Curbside Consult Thread

[San Juan Sun]

Recent phone call at 1 am...

Nurse: "Hi Dr. SJS. I'm calling you about patient Jow Blow in room 3431."

Me (groggily): "Ok..."

Nurse: "Dr. HomeSleepingSoundly ordered 20 milliequvalents of potassium chloride for him, but we're out of 20 mEq bags. Can I just give him two 10 mEq bags instead?"

Me: "Are you calling to ask me if 10 + 10 = 20?"

Nurse: "Hmmmm.... When you put it that way, I'm sorry to have bothered you."

Me: "No problem. Goodnight."

[hostile]

Recent phone call at 1 am...

Nurse: "Hi Dr. SJS. I'm calling you about patient Jow Blow in room 3431."

Me (groggily): "Ok..."

Nurse: "Dr. HomeSleepingSoundly ordered 20 milliequvalents of potassium chloride for him, but we're out of 20 mEq bags. Can I just give him two 10 mEq bags instead?"

Me: "Are you calling to ask me if 10 + 10 = 20?"

Nurse: "Hmmmm.... When you put it that way, I'm sorry to have bothered you."

Me: "No problem. Goodnight."

Hah. My favorite was the call from the floor at some crazy hour telling me that a patient had a slightly low BUN. I asked the nurse to order a stat infusion of BUN.

[ERCougar]

Hah. My favorite was the call from the floor at some crazy hour telling me that a patient had a slightly low BUN. I asked the nurse to order a stat infusion of BUN.

Funny quirk about ihc's critical lab notification system--i get a call if a patient has a BUN of 80, but nothing for a troponin of 10. I still can't figure that out.

[creekster]

Also I very strongly disagree with the statement, "God will not give you more challenges than you can handle". It is a feel-good statement but is not borne out by reality. This is really a Forum post, but it makes sense in this context.

I sort of disagree but also agree with this but in a different way; I think it is a trusim. If we are god's children then nothing here is more than we can bear. That some of us feel unable to bear things at times means that we have failed to fulfill (or realizeo runderstand) the measure of our creation. I dont think it ever menat that God is micromanaging the trials or challenges that any of us recevie.

[smokymountainrain]

Funny quirk about ihc's Intermountain's critical lab notification system--i get a call if a patient has a BUN of 80, but nothing for a troponin of 10. I still can't figure that out.

FIFY

[doctorcoug]

Recent phone call at 1 am...

Nurse: "Hi Dr. SJS. I'm calling you about patient Jow Blow in room 3431."

Me (groggily): "Ok..."

Nurse: "Dr. HomeSleepingSoundly ordered 20 milliequvalents of potassium chloride for him, but we're out of 20 mEq bags. Can I just give him two 10 mEq bags instead?"

Me: "Are you calling to ask me if 10 + 10 = 20?"

Nurse: "Hmmmm.... When you put it that way, I'm sorry to have bothered you."

Me: "No problem. Goodnight."

Honestly, I don't mind nursing phone calls and I try as hard as I possibly can to let the nurses know that I'm thankful they called. Med/surg nurses are notoriously the newest and least experienced. Improper communication is the cause of most medical errors at my institution, so I do come down hard on my interns who try to give the nurses crap for not knowing x, y, or z.

When I get calls like yours or when I get calls about tachycardia on tele (with no other vitals), it makes it very hard to keep smiling.

[CardiacCoug]

Did you guys see this?

http://www.deseretnews.com/article/865553297/Doctors-kill-thousands-due-to-death-tables-Utah-expert-says-in-new-study.html

I never used these narcotic conversion tables anyway even when I was prescribing narcotics a lot more than now. But it doesn't surprise me at all that they are so inaccurate.

Seems like a good idea to taper off one narcotic before you start another -- the effect of a med is so variable for different patients. I'm frequently surprised at how some blood pressure meds seem like they have no effect whatsoever and the same med and dosage will completely tank another patient's blood pressure to the point that they feel terrible or even faint.

