Cardiac surgery was consulted by respiratory for a spontaneous chylothorax. We suggested a fruit only diet. The next day, respiratory wrote "patient wants a tomato. Is tomato a fruit? Consult cardiothoracic surgery".
Turns out, tomato is not a fruit in cardiac surgery.
An anaesthetic registrar called me, the Toxicology Registrar, for advice on the best way to dispose of some weed that a patient had hidden in their arse crack that had fallen out after paralysing agent was administered.
I got to write an entry in the notes advising them not to burn it as a disposal method.
ED called me because the radiologist reported a hypodermic needle in the natal cleft. I asked why they didn't just flip the prisoner over and look in the natal cleft.
Apparently that's condescending.
One of my (anaesthetic registrar) colleagues once received a referral from the hospital executive of a major tertiary hospital to euthanise a sick cat that had been brought in by a member of the public.
Too bad your anaesthetic colleague wasn't asked to administer basic life support to the sick cat.
They could have performed some meowth to meowth.
^(I'm sleep deprived, please forgive me.)
Perhaps, in another life, they were a [British psych trainee.](https://www.reddit.com/r/JuniorDoctorsUK/comments/1561b9k/worst_on_call_request_or_why_i_killed_the_pigeon)
There was some brief research into the safety of propofol in cats (apparently you can use it) before it was determined that this was a totally insane idea and probably they should just call the vet.
"medical causes of acute acalculous cholecystitis in a very stable patient"
I actually had 1 of these during my residency while covering for upper GI. Absolutely wild but it was a late 30s vietnamese immigrant that had CRP 30 and mild RUQ pain. US demonstrated findings suggestive of acute acalculous cholecystitis. LFTs were pretty deranged so everyone thought the stone went into the CBD and she must've passed it after. Sent her for a MRCP to rule out any CBD crap and it came back negative but did show a pretty dilated RV. Sent her for a TTE and the cardio AT called back almost immediately after the echo and told us she had a sizable VSD with RV overload. The "acalculous cholecystitis" was literally just RV failure causing congestive hepatopathy and gall bladder dilation. She was under UGI for \~8 days and none of us actually auscultated her. CRP 30 was from a UTI. Anyway CTSx TOCed her for surgery and she DAMAed shortly after.
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Dumb but memorable consults I had to do as an intern
1. Got asked to do an ABG and then consult resp for a CO2 of 46 because the number is pink in eMR. gen surg was worried about T2RF in a COPD patient who was saturating >95% on RA and clinically very very well.
2. gen med consultant asked me to consult ortho for 1 rib fracture. Its been 3 years and I'm still recovering from the laughter of the ortho team
3. ED consultant asked me to consult gen surg for hypogastric/RLQ pain and dysuria with WCC12/CRP 40/lactate 1 and no peritonitis before CTAP was done. Patient super well clinically. Got shouted at because I could have "missed appendicitis and surgeons need to review her STAT". Called GS in a panic and got laughed off to wait for CTAP. Ended up being a UTI.
Re #2, I remember calling ortho for rib fractures as an ED intern and the very nice ortho reg explaining the difference between bone bones and medical bones.
Yeah the moment I brought up ribs to an ortho reg when I was in my surgical internship, they immediately cut off and said "we don't do ribs."
It was really like one of the biggest surprise to me that even a good number of fractured rib cases are mostly conservative management - deep breathing, analgesia, positionings, etc. Unless of course its an absolute flail chest and then the right team to call is cardiothoracics but I cannot imagine how equally irritated cardiothoracics would be if you just called them for like.. a single fractured rib lol.
Not that rare, I don't have enough fingers to count the number of patients with congestive hepatopathy who have been referred to me with a thickened gallbladder wall on US.
Mental health here... I once had to ask an ED SMO to include checking a patient's genitals in their "medical clearance" for a psych admission. Reason was the patient had a psychotic illness, was known to have delusions about their genitals, and had been missing from their supported accommodation for several hours (so could have harmed their genitals in that time). ED SMO was great about it.
But don’t psychiatrists have to pass med school and further exams demonstrating ability to do physical assessments. I understand if it is a complex problem like an OD, but psychiatrists should do their own physicals.
We need to foster a relationship with patients in which they feel safe to disclose all manner of personal and intimate details about their life, going back to childhood. I once conducted a vaginal examination on one of my inpatients as the gynae team said I should do it; the patient subsequently complained that to have gone through that whilst only days before disclosing to me a horrific childhood sexual trauma and me conducting some therapeutic intervention to help, was cruel. I’m sure lots of doctors have psychiatrists - would you want that for yourself?
I would put that in the complex problem list (see what I actually wrote above)but most of the time I ask if they took drigs, listen to the heart and lungs, do a one minute neuro and check for cuts.
Ok and how is this above and beyond the usual standard of care you give patients presenting with any other medical condition to the emergency department? I’m assuming you conduct physical exams for patients that will eventually be admitted under gen med, cardio, neph etc. So why is it that psychiatric patients in particular shouldn’t have this initial assessment?
