Consults- Memorable/Dismal/Ridiculous/Unique

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vhawk said:
Fair enough. However, for all the choledocholithiasis you've treated, how many of them are actually JAUNDICED? I'd guess close to zero
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Minion yellow - maybe 2. Catching some scleral icterus with whatever lighting is available - maybe 5 to 10. So yeah, not many.
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yeah definitely called a guy hilighter yellow, or glow in the dark

takes a day or two (at least) to get "minion yellow." If they have a stone that is gonna pass, they usually arent visibly jaundiced.
 
vhawk said:
yeah definitely called a guy hilighter yellow, or glow in the dark

takes a day or two (at least) to get "minion yellow." If they have a stone that is gonna pass, they usually arent visibly jaundiced.
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Well that's spooky. Despite not being on call I was just consulted today on an 86 yo F with 2 months of symptoms, 20 lbs weight loss and a double duct sign on a CT from 2 weeks ago. I blame you guys.
 
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Is there a trend in gen surg away from lap chole? At my fellowship institution (a surgical powerhouse), I feel like I can’t get a surgeon to take out a gallbladder to save my life. In a year and a half, I’m honestly not sure that I’ve seen a single chole. I’m not exaggerating when I say that I think 100% have gotten abx and an IR guided drain. And I don’t mean exclusively super-sick MICU players.
 
TimesNewRoman said:
Is there a trend in gen surg away from lap chole? At my fellowship institution (a surgical powerhouse), I feel like I can’t get a surgeon to take out a gallbladder to save my life. In a year and a half, I’m honestly not sure that I’ve seen a single chole. I’m not exaggerating when I say that I think 100% have gotten abx and an IR guided drain. And I don’t mean exclusively super-sick MICU players.
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Can't recall the last cholecystostomy I recommended. I have however declined to operate on some folks who were bad operative risks and were improving with antibiotics alone. Are you taking care of a lot of folks who are sort of stable but have lots of comorbidities?
 
TimesNewRoman said:
Is there a trend in gen surg away from lap chole? At my fellowship institution (a surgical powerhouse), I feel like I can’t get a surgeon to take out a gallbladder to save my life. In a year and a half, I’m honestly not sure that I’ve seen a single chole. I’m not exaggerating when I say that I think 100% have gotten abx and an IR guided drain. And I don’t mean exclusively super-sick MICU players.
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That's sad. I guess they are following the Tokyo guidelines. I can't find the interest to get past the abstracts whenever I see articles on it. It just seems like a very expensive and miserable (for patients) way to treat acute cholecystitis. I've placed maybe 2 C tubes in the last year one of which was a crash open C tube (long story).
 
TimesNewRoman said:
Is there a trend in gen surg away from lap chole? At my fellowship institution (a surgical powerhouse), I feel like I can’t get a surgeon to take out a gallbladder to save my life. In a year and a half, I’m honestly not sure that I’ve seen a single chole. I’m not exaggerating when I say that I think 100% have gotten abx and an IR guided drain. And I don’t mean exclusively super-sick MICU players.
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I would say that there's an awareness of the potential utility of cholecystostomy tubes. The other group besides the sick MICU players where I think the benefit does exist are those who present with >72 hours of symptoms.

However, I think the needle has swung much too far in the direction away from just doing the lap chole. Based on the actual numbers, I can tell you that the rate of tube placement has increased near exponentially at our place in the last 15 years. And while it's been shown to be "effective" in the sense that it treats cholecystitis, the data regarding to cost, quality of life, and more rigorous comparisons to early lap chole are lacking. I also think that as it's become more acceptable, some use it as a way to turn an acute issue into one that can be scheduled electively not because it's better for the patient, but for their own convenience.
 
FaytlND said:
I would say that there's an awareness of the potential utility of cholecystostomy tubes. The other group besides the sick MICU players where I think the benefit does exist are those who present with >72 hours of symptoms.

However, I think the needle has swung much too far in the direction away from just doing the lap chole. Based on the actual numbers, I can tell you that the rate of tube placement has increased near exponentially at our place in the last 15 years. And while it's been shown to be "effective" in the sense that it treats cholecystitis, the data regarding to cost, quality of life, and more rigorous comparisons to early lap chole are lacking. I also think that as it's become more acceptable, some use it as a way to turn an acute issue into one that can be scheduled electively not because it's better for the patient, but for their own convenience.
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Hmm, I do plenty of lap choles on people with more than 72 hours of symptoms. Haven't noticed anything that would make me want to just do a tube instead. Not sure if the fact I am usually doing it the next day after antibiotics got started because I tend not to go back for add ons after I leave one hospital and I don't do them at night affects how much they suck.
 
