Consults- Memorable/Dismal/Ridiculous/Unique

[VA Hopeful Dr]

i think two per week is a better number

You'll give the ER docs PTSD at that rate

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[kemper6036]

You'll give the ER docs PTSD at that rate

probably true...but better to give than to receive

 

[LucidSplash]

So many funny consults! Post yours here.

 

[Jolie South]

As a chief, I got a consult for "perirectal abscess" diagnosed by CT scan. I go talk to the patient, ask her about perianal/rectal pain, drainage, etc. She denies all. I then ask to do a rectal and look at her anus. Totally normal, no pain, but her entire uterus is prolapsed and just chillin on the bed. That's what was on scan.

Note reads: "General surgery signing off. No perirectal abscess. Completely normal rectal exam. + uterine prolapse. Recommend gyn consult."

 

[Jolie South]

ooooh another one from a fellow chief when he was at the VA.

Gets a call to come to like family medicine clinic or some crap for an anal fistula/abscess. "There's so much stool coming out. You guys need to get down here to see it."

My co chief goes down there and they have literally been packing the man's anus with iodoform gauze and he has absolutely no evidence of an abscess or fistula.

 

[TraumaLlamaMD]

ooooh another one from a fellow chief when he was at the VA.

Gets a call to come to like family medicine clinic or some crap for an anal fistula/abscess. "There's so much stool coming out. You guys need to get down here to see it."

My co chief goes down there and they have literally been packing the man's anus with iodoform gauze and he has absolutely no evidence of an abscess or fistula.

Haaaaaa! "I just don't understand - we've gone through three bottles of packing and the cavity just keeps going!"

 

[Jolie South]

My team had also placed a chest tube on a patient with PCP pneumonia/AIDS. He had like the worst ARDS I have ever seen. Day after chest tube is placed I get a call that patient is hypotensive and pneumothorax looks worse. I go see the patient. I see he is just septic and crappy because of his ARDS and another chest tube ain't gonna fix it.

As I am assessing the patient, the MICU attending comes up to me and says the "chest tube isn't working because it's not bubbling." I just like stare at him for a second like WTF.

I call my attending who says just place another tube. We do and probably injured the parenchyma massively because of all the pleural adhesions, so there is a massive air leak. The pleurevac is like rocking back and forth from the banging air leak.

The MICU attending comes over and says "thanks so much. I know this one is working much better because it is bubbling."

 

[Buzz Me]

Don't get me started on mismanagement of Pleur-Evacs...

 

[ThoracicGuy]

My team had also placed a chest tube on a patient with PCP pneumonia/AIDS. He had like the worst ARDS I have ever seen. Day after chest tube is placed I get a call that patient is hypotensive and pneumothorax looks worse. I go see the patient. I see he is just septic and crappy because of his ARDS and another chest tube ain't gonna fix it.

As I am assessing the patient, the MICU attending comes up to me and says the "chest tube isn't working because it's not bubbling." I just like stare at him for a second like WTF.

I call my attending who says just place another tube. We do and probably injured the parenchyma massively because of all the pleural adhesions, so there is a massive air leak. The pleurevac is like rocking back and forth from the banging air leak.

The MICU attending comes over and says "thanks so much. I know this one is working much better because it is bubbling."

 

[kemper6036]

Don't get me started on mismanagement of Pleur-Evacs...

at my old place, they would frequently be connected to low intermittent suction

 

[vhawk]

at my old place, they would frequently be connected to low intermittent suction

you dont want the tube to get caught up on the chest side wall do you?

 

[dynx]

Just received. From inpatient rehab doctor on a vascular patient. Wounds on feet. Already revascularized. Wound care taking. Care of feet. Sent to rehab 2 days ago.
"Consult: Dr. X, patient Mr. X reason: "can't walk"

That's why he's in f*cking rehab you stupid mthrfckr
I swear to god.

 

[dynx]

Just received. From inpatient rehab doctor on a vascular patient. Wounds on feet. Already revascularized. Wound care taking. Care of feet. Sent to rehab 2 days ago.
"Consult: Dr. X, patient Mr. X reason: "can't walk"

That's why he's in f*cking rehab you stupid mthrfckr
I swear to god.