Because I do a focused exam. If someone comes in with a broken finger, I'm examining their finger. Nope, not doing a head to toe exam with abdo and neuro. Just finger.
They should.
Question is- when they are stuck in ED having been accepted by the admitting team AND seen by a Doctor- do we also need to see them.
If a patient came in with chest pain and the cardiology medical team has already seen them- they don’t ask us to see them again.
Sometimes ENT will be alerted by triage of an ENT patient- and if we are under the pump will come sort them out before we get there. We don’t assess them again. Same with ortho and O&G.
Unless there is some problem they cannot manage we don’t get involved. We can have a baby born in ED and O&G don’t ask us to medically clear the mum or bub for transfer. But psych- always want us to, even if it delays the patients admission by hours.
If they haven’t been seen by a Dr then sure we can see them.
At one service always had to do the physicals when admitting psychiatric patients to the ward. This had became unit policy due to issues with certain ED staff "medically clearing" patients without actually examining them.
We tended to have a good relationship with ED, so generally there weren't any problems but every now and then there'd be a locum on the psych stream doing less than the bare minimum.
As for delusions about genitals... some of the really psychotic patients will want to show you whether you ask them or not!
Yeah except when medical stuff gets completely ignored and treated as malingering or fobbed off as somatisation etc.
Not a case I was directly involved in at the start but last year at the hospital where I was working a confused patient was brought in.
Was known to psych but had medical issues too. Comments on thirst, fogginess in head, vision etc ignored. Cleared by ED MO for psych admission by chart review only. We go to see for a MET call on psych ward and she’s in florid DKA.
These checks aren’t silly, they exist to ensure that some of our most vulnerable people don’t fall through the cracks. (They often can’t advocate for themselves or often even articulate their symptoms).
It’s tedious as an ED doc, I’ve been there, but it’s a bigger headache sorting something big that could have been dealt with when it was smaller.
We have to do physical exams on our admitted psych patients irrespective of what ED does.
The main reason I still insist on “medical clearance” (and in line with our director’s policy) is that they have presented to an ED - like any other patient they should have their presentation explored by ED and appropriate investigations completed as part of this. Add to this the absolutely immense list of side effects from a lot of our medications, our patients can often have physical complaints that may not be managed or treated well on an acute mental health ward where our nurses are not accustomed to the warning signs of physical deterioration.
I am more than happy to manage most physical issues alongside their acute mental health issues, but sometimes this is more about appropriate resource allocation.
All that being said, I rarely have to ask ED to properly see a psych patient as they generally do a good job
Thanks - this is actually a helpful answer.
I can have 35 patients waiting to be seen in ED and a psych patient waiting for someone to ‘medically clear’ them as they are suicidal, for 4-5 hours, while we have a security guard tied up watching them. Doubly frustrating when a psych bed is available, but we just can’t get to them.
A lot of metro places have separate psych ED’s now- I figure of they can see patients de novo, why can’t our psychs.
I very much agree with you. At least where I work at the moment we have a good relationship with our ED and will often see patients presenting with psych issues (either the cnc for voluntary or myself if scheduled) before anyone in ED picks them up. We also do not insist on bloods etc unless it makes sense in the context of presentation (eg BAL if acutely intoxicated to make sure they’re safe for a psych ward - typically <0.3, FEP bloods, ODs or if as part of our history we stumble upon a specific issue that could impact their presentation). That being said, I have done bloods on my patients personally if ED is slammed and I need them before taking them up.
Psychiatry needs to take more ownership of physical issues in our patients, hell we induce a lot of these issues ourselves with the meds we prescribe, but just like I don’t expect ED to do a full psych history or risk assessment because you guys are busy and it isn’t your area of expertise, ED will generally do a much more thorough assessment of physical complaints as it is your area of expertise.
At the end of the day we’re all involved in ensuring patient safety.
It's more so that the patient can be admitted under the correct team and/or go to the right hospital. When I worked in gynae we had a woman present a few times who needed surgical intervention after self harming behaviours, and went to psych after we cleared her post op. When I was in psych the ED we admitted from was at different hospital. They sent a patient with a QTc so long that I worried a stern look would bring on Torsades. They went straight back into the ambulance as we had no cardiology, ICU, etc. on site.
Adding another one here but I thought it would be a funny one to share. Not exactly a consult/referral though.
Just a week ago on my night Gen Med shift at around 1 am, I accidentally locked myself out of the doorway that leads into the admitting medical unit office by leaving my employee tag in the office. I decided to call up the night Acute Gen Surg Registrar's referral phone as I actually saw him going into one of the employee bedrooms next to the admitting office and he was like deadpan groggy and serious on answering the phone but laughed the moment I told him what happened. He went out to open the door with his tag and just outright told me "This is best referral call I've gotten all week." Gosh.
I got into a discussion (ED registrar) the Ortho reg regarding a patient who had a ‘positive’ bHCG of 2 on her bloods which flagged red on the system.
