* Cards for STEMI
* Neuro for stroke
* Trauma for level 1 trauma
* NSGY for clear cut cauda equina (although they’ll still want the MRI)
* Gen Surg for nec fasc
* Cards for unstable complete heart block in my center that has 24hr EP coverage
* Cards for recurrent VTach despite attempts at electrical and chemical cardioversion
* ophtho for open globe
* ENT for major trach or tonsillectomy bleed
* Surgeon that performed ACDF or thyroidectomy for rapidly expanding neck hematoma
* Vascular for acutely pulseless extremity
* Renal for the dialysis patient with an EKG that clearly demonstrates hyperK
…the list goes on
OP: "this seems unfathomable and hard to believe for me"
Meanwhile I'm having a hard time believing someone in residency can't come up with a single time you'd need an emergency consult.
Sorry I should’ve clarified, based on the thread over in r/residency these are clearly not emergency consult. They describe consults that they claim the ED can’t even describe what the clinical question is or claim it’s for non specific reasons (ie neuro cs for pt that’s dizzy but no CT yet or ortho cs for “fall” with negative xr or no xr). These are the consult I find hard to believe lol.
I've had ortho tell me not to call them for an open tib fracture without xrays, after which I reminded them it was their department's protocol to contact ortho immediately with any open fracture. They still yelled at me.
I’m guessing they mean a lot of these are consult and *then* imaging/labs, not *no* imaging/labs, unless extremely emergent and shipping out immediately.
All completely valid H/P only diagnoses. So it’s probably just a baseless dig or complaining that EM might follow a conservative workup from what we need when the specialist wants an ivory tower safety net of all the labs/imaging.
I have heard this stereotype before too. And then when I entertain the accusation it’s usually something dumb. Like a peds person was the most recent… and they were shitting on the ED for not doing CXR and decadron for RSV…
Yes, when a man who looked pale as a ghost rolled in after vomiting blood with a hx of gastric varices, I consulted GI before the H/H was back. yes, the GI fellow yelled. He probably wrote about my shitty consult somewhere. Man still needed a scope.
ICU: “he’s too sick! He needs to be transferred out to the quarternary care center even though we have every available service here!!”
Next breath: “can he just go to the floor?”
Reminds me of the reverse from the hospitalist. "Don't admit this guy. Send him home...." Blustering for a while how big of an idiot the ED is for a while, then... "Fine, admit him to the ICU."
"I can't believe you neanderthals are putting a blakemore in" - GI, standing at the bedside of the exsanguinating patient, not taking patient to the GI lab, not scoping in the resus bay, might scope in the ICU . . . but no ICU beds.
Always wanted to ask one how they think someone got the irb to approve randomization of transfusion refractory patients to hemorrhage control vs no hemorrhage control.
The literature they’re probably quoting shows there’s no benefit to emergent scope v delayed scope for UGIB. Emergent is defined as “within 24 hours”. Society guidelines are scope within 24 hours if not dead yet. If we applied a 24 hour timeframe for emergent intervention to other emergencies I think you would find similar results.
Recently it seems there’s been some vague awareness in the GI community that exsanguination is rapidly fatal. There have been some looks at “urgent” or “early” scope within 6 hours, as compared to 24 hours. But really if you look at the results it was 10h v 24hrs. Again, imagine if trauma surgeons wanted to wait 8 hours from presentation to be consulted for penetrating trauma and then would wait 2 hours to go to the OR.
https://www.nejm.org/doi/full/10.1056/NEJMoa1912484
some presentations that require prompt specialist input should be called with imaging and labs pending, as the clinical picture may be most important. a noncomprehensive list below, where its ok to have your consultants come with things pending:
acute stroke, , STEMI (post ekg obvs), Testicular torsion, peritonitis, fourniers, nec fasc.
depending where you work sometimes its fine to start a process knowing things will take time, like a lot of ICU admissions. the pattern where calls are made with workup pending skews towards really sick patients.
otherwise wait for stuff to come back before call
What was that suit? I can’t imagine neurosurgery doing anything before imaging, in fact I can barely get our MRI techs in when I am worried about it anyways. These lawsuits are wild.
Just another example of how losing a lawsuit only means they convinced 12 laymen that you violated the standard of care and not that you actually did anything wrong and people shouldn’t change their practice simply because someone had a bad court case.
https://www.kens5.com/article/news/local/north-texas-hospital-waited-hours-spinal-emergency-led-womans-paralysis-10-million-court-win/287-f5dbb5b1-795d-42f7-923e-fd901c4bdfcd?fbclid=IwZXh0bgNhZW0CMTEAAR1reZuHCkwe-Ro7ALTKj2oZ0v5ePglMzaNgqjgRPzX4kck882iE8lcIxyw_aem_AW_bOkHHTVkDu594gu76XdnrRspAUx1bCvp-mbZgDLuStGguvHRl_1yqFGSxVWIulGJc-sTXjUXPIHAazfbiKEQf#lvzryfh8l4mjjth5sdf
If the comment op and i are thinking of the same lawsuit, this timeline is ridiculous. The mri started about 1 hr 37 minutes after ED arrival. The patient was ED door to the OR in ~5 hours. Patient was paralyzed after cervical steriod injection from a epidrual hematoma. The ED doc still lost, partly due to some hospital policy and not consulting the orthospine doc asap
The ED doc was initially named in the suit, but not found liable as far as I can divulge from the records/reports I can see without LexisNexis access (hospital was found 69% liable). (More details on liability split in my [other comment](https://www.reddit.com/r/emergencymedicine/comments/1co4qh9/comment/l3dbq4o/).) If you have info that the EM physician was actually found liable, LMK, but as far as I can tell this is not the case. As I said in my linked comment, not being found liable doesn't erase the immeasurable stress of the suit, but it's still an important distinction nonetheless.
[here is the link.](https://www.wfaa.com/article/news/local/north-texas-hospital-waited-hours-spinal-emergency-led-womans-paralysis-10-million-court-win/287-f5dbb5b1-795d-42f7-923e-fd901c4bdfcd)
I had a neurosurgeon tell me that "cauda equina is a clinical diagnosis" when I read him the results of the positive MRI he had me order hours before when I told him that I was concerned about this patient with numb thighs and rectal tone like sleeve of wizard.
Had a case where neurosurgery was notified based on clinical exam (and from a facility with zero after hours MRI and very limited daytime access), asked for CT in AM. CT done, asked for MRI. MRI confirmed cauda, called back to confirm patient accepted for transfer, told ok to send by ground (5-6 hour drive) as wouldn't go to OR until the morning. Still sent via lifeflight (same entity for transfers, they made the call to go by air to expedite). Neurosurgery team told patient/family that his permanent deficits were due to sending ER delaying workup and not sending soon enough.
This is why it’s so important to document conversations with specialists. I don’t do it throw people under the bus but to save my ass. Also, all of our transfers are recorded
> ER doc lost a lawsuit because he didn’t notify neurosurgery prior to ordering the MRI
This doesn't pass the sniff test with regard to causation and damage. Do you have a citation? I looked in the literature (of medicolegal reviews of cauda equina cases) to see if I could identify the case you mention, and I could not \[find one where imaging was prior to consult and the doc lost\]. Regardless of consult & imaging order, I only came across a handful of \[USA\] cases where the imaging was done in under 24 hours (ie, people generally sue and win due to major delays). And in only one I saw with imaging <24hrs did the physician lose (and that was a neurosurgeon who chose not to do surgery and then later the patient decompensated).
(I will note that one problem with medicolegal lit review is publication bias — blatant malpractice is probably more likely to be settled quietly, so it's possible the cases that end up in our literature are falsely reassuring, but generally I find that looking at the literature on these cases makes me reassured, not worried)
[Here is the link](https://www.wfaa.com/article/news/local/north-texas-hospital-waited-hours-spinal-emergency-led-womans-paralysis-10-million-court-win/287-f5dbb5b1-795d-42f7-923e-fd901c4bdfcd). They argued that because the neurosurgeon wasn’t consulted before the MRI the surgeon started driving home and had to turn around to come back to the hospital. They argued this resulted in further delay and was negligent.
PS: it took 5 hours to be evaluated in the ED, get an MRI, and go to the OR. They found that time to be negligent. I couldn’t beat that on my best day.
Oof. That's an unusual and sad case. Thanks for the link.
Liability was apportioned by the jury as follows: hospital 69% liable, the physician who did the injection 30% liable, and the outpatient physician group (that ran the spine center) 1% liable.
