No Consults Thus Far Today

No consults today thus far.  While these requests for advice seem to be the last clinical work that keeps me energized from one day to the next, the slack time is appreciated when it arises.  Some time to read, some time to think, some time to organize.  Doctors never really run out of things to do, though we often run out of things we want to do.  Spent yesterday on the phone and on the screen with an afternoon in the office.  One consult that was straightforward, a person with newly acquired tsh suppression, borderline free t4, no symptoms and a fairly normal exam.  The hospitalist watched me do the consult, concerned most about whether the person could be sent home.  This being a common office referral, there was no problem with discharge and a decision made later on antithyroid drugs if the T3 was elevated or watchful waiting if it was not.  But none so far today.  I can look at more lab work or I can renew prescriptions and test strips though none of that is nearly as satisfying to me as taking a medical record apart from the first available entry and matching it with what becomes apparent at the bedside.  Maybe later or maybe tomorrow I'll get my next chance.

First Responder

My first real post.  By way of introduction, I am an endocrinologist, class of  '77, on medicine's exit ramp, or at least planning to retire from office care.  We can debate whether my hospital's EMR killed the golden goose or Father Time just caught up with me, but I have a genuine Medicare card in my wallet that has started to fray.  The final vestiges of my engagement are a real fondness for hospital consults, the more extreme the lab work, the more enthused I become, and expressing my opinion, which accounts for my not being on any important committees ever in forty years.

This weekend the beeper went off Saturday morning with at least one consult that should not wait until Monday.  It could have waited until Sunday, but having declared Sunday a Me Day, right after Shabbos Services, I schlepped to the hospital.  While there, I may as well round on everyone or at least look at all the glucoses.  I started from the top floor, planning to work downward. Player #1, just an insulin adjustment.  Player #2 I greeted as the physical therapist put him through his paces with a walker.  His sugars had gotten high and the therapist informed me of chills and a swollen arm.  Sure enough, he had been febrile for two days, seen by the ID consultant, judged not real sick, and wait and see advice seemed reasonable at the time.  But with chills and a temperature just under 39C, he got a real exam.  Ordinarily I would call the resident but he was assigned a non-resident service so I'm on my own.  Having been a hospitalist before there were hospitalists everywhere, I knew how to address a fever.  Some abdominal tenderness, probably a hot right wrist or cellulitis of the forearm.  However, I do not know much about antibiotics.  I called the attending physician to convey the findings, the ID consultant in a mournful plea for help, and ordered blood cultures x 2, urine culture, an xray of the wrist and forearm, and a single dose of vancomycin at the recommendation of the attending physician.  And he needed more insulin.  That I know how to do.   A resident stopped by and showed me how to enter an IV order on the computer.  And before I left, the cavalry in the form of the ID consultant made a trip in to save the day.

Then downstairs to newly identified rip-roaring primary hyperthyroidism, something I know how to address without help.

While I have become something of a mullet at sorting out fevers, diarrhea, headaches and insomnia, the things nurses call residents about, I am still from an era where we were taught to read charts and examine people.  A fever could come from anywhere.  That hot wrist could only be found if you went and looked at the patient without any preconceptions of where the fever might be originating.  It was a challenge, totally unexpected, but pretty gratifying to still be able to do this.