#I have an orthopedic consultation tomorrow….they will tell me what needs to be done…

[shima-draws]

I just gotta make it til tomorrow. I just gotta,, make it til. Til tomorrow. Tomorrow…

[aelaer]

First: welcome home & I hope you get the sleep you need to get back into your routines! Second: it's Feb. 2, a significant day to our beloved Stephen Strange. I know you're exhausted right now, and the timing is poor--but perhaps when you're up to, you could write a little one-shot about his feelings all these years later (is it 2022 or 2023?) on the anniversary of the accident that changed his life forever. Can't think of anyone better suited to write it! xx

This was sent a year ago but last month I planned to have it out for Feb 2nd, hah.

For canon, he comes back in 2023 in what I think was likely after Feb 2nd, so realistically he can address the anniversary again in 2024. It'd feel like only 3 years for him while, in actuality, it'd been 8. But when it comes to his experienced time versus actual passing time, Stephen's pretty messed up without the Decimation already (I'm not sure how I feel about the name of the "Blip" yet.)

The prompter also requested first person after I asked for more details, and I haven't ever written Stephen in first person so I thought I'd give it a go. I know first person isn't everyone's cup of tea, but if you're willing to give it a shot, call me very obliged.

Warning for canon compliance :P

——————

Staring Back In Time Rating: G (well, other than language)

An entry from the memoirs of Doctor Stephen Strange, Earth's Sorcerer Supreme, during his time as the Master of the New York Sanctum, several months after the Battle of Earth against Thanos:

February 2, 2024

Calendars don't mean as much as they used to. Once upon a time my life was ruled by the calendar. Consultation here, surgery there, society dinner over the weekend. Dates were important and generally set without change once marked down.

It doesn't work that way as a sorcerer. I keep a schedule, of course, one that marks down classes with apprentices and adepts and meetings with other Masters, never mind all the business outside of Kamar-Taj. But I learned early on that these set times shifted occasionally to accommodate the emergencies that the order often had to quash down, and it became obvious that as a Master, my schedule was more of a hopeful guideline than anything set in stone. Flexibility was a necessity.

Ever since my return to the living, keeping anything resembling a set schedule has been more of a laughable dream. Earth being the center of two universe-changing, Infinity Stone-powered events in a matter of hours did serious damage to the fabric woven about reality across the planet, and the Masters of the Mystic Arts are going to be dealing with the multidimensional repercussions for years to come. Nothing is predictable in my day-to-day anymore.

My relationship with time was fucked the moment I confronted Dormammu, so I can't say it's a large surprise that calendars have become mostly irrelevant.

If someone had told me that I, Doctor Stephen Strange, a man of order and precision, would learn to live with such unpredictability, I would have laughed in their face. But I'm not the man I once was (and thank God for that; that man was a dick). However, it's also because of this change that I didn't realize the day until it was nearly done.

I was reviewing my schedule for tomorrow, which I had set up on Google Calendar (Google had, naturally, survived the Decimation just fine, but like most other non-vital services, had many of their upcoming products delayed for years. But their email and calendar services continue to work great). Tomorrow's a Saturday, which means nothing in my world. My work continues on. The threats on our reality care little for weekends or holidays.

Still, it was only during this review, shortly before I planned to retire for the night, that I realized that today is February 2nd.

I won't ever forget the day, of course. It was both three years ago and eight years ago—or perhaps many lifetimes ago would be a more accurate description, though I lost track of time in both of my major journeys with the Time Stone. One day I'll write about them. Not now, but one day. Both memories are still too fresh.

The memory of the day of the accident, though? It feels both like yesterday and centuries ago. Some parts of the day are engraved in my memory like a film. I remember the last surgery down to the individual conversations. Christine's "thank you". Nick's watch. The cling of the bullet as I dropped it onto the tray.

