Consults- Memorable/Dismal/Ridiculous/Unique

[SLUser11]

Blah blah blah

The further you go in residency the slower you find yourself walking to so called "emergencies".....It might be the under-called consult with "you can see it in the morning, no big deal" (only to find dead gut an hour later) or the over-called vaginal bleed... Patients will die.


JAD

There's no melodrama or surgery savior complex. I just completely disagree with you. If there's any drama, it comes from your vivid imagery of the stupid and valiant surgery resident "wrapped like a patriot in the American flag."

I definitely don't think all medicine residents are stupid, and surgery is the light. I think there are dumb@sses in every specialty, including surgery, and there are excellent residents in all specialties, including medicine or, god forbid, emergency medicine. I do think, however, that once someone has shown their cards as a true dumb@ss, trying to manage a critical patient over the phone with them is very difficult and can be risky.

Anyway, I'm not as far as you in my training, but I have been doing this for a while, too. If you really want to get residents to accept your laid-back approach to emergencies, you need to start earlier. There's actually an "intern advice thread" recently started on this same page....but you better get over there quick...the first piece of advice is "always go see the patient."

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[JackADeli]

I do think, however, that once someone has shown their cards as a true dumb@ss, trying to manage a critical patient over the phone with them is very difficult and can be risky.

...If you really want to get residents to accept your laid-back approach to emergencies, you need to start earlier. There's actually an "intern advice thread" recently started on this same page....but you better get over there quick...the first piece of advice is "always go see the patient."

Obviously we will disagree. Though, I will add just a few final thoughts and clarification....
We are not talking about a nurse calling the intern with a hypotensive patient. It was clearly pointed out that this scenario was.... in an academic ICU setting. It is a resident/intern in an ICU calling about a patient he/she has not seen. I am not saying to ignore patient care requirements. I am saying end with the constant panic mode indoctrination and be smart. Yes, you can ask who, what, where, and when. You do not need to spend 5-7 years becoming one of Pavlov's dogs responding to that beeping/vibrating box. It beeps you jump.... heaven forbid you actually use your brain and ask appropriate questions and when the system is in place (i.e. academic ICU) ensure it is being used. You are a surgeon or want to be one. So, be the smart one on the phone. Get some vitals and have THEM (i.e. ICU residents) look at the patient. It's not about being "laid back" it's about using your brains and the systems in place... especially in residency. You should have little difficulty using the phone.

...I know that maybe nine times out of ten it doesn't make a difference, but the tenth time the patient can benefit greatly from my "over-enthusiasm."

Fatigue hurts patients and causes accidents. Jumping like the Pavlov dog to every beep and just seeing every patient shortchanges the patients that need your attention. The resident could have ascertained urgency over the phone from an academic ICU. Instead, I picture the drama I saw all to common in residency: gensurgery resident showing up to innapropriate consult. He/she is annoyed if not outright angry. Everyone made to pay at the scene.... MICU now full of fear calls consults far too late for patient. I say, be smart, ask questions particularly when the patient is in a relatively safe location with high-end medical back-up (i.e. academic ICU).

This horse is dead.... I think.

JAD

 

[SLUser11]

This horse is dead.... I think.

JAD

Well, at least we can agree on that.

 

[JackADeli]

Just thinking back to some of the more memorable consults:

Someone calling:
a consult to the pede surgery service for a 32 year old developmental delayed/Downs/etc.... "well, the patient is really small for their age....I mean he can't be any bigger then the average 15 year old"

Consult:
to see patient with "hard belly"..... chief resident takes the consult, he gets there promptly to find the patient is dead.... has been dead for hours....(no one is sure exactly how long) is in rigor and gaseous abdominal distention!!! Consult reads something like:
" asked to see dead patient. We concur, there is nothing surgery can offer to improve this patient's condition ....thank you for allowing us to participate in the care of this very interesting patient"

ED:
We are discharging this patient, there is nothing for surgery...."but you know how the environment is out there and we just wanted to share the liability"

 

[TheGrog]

Consult:
to see patient with "hard belly"..... chief resident takes the consult, he gets there promptly to find the patient is dead.... has been dead for hours....(no one is sure exactly how long) is in rigor and gaseous abdominal distention!!! Consult reads something like:
" asked to see dead patient. We concur, there is nothing surgery can offer to improve this patient's condition ....thank you for allowing us to participate in the care of this very interesting patient"

LMFAO!!!! I am amazed that the resident actually had the thought to even write something....let alone something that funny!

 

[JackADeli]

LMFAO!!!! I am amazed that the resident actually had the thought to even write something....let alone something that funny!

