My pager is going off again. It’s every five minutes, or so it seems. I’m on call as an infectious disease (ID) fellow, a position I’ve held since July 5.
For the most part, the pages fall into three categories: new consult requests, “curbside” consults (which are, in theory, brief discussions without the benefit of background research), and requests for approval of a restricted antibiotic. Just a few weeks ago, I was the one paging the ID fellow, but now the tables have turned.
The new consult may seem pretty straightforward at the start, but it has its own permutations. While there are few true ID emergencies, meningitis, malaria (let’s add babesia, too) and necrotizing fasciitis are the ones that will bring an ID fellow to the hospital at any hour of the day.
New consult type II might be a question on appropriate antibiotic choice and duration of treatment in a patient with osteomyelitis, or infection of the bone. These pages are generally pretty straightforward, though they can often have layers of complication, including patient baseline renal or liver function, allergies or comorbidities.
Much of the work involves gathering an extensive history and sifting through a great deal of data. For example, I recently was consulted on a patient who had a chronically infected prosthetic hip, which had been removed, replaced and removed again on multiple occasions. It had been infected with multiple different organisms over the course of more than 14 years. While the most recent data was the most relevant, a lengthy history of infection such as this takes a great deal of time to review.
Ahh, the curbside. Fraught with peril. The text page starts, “just wanted to curbside you on pt with ESBL E. coli bacteremia who we want to send home today.”
My first step is to look up the patient record and do a quick “chart biopsy.” When I return the page, my goal is to first determine if this is, indeed, appropriate for a curbside or if this should be a full consult.
In a recent example, I was curbsided about a patient being treated for metastatic ovarian cancer who had been admitted after blood cultures were growing what appeared to be a contaminant. The team wanted to know what they should do about it. Reading through the patient’s chart, I saw that the blood cultures had been taken from both her chemo port (an indwelling central venous catheter, which can provide a nice home for bacteria to establish an infection) and from a peripheral draw. Sure, it might be possible that both samples were contaminated, but I would be more reassured of contamination if the culture only grew from the peripheral. With the available data, my suspicion of a true infection and not just contamination was raised. I called back the covering intern to address the case. As we discussed the issue of a potentially infected port-a-cath, the curbside turned into a consult.
Factors that make me think a curbside should be a full consult include the type of organisms that have grown, patient factors such as existence of hardware or indwelling lines, the type of antibiotics that might be used, and the duration of treatment. Since it is early in the year, if I have any qualms or hesitation, I run the case by my attending.
This can be the bane of an ID fellow’s existence. Until a predetermined hour of the night, around 8 p.m., after which any physician can give whatever restricted antibiotic he or she thinks appropriate, an ID fellow has to approve all antibiotics that are restricted. In these situations, you call back the requesting physician and discuss the case, determining why that particular antibiotic is needed. In some cases, it is obvious—it is the only drug that will treat the organism or the patient has an allergy to the alternative therapy. In other cases, I may be able to convince the physician that the restricted antibiotic he wants is not the right one for his patient. On a few occasions, these requests for antibiotic approval turn into full consults because the underlying illness is complicated and warrants a full evaluation.
The learning curve in a fellowship is steep. In addition to all the formal teaching conferences, the amount of information not only from consults but from curbsides and antibiotic approval questions is tremendous. I have learned in this short period of time that most questions are not that straightforward. But, of course, that’s probably why they arose in the first place.
Erica Seiguer Shenoy, MD–PhD ’07, is a fellow in infectious diseases at Massachusetts General Hospital and Brigham and Women’s Hospital.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
Note: Although “curbside consultations” are common practice in every specialty and among primary care providers, they raise certain medico-legal issues. CRICO/RMF, the patient safety and medical malpractice company that serves Harvard-affiliated hospitals, cautions: “Complex questions that require time and consideration of multiple factors are best left to formal consultation.” Guidelines on curbside consultations are downloadable from the CRICO/RMF website.
