IM docs as ER docs

[Apollyon]

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please..in the real world the EM guys are looking to see how fast they can dispo the pt out of the ED...which doesn't mean that they actually touch a patient to do so...if they are old and "dwindly" they get admitted...heck if they are just old it will get them admitted...if their SCr is 4.2 when the baseline is 4.1, they get admitted...

...and i have NEVER seen an EM resident at a code...even in the CT scanner next to the ED...

Again, in the ivory tower. Your abusive invective notwithstanding, I doubt that you can speak of community EDs. Again, that is the VAST majority. You are taking your narrow, academic experience, and painting a whole group with it. You see what you want to see. Your outright statement that "we" don't touch patients is, frankly, offensive. What, you're at every bedside? And, just because you've never seen an EM resident at a code, that makes your experience de facto? Again, you can't extrapolate. I wonder, if you go to a secondary or tertiary care hospital (if you even do, as an endocrinologist - you can have a completely outpatient practice), will you be so shrill and dismissive?

 

[Siggy]

Dude, once you get into the real world, and out of the residency bubble, you'll see that, often, especially in the 90% of American hospitals that are community hospitals, where there are no residents, overnight, the emergency physician is the only doctor in the hospital (like I am right now). When I was a resident, we went to all first floor and lower codes, including in radiology. The IM guys were second floor and higher. Our relationships with IM sounded MUCH more collegial than all of the burning going on in here. In fact, just as a point, my program director was asked by the IM program director to stop working patients up so completely, because that was leaving his residents with nothing to do but chase labs and write notes. All the fun was gone, because we were taking it. Hell, I got a ceruloplasmin level (resulted) on a Sunday night!

...and to defend myself, I never took shots at EM for lack of a workup that didn't involve things that directly affected patient care in the ED. I don't expect the ED to do my work for me and will actively defend them when others do take shots.

What happens in your hospital is local; it likely can't - across the board - be extrapolated globally. In the community? Hospitalists are comfortable working floor codes. The admitting PMDs? Not so much. Where I am now, there is one IM doc that works ~2 shifts a month in the ED, and he is HORRIBLE: he knows NOTHING about Ob/Gyn, peds (he did a CT on a 3 WEEK old), or trauma, and is also culture-bound beyond that. He can't intubate, do an LP, or put in a chest tube. He WON'T do a pelvic. And he refuses to learn.

...and I also already posted in defense of EM that they get training in fields outside of medicine (as mentioned, trauma, surgery, peds, OB/Gyn). I can't comment on why he won't intubate, do an LP, chest tube, or pelvic. Hospital based internists (especially any that cover the ED) should be able to intubate, LP and do a pelvic since those should be learned through the normal course of an IM residency. If the choice is made to cover the ED, then an effort should be made to learn how to do a chest tube as well. Just because an ED isn't a trauma center doesn't mean that traumas won't find there way there.

So, outside the ivory tower of residency, and outside the upper floors of IM subspecialty, in the real world, people aren't so at each other's throats. And I go to the upstairs codes.

So I shouldn't defend IM when an EM resident comes in and says essentially, "All ya'll suck and can't do your job when it comes to working up medical emergencies"? Because that's essentially what Daedalus and Times did. Would we be having this conversation about how EM is better at trauma resuscitations than a trauma surgeon? Would we be having this conversation about how EM is better at OB/Gyn emergencies than an OB/Gyn? Probably not... but because it's a medical emergency, it's time to dump on internists.


I'll reiterate what I said before. EM is needed not because they are the best at any one thing. They're needed because the people who are best at each thing (IM and medicine, surgeons and trauma, OB/Gyn and OB/Gyn, pediatricians and pediatrics) are useless at all of the other things needed to be an EMP.

I also stand by my kickoff return man analogy when it comes to the expected workup from the ED.

 

[Apollyon]

I also stand by my kickoff return man analogy when it comes to the expected workup from the ED.

Actually, the analogy I use is that I tee off. I just have to stay on the fairway. I get it on the green. Then, someone else comes in to putt. Sometimes, I hole out, but, usually, I just need to stay in bounds. We're all on the same team, though.

 

[Siggy]

please..in the real world the EM guys are looking to see how fast they can dispo the pt out of the ED...which doesn't mean that they actually touch a patient to do so...if they are old and "dwindly" they get admitted...heck if they are just old it will get them admitted...if their SCr is 4.2 when the baseline is 4.1, they get admitted...