It got funnier in some ways. The chief informed the medicine resident... who propmtly asked, "should we call a code?", the chief said, "no, you should pronounce him and call the family....you can have the chart when I'm done".

 

[LovelyRita]

Just thinking back to some of the more memorable consults:

Someone calling:
a consult to the pede surgery service for a 32 year old developmental delayed/Downs/etc.... "well, the patient is really small for their age....I mean he can't be any bigger then the average 15 year old"

Consult:
to see patient with "hard belly"..... chief resident takes the consult, he gets there promptly to find the patient is dead.... has been dead for hours....(no one is sure exactly how long) is in rigor and gaseous abdominal distention!!! Consult reads something like:
" asked to see dead patient. We concur, there is nothing surgery can offer to improve this patient's condition ....thank you for allowing us to participate in the care of this very interesting patient"
ED:
We are discharging this patient, there is nothing for surgery...."but you know how the environment is out there and we just wanted to share the liability"

that's my line when I get a consult for bilateral leg swelling (for vasc surg) in a pt with a chf exacerbation.

Anyway, today I got a vascular consult for "no thrill or bruit in AV fistula." Turns out it was a guy we tied off his fistula a few weeks ago because he had an aneurysm.

So I wrote in the progress note "reason for no thrill or bruit in AVF is because it has been tied off. Please see op note from (2 weeks ago). F/u in office."

 

[Docgeorge]

Or maybe I'm just really good at finding peni.

Ummm...you free friday night????

 

[skiz knot]

Today at the VA I got myself a doozy of a consult. Patient seen in ED with complaints of suprapubic, RLQ (hx of appendectomy), and R flank pain. Was seen in same ED 3 days prior with similar complaints, CT scan normal. UA at that time showed +Est/+Nit/WBC/Bacteria. Patient sent home with lortab, no abx. It is a wonder she came back to the ED. It is more of a head scratcher that surgery was consulted to see this patient before any labs were drawn (which went on to show UTI?

 

[Winged Scapula]

Ummm...you free friday night????

Why yes, as a matter of fact...

 

[Dimoak]

Today at the VA I got myself a doozy of a consult. Patient seen in ED with complaints of suprapubic, RLQ (hx of appendectomy), and R flank pain. Was seen in same ED 3 days prior with similar complaints, CT scan normal. UA at that time showed +Est/+Nit/WBC/Bacteria. Patient sent home with lortab, no abx. It is a wonder she came back to the ED. It is more of a head scratcher that surgery was consulted to see this patient before any labs were drawn (which went on to show UTI?

You should've gotten her a pelvic ultrasound.

 

[DHT]

Ummm...you free friday night????

Looking for someone to help you find it?

 

[Docgeorge]

Why yes, as a matter of fact...

Too bad I'm in Ohio. Next time i'm in your neck of the woods i'll give you a holler...

 

[Docgeorge]

Looking for someone to help you find it?

It's much easier to find now that i've got Loupes!

 

[Winged Scapula]

It's much easier to find now that i've got Loupes!

The question is...2.5 or 3.5 mag?

 

[skiz knot]

You should've gotten her a pelvic ultrasound.

Pt with hx of chole, appy, TAH-BSO...

 

[JackADeli]

The question is...2.5 or 3.5 mag?

3.5 and never less...but maybe more

PS: and always an expanded field

 

[Docgeorge]

The question is...2.5 or 3.5 mag?

I've been told that its not the size that counts (not that im ashmed of the size) but rather the field width...at least thats my story and I'm sticking to it.

 

[surgres88]

Sorry to steer the thread back to an obviously less enjoyable subject matter, dismal consults. Here is one against "our" team.

Consult to medicine: 30 YO healthy woman POD # 5 s/p lap appy for appendicitis who presented with fevers and a CT scan showing an abscess in the RLQ. Patient was discharged 3 days prior from surgery service. Surgery was called and the patient's surgeon said: "We were in there but this isn't related to her surgery. Have OB/Gyn see and evaluate the patient and then ask medicine to admit her." When I heard the story, not sure what they taught this "board certified" surgeon in training, but this is pretty dismal on their part. Additionally, they didn't come to evaluate the patient. Also, I think this would be a set-up to be sued. Isn't abandoning your patient high up there on the rank of things to try to avoid. Maybe this "surgeon" is trying to avoid admitting bad outcomes/morbidities/afraid of decreased reimbursements/or just plain lazy. Any attendings/fellows in the real world please educate me on this one?