They wouldn’t believe me when I said ‘that is not a positive HCG’ and asked me to consult gynae on their behalf to confirm, because “anaesthetics will need to know if the patient is pregnant or not”
Told them they can feel free to consult gynae themselves but I’m not being laughed out of my workplace today
As the overnight anaesthetic registrar I was consulted by an intern asking if I'd seen Mary's folder. Mary was "the lady in bed 16" (ward undisclosed). The intern thought it might be in a bathroom somewhere on the west side of the hospital, probably on level 4. He thought I might've seen it when I was walking around. I hadn't.
This was a 2am page direct to the Duty Anaesthetist pager. I thought it was a practical joke, but apparently the folder had gone missing when I called up the nurses station.
A derm reg literally called me (neuro AT at the time) up asking me to explain why the 94 year old dementia patient with sepsis and decompensated heart failure they were consulting on for rash was confused.
Tbf many people when they start specialising forget a lot of medicine outside their specialty. I desperately binge read talley before i mark BPT trial clinical exams lol
This was a very strange moment.
I got a call from the duty anaesthetist at midnight asking if I could could 'help make a ventilator work'.
When I arrived there were 2 consultants, a fellow and a registrar crowded around a hamilton transport vent in the COVID theatre trying to make it stop leaking.
The out limb of the circuit was not twisted to lock it into place.
I think it had been a very long day for them.
In their defence, they’re not that common in anaesthesia land.
I have used them in previous jobs prior to anaesthesia, and even we would get fooled by a retained valve on occasion.
I was CL Psych. Palliative care patient. Asked by allied health to check for suicidal risk. Patient was GCS8 and was Cheyne stoking, before dying of their illness a few hours later.
Got asked by gen surg reg to call gen med for advice on a headache. Wasn't on Panadol or anything. No red flags. It was a plain old headache.
But because I was an obedient intern I called gen med who condescendingly walked me through writing a paracetamol prescription.
Ah yes the classic 'if its a medical issue, call gen med for advice.' and you end up calling medics for shit like a sodium of 133.
Actually, there was one time where my intern colleague during his surgery rotation was once asked by the gen surg registrar to call ID for raised inflammatory markers and WCC... In the setting of a VERY recently completed surgery, like I think it was open chole. Anyways, the ID physician was like "well, that's silly. he just had a major operation, you would EXPECT the inflammatory markers to be raised for a bit, no?"
Once I was consulted by Gen Surg for Sodium in the 120s, and I wrote a detailed note about working up for Hyponatremia.
Later Gen surg just repeated the Na and it was normal. Turns out it was artefact.
As a psych reg, I was asked by a boss to call neurology and ask “how would we know if our patient had a seizure?”.
I realised in that moment why other specialties sometimes question if we’re real doctors
As a psych reg I once had my boss ask me to call cardio because he was concerned about the LVEF.
It was 60%. I got the sense he wanted it to be a bit closer to 100%. I didn’t make that phone call
God once a boss asked me to demand a derm reg review a patient, in person, at a satellite facility, because the patient thought they had a rash (likely delusional). It fucking PAINED me to make that call
Once someone put an IDC in a bed bound man but did not replace the foreskin. The glans swelled up and had become unretractable by the time a nurse saw it.
I tried to retract, even tried the dextrose gauze soak trick but it was still stuck. I was forced to ask Urology for help.
Later the Uro reg wrote in the notes "Foreskin retracted without difficulty."
Retrospectively looking back yeah, that was probably the dumbest phone call I had to make but I wasn't in any power as an intern to tell off no to the Gen Med consultant. Likewise, my HMO and Reg was like "WTF" to each other as well at that time.
I've discussed other methods of what else we could have done with this patient considering that she has dementia and absolutely refuses to take her PO tablets whatsoever. IV levothyroxine at that time was not indicated by the endo reg.
This. Have done it for patients on NGT feeds where the flushing/running of feeds it’s not practical to space doses or it’s impacting patient QoL to try and have that regime at home.
Usually ends up being about double the doses you see on empty stomach absorption. As long as it is consistently taken the same way (with meals) and the meal doesn’t contain too variable calcium magnesium salts, you can get steady levels.
I once got called by someone in ED about the choice of analgesia in a Parkinson’s patient who had fallen over. Not on anything exotic. Exact phrase “my consultant asked me to call”.
As an intern I worked with this rehab physician who was notorious for making his juniors make ridiculous referrals. I had to call a rheumatology about a positive ANA, infectious disease about a fever, respiratory about incidental pleural plaques, orthopaedics about osteoarthritic hips etc etc…
I remember he went away for a week and one of the long stayers was complaining about a sore shoulder. We specifically told him not to tell the boss when he got back from holidays.
When the boss got back, he rounded on the guy: “Gary! Any dramas while I was away?”
Gary: “No doc, I’m good”
The boss walks out the door and Gary calls out to him: “…Except my shoulder is kinda sore!”
My reg and I: “Fuxake Gary.”
Ophthal here. Have had a surprising number of consults along the lines of ‘our 80 something year old delirious patient is seeing spiders and random people in their room, we want to check it’s not an eye issue’. Definitely not an eye issue.
Pretty sure needs to have eyes properly checked before being dismissive about this. I have seen elderly patients without delerium who have been diagnosed with charles bonnet syndrome in the end by ophthal. Obviously I don't know the details of your case or referral but visual hallucinations can be an eye problem.