...and i have NEVER seen an EM resident at a code...even in the CT scanner next to the ED...

So, I reiterate my comment earlier (post 18)... you're upset that the ED isn't doing your job for you? If there's literally no reason to admit, then it should be blocked (again, especially at night, it's likely not worth it). It's also why I don't like the ED doing bridge orders (99% of the time I get the call, review the chart, and put in basic orders immediately). I've had a PA think that an otherwise healthy 80 year old needed to be tele "because he's old." Now if I want to take 40 minutes to put in orders, then I don't get to complain about bridge orders. My hospital's ED is good at not bridging patients who are on the ICU/Tele threshold, but those are a different case where it makes sense to delay admit orders.

 

[Siggy]

Actually, the analogy I use is that I tee off. I just have to stay on the fairway. I get it on the green. Then, someone else comes in to putt. Sometimes, I hole out, but, usually, I just need to stay in bounds. We're all on the same team, though.

To be fair to EM... EM normally holes out 70-80% of the time (discharge from ED).

 

[emergentmd]

Ahhhhhhh... the bashing of the ED docs. I love it. The ignorance is telling. The envy is telling.

Docs, esp IM docs, who trash ED work ups and our care are like the half ******ed lazy welfare recipient sitting in front of their TV. They see a few plane crashes and they start to spew out How dangerous air flight is and major reform is needed even though its still the safest way to travel. Or riot when they see a few bad cops eventhough 99.9% does a great job.

They don't see the 99.9% of the great care I give, the appropriate pts I discharge. But that one pt where they disagree with my plan/workup, they start to generalize how poor all ED docs/workups are. No different than the ******ed lazy welfare recipient.

 

[Siggy]

[snip]like the half ******ed lazy welfare recipient sitting in front of their TV. They see a few plane crashes and they start to spew out How dangerous air flight is and major reform is needed even though its still the safest way to travel. Or riot when they see a few bad cops eventhough 99.9% does a great job..[snip]

Let me know when you get out of grade school because the only time I see people throw out ad hominem attacks are those who either lack a point, or lack the education necessary to make a proper, intelligent, and polite reply. I have no need to let you drag me into the muck with such trite drivel.

 

[deleted547339]

I never bashed IM, in fact I did quite the opposite. Read my posts.

All I said was that IM being the expert of medical emergencies is comical. This is what the entire field of EM is based around. If you think training in general adult medicine is better training in medical emergencies than an EM residency, you don't understand either of our training curriculums. A program that is set up to simultaneously prepare someone to practice or pursue further training as a outpatient practitioner, endocrinologist, hospitalist, palliative care doc, cardiologist, rheumatologist, etc does not provide better training in medical emergencies than someone who spends all of their time in medical emergencies. It's just a silly statement. I love my internest buddies and I appreciate their care and knowledge base greatly, but they're not emergency docs.

 

[emergentmd]

This typical IM dribble comes around all of the time. It pops up every time an IM doc has a bad day. They go home, whine and complain. No personal attack. Just the typical IM childish whinny complaint about ED docs when they have a bad admit/workup and generalize to 90% of ED docs like this thread.

Again, no different than the ****** at home who thinks all cops are bad b/c a few made poor judgements.

Its funny that these threads pops up all the time but I never hear an IM mouth off the same to an ED attending face to face.

No different than the whining I hear all the time about every other specialty from IM.

"Why doesn't the XXXX specialist" admit their own patient
"Why is this pt a direct admit from the clinic when they could deal with it themselves"
"Why did that specialist send the pt to the ED'
"Why can't Ortho take care of the pts diabetes"

IM hospitalists must be the most miserable people. No other specialist complain so much about every specialty.... trust me its not Just ED.