I'm gonna reply to myself and say the language could use some work (newer nicer me!)
But in the moment you receive those pages you just can't imagine how some people manage to remember to breath let alone graduate from medical school.

 

[dynx]

Just in case I didn't put this one up yet:
Consult SMA syndrome.
My reply: although it has the name of an artery right there in the name of the syndrome it's not a vascular surgery issue....and mostly doesn't require surgery. Get a general surgery consult. Thanks for the interesting consult!

2 days later. Poor guy is still sitting there NPO. Reconsult: SMA syndrome. This time I just phoned the "MD" back and told them to read the original consult and if they were still confused they could use google to complete their medical education. Been a bit frosty with that guy since then.

 

[dpmd]

Just in case I didn't put this one up yet:
Consult SMA syndrome.
My reply: although it has the name of an artery right there in the name of the syndrome it's not a vascular surgery issue....and mostly doesn't require surgery. Get a general surgery consult. Thanks for the interesting consult!

2 days later. Poor guy is still sitting there NPO. Reconsult: SMA syndrome. This time I just phoned the "MD" back and told them to read the original consult and if they were still confused they could use google to complete their medical education. Been a bit frosty with that guy since then.

Man, don't have them consult us. At least not until they have fattened the patient up for a while without resolution.

 

[Jolie South]

Just in case I didn't put this one up yet:
Consult SMA syndrome.
My reply: although it has the name of an artery right there in the name of the syndrome it's not a vascular surgery issue....and mostly doesn't require surgery. Get a general surgery consult. Thanks for the interesting consult!

2 days later. Poor guy is still sitting there NPO. Reconsult: SMA syndrome. This time I just phoned the "MD" back and told them to read the original consult and if they were still confused they could use google to complete their medical education. Been a bit frosty with that guy since then.

I had this same consult a couple weeks ago. I was like "sounds like it, but not my problem. Consult general surgery to fix it. We ain't touching bowel."

 

[ThoracicGuy]

Just in case I didn't put this one up yet:
Consult SMA syndrome.
My reply: although it has the name of an artery right there in the name of the syndrome it's not a vascular surgery issue....and mostly doesn't require surgery. Get a general surgery consult. Thanks for the interesting consult!

2 days later. Poor guy is still sitting there NPO. Reconsult: SMA syndrome. This time I just phoned the "MD" back and told them to read the original consult and if they were still confused they could use google to complete their medical education. Been a bit frosty with that guy since then.

Thats about as good as a consult for arteritis. Just because artery is in the name doesn't mean it needs a vascular consult.

 

[Velour Fog]

Consult: Foley not draining

Foley: in the vagina

 

[Buzz Me]

Thats about as good as a consult for arteritis. Just because artery is in the name doesn't mean it needs a vascular consult.

We would get consulted for every single patient in the hospital with a chest tube (no matter who placed it) or IR pleural drain. EVERY. SINGLE. PATIENT.

 

[vhawk]

Consult: Foley not draining

Foley: in the vagina

They didnt ask you where it WAS, Mr. Smartypants, they asked you to MAKE IT DRAIN

 

[Dr.LeoSpaceman]

Got one this week from the ED for "The patient has drains and wants to transfer care here." What surgery did he have? "I don't know." Why did they put the drains in? "I don't know." Not uncommon, but annoying as it's a straight sloth consult. Despite the fact that I dislike managing drains that aren't "mine", I know that it's our responsibility, so it wasn't that aspect. It's that the ED physician spent absolutely zero effort in trying to figure it out. He knew where the patient was previously treated, so at least an effort to get the records would have been appreciated. It's the mentality of "This is going to take some effort, so I'll just dump it on another person" that annoys the hell out of me.

 

[Jolie South]

We had a patient transferred across the state from an ER for essentially claudication because the on call vascular surgeons in that town refused to see the patient. We signed off and said outpatient angiogram.