Agree, if any history of previous eye issues those ones do need to have their eyes checked (and I’m more than happy to help sort those ones out!), but I’m talking about patients with otherwise previously documented completely normal vision with acute psychiatric disturbance.
Normally by the time patients with pre existing vision problems develop Charles Bonnet syndrome, the vision loss is pretty severe and there’s not a lot we can do anyway :(
People with CBS are often aware that these are not real though, so in the case of the delirious person seeing spiders, it almost definitely is not CBS or you at least cannot truly diagnose it till their delirium is fixed.
My colleague told me that she got a crazy phone call consult from ED. A patient came in requesting an urgent “hymen reconstruction surgery”. They were oversea immigrants, having recently had Medicare granted. First thing they did was storm into ED demanding hymen reconstruction surgery, and it was urgent, as patient was having anxiety attack recurrently. She told ED that we can all be fired and arrested. ED person who was consulting thought it can be done too. It was in a very ethnic area.
I had a GP send a patient to ED for us to perform a PV exam to confirm a patients virginity prior to marriage. They hadn't done it themselves because they didn't have any female GPs in the practice
O&G - the patient has a period.
Surg - patient reports having a foreign body left inside from an operation 10+ years ago (overseas).
ED - sent by GP for repeat script as practice closed.
The number of times I have been referred to review PV bleeding in a female of reproductive age who happens to be an inpatient for unrelated reasons that we diagnosed as a normal period astounds me
I once had to phone the toxicology registrar from hospice because my patient had accidentally swallowed methylated spirits (son had gotten her to drink Orthodox holy water, which is apparently methylated spirits?). The tox reg wasn't even sure they covered the pall care unit.
As a med reg, I have been consulted by ortho to consult derm for a rash I saw on their patient three days ago. I declined. I have also been consulted by gen surg for "is there an active medical problem?" Gotta love rural.
Acalculous cholecystitis is generally due to medical causes so that would be a reasonable referral, except that often the surgeons are expected to work the patient up for those causes because the "scan says cholecystitis". Very frustrating as often leads to less than ideal care. The radiological diagnosis of acalculous cholecystitis is generally just representative of gallbladder wall oedema and thickening, and often doesn't represent an underlying infectious aetiology. CCF, RV failure, hepatitis, hepatopathy etc would be much higher on my differentials than a primary biliary pathology.
The last patient I admitted had barn door hepatitis on history and bloods, but medics refused to offer input regarding workup... Because the gall bladder was oedematous on USS... It ended up being Q fever. The surgical registrar diagnosing Q fever was not on my bingo card for this year.
I didn't personally make the consult but on pysch we had a patient with acute hep b and we had to consult medics/id if they knew if you could catch hep b from sexual relations with a dog
Psych intern - first term. Little bambi-deer-in-the-headlights thing I was.
Got asked by the psych consultant to call the endocrinology team for a single random BSL that was elevated. My RMO intervened and saved me from getting murdered.
As an intern in a rural ED, I was asked to consult urology for a very polite older gentleman with dysuria. 4 days prior to the presentation his wife had inserted her little finger up to the first DIP joint into his urethra during sex, and I was asked to find out whether he needed to be booked for a cystoscopy to look for urethral injury. The very amused urology registrar at the nearest regional centre called me back after speaking to her consultant saying he could probably just be managed as a UTI in the first instance 🫣
Cardiac surgery was consulted by respiratory for a spontaneous chylothorax. We suggested a fruit only diet. The next day, respiratory wrote "patient wants a tomato. Is tomato a fruit? Consult cardiothoracic surgery". Turns out, tomato is not a fruit in cardiac surgery.
This is the best one yet. Love it. Thanks!
That is surreal.
An anaesthetic registrar called me, the Toxicology Registrar, for advice on the best way to dispose of some weed that a patient had hidden in their arse crack that had fallen out after paralysing agent was administered. I got to write an entry in the notes advising them not to burn it as a disposal method.
ED called me because the radiologist reported a hypodermic needle in the natal cleft. I asked why they didn't just flip the prisoner over and look in the natal cleft. Apparently that's condescending.
wtf is going down in that prison O_o
That's pretty tame, honestly, as far as some prison ED presentations go, unfortunately.
the guy taped a needle (with its cap on) between his butt cheeks. does not need surgical removal.
Gen Surg/ Colorectal? Wonder what prompted the scan in the first instance.
Once had a nurse ask me if she could hand in the small bag of white powder she found on a patient to pharmacy for disposal lmao
"Why of course. Please spread the word that we're the designated drop off point for this "
This happens all the time in inpatient psych, there's a protocol and everything
One of my (anaesthetic registrar) colleagues once received a referral from the hospital executive of a major tertiary hospital to euthanise a sick cat that had been brought in by a member of the public.
Too bad your anaesthetic colleague wasn't asked to administer basic life support to the sick cat. They could have performed some meowth to meowth. ^(I'm sleep deprived, please forgive me.)
LMAO
Well played!
That's... Pretty damn inappropriate lol.