 

[JackADeli]

...woman POD # 5 s/p lap appy for appendicitis who presented with fevers and a CT scan showing an abscess in the RLQ. Patient was discharged 3 days prior from surgery service.... evaluate the patient and then ask medicine to admit her." ...this is pretty dismal on their part. ...they didn't come to evaluate the patient. Also, I think this would be a set-up to be sued. ...Maybe this "surgeon" is trying to avoid admitting bad outcomes/morbidities/afraid of decreased reimbursements/or just plain lazy....

Ok, I will give this one a whack....
1. I will start with the heresy of reality and real world.... Surgeons in community practice do in fact practice similar to ortho and other subspecialties.... In fact, is quite common for a patient to present with acute appy, ed calls GSurge, Gsurge confirms patient stable (over phone), patient admitted to medicine over night on IV antibiotics, lap appy in AM.... Gist of it is, GSurge does in numerous locals act as consultant and not primary.

2. Patient presents post-appy with localized RLQ abscess. By scenario (given) sounds like not unstable and not shock.... The treatment is almost universal non-operative.... Thus (refer to 1), recommendations would be admit to medicine, IR/CT drain, IV antibiotics....

3. As far as not evaluate.... well, if a decent report given over phone "wound looks excellent, no purulence/erythema, patient hemodynamic stable, CT-Scan report shows x,y,z , IR going to drain, ..." then in an otherwise healthy young patient there is nothing further for the surgeon to evaluate. "Trying to avoid".... I don't know the community particulars. But see 1&2 above. There is really no surgeon intervention required. Ideally, surgeon will stop by and meet with family, etc.... that helps maintain some interaction and good blood... The hospital & hospitalist & IR will all make money on this deal.

Yes, I know the residency programs preach the all knowing & all encompassing GSurgeon picking up for all the innadequate medical fields... But, again, in numerous communities, the surgeon is NOT a primary provider, rather a highly skilled consultant... In fact, if an operative patient falls off protocol trajectory, it is common to immediately transfer to medicine. I remember in residency that alll DM foot wounds were admitted to Vasc service. Other centers these are admitted to ID medicine service with vasc consult. In my residency, most of the subspecialty medicine services were consult only and had no "service" to admit to.... In numerous communities it is the oposite, surgical specialties are consult with limited primary service and medical specialties do actually admit to a service..... Remember, isn't medicine suppose to be the "Gate Keeper"....

JAD

 

[surgres88]

Ok, I will give this one a whack....
1. I will start with the heresy of reality and real world.... Surgeons in community practice do in fact practice similar to ortho and other subspecialties.... In fact, is quite common for a patient to present with acute appy, ed calls GSurge, Gsurge confirms patient stable (over phone), patient admitted to medicine over night on IV antibiotics, lap appy in AM.... Gist of it is, GSurge does in numerous locals act as consultant and not primary.

2. Patient presents post-appy with localized RLQ appy. By scenario sounds like not unstable and not shock.... The treatment is almost universal non-operative.... Thus (refer to 1), recommendations would be admit to medicine, IR/CT drain, IV antibiotics....

3. As far as not evaluate.... well, if a decent report given over phone "wound looks excellent, no purulence/erythema, patient hemodynamic stable, CT-Scan report shows x,y,z , IR going to drain, ..." then in an otherwise healthy young patient there is nothing further for the surgeon to evaluate. "Trying to avoid".... I don't know the community particulars. But see 1&2 above. There is really no surgeon intervention required. Ideally, surgeon will stop by and meet with family, etc.... that helps maintain some interaction and good blood... The hospital & hospitalist & IR will all make money on this deal.

Yes, I know the residency programs preach the all knowing & all encompassing GSurgeon picking up for all the innadequate medical fields... But, again, in numerous communities, the surgeon is NOT a primary provider, rather a highly skilled consultant... In fact, if an operative patient falls off protocol trajectory, it is common to immediately transfer to medicine. I remember in residency that alll DM foot wounds were admitted to Vasc service. Other centers these are admitted to ID medicine service with vasc consult. In my residency, most of the subspecialty medicine services were consult only and had no "service" to admit to.... In numerous communities it is the oposite, surgical specialties are consult with limited primary service and medical specialties do actually admit to a service..... Remember, isn't medicine suppose to be the "Gate Keeper"....

JAD

Thank you for your response. I think your description is true, accurate, and appropriate regarding surgeons at community practice. And, yes I agree nearly all post-op appy abscess do not require surgery to do much. What set me off, is having heard from the MD who talked to surgeon and was told "We were there this isn't related to our operation." Getting OB/GYN to check her out. I'm only a male R4, I can't make the leap from a post-op appy abscess (surg path confirmed appy and CT diagnosis of abscess) to needing an OB/GYN consult. Granted maybe my DDx. isn't long enough.

