Consults- Memorable/Dismal/Ridiculous/Unique

[coastal]

Which is not to say medicine does not get BS consults. Ortho works very hard to see to that.

lol! That is so true. I take neither pride nor interest in maintaining the ability to manage medical issues.

Gosh that makes me sound like a bad doctor.

Anyways, medicine (who I love for being so obliging in looking after our patients), gave us a sweet consult yesterday - please see this old chap with a hip fracture. That's fine, except that he's been having tremendous pain and difficulty mobilizing for over a month and actually had a fall 5 weeks previous. His x-ray had an old fracture.

My favourite is one of our ER attendings who, while she was at another institution, consulted Gen Surg for appendicitis in a patient who had already had their appendix removed. She never examined the patient and obviously didn't take much of a history!

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[Dr.LeoSpaceman]

Nothing used to piss me off more than the "we just need you on board" consult. Really?? You just want me to round on a non-surgical patient just in case? <sigh>

I've been struggling with this one recently. Some of the "just so you are onboard" consults are worthless. But we have had a few of these for pSBOs that ended up being surgical, and to be honest, I think it's better for a surgery team to be involved early for those situations. I don't trust medicine teams to know when someone might require surgical intervention for obstruction, so it's probably better just to be involved on all of them.

 

[Apollyon]

Patient with abdominal pain in the ER? Get ready for the non-contrast CT abdomen/pelvis.

I order more acute abdominal series xrays than anyone in our department (I've been told). I don't know how many CTs I avoid. The patients are also agreeable.

 

[kirurg]

Recently got an emergent consult for after an xray on a MICU patient showed "gastric volvulus" (diagnosed by the medicine resident). The patient had been on BiPAP all night, and there was no volvulus, just a stomach full of air.

I didn't know that medicine residents actually looked at films...

 

[maxheadroom]

I've been struggling with this one recently. Some of the "just so you are onboard" consults are worthless. But we have had a few of these for pSBOs that ended up being surgical, and to be honest, I think it's better for a surgery team to be involved early for those situations. I don't trust medicine teams to know when someone might require surgical intervention for obstruction, so it's probably better just to be involved on all of them.

It's been a long time since I've dealt with pSBOs (had to think about what that was). It's pretty reasonable for a surgeon to "lay hands" on those patients, even if they're complete non-op patients. The one that always pissed me off was the consult for cellulitis. Really?? Simple cellulitis?? I recommend antibiotics. Call me if an abscess forms after a few days. I really don't feel the need to see that patient daily, though.

 

[LucidSplash]

Recently got an emergent consult for after an xray on a MICU patient showed "gastric volvulus" (diagnosed by the medicine resident). The patient had been on BiPAP all night, and there was no volvulus, just a stomach full of air.

I didn't know that medicine residents actually looked at films...

Arg. Recently got a stat consult for "free air" on a MICU pt. Had been admitted with DKA and had abdominal pain, renal had ordered a flat and upright. So, the good little intern that could came running and looks at the xray. First, there is no flat and upright, just a supine, and the only air I see is the stomach. Turns out the radiology tech came to do the xray, saw "air" on the supine and had the nurse call renal to clarify if they should do the xray "up higher" to "look at the air." Without looking at the xray, renal said "if there's air, stat consult to general surgery." Also, the tech left without doing the upright. Totally benign abdomen.

I dutifully wrote my consult note, called rads to come do the upright which had already been ordered for good measure, and then had to let my chief know about the consult. His only response was "You're kidding me, right?"

Ug. I'll even take a silly cellulitis consult over an "I didn't even look at the images or examine the patient and had the nurse call in a stat consult" consult.

 

[Buzz Me]

I order more acute abdominal series xrays than anyone in our department (I've been told). I don't know how many CTs I avoid. The patients are also agreeable.

 

[Apollyon]

I explain it like this: "If we go to CT first, and it's something that the Xray would show, it's overkill. If we do the Xray first, it save you A LOT of radiation, and, if the Xray doesn't tell us what we need, we can then do the CT. Think of the studies in terms of "radiation dollars" - if the Xray is $1, and the CT is $100, you don't want to spend $100 on a $1 problem. However, if we have to go to CT, $101 versus $100 is negligible".

It's almost verbatim to that. The good thing is that I 1. don't work in an academic hospital and 2. have a really good patient base (about 40% of whom were born not in the US, but English speaking countries, and only about 20% white - and less than half of them mainland losers).

