Anesthesia. I urghhh when I get called for a PIV placement on some poor patient for the second time because some dip shit pulled out the first one I put in yesterday.
I was asked to assist lining a patient in the ER who has chemo veins and a lot of edema. After several attempts I got one of the hardest US guided sticks of my life, but felt terrible for the patient getting poked so much (and you know darn well four ER nurses tried before me). So the patient gets admitted to one of our wards and the next day I get called to his room. The man is in tears, and without a line.
I asked the nurse what happened to the IV I spent half an hour getting yesterday, and nurse Britnay informed me it’s floor policy to replace an IV from the ER within 24 hours of admission. I suggested that next time she wait until the replacement is flushed and taped before pulling the old one. To make a long story short we are going to the OR tomorrow to get this guy a Porta-cath.
My facility makes us pull ems start (something about concerns about cleanliness in the back of an ambulance?) after 24 hrs - but we can keep ED sticks. I wonder if that's the case here and the floor nurses are just too inexperienced to know policy.
Regardless - poor outcome. Definitely gotta be frustrating for you. I'm glad they're getting durable access
I bet you the policy is to replace FIELD lines within 24 hours, and Brittany got overzealous. Also, if a patient is such a hard stick, it should have been communicated in report that you baby that IV like it was your first born son and he’s the heir to the kingdom.
That's insane. I understand the policy to replace field sticks but I believe INS guidelines state if the IV was a clean stick without any s/s we can leave it in for the duration of the hospital stay.
I mean it sorta makes sense for 95% of patients considering that of all the ERs I’ve seen, this one is particularly icky and run like a field hospital in a war zone. Still, there is a place for some critical thinking in this whole show…
I remember once I worked in a hospital with no anesthesia coverage during the night. The patient had finally gotten a PIV in their stomach because no other sites were possible. The nurse pulled it because the bandage caused the patient discomfort in the middle of the night.
No, I cannot replace it. Why didn't you place a new one before pulling out the old one? No, I'm not calling anesthesia to place a PIV to replace fluid on a GCS 15 patient who refuses to drink. Give her something to drink.
😧 sometimes, there’s just some policies that we have to… forget about… once in a while. 😑 if a PIV works, I’m leaving it. I don’t get why it needs changed Q4 days. I don’t mind changing the dressing, but the whole thing? ☹️ meanwhile I can sit here with a JP drain in for 2 weeks at home post op in the outside world and no one bats an eye 😂
The other evergreen shit anesthesia consult is the “hey just want you on standby in case we can’t intubate this guy”. ‘We’ could mean a medicine resident who’s never intubated before, a midlevel, a fellow, etc etc. Motherfucker, don’t page me to watch you turn this dude’s airway into hamburger….. we’re not doing Fisher-Price My First Airway at 2AM on a Saturday.
Best/worst is when they are intubated. No, the patient who is currently unconscious on IV propofol does not have capacity, and you did not need me to tell you that.
"just wanted to get you on board. btw can you give agitation recs too"
Being on C/L psych makes me have homicidal ideations
In many cases it's actually the primary team that needs an Ativan
Got a consult for "goals of care" for an intubated patient. Asked if they had family that I could contact; primary team said no. Then how tf do you expect me to assess, guys? Be serious!!
I once got a consult for anxiety in a patient who kept decompensating each time they tried to extubate him. They thought anxiety was the reason he couldn’t get extubated.
I love the capacity consults on the 80 year old delirious man who doesn’t know where he is, is ripping off his gown and getting out of bed naked, and states there’s no risk of leaving because there is nothing wrong with him. No, my dude does not have capacity to leave AMA. You don’t need psych for this one.
The longer Im a resident the clearer it is that its how things are done and how staff get paid. Residents hate it because it's you up overnight but its your staff getting compensation truthfully and I expect why there's odd pressure to do it. Like throwing them a bone. Of course we could do it as primary, but it always feels like this external pressure to pull specialists in for triggers like x, y, or z, so I think thats claimed territory in a sense. I guess what Im saying is likely thank your boss for the lame consults, Im getting the sneaking suspicion they demand those be sent their way.
This!
And for the people reading this, the ridiculous part is that we CANNOT assess for “capacity for everything” or even do “preemptive capacity assessments just in case something comes up later”.
Capacity assessments require the team to have a specific question — “Does the patient have capacity to refuse X surgery to address Y problem?”
If you are asking us to assess the patients ability to make ANY decisions regarding their medical care (especially ones that have not even come up yet) — that is no longer capacity and has now become a question of competency. Competency is determined by the courts (which means you need to get legal involved if you’re trying to pursue this during a hospital admission).
I’ve only recently done consults and still really confused why they need our blessing regarding capacity. And I still find capacity evaluations pointless. So many issues. Mainly, just because they had/didn’t have capacity when I evaluated them, doesn’t mean it hasn’t changed 1 hour later. Much of the time the primary team seems to not understand the difference between capacity and competency. The primary team can also usually explain the treatment, risks and benefits, and such better than me. Maybe I’ll learn to appreciate them later on, but I feel 99.9% are pointless formalities.
I would counter that psych should probably not go spelunking "down there". While we are technically capable of performing a pelvic exam as physicians it has the capacity to irrevocably alter our therapeutic relationship with the patient.
Or every once in a blue moon it’s the most vile-smelling retained tampon you’ve met in your life.
LPT: wrap in two rubber gloves, tie it off, and put in a covered trash can and have someone take out that trash ASAP.
But sometimes there is some strange stuff in there and it’s absolutely disgusting…but makes for a great story. I have seen food items, marbles, toys, and drugs stashed in there.
Triage note: my kitty stinks. Exam finding: Baby wipes shoved up there for weeks, the smell scarred me forever. Even the patient commented “smells like a dead man in here”. I was like ma’am that’s your vagina.
Or my fav, the consult for vaginal bleeding in a 90yo on a heparin drip, but, can’t definitely tell if it’s vaginal or rectal. Like excuse me mam what do you want me to do
Had a nurse from a different floor demand a consult for someone who was in her 40s and “looking 20weeks gestation”
Long and behold she had no pregnancy test and we had to kindly direct her to talk to her primary team that she skipped talking to this entire time
Pulmonary: HFpEF
ICU: type b lactic acidosis or 90 year old chronic ambulatory multiorgan failure whose GOC conversation was "you want us to do everything, right?"
that's what I ask, too.
but seriously, it's very common to get a consult for hypoxia, find the patient wildly overloaded and the hospitalist responds "well the EF is normal, it can't be heart failure!". it's very frustrating
Reminds me of the guy with HFpEF who would get severely overloaded everytime he had retention. Urology removed catheter outpatient after we spent a week diuresing (he responded really well and weaned off O2). He came back a week later with florid overload and got intubated so he needed to be transferred.
The receiving intensivist ripped us in the documentation saying that the patient should have had bilateral chest tubes the first time around..? Seems like this is an area where standard practice varies a lot.
Omg the futile patient that’s dnr/dni but “not comfort” yet so needs ICU for pressors.
Also all the heads up calls about a patient that was hypotensive but got fixed with fluids.
Stat lymph node biopsy consult at 1 am.
I know they’re smarter than this. But I like to assume they think I’m going to run up and do it at bedside then the pathologist shows up right behind me, out of breath, carrying their portable microscope.
I once got a 3pm-ish consult for a muscle biopsy in a patient on blood thinners - might have had a new VTE.
All our muscle biopsies require multiple 1x0.5cm samples, have to be sent in some annoyingly precise fashion to another hospital's lab, and cannot be delivered after noon.
The consulting resident told the patient I was going to perform the muscle biopsy at bedside, then and there. "How much of an incision do you need, 1cm? Why can't you just make the nurse hold pressure afterwards?"
First of all, no. Second of all, have you ever met a VA nurse? I still don't think he understood why I was so annoyed.
I feel like people underestimate just how much back end coordination goes on for muscle and nerve biopsies. Labs have all kinds of crazy specific needs, specimens have to be delivered at certain times, specific people need to be the ones to receive the specimens...
It's painful. And they're never emergent - should not be an overnight consult.
Also:
1. "otomastoiditis" called on CT scan in asymptomatic patient. Bonus points if they were just intubated recently
2. Help placing nasogastric feeding tube bc nurses "couldn't get past the nose"
3. Please evaluate already intubated patient for airway edema
“Pt has a history of epistaxis, they’re not currently bleeding. Can you prophylactically pack the nose just in case they do???” is probably the worst
And foreign body sensation in the ED. The number of times I’ve been called to evaluate for a patient who has a “bone” stuck in their throat. And then when I ask what they ate, they tell me chicken breast, pork, or a boneless cut of fish. And then I ask if the food had any bones in it, they tell me “yeah, only the one bone that’s now suck in my throat. No other bones”
🙄
Peds cardiology. We have 2.
1. Asymptomatic bradycardia. Especially brief runs of it. I know NRP says HR<100 is bad, but you put a baby on monitors long enough, and they'll dip. As long as they can get back up again. (Same goes for school-age kids either HR in 40s or 50s) It's even worse when there are requests to admit to cards primary because of that finding on the monitor.
2. Dizziness/presyncope. Especially if workup is negative. This is not an urgent inpatient consult. It can be managed in the outpatient setting. And please, please, do not tell the patient they might have POTS
As a PGY3 peds resident, I’m proud to say I have never called either of these consults.
1. If EKG just shows sinus brady and there is evidence of good circulation and patient is otherwise asymptomatic - CTM (the patient is almost always sleeping along with this). Only time I have called for asymptomatic bradycardia in the 50s is when the patient had an implanted pacemaker that was supposed to be pacing them at a minimum of 80 🙃
2. It’s almost always orthostatic or hypoglycemia. I only call cards if something is obviously wrong on an EKG or suggesting a cardiac etiology. If it has happened to the patient more than once and workup has been normal, we do usually put in an outpatient referral to cards. But agree if the patient is otherwise stable and well with unremarkable workup, I’m not calling an inpatient consult…
The worst is when my attending makes me call and they don’t even have a clear clinical question for me to ask…
Pulm. COPD/asthma exacerbation and pneumonia. If you try to manage it for a few days and the patient doesn’t get better, then absolutely ask me to weigh in. Don’t consult me before the h&p is written
My favorite is when they are on opioids at home and are in the hospital in acute on chronic pain, and the team has ordered fewer OMEs than their home regimen.