 

[rokshana]

Again, in the ivory tower. Your abusive invective notwithstanding, I doubt that you can speak of community EDs. Again, that is the VAST majority. You are taking your narrow, academic experience, and painting a whole group with it. You see what you want to see. Your outright statement that "we" don't touch patients is, frankly, offensive. What, you're at every bedside? And, just because you've never seen an EM resident at a code, that makes your experience de facto? Again, you can't extrapolate. I wonder, if you go to a secondary or tertiary care hospital (if you even do, as an endocrinologist - you can have a completely outpatient practice), will you be so shrill and dismissive?

worked as a hospitalist in between residency and fellowship...in a community hospital in southwest va as well as central pa as well as urban academic in philly (those in philly know where i'm talking about) so my experience is a bit cross sectional...and sure there are good guys in the ED(who I rarely heard from for admission and when i did, never questioned those admissions) but there are, unfortunately, more often than not, those who just want to get the pt "out of MY ED" (quote from a ED resident)...and its EM training that is to blame here...they put an emphasis on trying to see who can have the most pts going at the same time, and not passing anyone on to the next shift more than trying to get them well enough to d/c from the ED...if the ED was dinged for every admission that turned out not to qualify for inpt admission, you would probably see a change in what actually is called from the ED for an admission (and if the CDU was run by the ED and not the hospitalist, there would be a lot less Obs admissions as well).

and BTW as endo there is inpt as well...what? you have never consulted endo for what you think is adrenal crisis or myxedema coma?

and God no...when you are the attending, you welcome the"really? I can't believe they are consulting for this?" because its easy peasy money...but it doesn't change my opinion...

 

[emergentmd]

Let me know when you get out of grade school because the only time I see people throw out ad hominem attacks are those who either lack a point, or lack the education necessary to make a proper, intelligent, and polite reply. I have no need to let you drag me into the muck with such trite drivel.

I am not even directing this at anything you said. Its the other dribble on the 1st page. I have great relationship with all specialists/IM docs. I get that they hate the social admits or soft admits. But this is EM medicine. Not all admits are slam dunks. There are times when I admit old granny who is weak and the family wont take her home. What am I supposed to do with her if the family wont take her home? Wheel her outside the ED and throw her to the curb?

I get the social admits and soft admits sucks, but if you really do not think they need admissions then come down/see the pt/and discharge them. I am fine with this.

 

[rokshana]

Its funny that these threads pops up all the time but I never hear an IM mouth off the same to an ED attending face to face.
.

no...i would just tell the pt that they did not need to be admitted and discharge them from the ED... and then told the ED attending

 

[rokshana]

I get the social admits and soft admits sucks, but if you really do not think they need admissions then come down/see the pt/and discharge them. I am fine with this.

these are not the admissions that are an issue...ED doc pages and say, sorry, i have a papa, mama, nursing home dump and its a purely social admit...no problem, they do suck, but what are you gonna do...it is what it is...but don't try to tell me that there is a real reason it admit...it makes you look either lazy that you can't figure it out, or too stupid to know the difference.

 

[Siggy]

I am not even directing this at anything you said. Its the other dribble on the 1st page. I have great relationship with all specialists/IM docs. I get that they hate the social admits or soft admits. But this is EM medicine. Not all admits are slam dunks. There are times when I admit old granny who is weak and the family wont take her home. What am I supposed to do with her if the family wont take her home? Wheel her outside the ED and throw her to the curb?

I get the social admits and soft admits sucks, but if you really do not think they need admissions then come down/see the pt/and discharge them. I am fine with this.

Ok... sorry for snapping back. I agree with you on the drivel.

Also, unlike a lot of my fellow residents, I don't give the ED crap for social admits. Yep, it sucks that we're admitting the drunk until they sleep it off. Yep, it's a lot of useless work. Yep, it would be better half the time if they spent the night in jail. That's not going to happen and the patient can't stay in the ED. At most, and with a smile on my face, I'll tell the ED attending, "Thank you for this interesting consult" (and to be clear, everyone knows it's a BS patient for both the ED and the inpatient team and not a slight against the ED).

 

[emergentmd]

no...i would just tell the pt that they did not need to be admitted and discharge them from the ED... and then told the ED attending

I can tell you in the 15 yrs, I can count on 1 hand the number of pts I wanted to admit where an internist came/saw the pt/and discharged them from the ED. I would put the number at about 2 pts in 15 yrs. Maybe you are just a much better clinician than all of the other internist that I have worked with.

 

[Apollyon]

and BTW as endo there is inpt as well...what? you have never consulted endo for what you think is adrenal crisis or myxedema coma?

From the ED? Never. Hell, when I was a resident, I never called endocrine (and I was at one of the highest ivory towers in the country). Those patients went to the unit, and IM consulted endocrine from there. That was just how the system worked. The most recent places I've worked didn't even have endocrine, so there's no one to call.