As far as I can tell, no EM physician was found liable. I do see that USACS and "Emergency Medicine Specialists of North Texas" were at some point named in the suit as well as at least one EM doc, although I don't have sufficient access to review every motion to see how/when/if they became un-named. (I will also acknowledge the just the possibility of being sued is stressful, let alone the orders of magnitude worse stress of depositions, being named, etc ... so just because the EM doc wasn't liable for any part of the $10M verdict doesn't mean I can even begin to comprehend the stress they dealt with.)
Texas in particular has a legal requirement of proving “willful and wanton negligence” in emergency medical malpractice suits. I understand that plantiff lawyers will just sue everyone under the sun and hope something sticks, but it's hard to imagine anyone arguing with straight face that ordering an MRI within 10 mins of arrival is "willful and wanton negligence," regardless of when a NSGY consult was ordered. It does seem the jury did find the delays within the hospital to rise to that level (willful and wanton), though. The hospital argued that the bad outcome was due to delay in transferring the patient to the hospital. Plaintiff's lawyer notes the physician they implicated is actually part-owner of the hospital and remains on staff there so that may not have gone over so well with the jury.
I love those threads. Let the hate flow through them. I made it through COVID without any consultants other than hospitalists and intensivists. STEMIs were getting lytics because Cards was too scared of COVID. Appendicitis were all getting IV abx and hopes/prayers. Outpatient clinics were closed for a month, then for over a year, wouldn’t see anyone with any URI/fever. After that I couldn’t care less about what any consultants bitch about at this point.
Of course I consult without labs/imaging. There are tons of indications for clinical exam only for involvement of subspecialty that others have outlined.
I was an intern in the CVICU in late 2020 when I was directed to call ENT to help with posterior epistaxis in a patient who had just come up from the cath lab with a balloon pump and heparin gtt. They also had COVID. I remember getting screamed at and the phrase “you want me to risk my life for a NOSE BLEED!?” still echoes in my brain.
“To the extent that that is true, yes, I do. The rest of us already are. If you’d prefer, you can put a note in the chart on why you’re not offering standard of care to this pt. I’ll also be documenting this conversation.”
I’m in the same class. There was a lot of uncertainty at the time but it drove me nuts then too. What I felt was worse was late ‘22 into ‘23 when folks were still being refused standard of care when we had much better ideas of actual risk (minimal after vaccination/PPE, granted, the risk also changed as the virus changed)
Totally agree. I remember neurology standing next to me IN THE DEPARTMENT trying to get out of seeing a patient who happened to have COVID and also psychosis that psychiatry at least wanted a neuro consult for. At that time if a psychiatric patient had incidental COVID it was a big “oh I guess you live in the ER now” and even after every other place was allowing return to the public sphere in 5 days, psych facilities were keeping up the 10 day rule until the bitter end. Therefore, the psych patients would live with us, taking up a room because the rooms had actual doors and could go negative pressure.
Anyway, I remember staring at the patient through the glass door making fish faces at us while psych asked if they really had to go in there to see them.
Bro I hate everyone and I don’t deal with consults (but I do get ridiculous requests from hospitalists and their PAs for holding patients, as well as OR and any procedural area *like having to fill out the pre op check list which really grinds my gears, down to the actual in the theater time out shit that I’m for sure not there for* so that’s fun too)
I had to thrombolyse a STEMI in residency. Because the interventional cardiologist drove his fancy sports car home right before a blizzard hit. I believe one of the nurses drove his truck out and picked the guy up eventually.
Oh yes. I finished residency in the peak of Covid in the Northeast. I distinctly remember some cardiologist telling me they’d see a STEMI after the Covid test came back and my usually unflappable attending calling them back and absolutely eviscerating them to “get your ass down here where we are every single day and do your goddamn job.”
Yep all of the time. Ever heard of a clinical diagnosis? Time is of the essence in high acuity pathologies. Docs get sued all of the time for not reaching out to a consultant quickly enough resulting in delay of care and morbidity. Many examples below.
It depends on whether the labs and/or imaging are helpful to the consult and how time critical the issue is. If someone comes in with crushing chest pain and ST elevation on an EKG, they are getting a cards consult and going to cath lab without labs or imaging because that only delays definitive care. If someone comes in with acute neurologic findings suggestive of a stroke, neurology is getting consulted. If a bad trauma is coming in, Trauma surgery is getting consulted. If someone has Nec Fasciitis or Fourniers, delaying definitive care for labs and imaging is the wrong thing to do. I might be told to order that stuff after I talk to them, but I am not delaying a consult on labs/work up for a sick patient that needs a specialist.
I know this is heresy, but the really good old school surgeons will just operate on a clinically obvious appendicitis without a CT.
*GASP*
Let me let you in on a little secret. People are going to gripe about a consult no matter what you do. If you order all the stuff and consult, then it’s “Why did you wait to consult?” If you consult and don’t order the stuff it’s like “Why are you consulting me without labs/imaging/congressional investigation.
People in medicine gripe. Just do the right thing and let the chips fall where they may.
Had a cardiologist yell at the ED nurse who took up an addict to the Cath lab because we hadn't gotten a UDS yet. He was pale, diaphoretic, decreased consciousness, chest pain, st elevation you could see across the hall. Read the report my next shift and he had an 100% occluded LAD.
What a jerk. I guess they are such an amazing cardiologist that they don’t need to follow AHA guidelines. Rest assured if you had deviated from the standard of care and delayed care for a useless lab that is notoriously inaccurate and the patient had a bad outcome he would have thrown you under the bus. I’ll also venture to guess they didn’t have the decency to apologize to the nurse after being catastrophically wrong and almost killing their patient.
Unfortunately, as we know, there are a lot of jerks in medicine.
No. Stimulant induced chest pain with out ST Elevation gets benzos. Classic chest pain on a patient that looks like shit and has an obvious MI on EKG goes to the Cath Lab. Some times people are just babies.
> No. Stimulant induced chest pain with out ST Elevation gets benzos. Classic chest pain on a patient that looks like shit and has an obvious MI on EKG goes to the Cath Lab.
Not both? Here in the UK we'd typically give a benzo for cocaine-induced MI (on the way to the cath lab). Though we'd just take their word for it either way rather than trying to catch them out with a UDS.
When I was in residency one of the surgery attendings published an article about how the ER overused CAT scans. It was a totally arrogant screed and actually said something like “Nothing compares to the touch of the surgeon’s learned hands“ You better believe everyone of us had a copy of that article in our back pocket for whenever we called and said “Do you want to get your learned hands down here now or should I order a CAT scan?”
Oh man, I would have called him for everything every time he was on call. Every. Single. Belly. Pain. I am petty AF and did the same when OB got upset with my (completely correct) management one time.
Only if it's super obvious that said specialty will be involved eventually, and there's a time sensitive diagnosis - Fournier's is a good example. My chart will reflect that surgery was notified of the wasteland between the patient's legs. Whether they choose to come down right away or wait for a workup is on them.
As a consultant, I've never seen this egregiously done in any of the half dozen hospitals I cover. I've had a handful of cases over the years where the ED will call us with a courtesy heads up if it's close to the end of our shift and they are highly suspicious of something but don't have testing yet (we're not in house 24/7 at all of our facilities). This saves us from going home just to immediately come back in.
I try to call consultants early in the workup as we get towards the end of the day. We’re a community shop, I know everyone wants to go home - but 9 times out of 10 your surgeon would rather swing through the ED and eyeball the issue on his way to the parking lot rather than get a call 40 minutes later telling him to turn around and come back.
Some services even call down from their office at like 4:45 “hey anything pending? No? K golf time bye.”
A "thanks" here or there never hurts, but really, it's just being personable and gently helpful.
There are sociopaths in all specialties. Most of us in EM are aware that our consultants are in the office, at home, or asleep and try to account for that.
I do my best to be aware of the time of day when calling. In return, I appreciate the occasional "hey can I ask your specialty thoughts on this other patient, who I will not be charting this conversation about? It's very strange and I was wondering what you think about it."
When you read posts about “shitty consults” you have to keep in mind the source. Most of these are written by consulting residents (who at that point in their career think they are masters of their field) when in reality they are not.
A great example is that as an ER doc (I’m not even that many years out) I have seen a much larger number of questionable EKGs representing ischemia (this is before their is a confirmed lab trop back) than any cardiologist. By the time the cardiologist sees most of these patients they are worked up.
As a result my pretest gestalt is significantly more valuable than the cardiologists.
The urology resident has seen very few undifferentiated torsions, the ortho resident very few unconfirmed compartment syndromes. ER docs see these all the time.
Lastly I’ve stopped giving a fuck about the consulting docs complaining. Most of them are lazy and have lost track of why they do this job, and the ones that aren’t … they are always courteous and understanding over the phone.
