Consults

We were talking about this phenomenon the other day: on very consult service I've ever been on, they whine and complain about the crappy, bogus consults they get, yet when those very same residents are on other services, they make those same bogus consults. One resident felt ardently that you should not call a consult unless you've done most of the workup yourself, ie, if you're calling a consult for altered mental status, then you should probably have actually checked the mental status. Others felt like they would call consults for things their physical exam was lacking, ie, calling an gyn consult to do a pelvic exam, whereas I KNOW the ob/gyn docs whine about those consults ("oh my god, we're all doctors, you learned how to do a freaking pelvic exam in medical school"). So when is it appropriate to consult?

For starters, it helps to have a specific consult question. Your question may be diagnosis (What the eff does this person have??), workup (What kind of tests do I need to run?), management (What do I give this person?), or a combination of the above. You may need to consult a procedural service, such as surgery for belly pain or GI for a colonoscopy. Prognosis is another type of consult question, when the consulting service knows the diagnosis but isn't sure what it means for that particular patient. For C/L psych, the consult question may be "This patient is a pain in the ass", meaning that you may have to deal with the patient, or you may have to deal with the staff (or both).

Don't be vague; if you don't have a clue what's going on then say so, but the more information you can give about the patient, the better. In other words, if you're calling a consult for belly pain, say "66yo WF with DM, HTN, Afib, now with intermittent diffuse abdominal pain worse after eating", not "she says her tummy hurts." If the diagnosis isn't clear to you, then give more information, and tell the consultant that's why you're calling ("Look dude, I don't have a freaking clue" usually works, as does "I'm only an intern.")

Of course, following consult etiquette is also important. It's usually best to actually speak to the consultant (or resident) on the phone to give them the patient's info, previous workup, and of course, the consult question. Most hospitals will let you order a consult in the EMR or the chart, but it's good manners to actually talk to the doctors whose help you are requesting. Be polite, always; after all, you're asking them to do you a favor (a favor which is part of their job, but still, they've got plenty to do without your consult). One bonus to the phone thing is that you can request the "curbside" consult--in other words, if you just had a quick question ("What dose of enalapril would you use in a dude with HTN, DM, and a creatinine of 2.5?"), then it doesn't entail a full consult note, just a quick phone chat. Also, if you call, and the consultant thinks it's a crap consult, they have a chance to turn it down ("Hey, man, don't you have UpToDate? Why are you calling me with this crap!")

Where it gets crappy for everyone is in the gray area around the above questions. Sometimes, an attending or upper-level resident may ask the intern to call a consult on a patient they're unfamiliar with, so that when you call, you don't have pertinent patient information. Bad situation. Sometimes, your team will have a plan, but will call a consult "just to get Heme/Renal/Neuro 'on board'". This may or may not be appropriate, so just keep in mind that getting so-and-so "on board" requires them to come write notes, perhaps daily, and it may not be an urgent inpatient matter. Psych patient who is psychotic in the hospital? Sure! Psych patient with a remote hx of depression, not on meds, doing fine, in the hospital for something else? Probably not.

Sometimes, you disagree with your upper level or attending about the appropriateness of the consult, but you have to call anyway. This sucks. However, you just have to suck it up and do it. If the consultant says "Okay, I'll come", then great. If they say "Uh, no, that's a crappy consult", then you shouldn't really say "Oh, yeah, I thought so, but my attending wanted it..." I think it's okay to say "My attending requested that I call you," but badmouthing your attending is never a good idea, unless you're home with your non-medical spouse and you're sure no one else is within a 50-mile radius.

Other than the basic rules, just keep in mind when you're on a consult service that no one else in the hospital has the expertise that your team does in your subject. Sure, you think "Well, we all went to med school, they should know such-and-such," but that's not always the case. Also, teams are busy, and may not have or want to take the time to research a topic they're unfamiliar with. So instead of thinking "OMFG, not another consult for Bell's palsy/remote psych hx/benign tachycardia/delirium/benign colonization of urine with a Foley," try to think of it as an opportunity to teach. Or, if you prefer, a time to feel really smart compared to someone else. And just remember, when you're on your next rotation, to kiss up a little when you call your old team for a crappy, bogus consult.