 

[Hamhock]

Got one this week from the ED for "The patient has drains and wants to transfer care here." What surgery did he have? "I don't know." Why did they put the drains in? "I don't know." Not uncommon, but annoying as it's a straight sloth consult. Despite the fact that I dislike managing drains that aren't "mine", I know that it's our responsibility, so it wasn't that aspect. It's that the ED physician spent absolutely zero effort in trying to figure it out. He knew where the patient was previously treated, so at least an effort to get the records would have been appreciated. It's the mentality of "This is going to take some effort, so I'll just dump it on another person" that annoys the hell out of me.

I hear you that the ER doc could at least ask what operation was performed. And I get it that this consult complete sucks. And maybe the ER doc could have asked the clerk to request some records while you are on your way down.

However, spending more than a few seconds getting the surgical history here would be just completely wasted time. There is absolutely no role for an ER doc with this patient other than calling the surgeon, as apparently the patient is unable to navigate the system and the patient's primary surgeon is unable or unwilling to help.

HH

 

[LucidSplash]

I hear you that the ER doc could at least ask what operation was performed. And I get it that this consult complete sucks. And maybe the ER doc could have asked the clerk to request some records while you are on your way down.

However, spending more than a few seconds getting the surgical history here would be just completely wasted time. There is absolutely no role for an ER doc with this patient other than calling the surgeon, as apparently the patient is unable to navigate the system and the patient's primary surgeon is unable or unwilling to help.

HH

Except multiple surgical specialties (ALL) use drains. So if the ED doc didn't even bother to ask what surgery the patient had, how did they know what type of surgeon to call? I call BS on your attempt to pass the buck on this.

 

[VincentAdultman]

I hear you that the ER doc could at least ask what operation was performed. And I get it that this consult complete sucks. And maybe the ER doc could have asked the clerk to request some records while you are on your way down.

However, spending more than a few seconds getting the surgical history here would be just completely wasted time. There is absolutely no role for an ER doc with this patient other than calling the surgeon, as apparently the patient is unable to navigate the system and the patient's primary surgeon is unable or unwilling to help.

HH

But it sounds like the ER doc didn't even put in a few seconds of effort. They put in zero effort.

 

[dpmd]

Except multiple surgical specialties (ALL) use drains. So if the ED doc didn't even bother to ask what surgery the patient had, how did they know what type of surgeon to call? I call BS on your attempt to pass the buck on this.

Yeah. Even a "this patient had no idea what surgery they had or why the drains were placed and I requested records but haven't gotten them yet but the scan shows the drains are in the abdomen so can you consult" would have been better. At least then I am pretty sure they shouldn't be calling the thoracic surgeon or vascular surgeon

 

[Jolie South]

Except multiple surgical specialties (ALL) use drains. So if the ED doc didn't even bother to ask what surgery the patient had, how did they know what type of surgeon to call? I call BS on your attempt to pass the buck on this.

I was about the say the same thing. Gyn? Urologic? Colon? Biliary? Pancreatic? All could have drains in the abdomen.

And just because a patient has drains and their previous surgeon doesn't want to "deal with the patient" doesn't mean that they are in need of another operation or that they need to be admitted to a surgical service.

 

[dpmd]

I was about the say the same thing. Gyn? Urologic? Colon? Biliary? Pancreatic?

And just because a patient has drains and their previous surgeon doesn't want to "deal with the patient" doesn't mean that they are in need of another operation or that they need to be admitted to a surgical service.

Actually sounds like the patient didn't want to deal with the surgeon. Also, I was giving the benefit of the doubt that the person required admission and had surgical issue but you are absolutely right that there is no reason to assume that.

 

[vhawk]

I hear you that the ER doc could at least ask what operation was performed. And I get it that this consult complete sucks. And maybe the ER doc could have asked the clerk to request some records while you are on your way down.

However, spending more than a few seconds getting the surgical history here would be just completely wasted time. There is absolutely no role for an ER doc with this patient other than calling the surgeon, as apparently the patient is unable to navigate the system and the patient's primary surgeon is unable or unwilling to help.