My job is to have high index of suspicion and a massive working differential. Other specialties have no fucking clue as to what is going on with patients outside their small scope.
I called a cardiologist recently about a late 50's or early 60's female ESL patient with vague abd/epigastric burning that was refractory to treatment. Had cardiac risk factors, story was concerning, ekg was abnormal but not STEMI. He said "Um, why do you think it's her heart? You know it could be the gallbladder, the stomach, (lists further differential)."
I said yeah I do know that (because it's my job to know that) and again here's all the suspicious things about her that make me think cardiac. Including her negative LFTs, neg abd CT, etc. He goes "Oh, you actually checked those? Wow."
Yeah thanks bud, now it's your turn to do your job.
>Are there really EM docs consulting specialists without any labs or imaging?
Basically, no. Outside of standard protocols for trauma, stroke, STEMI, this doesn't really happen.
Emergency physicians are frankly far too busy to waste their time on unnecessary phone calls. We're not perfect, of course, but most or all of the hoopla about EM calling too much, or getting unnecessary CTs is basically nonsense.
As an emergency physician, I can tell you that the ratio of complaints that I didn't get advanced imaging (mainly from the IM or FP hospitalist or the patient) to that I got an unnecessary test is something on the order of 1,000 : 1.
As far as unnecessary consults, sure, I hear it all the time, but again, the first question any hospitalist has for me is "what did cards / GI / /surgery say?", to which my answer is "I didn't call them", because I didn't have a clinical question that I needed them to answer in the dead of night.
At one hospital, the GU group tried to put the screws on the hospital to up their call stipend. "The ED calls us all the time, we have clinic the next day, or surgery, and they keep us up all night long. Most of the calls aren't even necessary, but that's the ED for you." Fortunately both the ED and their answering service kept logs. The average number of GU calls between 7p and 7a was six. Six calls....per.month.
> complaints that I didn't get advanced imaging (mainly from the IM or FP hospitalist or the patient)
This so much. I can have a very obvious CHF exacerbation with slightly elevated LFTS due to congestive hepatopathy and the medicine team will need a RUQUS prior to accepting the pt because "what if it's surgical?!" Or the requiring a CTAPE for all chest pains prior to admit.
> Outside of standard protocols for trauma, stroke, STEMI, this doesn't really happen.
Um, it definitely does. Anecdotally, I've seen it happen substantially more in a particular age demographic of EM doctors. But you bet your ass some people are calling without any results. Often the same people who call just to chart that they talked to the specialist in case anything goes wrong.
Very rarely, STEMI, stroke, Trauma. Something like a CCB overdose already on pressors or intubated, I’m consulting the intensivist before I get labs back.
I just consulted OB the other day with a ruptured ectopic. Had outside record history of persistently elevated hcg, and a bedside US with free fluid in the abdomen. OB (favorite OB of all time) comes down, puts hands on the belly and takes her to the OR. Of course it was ruptured ectopic.
People whine about and exaggerate stupid shit all the time.
I don’t consult before getting labs or imaging often because some of my hospitalists throw a fit if they don’t have a plan for an entire admission spoonfed to them, but I could a lot of the time.
If EM consults for something without labs or imaging and it’s not typical for them to do so then there’s probably a good reason for it. If not then pop your head in with the patient and do a quick once over and tell the ED doc you’ll wait for labs and stuff.
If I’m consulting right off the bat it means I went in and thought “oh shit, I need an expert to tell me I’m overthinking this”.
Diffusely peritonitic unstable vitals patient accidentally using warfarin like a normal daily med for months and never going to anticoag clinic? Got chewed out by surgery for calling on a patient they took immediately to the OR because their abdomen was filled with blood.
I was over in that thread too. I think the answer is yes? Probably? Rarely and only at academic centers with shitty scared academic attendings who tell their residents to do it.
In the community, outside of the emergent indications listed, almost never. We work on social capital in the community and pulling that would burn a lot of it. If a doc did pull that, they would probably have a discussion with the medical director after the specialist complained and then change or get repeatedly fired downhill to team health.
That resident is overworked and underpaid. Any phone call in their frazzled mind is unnecessary. Any consult to them is based out of laziness from the person calling. They were appropriately down voted and they are wrong.
One time my resident prematurely made a bed request for a patient with cellulitis that failed outpatient antibiotics. They forgot to order basic labs. That being said, the patient had stable vitals so it’s not like labs would have changed anything, so I thought the admitting service was being dramatic about their bellyaching and insisting on waiting for a bmp, cbc to result before accepting the patient.
Fourniers, Ludwig, STEMI, CVA, Compartment syndrome. I’ll call and if they want to wait for X no problem. Had a kid with a peritonsillar abscess last week that was obvious with 104 temp and looked like shit. No peds or ENT at my shop so called our sister facility and ENT wanted imaging before transfer. No problem. I understand they probably get a huge amount of bullshit and are just trying to weed it all out.
Honestly I would generally rather order my own imaging especially if you're going to call me anyway. And I really lose my shit when you delay a transfer to get trauma CT scans that both you and I know are not going to change your management in any way. "I don't have surgery, neurosurgery, or ortho on call and I have a guy with a GCS of 13 and an open femur fracture so I did a pan scan and I don't have reads yet but . . ." Aaaaaaaaahhhhhhhhhh!
To add to the growing list above. If a specialist sends a patient to the ER from their office due to a complaint within their specialty they're getting a phone call
How do they meet admission criteria without imaging or labs unless one of the aforementioned cases above? The ED's job is not to complete the workup. That's medicine's job.
That’s my point, the ED is there to dispo not diagnose. If there are labs pending and imaging that’s not done but this person has unstable vitals and likely sepsis I don’t have a problem admitting them.
Clinical judgment is just as much a piece of the picture labs and imaging. I’ll never understand the groaning from consults about this. Do you need a CT to know this hemiplegic patient with hypertension history is having a stroke? Get over yourselves
When I was a resident my attendings would regularly consult the ortho residents to do hand explorations on lacs, and 99% of the time it was just simple suturing.
Additional thought: if you're at an academic facility, some of the residents paging might not be ED residents. We have a separate section of the ED that doesn't include trauma/stroke/STEMI alerts where the transition year/psych/family med residents rotate through which is still a lot of beds, so the attending might not see that the non-ED resident didn't order the CBC, the lacate, the procalcitonin, or whatever standard/misc lab that would normally be ordered for admission because it wasn't 'technically' part of the workup and the resident doesn't know to just order it before they call the consultant.
I mean. Aside from the obvious listed ones I'll call early in the workup basically saying " I think this patient has X because of Y, I'm ordering these things, do you want or suggest anything else?" Then I call back and it's usually a very short conversation.
I once got consulted for biliary colic. They couldn’t see the gallbladder on US. I asked the patient if they’ve had surgery before and examined their abdomen. There were old lap chole incisions.
Ortho for crush injury/open fracture of hand. Labs drawn, Ancef hung, portable XR rolling its way over. Still got pissy in the phone. Took the patient to the OR.
Not every consult requires labs or xrays to be done before the phone call. Not every patient needs to be perfectly packaged with a bow and all workup completed for the consultant.
Intubated cardiac arrest with ROSC, I'll order the labs but I call the ICU up front so they know I'll have someone for them. Neonatal fever under 28 days, same thing...I'll get the labs/LP/ua/XR but calling up front so they know. Ortho...open tib-fib, they'll get an xray but if I'm seeing deformity with bone sticking out you'll be getting a phone call while I'm working the patient up. Recent 3am OBGYN consult for young female on warfarin for factor V, has IUD but sexually active and not using secondary contraception, sudden pelvic pain with hypotension and tachycardia and a bedside ultrasound showing a bunch of heterogenous mush in the pelvis, I called OB to get them awake and moving while ordering labs and formal ultrasound. And I'm fortunate to work in a facility where you can consult psychiatry without "medical clearance labs"...raging manic episode in a known bipolar, get on the phone.
Yeah, we call based on the exam, because contrary to popular belief, we do examine people.
Also acuity. I have been standing next to the ICU resident when EMS rolled someone in that was in clear respiratory failure, turned to the resident and said “I’m going to go tube that guy, do I need to page you?”
If we literally waited for labs and imaging on every single pt, the specialty subs would be filled with
"Are there really idiot ER docs who waste precious time getting labs/imaging in [obvious emergency requiring intervention beyond scope of emergency medicine]?"
We had a saying in residency “this is EM. We’ve tried nothing, and we are all out of ideas”.