 

[Siggy]

Myxedema coma? You give IV synthroid... more IV synthroid... and some more IV synthroid (there's no evidence, unless some new ground breaking study has been released, that there's a difference in outcome between T4, T3, and T4/3 combined medications), and you pray.

Adrenal crisis? Fluids, fluids, fluids, solu-cortef.

The three IM specialties without an emergency consult: endocrine (any decent IM hospitalist or critical care doc should be able to stabilize), derm (transfer to burn center), and rheum (someone else can link the Gomerblog rheum consult story).

 

[rokshana]

From the ED? Never. Hell, when I was a resident, I never called endocrine (and I was at one of the highest ivory towers in the country). Those patients went to the unit, and IM consulted endocrine from there. That was just how the system worked. The most recent places I've worked didn't even have endocrine, so there's no one to call.

just because you don't do it, doesn't mean your brethren doesn't...and key word is think...generally wasn't either...

 

[Apollyon]

just because you don't do it, doesn't mean your brethren doesn't...and key word is think...generally wasn't either...

Seriously? You asked a direct question, and I gave you a direct answer. Are you honestly saying you routinely get consulted to the ED? And I honestly don't understand what you mean with "think" in italics, and what "generally wasn't either" means.

 

[ERDude]

For an alternative perspective (from a community ER doc 5 yrs out of residency): In my experience most docs are much more collegial than is demonstrated in this thread. We have a great relationship with our hospitalists and there is mutual respect.

And having a *****y attitude as a resident can often fly (and is probably tolerated more in academia in general) but will likely limit your success in most community hospitals (exception being if you are a very high value procedurally based specialist b/c they bring in tons of $$$ for the hospital).

Also it's important to have thick skin and not be overly defensive. If somebody who doesn't understand your job tries to tell you how to do your job (assuming their advice is off base or unhelpful) say "thanks for the input", ensure the patient is getting appropriate care, and move on.

 

[IMreshopeful]

This typical IM dribble comes around all of the time. It pops up every time an IM doc has a bad day. They go home, whine and complain. No personal attack. Just the typical IM childish whinny complaint about ED docs when they have a bad admit/workup and generalize to 90% of ED docs like this thread.

Again, no different than the ****** at home who thinks all cops are bad b/c a few made poor judgements.

Its funny that these threads pops up all the time but I never hear an IM mouth off the same to an ED attending face to face.

No different than the whining I hear all the time about every other specialty from IM.

"Why doesn't the XXXX specialist" admit their own patient
"Why is this pt a direct admit from the clinic when they could deal with it themselves"
"Why did that specialist send the pt to the ED'
"Why can't Ortho take care of the pts diabetes"

IM hospitalists must be the most miserable people. No other specialist complain so much about every specialty.... trust me its not Just ED.

This isn't misery. This is just complaining. Every specialty in the hospital complains about the ED, but IM tends to be more vocal about it outwardly (at least online or from the resident realm). Every medical specialty, INCLUDING EM, complains about other specialists - the number of times I've heard EM doctors bitching about how the IM resident wanted him to order more labs or get an extra CT (whether or not it was warranted), the Ortho doc who bitched about the IM doc not immediately coming to see the consult on his patient with a BP of 140/80 having 10/10 pain, etc, the gen surgeon bitching about anesthesia, etc. So the idea complaining is somehow only the domain of IM is ridiculous.

I hope this wasn't specifically directed to me in the first place, as my only contention is with the fact that some EM residents become immensely jaded post residency and their workups become extremely cursory ("this patient is old and has chest pain, therefore needs to be admitted, but the troponin is still pending and we haven't given them nitrates or aspirin yet"). And to some extent it has to do with patient satisfaction, fear of litigation, and need to keep down wait times to keep the hospital administration happy, not the doctors involved.

I respect fully that ED training is entirely to deal with emergencies (never mind the fact that the bulk of EM is not real emergencies). However, you can't say that some of the examples listed previously weren't hugely egregious. No need to be calling anyone a "******" over it.

 

[IMreshopeful]

From the ED? Never. Hell, when I was a resident, I never called endocrine (and I was at one of the highest ivory towers in the country). Those patients went to the unit, and IM consulted endocrine from there. That was just how the system worked. The most recent places I've worked didn't even have endocrine, so there's no one to call.