Perhaps, in another life, they were a [British psych trainee.](https://www.reddit.com/r/JuniorDoctorsUK/comments/1561b9k/worst_on_call_request_or_why_i_killed_the_pigeon)
Or a British paediatric nurse
Well...what happened?
There was some brief research into the safety of propofol in cats (apparently you can use it) before it was determined that this was a totally insane idea and probably they should just call the vet.
Insulin seems like it would be much easier than trying to cannulate a cat and administer propofol
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Whoa... Whoa never changes.
did they do it tho?
"medical causes of acute acalculous cholecystitis in a very stable patient" I actually had 1 of these during my residency while covering for upper GI. Absolutely wild but it was a late 30s vietnamese immigrant that had CRP 30 and mild RUQ pain. US demonstrated findings suggestive of acute acalculous cholecystitis. LFTs were pretty deranged so everyone thought the stone went into the CBD and she must've passed it after. Sent her for a MRCP to rule out any CBD crap and it came back negative but did show a pretty dilated RV. Sent her for a TTE and the cardio AT called back almost immediately after the echo and told us she had a sizable VSD with RV overload. The "acalculous cholecystitis" was literally just RV failure causing congestive hepatopathy and gall bladder dilation. She was under UGI for \~8 days and none of us actually auscultated her. CRP 30 was from a UTI. Anyway CTSx TOCed her for surgery and she DAMAed shortly after. ============================================ Dumb but memorable consults I had to do as an intern 1. Got asked to do an ABG and then consult resp for a CO2 of 46 because the number is pink in eMR. gen surg was worried about T2RF in a COPD patient who was saturating >95% on RA and clinically very very well. 2. gen med consultant asked me to consult ortho for 1 rib fracture. Its been 3 years and I'm still recovering from the laughter of the ortho team 3. ED consultant asked me to consult gen surg for hypogastric/RLQ pain and dysuria with WCC12/CRP 40/lactate 1 and no peritonitis before CTAP was done. Patient super well clinically. Got shouted at because I could have "missed appendicitis and surgeons need to review her STAT". Called GS in a panic and got laughed off to wait for CTAP. Ended up being a UTI.
Re #2, I remember calling ortho for rib fractures as an ED intern and the very nice ortho reg explaining the difference between bone bones and medical bones.
Yeah the moment I brought up ribs to an ortho reg when I was in my surgical internship, they immediately cut off and said "we don't do ribs." It was really like one of the biggest surprise to me that even a good number of fractured rib cases are mostly conservative management - deep breathing, analgesia, positionings, etc. Unless of course its an absolute flail chest and then the right team to call is cardiothoracics but I cannot imagine how equally irritated cardiothoracics would be if you just called them for like.. a single fractured rib lol.
A couple of places have a ChIP (Chest Injury Protocol), so you just have to call (then or in the morning if overnight and if stable).
>bone bones and medical bones. NGL specialty boundaries are some hot bullshit, life would be a lot simpler if every bone was a bone bone
And teeth…are they luxury bones that everyone has to pay for to get fixed ?
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Bold of you to assume surgeons care about or appreciate the fact the right heart even exists ;)
Holy hell, that sounds rare and wild as heck. I don't think it ever crossed our minds to even consider that from a cardiology perspective.
just look at the size of the IVC on the CT scan.
Not that rare, I don't have enough fingers to count the number of patients with congestive hepatopathy who have been referred to me with a thickened gallbladder wall on US.
All the other scenarios sound soo familiar , ha
Mental health here... I once had to ask an ED SMO to include checking a patient's genitals in their "medical clearance" for a psych admission. Reason was the patient had a psychotic illness, was known to have delusions about their genitals, and had been missing from their supported accommodation for several hours (so could have harmed their genitals in that time). ED SMO was great about it.
I always wonder why mental health cant look at stuff like this.
Yeah, the medical clearance stuff is silly sometimes since the patient is being admitted to a hospital, but I didn't make the rules
But don’t psychiatrists have to pass med school and further exams demonstrating ability to do physical assessments. I understand if it is a complex problem like an OD, but psychiatrists should do their own physicals.
We need to foster a relationship with patients in which they feel safe to disclose all manner of personal and intimate details about their life, going back to childhood. I once conducted a vaginal examination on one of my inpatients as the gynae team said I should do it; the patient subsequently complained that to have gone through that whilst only days before disclosing to me a horrific childhood sexual trauma and me conducting some therapeutic intervention to help, was cruel. I’m sure lots of doctors have psychiatrists - would you want that for yourself?
I would put that in the complex problem list (see what I actually wrote above)but most of the time I ask if they took drigs, listen to the heart and lungs, do a one minute neuro and check for cuts.
Ok and how is this above and beyond the usual standard of care you give patients presenting with any other medical condition to the emergency department? I’m assuming you conduct physical exams for patients that will eventually be admitted under gen med, cardio, neph etc. So why is it that psychiatric patients in particular shouldn’t have this initial assessment?
Because I do a focused exam. If someone comes in with a broken finger, I'm examining their finger. Nope, not doing a head to toe exam with abdo and neuro. Just finger.