I can remember my last conversation with Billy, too, in the car. Every damned word. But the drive itself is fuzzy, even in my head with my memory. I remember it began to rain during the drive, not beforehand, and I know the road was narrow and two-laned. I know I avoided a direct route to avoid traffic, driving first into Jersey before heading north and crossing the river again. But the rest is forgotten to time, or perhaps to trauma.

I was told that Billy was the first to call 9-1-1 as he heard the tearing of metal and shattering of glass before the connection was lost. The driver I hit—I learned much later that she escaped with only minor injuries—called a couple minutes later. But it was out in the mountains, dark, and raining. It took them hours to find me and extract me from the car.

Funny. Never thought I'd ever write about one of the worst days of my life like this. But I was told early on that personal journals were encouraged for all who stay in Kamar-Taj. Something about its therapeutic benefits was mentioned at some point. I only picked up the practice once I learned that each gifted journal was inaccessible to others until the time of their death, and after I mastered the art of enchanting a pen to write the words I spoke. Unfortunately this journal appeared to others after the Decimation, but Wong has reassured me that no one read it and it has since disappeared again from public view. 

Still, the point is that, one day, someone just might read this—account of a man who was part of an effort to save the universe. And it is difficult for a reader to judge my actions if they don't know how I was the one who ruined my life. My driving was reckless and stupid. I was running a little late, but it wouldn't have mattered in the long run had I been fifteen, twenty minutes, thirty minutes late. Not really.

Then again, I suppose it would have. I certainly wouldn't be here right now.

One could say that the accident and everything that has followed is some sort of penance for my hubris as a surgeon. I enjoy my newer abilities—quite a bit—but the responsibility that has come with them has not come without its own hardships and sacrifices. Perhaps the worst of the sacrifices were the ones I was unable to prevent others from performing, all for the sake of the universe.

Those sacrifices were made willingly, but I cannot help but feel responsible for them, regardless. 

During my first winter again returned to the living, when the days grew colder and my hands ached in the bad weather, and the only thoughts to accompany the pain were bitter, another thought was born. I was tempted, for the first time in a long time, to give it all up, restore my fine motor skills with channeled magic, and go back to the world I once knew, for a life much, much easier than this one is now. Even with all the troubles that had cropped up as people tried to reorganize a world that doubled in size overnight, it was miles away from the difficulties we were facing in Kamar-Taj.

Their sacrifices—the fates I pushed so many people towards—quelled the idea quickly. It did little to ease the physical pain or sting of guilt, but it lifted the temptation. And ever since that day, I have considered the situation and I don't think I will ever be tempted by the idea of giving up my duties for an easier, pain-free life again.

And I suppose that counts for something.

——————

(Hey look, my interest in geography's leaked again.)

I've always wondered where Stephen actually crashed mostly because New York City is *flat* and those mountains were *very much not flat*. I figured out the bridge that he crossed to get out of the city (there are like, 21 bridges that lead out of Manhattan) was the George Washington Bridge, and it leads to New Jersey—but that's not necessarily useful because it can quickly turn back into New York state if you turn north. We also know he crashed down into a body of water, which *might* be the Hudson, but also might not, but that the body of water is to his left, which narrows it down a bit. But again, not much. And the site of his crash is so dark in the videos and screenshots that I can barely tell what's on it. It looks like a bridge and some industrial building, so the Hudson's a good guess, but otherwise? Well, basically I turned on the topography part of Google maps and started searching.

The 202 on the east side of the river just north of Peekskill (again in New York) matches the movie road's windiness, height, and closeness to the river, and even has a bridge that could be just to the north of the crash site. Unfortunately the railing's off and there's no industrial building thingy by the bridge. It also makes the route out of the city via George Washington Bridge make no sense. Like the Stark Industries area in LA in the films, it's probably a completely fictional landscape.