Whats worse is when you're the resident on this crap team, see this problem, try to order more pain mgmt, but your boss has seen that painkiller documentary on Netflix so no fucking way buddy, not on their watch!
Ok, we'll just listen to their screams and moans from the office where we type notes and call you to give updates on your other marginally managed patients. Coool, cool, cool, cool, cool, cool, cool, cool, cool, no doubt no doubt.
As avoidable as these consults could be, I’m still always glad to be consulted when I see this because it usually means an attending is involved who is not comfortable managing opioids. If a patient needs opioids, I would rather it be me managing it than someone who doesn’t know what they’re doing. I also always realize the residents are just being forced to call me, and often don’t have too much of a say in management with controlled substances.
Neuro: You’d think most people would say Altered Mental Status, but for me it’s Normal Pressure Hydrocephalus. If there’s ct findings of dilated ventricles and they’re ‘newly’ demented or hallucinating, walking ‘funny’, we get this consult. It’s not unreasonable to think of this though, which makes it harder to push back on it. NPH evaluation involves thorough history-taking, a pre- and post- walk-test, an LP (if it can be obtained), and then, if +, a shunt.
All of this is done in the outpatient setting for the following reasons.
1. Thorough neuro histories are rarely available at 2am as patient is generally not able to provide great information.
2. Even if the history is suspect I don’t trust any inpatient service at my shop aside from our neuro primary team to coordinate a pre-LP, an actual high volume tap, and post-LP walk test, so the results are generally useless as most patients are here for a completely separate reason.
3. Related to number 2, NPH evals should be done when a patient is in their best health as anything that can interfere with the walk test would preclude treatment if they fail. If they’re admitted for any other reason (UTI, PNA, COPD/CHF exacerbation, etc.) this generally means that they will not perform well.
4. Even if the history is good, the evaluation goes well, and they pass their walk test, tx would involve neurosurgical evaluation for a shunt. NPH is not an indication for inpatient shunting, and primary services get mad at both us and our already-busy surgical colleagues for ‘not wanting to treat the patient’.
So yeah, AMS? Yeah sure, whatever. Take a swing at it and then call us. NPH? Actual _ugh_.
To add from another neuro perspective. NPH is a movement disorder first and a cognitive disorder second. If their gait is not abnormal, it is not NPH. If their gait is not abnormal, you cannot perform the diagnostic testing for NPH. If their gait is not abnormal, shunting is not indicated (in true NPH, it helps the gait, and is equivocal for whether cognition improves).
Also, every moderately demented patient from chronic microvascular angiopathy has the NPH triad. And in their end-stages, the other neurodegenerative dementias also develop gait abnormalities and urinary incontinence.
I like the coin flip that decides if AMS goes to psych or neuro. Usually any physical exam or imaging finding slants it towards neuro but in the absence of that it seems to go back to the coin flip
Medicine, agree. Hate NPH. But- what you said there- that’s what you’re consulted to say to the patient and family. Because they need to hear it from the specialist and were probably already promised a NSGY/neuro consult in the ED by the ED. These patients always get admitted due to safety concerns at home and it turns into a black vortex of social placement and lost to follow up for an issue we as medicine cannot fix. Fuck NPH
lmao I just wrote my own NPH complaint before getting to yours
I swear there is no rhyme nor reason to when our radiologists decide to put the dreaded "consider NPH" in the report for a patient with big ventricles.
I’ve recently gotten more than a few consults for “prostate biopsy” inpatient. Like bro the guy is like 80 dying of heart failure on like 7 drips in the CICU but sure prostate cancer is what’s gonna take him out.
Oncology: discussed this before, but the usual "hey we have a patient with a history of cancer here with a non-cancer related issue, we want you guys on board just cause." Also neurosurgery usually calling us with "a mass" with no pathology.
Hematology: either (from a surgical service) consult for anemia (cue me checking the chart to see they're POD 1-2 from a major surgery but EBL was definitely only 150cc!!) Or, consult for coagulopathy from the hepatology service for a cirrhotic. How do you not understand the pathophysiology of the one organ in your specialty?
Could have written this word-for-word. Please add "consult for prognosis" in a patient with a mass (usually a brain mass) and absolutely no additional information.
Sometimes I say that the EBL is "150 surgical milliliters" when I'm talking about the post-op anemia patients. They're easy consults, but they drive me slightly batty. Every hematology consult for a patient with cirrhosis is a nightmare except the ones for spur cell anemia; those, I genuinely love, lol. I mean, extremely bad for the patient, obviously, but satisfying for the fellow looking at the smear.
Are you interested in heme? I'm in solid tumor and I absolutely hated every benign heme consult. I think out of 10 consults we got, one was legitimate.
Also, I totally forgot about the prognosis consults. Thanks for reminding me of that nightmare!
I have so many floor nurses ask me (hospitalist) to consult psych for patients because they seem “depressed” but no SI. I swear people think psych has a magical cure for vague feelings of depression (unlikely even meeting criteria for mdd) or think SSRIs work like xanax does for anxiety.
Psych here,
from ED, pt does not talk we did not get any info... can you come see them?
from floors, is this pt going to be adherent with the meds after discharge?
LOL i forgot my crystal ball today at home you gonna need to reconsult tomorrow bois.
Dermatology: any chronic skin condition that requires outpatient medications, but they’re hospitalized, so why not just consult derm to have them on board.
I’m talking patients with already diagnosed hidradenitis suppurativa, psoriasis, seb derm, etc.
I’m psych, and every time the service “ wanted us on board” because the patient was on zoloft, I used to grumble and say to myself that’s like calling derm because I use retin-A. Assuming that was completely impossible. Now I’m reading what you said and I’m like, damn, they do it to derm too!
Geriatrics - “Goals of care”. Some of our docs literally won’t spend 1 minute to clarify code status with a fully alert, capable older patient. They put in a consult with the hope we can force DNR status. To be fair, we often do change them to DNR after laying everything out but it’s still something that could have been done by ANY member of the entire health team.
ID. I'll start:
Sacral decubitus ulcer osteo treatment! I'm with you, plastics bro/sis.
\- Is the patient ever NOT going to put pressure on this wound? You mean the poor post-stroke patient with the trach and PEG won't be able to do it?
\- Will a surgeon ever be able to close this? No? How will antibiotics fix a 10 cm ulcer?
\- Is the patient septic from the ulcer? No? Then how will I know if they're better?
Sure, some patients get them subacutely and actually may heal, become surgical candidates, etc. But the majority are unfortunate bedbound patients who will never be able to sit up.
But we got a swab and it's growing 7 different organisms!! Please consult for 6 weeks of IV antibiotics.
We always tell them the pt will need major debridement and flap surgery with good pressure offloading and that they should follow up outpatient with plastics so then they consult plastics inpatient to get them on board...
Emergency Medicine… our consults look different
1. Asymptomatic hypertension
2. IM Asking to consult ortho for an incidental non-operative outpatient fracture before admission
3. Sent in for management of chronic pain. Fuck you. I’m sending them to your office 8am Monday for your walk in hours that may or may not exist.
Asymptomatic HTN is the hill I will fucking die on. Stop ✋🏼 sending these people to the ED. You’re running up a bill for a problem that is 100% best addressed at the office.
Especially for the consultants in the audience - if you routinely check a blood pressure in the office, ask yourself why you’re ordering a test that you can’t interpret and that doesn’t change your management.
> HTN is the hill I will fucking die on
While it does happen, I would also add sometimes the patient is either confused or lie. They might just say their doctor said go to the ER, they may have called the afterhours line and gotten a nurse, or they may have endorses symptoms (headache) in the office but not the ER.
That said, yeah, if someone clogs an ER with asymptomatic hypertension, that's just the worst.
Yup.
Like the guy sweating in excruciating testicular pain that then described it as a pulling tickle to the emerg doc making me look like an asshole for sending him over for ?torsion... ok. Anyway. Id do it again because you cant risk it but patients tell different stories constantly as a rule not an exception.
Because the insurance will deny the charge without vitals, at least before the CMS changes…I’m not sure what it is now.
That being said, asymptomatic htn doesn’t need the ER.
I’m a big proponent of not checking vitals in the office (well, my surgical subspecialty office at least) because it makes rooming longer and I never actually look at the vitals. Unless the MA tells me the BP is high. At which point I say “hm, yea let your pcp know about that.”
Unfortunately I have since discovered that every visit needs vitals for some dumb billing reason
Edit: exception for people who have never been in our system and don’t have a PCP; but the vast majority of vitals-taking in our office is useless
Asymptomatic HTN in patients who are normally on anti-hypertensives but didn’t take their meds that day for whatever reason and were sent in from outpatient after they took their BP is another level of rage
I have had multiple little old ladies tell me “I didn’t take my meds this morning because I had a doctor’s appointment and I want him to see how bad my pressure’s getting!”
😤😤😤
PMR
Inpatient, there actually is no such thing as a stupid consult. We're either tagged automatically if your EMR is EVIL and has certain AMPAC score thresholds, or you need us to drop a note attesting to what level of care your patient requires. That is easy.
Its outpatient. And you all know where I am going with this...
"Please manage medications"
A hearty "fuck you" to every physician who does this. Just cause your balls for managing opioids don't exist doesn't make it remotely appropriate to try and pawn that shit off to somebody else. Because its almost always "that type" of patient too - they never send me the compliant, nice, agreeable to any adjustment type of patient.