Busy, Sorry

Inpatient rotation with q4 call = busy TS. Sorry for the lack of posts. It will probably be next week sometime before I can start posting with regularity (sounds like something you take Dulcolax for, doesn't it?) Anyhow, I'll be back soon!

A Strong Statement

To those people who chose not to evacuate when placed under mandatory evacuation during Hurricane Ike:

Your decision not to evacuate, despite being warned of storm surge threats and of the threat of the hurricane, has placed hundreds of rescue workers in danger. In addition to having to rescue people who could not leave (those who tried to call 211 and could not obtain help, or those without means or were ill), or those who were in areas without evacuation who experienced flooding or fire, they have to come rescue those of you who said, "well, the last hurricane didn't hit us, so we didn't think this one would hit us, either". I'm sorry your house was flooded, and I'm sorry that you suffered, and fortunately you are still going to get rescued. Unfortunately, though, you are increasing the burden on rescue workers, hospitals, law enforcement, etc, and it's entirely through your own choice. If you have children and didn't evacuate those children, then shame on you for putting them at risk when you were TOLD to leave.

It's akin to a severe diabetic not taking insulin and eating cheeseburgers despite warnings that they could lose their heart, brain, kidneys, and extremities. We will still come fix you, but if you had helped yourself then we'd all be in a much better place.

To everyone in the areas affected by Ike, my thoughts go out to you. I hope everyone is okay.

The Almighty Defibrillator

And now, to change the subject just a wee bit...

I've run across some misinformation amongst some of my family members recently, regarding the use of defibrillators. Articles like this one from February indicate that they're not the only ones who may not understand. So what is a defibrillator, and what is it good for?
We'll start with the heart. It beats between 60-90 beats per minute (normally) in all of us who are alive to read this. The heart beats because inside the heart the "pacemaker", or sinoatrial node, generates an electric signal that courses through the heart muscle, which causes the muscles to contract, forcing blood up and out.

When the rhythm of the heart beat is normal, we call it "normal sinus rhythm". It looks like this:
Sometimes, the electrical system of the heart gets screwed up. It starts to fire in an abnormal fashion, causing the heart beat to become abnormal. We call this an arrhythmia. There are many types of arrhythmias. You can start with slow versus fast patterns. The thing to remember is there are MANY TYPES. Since there are many types of arrhythmias, it makes sense to think that patients have many types of reactions to their arrhythmias. Some patients with a benign arrhythmia may have no symptoms or may have severe symptoms. Some have a potentially lethal pattern and may have severe symptoms or no symptoms.

Now, what do you see on TV? Patient says "I can't breathe!", grasps their chest, and keels over; someone slaps the paddles together, yells "CLEAR!", then you hear BOOM! and the patient sits straight up, fit as a fiddle.

Not exactly.

In real life, the paddles only come out when a) the patient is sick enough and b) the rhythm is shockable. On airplanes and in school gyms, automated external defibrillators may be used instead of the big fancy paddles. Someone goes down, isn't breathing, and they look bad. Bystander grabs the AED, slaps on the pads, and the machine starts to analyze the patient. It has two options: shockable rhythm or non-shockable rhythm. That's it. The machine doesn't know if the patient is breathing, or conscious, or has no blood pressure; the machine simply knows whether it should deliver a strong shock or not.

So when will the machine deliver a strong shock? Two rhythms only: ventricular tachycardia and ventricular fibrillation. Both of these rhythms can be fatal, as the heart beats too fast to pump blood, so the brain dies, and the heart wears out, so it dies.

Unlike on TV, if someone's heart has stopped completely, or is in asystole, they don't get shocked. In that case, the only thing to do is good old-fashioned CPR: manual chest compressions and mouth-to-mouth (or bagging if you're in a hospital).