But as I wasn't able to find a better locale that was still close enough to NYC to direct an emergency helicopter to, my headcanon for this scene is that he left via George Washington bridge to avoid some major traffic or something, crossed the river via the 287 a bit further up north to get back to the east side of the river, then went up the 9 to the 202. Unless someone who lives in the area can find the actual road he was driving (if it's real), this is what I'm gonna go with. (And if someone DOES please let me knowwwww). Funny enough, I don't see him getting led to *his* hospital totally unrealistic, because he'd need a very talented orthopedic surgeon with a specialty in hands to come in, and generally speaking a patient can be helicoptered to another hospital where such a surgeon is available. If Stephen is working at the Metro-General, it's likely they can afford a large cast of talented surgeons. So I don't think Nick was necessarily the lead surgeon in his case, just one of many necessary surgeons.

[inqyre]

Consult etiquette

July means new interns. Freshly minted MDs in crispy white coats disperse throughout the hospital. They pick up their list of five or ten or twenty patients, and proudly sign their names on the electronic medical record as the “responsible provider”. They are excited to type various orders in the computer, from q4 hr vitals, to rectal enemas, to daily renewal of restraints, because for the first time, they don’t need any body to co-sign them. With this infusion of positive energy, also comes a deluge of pages ringing on the waistline of everyone else. It seems like every patient under the care of an intern is getting consults to every specialty in the hospital. Of course I’m making overarching exaggerated statements, but it really seems that way.      

A friend of mine, who is in the last weeks of her fellowship thus soon to be attending, recently has been getting bombarded with inappropriate pages for non-urgent consults in the middle of the night. Being a responsible and the sole representative of her specialty at night, she promptly calls back the numbers on the pages. She then finds discombobulated and clueless interns at the other end of the line, not able to tell her any useful information about the patient, instead merely asking her to “please come see them”. Why are they calling the consult? Because it is on the “to-do” check list next to their evening sign out. Why are they calling in the middle of the night? Because they have to get all the items on the list ticked off by the morning. Thanks to the diligent interns compulsively engaged in scut work, dozens of specialist residents and fellows are losing faith in humanity from fragmented sleep. Am I implicating the loathed and no-longer politically correct sense of hierarchy in medicine? Yes, and take solace that my friend, soon, as an attending, will not need to answer every consult page herself. But I can just as well bring out the justice-for-all principles of efficient resource utilization, teamwork, shared medical decision making, patient-center care... all the good stuff that is supposed to make hospital a happier safer place. 

Whatever the labels I can slap on to justify my motivations, I feel an urge to spell out the previously implicit etiquettes on consults. Some of them are passed on to me from my senior residents when I was an intern. Some are told to me by specialists on the receiving end of my calls. Some are what I tell others when I became the specialist. Some are common sense. I will suggest that consult etiquette be a routine part of intern orientation. We have all been there, and there’s no need to keep making the same mistakes. My friend may be nice enough to still go see the patient after a vague consult request, but many will not, and may even harbor a negative image of the requester and care team, and write it up in a, god-forbid, safety report. 

So how can you sound competent, efficient, caring, and convincing on your consult calls? How can you not only get your point across but also make the consultant merrily jump to their feet to come help take care of your patient?

Know the basic info of your patient At minimum, you should have the patient name, medical record number, age, gender, and location (floor and bed) ready when you pick up the phone. Location is particularly important because you want your consultant to be able to find the right patient. Know why your patient is in the hospital. What are they admitted for? How sick are they?

Have a good reason for the consult.  Consultants work the best on solving well-defined, singular problems. They are not good at embarking on an exploratory intellectual journal with you. Formulate your consult into a short, simple question that is not “Can you come see them?” Instead ask, “What antibiotics is best to treat this multi-drug resistant infection?”, “Does this patient need dialysis?”, “Why is this patient thrombocytopenic?”, “How should I adjust the insulin pump?”, “What tests do I need to stage this cancer?”. If you are consulting a proceduralist, have a procedure in mind that you want them to do. The proceduralist may have their own opinions about the type and indication of the procedure to be performed, but they will gladly come assess the patient and determine for themselves. The most frustrating consult requests are to “help manage” common chronic conditions like hypertension, COPD, diabetes, and osteomyelitis. There isn’t really a yes/no question or a definitive answer the consultant can give for the patient, and the consultant is stuck with the patient for the rest of the hospitalization. They may enjoy billing for the two-line note on the patient every morning, but most of the time, they’d rather see the patient dropped of their long list. 

