a lot lately, as I get more senior and take fewer direct consults. As a PGY3, especially, I would be so annoying, condescending, rude, etc to people calling me consults. How dare someone call me with such an unimportant problem! I have 1030320429 other things to do. Really I think I was just busy and didn't want to deal with one more thing to do. Now I'll talk with them, explain how I see it/work it up, what I can do, and so forth. This approach might even get me out of more consults than just being rude did.

 

[kitsunepixie]

Bullets are compatible with MRI?

They didn't know she had gotten shot when they ordered the MRI...

Another crazy consult: a newborn baby who fell out of mom's vagina while she was in the process of getting her epidural and the baby...landed on the floor and got an epidural hematoma. We watched it and I saw the baby a month later and she's doing great. Things can only go up from there, kiddo.

 

[WheezyBaby]

Bullets are compatible with MRI?

Radiology let me order a brain mri on a patient with one in their abdomen, but only because it was lodged in abdominal wall musculature. He had also had a documented mri in system. They were still hesitant though

 

[Dr.LeoSpaceman]

I think this is a really good point. There is a whole other side to the practice of surgery that involves all of these sorts of things, the taking care of your patients even outside the periop period, the being the contact person for that patient, making things happen for them and making sure they get treated approrpriately. Residents are often overworked but more I think its just that they have no concept of that at all. THEY dont wanna see this little old lady who had her GB out and now had a fall, so why would her SURGEON want to see her? I dont really know how to go about teaching them that though. If they spent time in a private model I think they'd get it, but even more junior academic attendings dont really practice or preach the "affable, available, able" mantra. Its definitely unfair to the ED residents calling consults. The further I get from intern year the more dismayed I am by the nasty tone and condescension I see from the junior surgery residents when dealing with consults. At the VERY least, you need to realize why you even exist in the first place. And you should be a lot less smug that you know what is and isnt an appropriate call.

I certainly agree with this, and don't see the point of being nasty on the phone. I tell my juniors that if someone is calling a consult, they aren't going to "get out of it" so there is no point in doing anything accept cordially taking the info. That being said, I do get a bit miffed when I get consults called by an ED resident who has not taken the time to at least briefly see the patient and perhaps order some labs if appropriate. I don't expect them to have a diagnosis, but if they've seen the patient and we can talk about it, it can often expedite the tests that they may need (or avoid tests they don't) and ultimately expedite the process of getting them through the ED.

 

[DoctwoB]

I certainly agree with this, and don't see the point of being nasty on the phone. I tell my juniors that if someone is calling a consult, they aren't going to "get out of it" so there is no point in doing anything accept cordially taking the info. That being said, I do get a bit miffed when I get consults called by an ED resident who has not taken the time to at least briefly see the patient and perhaps order some labs if appropriate. I don't expect them to have a diagnosis, but if they've seen the patient and we can talk about it, it can often expedite the tests that they may need (or avoid tests they don't) and ultimately expedite the process of getting them through the ED.

That depends on the service you are on and what services you are consulted to provide. If I didn't refuse foley placement consults until the most experienced nurse tried, they used an 18-20 coude and/or tried a small silicon catheter I wouldn't be doing anything else. Likewise for suprapubic tube exchanges. Additionally, many consults I redirect into the outpatient setting. Asymptomatic microscopic hematuria? Incidental non-obstructing small kidney stones? Follow up in clinic. That being said, things like what most of you have been discussing on here (post-op patients with ?related complaints, anybody really sick, etc.) get seen right away.

Also, stating that the primary team or nurse needs to do x, y, and z before we get involved can be done in a polite fashion or rudely, and in my opinion there is no good reason for the latter. We are all professionals and should act like it.

 

[deleted547339]

I certainly agree with this, and don't see the point of being nasty on the phone. I tell my juniors that if someone is calling a consult, they aren't going to "get out of it" so there is no point in doing anything accept cordially taking the info. That being said, I do get a bit miffed when I get consults called by an ED resident who has not taken the time to at least briefly see the patient and perhaps order some labs if appropriate. I don't expect them to have a diagnosis, but if they've seen the patient and we can talk about it, it can often expedite the tests that they may need (or avoid tests they don't) and ultimately expedite the process of getting them through the ED.