Since my surgeons are also very active in transplant (and there's one CT guy that WILL cut neck to nuts - he just likes it; he almost did a hysterectomy one day 2 years ago when my medical director could NOT get an Ob/Gyn), I do NOT abuse them, and they help me out immensely when I really need them.

 

[45408]

The idea of "getting surgery on board early" is completely beyond me. Same thing goes for "potential difficult airways". All you need to do is stat page overhead if there's actually an issue and we come running...

Yep. We had one GI bleed (more like a trickle), and GI wasn't even going to see the pt until the morning, but the hospitalist had to have surgery come evaluate a hemodynamically normal patient at 10pm. Surprise surprise, the patient ultimately went home without any surgical intervention.

My favourite is one of our ER attendings who, while she was at another institution, consulted Gen Surg for appendicitis in a patient who had already had their appendix removed. She never examined the patient and obviously didn't take much of a history!

Yeah, I remember a post here on SDN of an ER doc who consulted surgery for appendicitis on a patient who was s/p Ladd's procedure. the op note apparently even indicated that they had performed an appendectomy.

 

[Winged Scapula]

Some thoughts:

1) I too hate the "get surgery on board just in case" mentality; it was the bane of my existence as a resident

2) while I still hate those "CYA" consults I get, they help pay the bills. This will change once you start getting paid for them.

3) I am not sure for any other reason why you would round on these patients daily, when there is no acute surgical need, except that the attending can bill for an inpatient consult and follow-up (if they are seeing them and writing a note).

I actually somewhat enjoy these annoying consults now because they allow for a lull in the middle of a busy day and I get paid the same for the consult as if it were for a real surgical issue.

 

[OtoHNS]

I had this winner a couple of weeks ago:

8 pm Sunday night: text paged for consult on inpatient on hospitalist service for "symptoms of sinusitis." Fortunately I live 2 minutes from the hospital so I go see the patient.

Me: "So you think you have a sinus infection. What makes you think that?"

Patient: "Well, I'm really lightheaded and I had some pressure in my ears last week but that went away a few days ago."

***Note: patient has been admitted for anemia with a hemoglobin of 4.5***

Me: Asks patient about several symptoms that are actually associated with sinusitis.

Patient: denies having any of those symptoms.

Physical exam = normal

Unindicated CT scan done before consult was called shows completely clear sinuses

A/P No sinusitis. Thank you for this fascinating consult.

Billed for inpatient consult, level 3, cha-ching bitchez!!!!$$$$$$$

 

[Buzz Me]

I think it'd all be different if we got paid to see consults.

 

[Pir8DeacDoc]

Billed for inpatient consult, level 3, cha-ching bitchez!!!!$$$$$$$

You should have done rigid endoscopy at the bedside to up the ante and add a procedure to your level III

 

[Winged Scapula]

You should have done rigid endoscopy at the bedside to up the ante and add a procedure to your level III

Nah, doing a procedure the same day as a consult requires a modifier 25 and generally doesn't pay as much.

What he should have done is say "needs endoscopy to R/O sinusitis will return tomorrow for 'BS' procedure" then bill for it separately...cha ching!

 

[SLUser11]

Homeless chronic alcoholic with multiple ER visits for EtOH intoxication, comes in to ER for same reason, ER doc discovers he was punched in the face 2 days ago...one hit, no LOC, no current complaints. CT face shows non-displaced nasal fracture (probably new) and a C7 transverse process fracture (old or new, nothing to be done...not even a collar).

Of course his neck is non-tender....the nasal fracture is a prn plastics outpatient follow up....the C7 TP fracture is a prn neurosurgery outpatient follow up.

So what should we do with him? When I suggested that he doesn't really need an admission to the trauma surgery team, the ER doc threw a hissyfit, and said "you guys admit these patients all the time!" then accused me of being new and naive to the process. I informed him I was the trauma chief resident, and I was aware that we admit these bulls@$t patients all the time, but that doesn't make it right. This one wasn't getting admitted....he should go somewhere else to detox.

"But he has a head injury! He has a cervical fracture! He could have ligamentous injury, and he's drunk so we can't trust his exam!" My response is that he does not have a "head injury," he doesn't have a dangerous mechanism, the C7 fracture is probably old, and an F-ing transverse process fracture without significant mechanism does not have a reasonable chance of harboring instability not ID'd on CT. "But he was hit in the head, that means a head injury. This is a trauma patient now."