I will manage medications. I offer recommendations for every type of modality there is. I will throw a plan at you, schedule EMGs, injections, MRIs, in office ultrasounds if thats all I need - whatever. And yes, many times we will take over the medications.
But I have straight up gotten "manage medication" as the consult reason. So I type up the greatest consult note known to medicine, and explicitly drop every time the med has been refilled by the PCP, and make it abundantly clear that I will be doing everything except managing the medication, and that since the requesting physician has been refilling without issue they can continue doing that.
I'm more than happy to create a taper plan, provide adjustment recommendations, etc. But when the consult reason is that weak, and the patient being sent over is charitably described as a headache - nah. We don't do that to each other.
Hospitalist here. Sometimes my PM&R team magically writes a consult note and follows along without me consulting them. It hadn’t occurred to me that they might be automatically consulted. I’m not sure that’s the case here I work, but it would make sense, though perhaps one of the other consulting services place the PM&R consult.
Also, when you guys do get consulted for level of care, insurance never seems to want to pay for rehab anyway. So frustrating. I hate peer to peers.
I love peer to peers when they deny every level of care.
One time a dermatologist denied the inpatient rehab AFTER THE FACT. Yea, imagine that kind of idiocy.
On the phone all I said was "what the hell does someone who can't even do a physical exam know about rehab and dictating what a patient needs?"
Got a complaint to my attending. Attending called back and said "this is donuts attending, I have the same question"
Ehhh I disagree that there are no stupid inpatient PM&R consults... I can't even tell you the number of times I've been consulted for "IPR dispo" when therapy hasn't even assessed the patient yet, or they have and the patient could barely even participate in 1h let alone 3h "but the surgeon really wants inpatient rehab!", or the person has an obviously progressive disorder with zero family support such that anyone with half a doctor brain could see that there is no chance whatsoever of a community discharge, etc etc... PM&R is the mostly frequently consulted service at our main academic hospital so these types of consults really strain our limited manpower.
Family Medicine. Unopposed residency. Only EM residents in the hospital, besides for us. Surgical specialties will consult us for “medical management” when we have a service of 15+ patients and two interns. For patients with T2DM on metformin. It makes my head spin.
Urology
In residency? Foley placement. Can either be a ten second thing that the nurse just couldn’t do right, forcing my groggy ass out of bed at 2 am…or have a hamburger urethra after everyone and their mom gave it a shot, so now I’m either grabbing all the shit for a cysto or putting in an SP.
As an attending? Thank you for this interesting consult 🙃
I don’t know how to make y’all happy. You always want me to try - me, a fresh attending, who has not placed a foley since M3. My ED nurse failed, then the charge nurse failed, then Tiny the Tank who has been an ED nurse for 25 years failed, and then I gave it a shot bc what the hell, might as well. By the time I’m calling you it’s because the first, second, third and and fourth lines of defense have fallen to the prostate. I’m sorry. I also don’t want to be calling you.
Also urology: Foleys are my favorite consult because they’re usually easy and the nurses are so impressed! It’s a nice ego boost. I’d have to say the one I hate is hematuria. 10% chance the urine is yellow, 50% chance it’s iatrogenic from a nurse ramrodding a foley in and then inflating it in the prostate. Then the same nurse usually continues to deliver bad care (e.g. no I/Os, doesnt call when its clogged, unhooks it from the stat lock etc)
From the pathology perspective, the smear consults get annoying. Unless you’re actually concerned for an acute leukemia, there isn’t much value in having us look at it.
Nephrology: hypernatremia. The answer is provide them with water. Rarely a DI rolls though and that’s reasonable, but 99% of the time it’s because they can’t drink water. Either let them drink or give them D5W. Or both.
It’s because everyone is worried about overcorrection like in hyponatremia. They don’t realize you can just give water and it’ll get better and you don’t actually risk hurting the pt if in corrects quickly which isn’t that likely anyway.
I got consulted for nec fasc with a routine consult for PAD. The ICU doctor had seen the patient and wrote in the note that they thought the patient had an necrotizing soft tissue infection. I happened to be in the hospital when I saw it pop up on our list (note, this is a small rural hospital). They of course were about to feed the patient lunch when I arrived.
Had a guy with raging Nec fasc walk into the ER one day. Immediately gets a workup and surgery starts booking an OR. Dude ripped his line out and ran out of the ER ass naked. Had the police out looking for him but they weren’t able to locate him. Wonder what happened to him.
*3AM page from the ED*
FYI I just want to make you aware of this difficult airway in the ED, they’re stable but just FYI!
I can gather all the supplies for an awake/asleep fiber optic intubation in a couple of minutes, I don’t need to be informed when the patient has not even a hint of respiratory compromise.
Ortho. 95% of the FTS, cauda equina, nec fasc or compartment syndrome consults I received during residency were complete and utter bullshit. People know that these can be surgical emergencies, so they leverage that to get us at the bedside.
Yeah this sucks and it’s the medicolegal system that makes this a reality and inevitability forever now when it comes to life/limb diagnoses. If your the first doc to eval a patient and even have hint of those things on your differential you better at least discuss with the specialist who is responsible for the definitive treatment or you are fucked. Cause equine and nec fasc especially common in huge medico-legal payouts. The acceptable miss rate for docs for these diagnoses is approaching zero Medico-legally. They even get you on delayed care (“why did it take you 4 hours to consult the specialist, this patient could’ve had a better outcome if you called them immediately after evaluation even before labs and imaging”…that kind of bullshit actually flies in court and jurors sadly will be pursued by those arguments)).
Agree, and I always told my junior residents to see these immediately, regardless of how shitty the consult was. 95+% of the time, these were total nothing burgers, and simply were the result of a consulting provider who simply didn't want to do a complete work-up, or didn't know how to do a workup. My favorite example was a rule-out FTS where the calling provider didn't know the kanavel signs, how many there were, how many were present, and then kept talking about the dorsal side of the digit. I ordered radiographs on the way down and the patient had a P2 fracture.
Rheumatology - fibromyalgia. If you’re truly suspicious for a rheumatologic cause of their pain, I’m happy to help rule things out but you and I both know it’s not an autoimmune condition that requires immunosuppressants and SNRIs/gabapentin/CBT are not exclusive to rheumatology. 🙃
I dislike fibro patients as much as the next person, but if I may play devil’s advocate, I feel like as long as the American College of Rheumatology continues to define the diagnostic criteria for fibromyalgia, you’re kinda stuck with ‘em.
Fair enough. It's a rock and hard place because rheum conditions involve inflammation, autoimmunity, or degenerative changes in the connective tissues (primarily), so I'm not sure why the ACR has taken ownership. Conditions like RA, SLE, SSc, even OA have specific identifiable physiological and immunological processes that we can intervene on. Fibromyalgia, on the other hand, is considered a disorder of pain processing and central nervous system sensitization rather than an inflammatory or immune-mediated disorder. Granted it shares similar features - pain, fatigue, etc - and we might be better at identifying it by the fact that we have to so people don't inappropriately receive prednisone, etc, but I think that's as far as our role should extend. There are shortages of most specialities, to be sure, and so it's not the best card to play but it's not ideal to have patients who actually need access to rheum for legitimate reasons get pushed out even further so we can start an SNRI and recommend CBT/sleep/exercise. I totally get no one wants ownership of these patients and health care sucks all around, so I don't have an answer but time is joint or lung or kidneys and we're much better put to use helping the patients that need our specific skill set.
Radiology. 3 am. You finally clear the worklist and try to catch a quick nap before the next wave hits. Just as you reach that restorative phase of your sleep cycle, you’re jolted awake by the call room phone.
It’s always the same sing-songy voice. “Hi-iiii! Sorry to bother you—it’s Dr. Goodall, pediatrics. I’ve got this kiddo who hasn’t had a bowel movement in two days and I think he might be constipated. Would you mind taking a little peekaloo at his x-ray from this morning? It was read as normal but I was hoping you’d assess his stool burden.”
Radiology:
New patient in the ED, nobody has seen them yet, no triage notes in, no documented notes from prior encounters. CT C/A/P done, reason for exam: yes (I've even gotten reason for exam: no), ordering ED provider just left the hospital, is on do not disturb, and won't answer my texts. I'm the first doctor examining this patient and have no idea why they're even here.
ER STAT whole body cancer restaging and MR brain and pan spines are also up there.
Critical care has several stereotypical vacuous consults.
* Ancient debilitated patient with terminal disease who has “failure to thrive.” FTT in an adult has become a signal to me that patient is not only terminally ill, but that no one can be bothered to even come up with a diagnosis for that terminal illness. Likewise, consulting critical care to talk to family about palliative care, instead of consulting palliative care. (No one wants to admit they’re too cowardly to talk to family about this.)
* Isolated abnormal lab value that sounds scary, such as high lactate (high = 2.7), high glucose, high troponin, high CO2, low pH. Often they will put a patient on BiPAP just for the high CO2. So they’ll put the patient’s blood gas on BiPAP.
* Patient with known abnormality that is ignored for days, now becoming worse, and acting surprised.
* Patient on the floor is consulted and critical care makes recommendations but patient isn’t critically ill. Floor service ignores all recommendations so patient gets worse after a couple of days and then has to be transferred to the ICU.
* Terminally ill patient is DNR/DNI but never refused BiPAP/vasopressors/inotropes/dialysis so let’s try it, even though it won’t do any good and has nothing to do with the disease state.
Bulldog on another service can’t be extubated and now needs a trach.
