Consults- Memorable/Dismal/Ridiculous/Unique

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VisionaryTics said:
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.
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My favorite is this one time I got a surgery consult for a newly discovered liver cancer in the ed... I read CT to effect of: "No hepatic masses." This one time, the ED even did me the favor of talking to the patient about their "diagnosis" before I got there too. Setting the bar real high with the reading failure...
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SouthernSurgeon said:
I usually ask the primary team when I call them back whether the patient/family knows that surgery is being consulted...
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I should really try that. but unfortunately, at the end of the day you still gotta come. so it's like just wasted breath for the inevitable...
 
VisionaryTics said:
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.
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True. But on the flip side, the nice thing about that situation is that primary hasn't told the family that the 92 yo w/ GCS of 3 will get that trach/PEG and it will be THE answer. And then primary team helpfully tells me they already "consented" the family by explaining how it's super low risk and no downsides at all and no way anything can go wrong. And, no, there hasn't been a discussion of comfort care or palliative care or really what the patient and family wants.


This week: got a(nother) consult for pSBO w/ pt actively passing gas and having BMs. Got a consult for possible mesenteric ischemia in the sweetest little old lady on the floor...without abdominal pain who was happily eating her roast beef when I saw her.
 
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Recent consult: 50 yo admitted to hospitalist for COPD exacerbation. Got a CT angio to r/o PE on admission. He was a big guy and was stuffed into the CT scan. Rads read said "mild subcutaneous changes in upper abdominal wall that could represent cellulitis. please correlate clinically". Looking at the scan, his upper abdomen was squished in there (he was 400#).
Enter surgery consult to rule out cellulitis....in a patient with no pain, redness or any abdominal complaint whatsoever.
 
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Smurfette said:
Recent consult: 50 yo admitted to hospitalist for COPD exacerbation. Got a CT angio to r/o PE on admission. He was a big guy and was stuffed into the CT scan. Rads read said "mild subcutaneous changes in upper abdominal wall that could represent cellulitis. please correlate clinically". Looking at the scan, his upper abdomen was squished in there (he was 400#).
Enter surgery consult to rule out cellulitis....in a patient with no pain, redness or any abdominal complaint whatsoever.
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I had you're paid on productivity, cause that's an easy 1.5 wRVUs...
 
Smurfette said:
Recent consult: 50 yo admitted to hospitalist for COPD exacerbation. Got a CT angio to r/o PE on admission. He was a big guy and was stuffed into the CT scan. Rads read said "mild subcutaneous changes in upper abdominal wall that could represent cellulitis. please correlate clinically". Looking at the scan, his upper abdomen was squished in there (he was 400#).
Enter surgery consult to rule out cellulitis....in a patient with no pain, redness or any abdominal complaint whatsoever.
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Isn't cellulitis a medical diagnosis? I mean I could understand if the worry was nec fasc...

That's like admitting to hospitalist and them consulting you to rule out COPD exacerbation.
 
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evilbooyaa said:
Isn't cellulitis a medical diagnosis? I mean I could understand if the worry was nec fasc...

That's like admitting to hospitalist and them consulting you to rule out COPD exacerbation.
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Yes, cellulitis is a medical diagnosis. Yet it is a tricky beast. Somehow if it's on the scrotum it's a urology consult. If it's over a joint it's a septic joint. If it's on the breast . . . Well you get the idea.
 
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Smurfette said:
Recent consult: 50 yo admitted to hospitalist for COPD exacerbation. Got a CT angio to r/o PE on admission. He was a big guy and was stuffed into the CT scan. Rads read said "mild subcutaneous changes in upper abdominal wall that could represent cellulitis. please correlate clinically". Looking at the scan, his upper abdomen was squished in there (he was 400#).
Enter surgery consult to rule out cellulitis....in a patient with no pain, redness or any abdominal complaint whatsoever.
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More importantly....why do you need a surgery consult for cellulitis?
 