His line of reasoning means every drunk person who gets hit in the face should be admitted to the trauma service since we can't trust his/her exam.

Obviously this isn't the first dump I've inherited from the ER, but I just got particularly fired up about it tonight. I think as trauma surgery residents, we need to pony up and tell the ER docs that it's not our problem, and they should find somewhere else to turf their drunk homeless guys.

 

[maxheadroom]

We had similar issues. The ED eventually developed an observation unit where patients like this could stay for 23 hours or less to dry out and have their repeat exams by the EM physicians. It came about after a new Trauma attending threw a hissy fit at the Trauma Director in a meeting with the hospital CEO, ED Director, and Chief of Staff. He essentially told them that they could go **** themselves if they thought that he was going to round on these patients every day and that a better system had to be developed. Since they were short on Trauma staff, he won.

 

[Buzz Me]

Obviously this isn't the first dump I've inherited from the ER, but I just got particularly fired up about it tonight. I think as trauma surgery residents, we need to pony up and tell the ER docs that it's not our problem, and they should find somewhere else to turf their drunk homeless guys.

If only.

Every single drunk "ground level fall" patient (which sometimes just means they tripped ) gets at least a trauma consult here. Even the drunk idiots who fall WHILE IN THE ER.

 

[Winged Scapula]

If only.

Every single drunk "ground level fall" patient (which sometimes just means they tripped ) gets at least a trauma consult here. Even the drunk idiots who fall WHILE IN THE ER.

God, I don't miss those days.

My favorite was the drunk "found down" and assumed to have had some trauma on the way down, so a Trauma was called for him. Didn't have a scratch on 'im but the ED thought we should admit him for Obs.

No way Jose was my response, *you* can watch him dry out.

 

[dpmd]

I'm so glad my program doesn't have that issue. Stupid **** doesn't get activated (well, you can argue about some of the penetrating trauma-it used to be extremity penetrating trauma only got activated if there was vascular compromise, now if it is coming via ambulance it does but if someone comes in through triage with it they usually won't activate unless there is a ton of bleeding/issue with pulses which I think is appropriate). Sometimes there are people that don't really have anything wrong, but at least they had a decent mechanism. One thing that can cause issues is with patients at the extremes of age. For some reason certain ED attendings feel that every kid that bumped their head in the accident should be kept for observation, or that every old person with a ton of medical problems but negative studies and exam should be kept at least overnight.

 

[filter07]

Obviously this isn't the first dump I've inherited from the ER, but I just got particularly fired up about it tonight. I think as trauma surgery residents, we need to pony up and tell the ER docs that it's not our problem, and they should find somewhere else to turf their drunk homeless guys.

Tried that once; it bought me a phone call from the head of the ED to my trauma attending in the middle of the night. Not gonna fight that battle again anytime soon...

 

[filter07]

Yep. We had one GI bleed (more like a trickle), and GI wasn't even going to see the pt until the morning, but the hospitalist had to have surgery come evaluate a hemodynamically normal patient at 10pm. Surprise surprise, the patient ultimately went home without any surgical intervention.

I've often wondered how the medical subspecialists get away with not seeing consults in the middle of the night. Is it because they are more experienced? (They are at least PGY4+ as fellows, whereas most surgical consults are seen by PGY1-3). Or is it that surgery is just used to worrying about the worst case scenarios?

As a junior resident I was always paranoid that the story over the phone wasn't accurate, and if I didn't see the patient myself I could be missing something life threatening. Some medicine fellows don't seem to have that issue.

What do the more senior surgery folks here think?

 

[Buzz Me]

God, I don't miss those days.

The definition of "trauma" sometimes gets a little blurred.

Witnessed ground level fall --> Patient found down with head trauma --> Drunk/high homeless patient found lying on the ground, snoring with "presumed head trauma"

Peds vs. auto --> Patient ran into parked car --> Patient tripped over curb and now has isolated tib-fib fracture

Penetrating chest trauma with pneumothorax --> Rib fracture causing pneumothorax --> Spontaneous pneumothorax with questionable history of patient "twisting their torso" or "violently stretching"

 

[DHT]

Great consult today.

I get a call from a medicine attending:

Genius: Hi, I would like you to see a patient of mine. He needs to have his port-a-cath replaced because it is clotted off. His name is Jxxxx Txxxxxxxx.

Me: Have you tried anything to declot it yet?

Genius: No

Me: Ok, what's his MRN?

Genius: I don't know, I think it starts with 555....