 

[JackADeli]

... I think your description is true, accurate, and appropriate regarding surgeons at community practice. And, yes I agree nearly all post-op appy abscess do not require surgery to do much. What set me off, is having heard from the MD who talked to surgeon and was told "We were there this isn't related to our operation." ...I can't make the leap from a post-op appy abscess...

Yep, I can't speak to the particulars.... Unfortunately, residency sets up experiences that is in numerous cases backwards from what "real" practice is. This has caused numerous problems within the community. The fresh out medicine attending.... now having to admit and manage patients that they used to be able to find some reason or another to insist on a surgery admit. The fresh out surgery attending used to having mighty control and admit everything.... Maybe just too hard to let go and so you seek an excuse. I don't know. Now, you find very peculiar and convoluted reasons why not to admit to surgery....

All the surrounding commentary is just fluff and unnecessary. Could have just been a phone call, description, then admit med, IV antibiotics, IR drainage, I will say hello to the family in the morning.... if any "social issues" in history then yes have OB see patient, etc.... but most likely a post-op peri-appy bed abscess that is NOT in and of itself a complication of the procedure; just another component of the primary disease process that does happen. There is no surgical technique that can be applied and absolutely prevent the occurence 100%....

I would caution you on what the attending may or may not have reported to you. There is a great deal of hyperbole in the stories. I once heard about the resident that saved a patient in the MICU from death by identifying a vaginal bleed A great deal of one-upmanship.... People taking pride in the great salvation and talking about "abandonment", etc.... Alot of that is used to try and bully sub-specialties into doing this or that....

JAD

 

[SocialistMD]

3. As far as not evaluate.... well, if a decent report given over phone "wound looks excellent, no purulence/erythema, patient hemodynamic stable, CT-Scan report shows x,y,z , IR going to drain, ..." then in an otherwise healthy young patient there is nothing further for the surgeon to evaluate. "Trying to avoid".... I don't know the community particulars. But see 1&2 above. There is really no surgeon intervention required. Ideally, surgeon will stop by and meet with family, etc.... that helps maintain some interaction and good blood... The hospital & hospitalist & IR will all make money on this deal.

I have a problem with this mentality. If the patient continues to develop problems or fails the abx/drain route or it turns out it is actually a staple-line dehiscence and there is a hole in the bowel that just hasn't manifested free air yet, the surgeon is going to have to go back in. Having them driving the ship from the start would be ideal, as (a) they know the expected trajectory much better than internists and (b) an intraabdominal abscess is still predominantly a surgical problem despite the fact that IR can put a drain in (talk about not having an admitting service).

 

[JackADeli]

...I have a problem with this mentality...

I think alot of folks, especially residents and academic attendings would have a problem with this "mentality". Yet, it is quite common practice & common place in actual community practice.... I would add, if the surgeon did not admit the patient, rather med admit with antibiotics & IR drainage, and surgeon actually just formally served as consult.... would there be a problem? rhetorical....Like I said, just answering with the heresy of some of the reality that exists.

You raise the possibility of a true worst case scenario... one I heard about but never, ever saw in seven years of general surgery residency. At the university level, one can get away with CT scan every belly pain... endometriosis = scan her, biliary cholic = scan her, appy = scan her and super-size the order, order all the labs to go.... my residents will manage. In community practice, things are based on common things being common and rare being rare. Rhetorical, but what is the likelihood of staple line or endoloop failure vs just plain old ordinary peri-appy bed abscess?

I will also add for wood to the fire.... at the university level there are numerous reasons why patients are there, but the most frequent four I would argue are:
1. patients are uninsured (which at community level almost always equates tertiary care level of illness requiring transfer)
2. patients perceive better care at a big name University.
3. Community surgeon found patient healthcare needs would be too taxing for the local community hospital (this includes surgeon going on vacation, etc...)
4. patients are too sick?

Ultimately, if you practice general surgery, you will practice 1. the way your partners allow you to (as they may cover calls for you.... thus instructing "admit to medicine"), 2. the way that is acceptable community norm, and 3. to some degree the way you want to. Things do get cut when you and your partners become the full time "interns for life".

 

[Dimoak]

Pt with hx of chole, appy, TAH-BSO...

Ahh....in that case, better make sure you order it with SF6 so you don't miss anything.

 

[Winged Scapula]

JAD and I talked about this last week and I know he "gets its" in terms of how a community surgical practice runs (and since the vast majority of surgical care in the country is ministered in the community, this is "real world".)

The adjustment for me was HUGE coming from academia.

