Most of the time I just say I’ll see it and drop a note in the morning if it’s after hours. Trying to avoid it from the ED just ends up with a consult order the next day from the hospitalist. And I mean it is an easy couple of RVUs and sign off. Out in the community I am not coming in or sending the resident in (they do a rotation with us) unless I need to operate that night and that is as expected.
Gen surg so most of what is not operative is still a decent reason to get admitted ND we have hospitalists so I will see them at my leisure. Only exceptions would be when they very definitely need another service which we have available bit that is rare. Usually it is that they need a different service we don't have. If it is emergent enough I will try to be ent, hand surgery, or whatever if I can safely do it (like converting the needle cric to a trach or debriding the upper extremity nec fasc) but if transfer is possible I prefer that.
You missed out on a critical care level consult!
Same. If it's after hours, I do my best to triage the issue over the phone and get the ED to do whatever workup I think is appropriate. 90+% of the time, it's telling them what imaging I want, reviewing it with them by phone, and reassuring them that there's nothing catastrophic. Usually, we can get the patient in to see someone in clinic the next day. Or at the very least, we do a follow-up call with them.
I referred him after.
I love these - send my PA to go see it, stop up and say hi and give the patient my card, easy money. But my office is in the hospital across from the floors so it's a lot less annoying.
Yeah, I get it in that case. My office is about 15 minutes away from the hospital. And I'm just not interested in the effort to see that sort of garbage. But, maybe I should be
Why can’t you see this the next time you’re at the hospital?Yeah, I get it in that case. My office is about 15 minutes away from the hospital. And I'm just not interested in the effort to see that sort of garbage. But, maybe I should be
Sure, just have the patient stay admitted for days to wait for the next time the surgeon would otherwise normally go to the hospital instead of letting them make an outpatient appointment for their non urgent issue. Sounds like a great use of resources
I thought this was in reference to patients who were staying inpatient for a few days anyways for other reasons.
Thank you for this interesting consult. Patient is critically ill and very complex. No surgery indicated. 99255.
They can untangle his wire while they’re grabbing’ them kidneys. Win-win.
Wow. On behalf of my specialty, my apologies. 🤦🏼♀️
Just saying it out loud doesn't make it happen bro.
Huh, when I was a resident the vascular team at my hospital would call us to do Forearm fasciotomies even after they did their brachial artery revascs. They refused to do them. Their mantra was “we don’t do anything below the elbow.” I literally had the same experience when i was with rounding with the hand fellow who was talking to a vascular attending. The vascular attending repeatly told him “I don’t do anything below the elbow” over and over again.
The part of the story that is egregious is ignoring that the problem was caused by a bleeding fistula, not the fasciotomy part. To be fair, while I can do arm fasciotomies in a pinch (and have done so but always have to review it quickly beforehand), I’m not particularly comfortable with extending onto the hand/crossing the carpal tunnel which (for the trainees in the audience) is technically quoted as necessary for a complete fasciotomy of the forearm (but in reality isn’t always needed, depends on the clinical situation) and I definitely do not feel comfortable with hand fasciotomies if they are needed. In addition arm fasciotomies usually need some kind of skin grafting in the longterm because it is pretty rare that the skin will be able to be closed primarily.
This is exactly it. We told them and documented we deferred to them for the bleeding fistula but were available for intraop assistance with fasciotomies if needed. The very capable vascular surgery attending did not call us for assistance with this, although I suspect he would have if they extended distally into the forearm, carpal tunnel or hand.
That's BS lol. You should have a department to department talk about that. Being able to perform fasciotomies of the upper & lower limb is literally one of the core competencies required to graduate from an orthopaedic surgery residency. Maybe ask them if they want to be residents forever, or they can come to your OR to learn how to do fasciotomies so they can graduate. 😂
I’m in the same boat. My N=3 for forearm fasciotomies after revasc. And all three times it was bc whoever was on hand call was already tied up in another case. So what did we do? We Googled it, watched a video on YouTube and then did it. It’s the carpal tunnel release part into the hand that we have no training in. So even now in practice, having already done a handful of cold arms; if there was ever a question, I’m calling someone who does this for a living.
Yes. And I will also add that I don’t make a secret of it to my trainees when I’m looking something up on the fly for an emergency consult. I think some people are embarrassed or want trainees to think they are all knowing. But I think we all have stuff that we encounter IRL for the first time or close to the first time as attendings and sometimes there isn’t an attendier attending to ask. Thank goodness for the internet.
