Acute Pain Service pain

One of the best things about anesthesia is being a permanent consultant.  Apart from those who choose to subspecialize in chronic pain management or critical care, anesthesiologists generally sign on for the duration of a case, do their job, and sign off.  We typically do day-after-surgery postop checks on inpatients, but otherwise we don't round on patients or follow them past their surgeries.

A notable exception to this rule is the Acute Pain Service.  Lots of hospitals don't have APS, but in those that do the anesthesiologists can be consulted for patients with difficult-to-manage acute or chronic pain.  APS will evaluate those patients, write notes with their recommendations for pain management regimens, and generally also write orders for those patients' pain medications.  It's a nice service to have around, but as with many luxuries, it is sometimes abused.

There is one service in particular that seems to abuse APS more than the others.  This service -- we'll call it "Shmorthopedics" -- often comes up with flimsy excuses for consulting APS.  When I rotated on APS as a CA-1, I had several conversations that went more or less thusly:

Me: "Hi, this is APS returning a page."

Shmortho: "Hi, I'm calling to consult you on patient X.  He/she is having pain after having (insert shmortho procedure here)."

Me: "OK, what have you guys tried so far?"

Shmortho: "We gave him a couple Percocet and 1 milligram of morphine, and he's still having pain."

Me: "..."

Shmortho: "Anyway, we'd like your input."

Me: "..."

Shmortho: "Are you there?"

Me: "You gave him two Percocet and a milligram of morphine, and now you're calling me?"

Shmortho: "We're just not comfortable giving him more narcotics."

Me: "Tell you what, I'm going to give you some over-the-phone recommendations.  Give them a try, then call me again if they don't get his pain under control."

I'd give them some very basic recommendations, then never hear from them again.

Another disturbingly common conversation I had with Shmortho went like this:

Me: "Hi, this is APS returning a page."

Shmortho: "Hi, I've got four patients I'd like you to see."

Me: "You're consulting me on four patients at once?"

Shmortho: "Well, I'd just like you to help us optimize their medications."

Me: "OK, tell me about the first one."

Shmortho: "It's patient X, who had (insert shmorthopedic procedure here)."

Me: "OK, I've pulled him up in the computer.  It looks like you've already put in a discharge order for him."

Shmortho: "Yeah, we're discharging him this morning.  Can you help us streamline his meds?"

Me: "No, I can't.  APS is a service for inpatient consultations, not outpatient ones."

Shmortho: "He's an inpatient!"

Me: "No, this discharge order is timestamped two hours ago.  He's probably in his street clothes, has his IV out, and is on his way out the door.  He's an outpatient."

Shmortho: "You need to see him, we're consulting you for medication optimization!"

Me: "Look, clearly you have him on a medication regimen that's controlling his pain, otherwise you wouldn't be discharging him.  Do you really want me to mess with it right as he goes out the door?"

Shmortho: "So you can't help us?"

Me: "Let me phrase it this way: Do you really want to be paged at 3am when he's in Emergency screaming in pain because we messed up an effective pain management regimen?"

Shmortho: "..."

Me: "I thought not.  Are your other three consults in the same boat?"

Shmortho: "Yes."

Me: "OK, my answer for all of them remains the same.  Call me if you need help with someone who will be in-house at least overnight."

Sadly, I had these two conversations at least twice a week.  It's like banging your head into a wall again...and again...and again...