Do you homework and give data to back up your reason for consult.  If you ask a consultant to help you with a problem, they will frequently ask back what have you done toward finding a solution. Don’t ask general surgery to do an appendectomy on a patient with right lower quadrant pain without an ultrasound or CT scan to show enlarged appendix. Don’t ask hematology to work up anemia before you’ve ordered a smear. Worse yet, don’t call a consultant before you’ve personally laid eyes on the patient and done a thorough history and physical. 

Make sure you are calling the correct specialty.  With the way medicine is becoming, hyper-specialization in inevitable. So everyone has their turfs and boundaries. This has several implications. First, there might be multiple consult teams in a department. Don’t call the thyroid pager for diabetes, even though both are endocrinology. Don’t call the chronic pain pager for acute pain, even tough both are anesthesiology. Second, some body parts are shared between departments. Facial trauma may be split between plastics, oromaxillofacial, and ENT. Spine may be alternating between orthopedics and neurosurgery. Double check you are calling the department covering the body part that day. Third, know what your patient’s problem is and which specialty will treat that problem. The other day a woman came in vomiting blood and the emergency room resident reflexively called GI. It turns out she was throwing up blood because she was in DIC from a retained product one day after an unsuccessful abortion. A few routine history questions and blood tests would have clarified the source of her problem and gotten her to an OB several hours sooner. Calling the wrong consult can actually mean life and death. 

Don’t consult a specialist for things you can do yourself.  Associated with the hyper-specialization phenomenon is that physicians have become less and less confident about managing things outside of their silo across the board. This translates to generalists not being confident about anything at all. We forget the purpose of the grilling in med school and internship is to make us comfortable managing, or at least initiate the management of, the common ailments. You don’t need a cardiologist to treat hypertension, a pulmonologist to treat COPD exacerbation, a neurologist to work up a headache, or a psychiatrist to evaluate the patient’s decision-making capacity. I know we are all defensive and afraid that we might miss something. But why do we exist at all if our purpose is to make phone calls all day? Don’t call a consult for “help with diagnosis and management” until you have exhausted your own knowledge base. The consultants really have better things to do. 

Don’t call non-urgent consults at night.  What is urgent? Ask yourself, is the patient dying? Is the patient losing a limb? Is the patient going to deteriorate to the point of dying or losing a limb in the next 6 hours if not seeing by this specialist? If the answer is no, wait until the morning. Don’t send a page to “just get this patient on the list for tomorrow”. Teams change and there is no guarantee the groggy and irritated night consultant will pass the info onto the day consultant. Along the same line, all non-urgent consults should be paged between 8am and 3pm. No one wants to receive a new consult at 5pm, because it means staying late to see the patient, or burden the night team with unnecessary work that should have been done during the day. Also don’t send a page during the shift-change hours. It will increase the likelihood of your page bring lost and never returned. 

For truly urgent consults, clearly communicate the need.  The key to do this well is to know the trigger words for the specialty you are consulting. For neurosurgery, it might be things like “expanding subdural hematoma” or “new motor deficits”. For orthopedics, say “open fracture” or “degloving injury”. If you really need a cardiologist to come treat hypertension for you in the middle of the night, you might want to mention “acute ischemia from increased afterload”, “uncontrolled rhythm”, or “pending heart failure”.  Usually “hemodynamic instability” grabs most people’s attention, but you may be asked what are you doing to stabilize the patient, and why are you not calling a code. 

On an optimistic note, I’m going to reframe the scut work of calling consults into an exercise of interdisciplinary communication and learning opportunity to collectively generate the best plan for patient care. Responsible consult practices, we can make it happen.