What do I do exactly…?

I saw a very disheartening quote in a patient chart recently:

“…consider curbsiding ID for antibiotic recommendations…” Followed a few pages later by “Follow ID recs…”

It was disheartening in several ways: firstly that although someone had obviously thought us worthy of asking for advice they hadn’t actually called me about the patient; and secondly that they thought this question was worthy only of a “curbside”.

Regular readers and followers will already know my thoughts on curbsides – but I didn’t really delineate what I actually do. I addition, what should I expect of a consult and what should a consulter expect of the consultant?

A consult is triggered, at least on the inpatient side, when a physician asks a question of a colleague in another speciality. Now this happens informally all the time – we live in a learning environment after all – but a question along the lines of “I have a patient…” generally means that there are healthcare decisions being made on a real patient, and these are the real issue.

Most of the time a consult requires a specific question – I have had colleagues in fact pause for thought and tell me “I’m not really sure what question I have for you…” and then not bother formally consulting. In my mind, it’s very simple – if you are concerned or uncertain enough to seek out a subspecialty colleague for advice on a specific patient, that by itself is valid grounds for a consult. I have done more than my share of consults for “please assist with antibiotic management or further workup”. It’s not failure or weakness, nor a waste of my time – it’s what I do and it’s in the best interests of the patient.

I do expect a somewhat valid reason – a specific question is ideal, but even if I’m asked about antibiotic treatment I will usually try to go beyond that and include alternative diagnoses, testing, followup recommendations etc. I also expect timeliness – a consult should be called early, both early in the disease course and early in the day! I prefer to avoid problems than have to dig people out of them. I also like time to go to the lab before seeing the patient…and recently I had to fish culture plates out of the trash in order to help a colleague with antibiotic recommendations. Had they waited another day we would have had to use unnecessary antibiotics to treat more broadly than we needed to. Calling a consult prior to knowing all the information is ideal – I can often get preliminary results faster than the lab will report them and add on additional workup days ahead of time.

When I get asked a “simple” question like what antibiotics are recommended I go through the following steps:

Initial shoot-from-the-hip thoughts – what info do we have so far? How sick is this kid, risk factors, early lab results and prelim microbiology workup. I will ask for CBC (with diff, always with diff), CRP and sometimes ESR, renal and hepatic function as appropriate. Urinalysis results, and CSF findings if an LP was done. Empiric bugs will depend on likely source of infection and likely site of infection – the two might be quite different! Then I ask what drugs the kid is on and line up the likely antimicrobial activity of those drugs against the likely bugs and see if there are holes in coverage. I do this last step mentally over the course of a few seconds (usually) but I do it every time. Typically when I do the same process with residents or students it’s a several-minute slog through the bug/drug matchup table. Just because it’s easy for me doesn’t make it worthless though, it just makes me efficient. If the kid is “safe” then I tell them to stay put, if not I suggest additional empiric coverage before I even see the patient.

Second stage – chart review. I read the chart. Yeah, I really try to read it. ER records, admission note, progress notes, operative notes and even resident signout notes… I will scroll through every lab in the computer even if I don’t transcribe every one into the chart. Every microbiology lab, positive, negative or pending is recorded. I personally looks at x rays, scans, even ultrasounds (although my ability to read those things is pretty near useless). I always review the scans myself and THEN read the radiology report. Sometimes I’ll go down to radiology and review it with the radiologist.

At this stage if there are questions or additional workup obviously needed I will call the lab or let the team know, and if I get the chance I will physically walk over to the lab to look at the cultures myself. What’s the value in that you might ask? Well more than once has an initial “gram positive” gram stain turned out to be a gram-negative bug, and in some cases a gram stain alone can, with the right eyes and expertise, result in a diagnosis all by itself. On the culture plates, bugs like proteus, klebsiella, strep viridans, listeria, E. coli and pseudomonas have a characteristic appearance (and smell!) that may jump start the management a day before the Microscan or Vitek machine gives you the formal identification. A visual peek at a urine plate reported out as “flora” might reveal a predominant organism that you can point to and ask to get worked up.

Lastly – the patient. Go to the bedside, lay on eyes and hands. Talk to the parents and patient and find out the little nuances in the story that others missed – the dog bite in a kid with fever, the recent dental visit in a kid with bacteremia, the rash in a mom that started the day after delivering her baby… Test hypotheses, confirm or refute suspicions.

Sometimes with all of this I rethink my initial plan – which only goes to show how unreliable the shoot-from-the-hip curbside is. I may back off from my broad empiric coverage, or I may rethink a diagnosis completely and expand both therapy and workup. It’s not unusual for me to be consulted on disease X and have to tell the team that it’s really disease Y all along. A curbside cannot possibly do that. Any result requires a conversation with residents, students, nurses and colleagues – all of it educational and a two-way process.

So if you add all this up, what does it mean? It usually means, at minimum, a level four inpatient consult. Consults come in five levels – short of a life-threatening condition this is about as high as you can realistically go.

Let that sink in for a bit. A simple question of “what antibiotic should I use?” is justifiably as difficult as a decision to do elective surgery. In fact, based purely on asking me to review the evidence running up to the decision, there’s enough work to bill at that level even if I say “you’re doing a fine job, I recommend no changes or further workup”.

Yes, Infectious Disease specialists do all sort of other cool stuff too – we diagnose rare diseases, can help with resistant organisms or diagnostic dilemmas – but fundamentally we’re trained in how to best manage all the routine stuff as well. That’s not to say we need to get called on every pneumonia, meningitis or urinary tract infection – but if you get stuck with a question or concern with any of these it’s ok to ask for help.

And if you’re going to ask for help, don’t, just don’t, assume it’s not worth anything. No-one would dare ask a surgeon to operate for free…why treat your ID colleagues any differently?

  1. #1 by Philip Lederer on November 21, 2013 - 16:34

    Great post!

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