Thus, if you strap on an AED, it will not always shock the patient. It shouldn't. Pulseless electrical activity, where the heart has some electricity but isn't pumping blood to the body, does not respond well to shock. Asystole does not respond well to shock. The slow arrhythmias, unless they start having ventricular fibrillation, do not respond to this kind of shock (and require a special pacemaker). The correct thing to do, if the machine says "no shock advised", and the patient still isn't breathing, or has no pulse, is to continue CPR.

AED's can and do save lives--it's true. You can't go wrong by strapping one on someone who's down without a pulse and not breathing. But don't forget the CPR.

So, what was my family's misinformation? They thought that the machine always shocked--and therefore always saved. Not true. And unfortunately, if there's not a shockable rhythm, and the patient can't get help within minutes, their prognosis is grim, even with the world's greatest CPR (although with CPR is better than without). A patient who goes down may still have a poor prognosis even if the AED delivers a shock, but now they've got a fighting chance. Since you don't know why the patient is down--they may have had a heart attack, or a stroke, or a pulmonary embolus, or a chemical imbalance in their blood, any of which could trigger an arrhythmia--it's good to strap on the machine and do CPR.

Something random and (I think) fascinating: Hands-Only CPR can be just as effective as the regular kind. So, if you're worried about doing mouth-to-mouth, or don't have your barrier device handy, just work on the chest compressions (100 per minute, so faster than 1 per second, and compress the chest 1.5-2 inches in an adult).

--I'm going to use this for my family and other lay people who have questions about CPR and AED's. Let me know if there's something I should fix.

Psychopathology of The Office

Just for fun, while watching Season 4 of The Office tonight, I started thinking about DSM-IV criteria and the main cast of characters (yes, I'm a huge nerd). Obviously, these personalities are exaggerated for the sake of the show, because nowhere else on earth (except a psych ward or prison) would you see this many personality disorders in one room--they'd all kill each other. See what you think:

1) Michael: dependent personality disorder vs narcissistic personality disorder; manifests splitting, self-destructive behavior, pathological need to be liked, feels entitled, has some somatization, fears of being alone, rushes to new relationship when old one ends

2) Dwight: paranoid personality disorder vs schizotypal personality disorder; feels everyone is out to get him, has hidden weapons in the office, turns down a free drink because it may be poisoned, has some magical beliefs (the computer has free will, the websites are talking to each other to take over the world, the short guy is a Hobbit), ideas of reference, eccentric behavior

3) Angela: obsessive compulsive personality disorder; control-freak, stubborn and rigid, everything has to be done her way, inflexible with rules, perfectionist, devoted to work, reluctant to delegate tasks

4) Toby: avoidant personality disorder (soft call); can't have Pam so is leaving to go to Costa Rica

5) Andy: narcissistic personality disorder; believes he is special, is grandiose, is often jealous of others or thinks others are jealous of him

6) Jan: borderline personality disorder, alcohol abuse; repeated patterns of self-destructive behavior in work and relationships, impulsive, labile mood, fits of rage

7) Meredith: alcohol abuse/dependence--duh

8) Creed: antisocial personality disorder; exploitative, repeated arrests, irresponsible at work, lack of remorse

9) Kevin: pathological gambling--duh

10) Phyllis: personality disorder NOS with features of passive aggressive personality; always knocking stuff off Angela's desk or throwing things at her when she's frustrated

11) Kelly: histrionic personality disorder; OMG LOOK AT ME OH HI RYAN WANT TO GO ON A DATE I'M PREGNANT OH J/K HI DARRYL MMM LET'S MAKE OUT RIGHT NOW HEY PAM YOUR BOYFRIEND IS SOOOOO GOING DOWN

12) Ryan: narcissistic personality disorder vs substance abuse NOS (I'm not sure what but he was definitely on drugs in that club, looked like Ecstasy) vs pyromania*

That leaves Jim, Pam, Oscar, Darryl, Stanley, and Holly without a current diagnosis. Any thoughts?

Obviously, this is satire, and I just made this all up. This information is not intended to diagnose or treat any condition. I do not think everyone I meet has a personality disorder, I swear. It's just a joke. No, really. Stop looking at me, swan!