HH

You dont think there is any value at all in conveying to the accepting physician that you actually give two ****s about the patients in your care? You dont foresee any negative consequence to showing him that you, in fact, dont?

 

[Hamhock]

You dont think there is any value at all in conveying to the accepting physician that you actually give two ****s about the patients in your care? You dont foresee any negative consequence to showing him that you, in fact, dont?

...but that's the thing: this patient is not in the care of the ED doc. The patient is physically in the ED, but is not there in any way to see the ED doctor.

ED docs are mocked as 'triage monkeys' all the time, incorrectly. However, it sounds like the EM doc identified correctly her role as a 'triage monkey' and made the call and then moved on to patient's who needed urgent or emergent attention.

Yes, the ED doc could have performed a medical screening exam and then referred the patient to an outpatient clinic. This may be the right thing to do, but in our system (assuming this was in the US) there are pressures far more powerful than an irritated surgeon that make such a move a bad idea.

I highly suspect that this case was just as irritating to the ED doc as it was to the surgeon. The only difference is that the surgeon has to do more work. It completely sucks, I agree...but I don't think the ED doc spending a ton of time with this patient would make it any better (before responding, please see the caveats I put in my first post above).

HH

 

[tiedyeddog]

...but that's the thing: this patient is not in the care of the ED doc. The patient is physically in the ED, but is not there in any way to see the ED doctor.

ED docs are mocked as 'triage monkeys' all the time, incorrectly. However, it sounds like the EM doc identified correctly her role as a 'triage monkey' and made the call and then moved on to patient's who needed urgent or emergent attention.

Yes, the ED doc could have performed a medical screening exam and then referred the patient to an outpatient clinic. This may be the right thing to do, but in our system (assuming this was in the US) there are pressures far more powerful than an irritated surgeon that make such a move a bad idea.

I highly suspect that this case was just as irritating to the ED doc as it was to the surgeon. The only difference is that the surgeon has to do more work. It completely sucks, I agree...but I don't think the ED doc spending a ton of time with this patient would make it any better (before responding, please see the caveats I put in my first post above).

HH

Lol, one day soon a computer will perform the "ED triage monkey role". Our current technology could have done a better job, actually.

I feel comfortable it will take far longer for computers and robots to take over the surgeon role. Can't wait until Watson is calling me in the middle of the night for a consult. Might actually get a better sign out half the time.


Sent from my iPhone using Tapatalk

 

[akwho]

...but that's the thing: this patient is not in the care of the ED doc. The patient is physically in the ED, but is not there in any way to see the ED doctor.

ED docs are mocked as 'triage monkeys' all the time, incorrectly. However, it sounds like the EM doc identified correctly her role as a 'triage monkey' and made the call and then moved on to patient's who needed urgent or emergent attention.

Yes, the ED doc could have performed a medical screening exam and then referred the patient to an outpatient clinic. This may be the right thing to do, but in our system (assuming this was in the US) there are pressures far more powerful than an irritated surgeon that make such a move a bad idea.

I highly suspect that this case was just as irritating to the ED doc as it was to the surgeon. The only difference is that the surgeon has to do more work. It completely sucks, I agree...but I don't think the ED doc spending a ton of time with this patient would make it any better (before responding, please see the caveats I put in my first post above).

HH

Oh come on, that consult is straight lazy. I can't believe you are defending it. The consults I get where the ED doc missed something large is when they take off their doctor hat and put on their triage monkey hat. Don't be a monkey.

 

[vhawk]

...but that's the thing: this patient is not in the care of the ED doc. The patient is physically in the ED, but is not there in any way to see the ED doctor.

As in, he didnt make an appointment to see Dr. Ed? Yes I agree. Other than that, I dont really know what you mean. "physically in the ED, but not there in any way to see the ED doctor" seems to describe the majority of the patients under the care of Dr. Ed.

 

[VincentAdultman]

...but that's the thing: this patient is not in the care of the ED doc. The patient is physically in the ED, but is not there in any way to see the ED doctor.

