65 year-old woman with a history of essential thrombocythemia presents with four months of left upper quadrant abdominal pain.
The patient was admitted to an outside hospital two weeks prior to the current admission with similar complaints, and was found to have a gastric ulcer that was helical pylori positive. The patient was discharged with a course of antibiotics and a proton pump inhibitor. There was little improvement in the abdominal pain after discharge. Upon presentation to the Emergency Department, the patient underwent a CT scan with contrast that revealed multiple splenic infarcts. The Vascular Surgery service was consulted, and the patient was seen initially by the consult service’s physician assistant, who reported that the venous and arterial vasculatures appeared normal, including the splenic artery and superior mesenteric artery. The surgical consultation report stated that the case was discussed with the Chief Resident, with the final assessment being that there was no need for surgical intervention, and the consult service will “sign off”. The case was not presented to the vascular surgery service attending. The patient initially improved clinically with antiemetic and pain medications. On hospital day three, she became hypotensive, febrile, and complained of worsening left sided abdominal pain. Labs were significant for white blood cell count of 27,000 with 29% bandemia, and a serum lactate of 5. Vascular surgery consultation was requested again, and the attending physician was contacted directly. The admission CT scan was reviewed by the vascular surgery attending, who noted a partial occlusion of the superior mesenteric artery. An urgent CT angiogram of the abdomen and pelvis demonstrated complete occlusion of the superior mesenteric artery and extra luminal air in the left lower quadrant loop of the small bowel compatible with perforation. The patient was taken emergently to the operating room and underwent laparotomy, small bowel resection for mesenteric ischemia, thromboembolectomy, angioplasty, and stent placement in the superior mesenteric artery.
Surgical consultations are frequently requested by hospitalists. In many teaching institutions, the initial consultants are junior trainees. One barrier to a thorough evaluation is the tendency to not insist upon an attending physician’s assessment when initial consultation concludes no specialist intervention is needed. As this case illustrated, it is important to remember that junior members of the consultation team often do not have the medical expertise or experience to provide a definitive clinical assessment. At our institution, there does not appear to be a consistent requirement in surgical consultation services to have the consulted case presented to an attending physician. This can cause delays in patient care, prolong hospitalization, and lead to adverse patient outcomes.
In academic institutions where the consultation team includes trainees, it is important to confirm that the final evaluation and recommendations have been made by an attending physician.