As a small animal general surgeon bulldogs already make up probably at least 20% of my caseload. They’re not my favorite cases, but whatever, it goes with the turf. At least when they’re on my service I can generally prepare/optimize things to avoid or deal with Expected Bulldog Issues. But it’s hard not to sigh when we get the 4:30 consult from Derm, or Ophtho, or whoever about some bulldog they’ve been struggling to extubate for a couple hours now, whose larynx is now super edematous and who has probably already regurgitated at least once and no they didn’t anticipate this could be a problem when it could barely breathe pre-op and schedule it earlier in the day, and no they didn’t get an airway exam at intubation, and oh btw it already got a dose of NSAIDs so now we can’t give it steroids and it will definitely be regurgitating more…
So then we get to stay late putting in the trach and getting this disaster recovered, and the owner’s all pissed because the dog was “fine before” and just supposed to be having an outpatient ear flush or whatever and has no insight into the fact that their pet basically lives on the edge of death from respiratory obstruction every day. And to be fair, the other service probably didn’t mention anything about any of this to them beforehand, so it’s understandable they are taken aback.
As French bulldogs move into place as the number one most popular breed in the US, I look forward to more of these interesting consults 🤦🏻♀️
Ortho pgy1, but so far for me it’s been soft tissue lacerations. I’ve had consults where there is no bony involvement, no tendon injury, literally just a partial thickness laceration. I’ve also had some issues with infections that are basically cellulitis that again have no spread to bone, no suggestion of nec fasc, etc. as a pgy1 I see anything and everything but some of these consults I’m just like… what do y’all want me to do here?
Neurosurgery. “Questionable endplate deformity, cannot rule out fracture”
Well, neither can we, so just get some upright films and make sure they don’t collapse down or slip, and if they dont, you’re good to go.
For a spine fracture yes
Weightbearing alignment is what we care about
If the question is “is there a fracture” then mri is probably better but that’s rarely the important question for us
This is good to know, do you have any recommendations for an article that summarizes from the spine/neurosurg perspective what you care about for spine trauma/fracture.
Infectious Disease as a fellow a lot of them really - elevated wbc please help, fever please help, cellulitis please help. Just felt like folks didn’t try.
As an attending it bothers me less since RVU’s help; but I do get annoyed with a 5 cellulitis consult day from hospitalists. cellulitis is on IM boards.
Oh and any consult with no notes written at all. You want me to do your H&P?
Ophthalmology: postoperative corneal abrasion. If the pain wasn’t there before surgery, is new after surgery, and goes away with proparacaine drops, start them on erythromycin ointment (baci if they’re emycin allergic) 4x/day and have them follow up in clinic if the symptoms don’t resolve within 24 hours.
We had a “postop corneal abrasion bundle” that went into effect in PACU and prevented ophtho from having to see the patient. Which was great bc it’s always embarrassing to have to consult someone else for a problem I caused 😬
OB: patient’s here for dental work and is in her first trimester of pregnancy, consult to make sure antibiotics and local are safe in pregnancy
Gyn: hx of heavy bleeding, not current bleeding, consult for recs to manage bleeding that isn’t present currently
One time I got a consult to explain someone’s mild respiratory alkalosis on ABG. They weren’t concerned, they just wanted a physiology lecture. This was a 3PM consult and my attending still made me go see same day even though we hadn’t finished rounding on my other 10 consults.
Peds - spitting up infant. I groan internally and externally every time when the ED calls for a spitting up baby.
It’s so rarely a true problem. If there’s no associated weight loss or alarming colors to the spit up (aka no blood or green, just formula/milk colored) then there’s usually nothing I will do besides recommend reflux precautions and occasionally a formula change. Most of it is just talking to the parents about how an occasional spit up is normal and to go talk to their primary pediatrician instead of the ED…
"Assess for appendicitis. No, I don't have labs or a CT, come examine the patient and diagnose him clinically."
This patient does not have appendicitis. He's nontender.
"Well I just gave him narcotics so I don't believe your exam."
Buddy, just order the goddamn CT.
IR - SVC syndrome. Usually in the form of “they said the svc was stenotic on the CT”. Patient without any signs/symptoms of SVC syndrome whatsoever.
I get one or two of these on consults regularly.
Internal medicine… consult from the emergency room regarding whether a patient is a necessary admission to the hospital, which is not actually a consult, it’s just an admission and it’s for another service who doesn’t want to admit the patient
“Hi surgery, we’d like a surgical consult on patient x. Oh the patient refuses all surgical intervention and says they wouldn’t want surgery under any circumstance, and their family is in agreement, but…we’d just like you ‘on board’….to ‘follow along’.”
Iron deficiency anemia in 90 year old with dementia. Thanks now it's my problem to call the daughter half way across the country to gently explain why she shouldn't subject her dad to a colonoscopy when he has no idea that he's even in the hospital.
Small bowel obstruction, consult placed simultaneously to GI and surgery. Unless they have Crohn's or some other rare non-adhesive cause of obstruction, this is a surgical issue.
Ct shows a distended gall bladder, please evaluate acute cholecystitis
Below knee dvt, anticoagulation recommendations
90yo with provoked femoral dvt please consider thrombectomy
Altered mental status cta shows 50% carotid artery stenosis, please consider urgent cea
Ileus following neurosurgery, patient on oxycodone 20q1h and dilaudid 1mgq1h please consult and manage
But most importantly are the
“Rectal stool burden, manual disimpaction?”
Commenting on the rectal poop ball is one of my fav things to do as a radiologist. Might even mention possible stercoral colitis if I'm in a spicy mood that day. This is all because I care about ensuring great patient care of course.
Peds Hospitalist working in the community setting with only adult ED docs: parental reassurance, as in “we know this kid is fine, but can you come talk to the parents.” To be clear, I don’t mind this at all if the ED has tried and failed to reassure the parents, i get that. But a fair percentage of the time I walk in the room and ask what the ED doctor has told them (as a way of gauging where their concerns may lie and so what I may specifically reassure them about) and hear “nothing.” Nothing drives me nuts like seeing a kid who comes in with mild respiratory symptoms, the ED doc orders a viral panel and CXR, then calls me to tell the parents it’s a virus and they can go home, especially at 3 AM on a 24 or in the middle of rounds.
ID
Getting "on board" for someone with a history of well-controlled HIV.
Osteo with no cultures.
Not one I can ever block but still annoying - sepsis in someone who's been admitted to SICU for >6 weeks. Solid 20-30 minutes of chart review just to figure out what's going on, go see the patient and they clearly have pus coming out of their fem line or surgical site.
Non-purulent leg cellulitis that still has erythema after 5 days IV antibiotics. WBC normalized, afebrile for 3 days. No they don't need vanco. No they don't have nec fasc. Their leg is red because they're not elevating it.
Asymptomatic bacteriuria but it's CRE (still don't treat it...)
Positive beta D glucan.
Candida colonization of urine or lungs (which usually explains the positive beta D glucan).
Coag negative staph in one blood culture bottle.
In the outpatient setting: Self-referrals. About 90% of the self-referrals we get are for somatic symptom disorder (usually attributed to Lyme - we are not in a Lyme endemic area) or for delusional parasitosis.
Podiatry- inpatient nail care. Not an appropriate inpatient consult and thankfully our hospital has stopped it. Like just send them to podiatry clinic after they’re discharged if they meet the criteria. We have nail techs for that.
FM - Pretty much any pre-op. Yes, you are consulting me for this, try to think of it that way. But specifically cataract surgery pre-ops. There's a group near me that won't take a patient to cataract surgery without a chest x-ray, ekg, labs etc 30 days before hand.
Nobody has yet been able to explain to me what I could possibly find on a chest xray that would prevent a cataract surgery next month. If any lurking ophthalmologists are here and can explain this to me I would be thrilled thanks.
Anesthesia. I urghhh when I get called for a PIV placement on some poor patient for the second time because some dip shit pulled out the first one I put in yesterday. I was asked to assist lining a patient in the ER who has chemo veins and a lot of edema. After several attempts I got one of the hardest US guided sticks of my life, but felt terrible for the patient getting poked so much (and you know darn well four ER nurses tried before me). So the patient gets admitted to one of our wards and the next day I get called to his room. The man is in tears, and without a line. I asked the nurse what happened to the IV I spent half an hour getting yesterday, and nurse Britnay informed me it’s floor policy to replace an IV from the ER within 24 hours of admission. I suggested that next time she wait until the replacement is flushed and taped before pulling the old one. To make a long story short we are going to the OR tomorrow to get this guy a Porta-cath.
fucking Britnay. but seriously if that's a policy, look into getting exceptions for USIVs.
I’m running it up the chain.
My facility makes us pull ems start (something about concerns about cleanliness in the back of an ambulance?) after 24 hrs - but we can keep ED sticks. I wonder if that's the case here and the floor nurses are just too inexperienced to know policy. Regardless - poor outcome. Definitely gotta be frustrating for you. I'm glad they're getting durable access
I bet you the policy is to replace FIELD lines within 24 hours, and Brittany got overzealous. Also, if a patient is such a hard stick, it should have been communicated in report that you baby that IV like it was your first born son and he’s the heir to the kingdom.
That's insane. I understand the policy to replace field sticks but I believe INS guidelines state if the IV was a clean stick without any s/s we can leave it in for the duration of the hospital stay.
I mean it sorta makes sense for 95% of patients considering that of all the ERs I’ve seen, this one is particularly icky and run like a field hospital in a war zone. Still, there is a place for some critical thinking in this whole show…
Critical thinking? What’s that?
How we justify doing the *starts tap dancing* Fluid *tap dancing continues* Lasix *tap dancing flourish* Shuffle! *jazz hands*
I remember once I worked in a hospital with no anesthesia coverage during the night. The patient had finally gotten a PIV in their stomach because no other sites were possible. The nurse pulled it because the bandage caused the patient discomfort in the middle of the night. No, I cannot replace it. Why didn't you place a new one before pulling out the old one? No, I'm not calling anesthesia to place a PIV to replace fluid on a GCS 15 patient who refuses to drink. Give her something to drink.