I honestly didn't realize that many surgeons in the community don't even round on their post-op patients until the Charge Nurse at one of my hospitals was talking with me. He was asking for my card to give to a close friend and flattered as I was, I said thank you and "I'm suprised you wouldn't have asked Dr. X, she's been around here for years."

His response, in addition to other comments, was essentially that he felt like I took good care of my patients because I rounded q daily, always returned calls , etc. I inquired about this and he said that most of the surgeons didn't round on their patients on the floor, or only rarely did. The subspecialists may send their PA but the general surgeons just called in and if the patient was doing well would discharge them or *might* stop by late in the day. Of course, you don't get paid to round on the patients post-op so from a financial standpoint, it makes more sense to be doing someone else instead of rounding.

When I thought about it I realized I should have known this as the nurses seemed suprised about my micromanagement, my notice that some orders weren't carried out, etc. Clearly if you aren't around and are just relying on what is told to you, then you don't notice if the patient doesn't *really* know how to manage their JP or the Foley is *still* in (despite the order to DC).

I also didn't know I didn't have to go in and see patients in the ED unless they urgently needed intervention. "We'll admit to the hospitalist and you can see him/her in the am." Of course, this was common at the community hospital I moonlit at as a resident and fellow, but for the MEDICINE guys. But perhaps since the surgeons had me in house, they didn't bother to come in either unless we needed to operate.

Uninsured patients are a major problem in the community. I am seeing more and more self-pay patients and I have a pretty middle to upper middle class pop. It worries me because while the office consult might be $250 what if you need surgery or a biopsy? I'll admit I send them to county if they clearly need major surgery and adjuvant treatment. Its not really dumping IMHO, although I know someone has to pay the bills, but in the community they simply will NOT get the treatment they need without cash up front.

At any rate, this is common in the community although I'd admit that "have OB-Gyn" see my immediate post-op patient because an abscess couldn't be due to my surgery, seems the height of arrogance. But we ARE talking about surgeons, aren't we?

 

[JackADeli]

...how a community surgical practice runs (and since the vast majority of surgical care in the country is ministered in the community, this is "real world".)

The adjustment for me was HUGE coming from academia.

I honestly didn't realize that many surgeons in the community don't even round on their post-op patients...

...I inquired about this and ...most of the surgeons didn't round on their patients on the floor, or only rarely did. ...the general surgeons just called in and if the patient was doing well would discharge them or *might* stop by late in the day...

...I also didn't know I didn't have to go in and see patients in the ED unless they urgently needed intervention. "We'll admit to the hospitalist and you can see him/her in the am." Of course, this was common at the community hospital...

Uninsured patients are a major problem in the community. ...send them to county if they clearly need major surgery and adjuvant treatment. ...in the community they simply will NOT get the treatment they need without cash up front...

Yep.
It really is strange how we are trained in numerous situations completely opposite of what the actual "job" and community practice is. As I noted, in residency, we were suppose to be everyone and manage everything. Fills you with some apprehension about what you will do in practice. I mean, you see the work it takes to manage just a few patients in house with a pack of residents, NPs, PAs, etc... Can you image now going into a practice with maybe one or two partners and none of that? It's only when you get out there that you realize how it is done.... You no longer "own" the patient, you are a consultant and you must heavily rely on the hospitalist & medicine subspecialist. If anything, that reality should encourage surgery residents to attempt to educate our medicine resident colleagues... because we will be needing them.

Final point, in residency, you have to round and thus must finish before ORs, etc.... How many times did the patients complain about the wake-up and examination somewhere between 4-6:30 AM? Alot where I trained. Some patients even filed formal complaints against residents. Go to the community, you surely better not be pulling that kind of stuff..... please do not disturb the sleeping bear! The sleep deprivation of patients in teaching institutes is astounding.... and we do it to provide "better" care!

JAD

 

[45408]

The sleep deprivation of patients in teaching institutes is astounding.... and we do it to provide "better" care!

Yeah, it only took me a few months in M3 to realize that the patients aren't kidding around when they say they're exhausted.

 

[dynx]

Yeah, it only took me a few months in M3 to realize that the patients aren't kidding around when they say they're exhausted.

And a few month after that you figure out you don't give a **** if thier exhausted.

furthermore...you should flat out tell people this isnt a hotel, this is where i work and this is the way it works. You talk to me when i get there, your family has questions? show up when we're rounding or call late in the afternoon. you show up at noon, you're going to wait till I round in the evening. My schedule has very little to do with yours. you want to be discharged at two? whoops should have told me yesterday, now you'll wait till I have time. I have no idea where this idea of accomidation came from but we need to sack up and toss it out the window...patients that pay premium rates get premium service. Your medicare fee doesnt encourage me to give a crap if you have a meeting to get to...if your meeting was that important you'd make enough to pay for the services you recieved.

