The Overnight Consult
Cut to the Chase: General Surgery Survival Series — Post 33
Aden Davis, MD
For PGY-2s, and the interns reading ahead
The page comes a minute after you've sat down. The Emergency Medicine physician has a woman in her eighties in Hall 2 who has been vomiting since yesterday. Her CT shows a small bowel obstruction, and she has never had an operation.
Her belly is soft, the NG is in, and he'd like to know whether medicine can admit her with surgery following.
You have a full list upstairs and a man in the unit you'd rather be watching. Part of you, the tired part, hopes she never becomes your patient.
He's asking which team admits her. Your question is why a woman who has never had an operation is obstructed, and nothing he's told you answers it.
Once surgery writes "No acute surgical issue," everyone else stops watching her belly. If that note was written from the phone, nobody has actually looked.
New seniors tend to settle these nights one of two ways. Some admit everybody, and a man with pneumonia spends two days on a surgical floor with people who think in drains. Others clear everybody, because no takes less time than maybe.
I've taken a few thousand of these calls. Most of the patients turned out to be exactly what the Emergency Medicine physician said they were, which is what makes the other ones so easy to walk past.
We were all taught to settle consults on the phone. We even do this as attendings, but with much more skepticism. The phone is fine for deciding how fast you go down, but it never decides whether you go.
Some of these calls come with an edge, from a department that's been told no all night. You're going down there either way, so there's nothing to win on the phone.
Get her vitals, a lactate if one was drawn, and whether anyone has examined her since the CT.
Ask him what's bothering him about her, and then stop talking. He's been in and out of her curtain since dinner, and you haven't met her yet.
Before you hang up, tell him: "I'll be down in twenty minutes. Keep her NPO, and please don't send her upstairs before I've seen her."
Downstairs, read the triage note before his. It was written before anyone decided what this was, usually in her own words.
Then examine her. A hallway gives her almost no privacy, so make what you can: introduce yourself, tell her what you're about to do, pull the curtain as far as it goes, and uncover only what you're examining.
Look at her abdomen for old scars, and notice when there aren't any.
Feel both groins on anyone who's obstructed, even after the CT has been read. Everyone who examined her before you was asked to look at her belly.
And don't let a normal lactate reassure you. It doesn't mean the bowel is alive.
In fellowship I took a call that sounded a lot like this one, a little before one in the morning, about a different woman. I was in the unit beside a man on two pressors, and the intern was in the middle of an appy.
I said medicine could take her, that we'd follow, and that I'd be down when I got out of the unit.
I got there at a quarter past three. She was on a stretcher by the ambulance doors, NG to suction, sheet up to her chest. There was a firm, tender lump in her right groin that wouldn't go back.
She went to the OR at five with a strangulated femoral hernia and came back without a piece of her small bowel. The note I'd dictated from the unit is still in her chart: "Agree with admission to medicine, surgery will follow."
I knew what an obstruction could mean in a belly that had never been operated on. I answered in under a minute anyway, hoping she had what the department said she had.
She spent the next two hours in a hallway waiting for somebody to lift the sheet.
Back in Hall 2, if your patient doesn't need an operation tonight, write a note that shows how you know. Put down what you found, what you looked for and didn't find, and what would bring you back.
Write the time you examined her next to "No acute surgical issue." Whoever reads it at six has no other way to know when you saw her.
If you write "Surgery will follow," write when you're coming back, and show up at that hour. My note didn't have a time on it.
Put her on your own sign-out and call whoever admits her. Medicine won't read your note before breakfast.
Give them the one finding that brings you back. If she vomits around the tube or needs a second dose of morphine before six, they call you directly.
Tell your chief or your attending before you turn anybody down. Your no is the only surgical opinion she gets before rounds.
If your attending is scrubbed in, call anyway. The circulator will hold the phone to her ear, and she's taken harder calls with both hands in somebody's belly.
The anxiety on the way to that phone is usually about sounding like you couldn't handle the night. I've been woken up plenty of times for things that could have waited, and I don't remember any of them.
Most of the consults you go down for will be exactly what they sounded like, and you won't remember them either.
I still remember the woman by the ambulance doors.
What to Read Next: Post 34 — When Your Senior Disagrees With You. This one had you saying your no out loud to someone above you. The next one is about the morning that person looks at the same patient and calls it differently.
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