Thanks. Sorry to derail, but I always like coming to y’alls forum to get a feel for what the surgeons outside of my institution are doing. Sometimes it’s tough to know if certain things are quirky things about my institution or if it’s the way surgery is moving.

I’m doing CCM, so obviously I’m dealing with a sicker cohort which will bias my opinion (vs. residency in EM when everyone got their gallbladder out the next morning), but I think it’s more generalized culture here. As in, the not super sick patients get tubes over doing a lap chole - e.g. young diabetic went into mild dka, resolved after a short run on an insulin drip. Also, IR doesn’t give any pushback so it’s the path of least resistence.
 
TimesNewRoman said:
Thanks. Sorry to derail, but I always like coming to y’alls forum to get a feel for what the surgeons outside of my institution are doing. Sometimes it’s tough to know if certain things are quirky things about my institution or if it’s the way surgery is moving.

I’m doing CCM, so obviously I’m dealing with a sicker cohort which will bias my opinion (vs. residency in EM when everyone got their gallbladder out the next morning), but I think it’s more generalized culture here. As in, the not super sick patients get tubes over doing a lap chole - e.g. young diabetic went into mild dka, resolved after a short run on an insulin drip. Also, IR doesn’t give any pushback so it’s the path of least resistence.
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I was intrigued so I looked up some studies and there were some that indicated that a tube even in the not sick patients who just have worse gallbladders (or longer time since onset) resulted in less conversion to open, less bleeding, and shorter hospital stay. If my conversion rate wasn't so low already, and I had run into clinically significant bleeding or long hospital stays I would be considering a change in practice. I have to wonder if volume of laparoscopic cases is a factor since most of the studies I saw were dealing with pretty small numbers of patients and maybe they spend most of their time doing big hepatobiliary cases rather than lap choles. Or maybe their bad gallbladders are just worse than mine or they aren't as willing to leave back walls or let the gallbladder perforate as they work.
 
dpmd said:
I was intrigued so I looked up some studies and there were some that indicated that a tube even in the not sick patients who just have worse gallbladders (or longer time since onset) resulted in less conversion to open, less bleeding, and shorter hospital stay. If my conversion rate wasn't so low already, and I had run into clinically significant bleeding or long hospital stays I would be considering a change in practice. I have to wonder if volume of laparoscopic cases is a factor since most of the studies I saw were dealing with pretty small numbers of patients and maybe they spend most of their time doing big hepatobiliary cases rather than lap choles. Or maybe their bad gallbladders are just worse than mine or they aren't as willing to leave back walls or let the gallbladder perforate as they work.
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While I hate doing choles in people with more than 2-3 days of pain, unless they have truly prohibitive comorbidities, I still do them. I maybe recommend a perc tube 1-2 times a year. Doing a chole in a patient who previously had a cholecystostomy tube is not fun either, and most patients bounce back after lap chole so fast that a perc tube only prolongs their initial hospitalization as it's rare for a post op lap chole to stay more than a day or two. In the super sick people, I still think they look better sooner on average after a lap chole than with just a perc chole tube. Most patients I recommend a perc tube on are patients I don't foresee ever being medically "safe" to operate on---severe cardiomyopathies, severe COPD on high amount of O2, etc. I don't recall ever having an EBL in an acute chole so high that I needed to transfuse intraop or even POD#1. Certainly not often enough to make me think perc tubes are better. I've also found that the perc chole tubes have a tendency to fall out and need replacement, which seems to be ubiquitous across the hospitals I've worked at.

My perception is that these studies are done in academic centers with residents, where op times are already longer and the attendings likely do fewer choles a year (and certainly less themselves vs. taking a resident through) than those of us not in academics. The trigger to convert when you have a resident doing the case is different than the trigger to convert when you're doing it yourself and know your own capabilities. Usually when I convert, it's not any easier open. I know there was a discussion a while back on ACS communities and the overwhelming majority of people seemed to be in the operate camp.
 