 

[maxheadroom]

And a few month after that you figure out you don't give a **** if thier exhausted.

furthermore...you should flat out tell people this isnt a hotel, this is where i work and this is the way it works. You talk to me when i get there, your family has questions? show up when we're rounding or call late in the afternoon. you show up at noon, you're going to wait till I round in the evening. My schedule has very little to do with yours. you want to be discharged at two? whoops should have told me yesterday, now you'll wait till I have time. I have no idea where this idea of accomidation came from but we need to sack up and toss it out the window...patients that pay premium rates get premium service. Your medicare fee doesnt encourage me to give a crap if you have a meeting to get to...if your meeting was that important you'd make enough to pay for the services you recieved.

Wow, bitter much? Seriously, it's not the patient's fault that he is ignorant of how things work in the hospital. Sure, prissy patients are a pain in the ass, but most patients are just ill-informed and scared.

 

[dynx]

Wow, bitter much?

I don't know. Shocked, amazed, dumbfounded...yes. Bitter? I don't think so. I'm suprised when these things happen (still...amazingly) but i'm not sure I'm bitter because I don't accomidate them so it doesn't have much of an effect on me. I just have an abnormally firm idea of the way things "should" be.

 

[JackADeli]

...you should flat out tell people this isnt a hotel, this is ...the way it works. ...you want to be discharged at two? whoops should have told me yesterday, now you'll wait till I have time. I have no idea where this idea of accomidation came from but we need to sack up and toss it out the window...patients that pay premium rates get premium service...

Good luck.

...it's not the patient's fault that he is ignorant of how things work in the hospital. ...most patients are just ill-informed and scared.

I think WS & I have comented to some degree. Again, the way teaching institutions run "services" is quite different from community centers. Thus families are quite shocked & surprised at teaching centers. Imagine finding out you need surgery at the "University". You don't think you are going to be awakened and examined by a "student"/"student doctor"/etc... at 4am and then see your real doctor at some point between noon and 9pm. You speak with your family that has been treated at a community hospital and they are not awaked at all hours or made NPO all day to only find their procedure was canceled, etc....

I don't know. Shocked, amazed, dumbfounded...yes. Bitter? I don't think so. I'm suprised when these things happen... ....I don't accomidate them so it doesn't have much of an effect on me. I just have an abnormally firm idea of the way things "should" be.

Interesting wisdom for a resident with presumably a limited perspective of experience.

JAD

 

[maxheadroom]

Good luck.I think WS & I have comented to some degree. Again, the way teaching institutions run "services" is quite different from community centers. Thus families are quite shocked & surprised at teaching centers. Imagine finding out you need surgery at the "University". You don't think you are going to be awakened and examined by a "student"/"student doctor"/etc... at 4am and then see your real doctor at some point between noon and 9pm. You speak with your family that has been treated at a community hospital and they are not awaked at all hours or made NPO all day to only find their procedure was canceled, etc....Interesting wisdom for a resident with presumably a limited perspective of experience.

JAD

Very true. I guess I'm just tired of seeing some of the residents at my place act as though the patients are the problem. Sure, they can be difficult, but we went into medicine because we want to take care of people, right? I get frustrated when people lose sight of the fact that the reason why we're here is to take care of patients (as part of our education).

 

[Conky]

Post op gastric bypass patient:

2300 - Vitals
0000 - finger stick
sometime in here - get up and walk, please.
0300 - Vitals
0500ish - phelobotomy draws labs
0500ish - empty JP and Foley
0600- visit from residents/students
0600 - finger stick
0700 - Vitals

It's not the Marriott, but patients - for the most part - are understanding and surprisingly reasonable about being woken up so much.

 

[SocialistMD]

I think WS & I have comented to some degree. Again, the way teaching institutions run "services" is quite different from community centers. Thus families are quite shocked & surprised at teaching centers. Imagine finding out you need surgery at the "University". You don't think you are going to be awakened and examined by a "student"/"student doctor"/etc... at 4am and then see your real doctor at some point between noon and 9pm. You speak with your family that has been treated at a community hospital and they are not awaked at all hours or made NPO all day to only find their procedure was canceled, etc....