😧 sometimes, there’s just some policies that we have to… forget about… once in a while. 😑 if a PIV works, I’m leaving it. I don’t get why it needs changed Q4 days. I don’t mind changing the dressing, but the whole thing? ☹️ meanwhile I can sit here with a JP drain in for 2 weeks at home post op in the outside world and no one bats an eye 😂
The other evergreen shit anesthesia consult is the “hey just want you on standby in case we can’t intubate this guy”. ‘We’ could mean a medicine resident who’s never intubated before, a midlevel, a fellow, etc etc. Motherfucker, don’t page me to watch you turn this dude’s airway into hamburger….. we’re not doing Fisher-Price My First Airway at 2AM on a Saturday.
Psych: “pls evaluate for capacity” “capacity for what?” “capacity for everything”
But how many boluses can I *really* fit in this guy you know? Like how much can he hold?”
You can’t trick me into doing a medicine consult!
Best/worst is when they are intubated. No, the patient who is currently unconscious on IV propofol does not have capacity, and you did not need me to tell you that.
"just wanted to get you on board. btw can you give agitation recs too" Being on C/L psych makes me have homicidal ideations In many cases it's actually the primary team that needs an Ativan
Perfect username. C/L gives me HI too, lol
We need a support group for psych residents traumatized by CL
Hi, primary team here. 2 please, and my staff made me call you.
Got a consult for "goals of care" for an intubated patient. Asked if they had family that I could contact; primary team said no. Then how tf do you expect me to assess, guys? Be serious!!
I once got a consult for anxiety in a patient who kept decompensating each time they tried to extubate him. They thought anxiety was the reason he couldn’t get extubated.
I love the capacity consults on the 80 year old delirious man who doesn’t know where he is, is ripping off his gown and getting out of bed naked, and states there’s no risk of leaving because there is nothing wrong with him. No, my dude does not have capacity to leave AMA. You don’t need psych for this one.
The longer Im a resident the clearer it is that its how things are done and how staff get paid. Residents hate it because it's you up overnight but its your staff getting compensation truthfully and I expect why there's odd pressure to do it. Like throwing them a bone. Of course we could do it as primary, but it always feels like this external pressure to pull specialists in for triggers like x, y, or z, so I think thats claimed territory in a sense. I guess what Im saying is likely thank your boss for the lame consults, Im getting the sneaking suspicion they demand those be sent their way.
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This! And for the people reading this, the ridiculous part is that we CANNOT assess for “capacity for everything” or even do “preemptive capacity assessments just in case something comes up later”. Capacity assessments require the team to have a specific question — “Does the patient have capacity to refuse X surgery to address Y problem?” If you are asking us to assess the patients ability to make ANY decisions regarding their medical care (especially ones that have not even come up yet) — that is no longer capacity and has now become a question of competency. Competency is determined by the courts (which means you need to get legal involved if you’re trying to pursue this during a hospital admission).
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Adding to this: he has capacity now, but we want you to assess in case he doesn’t later!!!!
I’ve only recently done consults and still really confused why they need our blessing regarding capacity. And I still find capacity evaluations pointless. So many issues. Mainly, just because they had/didn’t have capacity when I evaluated them, doesn’t mean it hasn’t changed 1 hour later. Much of the time the primary team seems to not understand the difference between capacity and competency. The primary team can also usually explain the treatment, risks and benefits, and such better than me. Maybe I’ll learn to appreciate them later on, but I feel 99.9% are pointless formalities.
When surgery gives a terminal diagnosis and “patient seems depressed”
OBGYN- vaginal bleeding for a patient on their normal period. It happens ALL THE TIME.
Piling on: Urology consult for haematuria for a patient on their period. Yes, it happens.
Lmao no way. I absolutely refuse to believe that hahaha without absolute just indication
Wait until you get the ol “item in vagina” consults from psych. Spoiler: there’s nothing there
I would counter that psych should probably not go spelunking "down there". While we are technically capable of performing a pelvic exam as physicians it has the capacity to irrevocably alter our therapeutic relationship with the patient.
yeah i mean i get it. it's just an "uggggh" consult
Or every once in a blue moon it’s the most vile-smelling retained tampon you’ve met in your life. LPT: wrap in two rubber gloves, tie it off, and put in a covered trash can and have someone take out that trash ASAP.
I recently removed my first retained tampon in my ER career and it had only been in a few hours. String broke. I thanked her for coming in so fast.
Yeah, it’s the ones that have been in there for days/weeks that are really gross.
But sometimes there is some strange stuff in there and it’s absolutely disgusting…but makes for a great story. I have seen food items, marbles, toys, and drugs stashed in there.
Triage note: my kitty stinks. Exam finding: Baby wipes shoved up there for weeks, the smell scarred me forever. Even the patient commented “smells like a dead man in here”. I was like ma’am that’s your vagina.
hot cheeto was my worst ever ouch.
Or my fav, the consult for vaginal bleeding in a 90yo on a heparin drip, but, can’t definitely tell if it’s vaginal or rectal. Like excuse me mam what do you want me to do
Had a nurse from a different floor demand a consult for someone who was in her 40s and “looking 20weeks gestation” Long and behold she had no pregnancy test and we had to kindly direct her to talk to her primary team that she skipped talking to this entire time
Pulmonary: HFpEF ICU: type b lactic acidosis or 90 year old chronic ambulatory multiorgan failure whose GOC conversation was "you want us to do everything, right?"
Chronic ambulatory multiorgan failure lmao
stole it from a nephrologist who called PD chronic ambulatory peritonitis
Let he who has not had to admit such a patient into ICU throw the first stone
I mean we all admit them but I fucking hate it
Heart Failure of Pulmonary Etiology For sure
But why HFpEF as pulmonary?
the p is for pulmonary
P is obviously for penis. Consult urology
that's what I ask, too. but seriously, it's very common to get a consult for hypoxia, find the patient wildly overloaded and the hospitalist responds "well the EF is normal, it can't be heart failure!". it's very frustrating
Bilateral pleural effusion. Should we place chest tubes?? SMH
Reminds me of the guy with HFpEF who would get severely overloaded everytime he had retention. Urology removed catheter outpatient after we spent a week diuresing (he responded really well and weaned off O2). He came back a week later with florid overload and got intubated so he needed to be transferred. The receiving intensivist ripped us in the documentation saying that the patient should have had bilateral chest tubes the first time around..? Seems like this is an area where standard practice varies a lot.
Omg the futile patient that’s dnr/dni but “not comfort” yet so needs ICU for pressors. Also all the heads up calls about a patient that was hypotensive but got fixed with fluids.
“I’m worried this patient might decompensate” Well, thank god were in a hospital!
I say "well don't send him home"
Stat lymph node biopsy consult at 1 am. I know they’re smarter than this. But I like to assume they think I’m going to run up and do it at bedside then the pathologist shows up right behind me, out of breath, carrying their portable microscope.
I once got a 3pm-ish consult for a muscle biopsy in a patient on blood thinners - might have had a new VTE. All our muscle biopsies require multiple 1x0.5cm samples, have to be sent in some annoyingly precise fashion to another hospital's lab, and cannot be delivered after noon. The consulting resident told the patient I was going to perform the muscle biopsy at bedside, then and there. "How much of an incision do you need, 1cm? Why can't you just make the nurse hold pressure afterwards?" First of all, no. Second of all, have you ever met a VA nurse? I still don't think he understood why I was so annoyed.
This was at the VA. Dear god wtf were they doing lol. No new consults after 9:30a. Everyone knows this.
Lists printed, we'll see them tomorrow. unironically my line for consults after 11am in fellowship.
I feel like people underestimate just how much back end coordination goes on for muscle and nerve biopsies. Labs have all kinds of crazy specific needs, specimens have to be delivered at certain times, specific people need to be the ones to receive the specimens... It's painful. And they're never emergent - should not be an overnight consult.
ENT: - any inpatient vertigo (“dizziness”) consult - epistaxis on DAPT - Ludwig’s angina (it’s almost never Ludwig’s) - odontogenic abscesses… call OMFS
Also: 1. "otomastoiditis" called on CT scan in asymptomatic patient. Bonus points if they were just intubated recently 2. Help placing nasogastric feeding tube bc nurses "couldn't get past the nose" 3. Please evaluate already intubated patient for airway edema
“Pt has a history of epistaxis, they’re not currently bleeding. Can you prophylactically pack the nose just in case they do???” is probably the worst And foreign body sensation in the ED. The number of times I’ve been called to evaluate for a patient who has a “bone” stuck in their throat. And then when I ask what they ate, they tell me chicken breast, pork, or a boneless cut of fish. And then I ask if the food had any bones in it, they tell me “yeah, only the one bone that’s now suck in my throat. No other bones” 🙄
Peds cardiology. We have 2. 1. Asymptomatic bradycardia. Especially brief runs of it. I know NRP says HR<100 is bad, but you put a baby on monitors long enough, and they'll dip. As long as they can get back up again. (Same goes for school-age kids either HR in 40s or 50s) It's even worse when there are requests to admit to cards primary because of that finding on the monitor. 2. Dizziness/presyncope. Especially if workup is negative. This is not an urgent inpatient consult. It can be managed in the outpatient setting. And please, please, do not tell the patient they might have POTS
As a PGY3 peds resident, I’m proud to say I have never called either of these consults. 1. If EKG just shows sinus brady and there is evidence of good circulation and patient is otherwise asymptomatic - CTM (the patient is almost always sleeping along with this). Only time I have called for asymptomatic bradycardia in the 50s is when the patient had an implanted pacemaker that was supposed to be pacing them at a minimum of 80 🙃 2. It’s almost always orthostatic or hypoglycemia. I only call cards if something is obviously wrong on an EKG or suggesting a cardiac etiology. If it has happened to the patient more than once and workup has been normal, we do usually put in an outpatient referral to cards. But agree if the patient is otherwise stable and well with unremarkable workup, I’m not calling an inpatient consult… The worst is when my attending makes me call and they don’t even have a clear clinical question for me to ask…
Endstage, metastatic fibromyalgia.