ED docs are mocked as 'triage monkeys' all the time, incorrectly. However, it sounds like the EM doc identified correctly her role as a 'triage monkey' and made the call and then moved on to patient's who needed urgent or emergent attention.

Yes, the ED doc could have performed a medical screening exam and then referred the patient to an outpatient clinic. This may be the right thing to do, but in our system (assuming this was in the US) there are pressures far more powerful than an irritated surgeon that make such a move a bad idea.

I highly suspect that this case was just as irritating to the ED doc as it was to the surgeon. The only difference is that the surgeon has to do more work. It completely sucks, I agree...but I don't think the ED doc spending a ton of time with this patient would make it any better (before responding, please see the caveats I put in my first post above).

HH

I think you couldn't be more wrong, but I applaud you for coming to the surgery forum to defend it. Takes some balls.

 

[Dr.LeoSpaceman]

ED docs are mocked as 'triage monkeys' all the time, incorrectly. However, it sounds like the EM doc identified correctly her role as a 'triage monkey' and made the call and then moved on to patient's who needed urgent or emergent attention.

Except in this situation, it's correct to call this a "triage monkey" move. This episode is precisely why I use the term, because it's not an isolated thing. And yeah, we all want to be doing more exciting stuff. I would prefer 30-45 minutes of my day weren't spent on meaningless adminstrative tasks. And yet, I do them because they're part of my job.

And for clarity, this is not some bustling ED...it's 15 beds with 3 attendings. Asking the clerk to call the other hospital wasn't going to tear him away from some life or death episode of atypical chest pain. I even asked, "Can you just send him out and refer him to our clinic?" The answer was, "No, I think you better come down and see him." How can he say that when he knows essentially nothing about the patient?

You response here is exactly what annoyed me in the first place. The implication being that your time is more valuable than mine. If he would have said "Hey, I'm getting slammed down here and havent had a chance to get more info", I would have said "No problem, I can figure things out." It's 5pm on a OR day, which means there are a number of other things I'm trying to do. And considering that every ED resident I know brags about working so few shifts in order to be full time, I don't feel bad if you have to do a little extra here and there.

Finally, you are wrong that the info wouldn't have changed things. The info would have changed things if the drains were the results of a procedure that wasn't general surgery.

 

[dpmd]

Except in this situation, it's correct to call this a "triage monkey" move. This episode is precisely why I use the term, because it's not an isolated thing. And yeah, we all want to be doing more exciting stuff. I would prefer 30-45 minutes of my day weren't spent on meaningless adminstrative tasks. And yet, I do them because they're part of my job.

And for clarity, this is not some bustling ED...it's 15 beds with 3 attendings. Asking the clerk to call the other hospital wasn't going to tear him away from some life or death episode of atypical chest pain. I even asked, "Can you just send him out and refer him to our clinic?" The answer was, "No, I think you better come down and see him." How can he say that when he knows essentially nothing about the patient?

You response here is exactly what annoyed me in the first place. The implication being that your time is more valuable than mine. If he would have said "Hey, I'm getting slammed down here and havent had a chance to get more info", I would have said "No problem, I can figure things out." It's 5pm on a OR day, which means there are a number of other things I'm trying to do. And considering that every ED resident I know brags about working so few shifts in order to be full time, I don't feel bad if you have to do a little extra here and there.

Finally, you are wrong that the info wouldn't have changed things. The info would have changed things if the drains were the results of a procedure that wasn't general surgery.

What ended up happening with the patient? I think we are all curious now.

 

[Dr.LeoSpaceman]

What ended up happening with the patient? I think we are all curious now.

2x PTC and perc chole tube for cholangitis, though his acute episode had completely resolved and he was just waiting for definitive therapy. History of gastric bypass, so we inherited his ned for lap assisted ERCP and chole (which I doubt will be a chip shot).

 

[dpmd]

2x PTC and perc chole tube for cholangitis, though his acute episode had completely resolved and he was just waiting for definitive therapy. History of gastric bypass, so we inherited his ned for lap assisted ERCP and chole (which I doubt will be a chip shot).

