Dr. Andy

Reflections on medicine and biology among other things

Thursday, November 03, 2005

Bad consults

Barbados Butterfly has a great story about incompetence in the ER causing her much uneccesary pain:
Bleeding into the brain is to be considered a more significant health problem than an eyebrow laceration. Patients who have "an eyebrow laceration" require significantly different management to patients who have "an eyebrow laceration and an intracerebral bleed and a maxillary fracture following blunt head trauma". It's important to distinguish between the two if you want your patients to live.
It reminded me of one of my worst consults as a fellow, which I'll try to present in the same style. Briefly, as a fellow covering the pediatric rheumatology service I got called to see a 15 year old girl with Kawasaki disease (KD), which is basically a systemic inflammatory illness of unclear cause that occurs mostly in young kids. After seeing the young women I made the following points to the peds resident who saw the patient in the ED.

1. I am happy to come into the ED from home on a Friday evening to see patients who need my help. I am less happy to come in because of your incompetence.
2. Fever and rash are not always Kawasaki disease
3. KD is unusual, but not unheard of, in an adolescent. It is advisable to consider other illnesses in the differential diagnosis
4. Toxic shock syndrome shares many features with Kawasaki's, but, unlike KD, often presents in adolescent females. It is associated with tampon use and particularly retained tampons. A pediatric resident is perfectly capable of obtaining a menstrual history and obtaining the information that the patient put a tampon in >24 hours ago and hasn't removed it.
5. A second year resident may not be aware that hypotension is common in toxic shock but rare at best in KD. However, if you need the rheumatology fellow to point out that a patient who has recieved 5 liters of normal saline and not achieved a measurable diastolic blood pressure is in need of more intervention than a "rheum consult" you might consider another line of work.

The patient eventually was transferred to the ICU, got appropriate therapy and did well.


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