Case: Surgical Co-Management's Finest Hour

One day I was trying to get ready to go to the hospital when I got a page. It was one of the orthopedic surgeons asking me to consult on a patient.

"The nurses called me and they're freaking out," said the orthopod. "The guy threw up red stuff and they're afraid he's got a GI bleed. I'm supposed to take him to the OR at nine-thirty."

I hate it when I have to clear a patient for surgery on extra-short notice. I got the hospital and was relieved to see he was a young, otherwise healthy man who'd gotten a bit drunk and fallen off a porch. He had a bimalleolar fracture that needed fixing, but what was the deal with throwing up red stuff?

"What happened?" I asked, after introducing myself.

"I don't know," he said. "They told me I couldn't have anything after midnight, so I went to bed and next thing I woke up and puked."

"Have you ever been told you had liver disease?" I asked him. My eye was on the clock, which said the guy was due in the OR in fifteen minutes.

"No."

"Stomach ulcers?"

"No."

I had a thought. "What was the last thing you had to eat or drink?"

He thought for a moment. "I had a tuna sandwich for dinner," he said, thinking hard.

"And?"

He looked right at me with an aha! expression on his face. "And I drank a big thing of Kool Aid before I went to bed."

"Flavor?"

"Cherry."

I found an emesis basin where there was a bit of residue left. It was bright, fruity red, and there was no evidence the contents had coagulated. A faint aroma of artificial sweetner arose from the basin.

I ran a stat CBC. His hematocrit was the same as it was when he was admitted. I cleared him for the OR. In my note, under Assessment, I wrote: "Probable Kool Aid ingestion."  I hope we get paid for this consult.

Comments

[Dr. Dredd]

I'm sorry, but Kool Aid ingestion is not a diagnosis covered by this insurance company. Accordingly, your claim is disallowed. Please submit forms 487X, 529Y, and 601Z if you wish to appeal. We pledge to respond within the next Presidential term. Thank you for your excellent care of our patients.

[Theresa]

Excellent statement of the problem, Dr. Happy. You are absolutely right about the decision falling to the anesthesiologist. We also work with a CNRA on our staff who doesn't have the comfort level to make those calls, hence my role as hospitalist. Or lunch monitor, or whatever you want to call me. Truth is, I got paid to see this patient, but whether the hospital or group will....

[Xavier Emmanuelle]

Hee hee!

[The Happy Hospitalist]

I might add that hospitalists don't clear patients for surgery. We risk assess. Ultimately, the anesthesiologist and the surgeon have to decide if they will put the patient under. In 5 years as a hospitalist I can think of only a handful of patients that weren't "cleared"

Because I see acute presentations of illness, the surgery is usually required to survive. I don't have the luxury of doing a "pre-operative evaluation", even though that's what I get asked to do. I know all they want is an H&P. Lets stop kidding ourselves. Especially when the consult comes from an ophthalmologist. But since Medicare is paying, Happy gets paid and everyone is happy while the system goes bankrupt.