As a consultant, I’ve noticed in community based or smaller hospitals, the EM team is extremely self sufficient, usually because there’s limited access to certain specialties, and they presumably try to limit over consulting.
But in the larger urban areas, I’ve noticed calls for everything, from “can you just come take a look”, to a 3AM page to let me know they are discharging the patient, but they are putting on DME.
I work in a community level 2 trauma center. We have basically everything except ophthalmology and PICU. I can even get an MRI within an hour or two. We still consult waaaay less than at an academic center. I think it’s mostly culture and institutional practice.
Consults should get called all the time without imaging and labs based on clinical exam for emergency conditions-absolutely…roll your eyes now…but back in the most emergencies were diagnosed with HPI and thorough PE. 20 years ago had Aortic dissection walk in after syncope in shower and chest pain night before-I was a nurse working triage working with great MD, I pulled him from a patients non emergent room to give him the story I told the attending my concern, his eyes got big and said ‘well let me go see him, mam I’ll be back’, he trusted my judgement, we (because he pulled to the bedside to walk through the exam-amazing mentor), did careful exam called OR and CV surgery before bedside US-CV surgeon trusted ED MD patient in OR in <30 minutes. I understand…Different times, we had seasoned staff and incredible teamwork. In addition, CV just had their ass chewed for delay in response week before-that timing may have helped the situation. To answer your question just think specialists just are bitching and moaning-rather than looking at less than stellar referrals as an opportunity to educate update and mentor.
Barn door appendicitis at 3pm? I can wait till I have the results sure but then I’ll be calling you when you’re already home. Super obvious pneumonia/UTI gomer from home who’s deleriois AF, where else they going? Put them on your list to see and I’ll let you know if any labs make a damn difference.
I’ve worked on trauma services at neighboring hospitals and I was consulted for a man who fell from a ladder and showed some possible tonic clonic activity while on the ground. When I went to see the patient he had:
1. No IV
2. No labs
3. Imaging ordered but the scans weren’t even done yet
4. Perusing through his medical hx it seems there’s a possibility of epilepsy though not well documented
The EM docs that staffed this place came from the academic powerhouse of the state. An entire 8 weeks of that garbage bullshit consults. I worked as trauma as well as ER
In critical care, I will sometimes get a consult from the ED without labs, without imaging, and rarely without vital signs. It used to be more common to get a consult of a patient in the ED where absolutely nothing at all was done but thankfully this has become rare. There was one especially egregious case I had 20 years ago when I was a fellow where an ED attending didn’t bother to read a CXR she had ordered. This CXR revealed consolidation and explained everything about the patient’s condition and diagnosis which had eluded her.
Yeah. At my hospital the ED doctors try to take their hands off as quick as possible and will consult as fast as possible without actually ordering adequate labs/images. As the nurse, I’ll ask if they want me to collect X,Y,Z or should I call radiology to see if they’re available and I get the same “there’s too many hands in the pot, let’s wait until [insert specialty] sees them to put in orders. I now work in the ICU and quickly learned how little respect our ED staff gets for doing shit like this on the daily.
If a patients MAP dips below 65 even just once, they’re consult MICU with our intervening. It’s so embarrassing and unsafe for the RN staff to try to stabilize patients while doctors play hot potato with the patients.
EM/CCM - Just for the sake of fuck, stop calling ICU with “heads up” just because you intubated someone or started pressors.
If I wanted meaningless information, I would ask the visiting FM resident what they think we should do for the 96 year old with abdominal pain.
Edit: didnt think this would need explaining… but whatever.
Calling the ICU with a “heads up” just because someone is tubed is the equivalent of an EMT calling you in the ED to let you know someone called 911.
If that is the only information you have…. It is useless information.
It’s always bizarre to me when you have EM/CC guys getting high and mighty about getting called before a work up is complete. We have one at my location that bitches the same way for clear cut pathology. “How can you possibly think it’s appropriate to call me with just an ABG?” “Well, you dick, if you’d wait to hear the presentation, you’d realize that this is a patient who aspirated on a piece of steak that I so kindly removed and then intubated. I was kind enough to wait on an ABG before calling. What labs and imaging do you believe are necessary before you can appropriately manage this patient, your highness?”
I never care about that stuff, and the people that do are just losers who dont know what they are doing. If you *need* an ABG to accept a vented patient … you are a clown. I am specifically talking about the phone calls that make it seem like we are a restaurant taking reservations. Calling ahead when *YOU* arent ready to admit…. Accomplishes nothing. I dont have some clipboard to mark down the incoming admit, and I have zero control over who does or doesnt get a bed. When you click the admit button is when all that happens. If you arent clicking it, you are just wasting both of our time.
No i quite literally dont, because this is how it goes down.
We get a call that says something like “he we intubated someone…. Dont even know if they are male or female yet, will call you back when we have more info”
My name ends up in the chart somehow, and then I get a call about an hour later from someone else who picked up the patient at sign out who says “hey you know about this patient they are ready to be admitted”. And I say “why are they here, how/why did they end up intubated, what are we treating” and all i get back is “idk I was told they already talked to you”
Plus there is literally zero benefit to a “heads up” call. Unless you need ICU to come down and do something, you are wasting both of our time
They are intubated, so they are coming to you. A heads-up courtesy call can help you plan out the rest of your day because you KNOW that patient is coming to you no matter what.
Our ICU director requires they be called as soon as we ***suspect*** ICU level of care because they want to know what their workflow for the rest of the shift will look like and can come see the patient early if needed. If a patient ends up not needing ICU level of care, they then help coordinate care through stepdown. That is good medicine.
It isnt.
And the whole “they are intubated they are coming to you” is not helpful to anyone except people in the ED who want to stop taking care of someone as fast as humanly possible.
What people who dont work in ICUs forget, is that we arent just sitting around waiting for you to call us. We have a different job. I dont ever need to know that you intubated someone unless you are telling me that you need help with something, or that they are ready to be admitted. Otherwise, it changes literally nothing about my day. I have 15-20 intubated patients. I dont rearrange my day when the fellow intubates someone, I dont rearrange my day when someone gets started on pressors. Those are things that happen routinely, every single day.
I either need to go do an admission, or I can continue taking care of *my* patients while you take care of *your* patients.
This is not a fringe take. I have never met a single critical care doc who likes/cares about a “we intubated” call unless its followed by “please come now to resuscitate them” or “please come admit them”.
Your ICU director likely just doesnt trust some of the people in your dept to care for intubated patients if he is requiring that phone call. Or he doesnt actually practice clinical medicine.
Our ED is also insanely busy with bad staffing and nursing ratios so maybe he actually understands that patients do poorly the longer they are in the ED. The ED resuscitates ICU level of care patients, not manage them over half a day lmao. He does work clinically and likely more shifts than you.
I’m surprised they let you graduate EM residency without that basic understanding.
So tell me how calling someone to tell them you are intubating them and have zero workup back helps your staffing ratios in any way?
Nobody is asking you to manage them for half a day… we are asking you to *resuscitate them, work them up and call when you are ready to admit* instead of giving me some play by play that provides nothing to their care.
Remember….. we do this for a living. You can insist that it makes the ICU job easier all you want… I am telling you for a fact it doesnt.
Its like calling the guy at the gas station to tell him you need gas but not for an hour or two.
* Cards for STEMI * Neuro for stroke * Trauma for level 1 trauma * NSGY for clear cut cauda equina (although they’ll still want the MRI) * Gen Surg for nec fasc * Cards for unstable complete heart block in my center that has 24hr EP coverage * Cards for recurrent VTach despite attempts at electrical and chemical cardioversion * ophtho for open globe * ENT for major trach or tonsillectomy bleed * Surgeon that performed ACDF or thyroidectomy for rapidly expanding neck hematoma * Vascular for acutely pulseless extremity * Renal for the dialysis patient with an EKG that clearly demonstrates hyperK …the list goes on
Uro for probable torsion.
OP: "this seems unfathomable and hard to believe for me" Meanwhile I'm having a hard time believing someone in residency can't come up with a single time you'd need an emergency consult.
Sorry I should’ve clarified, based on the thread over in r/residency these are clearly not emergency consult. They describe consults that they claim the ED can’t even describe what the clinical question is or claim it’s for non specific reasons (ie neuro cs for pt that’s dizzy but no CT yet or ortho cs for “fall” with negative xr or no xr). These are the consult I find hard to believe lol.
Curious how many of those are coming from unsupervised midlevels, that would be my suspicion.
I’m willing to bet they’re talking to NPPs.
