VAIL, CO – At this year’s meeting of the College of Orthopedic Surgery, new guidelines were proposed for hospitalists and emergency physicians to review prior to ordering inpatient consultation.
“We have recently seen an increase in the amount of unnecessary consults that are called, whether for patients who have extremity pain that has not yet been treated conservatively, or have chronic joint pains, or even just because patients have pain and also have bones. We are drowning in health care costs and such consults only add to the burden. These guidelines should help keep unnecessary consults to a minimum.”
“We have found that generalists mostly do not remember the 25 minutes of orthopedics they learn in medical school,” he added, “nor any extremity anatomy whatsoever,” he grumbled, “so we also made these as simple and educational as we could.”
A selection of the guidelines appears below:
- Have an idea of what the bone in question is called. Asking Orthopedic Surgery to come evaluate a patient’s “distal radial head” or “tibula” is poor form.
- Order an X-ray prior to consulting Orthopedic Surgery. Except in emergency situations, allow some time for that X-ray to be performed and for you to actually review the image (or at least the radiologist’s report) prior to calling.
- Do not read the Radiology’s report to Orthopedic Surgery. Orthopedic Surgery can read. They outscored you on Step 1. If you think they are Neanderthals, what exactly does that make you?
- Osteoarthritis is treated as an outpatient.
- Call Rheumatology for gout. If you think the joint might be infected, or if Rheumatology is not available and you are pretending that you think it is infected so that Orthopedic Surgery will come evaluate the patient, at least have the courtesy to order WBC, ESR, and CRP.
- Patients that are comfortably sitting in bed eating Popeye’s fried chicken with 1 out of 10 pain are not suffering from compartment syndrome.
- If you know the patient does not have compartment syndrome, but are just pretending to be suspicious because you want Orthopedic Surgery to examine the patient so you don’t have to figure out what is wrong with their extremity, at least have the courtesy to make the patient NPO.
- “Fractured” and “broken” are used interchangeably, and do not signify different conditions.
- Foot pus? Hangnails? Diabetic ulcers? Please call Podiatry, thanks.
- If a patient’s extremity (arm or leg) hurts them, and you are concerned for fracture, order an X-ray of the bone you suspect is involved. This process generates an actual image which you can view in the EHR, not just a bunch of words the radiologist dictates after the patient returns from X-ray.
- If the bone is indeed fractured, and it is displaced (meaning the broken ends are not right next to each other) call Orthopedic surgery. Also order X-rays of the joint above and below the injured bone. Consider ordering pain medication.
- If the bone is fractured, and not displaced, you may be able to treat it yourself. Look in UpToDate, which is the website open in the other tab in your browsing window right now, and it may tell you.
- If the radiologist’s read includes “Unremarkable study,” try giving the patient pain medication, ice, and having them rest the extremity. Do not order a CT scan. Do not call Orthopedics.
- If the patient has a broken bone (bones are white) sticking out of their skin, this is an open fracture. Order Ancef, an X-ray of the bone you think it might be, and call Orthopedic Surgery. Also, the patient would probably appreciate pain medicine.
- If the patient has a broken bone in one extremity and a laceration in another extremity, that is NOT an open fracture.
- “Clinically dislocated” is not a reason to call Orthopedic Surgery. “Radiographically dislocated” is much more acceptable.
- Simple shoulder dislocations do not require consultation. If you do not feel comfortable treating this condition and are an Emergency Medicine physician, hang your head in shame.