Me: Ok do you have his birthday or his room number?

Genius: I don't have his DOB but he is on 5T, I don't know which room.

Me: OK I'll do my best to find him.

So I go see the patient and do a full history and during the physical exam I notice that the port is not even accessed. I asked him if they have tried to use it this admission? He says no. He has not needed it in 1.5 years and currently does not need for anything other than he is tired of being stuck for peripheral IV's.

So I have the nurse access it and of course it works perfectly.

It was so hard not being an a**hole in my note. Ultimately I recommended against replacing the portacath at this time, but to please feel free to call/page with any further questions.

 

[dpmd]

Not sure if I already told this one, but the last post reminded me of it. Got a call for port placement for ampho. Went to see the patient and let him know why I was there. When I started talking about the port he said "you mean this" and pointed to his accessed port through which his ampho was running. Site was great-no infection, was running fine, etc. Left a very short note in which my recommendation was to examine functional right chest port site and reconsult if needed.

 

[45408]

I've often wondered how the medical subspecialists get away with not seeing consults in the middle of the night. Is it because they are more experienced? (They are at least PGY4+ as fellows, whereas most surgical consults are seen by PGY1-3). Or is it that surgery is just used to worrying about the worst case scenarios?

Yeah, it's probably a lot of those things. I actually saw the patient with my PGY-5 chief...

We don't have GI fellows, so this was a GI attending saying they would see it in the morning. In this case, that was a reasonable approach, based both on the report over the phone as well as my actual H&P.

As a junior resident I was always paranoid that the story over the phone wasn't accurate, and if I didn't see the patient myself I could be missing something life threatening. Some medicine fellows don't seem to have that issue.

My chief knew that it could wait until morning, but our staff don't like it if we put off a consult like that. So we see it, and most likely, our staff won't see it until morning anyways. Such is life.

 

[opr8n]

I recently had a jaw dropping moment with our cardiology folk

Guy came through ER with "epigastric pain", 40 y/o
Got admitted to cardiology and Cathed!!
Findings: none ... shocking

STAT consult at MN to gen surg to workup abdominal pain, and oh by the way would you take the pat on your service ... ummm no

CT and RUQ u/s and LFTs normal
Wanted to do an EGD, endo could not accomodate me in the am the next day when we were post call, so we booked it for the following day.

Cardiology comes by to round on their patient, dosent like the fact that he cant get his scope done tomm, so consults GI to see the pt and scope them tomm. The GI doc bumps his own 8am case (which is why we wouldne get in) to do the pt when we wanted to do him

my head almost exploded

 

[opr8n]

I too have had my recent non-trauma trauma admission
Old guy with a brain tumor, bleeds into the tumor, passes out and falls onto his CARPETED FLOOR
He comes in as a CAT1 alert
CT scan confirms the above suspected finding
Med/NeuroCC/NSG all refuse to admit the patient because he "fell" and is a trauma. NSG vehamently denies it is a tumor that bled. 2 days later NSG changes their mind and says, well i guess now it looks like a tumor, and took the patient to surgery, and refused to take the patient on their service

 

[dpmd]

At my hospital, pts with ground level falls and isolated head bleeds (usually old folks) go to medicine-usually without a trauma activation unless someone misunderstood the report. So much nicer that way, and since they usually have a bunch of medical problems it makes sense.

 

[Buzz Me]

At my hospital, pts with ground level falls and isolated head bleeds (usually old folks) go to medicine-usually without a trauma activation unless someone misunderstood the report. So much nicer that way, and since they usually have a bunch of medical problems it makes sense.

I wish that were the case here. The "old patient with AFib on Coumadin who fell and now has a head bleed" case is just too common here.

 

[S4surgery]

Nah, doing a procedure the same day as a consult requires a modifier 25 and generally doesn't pay as much.

What he should have done is say "needs endoscopy to R/O sinusitis will return tomorrow for 'BS' procedure" then bill for it separately...cha ching!

great ethics, remember u r not punishing the consulting service, u r just punishing a patient and driving medicare bankrupt

 

[Pir8DeacDoc]

great ethics, remember u r not punishing the consulting service, u r just punishing a patient and driving medicare bankrupt

lighten up there Francis. It's a joke. Did you turn off your sarcasm meter this morning?

 

[Winged Scapula]

great ethics, remember u r not punishing the consulting service, u r just punishing a patient and driving medicare bankrupt

lighten up there Francis. It's a joke. Did you turn off your sarcasm meter this morning?