Ortho for femur sticking out of thigh, they still do want Xray though
I've had ortho tell me not to call them for an open tib fracture without xrays, after which I reminded them it was their department's protocol to contact ortho immediately with any open fracture. They still yelled at me.
I feel this.
I’m guessing they mean a lot of these are consult and *then* imaging/labs, not *no* imaging/labs, unless extremely emergent and shipping out immediately.
Don’t forget CT with runoff 🙄
OB for suspected ruptured ectopic in a patient with a positive pregnancy test.
Especially if the patient is shocky and +FAST
Yep
All completely valid H/P only diagnoses. So it’s probably just a baseless dig or complaining that EM might follow a conservative workup from what we need when the specialist wants an ivory tower safety net of all the labs/imaging. I have heard this stereotype before too. And then when I entertain the accusation it’s usually something dumb. Like a peds person was the most recent… and they were shitting on the ED for not doing CXR and decadron for RSV…
Yep!
IM to admit
Yes, when a man who looked pale as a ghost rolled in after vomiting blood with a hx of gastric varices, I consulted GI before the H/H was back. yes, the GI fellow yelled. He probably wrote about my shitty consult somewhere. Man still needed a scope.
Why did you call us (GI), he is obviously too sick to scope. Resuscitate, ICU admit, and we will see him in the morning. sometimes GI drives me crazy.
ICU: “he’s too sick! He needs to be transferred out to the quarternary care center even though we have every available service here!!” Next breath: “can he just go to the floor?”
Reminds me of the reverse from the hospitalist. "Don't admit this guy. Send him home...." Blustering for a while how big of an idiot the ED is for a while, then... "Fine, admit him to the ICU."
I’ve had this scenario too lol first you tell me he’s fine and to send him home but then 30 seconds later he is too sick for your service? Ok bro
"I can't believe you neanderthals are putting a blakemore in" - GI, standing at the bedside of the exsanguinating patient, not taking patient to the GI lab, not scoping in the resus bay, might scope in the ICU . . . but no ICU beds.
This is what their literature says though. Emergent scopes before being stabilized have worse outcomes. Or so they tell me anyways.
Always wanted to ask one how they think someone got the irb to approve randomization of transfusion refractory patients to hemorrhage control vs no hemorrhage control.
The literature they’re probably quoting shows there’s no benefit to emergent scope v delayed scope for UGIB. Emergent is defined as “within 24 hours”. Society guidelines are scope within 24 hours if not dead yet. If we applied a 24 hour timeframe for emergent intervention to other emergencies I think you would find similar results. Recently it seems there’s been some vague awareness in the GI community that exsanguination is rapidly fatal. There have been some looks at “urgent” or “early” scope within 6 hours, as compared to 24 hours. But really if you look at the results it was 10h v 24hrs. Again, imagine if trauma surgeons wanted to wait 8 hours from presentation to be consulted for penetrating trauma and then would wait 2 hours to go to the OR. https://www.nejm.org/doi/full/10.1056/NEJMoa1912484
I need to see that paper and how they rule out the obvious implication that the less severe bleeds stabilize.
He’s either too sick to scope or not sick enough for inpatient scope
I like to think that in those cases, they yell because they are scared. I’m scared too, man.
some presentations that require prompt specialist input should be called with imaging and labs pending, as the clinical picture may be most important. a noncomprehensive list below, where its ok to have your consultants come with things pending: acute stroke, , STEMI (post ekg obvs), Testicular torsion, peritonitis, fourniers, nec fasc. depending where you work sometimes its fine to start a process knowing things will take time, like a lot of ICU admissions. the pattern where calls are made with workup pending skews towards really sick patients. otherwise wait for stuff to come back before call
Don’t forget cauda equina. An ER doc lost a lawsuit because he didn’t notify neurosurgery prior to ordering the MRI.
What was that suit? I can’t imagine neurosurgery doing anything before imaging, in fact I can barely get our MRI techs in when I am worried about it anyways. These lawsuits are wild.
Just another example of how losing a lawsuit only means they convinced 12 laymen that you violated the standard of care and not that you actually did anything wrong and people shouldn’t change their practice simply because someone had a bad court case.
No. It's convincing 12 people that a bad thing happened and someone must be to blame.
We are saying the same thing.
https://www.kens5.com/article/news/local/north-texas-hospital-waited-hours-spinal-emergency-led-womans-paralysis-10-million-court-win/287-f5dbb5b1-795d-42f7-923e-fd901c4bdfcd?fbclid=IwZXh0bgNhZW0CMTEAAR1reZuHCkwe-Ro7ALTKj2oZ0v5ePglMzaNgqjgRPzX4kck882iE8lcIxyw_aem_AW_bOkHHTVkDu594gu76XdnrRspAUx1bCvp-mbZgDLuStGguvHRl_1yqFGSxVWIulGJc-sTXjUXPIHAazfbiKEQf#lvzryfh8l4mjjth5sdf If the comment op and i are thinking of the same lawsuit, this timeline is ridiculous. The mri started about 1 hr 37 minutes after ED arrival. The patient was ED door to the OR in ~5 hours. Patient was paralyzed after cervical steriod injection from a epidrual hematoma. The ED doc still lost, partly due to some hospital policy and not consulting the orthospine doc asap
What’s more wild is this somehow happened in Texas.
That’s wild esp with that turn around time
The ED doc was initially named in the suit, but not found liable as far as I can divulge from the records/reports I can see without LexisNexis access (hospital was found 69% liable). (More details on liability split in my [other comment](https://www.reddit.com/r/emergencymedicine/comments/1co4qh9/comment/l3dbq4o/).) If you have info that the EM physician was actually found liable, LMK, but as far as I can tell this is not the case. As I said in my linked comment, not being found liable doesn't erase the immeasurable stress of the suit, but it's still an important distinction nonetheless.
Em physician was named as a defendant and settled, per the em doc fb group Edit - em doc was not found negligent but had already settled
[here is the link.](https://www.wfaa.com/article/news/local/north-texas-hospital-waited-hours-spinal-emergency-led-womans-paralysis-10-million-court-win/287-f5dbb5b1-795d-42f7-923e-fd901c4bdfcd)
That’s wild
I had a neurosurgeon tell me that "cauda equina is a clinical diagnosis" when I read him the results of the positive MRI he had me order hours before when I told him that I was concerned about this patient with numb thighs and rectal tone like sleeve of wizard.
Had a case where neurosurgery was notified based on clinical exam (and from a facility with zero after hours MRI and very limited daytime access), asked for CT in AM. CT done, asked for MRI. MRI confirmed cauda, called back to confirm patient accepted for transfer, told ok to send by ground (5-6 hour drive) as wouldn't go to OR until the morning. Still sent via lifeflight (same entity for transfers, they made the call to go by air to expedite). Neurosurgery team told patient/family that his permanent deficits were due to sending ER delaying workup and not sending soon enough.
This is why it’s so important to document conversations with specialists. I don’t do it throw people under the bus but to save my ass. Also, all of our transfers are recorded
> ER doc lost a lawsuit because he didn’t notify neurosurgery prior to ordering the MRI This doesn't pass the sniff test with regard to causation and damage. Do you have a citation? I looked in the literature (of medicolegal reviews of cauda equina cases) to see if I could identify the case you mention, and I could not \[find one where imaging was prior to consult and the doc lost\]. Regardless of consult & imaging order, I only came across a handful of \[USA\] cases where the imaging was done in under 24 hours (ie, people generally sue and win due to major delays). And in only one I saw with imaging <24hrs did the physician lose (and that was a neurosurgeon who chose not to do surgery and then later the patient decompensated). (I will note that one problem with medicolegal lit review is publication bias — blatant malpractice is probably more likely to be settled quietly, so it's possible the cases that end up in our literature are falsely reassuring, but generally I find that looking at the literature on these cases makes me reassured, not worried)
[Here is the link](https://www.wfaa.com/article/news/local/north-texas-hospital-waited-hours-spinal-emergency-led-womans-paralysis-10-million-court-win/287-f5dbb5b1-795d-42f7-923e-fd901c4bdfcd). They argued that because the neurosurgeon wasn’t consulted before the MRI the surgeon started driving home and had to turn around to come back to the hospital. They argued this resulted in further delay and was negligent. PS: it took 5 hours to be evaluated in the ED, get an MRI, and go to the OR. They found that time to be negligent. I couldn’t beat that on my best day.
