Curbside Consult Thread

[San Juan Sun]

And I've worked in all sizes of hospitals, including a trauma center in one of the worst malpractice areas in the country.

Word.

[doctorcoug]

I can't imagine a place where ER docs routinely consult out LPs. And I've worked in all sizes of hospitals, including a trauma center in one of the worst malpractice areas in the country. Your hospital is either screwed up or you're only seeing the ones that are being sent out. It would be beyond stupid, both from a financial and a patient flow standpoint, to call radiology for all LPs.

You are correct about the ones I see. The ones that are consulted are elderly osteoporotic patients and failed attempts.

It is the chest tubes that are nearly all surgical consults, unless patient is actively dying.

[wuapinmon]

A 69-year-old man presented with a 25-year history of gradual, asymptomatic thickening and wrinkling of the skin on the left side of his face. The physical examination showed hyperkeratosis with accentuated ridging, multiple open comedones, and areas of nodular elastosis. Histopathological analysis showed an accumulation of elastolytic material in the dermis and the formation of milia within the vellus hair follicles. Findings were consistent with the Favre–Racouchot syndrome of photodamaged skin, known as dermatoheliosis. The patient reported that he had driven a delivery truck for 28 years. Ultraviolet A (UVA) rays transmit through window glass, penetrating the epidermis and upper layers of dermis. Chronic UVA exposure can result in thickening of the epidermis and stratum corneum, as well as destruction of elastic fibers. This photoaging effect of UVA is contrasted with photocarcinogenesis. Although exposure to ultraviolet B (UVB) rays is linked to a higher rate of photocarcinogenesis, UVA has also been shown to induce substantial DNA mutations and direct toxicity, leading to the formation of skin cancer. The use of sun protection and topical retinoids and periodic monitoring for skin cancer were recommended for the patient.
Via: nejm.org

I thought the attendings might like this.

[doctorcoug]

I thought the attendings might like this.

I'm not an attending for another 30 days, but I still thought that was an interesting case.

I just got the dreaded phone call tonight. One of my beloved patients from a favorite family I care for has a huge renal tumor with infiltration of renal vein, hepatic vein and IVC. We talked months ago about some imaging for other complaints, but she couldn't afford it as she is self pay. Very frustrating.

I am far away on vacation, so all I could really do was talk with her over the phone as my team cares for her. It was devastating when she asked me, "Doctor, is this going to kill me"? This coming from a lady who has cared for everybody in her extensive pedigree without thought for herself. I've given bad news pretty much everyday that I work in the hospital; this should come natural to me. It just didn't, maybe because I care so much for her and her family.

Why does it seem that sometimes the best people get hit the hardest?

[San Juan Sun]

For all intent and purposes, my residency ends tonight. I'm on call for the last time, with 3 hours and 20 minutes until the next crew takes over. Just in case there was any doubt, I have again found out that in any of the following:

drunk guy vs brick
drunk guy vs stairs
drunk guy vs motorcycle

drunk guy is probably going to be the loser. Pimpin ain't easy, I guess. Good news though, all three will eventually be fine.


I've also learned that having gallstones for years (without acute symptoms), it's totally rational to come to the ER at 2am, because "I want some answers and shit."

3 hours, 13 minutes to go... and my pager just went off again.

[doctorcoug]

For all intent and purposes, my residency ends tonight. I'm on call for the last time, with 3 hours and 20 minutes until the next crew takes over. Just in case there was any doubt, I have again found out that in any of the following:

drunk guy vs brick
drunk guy vs stairs
drunk guy vs motorcycle

drunk guy is probably going to be the loser. Pimpin ain't easy, I guess. Good news though, all three will eventually be fine.


I've also learned that having gallstones for years (without acute symptoms), it's totally rational to come to the ER at 2am, because "I want some answers and shit."

3 hours, 13 minutes to go... and my pager just went off again.

How are you finishing three weeks early?

[San Juan Sun]

How are you finishing three weeks early?

Saved my vacation for the end.

[doctorcoug]

Saved my vacation for the end.

My PD had me convinced that the ACGME doesn't allow more than one week of vacation in a block. Lucky you.

[doctorcoug]

I've done a disservice to the taxpayers. I had a profound MR patient who is a ward of the state come to my ICU yesterday who was down at the nursing home "for hours". He was toast, but a full code. Nobody from the state was willing to sign DNR papers on a Sunday...so I treated him like a full code. Levo, vaso, neo, epi, bicarb drip, pH 6.9 and PaO2 of 40, WBC 0.4, lactic acid 11.8, smashed with fluids, blood, ffp, and abx.

Now that it is Monday and his guardian is back at the office today, we will extubate. This is so screwed up.

[The_Douger]

Blah, what a mess.

What if you'd have done nothing since he came in such bad shape?

I run an urgent care and it seems like the kids are always bringing in mom or dad because they're not comfortable, they have renal disease, they don't feel good, etc. They aren't critical, but they're going downhill, and nobody ever wants to get hospice involved.

I mean, why are you taking your BP and thyroid meds when your creatinine is 7.9, you aren't on dialysis, and you're just at home sleeping 18 hours a day?

[doctorcoug]

Creatinine of 7.9 and stopped dialysis? That is less than two weeks life expectancy. Why, oh why do you take grandma to the urgent care with that prognosis? Where on earth is the primary? This is, in my opinion, a failure of primary care.

[The_Douger]

Exactly.

I'm like "Well, why don't we get hospice involved."

And they're totally against it. I mean, this patient does nothing but sit in bed and drink a little bit. Primary was "too busy" to see them that day.

Fun fun.

[doctorcoug]

Exactly.

I'm like "Well, why don't we get hospice involved."

And they're totally against it. I mean, this patient does nothing but sit in bed and drink a little bit. Primary was "too busy" to see them that day.

Fun fun.

We have same day spots available everyday. All PCP offices should offer this.

Sadly, this patient will be dead in a couple of weeks or will be in an ICU in a couple of days.

[San Juan Sun]

Exactly.

I'm like "Well, why don't we get hospice involved."

And they're totally against it. I mean, this patient does nothing but sit in bed and drink a little bit. Primary was "too busy" to see them that day.

Fun fun.

You consult hospice from an urgent care?

[SteelBlue]

I have a question for any/all of you docs. My dad is turning 65 next week. He's always been very healthy though in the past couple of years the family history of diabetes has caught up with him but he's able to control with diet. Anyway, in the past 6 months he's had a horrible cough 4 times, lasting a couple of weeks each time. This is a guy that I don't remember ever being sick when I was growing up. And he's not just sick when this cough comes on, he's weak, almost puny by the end of it and then bounces back. No night sweats or anything like that. No weight loss. Just really violent coughing for a couple of weeks followed by great health and then the cough again.

His MD doesn't seem worried at all but I worry because it's so uncharacteristic of him. I also worry because the illnesses take such a toll on him for a "cough". Reading this, is there something that you think I should tell him to have his MD look at? I just have one of those gut feelings that something is more wrong than it seems.