Good Lord. As Pir8 notes, its sarcasm. Guess *he's* familiar enough with me to know the difference.

And I'm not doing anything to Medicare/CMS; my patient population is only 10% CMS reimbursed. You residents with all your "inappropriate test ordering and take backs for complications" are doing that all on your own. <----- see emoticon? That's sarcasm.

 

[Gastrapathy]

I recently had a jaw dropping moment with our cardiology folk

Guy came through ER with "epigastric pain", 40 y/o
Got admitted to cardiology and Cathed!!
Findings: none ... shocking

STAT consult at MN to gen surg to workup abdominal pain, and oh by the way would you take the pat on your service ... ummm no

CT and RUQ u/s and LFTs normal
Wanted to do an EGD, endo could not accomodate me in the am the next day when we were post call, so we booked it for the following day.

Cardiology comes by to round on their patient, dosent like the fact that he cant get his scope done tomm, so consults GI to see the pt and scope them tomm. The GI doc bumps his own 8am case (which is why we wouldne get in) to do the pt when we wanted to do him

my head almost exploded

I have a simple question for you. Do you do therapeutic endoscopy? EMR a large gastric polyp or perform endoscopic hemostasis?

Where I trained, the surgical residents wanted to do EGDs but couldn't do anything more than biopsy when they found something. You want a head to explode, try getting called to "help" when they encountered a bleeding ulcer.

If your staff is credentialed and able to do therapeutics, scope away. Otherwise, you aren't as good as the gastroenterologist who stole your case and you need to get over it.

 

[Plastics13]

Here was one of my highlights from last month:

32yo F came to the ED with LLQ abdominal pain. Exam by ED provider shows no RLQ, RUQ, or MEG tenderness. They obtain CT abd which shows terminal ileitis and "appendix not visualized" and "appendicitis very unlikely". Admitted to family medicine whose notes state: Spoke with Radiology- no concern for appendicitis. Will consult Surgery if pain is there in morning.

701 am next day- paged to r/o appendicitis. I go see her, she states pain improved, no WBC count, afebrile, no RLQ pain, negative Rovsings, negative McBurneys, mild generalized L sided abd pain. I sign off with recs stating, "zero concern for appy, ileitis on CT, call GI"....

4 days later, reconsulted to r/o possible perforated appendicitis, GI still not consulted for IBD workup. THey repeat CT scan which shows no appendicitis, still with terminal ileum inflammation. GI staff note then states that she could have perforated appendicitis and they will not scope until CT enterogram done and definitively states no appy. Her exam is pain free at this point.

Argument still going on- now 6 days into care, still normal WBC, afebrile, normal vitals
RIDICULOUS.....

 

[SLUser11]

I have a simple question for you. Do you do therapeutic endoscopy? EMR a large gastric polyp or perform endoscopic hemostasis?

Where I trained, the surgical residents wanted to do EGDs but couldn't do anything more than biopsy when they found something. You want a head to explode, try getting called to "help" when they encountered a bleeding ulcer.

If your staff is credentialed and able to do therapeutics, scope away. Otherwise, you aren't as good as the gastroenterologist who stole your case and you need to get over it.

I can't speak for Opr8n, but we do therapeutics in Wichita. Epi or Saline injection and gold probe, etc. I feel relatively comfortable with "endoscopic hemostasis" as long as it's not a cirrhotic. We don't do EMR or variceal banding...of course there's no fight over those cases, and we get along very well with our GI colleagues.

As far as your last comment goes, it's sort of uncalled for. The patient in question had vague epigastric pain and needed a diagnostic scope....Opr8n's frustration comes from the fact that general surgery was good enough to see that patient at midnight, but not good enough to take care of the patient when 7am rolled around.

If you want us to subscribe to the "get over it" attitude, then you'll have to "get over" coming in at midnight for a bulls@#t consult. General surgery residents get tired of being dumped on, just like anyone else.

 

[45408]

If you want us to subscribe to the "get over it" attitude, then you'll have to "get over" coming in at midnight for a bulls@#t consult. General surgery residents get tired of being dumped on, just like anyone else.

Midnight endoscopies are right next to the hen's teeth in aisle 3 at my hospital...

 

[Apollyon]

Diagnosed another SBO with the history and physical exam (!) and an acute abdominal series. No CT in sight.

 

[SLUser11]

Diagnosed another SBO with the history and physical exam (!) and an acute abdominal series. No CT in sight.