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Smurfette said:
While I hate doing choles in people with more than 2-3 days of pain, unless they have truly prohibitive comorbidities, I still do them. I maybe recommend a perc tube 1-2 times a year. Doing a chole in a patient who previously had a cholecystostomy tube is not fun either, and most patients bounce back after lap chole so fast that a perc tube only prolongs their initial hospitalization as it's rare for a post op lap chole to stay more than a day or two. In the super sick people, I still think they look better sooner on average after a lap chole than with just a perc chole tube. Most patients I recommend a perc tube on are patients I don't foresee ever being medically "safe" to operate on---severe cardiomyopathies, severe COPD on high amount of O2, etc. I don't recall ever having an EBL in an acute chole so high that I needed to transfuse intraop or even POD#1. Certainly not often enough to make me think perc tubes are better. I've also found that the perc chole tubes have a tendency to fall out and need replacement, which seems to be ubiquitous across the hospitals I've worked at.

My perception is that these studies are done in academic centers with residents, where op times are already longer and the attendings likely do fewer choles a year (and certainly less themselves vs. taking a resident through) than those of us not in academics. The trigger to convert when you have a resident doing the case is different than the trigger to convert when you're doing it yourself and know your own capabilities. Usually when I convert, it's not any easier open. I know there was a discussion a while back on ACS communities and the overwhelming majority of people seemed to be in the operate camp.
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I know some people don't even attempt lap if things seem severe enough or if there are other factors (like prior operations) which is ridiculous to me. Like you the times I convert it isn't easier once I get open. Maybe it is a function of the extreme infrequency with which I actually convert (I threaten it way more than it becomes necessary-as in I call for extra hands and the open instruments to be counted while I keep chipping away at the inflammation or hold pressure on whatever was bleeding then before I pull everything out I look again and discover a window of recognizable anatomy or the bleeding has slowed enough to see how to control it safely). Will be interesting if we don't manage to get laparoscopic equipment for this surgical mission I am going on in April and I am forced to do a bunch of open choles.
 
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TimesNewRoman said:
Is there a trend in gen surg away from lap chole? At my fellowship institution (a surgical powerhouse), I feel like I can’t get a surgeon to take out a gallbladder to save my life. In a year and a half, I’m honestly not sure that I’ve seen a single chole. I’m not exaggerating when I say that I think 100% have gotten abx and an IR guided drain. And I don’t mean exclusively super-sick MICU players.
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We do a ton of choles. Saw an open chole last week.
 
TimesNewRoman said:
Thanks. Sorry to derail, but I always like coming to y’alls forum to get a feel for what the surgeons outside of my institution are doing. Sometimes it’s tough to know if certain things are quirky things about my institution or if it’s the way surgery is moving.

I’m doing CCM, so obviously I’m dealing with a sicker cohort which will bias my opinion (vs. residency in EM when everyone got their gallbladder out the next morning), but I think it’s more generalized culture here. As in, the not super sick patients get tubes over doing a lap chole - e.g. young diabetic went into mild dka, resolved after a short run on an insulin drip. Also, IR doesn’t give any pushback so it’s the path of least resistence.
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Witholding definitive surgery from a patient who presented with dka from cholecystitis is mismanagement in my opinion especially if the patient is unfunded and likely to have trouble getting an elective cholecystectomy scheduled.
 
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vhawk said:
How'd the lap chole go?
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Routine-ish. Patient presented with some element of cholangitis so GI had cleared the duct of a 1cm stone before I was called. Tissues were soft and cystic duct was wide and short so some adjustments had to be made during the case. Going home today. Probably could have gone home yesterday.
 
Not really a consult but :mad::mad::mad:.

Nurse for patient (consult): Why isn’t patient going to OR today?
Me: Gives answer.
Nurse: OK.
(5 seconds later male cofellow exits patient room)
Nurse: (to cofellow) Why isn’t patient going to OR today?
Cofellow: (Same answer)
Me to nurse: Why did you ask me a question if you weren’t going to accept my answer?
Nurse: (Annoying nervous giggle) I just wanted to doublecheck to be sure.
Me: Do not ask me questions if you aren’t going to accept my response.
Nurse: :bored:
 
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LucidSplash said:
Not really a consult but :mad::mad::mad:.

Nurse for patient (consult): Why isn’t patient going to OR today?
Me: Gives answer.
Nurse: OK.
(5 seconds later male cofellow exits patient room)
Nurse: (to cofellow) Why isn’t patient going to OR today?
Cofellow: (Same answer)
Me to nurse: Why did you ask me a question if you weren’t going to accept my answer?
Nurse: (Annoying nervous giggle) I just wanted to doublecheck to be sure.
Me: Do not ask me questions if you aren’t going to accept my response.
Nurse: :bored:
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That would piss me off greatly. Not sure if talking to her supervisor would be worthwhile or not. Maybe if it is a recurrent issue with failing to recognize your authority.
 