What are ya'lls thoughts on the pre-consult ED call, I.e. I have your post-op <insert surgery> patient here with <insert complaint related to surgery that will ultimately result in admission to your service>. I'm playing on doing tests X, Y and Z. Is there anything else you'd like me to get done before you see the patient?

I tend to like these calls because it often leads to quicker admits with non-emergent workups being done on the floor and keeps from getting my whole work up done then hearing "oh, I really need rest X that's going to take another hour and you didn't know to order because you're an ER doc and not a surgeon."

I feel like this would also make your workflow better as you know "ok, I have about an hour before I have to go see this patient, I should really go eat now/see this other patient/whatever because I know I have this to do later.

Does this make ya'lls lives easier, more difficult?

 

[deleted547339]

That depends on the service you are on and what services you are consulted to provide. If I didn't refuse foley placement consults until the most experienced nurse tried, they used an 18-20 coude and/or tried a small silicon catheter I wouldn't be doing anything else. Likewise for suprapubic tube exchanges. Additionally, many consults I redirect into the outpatient setting. Asymptomatic microscopic hematuria? Incidental non-obstructing small kidney stones? Follow up in clinic. That being said, things like what most of you have been discussing on here (post-op patients with ?related complaints, anybody really sick, etc.) get seen right away.

Also, stating that the primary team or nurse needs to do x, y, and z before we get involved can be done in a polite fashion or rudely, and in my opinion there is no good reason for the latter. We are all professionals and should act like it.

Yea, I never understood how a single failed attempt on a spontaneously voiding patient at 3AM leads the intern to believe they should call ya'll emergently. I'm a crit care fellow and I try to impress this on my interns and residents. It's also just sad that they don't think through trouble shooting a foley the same way they would something else and would rather just consult urology to do their work.

 

[VisionaryTics]

Yea, I never understood how a single failed attempt on a spontaneously voiding patient at 3AM leads the intern to believe they should call ya'll emergently. I'm a crit care fellow and I try to impress this on my interns and residents. It's also just sad that they don't think through trouble shooting a foley the same way they would something else and would rather just consult urology to do their work.

Same with trachs. Cuffed trachs are pretty much the same thing as cuffed orotracheal tubes, just through the neck, but I've never been consulted for "routine intubation care" like I get called for "routine trach care". No one has any idea how to trouble-shoot or manage trachs.

Don't get me started on laryngectomies. The concept of a laryngectomy is completely foreign to 95% of physicians.

I had a critical care fellow page me a few weeks ago at 2am to put a trach in a 25-year-old laryngectomy stoma because the guy was having a COPD exacerbation and needed to be vented. I'm not coming in to pop a tube into a mile-wide stoma. He refused to even try. When I told him to try an 8 DCT and if that doesn't fit, try a 6, he told me "I'm not comfortable with sizing trachs and would like you to do it." I called respiratory, and their response was "Officially, I'm not allowed to put trachs in at this hospital, but I will show the fellow what to do."

 

[LucidSplash]

A critical care fellow wasn't comfortable sizing trachs? Wtf. That's like 50% of the procedures they do in that fellowship. We start teaching our residents to size up/down and change trachs at the bedside at the junior level.

 

[Pir8DeacDoc]

Nothing worse than taking care of someone else's trach. If you can't manage it then don't do the procedure. And God help us all if a pedi patient in PICU has a trach. No matter if you could drive a truck through the stoma and it's been there for years the PICU attendings and Pedi residents will be more than comfortable to hammer page without any attempts at trying to replace it themselves.

 

[WheezyBaby]

Nothing worse than taking care of someone else's trach. If you can't manage it then don't do the procedure. And God help us all if a pedi patient in PICU has a trach. No matter if you could drive a truck through the stoma and it's been there for years the PICU attendings and Pedi residents will be more than comfortable to hammer page without any attempts at trying to replace it themselves.

Not sure why. Just grab a trach a couple sizes up from whatever's available in the room, snip the stay sutures, and blindly press the trach into the stoma

 

[Raryn]

I stalk the ED list sometimes to see if there are any potential calls. Some people get sent home very inappropriately.

We got a consult for a septic stone well after it was admitted. The IM resident's note specifically says obstructing stone, UTI, pyelo, sepsis -> no indication for urgent urologic evaluation, will call in the morning. Not sure where they got that from because that's a prime urologic emergency. Thankfully the patient did alright after emergent stenting.