I would still get the CT, though, once you had SB dilation identified on x-ray...IV and PO contrast.

CT can give you a lot of information about the SBO that can affect your management....and there are a lot of things that can hang out in the abdomen besides adhesions that you won't pick up on a plain film.

That's the double-edged sword of ER care.....surgeons make back-handed comments about how "patients can't go to the ER without getting a CT as they walk through the door...he-he...." but then there's still a big population of surgeons who won't see an appy consult without a CT (which is BS).

A side problem, however, is the ER doc ordering the wrong kind of scan, then you have to try to make a decision based on it....e.g. non-contrasted abdominal CT for trauma or for r/o Appy.

But, that's what makes us surgeons look like hypocrites....we talk crap on the ER for not working up their patients, then when a workup is done by them, we talk crap about the labs/xrays that they chose....can't have both.

 

[blue2000]

I would still get the CT, though, once you had SB dilation identified on x-ray...IV and PO contrast.

CT can give you a lot of information about the SBO that can affect your management....and there are a lot of things that can hang out in the abdomen besides adhesions that you won't pick up on a plain film.

That's the double-edged sword of ER care.....surgeons make back-handed comments about how "patients can't go to the ER without getting a CT as they walk through the door...he-he...." but then there's still a big population of surgeons who won't see an appy consult without a CT (which is BS).

A side problem, however, is the ER doc ordering the wrong kind of scan, then you have to try to make a decision based on it....e.g. non-contrasted abdominal CT for trauma or for r/o Appy.

But, that's what makes us surgeons look like hypocrites....we talk crap on the ER for not working up their patients, then when a workup is done by them, we talk crap about the labs/xrays that they chose....can't have both.

I agree with SLUser11 completely. I think in academia, where work is just work rather than salary, we talk out of both sides of our mouths a great deal. I think a workup of SBO by the ER that includes labs and plain films (as well as history and physical) is the perfect point at which to consult general surgery. At that point, you know the patient is getting admitted, general surgery can admit or decline at that point and/or decide what additional imaging needs to be done. In your institutions, are SBOs admitted to medicine, surgery or both?

 

[SLUser11]

I agree with SLUser11 completely. I think in academia, where work is just work rather than salary, we talk out of both sides of our mouths a great deal. I think a workup of SBO by the ER that includes labs and plain films (as well as history and physical) is the perfect point at which to consult general surgery. At that point, you know the patient is getting admitted, general surgery can admit or decline at that point and/or decide what additional imaging needs to be done. In your institutions, are SBOs admitted to medicine, surgery or both?

At my institution, SBOs are typically admitted to surgery. We very rarely get IM docs or hospitalists involved.

Anyway, most situations where I'm admitting a patient for SBO I want a CT scan, and I'll order it if it hasn't been done. There are some exceptions of course.

 

[Apollyon]

At my institution, SBOs are typically admitted to surgery. We very rarely get IM docs or hospitalists involved.

Anyway, most situations where I'm admitting a patient for SBO I want a CT scan, and I'll order it if it hasn't been done. There are some exceptions of course.

A little more detail - community hospital, but with a very active transplant program (on-call surgeon was putting in a kidney that was flown in by American Airlines - got here an hour early!). SBOs are routinely admitted by the hospitalist, with a GSx consult in the morning.

This guy was a recurrent. He has survived two cancers (pelvic osteosarcoma and prostate Ca), and had a R hemi after a polyp was found that was too big to snare on colonoscopy. He's nearly 80, but looked like my Dad did at 60. All dehydrated out and wan and wasted, and he still looks well younger than stated age.

As I stated on the last page, I start with the plain films. If there's question, then I CT. In my community practice, the surgeons are pretty reasonable. Honestly, I wonder if it's because of a Chinese and Filipino thing (and one Japanese guy).

 

[balaguru]

I would still get the CT, though, once you had SB dilation identified on x-ray...IV and PO contrast.

CT can give you a lot of information about the SBO that can affect your management....and there are a lot of things that can hang out in the abdomen besides adhesions that you won't pick up on a plain film.

How wound a CT scan change your management if you see dilated SB and decompressed colon on KUB? Everybody gets decompressed and gets better or they don't and will need surgical intervention regardless of the reason for their obstruction.

On the subject of improperly ordered scans, my experience has been that the ED was working up renal colic and happen to find something that looked like appendicitis.

 

[JayDoc06]

Can't remember most of them, the ridiculous ones seem to blur together into one fog of pain.

