Master of the House

Emergency Medicine programs have the most "off-service" rotations of any specialty, and emergency departments feature the most rotators from other specialties.

So it was not unusual for me, an EM resident rotating through Surgery, to receive a emergency consult from a medicine resident, rotating in the ED:

"An elderly man fell and broke his hip. Pain's under control, vitals stable, ortho will see him -- but what concerns me is his giant inguinal hernia. His scrotum is the size of a volleyball."

I came down to the ED to evaluate the hernia. It was indeed large, but nontender. The patient was too demented to tell me much about it, but a family member showed up and informed me he'd had the hernia for many years. Furthermore, he had no trouble eating, voiding, or ambulating.

As I presented the case to the surgery chief, he interrupted me and said, "This seems like an inappropriate consult. Who called it in? One of your colleagues?"

"Well, actually, a medicine resident."

The surgeon shook his head and said, "Loss of domain."

"Excuse me?" I asked.

"When that much bowel has relocated outside the abdomen, for so long, it'll never go back. It's called loss of domain."

"Oh, ok" I said. "I thought you were referring to the difficulty emergency programs have ensuring consistency, with so many rotators coming and going."

"Well, that too."