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dpmd said:
That would piss me off greatly. Not sure if talking to her supervisor would be worthwhile or not. Maybe if it is a recurrent issue with failing to recognize your authority.
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Not a recurrent issue because Pt isn’t on the vascular floor where most of my patients are. We don’t have many consults from that floor. Would not occur on the vascular floor. So not worth it. Just needed to vent.
 
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LucidSplash said:
Not really a consult but :mad::mad::mad:.

Nurse for patient (consult): Why isn’t patient going to OR today?
Me: Gives answer.
Nurse: OK.
(5 seconds later male cofellow exits patient room)
Nurse: (to cofellow) Why isn’t patient going to OR today?
Cofellow: (Same answer)
Me to nurse: Why did you ask me a question if you weren’t going to accept my answer?
Nurse: (Annoying nervous giggle) I just wanted to doublecheck to be sure.
Me: Do not ask me questions if you aren’t going to accept my response.
Nurse: :bored:
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Avatar checks out.

dpmd said:
That would piss me off greatly. Not sure if talking to her supervisor would be worthwhile or not. Maybe if it is a recurrent issue with failing to recognize your authority.
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0203_authoritah1.jpg
 
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I got a page from the ED because the overnight radiologist called a fabella an avulsion fracture. Then the resident radiologist tried to argue with me about it. I heard him show his attending in the background, and his attending made fun of him. Ultimately ended up conceding defeat in the most radiologist way possible, "my attending thinks it's probably a fabella, but we cannot rule out avulsion fracture." Love me the MSK radiologists but some of the overnight juniors, ???.

The end of the story: we got an MRI as an outpatient and patient ended up having a medial meniscus tear.

upload_2018-3-27_11-35-20.png
 
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akwho said:
I got a page from the ED because the overnight radiologist called a fabella an avulsion fracture. Then the resident radiologist tried to argue with me about it. I heard him show his attending in the background, and his attending made fun of him. Ultimately ended up conceding defeat in the most radiologist way possible, "my attending thinks it's probably a fabella, but we cannot rule out avulsion fracture." Love me the MSK radiologists but some of the overnight juniors, ???.

The end of the story: we got an MRI as an outpatient and patient ended up having a medial meniscus tear.

View attachment 231183
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Lmao I would have ripped that guy a new one. Avulsion of what, exactly?


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akwho said:
I got a page from the ED because the overnight radiologist called a fabella an avulsion fracture. Then the resident radiologist tried to argue with me about it. I heard him show his attending in the background, and his attending made fun of him. Ultimately ended up conceding defeat in the most radiologist way possible, "my attending thinks it's probably a fabella, but we cannot rule out avulsion fracture." Love me the MSK radiologists but some of the overnight juniors, ???.

The end of the story: we got an MRI as an outpatient and patient ended up having a medial meniscus tear.

View attachment 231183
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Oh jeez, I think all of the radiology residents at my program know what a fabella is. I don't even mention in them in my reports since they're so common.

It's also well-corticated, another knock against it being an avulsion fracture, among many others.
 
Not a consult, but **** someone better get some amusement out of it because I want to cry...

I'm reviewing things from earlier in the day and am looking for a CTV that I ordered in the morning. My order has been cancelled and replaced by a CT w/wo. There is a medicine intern's note saying that they corrected the order because they were told by the radiology tech that a CTV is the same thing as a CT with IV and PO contrast. This is immediately followed by a nursing note that says that the scan was not obtained because the patient refused to drink the PO contrast. So, everyone is sitting around with a thumb up their ass. In the 13 hours since I ordered the test, not once was I called or did they attempt to contact me. While I was scrubbed for most of the day, could have corrected that over the phone in 2 seconds.
 
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mimelim said:
Not a consult, but **** someone better get some amusement out of it because I want to cry...

I'm reviewing things from earlier in the day and am looking for a CTV that I ordered in the morning. My order has been cancelled and replaced by a CT w/wo. There is a medicine intern's note saying that they corrected the order because they were told by the radiology tech that a CTV is the same thing as a CT with IV and PO contrast. This is immediately followed by a nursing note that says that the scan was not obtained because the patient refused to drink the PO contrast. So, everyone is sitting around with a thumb up their ass. In the 13 hours since I ordered the test, not once was I called or did they attempt to contact me. While I was scrubbed for most of the day, could have corrected that over the phone in 2 seconds.
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Jw13.gif
 
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I just got a consult on a patient “known to you” with hx of line associated DVT. No new symptoms, no new studies, already on eliquis. Just missed her clinic follow up. Has only been one month into anticoagulation. Ummmmmt, what exactly do you want me to do here?
 