One does stick out, very last page after long night of trauma call, trying to leave sometime mid-day.

Unhelpful Medicine PGY-x: "Drain fell out"

Me: "What drain?"

UM-PGYx: "Drain fell out"

Me: "Who is the patient? Did he/she have an operation? Where was the drain?"

UM-PGYx: "Mrs Doe, Room 345673, Drain fell out"

Me: "Who operated on her, where was it done, what operation?"

UM-PGYx: "I dont know, come look at the drain."

Me: "Did she come from another hospital?"

UM-PGYx: "Yes"

Me: "What does transfer summary say? Any OP notes?"

UM-PGYx: "I haven't had time to look through any of those papers."

Me: "What is her diagnosis?"

UM-PGYx: "I don't know, she was checkout to me."

Me: "(Blast of explicatives)"

UM-PGYx: "Are you going to look at drain or not because it fell out?"

Me: "No, after you learn something about your patient, you call the on-call resident back, give an appropriate consult, and go EF yourself (can't remember if I said the last part... probably did)"


Never heard anything. On call team said they never called back.

 

[SLUser11]

How wound a CT scan change your management if you see dilated SB and decompressed colon on KUB? Everybody gets decompressed and gets better or they don't and will need surgical intervention regardless of the reason for their obstruction.

+/- Transition point (prox/distal, partial/complete)
+/- Signs of bowel ischemia/decreased enhancement/pneumatosis
+/- Swirl sign in mesentery
+/- mass, abscess, intussusception, etc.
+/- Microperforation or macroperforation, free air, free fluid
+/- Hernia causing obstruction (not always evident on PE, especially in fat people.


Those are the first few things I could think of. The approach of "they'll get better or they won't" could waste time and resources on a patient unlikely to progress, and it could expose patients to unnecessary morbidity/mortality.

And if your conservative management is successful, which it usually is, then you'll never know what happened for sure. If the patient is not progressing, a CT scan can help you decide if laparotomy or SBFT should be the next move.


Anyway, I just couldn't disagree more with your statement.

 

[balaguru]

+/- Transition point (prox/distal, partial/complete)

I would argue this doesn't matter. They still get an NGT and observation, at least around here.

+/- Signs of bowel ischemia/decreased enhancement/pneumatosis
+/- Swirl sign in mesentery

Should be evident clinically: fever, tachycardia, abd pain, leukocytosis, lactate.... Which by the way buys them a trip to the OR.

+/- mass, abscess, intussusception, etc.

Mass and TRUE intussusception are too rare to justify CT scans in everybody. Abscess should have other clinical markers.

+/- Microperforation or macroperforation, free air, free fluid

Never seen a microperf in the setting of SBO but I would think that clinical picture would trump that finding. Macroperf should be evident on plain films and exam should be concordant.

+/- Hernia causing obstruction (not always evident on PE, especially in fat people.

Agreed. I'm not against CT scans in the evaluation of SBO. There are scenarios where they have utility. I just don't think they are needed in the majority of patients: h/o abd surg and classic plain film findings.

Those are the first few things I could think of. The approach of "they'll get better or they won't" could waste time and resources on a patient unlikely to progress, and it could expose patients to unnecessary morbidity/mortality.

We admit at least 2 of these every day. I would argue that CT scanning them all is a waste of resources.

And if your conservative management is successful, which it usually is, then you'll never know what happened for sure. If the patient is not progressing, a CT scan can help you decide if laparotomy or SBFT should be the next move.


Anyway, I just couldn't disagree more with your statement.

If conservative management is successful then it was likely just SBO 2/2 adhesive disease. If they come back I'd offer them surgery right off the bat. I can't justify spending $2000 on everybody just to see dialated bowel +/- transition point and no other findings which is what I seem to see in the vast majority of patients that get a scan. If a patient fails to progress they get an operation. Around here that means a celiotomy but when I'm in practice I think I'll start with a scope.

 

[idiot07]

I have a simple question for you. Do you do therapeutic endoscopy? EMR a large gastric polyp or perform endoscopic hemostasis?

Where I trained, the surgical residents wanted to do EGDs but couldn't do anything more than biopsy when they found something. You want a head to explode, try getting called to "help" when they encountered a bleeding ulcer.

If your staff is credentialed and able to do therapeutics, scope away. Otherwise, you aren't as good as the gastroenterologist who stole your case and you need to get over it.

