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  • Performing the Perfect Inpatient Ophthalmology Consult

    Inpatient consults are a large part of residency training, and there is much to be learned by seeing these complex patients. In some programs, inpatient consults may be shouldered largely by junior residents. In other programs, consult responsibility may be shared by junior and senior residents. Regardless of how long you’ve been training, you’ll find these tips helpful when heading out to perform inpatient consults.

    1. Think Ahead

    Bring everything you need in your consult bag. In some training programs, residents may only have to perform consults at one hospital setting. In other programs, residents may be responsible for patients at multiple facilities. Ensure that your program invests in a large, ergonomic consult bag that you can easily bring with you to any location when seeing consults. Sometimes this can be a large backpack or a rolling suitcase. Every week, check and make sure that you have all of the necessary supplies in this bag. Never leave for a consult without anesthetic and dilating drops, a near vision acuity card, a tonopen with sufficient tonopen covers, fluorescein strips, a portable indirect headset and your lenses. The worst scenario is to arrive at a consult far from your outpatient clinic and not have the correct equipment.

    Think ahead and bring specialty equipment for the condition the consult might be for.

    For a patient with a possible corneal perforation or corneal ulcer, it is helpful to have an eyelid speculum, plenty of fluorescein strips, culture plates and culture swabs handy along with a portable slit lamp to optimally visualize the corneal surface.

    For a patient with a history of glaucoma who may have uncontrolled eye pressure, pack pressure-lowering drops in your consult bag to use if necessary.

    If a patient has signs concerning for a retrobulbar hemorrhage, be prepared with local anesthetic, surgical loupes and Stevens or Wescott scissors in case you need to perform an emergent canthotomy/cantholysis.

    When seeing a patient with possible optic nerve concerns, bring color plates to check for changes in color vision.

    2. Communicate respectfully with the consulting inpatient team.

    Ask the right questions. When an inpatient team calls you for an ophthalmology consult, always be respectful and ask appropriate questions. They are calling you for your ophthalmologic expertise, and it is important to triage every scenario and determine the best next steps. Always find out why they are asking for a consult, get a summary of the patient’s medical and ocular history and ask what the team knows about the patient’s current symptoms and vision. If the team doesn’t immediately know the answers to your questions, have them get back to you so you can better prepare. For instance, if a patient has a history of recent trauma and has not yet had orbital and head imaging, request this from the primary team before heading in so you can have that information to help better assess the patient.

    Make a timeline. It is also important to establish a clear timeline with the inpatient team. Depending on the severity of the case and the time sensitivity of the consult, you should let them know when you will be able to see this patient (e.g., within the next hour versus within the next few days) and set appropriate expectations. Some consults may be best suited for evaluation in the clinic setting. For instance, if a patient is seeking a new glasses prescription because they broke their glasses while in the hospital, it is appropriate to explain to the inpatient team why this patient would be better suited for a scheduled outpatient clinic appointment where a thorough refraction can be performed.

    Okay to dilate? When you’re ready to see the patient, always ask the consulting team if it is okay to dilate the patient, as dilation drops can last for several hours. This can be especially important for patients in the medical or surgical intensive care setting. For instance, a co-consulting neurosurgical team for a patient with recent intracranial surgery may have requested the nurses to perform pupil exams every few hours and dilating patients in this scenario for your eye exam can be disconcerting for the other team.

    If you’re performing consults on pediatric patients or in the neonatal intensive care unit, ask the inpatient team for support if extra sedation or help is needed when examining these patients to ensure you can perform a thorough exam.

    Provide an update. Lastly, once you have seen the patient, take an extra few minutes to personally update the medical and nursing team on your findings rather than just leaving a note in the medical record that may not be seen immediately. Let them know at what time you dilated the patient (if you did) and how long the effects will last so the nurses are not alarmed. Make a sign or write it on the whiteboard. Present your recommendations and let them know if you are starting any new ophthalmic medications and how often they should be administered.

    Other times, you may request that the inpatient team obtains additional consults (i.e., infectious disease) to help guide antimicrobial therapy management for an ophthalmic infection.

    If your patient will need surgical intervention, communicate clearly with the inpatient team that the patient needs to remain NPO after a certain time to ensure the patient gets to the OR on time.

    3. Be efficient with your time.

    It is not uncommon for you to be asked to see multiple consults within a short period of time. Your time (and sleep) is valuable, and you need to be strategic about how to tackle all of these consults. Do research beforehand on the patient and their reason for hospitalization as well as their medical and ocular history. Make a list of what equipment you need for each consult. Ask the inpatient team to obtain necessary imaging or have supplies ready for you at bedside if you need to perform an emergent procedure.

    Also prioritize your consults in order of severity and, sometimes, based on location, whether there are multiple consults at a given hospital. When seeing multiple patients in the same location, it is helpful to start with a patient who may be new to you, complete the initial exam and place dilating drops. While this patient is dilating, you can see some quicker or more established consult patients before returning to complete the dilated exam.

    4. Ask for help if you need it.

    If you think a patient is critically ill and needs subspeciality care, see if a senior resident, subspeciality fellow or attending can come with you to follow up on the patient. Other times, you can bring a patient to the clinic setting to be better examined by specialists and obtain any necessary imaging (i.e., a visual field, optical coherence tomography or slit-lamp photos) and then have them brought back to their inpatient ward for ongoing care.

    With time and persistence, all trainees will grow more comfortable with inpatient consults. Inpatient teams and your colleagues will always be willing to help, and you will learn so much from these patients.

    By following these strategies, you will certainly excel at your inpatient ophthalmology consults!

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    Nandini Venkateswaran, MDNandini Venkateswaran, MD, is a cataract, cornea and refractive surgery specialist at the Massachusetts Eye and Ear Infirmary in Waltham, MA. She is also a clinical instructor of ophthalmology at Harvard Medical School. She joined the YO Info editorial board in 2020.