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Jolie South said:
I just got a consult on a patient “known to you” with hx of line associated DVT. No new symptoms, no new studies, already on eliquis. Just missed her clinic follow up. Has only been one month into anticoagulation. Ummmmmt, what exactly do you want me to do here?
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Sometimes services want to know when one of their patients is admitted. It's a courtesy call, not a consult.
 
Psai said:
Sometimes services want to know when one of their patients is admitted. It's a courtesy call, not a consult.
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I get it for someone we are doing wound care or post op from something, but for DVTs?!?

Unless it has progressed and there is phlegmasia, I don’t care if they are in house. ‍♀️
 
Jolie South said:
I get it for someone we are doing wound care or post op from something, but for DVTs?!?

Unless it has progressed and there is phlegmasia, I don’t care if they are in house. ‍♀️
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Yea, but there’s just no winning. I’ve seen someone screaming because they weren’t called about a patient of there’s being admitted.
 
mimelim said:
Not a consult, but **** someone better get some amusement out of it because I want to cry...

I'm reviewing things from earlier in the day and am looking for a CTV that I ordered in the morning. My order has been cancelled and replaced by a CT w/wo. There is a medicine intern's note saying that they corrected the order because they were told by the radiology tech that a CTV is the same thing as a CT with IV and PO contrast. This is immediately followed by a nursing note that says that the scan was not obtained because the patient refused to drink the PO contrast. So, everyone is sitting around with a thumb up their ass. In the 13 hours since I ordered the test, not once was I called or did they attempt to contact me. While I was scrubbed for most of the day, could have corrected that over the phone in 2 seconds.
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What the ****?

That’s some bull****...
 
TimesNewRoman said:
Yea, but there’s just no winning. I’ve seen someone screaming because they weren’t called about a patient of there’s being admitted.
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I get both sides of this. Personally, I'd prefer to know if a post-op patient gets readmitted for essentially any reason, even if it's not to my service. That being said, its unclear why that requires a formal consult. Especially in an academic center it just creates busywork for some resident.
 
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mimelim said:
Not a consult, but **** someone better get some amusement out of it because I want to cry...

I'm reviewing things from earlier in the day and am looking for a CTV that I ordered in the morning. My order has been cancelled and replaced by a CT w/wo. There is a medicine intern's note saying that they corrected the order because they were told by the radiology tech that a CTV is the same thing as a CT with IV and PO contrast. This is immediately followed by a nursing note that says that the scan was not obtained because the patient refused to drink the PO contrast. So, everyone is sitting around with a thumb up their ass. In the 13 hours since I ordered the test, not once was I called or did they attempt to contact me. While I was scrubbed for most of the day, could have corrected that over the phone in 2 seconds.
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I got amusement out of it.

I'd have a pretty stern talking to with the medicine team - "If you guys are going to consult us for stuff, then stop letting your ******* intern mess around with my orders and stop us from doing the stuff that needs to be done".
 
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Psai said:
Sometimes services want to know when one of their patients is admitted. It's a courtesy call, not a consult.
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At the hospitals I rotate through, we are told by the attendings that all "courtesy calls" require a full consult, including documentation and an attending phone call,
 
One that I called to ortho once upon a time (not a surgeon): “I know this is probably a dumb q but. Look at this guy’s MRI. Is there any possibility that his leg could...you know...FALL OFF? My nurses are scared to turn him in the bed.”

The context was a sacral decub so bad that it had eaten away all attachments of the head of the femur to the pelvis. Which pelvis and head of femur could be visualized at bedside. I was assured with a bit of a chuckle that it would at least hang on at the knee via some remaining quadriceps. Yow. Remains one of the worst things I’ve ever seen.
 
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siliso said:
One that I called to ortho once upon a time (not a surgeon): “I know this is probably a dumb q but. Look at this guy’s MRI. Is there any possibility that his leg could...you know...FALL OFF? My nurses are scared to turn him in the bed.”

The context was a sacral decub so bad that it had eaten away all attachments of the head of the femur to the pelvis. Which pelvis and head of femur could be visualized at bedside. I was assured with a bit of a chuckle that it would at least hang on at the knee via some remaining quadriceps. Yow. Remains one of the worst things I’ve ever seen.
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I think I was also consulted on this patient recently.
 
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