Granted my community experience in this area only comes from one community hospital where I moonlight and where >90% of the surgeons trained at my institution, but I think the NPO problem occurs there more than it does here, as there isn't really anyone on the floor to change the diet orders. Yes, they cancel procedures less frequently, but when it happens it is likely to go unnoticed until the attending comes by at the end of the operative day. Furthermore, the surgeons do start rounding prior to their first case (7:30), so some patients are wakened between 6:30 and 7:30. Even more interesting to me is that the surgical subspecialties there are more likely to admit to their own service rather than to medicine (particularly shocking are the ortho admits I get at night with multiple medical comorbidities who have a "medicine consult" instead of the opposite that I see at my academic institution) and the surgeons are more prone to admit patients without clearly surgical issues (i.e. abd pain with stones on CT gets admitted to surgery for U/S in am despite pain pattern not suggestive of GB as source of pain). Again, it may be an anomalous hospital, but it is the only one from which I can base my experience.

 

[dynx]

....Interesting wisdom for a resident with presumably a limited perspective of experience.

JAD

Indeed:
1. I noted my thought process was abnormal at least in its extent
2. More experience/differing institutional perspective would likely alter my view of the way things are...which has little to do with the way things "should" be.

So...I agree with you, but you failed to say anything substantial. What was the point?

 

[JackADeli]

Very true. ...tired...seeing some of the residents ...act as though the patients are the problem. ...

Agreed.

 

[butterfly0660]

So...back to the dumb consults thing....I got a consult on a weekend evening from a surgical subspecialty to remove a non-infected port, because "the patient just wants it out and we were supposed to call while we had the guy in the OR last week, but we forgot." Its bad enough that they thought the fact that they forgot meant it was a worthwhile emergent weekend consult. But then, I got there to find a very pleasant patient with no port. Only a beautiful healed scar where it had been removed almost a year ago!

 

[Krazykritter]

My most memorable consult to date was a RLQ/R. Pelvic pain from one of our ER docs who is known for calling us before a decent history & with only a cursory physical.

Anyway, walk in & introduce myself to the patient & the other person in the bay & make the first mistake of saying, "Excuse me, sir" to what ended up being her female partner who was very butch looking w/ a hat & shorter hair than I have. After that, I notice the patient is wearing a purple shirt w/ an upside-down traingle rainbow & her partner has a T-shirt emblazoned w/ a Dike, Iowa logo (real town).

The real memorable part of the consult comes when the patient relays a history of cervical cancer, dyspareunia...no pelvic done by ER doc. So...Right before the pelvic, ask if there have been any unusual changes etc. & the partner chimes in that there has been this 'one spot' that causes the patient to cringe every time she touches it. Pelvic exam commences & the patner comments, "You just need to crook your finger up...Here, do you want me to show you??" As if this wasn't bad enough, she continues to give suggestions during the remainder of the pelvic.

Don't know what ended up happening to her as her CT was negative for surgical pathology so she got turfed to Gyne where she should have been in the first place.

 

[dpmd]

Pelvic exam commences & the patner comments, "You just need to crook your finger up...Here, do you want me to show you??" As if this wasn't bad enough, she continues to give suggestions during the remainder of the pelvic.

Am I the only one who is surprised that you did a pelvic on her? Maybe I am lazy, but I would have told/asked the ED to do one and consult gyn if the rest of the story and my abd exam wasn't consistent with something I would take care of (ie. appy).

The port story reminds me of a consult I once got for a port for ampho. When I got around to checking the patient out I found them currently receiving ampho. When I explained to the patient why I was there they pointed to their chest and said "oh, do you mean this (pointing at the perfectly well functioning and pristine looking port through which the ampho was infusing)". I wrote a very short note where my recommendations were to please examine the patient as port already in place and functional, surgery signing off-reconsult if needed.

 

[Krazykritter]

Am I the only one who is surprised that you did a pelvic on her? Maybe I am lazy, but I would have told/asked the ED to do one and consult gyn if the rest of the story and my abd exam wasn't consistent with something I would take care of (ie. appy).

It seems that the expectations around here are a little different. It might be b/c we only have GS & FM residents at my hospital, but it seems like we are always to do everything relevant to diagnose &/or rule out our involvement before the ED guys will call another attendings' service. In my case, it was a good thing I did a pelvic b/c my senior's first question after hearing the story was, "Did she have a positive Chandelier sign?"

Not saying that I don't agree w/ your response, but I doubt it would have went over very well for me.

 

[surgres88]

It seems that the expectations around here are a little different. It might be b/c we only have GS & FM residents at my hospital, but it seems like we are always to do everything relevant to diagnose &/or rule out our involvement before the ED guys will call another attendings' service. In my case, it was a good thing I did a pelvic b/c my senior's first question after hearing the story was, "Did she have a positive Chandelier sign?"

Not saying that I don't agree w/ your response, but I doubt it would have went over very well for me.