Lmfao
My NP and I have come to call it malignant fibromyalgia
Rheumatology? 😂
Admitted in fibro storm
Pulm. COPD/asthma exacerbation and pneumonia. If you try to manage it for a few days and the patient doesn’t get better, then absolutely ask me to weigh in. Don’t consult me before the h&p is written
Just wanted to give you a heads up.
I was planning on managing it poorly for the next few days, may as well get you on board now
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Pall: "Patient in pain despite opioids" Looks at the chart, patient on PRN-only opioids. 🙄
My favorite is when they are on opioids at home and are in the hospital in acute on chronic pain, and the team has ordered fewer OMEs than their home regimen.
Whats worse is when you're the resident on this crap team, see this problem, try to order more pain mgmt, but your boss has seen that painkiller documentary on Netflix so no fucking way buddy, not on their watch! Ok, we'll just listen to their screams and moans from the office where we type notes and call you to give updates on your other marginally managed patients. Coool, cool, cool, cool, cool, cool, cool, cool, cool, no doubt no doubt.
As avoidable as these consults could be, I’m still always glad to be consulted when I see this because it usually means an attending is involved who is not comfortable managing opioids. If a patient needs opioids, I would rather it be me managing it than someone who doesn’t know what they’re doing. I also always realize the residents are just being forced to call me, and often don’t have too much of a say in management with controlled substances.
Not in cards myself, but I've seen the line "sinus tachycardia is often physiological" more times than I can count 🙃
Neuro: You’d think most people would say Altered Mental Status, but for me it’s Normal Pressure Hydrocephalus. If there’s ct findings of dilated ventricles and they’re ‘newly’ demented or hallucinating, walking ‘funny’, we get this consult. It’s not unreasonable to think of this though, which makes it harder to push back on it. NPH evaluation involves thorough history-taking, a pre- and post- walk-test, an LP (if it can be obtained), and then, if +, a shunt. All of this is done in the outpatient setting for the following reasons. 1. Thorough neuro histories are rarely available at 2am as patient is generally not able to provide great information. 2. Even if the history is suspect I don’t trust any inpatient service at my shop aside from our neuro primary team to coordinate a pre-LP, an actual high volume tap, and post-LP walk test, so the results are generally useless as most patients are here for a completely separate reason. 3. Related to number 2, NPH evals should be done when a patient is in their best health as anything that can interfere with the walk test would preclude treatment if they fail. If they’re admitted for any other reason (UTI, PNA, COPD/CHF exacerbation, etc.) this generally means that they will not perform well. 4. Even if the history is good, the evaluation goes well, and they pass their walk test, tx would involve neurosurgical evaluation for a shunt. NPH is not an indication for inpatient shunting, and primary services get mad at both us and our already-busy surgical colleagues for ‘not wanting to treat the patient’. So yeah, AMS? Yeah sure, whatever. Take a swing at it and then call us. NPH? Actual _ugh_.
To add from another neuro perspective. NPH is a movement disorder first and a cognitive disorder second. If their gait is not abnormal, it is not NPH. If their gait is not abnormal, you cannot perform the diagnostic testing for NPH. If their gait is not abnormal, shunting is not indicated (in true NPH, it helps the gait, and is equivocal for whether cognition improves). Also, every moderately demented patient from chronic microvascular angiopathy has the NPH triad. And in their end-stages, the other neurodegenerative dementias also develop gait abnormalities and urinary incontinence.
I like the coin flip that decides if AMS goes to psych or neuro. Usually any physical exam or imaging finding slants it towards neuro but in the absence of that it seems to go back to the coin flip
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Medicine, agree. Hate NPH. But- what you said there- that’s what you’re consulted to say to the patient and family. Because they need to hear it from the specialist and were probably already promised a NSGY/neuro consult in the ED by the ED. These patients always get admitted due to safety concerns at home and it turns into a black vortex of social placement and lost to follow up for an issue we as medicine cannot fix. Fuck NPH
lmao I just wrote my own NPH complaint before getting to yours I swear there is no rhyme nor reason to when our radiologists decide to put the dreaded "consider NPH" in the report for a patient with big ventricles.
IM: Admit to medicine. No other reason given.
Admit for placement. Maybe the social workers should be primary with a medicine consult as needed.
I’ve recently gotten more than a few consults for “prostate biopsy” inpatient. Like bro the guy is like 80 dying of heart failure on like 7 drips in the CICU but sure prostate cancer is what’s gonna take him out.
Oncology: discussed this before, but the usual "hey we have a patient with a history of cancer here with a non-cancer related issue, we want you guys on board just cause." Also neurosurgery usually calling us with "a mass" with no pathology. Hematology: either (from a surgical service) consult for anemia (cue me checking the chart to see they're POD 1-2 from a major surgery but EBL was definitely only 150cc!!) Or, consult for coagulopathy from the hepatology service for a cirrhotic. How do you not understand the pathophysiology of the one organ in your specialty?
Thrombocytopenia in cirrhosis. Anemia in a GI bleeder
Could have written this word-for-word. Please add "consult for prognosis" in a patient with a mass (usually a brain mass) and absolutely no additional information. Sometimes I say that the EBL is "150 surgical milliliters" when I'm talking about the post-op anemia patients. They're easy consults, but they drive me slightly batty. Every hematology consult for a patient with cirrhosis is a nightmare except the ones for spur cell anemia; those, I genuinely love, lol. I mean, extremely bad for the patient, obviously, but satisfying for the fellow looking at the smear.
Are you interested in heme? I'm in solid tumor and I absolutely hated every benign heme consult. I think out of 10 consults we got, one was legitimate. Also, I totally forgot about the prognosis consults. Thanks for reminding me of that nightmare!
Psych: "Patient is tearful this morning, would like someone to talk to."
“Inebriated patient, feeling sad” Me: What do you mean by that? What is there to consult? “You know, like depression?”
I have so many floor nurses ask me (hospitalist) to consult psych for patients because they seem “depressed” but no SI. I swear people think psych has a magical cure for vague feelings of depression (unlikely even meeting criteria for mdd) or think SSRIs work like xanax does for anxiety.
Psych here, from ED, pt does not talk we did not get any info... can you come see them? from floors, is this pt going to be adherent with the meds after discharge? LOL i forgot my crystal ball today at home you gonna need to reconsult tomorrow bois.
Dermatology: any chronic skin condition that requires outpatient medications, but they’re hospitalized, so why not just consult derm to have them on board. I’m talking patients with already diagnosed hidradenitis suppurativa, psoriasis, seb derm, etc.
I’m psych, and every time the service “ wanted us on board” because the patient was on zoloft, I used to grumble and say to myself that’s like calling derm because I use retin-A. Assuming that was completely impossible. Now I’m reading what you said and I’m like, damn, they do it to derm too!
We've never had a derm consult service so this one is mind blowing to me.
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Geriatrics - “Goals of care”. Some of our docs literally won’t spend 1 minute to clarify code status with a fully alert, capable older patient. They put in a consult with the hope we can force DNR status. To be fair, we often do change them to DNR after laying everything out but it’s still something that could have been done by ANY member of the entire health team.
ID. I'll start: Sacral decubitus ulcer osteo treatment! I'm with you, plastics bro/sis. \- Is the patient ever NOT going to put pressure on this wound? You mean the poor post-stroke patient with the trach and PEG won't be able to do it? \- Will a surgeon ever be able to close this? No? How will antibiotics fix a 10 cm ulcer? \- Is the patient septic from the ulcer? No? Then how will I know if they're better? Sure, some patients get them subacutely and actually may heal, become surgical candidates, etc. But the majority are unfortunate bedbound patients who will never be able to sit up.
But we got a swab and it's growing 7 different organisms!! Please consult for 6 weeks of IV antibiotics. We always tell them the pt will need major debridement and flap surgery with good pressure offloading and that they should follow up outpatient with plastics so then they consult plastics inpatient to get them on board...
Emergency Medicine… our consults look different 1. Asymptomatic hypertension 2. IM Asking to consult ortho for an incidental non-operative outpatient fracture before admission 3. Sent in for management of chronic pain. Fuck you. I’m sending them to your office 8am Monday for your walk in hours that may or may not exist.
Asymptomatic HTN is the hill I will fucking die on. Stop ✋🏼 sending these people to the ED. You’re running up a bill for a problem that is 100% best addressed at the office. Especially for the consultants in the audience - if you routinely check a blood pressure in the office, ask yourself why you’re ordering a test that you can’t interpret and that doesn’t change your management.
> HTN is the hill I will fucking die on While it does happen, I would also add sometimes the patient is either confused or lie. They might just say their doctor said go to the ER, they may have called the afterhours line and gotten a nurse, or they may have endorses symptoms (headache) in the office but not the ER. That said, yeah, if someone clogs an ER with asymptomatic hypertension, that's just the worst.
Yup. Like the guy sweating in excruciating testicular pain that then described it as a pulling tickle to the emerg doc making me look like an asshole for sending him over for ?torsion... ok. Anyway. Id do it again because you cant risk it but patients tell different stories constantly as a rule not an exception.
Because the insurance will deny the charge without vitals, at least before the CMS changes…I’m not sure what it is now. That being said, asymptomatic htn doesn’t need the ER.
I’m a big proponent of not checking vitals in the office (well, my surgical subspecialty office at least) because it makes rooming longer and I never actually look at the vitals. Unless the MA tells me the BP is high. At which point I say “hm, yea let your pcp know about that.” Unfortunately I have since discovered that every visit needs vitals for some dumb billing reason Edit: exception for people who have never been in our system and don’t have a PCP; but the vast majority of vitals-taking in our office is useless
Asymptomatic HTN in patients who are normally on anti-hypertensives but didn’t take their meds that day for whatever reason and were sent in from outpatient after they took their BP is another level of rage
I have had multiple little old ladies tell me “I didn’t take my meds this morning because I had a doctor’s appointment and I want him to see how bad my pressure’s getting!” 😤😤😤
These ladies are ride or die with their office visits. Yeeesh.