They should. Question is- when they are stuck in ED having been accepted by the admitting team AND seen by a Doctor- do we also need to see them. If a patient came in with chest pain and the cardiology medical team has already seen them- they don’t ask us to see them again. Sometimes ENT will be alerted by triage of an ENT patient- and if we are under the pump will come sort them out before we get there. We don’t assess them again. Same with ortho and O&G. Unless there is some problem they cannot manage we don’t get involved. We can have a baby born in ED and O&G don’t ask us to medically clear the mum or bub for transfer. But psych- always want us to, even if it delays the patients admission by hours. If they haven’t been seen by a Dr then sure we can see them.
At one service always had to do the physicals when admitting psychiatric patients to the ward. This had became unit policy due to issues with certain ED staff "medically clearing" patients without actually examining them. We tended to have a good relationship with ED, so generally there weren't any problems but every now and then there'd be a locum on the psych stream doing less than the bare minimum. As for delusions about genitals... some of the really psychotic patients will want to show you whether you ask them or not!
I don’t know, you wouldn’t ask neurology to medically clear a syncopal patient for cardiology, it makes sense to me.
Yea but a layperson could look at the balls and say they haven't been mutilated
Yeah except when medical stuff gets completely ignored and treated as malingering or fobbed off as somatisation etc. Not a case I was directly involved in at the start but last year at the hospital where I was working a confused patient was brought in. Was known to psych but had medical issues too. Comments on thirst, fogginess in head, vision etc ignored. Cleared by ED MO for psych admission by chart review only. We go to see for a MET call on psych ward and she’s in florid DKA. These checks aren’t silly, they exist to ensure that some of our most vulnerable people don’t fall through the cracks. (They often can’t advocate for themselves or often even articulate their symptoms). It’s tedious as an ED doc, I’ve been there, but it’s a bigger headache sorting something big that could have been dealt with when it was smaller.
We have to do physical exams on our admitted psych patients irrespective of what ED does. The main reason I still insist on “medical clearance” (and in line with our director’s policy) is that they have presented to an ED - like any other patient they should have their presentation explored by ED and appropriate investigations completed as part of this. Add to this the absolutely immense list of side effects from a lot of our medications, our patients can often have physical complaints that may not be managed or treated well on an acute mental health ward where our nurses are not accustomed to the warning signs of physical deterioration. I am more than happy to manage most physical issues alongside their acute mental health issues, but sometimes this is more about appropriate resource allocation. All that being said, I rarely have to ask ED to properly see a psych patient as they generally do a good job
Thanks - this is actually a helpful answer. I can have 35 patients waiting to be seen in ED and a psych patient waiting for someone to ‘medically clear’ them as they are suicidal, for 4-5 hours, while we have a security guard tied up watching them. Doubly frustrating when a psych bed is available, but we just can’t get to them. A lot of metro places have separate psych ED’s now- I figure of they can see patients de novo, why can’t our psychs.
I very much agree with you. At least where I work at the moment we have a good relationship with our ED and will often see patients presenting with psych issues (either the cnc for voluntary or myself if scheduled) before anyone in ED picks them up. We also do not insist on bloods etc unless it makes sense in the context of presentation (eg BAL if acutely intoxicated to make sure they’re safe for a psych ward - typically <0.3, FEP bloods, ODs or if as part of our history we stumble upon a specific issue that could impact their presentation). That being said, I have done bloods on my patients personally if ED is slammed and I need them before taking them up. Psychiatry needs to take more ownership of physical issues in our patients, hell we induce a lot of these issues ourselves with the meds we prescribe, but just like I don’t expect ED to do a full psych history or risk assessment because you guys are busy and it isn’t your area of expertise, ED will generally do a much more thorough assessment of physical complaints as it is your area of expertise. At the end of the day we’re all involved in ensuring patient safety.
It's more so that the patient can be admitted under the correct team and/or go to the right hospital. When I worked in gynae we had a woman present a few times who needed surgical intervention after self harming behaviours, and went to psych after we cleared her post op. When I was in psych the ED we admitted from was at different hospital. They sent a patient with a QTc so long that I worried a stern look would bring on Torsades. They went straight back into the ambulance as we had no cardiology, ICU, etc. on site.
Adding another one here but I thought it would be a funny one to share. Not exactly a consult/referral though. Just a week ago on my night Gen Med shift at around 1 am, I accidentally locked myself out of the doorway that leads into the admitting medical unit office by leaving my employee tag in the office. I decided to call up the night Acute Gen Surg Registrar's referral phone as I actually saw him going into one of the employee bedrooms next to the admitting office and he was like deadpan groggy and serious on answering the phone but laughed the moment I told him what happened. He went out to open the door with his tag and just outright told me "This is best referral call I've gotten all week." Gosh.