[doctorcoug]

Did you guys see this?

http://www.deseretnews.com/article/865553297/Doctors-kill-thousands-due-to-death-tables-Utah-expert-says-in-new-study.html

I never used these narcotic conversion tables anyway even when I was prescribing narcotics a lot more than now. But it doesn't surprise me at all that they are so inaccurate.

Seems like a good idea to taper off one narcotic before you start another -- the effect of a med is so variable for different patients. I'm frequently surprised at how some blood pressure meds seem like they have no effect whatsoever and the same med and dosage will completely tank another patient's blood pressure to the point that they feel terrible or even faint.

I've used it a couple of times with sicklers, they always seemed to hurt more. I stopped using it and started relying more on experience than a calculator (our service has at least 1-2 sicklers a day).

I've never ever ever prescribed methadone and hope to never ever ever do the same. Sometimes in family medicine we get stuck with patients while they wait to see pain management or addiction. Luckily this doesn't happen to me often because the word has gotten around that I don't dispense.

[Uncle Ted]

Calling someone to tell them their spouse has died (very unexpectedly) is heartbreaking.

I could hear American Idol in the background as the spouse fumbled for words. And all I could think about was that one minute he was watching TV, and then the phone rings and his life is ripped apart.

This is why I could never be doctor. More power to you guys.

[ERCougar]

35 yr old man with alleged ulcerative colitis (can't see any confirmation of this) with concomitant acute narcotic deficiency/work fatigue presents two days ago for about the tenth time this year. Says his pain is a little different this time and his annoying and enabling mother is convinced it's his gallbladder, so I make the mistake of getting an ultrasound. It shows no stones, but some sludge, so I recommend they go see the surgeon, mostly to shut her up. They do so today and are flabbergasted that the surgeon would actually ask to be paid to take out his gallbladder, so of course they come here so I will do it. After explaining to them that they probably don't want me to do that, that in America, we can't make people do things for free (except for me seeing him, of course), and that even if we could, it probably wouldn't relieve his "pain", they are furious.

I wonder if he would agree to go to work if his employer just told him he didn't have any money for him. Oh...but that would require that he have a job.

[doctorcoug]

concomitant acute narcotic deficiency/work fatigue

I quite literally shot coke out my nostrils on that one.

[doctorcoug]

Got a call from the cardiologist today who read the dobutamine echo I ordered on my patient who had anginal-type symptoms. The guy had anterior lateral ischemia, but what was really cool was he had an atrial aneurysm with a 4 cm thrombus in it.

The dude just bought himself lifelong coumadin and a cath to go with it.

[Viking]

concomitant acute narcotic deficiency/work fatigue

I quite literally shot coke out my nostrils on that one.

You need to cut back on the coke.

[San Juan Sun]

acute narcotic deficiency/work fatigue

This made me laugh too. I've stolen it without shame this week. I've already diagnosed:

Acute narcotic deficiency (very common)
Acute sandwich deficiency (also common, kind of sad)
Acute cocaine deficiency (presenting secondary to an acute fisticuffs overdose)

I've amused myself all week, and the med students think I'm hilarious (maybe they have to laugh though). Thanks ERCoug.

[CardiacCoug]

Got a call from the cardiologist today who read the dobutamine echo I ordered on my patient who had anginal-type symptoms. The guy had anterior lateral ischemia, but what was really cool was he had an atrial aneurysm with a 4 cm thrombus in it.

The dude just bought himself lifelong coumadin and a cath to go with it.

That doesn't sound like something that really happens.

You can get clot in the left atrial appendage (in the setting of atrial fibrillation) but that's almost impossible to see on a surface echo. Other atrial masses visible on a surface echocardiogram are almost always myxomas rather than thrombus. There is an entity known as an interatrial septal aneurysm but these don't contain clot. Otherwise there really isn't such a thing as an "atrial aneurysm". Is it an aortic aneurysm?

Your patient needs a TEE and a more reasonable diagnosis unless I am missing something. Maybe they can do bypass surgery and remove the 4 cm thrombus or myxoma while they are at it.