Where I trained, typically trauma took the thorax/abdominal ones and ortho mostly managed the ones associated with extremity fracture, but got PRS on board to take over pretty quickly. But totally possible not to see one of these in gen surg residency especially if your home program didn’t have trauma and you rotated away for it.
There was an official discussion where they all claimed they didn't know how to deal with nec fasc so they wouldn't get involved even though a lot of the ones we get just need fasciotomies plus or minus debridement of dead muscle depending on how long the patient sat in the hospital before they called me after gen surg and ortho on call both said no. The transfer to higher level of care sounds good until you realize even ED to ED transfer for this is likely to take over 6 hours to possibly days. What kills me is that almost every ortho refuses to even see these patients. Some of my gen surg colleagues will pull the same crap but most will at least examine the patient before saying the patient needs higher level of care. Have even had ortho refuse to help with a patient whose hip joint I just exposed by debridement (they said just wash it out well and leave a drain under the skin I was able to cover the area with) and refuse to help with amputation when one had everything from the knee down die off. Finally got one older dude who had done AKA many years ago who agreed to come do it with me (I have no privileges for amputation and had never seen or helped with an above knee one before this but together we pulled off a good job and she was able to get fitted for a prosthesis and walk into my clinic a year later to show off and say thanks).
I had to look that up too. Seems like a problem I have perhaps seen before and just never learned that name.
I helped with a iliac crest osteocutaneous flap once as an intern. The attending was rather fresh from fellowship and she had photocopied the technique from a textbook and taped it to the OR wall so she could consult it as needed. I liked it because it modeled good behavior for when doing something one has not done a lot of and it also showed me what we were going to do (I think I was assigned to the case that morning) so I could try to be more helpful. Would probably be nice for me to tape up pictures of the forearm anatomy for when I am doing the nec fasc cases to remind me of the details of anatomy that I only recall in a vague sense so then I spend time thinking hmm, is this something I should try harder to save or what.
We had an attending none of the support staff liked (including a lot of the residents) who taped up an operative plan for a BKA. The nurses reported him with a PSN for "not knowing how to operate" and accused him of "operating from a cookbook." I was the resident on the case and thought it was very conscientious of him to have his operative plan written out, and the case went well.
That’s a damn shame. Those nurses clearly have no idea that the best surgeons review operative plans and surgical atlases before cases all the time. Tsk.
Whenever I proctor new docs (like fresh out of residency or fellowship) I have to defend them to the nurses and techs for being slow. I recognize that if something happens to me they figure it was a hard case or something special about the patient because they know I am good, while if something bad happens for the newbies they get a long lasting rep for being bad.
Please don’t misinterpret what we are saying here. Most of what we are discussing is not having seen a specific thing (because it is relatively rare) but the techniques were are trained in are sufficient to manage it - like the Morel-Lavallée lesion that was mentioned. This is a closed degloving injury and the management of soft tissue injuries overall is something the respective services are well versed in; not having seen an ML lesion before doesn’t mean someone is not equipped to handle it.
That makes sense thanks for the insight interesting to read about
Absolutely. I do this routinely for cases, especially if I haven't done a lot of a particular case or it's been a little while. For instance, anytime I get called for an esophageal perforation, I usually review my notes and atlas for an exclusion and diversion with a cervical esophagostomy. Fortunately, I've only had do to that once, but I'm prepared for that kind of disaster case every time.
I basically did this case except there was no chest tube present and no one ever considered asking thoracic to do it. I did call thoracic when I could not for the life of me reduce the stomach out of the chest but they were reluctant to get involved. I ended up making the gastric perforation bigger within the chest (from below of course because I wasn't about to open the chest) so I could empty the stomach out at which point I finally got it to fit through the opening in the diaphragm but was left with a question of what to do with the chest that had all that vegetative gastric contents evacuated into it. I washed out from below as best as I could but she ended up needing a VATS later to clean it out some more. Not sure that would have been avoided had they done something at my surgery though.
Since about 4th year as a general surgery resident I have been the regional expert in emergent crics by nature of having done five. I am not pleased with this designation but have not been out done any place I have physically gone.
I think I only have 2 and then around 6 conversions of a cric placed by er to a trach.