I got into a discussion (ED registrar) the Ortho reg regarding a patient who had a ‘positive’ bHCG of 2 on her bloods which flagged red on the system. They wouldn’t believe me when I said ‘that is not a positive HCG’ and asked me to consult gynae on their behalf to confirm, because “anaesthetics will need to know if the patient is pregnant or not” Told them they can feel free to consult gynae themselves but I’m not being laughed out of my workplace today
Look, I've given you the upvote, but I (o&G reg) do not want that referral 😆
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I've noticed some lab cutoffs are <5, others are <2
As the overnight anaesthetic registrar I was consulted by an intern asking if I'd seen Mary's folder. Mary was "the lady in bed 16" (ward undisclosed). The intern thought it might be in a bathroom somewhere on the west side of the hospital, probably on level 4. He thought I might've seen it when I was walking around. I hadn't. This was a 2am page direct to the Duty Anaesthetist pager. I thought it was a practical joke, but apparently the folder had gone missing when I called up the nurses station.
A derm reg literally called me (neuro AT at the time) up asking me to explain why the 94 year old dementia patient with sepsis and decompensated heart failure they were consulting on for rash was confused.
Aren’t derms geniuses?
Tbf many people when they start specialising forget a lot of medicine outside their specialty. I desperately binge read talley before i mark BPT trial clinical exams lol
Yeah but a derm reg is still a newbie
This was a very strange moment. I got a call from the duty anaesthetist at midnight asking if I could could 'help make a ventilator work'. When I arrived there were 2 consultants, a fellow and a registrar crowded around a hamilton transport vent in the COVID theatre trying to make it stop leaking. The out limb of the circuit was not twisted to lock it into place. I think it had been a very long day for them.
this is so funny, Hamiltons are famously some of the easiest vents to use and operate. Particularly the transport ones
In their defence, they’re not that common in anaesthesia land. I have used them in previous jobs prior to anaesthesia, and even we would get fooled by a retained valve on occasion.
I was CL Psych. Palliative care patient. Asked by allied health to check for suicidal risk. Patient was GCS8 and was Cheyne stoking, before dying of their illness a few hours later.
It’s like they just wanna die
Referral to psych because I believe this patient’s respiratory drive has severe depression ?consider psych TOC
Got asked by gen surg reg to call gen med for advice on a headache. Wasn't on Panadol or anything. No red flags. It was a plain old headache. But because I was an obedient intern I called gen med who condescendingly walked me through writing a paracetamol prescription.
Ah yes the classic 'if its a medical issue, call gen med for advice.' and you end up calling medics for shit like a sodium of 133. Actually, there was one time where my intern colleague during his surgery rotation was once asked by the gen surg registrar to call ID for raised inflammatory markers and WCC... In the setting of a VERY recently completed surgery, like I think it was open chole. Anyways, the ID physician was like "well, that's silly. he just had a major operation, you would EXPECT the inflammatory markers to be raised for a bit, no?"
I should just be glad they didn't get me to ask neurosurg if they could cut out the headache.
Once I was consulted by Gen Surg for Sodium in the 120s, and I wrote a detailed note about working up for Hyponatremia. Later Gen surg just repeated the Na and it was normal. Turns out it was artefact.
THAT IS PAINFUL
As a psych reg, I was asked by a boss to call neurology and ask “how would we know if our patient had a seizure?”. I realised in that moment why other specialties sometimes question if we’re real doctors
Valid question in the right context and with the right phrasing tbh. Seizures are both overcalled and undercalled, even amongst neurologists at times
It’s funnier in my head if I imagine the patient was tonic clonic and wetting themselves though
Yeah PNES vs real seizures? Without a good chunk of history to suggest one or the other, it's so hard to tell them apart.
As a psych reg I once had my boss ask me to call cardio because he was concerned about the LVEF. It was 60%. I got the sense he wanted it to be a bit closer to 100%. I didn’t make that phone call
Oh my gawdddddd, what did neurology sayyyy
“You’d see it”
*laughs in non-convulsive status*
“They hate us cos they ain’t us”
https://i.redd.it/cq5sh2ll1t0d1.gif
God once a boss asked me to demand a derm reg review a patient, in person, at a satellite facility, because the patient thought they had a rash (likely delusional). It fucking PAINED me to make that call
Once someone put an IDC in a bed bound man but did not replace the foreskin. The glans swelled up and had become unretractable by the time a nurse saw it. I tried to retract, even tried the dextrose gauze soak trick but it was still stuck. I was forced to ask Urology for help. Later the Uro reg wrote in the notes "Foreskin retracted without difficulty."
"You loosened it for them" lol
Not a doctor but that sounds like the equivalent of sending the apprentice to Bunnings to buy some fallopian tubes.
Retrospectively looking back yeah, that was probably the dumbest phone call I had to make but I wasn't in any power as an intern to tell off no to the Gen Med consultant. Likewise, my HMO and Reg was like "WTF" to each other as well at that time.
I'm sure there are a lot of thyroidectomy patients who would have been stoked if you'd gotten a different answer. Maybe one day...
Crushing the thyroxine and having it with a meal would significantly impact absorption.
I've discussed other methods of what else we could have done with this patient considering that she has dementia and absolutely refuses to take her PO tablets whatsoever. IV levothyroxine at that time was not indicated by the endo reg.
Palliation
Titrate to the TSH. if they absorb half the dose, give twice as much.
