The Nightmare

It is a dark and stormy Friday night, been busier than usual. While hustling between two traumas that recently came rushing in, you get word that a new GI case just got put in a room. When you get to the room, you meet a very pleasant man and his wife.

He is 68 and presenting with three days of worsening crampy abdominal pain. The pain localizes to the left lower quadrant. He feels nauseated but denies vomiting. He had a small stool a few days ago but denies any bowel movements since.

On examination, he has a low-grade temperature, with vitals otherwise stable. The physical exam is otherwise remarkable only for a mildly distended abdomen, hypoactive bowel sounds, and marked left lower quadrant tenderness with voluntary guarding. Stool is negative for occult blood. Labs show a white blood cell count of 12,300, with no left shift. A plain film shows no pneumoperitoneum and … nothing else.

You suspect a case of acute diverticulitis and begin the appropriate therapy of IV hydration, NPO, and antibiotics. Later, his CT scan confirms a pericolic abscess.

It’s time for emergent surgical intervention—time for a consult. How can you present the information to the consulting physician in a way that concisely and effectively reflects all the important details of this patient’s situation in order to achieve the best possible outcome?

Introducing the 7 C’s: your way to ensure smooth sailing through all your consults:

1. Contact: Introduce consulting and consultant physicians. Build relationship.

You greet the consultant by deftly stating your name, rank, and service. In his response, you learn his name is Frank. If you’re a resident, you then identify his supervising attending. All of this serves as a quick and cordial introduction to help build the relationship.

2. Communication: Give a concise story and ask focused questions.

You present a succinct recounting of the patient’s ED stay and speak clearly about pertinent past medical history, symptoms, and progression since IV fluids, NPO status, and antibiotics were started. You clearly identify the case as diverticulitis with associated pericolic abscess.

3. Core Question: Have a specific question or request of the consultant. Decide on a reasonable timeframe for consultation.

Given this situation, you discuss the need for admission and surgical intervention.

4. Confidence: Express confidence in the proposed diagnosis and explain the logic of the differential diagnosis and/or diagnostic criteria.

Concisely walk the consultant through a brief summary of the evaluation, building your case.

5. Urgen“C”y: Indicate the patient’s acuity level and how quickly the consultant should come and evaluate the patient.

Be clear about what your asking for, what your expectation is, and why.

6. Collaboration: After the discussion with the consultant, decide together a course of action, including any alteration of management or testing.

Entertain any reasonable requests of the consultant (eg, an additional lab order).

7. Close the Loop: Ensure that both parties are on the same page regarding the plan and maintain proper communication about any changes in the patient’s status.

We cannot direct the wind, but we can adjust the sails.
—Bertha Calloway

No matter how rough the waters of a consult appear, just follow the 7 C’s and your sailing will be smooth. Good luck!

Mr. Tsipis is a 2015 MD/MPH candidate at Duke University School of Medicine in in Durham, North Carolina. Dr. Kessler is deputy chief of staff at Durham VA Medical Center and associate professor of emergency medicine and internal medicine at Duke University School of Medicine.