Ah, see at my hospital that would absolutely have been vital information because it would have meant the patient absolutely should not be admitted and should instead be transferred for higher level of care (because our GI guys won't even try the ERCP and I wouldn't want to **** around with an open CBDE since we have no lap CBDE equipment in our facility and I haven't done either since residency). By failing to get the info the EM doc might have gotten the patient admitted to the hospitalist then we would be stuck trying to do an inpatient to inpatient transfer instead of ED to ED (or outpatient which it sounds like the patient could have had). Inpatient to inpatient attempt would have bought the patient a week or more in the hospital waiting for a bed to open up. Very glad our EM folks tend to not be triage monkey types.

 

[Gastrapathy]

Just as an aside, if someone had a PTC, they should not need lap-ERCP for duct clearance. You can do everything, including Spy/lithotripsy thru a 12f sheath from above. Have to do sphincteroplasty instead of sphinceterotomy but otherwise it's the same.

 

[dpmd]

Just as an aside, if someone had a PTC, they should not need lap-ERCP for duct clearance. You can do everything, including Spy/lithotripsy thru a 12f sheath from above. Have to do sphincteroplasty instead of sphinceterotomy but otherwise it's the same.

I feel pretty confident that no one in town does that either.

 

[Dr.LeoSpaceman]

Just as an aside, if someone had a PTC, they should not need lap-ERCP for duct clearance. You can do everything, including Spy/lithotripsy thru a 12f sheath from above. Have to do sphincteroplasty instead of sphinceterotomy but otherwise it's the same.

Very interesting. Not sure I have ever seen that. All these patients get funneled to GI, and I wonder if they don't want to give away the scopes. It's certainly not because our staff enjoys doing lap-assisted ERCP.

 

[Gastrapathy]

Once the patient has a hole in their BD, I've never understood making a hole in their stomach to position a scope to allow us to make a hole in their BD.

EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. - PubMed - NCBI

Also an option in a few centers and likely soon to be a relatively available option.

Combined surgical procedures are day-destroying banes of my existence.

 

[pleh]

I once received a consult from an EM/IM resident in the ED (one notoriously known for being a condescending jerk) for a bowel obstruction. I asked why he thought the pt had an obstruction and he said what he knew I'd want to hear (abdominal pain, n/v, no BM, etc) + plain series showed an "obstructive gas pattern". So I said ok sounds good, I'll be right there! Go down to see the patient. Proceed with abdominal exam and see that patient has an ostomy. bag full of formed stool and air. No abdominal tenderness. The patient said he felt fine now, but had some pain earlier, ostomy had been productive of stool and air. Had an episode of emesis the night before. I went and found the resident, who happened to be sitting next to his attending at the time. Told him I examined the patient and asked him what he thought of the abdominal exam? He said "tender throughout". And his ostomy I asked? He looked at me like a deer in the headlights....he had never examined the patient, had no idea what his surgical history was. Had received the patient during signout from the previous resident (hours ago) and was told to consult surgery (which was all based on an xray).

 

[DoctwoB]

...but that's the thing: this patient is not in the care of the ED doc. The patient is physically in the ED, but is not there in any way to see the ED doctor.

ED docs are mocked as 'triage monkeys' all the time, incorrectly. However, it sounds like the EM doc identified correctly her role as a 'triage monkey' and made the call and then moved on to patient's who needed urgent or emergent attention.

Yes, the ED doc could have performed a medical screening exam and then referred the patient to an outpatient clinic. This may be the right thing to do, but in our system (assuming this was in the US) there are pressures far more powerful than an irritated surgeon that make such a move a bad idea.

I highly suspect that this case was just as irritating to the ED doc as it was to the surgeon. The only difference is that the surgeon has to do more work. It completely sucks, I agree...but I don't think the ED doc spending a ton of time with this patient would make it any better (before responding, please see the caveats I put in my first post above).

HH

Are you freaking kidding me? He is in the ED and has not been accepted to an admitting service. He is YOUR patient. Be a doctor. Even if you are just serving as triage, in this case triaging means getting the patient to the right specialty, which means figuring out what they are there for.