I'm going to have to agree on this one. Even as an inpatient I've only consulted for either academic reasons (i.e. newly diagnosed T1DM for more specialized patient education and fellow exposure) or if we were swamped and had patients with heavily uncontrolled diabetes. Even the endocrine emergencies we dealt with on the floor or ICU - including myxedema coma, thyrotoxicosis, etc - we could stabilize and handle ourselves and we typically consulted endocrine to ensure followup, education, and make sure we're not missing anything more long term in our management.

I feel like medical subspecialty consults from the ED are useful either if they're going to the primary team if that specialty has one (e.g. cardiology) or if it's something emergent requiring a procedure or specialized medication (e.g. acute leuk requiring plasmapheresis and emergency induction, STEMI/bad NSTEMI requiring cath, massive GIB requiring urgent GI intervention etc).

 

[ERDude]

[QUOTE="I respect fully that ED training is entirely to deal with emergencies (never mind the fact that the bulk of EM is not real emergencies). However, you can't say that some of the examples listed previously weren't hugely egregious. No need to be calling anyone a "******" over it.[/QUOTE]

This isn't really true depending on your definition of "emergency". I mean a facial laceration, dislocated shoulder, fussy baby, threatened miscarriage, undifferentiated chest pain/abdo pain/headache, etc..these aren't generally "emergencies" in that they are not immediate life threats - however they are firmly within the scope of EM training and require expedited evals/mgmt. You are correct that the bulk of EM is not resuscitation of the arrest or peri-arrest patient but still most ED patients are very much legitimate ED patients (like the examples above - the vast majority of which hospital based internists never see or hear about, and which outpatient internists would typically refer to ED for mgmt).

 

[Siggy]

I hope this wasn't specifically directed to me in the first place, as my only contention is with the fact that some EM residents become immensely jaded post residency and their workups become extremely cursory ("this patient is old and has chest pain, therefore needs to be admitted, but the troponin is still pending and we haven't given them nitrates or aspirin yet").

The only thing I truly care about the ED's workup is the CXR (r/o surgical issues) and the EKG (r/o STEMI). Should the ED do those other things? Definitely, but if they don't I'll order it on admission. The only exception is if the chest pain is atypical enough that the patient won't be admitted for observation.

Also nitrates don't decrease morbidity or mortality.

 

[IMreshopeful]

The only thing I truly care about the ED's workup is the CXR (r/o surgical issues) and the EKG (r/o STEMI). Should the ED do those other things? Definitely, but if they don't I'll order it on admission. The only exception is if the chest pain is atypical enough that the patient won't be admitted for observation.

Also nitrates don't decrease morbidity or mortality.

I'm aware that nitrates don't decrease morbidity or mortality. I've read GISSI-3. I was referring to an instance where a pt I had admitted was having recurrent chest pain and nobody thought to try a nitro.

Youre saying if the ED sees a case they think is UA or ACS of any kind you wouldn't at least expect them to give an aspirin?

 

[Siggy]

Youre saying if the ED sees a case they think is UA or ACS of any kind you wouldn't at least expect them to give an aspirin?

I very much expect them to give ASA. If, for what ever reason, they fail, then I can't go back in time and give it. The best I can do is write the order and tell the ED nurse to give it. I'm not going to hold up the admission over it.

 

[IMreshopeful]

I very much expect them to give ASA. If, for what ever reason, they fail, then I can't go back in time and give it. The best I can do is write the order and tell the ED nurse to give it. I'm not going to hold up the admission over it.

Right perhaps we are misunderstanding each other. I would not simply "reject" the patient if I thought they were floor appropriate - id simply tell the ED staff to do whatever I ask. However I feel like there's this huge disconnect between academic EM and community EM in terms of what gets done for the patients and what the dispo threshold is.

 

[Gastrapathy]

This is the IM forum. Go bitch about us on your own turf. Besides your exhausting 3 shifts a week are over and you should be home telling everyone how you were almost a trauma surgeon today.

Let's say 90% of ER docs are the second coming of Osler. The other 10% cause 90% of our pain. None of us care how good you are when your dip**** partner orders PE CTs for tachycardia in an obvious upper GI bleed and aki now with bad contrast nephroapthy (today).

My latest ER frustration is the rise of crappy midlevels seeing the "simple" cases except they actually see anyone and your supervision process consists of telling them to call me so I can supervise them for you.