I salute your complete exam. Like you said, it depends on the environment...I did a Pelvic during my intern year for a consult...I still dread that coming up at my chief banquent. My Chief busted my balls for the rest of the month, when I presented a pelvic exam to him. He said in typical subtle and empathetic fashion with a thick Texan accent..."You need to learn two things from this consult, rookie. First, we (surgeons) don't do that at work. Second, you put your wrong body part in that hole."

 

[JackADeli]

..."You need to learn ...you put your wrong body part in that hole."

Exceedingly disgusting. Lines and humor of that nature will and are getting more and more healthcare providers in trouble.

 

[dpmd]

I thought it was hilarious. Of course I wouldn't recommend saying that in front of the patient.

My poor intern got a consult once at 5 am for a trach and peg...in a patient who had been at our facility for 5 days....who had been intubated at another hospital for 11 days (something about funding and not wanting to do the trach and peg there)...who had ESRD on dialysis, CHF, schizophrenia with a long history of noncompliance with dialysis, and who had suffered a 15 min cardiac arrest due to his hyperkalemia but was magically brought back only to have no purposeful activity and minimal activity on his EEG. The family was in complete denial about his condition and wanted "everything done". Luckily, the usual MICU attending happened to be around later when the family came in for another meeting (some other attendings had been covering for her) and when I brought this up things moved away from trach and peg and back towards withdrawal of care.

 

[surgres88]

Exceedingly disgusting. Lines and humor of that nature will and are getting more and more healthcare providers in trouble.

Agreed...it was disgusting, just like parts in Superbad (or INSERT your junior high mentality comedy here). I personally found the comment hilarious at the time, still do. Though there is no way I could pull it off, I don't have the Texas accent. Your warning about our medical PC environment is a good point for the sarcastically prone crew (myself included on this team).

 

[JackADeli]

...Your warning about our medical PC environment is a good point for the sarcastically prone crew (myself included on this team).

I appreciate raunchy humor. Something folks do not realize or are in denial, each time you make such comments, you are leaving some power over your future with someone else. Your nurse,secretary, OR staff may laugh at first. But, he/she can always toss these comments back or report them and you really have no defense. What's more, if the complaining party is unhappy with the hospital/agency response to the complaint, the complanent can just call a newspaper and get some publicity. "We" may find a comment about holes and body parts in context to be humorous.... but the public will invariably find this to be horrible. You could find your face on the news and accusations of sexual misconduct/etc... stem from just a comment.... all of which could lead to a career in a very rural, needy community with great outdoor opportunities

JAD

 

[San_Juan_Sun]

Two from the OB/GYN folks:

1. Called with a consult for NG tube placement. Asked why they couldn't place one. OB/GYN resident says "We don't place those. You do." When I asked why we needed to do a consult, when a simple friendly call asking for a hand would have sufficed, he had no answer.

2. Called at midnight by ED resident. Has a consult for post op ileus. Had a laparotomy/tubal ligation, sent home POD# 2 but not really tolerating PO. Back POD#4 with intractable nausea, vomiting. Was told that OB/GYN would be evaluating patient as well. Not sure why we need to see patient, but I go see them anyway. Check the chart and guess what I find? An OB/GYN consult with the only recommendation being "Admit to general surgery for post-op ileus management."

Needless to say, that didn't happen. The ED resident and attending were appalled, and called the OB/GYN attending at home. OB/GYN attending says "Please admit the patient to my service, and have my [expletive] resident call me right away."

I wish I could have listened in on that phone call.

Disclaimer: I love my OB/GYN homies. They just had a couple of interesting consults, that's all. I'm sure you could devote pages and pages of threads to the dumb things surgery residents do.

 

[Thanatos]

bumping epic hilarious thread.

Recently I got a consult from the CCU for "one of those gastric bypass procedures." The patient was a 25 yo F with a history of hypertrophic cardiomyopathy, had an EF of around 15%. The CCU team calculated that if the patient lost at least 150 lbs it would move her up on the list for a heart transplant.

My attending was not amused when we called him about this consult, at 10 pm on a friday. I wish I was making this up...

 

[Musashi450]

Well played sir, worth the bump.

Out of curiosity what was her approx. current weight?

 

[opr8n]

oh am i glad this thread came back

so my most recent disaster consults:

1. "Free Air" on a patient with an XR denonstrating and read by radiologist as "No evidence of pneumoperitoneum"

2. ER consult: attending 100% sure a kid with RLQ pain, nl wbc, h/o Ladds procedure for malrotation had acute appendicitis ..... I just starred at him for a minute and shook my head