Last call, a patient was transferred in because the outlying ER said they had dead bowel.

Patient arrives, we go evaluate. Diagnosis of dead bowel was based on elevated lactate. Patient had CT scan at the outside hospital where the intraabdominal contents were unremarkable. Patient's abdominal exam is normal. Patient asks how much of her bowel we are going to have to take out. Patient does not have dead bowel.

The did however miss the fact that the patient had a necrotizing infection of the vulva and mons pubis. Obvious on the CT and read as such by their radiologist. But nothing about that in ED notes indicated they recognized that. Actually called to check and make sure this was the same patient we accepted (didn't want some other dead bowel patient floating around out there to arrive unexpectedly). We say the patient has basically Fournier's. ED doc says he is sure there is dead bowel because lactate is high.

Ok then.
 
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Smurfette said:
Recent consult: 50 yo admitted to hospitalist for COPD exacerbation. Got a CT angio to r/o PE on admission. He was a big guy and was stuffed into the CT scan. Rads read said "mild subcutaneous changes in upper abdominal wall that could represent cellulitis. please correlate clinically". Looking at the scan, his upper abdomen was squished in there (he was 400#).
Enter surgery consult to rule out cellulitis....in a patient with no pain, redness or any abdominal complaint whatsoever.
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"No cellulitis noted. Thank you for the interesting consult."
 
LucidSplash said:
ED doc says he is sure there is dead bowel because lactate is high.
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If I have to call ID to get antibiotic approval, other people should have to call me to order a lactate. ED/MICU is always good for a few mild abdominal pain + negative CT + borderline elevated lactate every week.
 
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FaytlND said:
If I have to call ID to get antibiotic approval, other people should have to call me to order a lactate. ED/MICU is always good for a few mild abdominal pain + negative CT + borderline elevated lactate every week.
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I understand your sentiment, but tell that to he guy on the other end of the spectrum. Dead gut is a diagnosis made in the OR, period.

Also, come to my hospital - interns can put anyone on linezolid, dapto, mero and colistin.....great antibiotic stewardship, lol.
 
TimesNewRoman said:
I understand your sentiment, but tell that to he guy on the other end of the spectrum. Dead gut is a diagnosis made in the OR, period.

Also, come to my hospital - interns can put anyone on linezolid, dapto, mero and colistin.....great antibiotic stewardship, lol.
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Kind of want to order dapto and linezolid together to see how pharmacy responds."you see you get the pulmonary vascular penetration to cover septic emboli and the parenchymal penetration for any tissue spread. It's flawless"
 
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TimesNewRoman said:
I understand your sentiment, but tell that to he guy on the other end of the spectrum. Dead gut is a diagnosis made in the OR, period.

Also, come to my hospital - interns can put anyone on linezolid, dapto, mero and colistin.....great antibiotic stewardship, lol.
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If it's a diagnosis made in the OR I still don't see the value in ordering the lactate. If it's negative it's still a diagnosis made in the OR right?

The only purpose a lactate serves for me as a surgeon is as a way of degrading my confidence in the story the ED doc is trying to sell me. If she says "lactate is 4 but I realize that's not very specific" I'm instantly 5x more likely to take her seriously. It is literally a litmus test
 
LucidSplash said:
Last call, a patient was transferred in because the outlying ER said they had dead bowel.

Patient arrives, we go evaluate. Diagnosis of dead bowel was based on elevated lactate. Patient had CT scan at the outside hospital where the intraabdominal contents were unremarkable. Patient's abdominal exam is normal. Patient asks how much of her bowel we are going to have to take out. Patient does not have dead bowel.

The did however miss the fact that the patient had a necrotizing infection of the vulva and mons pubis. Obvious on the CT and read as such by their radiologist. But nothing about that in ED notes indicated they recognized that. Actually called to check and make sure this was the same patient we accepted (didn't want some other dead bowel patient floating around out there to arrive unexpectedly). We say the patient has basically Fournier's. ED doc says he is sure there is dead bowel because lactate is high.