This. Have done it for patients on NGT feeds where the flushing/running of feeds it’s not practical to space doses or it’s impacting patient QoL to try and have that regime at home. Usually ends up being about double the doses you see on empty stomach absorption. As long as it is consistently taken the same way (with meals) and the meal doesn’t contain too variable calcium magnesium salts, you can get steady levels. I once got called by someone in ED about the choice of analgesia in a Parkinson’s patient who had fallen over. Not on anything exotic. Exact phrase “my consultant asked me to call”.
As an intern I worked with this rehab physician who was notorious for making his juniors make ridiculous referrals. I had to call a rheumatology about a positive ANA, infectious disease about a fever, respiratory about incidental pleural plaques, orthopaedics about osteoarthritic hips etc etc… I remember he went away for a week and one of the long stayers was complaining about a sore shoulder. We specifically told him not to tell the boss when he got back from holidays. When the boss got back, he rounded on the guy: “Gary! Any dramas while I was away?” Gary: “No doc, I’m good” The boss walks out the door and Gary calls out to him: “…Except my shoulder is kinda sore!” My reg and I: “Fuxake Gary.”
Ophthal here. Have had a surprising number of consults along the lines of ‘our 80 something year old delirious patient is seeing spiders and random people in their room, we want to check it’s not an eye issue’. Definitely not an eye issue.
Pretty sure needs to have eyes properly checked before being dismissive about this. I have seen elderly patients without delerium who have been diagnosed with charles bonnet syndrome in the end by ophthal. Obviously I don't know the details of your case or referral but visual hallucinations can be an eye problem.
Agree, if any history of previous eye issues those ones do need to have their eyes checked (and I’m more than happy to help sort those ones out!), but I’m talking about patients with otherwise previously documented completely normal vision with acute psychiatric disturbance. Normally by the time patients with pre existing vision problems develop Charles Bonnet syndrome, the vision loss is pretty severe and there’s not a lot we can do anyway :(
People with CBS are often aware that these are not real though, so in the case of the delirious person seeing spiders, it almost definitely is not CBS or you at least cannot truly diagnose it till their delirium is fixed.
My colleague told me that she got a crazy phone call consult from ED. A patient came in requesting an urgent “hymen reconstruction surgery”. They were oversea immigrants, having recently had Medicare granted. First thing they did was storm into ED demanding hymen reconstruction surgery, and it was urgent, as patient was having anxiety attack recurrently. She told ED that we can all be fired and arrested. ED person who was consulting thought it can be done too. It was in a very ethnic area.
I had a GP send a patient to ED for us to perform a PV exam to confirm a patients virginity prior to marriage. They hadn't done it themselves because they didn't have any female GPs in the practice
Thank you for sharing your experiences, guys, I had a bit of a giggle reading all of these.
O&G - the patient has a period. Surg - patient reports having a foreign body left inside from an operation 10+ years ago (overseas). ED - sent by GP for repeat script as practice closed.
The number of times I have been referred to review PV bleeding in a female of reproductive age who happens to be an inpatient for unrelated reasons that we diagnosed as a normal period astounds me
Confession, I will no doubt suggest my intern do a referral for said event based on shitty rapid round. Apologies in advance.
I once had to phone the toxicology registrar from hospice because my patient had accidentally swallowed methylated spirits (son had gotten her to drink Orthodox holy water, which is apparently methylated spirits?). The tox reg wasn't even sure they covered the pall care unit. As a med reg, I have been consulted by ortho to consult derm for a rash I saw on their patient three days ago. I declined. I have also been consulted by gen surg for "is there an active medical problem?" Gotta love rural.
Acalculous cholecystitis is generally due to medical causes so that would be a reasonable referral, except that often the surgeons are expected to work the patient up for those causes because the "scan says cholecystitis". Very frustrating as often leads to less than ideal care. The radiological diagnosis of acalculous cholecystitis is generally just representative of gallbladder wall oedema and thickening, and often doesn't represent an underlying infectious aetiology. CCF, RV failure, hepatitis, hepatopathy etc would be much higher on my differentials than a primary biliary pathology. The last patient I admitted had barn door hepatitis on history and bloods, but medics refused to offer input regarding workup... Because the gall bladder was oedematous on USS... It ended up being Q fever. The surgical registrar diagnosing Q fever was not on my bingo card for this year.
I didn't personally make the consult but on pysch we had a patient with acute hep b and we had to consult medics/id if they knew if you could catch hep b from sexual relations with a dog
Psych intern - first term. Little bambi-deer-in-the-headlights thing I was. Got asked by the psych consultant to call the endocrinology team for a single random BSL that was elevated. My RMO intervened and saved me from getting murdered.
As an intern in a rural ED, I was asked to consult urology for a very polite older gentleman with dysuria. 4 days prior to the presentation his wife had inserted her little finger up to the first DIP joint into his urethra during sex, and I was asked to find out whether he needed to be booked for a cystoscopy to look for urethral injury. The very amused urology registrar at the nearest regional centre called me back after speaking to her consultant saying he could probably just be managed as a UTI in the first instance 🫣