Where I did my internal medicine residency, there literally was almost never an indication for urgent urologic evaluation. I had over a dozen septic stone patients and when we called the private practice urology group, 100% of the time the answer (after their PA saw the patient) was have IR put a nephrostomy tube in and have the patient follow up in the clinic. Given IR would pretty much never do one emergently, if I were admitting that specific patient, the answer would be inevitably to put them on broad spectrum antibiotics and have IR put in a nephrostomy tube in the morning. It was awful, we had patients coming in with repeated infected nephrostomy tubes because they missed their urology f/u for whatever reason or they happened to be homeless so they had no way to care for a nephrostomy tube on discharge, but there was never any indication for stone removal +/- stenting as an inpatient. Ever.

In three years, I think I got the urologists to actually physically see a patient themselves and do a procedure maybe three times, twice for massive hematuria that needed an emergent cysto and once for priapism that required b/l winters shunts. I had the PA help maybe two additional times with foleys that half the nurses in the unit failed.

So if your IM resident came from a med school that might have had a similar experience, it's not super surprising. If I hadn't done an excellent urology rotation in med school with pro-active faculty/residents, I'd probably assume the above was normal management.

 

[s109442]

Agree with Raryn, that's how my residency was and how things are done in my community now.

 

[Arch Guillotti]

but there was never any indication for stone removal +/- stenting as an inpatient. Ever.

The urologists I work with put at least one of these on a day sometimes it seems.

 

[Reisdasch]

Surgical consult for a pulsatile mass in the neck...it was the carotid artery

(and no, not aneurysmal or with a bruit. Just a normal carotid...)

 

[TraumaLlamaMD]

Called to see someone on hospital day 6 who had findings of "epiploic appendagitis" on her original CT scan - which we were very appropriately not consulted for, until GI came by for some other reason and documented "recommend surgical consult for epiploic appendagitis." THANKS GUYS

 

[turkeyjerky]

Called to see someone on hospital day 6 who had findings of "epiploic appendagitis" on her original CT scan - which we were very appropriately not consulted for, until GI came by for some other reason and documented "recommend surgical consult for epiploic appendagitis." THANKS GUYS

Just trying to fathom why this patient was admitted at all, much less for 6 days...

 

[Psai]

Just trying to fathom why this patient was admitted at all, much less for 6 days...

It must have been for some other reason like a gi bleed and then gi asked for a surgery consult for the incidentaloma. It's like when I caught a pa consulting ct surgery for a "tortuous aorta" on xray.

 

[TraumaLlamaMD]

It must have been for some other reason like a gi bleed and then gi asked for a surgery consult for the incidentaloma. It's like when I caught a pa consulting ct surgery for a "tortuous aorta" on xray.

Spot on. I refrained from pasting the UptoDate section on management of epiploic appendagitis into my consult note.

 

[kitsunepixie]

When I was a med student on my ED rotation, a Urology resident tried to get me to stick a needle in the dorsal vein of the penis on a priapism patient rather than come in to see the patient himself. My attending was like "F--- no!" IR wound up doing an embo. It was an exciting day...that patient was a prisoner who would tell me something new and weird about himself every time I came back in the room, and I can't forget the guard's face when the guy was begging me to cut off his junk. I'll stick to brains and spines, thanks!

I have other stories similar to above when I was a Uro patient about getting someone to physically come see me...i was about to stick a needle in my bladder myself when I had acute urinary retention (2L) and the nurses couldn't get a Foley in me. It was worse than labor! It depends on what group is on call that day. The Peds Urologist are all pretty great to work with where I'm at though and once I got set up with a Urogyn doc he's been wonderful.

 

[ThoracicGuy]

It must have been for some other reason like a gi bleed and then gi asked for a surgery consult for the incidentaloma. It's like when I caught a pa consulting ct surgery for a "tortuous aorta" on xray.

 

[DoctwoB]

Man, lots of urology bashing on this thread, though it sounds like most of it is deserved.

In my program, infected stones get seen immediately and stented emergently overnight. We only get IR involved for neph tubes if patient is literally too sick to move from the ICU, or if stenting failed or is highly likely to fail (e.g. giant pelvic tumor causing ureteral obstruction and distorting anatomy). Even in the case of the dying ICU patient, IR often refuses a bedside PCN because they're too fat or for any other number of reasons, and we end up trying to place a stent at the bedside at 2AM using a flexible cystoscope and intermittent KUBs instead of fluoro. Lots of fun. While there is no level one evidence for emergent stenting vs. delayed (such a trial would be unethical IMO), database analysis has shown time to stenting is a predictor for mortality.