 

[armybound]

I feel like there's a dichotomy in EM training. One school is to figure out who to consult as quickly as possible with the least amount of information necessary, and the other is to treat the patient as well as you can before requiring a consultant.

Interesting future for EM.

 

[Jolie South]

I feel like there's a dichotomy in EM training. One school is to figure out who to consult as quickly as possible with the least amount of information necessary, and the other is to treat the patient as well as you can before requiring a consultant.

Interesting future for EM.

I also like when I would get consulted as a resident to sew up a basic linear laceration because the EM person "doesn't have time." Right because I as the chief trauma resident definitely do and need the experience of sewing up a dumb lac. At least they get to bill for it! And maybe if they did it more than once in a blue moon it would look better than a 5 year old doing cross-stitch!

 

[vhawk]

Very interesting. Not sure I have ever seen that. All these patients get funneled to GI, and I wonder if they don't want to give away the scopes. It's certainly not because our staff enjoys doing lap-assisted ERCP.

I mean you really shouldn't be doing lap assist ercp on someone who already has a ptc. If the argument is to clear the duct INSTEAD of doing it percutabeously through the liver that's fair but the patient already has a ptc. You can clear their duct with almost no risk compared to making a hole in their stomach.

 

[HighPriest]

I had a consult once from the ER. 3am. Concerns for airway compromise due to angioedema. They state the patient has swelling of the face, changes in the voice. Of course, I'm not in the hospital. I race there, and as usual no one has called the in-house anesthetist or the in-house general surgeon for this emergent airway. There are no ER docs in the room. The patient isn't on pulse oximetry. No oxygen. Furthmore, the patient had presented for stomach pain, but the ER doc had made the angioedema call because of "facial swelling." There wasn't any facial swelling. The patient was simply a man changing gender, and so he had more prominent facial features than the ER doc had expected, and a lower voice than the ER doc had expected. I verified that's what the ER doc was worried about, and then we all looked at his driver's license, which showed no changes from his presentation.

Take home point: that's not angioedema, that's a man, baby. Also: an airway emergency shouldn't be the patient you leave in a dark room unattended, even if it is a man.

 

[tiedyeddog]

A consult I have appallingly seen multiple times: Old man sitting at home abruptly stops moving a single leg. Cannot feel nor move the entire leg. The leg is painful. STAT consult to neurosurgery for cauda equina. No imaging done, or maybe a CT or xray of lower back is done but negative, but I must evaluate patient IMMEDIATELY. I always ask "how are the pulses in the limb"? Always the same response "pulses palpable. Why do you ask?" Go see the patient. Leg is pale. Shiny. No pulses in the leg in question, including a femoral while the contralateral side has bounding femoral pulses. The leg is cold while the other is not. Patient is a heavy smoker, history of PAD/CAD. I usually call vascular surgery myself and the patient ends up getting rushed to OR/IR for thrombectomy.

Another awesome consult that occurs a couple times a month: patient PEA in field, coded for 45 minutes - 1 hour. Gets ROSC. Admitted to MICU. Head CT done showing global edema, MRI might show massive hypoxic-anoxic brain injury. Generates a STAT consult for bolt or surgical decompression. I go see patient. Patient is always off sedation, appears brain dead. No brainstem reflexes. My response is always the same, I am not a transplant surgeon. I don't do surgery on dead people....

 

[dpmd]

Another awesome consult that occurs a couple times a month: patient PEA in field, coded for 45 minutes - 1 hour. Gets ROSC. Admitted to MICU. Head CT done showing global edema, MRI might show massive hypoxic-anoxic brain injury. Generates a STAT consult for bolt or surgical decompression. I go see patient. Patient is always off sedation, appears brain dead. No brainstem reflexes. My response is always the same, I am not a transplant surgeon. I don't do surgery on dead people....

As annoying as I bet that is, it is overall a better outcomes than the ones I used to get consulted on for trach/peg because they still have just enough to not be brain dead (but no chance at anything besides a life at the vent farm)