Tag Archives: Consultant

Beware, the interns have arrived…

The last couple nights on pain night float have been complicated by the fact that the new interns have apparently begun taking call.  It doesn’t seem like that long ago I was beginning internship, but it’s already been three years.

As I look back at some of the earlier entries in this blog, I see some rather indignant posts describing my calling consultants who seemed to think we hadn’t done an appropriate work-up.  Even last year, I remember calling a cardiology consult for a stat echocardiogram in the ICU for a crumping patient (because the fellow wanted one), and the cardiology fellow was still a jerk about it.

Alas, I am now that consultant.  Last night found me returning a page from an intern who told me that his patient with a thoracic epidural catheter was having pain.  This was a very reasonable consult, but the intern couldn’t tell me much about the patient’s medical history, couldn’t give me more details about the patient’s pain, couldn’t tell me where the catheter was, how deeply it was placed, which medicine was being infused through it, and at which rate.  He stammered, “This is my first night on cardiothoracic, and I’m just cross-covering that patient.”

I responded, “You are that patient’s primary physician for the night, and you should know more about the patient than anyone else in the hospital.  You should know all these things before you call a consultant.  I wouldn’t dream of calling a cardiology consult if I couldn’t recite a brief history, and if I didn’t know what the last troponin was and what the EKG showed.”  Of course, I said it all in a nice–but firm–tone of voice, and the chastened intern apologized to me when I showed up on the floor.  I told him I wasn’t upset, but that it was important for him to learn sooner rather than later how to appropriately ask for help from a consultant.

This morning I received yet another page.  “This patient had back surgery and is having pain.  Could you come write a PCA?”  Again, I asked for more details, and at first the intern couldn’t tell me the patient’s medical record number, when the surgery was, and what pain regimen the patient was on.  For him, I simply said, “It sounds to me you know very little about this patient.  Please go look up the information and then you can call me back.”

In this case, I was busy and I didn’t have time to wait while the intern looked up every detail I asked for.  Sure, I could easily look up all the information, but it’s inappropriate not to be able to tell a consultant pertinent details.  I felt like this intern just hadn’t really bothered, and that conveyed the message that he felt like his time was more valuable than mine.

Ironically, I’m sure he did have a lot more than me I to do that morning, but I think he still got the idea that he needs to know his patient before calling the consultant.  I think of it as tough love.  You can’t coddle these interns who just spent the last six months skipping through an easy end to fourth year and being told how bright they are.  Better to work hard and to be prepared than to be bright.

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How to avoid a consult

This week I’m camping out at the hospital every night, covering the Acute Pain Service (post-surgical pain) and the Chronic Pain Service (all other kinds of complicated pain).  We have patients with complex oral regimens, standard intravenous Patient Controlled Analgesia (PCA), perineural catheters which infuse local anesthetics near a sensory nerve, epidurals, and even a gentlemen with metastatic cancer up in the ICU who has an intrathecal catheter (within the dural sac which surrounds the spinal cord) receiving intermittent doses of opiates.

I come in at 1900 and leave at 0800 Monday through Friday nights.  It’s great, because I can usually get at least six hours of sleep, so I feel like I’m having a miniature vacation here in the City.

Covering the pain services is also the rare time when we feel like true consultants.  Anesthesiologists fashion themselves to be consultants in perioperative medicine, which is true to an extent, but we really take on the patient and take care of every aspect of their physiology while the surgeons operate.  The pain services are more of a traditional consultative role.  As such, it’s nice to address the problems I know how to address, and leave the primary care team to deal with working up problems I’d rather not get involved with, as well as the painful aspects of coordinating care and planning discharges.

Sometimes nurses will try to consult us when their patients are in pain.  This is inappropriate.  A consultant comes when another physician calls, describes the patient, recounts what’s already been tried, and asks the consultant to address a specific problem.  “My patient’s in pain,” is not an appropriate way to get help.  A nurse would never call a cardiologist out of the blue and say, “Hi, yes, this is Nurse Williams.  Mr Jones on 8-South was having some chest pain.  I could have called the primary team first, but I thought it was probably his heart, so I called you to see about getting an EKG, an echo, and that sort of thing.”  Or the gastroenterologist, “Yes, Dr Smith, my patient just threw up and there were streaks of blood.  Could you come do an EGD?”  So why would they call the pain management physician and say, “My patient’s having pain”?

No.  The nurse should call the primary team, who then calls us.  And, young intern, there are certain things you should know when you call a consultant.  It doesn’t matter if you’re cross-covering so you don’t know the patient as well; it’s still your patient for the night.  Name. Medical Record Number. Location. Age. Pertinent medical history. Surgical history if applicable.  Surgical pain management.  Postoperative course.  Current problem–Where is the pain?  What is it like?  How has it changed?  What’s been done already to address that problem?

The reader with a keen eye for detail will notice that I bolded and italicized a sentence above.  This is because so many young doctors will call us, and they’ve done nothing yet.  I wouldn’t call a cardiologist until I’d interviewed the patient, done an exam, gotten an EKG, checked labs, and possibly floated a pulmonary-artery catheter.  I’d have the chart and data in front of me so that I can concisely tell the story.  But no.  We get calls, “The patient’s in pain.”  “What have you tried?”  “Well, we stopped his home medicines because we thought they were too much, and we started morphine 1mg subcutaneously Q3 hours prn, and now he’s having pain.” “Okay, so what did you do next?” “Well, that’s why we’re calling you.”

This example illustrates another point that many doctors misunderstand regarding chronic and acute pain.  A patient who has chronic pain well controlled on medicines, who then develops acute pain on top of that chronic pain, still needs to continue the chronic pain medications and get additional acute pain medications.  Many physicians will see a patient with not one, but two reasons to have pain, and will then give the patient less medicine rather than more.  Another basic skill that all physicians should have is a basic escalation in pain medicine.  If the patient’s on oral meds, try intravenous.  If the patient’s on morphine, try hydromorphone.

So, with that soapbox behind me, I’ll now relate the story of the nurse who called me.  “My patient’s in pain.”  I had to tease out of her the fact that she was a nurse, as well as the patient’s name, age, location, history, and story.  This patient was on a PCA.  “How frequently has he been using it?   Have you increased the demand dose as the orders permit you to?  Have you given a clinician bolus as the orders permit you?”  I don’t know, no, and no, were her answers.  My plan for her, over the phone, was simple: Give a clinician bolus as the orders already tell you to do.  Assess how frequently the patient is using the PCA.  If he’s not using it with appropriate frequency, then educate him that he can push the button every six minutes.  If he is using it frequently, then increase the demand dose as the orders already suggest you can do.

Problem solved.  Nurse gently educated.  Patient’s pain addressed.  Formal (and unnecessary) consult avoided.

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