All that said, we get paged about lots of "infected" stones that are anything but. A stone can cause pyuria and an inflammatory response, so if your UA is 2+ LE, 15 WBC, - nitrite, and your systemic WBC is 13, but you're afebrile, vitals are rock stable, and you don't look sick, it is not an emergency.

With respect to priapism, once again we see that right away and detumesce. There is something fishy about the Kitsunepixie's post though in that 1. we don't cannulate the dorsal vein, we stick needles in the corporal bodies, and 2. IR would only get involved if its a non-ischemic priapism from an AVM, which we would not detumesce anyways.

While all the Urologists I practice with would handle the above the right way, there are unfortunately a lot of crappy doctors out there. Half our priapisms are from non-urology run intracavernosal injection clinic, where they inject these old guys and then tell them to come to our ER when it won't go down. Likewise I just rotated through pediatric urology, where outside ERs with Urologists on call would fly a 17 year old with testicular torsion from 3 hours away to our ER because the urologist "won't operate on kids".

As for ridiculous consults, one of my favorites is the ER consult for flank pain. No testing or workup, but it could be a kidney stone so could I come assess patient?

 

[kitsunepixie]

With respect to priapism, once again we see that right away and detumesce. There is something fishy about the Kitsunepixie's post though in that 1. we don't cannulate the dorsal vein, we stick needles in the corporal bodies, and 2. IR would only get involved if its a non-ischemic priapism from an AVM, which we would not detumesce anyways.

While all the Urologists I practice with would handle the above the right way, there are unfortunately a lot of crappy doctors out there. Half our priapisms are from non-urology run intracavernosal injection clinic, where they inject these old guys and then tell them to come to our ER when it won't go down. Likewise I just rotated through pediatric urology, where outside ERs with Urologists on call would fly a 17 year old with testicular torsion from 3 hours away to our ER because the urologist "won't operate on kids".

As for ridiculous consults, one of my favorites is the ER consult for flank pain. No testing or workup, but it could be a kidney stone so could I come assess patient?

I was about to get my needle and go to town. Not having a penis myself, all I knew was that priapism was an emergency, and that you know things are bad when a guy is literally begging for a Lorena Bobbitt maneuver.

 

[mimelim]

Surgical consult for a pulsatile mass in the neck...it was the carotid artery

(and no, not aneurysmal or with a bruit. Just a normal carotid...)

I had a patient a month or so ago that felt his belly pulsating, so he saw his PCP and had a AAA. Pretty good catch. While I'm consenting him for his EVAR he tells me that he is concerned that he has aneurysms on both sides of his neck because he can feel his pulse there as well. Felt his neck and sure enough, he had bilateral carotid pulses. I assured him that it was normal, but if he was worried, a duplex wouldn't be crazy, especially given his other medical comorbidities. Fixed his AAA, but I'm sure that this experience has given him an anxiety disorder centered around his pulse.

 

[DoctwoB]

I was about to get my needle and go to town. Not having a penis myself, all I knew was that priapism was an emergency, and that you know things are bad when a guy is literally begging for a Lorena Bobbitt maneuver.

That is true. Even having a penis myself it's tough to imagine the kind of pain that would lead you to say "thank you" to someone sticking your penis with a 16 gauge needle.

 

[DoctwoB]

While I'm at it, a PSA for everyone.

Contrary to popular belief, the scrotum is in fact a dependent portion of the body, and will get edematous in a fluid overloaded state. When you consult me for scrotal edema in a CHF patient with 3+ pitting edema to their nipples, my consult note will read: edema 2/2 fluid overload, consider diuresis. Urology will sign off. Thank you for this interesting consult.

 

[Psai]

While I'm at it, a PSA for everyone.

Contrary to popular belief, the scrotum is in fact a dependent portion of the body, and will get edematous in a fluid overloaded state. When you consult me for scrotal edema in a CHF patient with 3+ pitting edema to their nipples, my consult note will read: edema 2/2 fluid overload, consider diuresis. Urology will sign off. Thank you for this interesting consult.

I wish there was a list of things like this

 

[ThoracicGuy]

While I'm at it, a PSA for everyone.