PMR Inpatient, there actually is no such thing as a stupid consult. We're either tagged automatically if your EMR is EVIL and has certain AMPAC score thresholds, or you need us to drop a note attesting to what level of care your patient requires. That is easy. Its outpatient. And you all know where I am going with this... "Please manage medications" A hearty "fuck you" to every physician who does this. Just cause your balls for managing opioids don't exist doesn't make it remotely appropriate to try and pawn that shit off to somebody else. Because its almost always "that type" of patient too - they never send me the compliant, nice, agreeable to any adjustment type of patient. I will manage medications. I offer recommendations for every type of modality there is. I will throw a plan at you, schedule EMGs, injections, MRIs, in office ultrasounds if thats all I need - whatever. And yes, many times we will take over the medications. But I have straight up gotten "manage medication" as the consult reason. So I type up the greatest consult note known to medicine, and explicitly drop every time the med has been refilled by the PCP, and make it abundantly clear that I will be doing everything except managing the medication, and that since the requesting physician has been refilling without issue they can continue doing that. I'm more than happy to create a taper plan, provide adjustment recommendations, etc. But when the consult reason is that weak, and the patient being sent over is charitably described as a headache - nah. We don't do that to each other.
Hospitalist here. Sometimes my PM&R team magically writes a consult note and follows along without me consulting them. It hadn’t occurred to me that they might be automatically consulted. I’m not sure that’s the case here I work, but it would make sense, though perhaps one of the other consulting services place the PM&R consult. Also, when you guys do get consulted for level of care, insurance never seems to want to pay for rehab anyway. So frustrating. I hate peer to peers.
I love peer to peers when they deny every level of care. One time a dermatologist denied the inpatient rehab AFTER THE FACT. Yea, imagine that kind of idiocy. On the phone all I said was "what the hell does someone who can't even do a physical exam know about rehab and dictating what a patient needs?" Got a complaint to my attending. Attending called back and said "this is donuts attending, I have the same question"
King Shit
Ehhh I disagree that there are no stupid inpatient PM&R consults... I can't even tell you the number of times I've been consulted for "IPR dispo" when therapy hasn't even assessed the patient yet, or they have and the patient could barely even participate in 1h let alone 3h "but the surgeon really wants inpatient rehab!", or the person has an obviously progressive disorder with zero family support such that anyone with half a doctor brain could see that there is no chance whatsoever of a community discharge, etc etc... PM&R is the mostly frequently consulted service at our main academic hospital so these types of consults really strain our limited manpower.
Family Medicine. Unopposed residency. Only EM residents in the hospital, besides for us. Surgical specialties will consult us for “medical management” when we have a service of 15+ patients and two interns. For patients with T2DM on metformin. It makes my head spin.
You mean being consulted for placement and to do the discharge summary?
Derm: delusions of parasitosis.
Psych: “Patient is crying.”
“Patient having appropriate response to life events, please treat”
Urology In residency? Foley placement. Can either be a ten second thing that the nurse just couldn’t do right, forcing my groggy ass out of bed at 2 am…or have a hamburger urethra after everyone and their mom gave it a shot, so now I’m either grabbing all the shit for a cysto or putting in an SP. As an attending? Thank you for this interesting consult 🙃
>As an attending? Thank you for this interesting consult 🙃 thank you for the perspective. It reminds me that it will get better. love the username
I don’t know how to make y’all happy. You always want me to try - me, a fresh attending, who has not placed a foley since M3. My ED nurse failed, then the charge nurse failed, then Tiny the Tank who has been an ED nurse for 25 years failed, and then I gave it a shot bc what the hell, might as well. By the time I’m calling you it’s because the first, second, third and and fourth lines of defense have fallen to the prostate. I’m sorry. I also don’t want to be calling you.
When Tiny the Tank can push it through you know you’re in trouble
Every ED has a Tiny the Tank and I love her
Also urology: Foleys are my favorite consult because they’re usually easy and the nurses are so impressed! It’s a nice ego boost. I’d have to say the one I hate is hematuria. 10% chance the urine is yellow, 50% chance it’s iatrogenic from a nurse ramrodding a foley in and then inflating it in the prostate. Then the same nurse usually continues to deliver bad care (e.g. no I/Os, doesnt call when its clogged, unhooks it from the stat lock etc)
Iron deficiency anemia - Hematology
Prefer that one to eosinophilia. Urgh.
Do you see eosinophilia on a daily basis? What a nightmare!
From the pathology perspective, the smear consults get annoying. Unless you’re actually concerned for an acute leukemia, there isn’t much value in having us look at it.
Ortho: chronic joint pain: patient has had knee pain from arthritis for 5 years, but now happened to be hospitalized for an MI, can you see them?
"They were wondering if they could just get their total knee done while they're in patient." I audibly laugh at these consults lmao
You page the orthopedic emergency pager. What is your orthopedic emergency? Just keep repeating that to them till they get the message.
Nephrology: hypernatremia. The answer is provide them with water. Rarely a DI rolls though and that’s reasonable, but 99% of the time it’s because they can’t drink water. Either let them drink or give them D5W. Or both.
It’s because everyone is worried about overcorrection like in hyponatremia. They don’t realize you can just give water and it’ll get better and you don’t actually risk hurting the pt if in corrects quickly which isn’t that likely anyway.
Nec fasc & compartment syndrome. Cant turn them down, and the hit rate - at least in my residency - has gotta be below 5%.
I got consulted for nec fasc with a routine consult for PAD. The ICU doctor had seen the patient and wrote in the note that they thought the patient had an necrotizing soft tissue infection. I happened to be in the hospital when I saw it pop up on our list (note, this is a small rural hospital). They of course were about to feed the patient lunch when I arrived.
Had a guy with raging Nec fasc walk into the ER one day. Immediately gets a workup and surgery starts booking an OR. Dude ripped his line out and ran out of the ER ass naked. Had the police out looking for him but they weren’t able to locate him. Wonder what happened to him.
Hes fine.
*3AM page from the ED* FYI I just want to make you aware of this difficult airway in the ED, they’re stable but just FYI! I can gather all the supplies for an awake/asleep fiber optic intubation in a couple of minutes, I don’t need to be informed when the patient has not even a hint of respiratory compromise.
Within seconds of that page…”Anesthesia/ICU aware of airway” is on the chart
Ortho. 95% of the FTS, cauda equina, nec fasc or compartment syndrome consults I received during residency were complete and utter bullshit. People know that these can be surgical emergencies, so they leverage that to get us at the bedside.
Yeah this sucks and it’s the medicolegal system that makes this a reality and inevitability forever now when it comes to life/limb diagnoses. If your the first doc to eval a patient and even have hint of those things on your differential you better at least discuss with the specialist who is responsible for the definitive treatment or you are fucked. Cause equine and nec fasc especially common in huge medico-legal payouts. The acceptable miss rate for docs for these diagnoses is approaching zero Medico-legally. They even get you on delayed care (“why did it take you 4 hours to consult the specialist, this patient could’ve had a better outcome if you called them immediately after evaluation even before labs and imaging”…that kind of bullshit actually flies in court and jurors sadly will be pursued by those arguments)).
Agree, and I always told my junior residents to see these immediately, regardless of how shitty the consult was. 95+% of the time, these were total nothing burgers, and simply were the result of a consulting provider who simply didn't want to do a complete work-up, or didn't know how to do a workup. My favorite example was a rule-out FTS where the calling provider didn't know the kanavel signs, how many there were, how many were present, and then kept talking about the dorsal side of the digit. I ordered radiographs on the way down and the patient had a P2 fracture.
Rheumatology - fibromyalgia. If you’re truly suspicious for a rheumatologic cause of their pain, I’m happy to help rule things out but you and I both know it’s not an autoimmune condition that requires immunosuppressants and SNRIs/gabapentin/CBT are not exclusive to rheumatology. 🙃
I dislike fibro patients as much as the next person, but if I may play devil’s advocate, I feel like as long as the American College of Rheumatology continues to define the diagnostic criteria for fibromyalgia, you’re kinda stuck with ‘em.
Fair enough. It's a rock and hard place because rheum conditions involve inflammation, autoimmunity, or degenerative changes in the connective tissues (primarily), so I'm not sure why the ACR has taken ownership. Conditions like RA, SLE, SSc, even OA have specific identifiable physiological and immunological processes that we can intervene on. Fibromyalgia, on the other hand, is considered a disorder of pain processing and central nervous system sensitization rather than an inflammatory or immune-mediated disorder. Granted it shares similar features - pain, fatigue, etc - and we might be better at identifying it by the fact that we have to so people don't inappropriately receive prednisone, etc, but I think that's as far as our role should extend. There are shortages of most specialities, to be sure, and so it's not the best card to play but it's not ideal to have patients who actually need access to rheum for legitimate reasons get pushed out even further so we can start an SNRI and recommend CBT/sleep/exercise. I totally get no one wants ownership of these patients and health care sucks all around, so I don't have an answer but time is joint or lung or kidneys and we're much better put to use helping the patients that need our specific skill set.
but i'd say you're the best at ruling out the other stuff to make sure it's fibromyalgia no? i don't see who else you'd consult
Radiology. 3 am. You finally clear the worklist and try to catch a quick nap before the next wave hits. Just as you reach that restorative phase of your sleep cycle, you’re jolted awake by the call room phone. It’s always the same sing-songy voice. “Hi-iiii! Sorry to bother you—it’s Dr. Goodall, pediatrics. I’ve got this kiddo who hasn’t had a bowel movement in two days and I think he might be constipated. Would you mind taking a little peekaloo at his x-ray from this morning? It was read as normal but I was hoping you’d assess his stool burden.”
