OMAHA, NE – Earlier today on an inpatient medical/surgical floor at Nebraska Medical Center, a confusing series of events in the care of hospitalized patient Josh Ledbury finally culminated in the biggest head-scratcher of them all when Medicine was consulted by Orthopedics to aid in management of the same Medicine patient.
“I’m really confused,” commented Dr. Claire Underwood of Medicine. “Really… really… confused.”
Two days ago, the 52-year-old Ledbury, who has a history of CAD and right total knee replacement in 2007, was hospitalized for further evaluation of fevers, chills, right knee pain, and difficulty ambulating. On exam, the patient had a hot and red right knee, an effusion, limited range-of-motion, and tremendous pain on flexion. Dr. Underwood of Medicine admitted the patient and consulted Orthopedics “to aid in management of suspected septic arthritis.” Empiric vancomycin was started.
“It’s certainly suspicious for hardware infection,” said Orthopedic surgeon Jake Tammany to Dr. Underwood. “Let’s get ID on board.” Infectious Diseases (ID) was promptly consulted and recommended right knee incision and drainage (I&D) with consideration of hardware removal. Orthopedics agreed.
“Looks like surgery is a strong possibility,” acknowledged Dr. Tammany. “I do worry about his CAD, newly-diagnosed since his last knee operation. Let’s get Cards on board.”
Cardiology was consulted and stated there was no further diagnostic testing or therapeutic interventions recommended and Orthopedics may proceed with surgery if needed.
At 3 o’clock yesterday morning, Dr. Tammany tried to consent Ledbury for right knee surgery when he found him completely disoriented. Worried about his mental status, Orthopedics recommended a Medicine consult and Psychiatry to aid with delirium and evaluation for medical decision-making capacity. Yesterday afternoon, Psychiatry felt the patient was appropriate but did recommend ruling out all other causes for delirium. Dr. Tammany played it safe and consulted Neurology, Cardiology again, Pulmonology, Infectious Diseases again, Endocrine, Rheumatology, and Hematology/Oncology.
All other causes were ruled out.
At 6 o’clock this morning, Dr. Tammany was concerned about the patient’s markedly elevated blood pressure of 178/80, tachycardia to 110, fever spiking to 38.6, and elevated white blood cell count of 14.2. Concerned for Ledbury’s well being, Dr. Tammany called and consulted Dr. Underwood of Medicine for “medical management.”
“What do you mean?” asked a confused Dr. Underwood of Medicine. “We’re already following, it’s our patient.”
“I know, you admitted the patient,” acknowledged Dr. Tammany of Orthopedics. “But are you consulting?”
“I’m not consulting because I’m the primary,” responded Dr. Underwood.
“Right, you’re not consulting,” replied Dr. Tammany. “You consulted me for septic arthritis and I’m happy to help. It’s only fair I consult you for medical management.”
“Let me get this straight,” said a flustered Dr. Underwood, trying to understand. “You want me to consult on a patient for whom I’m the primary?”
“Yes,” said Dr. Tammany. “I want to be sure you’re on board.”
“Would you like me to consult on my patient or another Medicine team to consult on my patient?” asked Dr. Underwood.
“I will defer to you,” said Dr. Tammany. “I’m not the primary.”
Dr. Underwood found herself flummoxed. Thinking Dr. Tammany was right and maybe she was the one that was crazy, she abided by Orthopedics wishes and consulted herself and a Medicine colleague on Ledbury’s care. When blood cultures came back positive for MRSA, Dr. Underwood insisted that ID consult Infectious Diseases and perhaps Pharmacokinetics as well. Pharmacokinetics recommended consulting Orthopedics and perhaps PT and OT.
Ledbury continues to slowly improve and is thankful for the care provided by all teams involved.
Tomorrow, Dr. Underwood plans to consult Orthopedics to evaluate for possible surgical intervention and, if needed, she may ask Orthopedics to consult Orthopedics for possible surgical intervention. It is likely that Medicine, Medicine, Orthopedics, and Orthopedics will consult Cardiology a third time and Otolaryngology a first time. PT and OT plan to consult themselves post-operatively unless Radiology beats them to it. In the meantime, Nutrition and Dermatology eagerly wait to be consulted by Pastoral Care.