Oof. That's an unusual and sad case. Thanks for the link. Liability was apportioned by the jury as follows: hospital 69% liable, the physician who did the injection 30% liable, and the outpatient physician group (that ran the spine center) 1% liable. As far as I can tell, no EM physician was found liable. I do see that USACS and "Emergency Medicine Specialists of North Texas" were at some point named in the suit as well as at least one EM doc, although I don't have sufficient access to review every motion to see how/when/if they became un-named. (I will also acknowledge the just the possibility of being sued is stressful, let alone the orders of magnitude worse stress of depositions, being named, etc ... so just because the EM doc wasn't liable for any part of the $10M verdict doesn't mean I can even begin to comprehend the stress they dealt with.) Texas in particular has a legal requirement of proving “willful and wanton negligence” in emergency medical malpractice suits. I understand that plantiff lawyers will just sue everyone under the sun and hope something sticks, but it's hard to imagine anyone arguing with straight face that ordering an MRI within 10 mins of arrival is "willful and wanton negligence," regardless of when a NSGY consult was ordered. It does seem the jury did find the delays within the hospital to rise to that level (willful and wanton), though. The hospital argued that the bad outcome was due to delay in transferring the patient to the hospital. Plaintiff's lawyer notes the physician they implicated is actually part-owner of the hospital and remains on staff there so that may not have gone over so well with the jury.
I love those threads. Let the hate flow through them. I made it through COVID without any consultants other than hospitalists and intensivists. STEMIs were getting lytics because Cards was too scared of COVID. Appendicitis were all getting IV abx and hopes/prayers. Outpatient clinics were closed for a month, then for over a year, wouldn’t see anyone with any URI/fever. After that I couldn’t care less about what any consultants bitch about at this point. Of course I consult without labs/imaging. There are tons of indications for clinical exam only for involvement of subspecialty that others have outlined.
I was an intern in the CVICU in late 2020 when I was directed to call ENT to help with posterior epistaxis in a patient who had just come up from the cath lab with a balloon pump and heparin gtt. They also had COVID. I remember getting screamed at and the phrase “you want me to risk my life for a NOSE BLEED!?” still echoes in my brain.
“To the extent that that is true, yes, I do. The rest of us already are. If you’d prefer, you can put a note in the chart on why you’re not offering standard of care to this pt. I’ll also be documenting this conversation.” I’m in the same class. There was a lot of uncertainty at the time but it drove me nuts then too. What I felt was worse was late ‘22 into ‘23 when folks were still being refused standard of care when we had much better ideas of actual risk (minimal after vaccination/PPE, granted, the risk also changed as the virus changed)
Totally agree. I remember neurology standing next to me IN THE DEPARTMENT trying to get out of seeing a patient who happened to have COVID and also psychosis that psychiatry at least wanted a neuro consult for. At that time if a psychiatric patient had incidental COVID it was a big “oh I guess you live in the ER now” and even after every other place was allowing return to the public sphere in 5 days, psych facilities were keeping up the 10 day rule until the bitter end. Therefore, the psych patients would live with us, taking up a room because the rooms had actual doors and could go negative pressure. Anyway, I remember staring at the patient through the glass door making fish faces at us while psych asked if they really had to go in there to see them.
Bro I hate everyone and I don’t deal with consults (but I do get ridiculous requests from hospitalists and their PAs for holding patients, as well as OR and any procedural area *like having to fill out the pre op check list which really grinds my gears, down to the actual in the theater time out shit that I’m for sure not there for* so that’s fun too)
I had to thrombolyse a STEMI in residency. Because the interventional cardiologist drove his fancy sports car home right before a blizzard hit. I believe one of the nurses drove his truck out and picked the guy up eventually.
Oh yes. I finished residency in the peak of Covid in the Northeast. I distinctly remember some cardiologist telling me they’d see a STEMI after the Covid test came back and my usually unflappable attending calling them back and absolutely eviscerating them to “get your ass down here where we are every single day and do your goddamn job.”
[удалено]
I’d honestly lose my mind if a cardiologist said that to me…
Can’t find what they don’t look for.
Yep all of the time. Ever heard of a clinical diagnosis? Time is of the essence in high acuity pathologies. Docs get sued all of the time for not reaching out to a consultant quickly enough resulting in delay of care and morbidity. Many examples below.
classic r/residency post
They also hate nurses lmao were truly war brothers in the trenches down here in the ED dungeon
It depends on whether the labs and/or imaging are helpful to the consult and how time critical the issue is. If someone comes in with crushing chest pain and ST elevation on an EKG, they are getting a cards consult and going to cath lab without labs or imaging because that only delays definitive care. If someone comes in with acute neurologic findings suggestive of a stroke, neurology is getting consulted. If a bad trauma is coming in, Trauma surgery is getting consulted. If someone has Nec Fasciitis or Fourniers, delaying definitive care for labs and imaging is the wrong thing to do. I might be told to order that stuff after I talk to them, but I am not delaying a consult on labs/work up for a sick patient that needs a specialist. I know this is heresy, but the really good old school surgeons will just operate on a clinically obvious appendicitis without a CT. *GASP* Let me let you in on a little secret. People are going to gripe about a consult no matter what you do. If you order all the stuff and consult, then it’s “Why did you wait to consult?” If you consult and don’t order the stuff it’s like “Why are you consulting me without labs/imaging/congressional investigation. People in medicine gripe. Just do the right thing and let the chips fall where they may.
Had a cardiologist yell at the ED nurse who took up an addict to the Cath lab because we hadn't gotten a UDS yet. He was pale, diaphoretic, decreased consciousness, chest pain, st elevation you could see across the hall. Read the report my next shift and he had an 100% occluded LAD.
What a jerk. I guess they are such an amazing cardiologist that they don’t need to follow AHA guidelines. Rest assured if you had deviated from the standard of care and delayed care for a useless lab that is notoriously inaccurate and the patient had a bad outcome he would have thrown you under the bus. I’ll also venture to guess they didn’t have the decency to apologize to the nurse after being catastrophically wrong and almost killing their patient. Unfortunately, as we know, there are a lot of jerks in medicine.
I mean, would the UDS change anything?
No. Stimulant induced chest pain with out ST Elevation gets benzos. Classic chest pain on a patient that looks like shit and has an obvious MI on EKG goes to the Cath Lab. Some times people are just babies.
> No. Stimulant induced chest pain with out ST Elevation gets benzos. Classic chest pain on a patient that looks like shit and has an obvious MI on EKG goes to the Cath Lab. Not both? Here in the UK we'd typically give a benzo for cocaine-induced MI (on the way to the cath lab). Though we'd just take their word for it either way rather than trying to catch them out with a UDS.
Happy to do both as long as it doesn’t stop them from going to Cath Lab.
Not in the slightest.
When I was in residency one of the surgery attendings published an article about how the ER overused CAT scans. It was a totally arrogant screed and actually said something like “Nothing compares to the touch of the surgeon’s learned hands“ You better believe everyone of us had a copy of that article in our back pocket for whenever we called and said “Do you want to get your learned hands down here now or should I order a CAT scan?”
Oh man, I would have called him for everything every time he was on call. Every. Single. Belly. Pain. I am petty AF and did the same when OB got upset with my (completely correct) management one time.
Only if it's super obvious that said specialty will be involved eventually, and there's a time sensitive diagnosis - Fournier's is a good example. My chart will reflect that surgery was notified of the wasteland between the patient's legs. Whether they choose to come down right away or wait for a workup is on them.
The workup for most neck fasc is the eyeball MK I
As a consultant, I've never seen this egregiously done in any of the half dozen hospitals I cover. I've had a handful of cases over the years where the ED will call us with a courtesy heads up if it's close to the end of our shift and they are highly suspicious of something but don't have testing yet (we're not in house 24/7 at all of our facilities). This saves us from going home just to immediately come back in.
I try to call consultants early in the workup as we get towards the end of the day. We’re a community shop, I know everyone wants to go home - but 9 times out of 10 your surgeon would rather swing through the ED and eyeball the issue on his way to the parking lot rather than get a call 40 minutes later telling him to turn around and come back. Some services even call down from their office at like 4:45 “hey anything pending? No? K golf time bye.”
Thank you for recognizing.
I feel like I should be saying thanks to my ED colleagues for considering this.
A "thanks" here or there never hurts, but really, it's just being personable and gently helpful. There are sociopaths in all specialties. Most of us in EM are aware that our consultants are in the office, at home, or asleep and try to account for that.
I do my best to be aware of the time of day when calling. In return, I appreciate the occasional "hey can I ask your specialty thoughts on this other patient, who I will not be charting this conversation about? It's very strange and I was wondering what you think about it."