Contrary to popular belief, the scrotum is in fact a dependent portion of the body, and will get edematous in a fluid overloaded state. When you consult me for scrotal edema in a CHF patient with 3+ pitting edema to their nipples, my consult note will read: edema 2/2 fluid overload, consider diuresis. Urology will sign off. Thank you for this interesting consult.

Do you ever prescribe a wheelbarrow so they can help carry around their massive cojones?

 

[DoctwoB]

Do you ever prescribe a wheelbarrow so they can help carry around their massive cojones?

Usually I just tell patients to bounce on them

A pro wrestling/Borat style mankini is also effective.

 

[armybound]

While I'm at it, a PSA for everyone.

Contrary to popular belief, the scrotum is in fact a dependent portion of the body, and will get edematous in a fluid overloaded state. When you consult me for scrotal edema in a CHF patient with 3+ pitting edema to their nipples, my consult note will read: edema 2/2 fluid overload, consider diuresis. Urology will sign off. Thank you for this interesting consult.

Against my better judgment, I recently went in to see a "difficult Foley." The patient was admitted for a CHF exacerbation and they wanted accurate I/Os while on a lasix drip. Obviously not an indication for a Foley, but this patient was otherwise incontinent and I sometimes give in and will try it.
So I ask what the nurses have tried -- the IM team doesn't want the nurses to try because he's edematous and uncircumcised. Umm, ok.
I had a consult at one hospital, so I drove across town to this hospital around 9pm to throw the Foley in. I walk in the patient's room, introduce myself, let him know that his team asked for a Foley to be placed and he simply said "Nope!" I asked again, he again said "Nope!" and that was the end of our interaction.
Would have been really nice if the primary team had discussed Foley placement with their patient before I was foolish enough to drive out there to do it at night.

 

[caffeinemia]

Against my better judgment, I recently went in to see a "difficult Foley." The patient was admitted for a CHF exacerbation and they wanted accurate I/Os while on a lasix drip. Obviously not an indication for a Foley, but this patient was otherwise incontinent and I sometimes give in and will try it.
So I ask what the nurses have tried -- the IM team doesn't want the nurses to try because he's edematous and uncircumcised. Umm, ok.
I had a consult at one hospital, so I drove across town to this hospital around 9pm to throw the Foley in. I walk in the patient's room, introduce myself, let him know that his team asked for a Foley to be placed and he simply said "Nope!" I asked again, he again said "Nope!" and that was the end of our interaction.
Would have been really nice if the primary team had discussed Foley placement with their patient before I was foolish enough to drive out there to do it at night.

This is the type of thing that reminds me of consults for ng tubes....=/

 

[TraumaLlamaMD]

Against my better judgment, I recently went in to see a "difficult Foley." The patient was admitted for a CHF exacerbation and they wanted accurate I/Os while on a lasix drip. Obviously not an indication for a Foley, but this patient was otherwise incontinent and I sometimes give in and will try it.
So I ask what the nurses have tried -- the IM team doesn't want the nurses to try because he's edematous and uncircumcised. Umm, ok.
I had a consult at one hospital, so I drove across town to this hospital around 9pm to throw the Foley in. I walk in the patient's room, introduce myself, let him know that his team asked for a Foley to be placed and he simply said "Nope!" I asked again, he again said "Nope!" and that was the end of our interaction.
Would have been really nice if the primary team had discussed Foley placement with their patient before I was foolish enough to drive out there to do it at night.

Wow. I get central line consults like that regularly (some indicated, some not so much) where the patient flat out refuses and it's obvious the primary team didn't bother to talk to him first - at least I'm in house!

 

[DoctwoB]

Wow. I get central line consults like that regularly (some indicated, some not so much) where the patient flat out refuses and it's obvious the primary team didn't bother to talk to him first - at least I'm in house!

I've even gotten a consult for "patient refusing foley catheter." Called primary team and asked just what exactly they wanted me to do. Consult was removed.

 

[Psai]

I've even gotten a consult for "patient refusing foley catheter." Called primary team and asked just what exactly they wanted me to do. Consult was removed.

Suprapubic catheter

 

[VisionaryTics]

Yes, I also love trach consults when the primary team has never discussed it with the family, then I have six family members ambush me at 1am with their indignant rage when I come in, like it was my personal idea to trach this patient.