Ok then.
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cant fix stupid. I can't blame the guy, however, he fulfilled the only part of his job he really cares about... disposition.
 
LucidSplash said:
Last call, a patient was transferred in because the outlying ER said they had dead bowel.

Patient arrives, we go evaluate. Diagnosis of dead bowel was based on elevated lactate. Patient had CT scan at the outside hospital where the intraabdominal contents were unremarkable. Patient's abdominal exam is normal. Patient asks how much of her bowel we are going to have to take out. Patient does not have dead bowel.

The did however miss the fact that the patient had a necrotizing infection of the vulva and mons pubis. Obvious on the CT and read as such by their radiologist. But nothing about that in ED notes indicated they recognized that. Actually called to check and make sure this was the same patient we accepted (didn't want some other dead bowel patient floating around out there to arrive unexpectedly). We say the patient has basically Fournier's. ED doc says he is sure there is dead bowel because lactate is high.

Ok then.
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That was probably the greatest punt to Urology (depending on your hospital's culture/by laws) of all time.
 
dpmd said:
I can't get urology to take care of fournier's in a woman where I am at (nor can I get gyn involved)so either way I would have been on the hook for it.
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Yeah, luckily have never seen Fournier's in a women requiring surgery so not sure who'd do it. Not sure I'd trust the regular Ob/Gyn's to handle it properly. Gyn-onc could.
 
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On the vascular surgery service you would not believe how many consults we get from medicine for "bilateral pulseless feet." Turns out you have to know where the pulses are to palpate them.
 
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evilbooyaa said:
That was probably the greatest punt to Urology (depending on your hospital's culture/by laws) of all time.
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Nah I just took her to the OR. I was already there and seeing her so just faster to take care of it myself. Though amusingly while waiting for the case to roll, sitting in the surgeons lounge, one of the OBGYN attendings overheard me explaining the case to the Med student. He's a nice guy but can be a little pompous. So he interjects "If I may, why did you get called about that and not us?" I explained the situation to him (sent for dead bowel, etc) and that it just seemed easier to take care of her but if he really wanted the case I'd be happy to defer to him and go home. I mean she was uninsured Lol and I know my boss won't care if a service patient goes to another service. Not like I was trying to steal his patient. He says "no no it's fine I'm sure you can handle it, I'm just thinking of my residents education."

I will damn sure remember that next time if I see Fournier's in woman again in the next 4.5 months.
 
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dpmd said:
I can't get urology to take care of fournier's in a woman where I am at (nor can I get gyn involved)so either way I would have been on the hook for it.
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Yea, no way are we taking care of that. There is a whole specialty dedicated to the lady parts -- and it's not urology. The ER already expects us to I+D every scrotal pimple that comes in.
 
cpants said:
Yea, no way are we taking care of that. There is a whole specialty dedicated to the lady parts -- and it's not urology. The ER already expects us to I+D every scrotal pimple that comes in.
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I have I and d'ed my share of scrotal abscesses mislabeled as perirectal abscesses (don't ask me why). Guess I could start looking at patients before adding them on, but so far none have been anything crazy that I didn't feel I could handle and I figured the urologists wouldn't mind. Now the labial abscesses I do grill the ER more on but for some reason they can't quite tell the difference between thigh, lower abdomen, and the labial majora. Granted these are pretty fat women but still, makes me sad for the sex partners of the ER docs.
 
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dpmd said:
I have I and d'ed my share of scrotal abscesses mislabeled as perirectal abscesses (don't ask me why). Guess I could start looking at patients before adding them on, but so far none have been anything crazy that I didn't feel I could handle and I figured the urologists wouldn't mind. Now the labial abscesses I do grill the ER more on but for some reason they can't quite tell the difference between thigh, lower abdomen, and the labial majora. Granted these are pretty fat women but still, makes me sad for the sex partners of the ER docs.
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Yeah I won't even discuss female nec fasciitis with the ER -- it's either gen surg or gyn -- we don't own any of that real estate. For men, it can be game of inches. If my neighborhood general surgeons shared your magnanimous attitude I'd never I+D again!
 
