Tuesday, August 18, 2015

Calling a Consult

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As a sub-I you may be called on to consult a service – that is, after all, one of the two end pathways of anyone who walks into the ED (ignoring AMA). Calling a consult from the ED is just as much a skill as intubation or IV placement. It can take a whole residency to develop, but having the basics will move you away from shadowing med student towards functional sub-I. 

Below is your step-by-step walkthrough of the process at the sub-I level.

1. Know why you’re consulting. Hopefully this is your patient, but if things get busy you might be asked to help with other patients (more so if the consult should be straightforward). Know the case, and specifically what you're calling for. Do you want the team to take them to the OR urgently, do you want them to come to the ED and write a note? This is something your senior residents and attending will help you identify. Phrase it as a question: "Does this patient need an emergency endoscopy? If not, we are wondering what your recommendations for this ongoing variceal bleeding are."

2. Do your homework. Pre-plan your pitch (and make no mistake, all consults are sales pitches), and practice it a bit, especially if this is one of your first few times consulting. Always identify yourself as a sub-I (it will avoid anger later if they think you're a resident). Do not overstate your case, and do not even think about lying (they'll see the same labs and patient you have), but be declarative. Lead with your reason for calling and then fill in your logic for reaching that conclusion. 

"Hi, this is sub-I X and we have a 35 year-old female with possible cholecystitis we would like you to see. She's had RUQ pain for 2 days, positive Murphy's, elevated alk phos and bilirubins, and U/S shows gallbladder wall thickening with stones. She's febrile but without peritoneal signs."

3. Less is more. You are not presenting a patient. The point of the call is to help the consulting service triage - do they need to drop what they're doing an run down there? Or is it a stable cholecystitis that can wait until the case they're scrubbed in finishes? Give enough highlights to convince them it's their problem, but you are not helping them formulate a differential. They will ask if they need more information, so have it at hand, and try to anticipate, but it is absolutely okay if you need to refer to the chart.

4. Be nice. This goes without saying, but here we are saying it. Even if they are grumpy. Be unfailingly nice.

5. Always pass it off if necessary. Sometimes the resident on the line gets a bit belligerent, or disagrees that this is a real consult, or isn't buying your sales pitch. You can always default to your senior or attending. Don't do it at the drop of the hat, but occasionally residents don't want to hear anything from a med student. It's wrong, but it happens. Don't take it personally. Know when the consult is actually sort of soft and don't be afraid to A) admit that your attending simply wants this consult, since residents will know that feeling well, and B) hand off to said attending to make the hard sell if you don't get any sympathy.

6. Details. Get the resident's name (very important!) and a sense of when they will staff the consult. Your team will want to know. So will your patient.



Odds and ends:

At NYP (and other institutions) consults are ordered through the EMR like a prescription. You may not have access to do this yourself. Either way, make sure you're listening for your name (or whoever ordered the consult) to come over the PA. 

One way to make friends with consulting services as a sub-I that a lot of EM residents cannot accomplish is by having a very good note in the EMR around the time you call. EM residents may not fully flesh out their note until the consult is seen, but you are unlikely to be working that hard. Consult services really appreciate it, especially in potentially complicated patients.

As with everything in EM, follow-up. Keep an eye out for the consult to occur, and try to catch the resident right after seeing the patient to get a sense of their thoughts so you don't need to wait for a note to come in. Done well this last can be very impressive to a team.

If it's a surgery consult, it's best if you have a diagnosis for them. Even if that diagnosis is "acute abdomen" (meaning there's peritonitis on exam).



Further Reading:

A deconstructed analysis of what a good consult - the actual talk on the phone - entails. "The Science Behind A Successful Consult Call"





And last, some tips for making the 2 a.m. consult call less painful.










2 comments:

  1. Really informative post and i am sure that it will come in use to many people. Thanks for sharing it with us and you're doing a terrific job on your blog!

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