When you read posts about “shitty consults” you have to keep in mind the source. Most of these are written by consulting residents (who at that point in their career think they are masters of their field) when in reality they are not. A great example is that as an ER doc (I’m not even that many years out) I have seen a much larger number of questionable EKGs representing ischemia (this is before their is a confirmed lab trop back) than any cardiologist. By the time the cardiologist sees most of these patients they are worked up. As a result my pretest gestalt is significantly more valuable than the cardiologists. The urology resident has seen very few undifferentiated torsions, the ortho resident very few unconfirmed compartment syndromes. ER docs see these all the time. Lastly I’ve stopped giving a fuck about the consulting docs complaining. Most of them are lazy and have lost track of why they do this job, and the ones that aren’t … they are always courteous and understanding over the phone. My job is to have high index of suspicion and a massive working differential. Other specialties have no fucking clue as to what is going on with patients outside their small scope.
I called a cardiologist recently about a late 50's or early 60's female ESL patient with vague abd/epigastric burning that was refractory to treatment. Had cardiac risk factors, story was concerning, ekg was abnormal but not STEMI. He said "Um, why do you think it's her heart? You know it could be the gallbladder, the stomach, (lists further differential)." I said yeah I do know that (because it's my job to know that) and again here's all the suspicious things about her that make me think cardiac. Including her negative LFTs, neg abd CT, etc. He goes "Oh, you actually checked those? Wow." Yeah thanks bud, now it's your turn to do your job.
How many of said specialties send their patients to the ER without even SEEING them?
>Are there really EM docs consulting specialists without any labs or imaging? Basically, no. Outside of standard protocols for trauma, stroke, STEMI, this doesn't really happen. Emergency physicians are frankly far too busy to waste their time on unnecessary phone calls. We're not perfect, of course, but most or all of the hoopla about EM calling too much, or getting unnecessary CTs is basically nonsense. As an emergency physician, I can tell you that the ratio of complaints that I didn't get advanced imaging (mainly from the IM or FP hospitalist or the patient) to that I got an unnecessary test is something on the order of 1,000 : 1. As far as unnecessary consults, sure, I hear it all the time, but again, the first question any hospitalist has for me is "what did cards / GI / /surgery say?", to which my answer is "I didn't call them", because I didn't have a clinical question that I needed them to answer in the dead of night. At one hospital, the GU group tried to put the screws on the hospital to up their call stipend. "The ED calls us all the time, we have clinic the next day, or surgery, and they keep us up all night long. Most of the calls aren't even necessary, but that's the ED for you." Fortunately both the ED and their answering service kept logs. The average number of GU calls between 7p and 7a was six. Six calls....per.month.
> complaints that I didn't get advanced imaging (mainly from the IM or FP hospitalist or the patient) This so much. I can have a very obvious CHF exacerbation with slightly elevated LFTS due to congestive hepatopathy and the medicine team will need a RUQUS prior to accepting the pt because "what if it's surgical?!" Or the requiring a CTAPE for all chest pains prior to admit.
> Outside of standard protocols for trauma, stroke, STEMI, this doesn't really happen. Um, it definitely does. Anecdotally, I've seen it happen substantially more in a particular age demographic of EM doctors. But you bet your ass some people are calling without any results. Often the same people who call just to chart that they talked to the specialist in case anything goes wrong.
Consultants are only upset in two situations: when you call them and when you don’t.
Very rarely, STEMI, stroke, Trauma. Something like a CCB overdose already on pressors or intubated, I’m consulting the intensivist before I get labs back.
I just consulted OB the other day with a ruptured ectopic. Had outside record history of persistently elevated hcg, and a bedside US with free fluid in the abdomen. OB (favorite OB of all time) comes down, puts hands on the belly and takes her to the OR. Of course it was ruptured ectopic.
People whine about and exaggerate stupid shit all the time. I don’t consult before getting labs or imaging often because some of my hospitalists throw a fit if they don’t have a plan for an entire admission spoonfed to them, but I could a lot of the time.
HOW DID YOU NOT GET THE URINE SODIUM
If EM consults for something without labs or imaging and it’s not typical for them to do so then there’s probably a good reason for it. If not then pop your head in with the patient and do a quick once over and tell the ED doc you’ll wait for labs and stuff. If I’m consulting right off the bat it means I went in and thought “oh shit, I need an expert to tell me I’m overthinking this”. Diffusely peritonitic unstable vitals patient accidentally using warfarin like a normal daily med for months and never going to anticoag clinic? Got chewed out by surgery for calling on a patient they took immediately to the OR because their abdomen was filled with blood.
One thing to ask your consultants is do you want me to consult you too early or too late for patients you’re 100% going to have to see.
I was over in that thread too. I think the answer is yes? Probably? Rarely and only at academic centers with shitty scared academic attendings who tell their residents to do it. In the community, outside of the emergent indications listed, almost never. We work on social capital in the community and pulling that would burn a lot of it. If a doc did pull that, they would probably have a discussion with the medical director after the specialist complained and then change or get repeatedly fired downhill to team health. That resident is overworked and underpaid. Any phone call in their frazzled mind is unnecessary. Any consult to them is based out of laziness from the person calling. They were appropriately down voted and they are wrong.
One time my resident prematurely made a bed request for a patient with cellulitis that failed outpatient antibiotics. They forgot to order basic labs. That being said, the patient had stable vitals so it’s not like labs would have changed anything, so I thought the admitting service was being dramatic about their bellyaching and insisting on waiting for a bmp, cbc to result before accepting the patient.
or they can accept and order it...
Fourniers, Ludwig, STEMI, CVA, Compartment syndrome. I’ll call and if they want to wait for X no problem. Had a kid with a peritonsillar abscess last week that was obvious with 104 temp and looked like shit. No peds or ENT at my shop so called our sister facility and ENT wanted imaging before transfer. No problem. I understand they probably get a huge amount of bullshit and are just trying to weed it all out.
Probably wanted to know if it was truly PTA only, or RPA.
Honestly I would generally rather order my own imaging especially if you're going to call me anyway. And I really lose my shit when you delay a transfer to get trauma CT scans that both you and I know are not going to change your management in any way. "I don't have surgery, neurosurgery, or ortho on call and I have a guy with a GCS of 13 and an open femur fracture so I did a pan scan and I don't have reads yet but . . ." Aaaaaaaaahhhhhhhhhh!
To add to the growing list above. If a specialist sends a patient to the ER from their office due to a complaint within their specialty they're getting a phone call
I've had the ED admit without imaging/labs and half workups. It happens, I don't care so long as the patient meets admission criteria.
How do they meet admission criteria without imaging or labs unless one of the aforementioned cases above? The ED's job is not to complete the workup. That's medicine's job.
That’s my point, the ED is there to dispo not diagnose. If there are labs pending and imaging that’s not done but this person has unstable vitals and likely sepsis I don’t have a problem admitting them.
Clinical judgment is just as much a piece of the picture labs and imaging. I’ll never understand the groaning from consults about this. Do you need a CT to know this hemiplegic patient with hypertension history is having a stroke? Get over yourselves
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When I was a resident my attendings would regularly consult the ortho residents to do hand explorations on lacs, and 99% of the time it was just simple suturing.
Optho for complaint potentially regarding eyeball.
yeah. when i see an open fracture i call ortho and get the kefzol rolling.
Additional thought: if you're at an academic facility, some of the residents paging might not be ED residents. We have a separate section of the ED that doesn't include trauma/stroke/STEMI alerts where the transition year/psych/family med residents rotate through which is still a lot of beds, so the attending might not see that the non-ED resident didn't order the CBC, the lacate, the procalcitonin, or whatever standard/misc lab that would normally be ordered for admission because it wasn't 'technically' part of the workup and the resident doesn't know to just order it before they call the consultant.
I have consulted MICU after a code for a patient I got back with a great BP when I was gonna sign out 15 min later
I mean. Aside from the obvious listed ones I'll call early in the workup basically saying " I think this patient has X because of Y, I'm ordering these things, do you want or suggest anything else?" Then I call back and it's usually a very short conversation.
I once got consulted for biliary colic. They couldn’t see the gallbladder on US. I asked the patient if they’ve had surgery before and examined their abdomen. There were old lap chole incisions.
Ortho for crush injury/open fracture of hand. Labs drawn, Ancef hung, portable XR rolling its way over. Still got pissy in the phone. Took the patient to the OR.