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cpants said:
For men, it can be game of inches.
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So true.




(Here, all nec fasc regardless of anatomic location goes to burn surgery; if a pt is a transfer from OSH, it doesn't even go through our ER. Thank goodness.)
 
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Another good one from today: Person with a bunch of prior operations (all at my institution with notes in the system), and I get a consult from the ICU to evaluate a "chronic wound".

The chronic wound was...a mucous fistula. I told them that packing it with Aquacel Silver (as they were doing) was probably futile.
 
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FaytlND said:
Another good one from today: Person with a bunch of prior operations (all at my institution with notes in the system), and I get a consult from the ICU to evaluate a "chronic wound".

The chronic wound was...a mucous fistula. I told them that packing it with Aquacel Silver (as they were doing) was probably futile.
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Late night consult:
"Help, ENT! Big neck wound!"
...Laryngectomy

(surgical haiku)
 
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No one outside of ENT seems to understand the concept of a laryngectomy. Creates a lot of confusion..like don't pre-oxygenate their nose/mouth anesthesia.
 
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Pir8DeacDoc said:
No one outside of ENT seems to understand the concept of a laryngectomy. Creates a lot of confusion..like don't pre-oxygenate their nose/mouth anesthesia.
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Went to a respiratory code recently where RT was bagging through an uncuffed trach. Strangely enough we got ROSC when someone finally got me an ETT to put through the stoma so we could provide some effective ventilation. Apparently despite having two uncuffed Shileys at bedside the nearest cuffed trachs were 4 floors down in the ED.
 
Pir8DeacDoc said:
No one outside of ENT seems to understand the concept of a laryngectomy. Creates a lot of confusion..like don't pre-oxygenate their nose/mouth anesthesia.
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Back in training, one of my fellow residents was in a case where the anesthesiologist was trying to preoxygenate for intubation and was covering their trach site... which was a laryngectomy.

The patient was struggling to move her hand so he could breathe!
 
ThoracicGuy said:
Back in training, one of my fellow residents was in a case where the anesthesiologist was trying to preoxygenate for intubation and was covering their trach site... which was a laryngectomy.

The patient was struggling to move her hand so he could breathe!
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This is simultaneously hilarious and horrifying.
 
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I love that they try to pre-oxygenate a laryngectomy. Like they need time to shove the ETT into the gaping hole in the front of the neck. We are all creatures of habit I suppose.
 
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ThoracicGuy said:
Back in training, one of my fellow residents was in a case where the anesthesiologist was trying to preoxygenate for intubation and was covering their trach site... which was a laryngectomy.

The patient was struggling to move her hand so he could breathe!
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Anesthesiologist or CRNA? I ask because this is an unlikely mistake for a board-certified anesthesiologist to make, and also because attendings rarely preoxygenate their own patients in an academic setting.


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I was so proud of this hospitalist, then so disappointed.

A bed-bound woman has a chronic SP tube and an end colostomy. She was admitted with what sounded like proctitis. In the H&P this hospitalist mentions how her urine is likely chronically colonized and they won't treat her urine because she's asymptomatic. Her family was also requesting a workup and consultation of a zebra diagnosis and the hospitalist wrote that they felt this was low yield and a poor use of resources, so they would not perform this workup or consult GYN for this other issue. I thought this was a good plan on both counts.

Then her urine culture grew Gram-negative rods and they consulted urology. For culture they said they wouldn't treat because they knew she would be colonized. After saying they wouldn't unnecessarily consult people.
 
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armybound said:
I was so proud of this hospitalist, then so disappointed.