Oh, and the ceruloplasmin example is kinda perfect. If you think a patient has acute Wilson disease, the right test is a slit lamp exam for KF rings. ceruloplasmin can be normal in that setting. So, it was the wrong test regardless of how fast you got it back. Unless you were working up otherwise uncomplicated elevated liver tests, in which case, why?

 

[jdh71]

This thread went about as expected.

Though there really is no need to mother-**** other specialties. People vent. People do stupid things. Everyone has anecdotes.

I personally don't think anyone in the ED should take "exception" to the notion that an IM trained person should be able to handle the same medical emergencies they are, and while it's a matter of nuance, I also don't think it's insulting to suggest that the IM trained person should be able to do it "better" given our training as . . . *ahem* . . . medicine people.

Though in the real world you just don't see as much medical "emergencies" in IM training initially as they do in the ED - coming out of training pound for pound the ED trained guy is going to be "better" - as lost of IM training is simply diluted with out-patient work and the stable sick. And if a hospitalist type never goes onto ever deal with the super sick except to admit after an ED resuscitation or just page the critical care guy in a panic, then of course, that IM person is also not as good at medical emergencies. You get good at what you do. IM need a bit more focused training to be able to do and do better what is done in the ED. I'd have no problem making the claim I can now handle medical emergencies better than most ED guys. It's not even said with any guile or condescension. I think it's the objective truth.

We can all get along and aknowledge some of the important points without getting mad. No one is bad. No one needs to be insulted.

 

[Gastrapathy]

Jesus jdh, when did we become the grown ups. IM rules. ER drools.

(Note the extra subtle use of ER instead of EM)

Yeah baby

 

[gutonc]

Jesus jdh, when did we become the grown ups. IM rules. ER drools.

(Note the extra subtle use of ER instead of EM)

Yeah baby

Seriously. When jdh is the voice of reason in a thread, you know that s*** has gone completely off the rails.

 

[Apollyon]

Oh, and the ceruloplasmin example is kinda perfect. If you think a patient has acute Wilson disease, the right test is a slit lamp exam for KF rings. ceruloplasmin can be normal in that setting. So, it was the wrong test regardless of how fast you got it back. Unless you were working up otherwise uncomplicated elevated liver tests, in which case, why?

This was 11 years ago. It was a guy that fell off his scooter and bonked his head, and was right at the tail pipe, breathing in the exhaust for an unknown amount of time. The CT was read as having some exotic finding, and part of the differential was Wilson's disease. At Duke, depending on who was admitting, you had to affirmatively rule out the differential, regardless of how outrageous/unlikely, including Wilson's disease. I figured, they want it, sure, I'll order it, and it will result in a day or two - until it resulted that Sunday night.

So, argue with Duke IM residents from a decade ago. From the cheap seats, it doesn't look kinda perfect.

 

[Siggy]

I don't know... maybe my ED is terrible (it's possible... as with any practice group, YMMV).

20 year old female "My boyfriend is away" EtOH and APAP overdose. 10-11 tylenols. Taken sometime in the last 5 hours (presentation time ~5AM, the patient is 100% sure that it was after midnight).

ED labs: APAP level 45. EtOH: 150. UDS negative (and... yes... the new synthetic street drugs aren't tested for in a standard UDS).

ED plan: IV n-acetylcystine, admit to ICU.

Patient is alert, talking, but obviously intoxicated.

APAP overdose is about as close to a pure paint by numbers possible... yet... ::sigh::

 

[deleted547339]

I don't know... maybe my ED is terrible (it's possible... as with any practice group, YMMV).

20 year old female "My boyfriend is away" EtOH and APAP overdose. 10-11 tylenols. Taken sometime in the last 5 hours (presentation time ~5AM, the patient is 100% sure that it was after midnight).

ED labs: APAP level 45. EtOH: 150. UDS negative (and... yes... the new synthetic street drugs aren't tested for in a standard UDS).

ED plan: IV n-acetylcystine, admit to ICU.

Patient is alert, talking, but obviously intoxicated.

APAP overdose is about as close to a pure paint by numbers possible... yet... ::sigh::

One thing I have difficulty explaining to an intensivist is that a lot of time you don't need them, you need their nurses. I have sent patients that aren't critically ill to the ICU, because they need 1:1 nursing for something other than critical illness. This is a patient that will be difficult to closely observe by the RN on the floor with several other patients. The floor RN doesn't have time to keep up with a suicidal patient that is white-girl-wasted and all of their other patients. The IV NAC, yea, I can't defend that.