Uh, then you guys can:

1) Train enough people to provide endoscopy to everyone who needs it. (I don't understand why GI docs are so mercenary about scopes, there's more than enough to go around, particularly in the boonies).
2) Admit your own patients.
3) Handle your own perf's and assorted complications.
4) Take the patient to the OR when your intervention fails.

Yes, the gi guys are generally better at complex endoscopy than your average general surgeon, but 95% of the time or greater the patient just needs a diagnostic scope or a simple intervention like a dilation or a polypectomy. Most of my attendings that scope are comfortable clippling and injecting an ulcer. Difficult cases are usually predictable (cirhottic, massive UGI bleed, etc). Should gi docs without super-fellowship training not do scopes because the patient might just need an ERCP or EUS/needle bx? Of couse not.

 

[Fah-Q]

Nah, doing a procedure the same day as a consult requires a modifier 25 and generally doesn't pay as much.

What he should have done is say "needs endoscopy to R/O sinusitis will return tomorrow for 'BS' procedure" then bill for it separately...cha ching!

While I do recognize the sarcasm, I'm not sure the statement is accurate. My understanding is that as long as you add -25 to the E&M code and link the procedure code to a separate ICD-9 then you should be paid fully for both codes.

Correct me if I'm wrong, WS.

 

[FLgirl]

I recently got paged by an pedi ER attending on a patient without a surgical problem because "I saw in the computer that you guys saw her last time"

 

[SLUser11]

I would argue this doesn't matter. They still get an NGT and observation, at least around here.



Should be evident clinically: fever, tachycardia, abd pain, leukocytosis, lactate.... Which by the way buys them a trip to the OR.



Mass and TRUE intussusception are too rare to justify CT scans in everybody. Abscess should have other clinical markers.



Never seen a microperf in the setting of SBO but I would think that clinical picture would trump that finding. Macroperf should be evident on plain films and exam should be concordant.



Agreed. I'm not against CT scans in the evaluation of SBO. There are scenarios where they have utility. I just don't think they are needed in the majority of patients: h/o abd surg and classic plain film findings.



We admit at least 2 of these every day. I would argue that CT scanning them all is a waste of resources.



If conservative management is successful then it was likely just SBO 2/2 adhesive disease. If they come back I'd offer them surgery right off the bat. I can't justify spending $2000 on everybody just to see dialated bowel +/- transition point and no other findings which is what I seem to see in the vast majority of patients that get a scan. If a patient fails to progress they get an operation. Around here that means a celiotomy but when I'm in practice I think I'll start with a scope.

I think you're putting a little too much stock into the accuracy of your clinical exam. There are plenty of patients with ischemia/perforation who don't manifest a perfect combination of fever/leukocytosis/acidosis with signs of peritonitis.

You say mass and intussusception are too rare to matter, but I put etc etc because there are a million things you can find in there you weren't expecting....when you add them all together, they're more common than you think. Perfect example: Abscess and associated ileus, no SBO.

As for microperforation, I've seen it several times, but I guess since I get CT scans and you don't, that difference in experience can be easily explained. Plain films are just not good for identifying free fluid or small to moderate amounts of air.

Come to think of it, plain films can't really differentiate ileus from SBO, or obstructing cecal mass from adhesive band. They really can't tell you much beyond the fact that the small bowel is dilated and the colon is not.

Different patients and different pathologies require individualized therapy. I'm not sure I can subscribe to the simplistic, cookbook approach of "NGT x 48 hours, then OR if they don't progress." Since I want to operate on some right away, and I want to sit on some other ones for as long as humanly possible, I use the CT to guide my therapy.

Maybe your hands are better than mine, but I've found that there's not always a great relationship between the physical exam and degree/severity of underlying pathology. Often times, the hands and the CT disagree.

Anyway, I think it's okay to have differing opinions. My opinion is that it's $2,000 well spent, since it guides my therapy...and I think it can ultimately lead to a cheaper hospital stay for a good portion of patients.

 

[Winged Scapula]

While I do recognize the sarcasm, I'm not sure the statement is accurate. My understanding is that as long as you add -25 to the E&M code and link the procedure code to a separate ICD-9 then you should be paid fully for both codes.

Correct me if I'm wrong, WS.

You are paid for both codes, but not as much as if you do them on separate days. This is especially true when you consider the reduction for multiple procedures. I see this every day in my office - I make less if I do a consult and a biopsy on the same day than if I do the consult and then bring them back another day for the biopsy.

YMMV depending on your insurers.