A bed-bound woman has a chronic SP tube and an end colostomy. She was admitted with what sounded like proctitis. In the H&P this hospitalist mentions how her urine is likely chronically colonized and they won't treat her urine because she's asymptomatic. Her family was also requesting a workup and consultation of a zebra diagnosis and the hospitalist wrote that they felt this was low yield and a poor use of resources, so they would not perform this workup or consult GYN for this other issue. I thought this was a good plan on both counts.

Then her urine culture grew Gram-negative rods and they consulted urology. For culture they said they wouldn't treat because they knew she would be colonized. After saying they wouldn't unnecessarily consult people.
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Sounds like someone dropped an L-bomb... lawyer. :smack:
 
armybound said:
I was so proud of this hospitalist, then so disappointed.

A bed-bound woman has a chronic SP tube and an end colostomy. She was admitted with what sounded like proctitis. In the H&P this hospitalist mentions how her urine is likely chronically colonized and they won't treat her urine because she's asymptomatic. Her family was also requesting a workup and consultation of a zebra diagnosis and the hospitalist wrote that they felt this was low yield and a poor use of resources, so they would not perform this workup or consult GYN for this other issue. I thought this was a good plan on both counts.

Then her urine culture grew Gram-negative rods and they consulted urology. For culture they said they wouldn't treat because they knew she would be colonized. After saying they wouldn't unnecessarily consult people.
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Re-consulted STAT(!!!!!) on the same patient yesterday. They were getting a pelvic US to rule out the zebra diagnosis they said they wouldn't work up, so they filled her bladder through her SP tube. In the most inconceivable of all side effects, she urinated... PER URETHRA! STAT re-consult for urinary incontinence.
 
armybound said:
Re-consulted STAT(!!!!!) on the same patient yesterday. They were getting a pelvic US to rule out the zebra diagnosis they said they wouldn't work up, so they filled her bladder through her SP tube. In the most inconceivable of all side effects, she urinated... PER URETHRA! STAT re-consult for urinary incontinence.
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Sounds like she needs her suprapubic out (though then you will just get called when the fistula won't close)
 
armybound said:
Re-consulted STAT(!!!!!) on the same patient yesterday. They were getting a pelvic US to rule out the zebra diagnosis they said they wouldn't work up, so they filled her bladder through her SP tube. In the most inconceivable of all side effects, she urinated... PER URETHRA! STAT re-consult for urinary incontinence.
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they did not seriously consult you for urinary incontinence...
 
mimelim said:
Consult: Bilateral non-palpable pedal pulses

Pt: Bilateral BKAs
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I think every physician should get 2 free open handed slaps per year that can be doled out to other physicians for particular episodes of just impressive stupidity.

This should be one of yours.
 
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WheezyBaby said:
Did they palpate / doppler his prostheses?
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That would have made it all the better, but no, it was from a hospitalist that hadn't seen the patient, being admitted for another problem, but because their chart said "PVD", they consulted vascular for non-palpable pulses -.-.

VA Hopeful Dr said:
I think every physician should get 2 free open handed slaps per year that can be doled out to other physicians for particular episodes of just impressive stupidity.

This should be one of yours.
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I could easily get behind this.
 
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mimelim said:
That would have made it all the better, but no, it was from a hospitalist that hadn't seen the patient, being admitted for another problem, but because their chart said "PVD", they consulted vascular for non-palpable pulses -.-.
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It should be illegal to consult another service without first seeing the patient.
 
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Two good ones recently were consult for "physiologic lordosis of the cervical spine" and a consult to rule out spinal stenosis after an elderly patient had fallen and was complaining of "radicular pain". By radicular pain they apparently meant hip pain, which was good, since I got an xray and diagnosed a hip fracture.
 
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VA Hopeful Dr said:
I think every physician should get 2 free open handed slaps per year that can be doled out to other physicians for particular episodes of just impressive stupidity.

This should be one of yours.
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i think two per week is a better number
 
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