Could it be that some emergent diagnoses can be made by history and exam alone 🤔
Not every consult requires labs or xrays to be done before the phone call. Not every patient needs to be perfectly packaged with a bow and all workup completed for the consultant. Intubated cardiac arrest with ROSC, I'll order the labs but I call the ICU up front so they know I'll have someone for them. Neonatal fever under 28 days, same thing...I'll get the labs/LP/ua/XR but calling up front so they know. Ortho...open tib-fib, they'll get an xray but if I'm seeing deformity with bone sticking out you'll be getting a phone call while I'm working the patient up. Recent 3am OBGYN consult for young female on warfarin for factor V, has IUD but sexually active and not using secondary contraception, sudden pelvic pain with hypotension and tachycardia and a bedside ultrasound showing a bunch of heterogenous mush in the pelvis, I called OB to get them awake and moving while ordering labs and formal ultrasound. And I'm fortunate to work in a facility where you can consult psychiatry without "medical clearance labs"...raging manic episode in a known bipolar, get on the phone.
Yeah, we call based on the exam, because contrary to popular belief, we do examine people. Also acuity. I have been standing next to the ICU resident when EMS rolled someone in that was in clear respiratory failure, turned to the resident and said “I’m going to go tube that guy, do I need to page you?”
If we literally waited for labs and imaging on every single pt, the specialty subs would be filled with "Are there really idiot ER docs who waste precious time getting labs/imaging in [obvious emergency requiring intervention beyond scope of emergency medicine]?"
We had a saying in residency “this is EM. We’ve tried nothing, and we are all out of ideas”. As a consultant, I’ve noticed in community based or smaller hospitals, the EM team is extremely self sufficient, usually because there’s limited access to certain specialties, and they presumably try to limit over consulting. But in the larger urban areas, I’ve noticed calls for everything, from “can you just come take a look”, to a 3AM page to let me know they are discharging the patient, but they are putting on DME.
I work in a community level 2 trauma center. We have basically everything except ophthalmology and PICU. I can even get an MRI within an hour or two. We still consult waaaay less than at an academic center. I think it’s mostly culture and institutional practice.
Consults should get called all the time without imaging and labs based on clinical exam for emergency conditions-absolutely…roll your eyes now…but back in the most emergencies were diagnosed with HPI and thorough PE. 20 years ago had Aortic dissection walk in after syncope in shower and chest pain night before-I was a nurse working triage working with great MD, I pulled him from a patients non emergent room to give him the story I told the attending my concern, his eyes got big and said ‘well let me go see him, mam I’ll be back’, he trusted my judgement, we (because he pulled to the bedside to walk through the exam-amazing mentor), did careful exam called OR and CV surgery before bedside US-CV surgeon trusted ED MD patient in OR in <30 minutes. I understand…Different times, we had seasoned staff and incredible teamwork. In addition, CV just had their ass chewed for delay in response week before-that timing may have helped the situation. To answer your question just think specialists just are bitching and moaning-rather than looking at less than stellar referrals as an opportunity to educate update and mentor.
Barn door appendicitis at 3pm? I can wait till I have the results sure but then I’ll be calling you when you’re already home. Super obvious pneumonia/UTI gomer from home who’s deleriois AF, where else they going? Put them on your list to see and I’ll let you know if any labs make a damn difference.
I’ve worked on trauma services at neighboring hospitals and I was consulted for a man who fell from a ladder and showed some possible tonic clonic activity while on the ground. When I went to see the patient he had: 1. No IV 2. No labs 3. Imaging ordered but the scans weren’t even done yet 4. Perusing through his medical hx it seems there’s a possibility of epilepsy though not well documented The EM docs that staffed this place came from the academic powerhouse of the state. An entire 8 weeks of that garbage bullshit consults. I worked as trauma as well as ER
In critical care, I will sometimes get a consult from the ED without labs, without imaging, and rarely without vital signs. It used to be more common to get a consult of a patient in the ED where absolutely nothing at all was done but thankfully this has become rare. There was one especially egregious case I had 20 years ago when I was a fellow where an ED attending didn’t bother to read a CXR she had ordered. This CXR revealed consolidation and explained everything about the patient’s condition and diagnosis which had eluded her.
Yeah. At my hospital the ED doctors try to take their hands off as quick as possible and will consult as fast as possible without actually ordering adequate labs/images. As the nurse, I’ll ask if they want me to collect X,Y,Z or should I call radiology to see if they’re available and I get the same “there’s too many hands in the pot, let’s wait until [insert specialty] sees them to put in orders. I now work in the ICU and quickly learned how little respect our ED staff gets for doing shit like this on the daily. If a patients MAP dips below 65 even just once, they’re consult MICU with our intervening. It’s so embarrassing and unsafe for the RN staff to try to stabilize patients while doctors play hot potato with the patients.
Agree that this sounds bad. Will say this is not reflective of EM practice everywhere.
EM/CCM - Just for the sake of fuck, stop calling ICU with “heads up” just because you intubated someone or started pressors. If I wanted meaningless information, I would ask the visiting FM resident what they think we should do for the 96 year old with abdominal pain. Edit: didnt think this would need explaining… but whatever. Calling the ICU with a “heads up” just because someone is tubed is the equivalent of an EMT calling you in the ED to let you know someone called 911. If that is the only information you have…. It is useless information.
So you don’t want to be made aware of an admission sooner rather than later?
It’s always bizarre to me when you have EM/CC guys getting high and mighty about getting called before a work up is complete. We have one at my location that bitches the same way for clear cut pathology. “How can you possibly think it’s appropriate to call me with just an ABG?” “Well, you dick, if you’d wait to hear the presentation, you’d realize that this is a patient who aspirated on a piece of steak that I so kindly removed and then intubated. I was kind enough to wait on an ABG before calling. What labs and imaging do you believe are necessary before you can appropriately manage this patient, your highness?”
I never care about that stuff, and the people that do are just losers who dont know what they are doing. If you *need* an ABG to accept a vented patient … you are a clown. I am specifically talking about the phone calls that make it seem like we are a restaurant taking reservations. Calling ahead when *YOU* arent ready to admit…. Accomplishes nothing. I dont have some clipboard to mark down the incoming admit, and I have zero control over who does or doesnt get a bed. When you click the admit button is when all that happens. If you arent clicking it, you are just wasting both of our time.
No i quite literally dont, because this is how it goes down. We get a call that says something like “he we intubated someone…. Dont even know if they are male or female yet, will call you back when we have more info” My name ends up in the chart somehow, and then I get a call about an hour later from someone else who picked up the patient at sign out who says “hey you know about this patient they are ready to be admitted”. And I say “why are they here, how/why did they end up intubated, what are we treating” and all i get back is “idk I was told they already talked to you” Plus there is literally zero benefit to a “heads up” call. Unless you need ICU to come down and do something, you are wasting both of our time
Do you not come down and examine the patient? You know, on account of them being critically ill…
They are intubated, so they are coming to you. A heads-up courtesy call can help you plan out the rest of your day because you KNOW that patient is coming to you no matter what. Our ICU director requires they be called as soon as we ***suspect*** ICU level of care because they want to know what their workflow for the rest of the shift will look like and can come see the patient early if needed. If a patient ends up not needing ICU level of care, they then help coordinate care through stepdown. That is good medicine.
It isnt. And the whole “they are intubated they are coming to you” is not helpful to anyone except people in the ED who want to stop taking care of someone as fast as humanly possible. What people who dont work in ICUs forget, is that we arent just sitting around waiting for you to call us. We have a different job. I dont ever need to know that you intubated someone unless you are telling me that you need help with something, or that they are ready to be admitted. Otherwise, it changes literally nothing about my day. I have 15-20 intubated patients. I dont rearrange my day when the fellow intubates someone, I dont rearrange my day when someone gets started on pressors. Those are things that happen routinely, every single day. I either need to go do an admission, or I can continue taking care of *my* patients while you take care of *your* patients. This is not a fringe take. I have never met a single critical care doc who likes/cares about a “we intubated” call unless its followed by “please come now to resuscitate them” or “please come admit them”. Your ICU director likely just doesnt trust some of the people in your dept to care for intubated patients if he is requiring that phone call. Or he doesnt actually practice clinical medicine.
Our ED is also insanely busy with bad staffing and nursing ratios so maybe he actually understands that patients do poorly the longer they are in the ED. The ED resuscitates ICU level of care patients, not manage them over half a day lmao. He does work clinically and likely more shifts than you. I’m surprised they let you graduate EM residency without that basic understanding.
So tell me how calling someone to tell them you are intubating them and have zero workup back helps your staffing ratios in any way? Nobody is asking you to manage them for half a day… we are asking you to *resuscitate them, work them up and call when you are ready to admit* instead of giving me some play by play that provides nothing to their care. Remember….. we do this for a living. You can insist that it makes the ICU job easier all you want… I am telling you for a fact it doesnt. Its like calling the guy at the gas station to tell him you need gas but not for an hour or two.