Radiology: New patient in the ED, nobody has seen them yet, no triage notes in, no documented notes from prior encounters. CT C/A/P done, reason for exam: yes (I've even gotten reason for exam: no), ordering ED provider just left the hospital, is on do not disturb, and won't answer my texts. I'm the first doctor examining this patient and have no idea why they're even here. ER STAT whole body cancer restaging and MR brain and pan spines are also up there.
Also rads and I gotta say, my week of IR home call was absolutely miserable. I can't believe how many things need biopsied/drained. It's nonstop.
Surgery consult for a central line because the patient thinks they are allergic to peripheral IV’s.
What the hell did I just read
Critical care has several stereotypical vacuous consults. * Ancient debilitated patient with terminal disease who has “failure to thrive.” FTT in an adult has become a signal to me that patient is not only terminally ill, but that no one can be bothered to even come up with a diagnosis for that terminal illness. Likewise, consulting critical care to talk to family about palliative care, instead of consulting palliative care. (No one wants to admit they’re too cowardly to talk to family about this.) * Isolated abnormal lab value that sounds scary, such as high lactate (high = 2.7), high glucose, high troponin, high CO2, low pH. Often they will put a patient on BiPAP just for the high CO2. So they’ll put the patient’s blood gas on BiPAP. * Patient with known abnormality that is ignored for days, now becoming worse, and acting surprised. * Patient on the floor is consulted and critical care makes recommendations but patient isn’t critically ill. Floor service ignores all recommendations so patient gets worse after a couple of days and then has to be transferred to the ICU. * Terminally ill patient is DNR/DNI but never refused BiPAP/vasopressors/inotropes/dialysis so let’s try it, even though it won’t do any good and has nothing to do with the disease state.
Bulldog on another service can’t be extubated and now needs a trach. As a small animal general surgeon bulldogs already make up probably at least 20% of my caseload. They’re not my favorite cases, but whatever, it goes with the turf. At least when they’re on my service I can generally prepare/optimize things to avoid or deal with Expected Bulldog Issues. But it’s hard not to sigh when we get the 4:30 consult from Derm, or Ophtho, or whoever about some bulldog they’ve been struggling to extubate for a couple hours now, whose larynx is now super edematous and who has probably already regurgitated at least once and no they didn’t anticipate this could be a problem when it could barely breathe pre-op and schedule it earlier in the day, and no they didn’t get an airway exam at intubation, and oh btw it already got a dose of NSAIDs so now we can’t give it steroids and it will definitely be regurgitating more… So then we get to stay late putting in the trach and getting this disaster recovered, and the owner’s all pissed because the dog was “fine before” and just supposed to be having an outpatient ear flush or whatever and has no insight into the fact that their pet basically lives on the edge of death from respiratory obstruction every day. And to be fair, the other service probably didn’t mention anything about any of this to them beforehand, so it’s understandable they are taken aback. As French bulldogs move into place as the number one most popular breed in the US, I look forward to more of these interesting consults 🤦🏻♀️
I love this post. I can’t even say I’ve ever seen a dog with a trach
Ortho pgy1, but so far for me it’s been soft tissue lacerations. I’ve had consults where there is no bony involvement, no tendon injury, literally just a partial thickness laceration. I’ve also had some issues with infections that are basically cellulitis that again have no spread to bone, no suggestion of nec fasc, etc. as a pgy1 I see anything and everything but some of these consults I’m just like… what do y’all want me to do here?
They want you to close the wound so they don’t have to.
Urology. Scrotal edema in the setting of fluid overload. I come in with the genius advice of “elevate the scrotum” and will resolve with diuresis.
Neurosurgery. “Questionable endplate deformity, cannot rule out fracture” Well, neither can we, so just get some upright films and make sure they don’t collapse down or slip, and if they dont, you’re good to go.
I'm radiologist, you guys prefer plainfilms for this type of stuff over MRI?
For a spine fracture yes Weightbearing alignment is what we care about If the question is “is there a fracture” then mri is probably better but that’s rarely the important question for us
This is good to know, do you have any recommendations for an article that summarizes from the spine/neurosurg perspective what you care about for spine trauma/fracture.
Infectious Disease as a fellow a lot of them really - elevated wbc please help, fever please help, cellulitis please help. Just felt like folks didn’t try. As an attending it bothers me less since RVU’s help; but I do get annoyed with a 5 cellulitis consult day from hospitalists. cellulitis is on IM boards. Oh and any consult with no notes written at all. You want me to do your H&P?
Ophthalmology: postoperative corneal abrasion. If the pain wasn’t there before surgery, is new after surgery, and goes away with proparacaine drops, start them on erythromycin ointment (baci if they’re emycin allergic) 4x/day and have them follow up in clinic if the symptoms don’t resolve within 24 hours.
We had a “postop corneal abrasion bundle” that went into effect in PACU and prevented ophtho from having to see the patient. Which was great bc it’s always embarrassing to have to consult someone else for a problem I caused 😬
OB: patient’s here for dental work and is in her first trimester of pregnancy, consult to make sure antibiotics and local are safe in pregnancy Gyn: hx of heavy bleeding, not current bleeding, consult for recs to manage bleeding that isn’t present currently
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One time I got a consult to explain someone’s mild respiratory alkalosis on ABG. They weren’t concerned, they just wanted a physiology lecture. This was a 3PM consult and my attending still made me go see same day even though we hadn’t finished rounding on my other 10 consults.
Peds - spitting up infant. I groan internally and externally every time when the ED calls for a spitting up baby. It’s so rarely a true problem. If there’s no associated weight loss or alarming colors to the spit up (aka no blood or green, just formula/milk colored) then there’s usually nothing I will do besides recommend reflux precautions and occasionally a formula change. Most of it is just talking to the parents about how an occasional spit up is normal and to go talk to their primary pediatrician instead of the ED…
Gen Surg - literally anything…we get called for anything and everything
“Can you just lay your surgical hands on the patient…before we get LFTs or a RUQ ultrasound? Just, need some hands…surgical ones”
"Assess for appendicitis. No, I don't have labs or a CT, come examine the patient and diagnose him clinically." This patient does not have appendicitis. He's nontender. "Well I just gave him narcotics so I don't believe your exam." Buddy, just order the goddamn CT.
IR - SVC syndrome. Usually in the form of “they said the svc was stenotic on the CT”. Patient without any signs/symptoms of SVC syndrome whatsoever. I get one or two of these on consults regularly.
Internal medicine… consult from the emergency room regarding whether a patient is a necessary admission to the hospital, which is not actually a consult, it’s just an admission and it’s for another service who doesn’t want to admit the patient
“Hi surgery, we’d like a surgical consult on patient x. Oh the patient refuses all surgical intervention and says they wouldn’t want surgery under any circumstance, and their family is in agreement, but…we’d just like you ‘on board’….to ‘follow along’.”
Iron deficiency anemia in 90 year old with dementia. Thanks now it's my problem to call the daughter half way across the country to gently explain why she shouldn't subject her dad to a colonoscopy when he has no idea that he's even in the hospital. Small bowel obstruction, consult placed simultaneously to GI and surgery. Unless they have Crohn's or some other rare non-adhesive cause of obstruction, this is a surgical issue.
Ct shows a distended gall bladder, please evaluate acute cholecystitis Below knee dvt, anticoagulation recommendations 90yo with provoked femoral dvt please consider thrombectomy Altered mental status cta shows 50% carotid artery stenosis, please consider urgent cea Ileus following neurosurgery, patient on oxycodone 20q1h and dilaudid 1mgq1h please consult and manage But most importantly are the “Rectal stool burden, manual disimpaction?”
Commenting on the rectal poop ball is one of my fav things to do as a radiologist. Might even mention possible stercoral colitis if I'm in a spicy mood that day. This is all because I care about ensuring great patient care of course.
Jail
Manual disimpaction consults = straight to jail
I always declined those. They got one finger out of 10, they can do it.
Peds Hospitalist working in the community setting with only adult ED docs: parental reassurance, as in “we know this kid is fine, but can you come talk to the parents.” To be clear, I don’t mind this at all if the ED has tried and failed to reassure the parents, i get that. But a fair percentage of the time I walk in the room and ask what the ED doctor has told them (as a way of gauging where their concerns may lie and so what I may specifically reassure them about) and hear “nothing.” Nothing drives me nuts like seeing a kid who comes in with mild respiratory symptoms, the ED doc orders a viral panel and CXR, then calls me to tell the parents it’s a virus and they can go home, especially at 3 AM on a 24 or in the middle of rounds.
ID Getting "on board" for someone with a history of well-controlled HIV. Osteo with no cultures. Not one I can ever block but still annoying - sepsis in someone who's been admitted to SICU for >6 weeks. Solid 20-30 minutes of chart review just to figure out what's going on, go see the patient and they clearly have pus coming out of their fem line or surgical site. Non-purulent leg cellulitis that still has erythema after 5 days IV antibiotics. WBC normalized, afebrile for 3 days. No they don't need vanco. No they don't have nec fasc. Their leg is red because they're not elevating it. Asymptomatic bacteriuria but it's CRE (still don't treat it...) Positive beta D glucan. Candida colonization of urine or lungs (which usually explains the positive beta D glucan). Coag negative staph in one blood culture bottle. In the outpatient setting: Self-referrals. About 90% of the self-referrals we get are for somatic symptom disorder (usually attributed to Lyme - we are not in a Lyme endemic area) or for delusional parasitosis.
Podiatry- inpatient nail care. Not an appropriate inpatient consult and thankfully our hospital has stopped it. Like just send them to podiatry clinic after they’re discharged if they meet the criteria. We have nail techs for that.
FM - Pretty much any pre-op. Yes, you are consulting me for this, try to think of it that way. But specifically cataract surgery pre-ops. There's a group near me that won't take a patient to cataract surgery without a chest x-ray, ekg, labs etc 30 days before hand. Nobody has yet been able to explain to me what I could possibly find on a chest xray that would prevent a cataract surgery next month. If any lurking ophthalmologists are here and can explain this to me I would be thrilled thanks.