Mumpu

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Yes, you all know what I'm talking about. Come shift change, the ER decides to admit ALL of their patients at once. Obvious admits sit in the ER for 12-14 hours with nothing being done (the "not sick" branch of the "sick-not sick" triage algorithm apparently doesn't extend to actual diagnoses or interventions) and then get urgently dumped at 6 pm with the ER screaming for admission orders stat. Or worse yet, that guy who came in at 9 am the day before and got 150 mL of NS running at KVO, MUST absolutely make it to the floor this very minute at 6:45 am.

I mean, how ignorant and disrespectful can you get to your IM colleagues...

(ok, just ranting :p)
 

Qtip96

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Mumpu said:
Yes, you all know what I'm talking about. Come shift change, the ER decides to admit ALL of their patients at once. Obvious admits sit in the ER for 12-14 hours with nothing being done (the "not sick" branch of the "sick-not sick" triage algorithm apparently doesn't extend to actual diagnoses or interventions) and then get urgently dumped at 6 pm with the ER screaming for admission orders stat. Or worse yet, that guy who came in at 9 am the day before and got 150 mL of NS running at KVO, MUST absolutely make it to the floor this very minute at 6:45 am.

I mean, how ignorant and disrespectful can you get to your IM colleagues...

(ok, just ranting :p)
ugh, that really sucks.

most academic IM programs have a medicine SAR (senior resident) or "pitboss" assigned to the ER to ensure appropriate triage and packaging for admission, and also to assess fitness for the various different services (GMS, cards, MICU, CCU, heme/onc, etc.). it's the job of a good SAR/pitboss to constantly survery the ED for pending admissions to streamline their workup and get a service/bed. it does no one any good ( for ED or IM) for patients to be squatting in an ED bed. looks to me that the ER SAR/pitboss during your block is sitting on his/her arse and not hearing about admissions until signout rounds in the ED. :mad:
 
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Mumpu

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Wish we had pitbosses. It's up to the ER chiefs to hand out the admits and most calls happen after the change-of-shift board rounds. Just another bug on my long list of beefs with emergency medicine (giving fluids before checking orthostatics and giving antibiotics before drawing cultures is up there too).
 

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Unless the earth rotated in the wrong direction we will always have terrible ER admissions. In my opinion, ALL ER programs should be 4 years with intense surgiacal and medicne exposure/rotations during the first 2 years. It may seem like a "long" residency, but these people are deciding who gets a $5000 room per night VS. going home with close follow up for nothing.
Don't get me wrong, I have many friends who are in ER and they are excellent at addressing acute problems/interventions....they are protecting their own assses...and have every right to do so. Just wish their sphincter tone was a little more relaxed!!!!
 

totalbodypain

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Swaydaa said:
Unless the earth rotated in the wrong direction we will always have terrible ER admissions. In my opinion, ALL ER programs should be 4 years with intense surgiacal and medicne exposure/rotations during the first 2 years. It may seem like a "long" residency, but these people are deciding who gets a $5000 room per night VS. going home with close follow up for nothing.
Don't get me wrong, I have many friends who are in ER and they are excellent at addressing acute problems/interventions....they are protecting their own assses...and have every right to do so. Just wish their sphincter tone was a little more relaxed!!!!
Come to my hospital (3rd busiest inner city ER in the country), start from scratch with 2-3 patients per hour trying to figure out which ones are getting ready to crump on you, which ones are seekers, which one's are full of s..t, which ones can go home and which ones are beligerant and likely to take a swing at you if you get too close while the rigs just keep coming in, switching from a med to surg to gyn problem between patients all the while not having a chance to take a leak let alone eat, read, go to a drug rep lunch or take a crap for that matter, then you can tell me you have a beef with how the ER is dumping the patients. Oh and you only have about five minutes to actually take a H and P from each patient because the rest of the time is spent yelling at staff to do there job, doing procedures to stabalize patients, chasing labs or lost labs, harrasing the CT tech to get the scan that you dont want but your consultant can't live without and basicall trying to get all your admissions as "packaged" as much as possible so you can move on. Sometimes I can get everything done and hand a polished patient on to the admitting team and sometimes I need a little help from them to get a patient who needs to be admitted to where they need to go. I get along great with the residents here so we usually try to cover each others backs between services. Sometimes I get that chest painer with nl ekg and multiple factors to the admissions resident and he or she is willing to help keep an eye on them till the trops come back and sometimes they just tell me to call back when the labs are back. Just a clue; If you tell me to call back after labs are back on a patient who is obviously going to be admitted, and if the labs come back fairly normal (i.e. needing no emergent action), then more than likely that patient will sit untill I catch up on the rest of my patients who do need emergent interventions (usually just before shift change). Sorry if this sounds like a bitch session but I get burnt when I hear EM residents bitching about the other services because I have been there and I get tired of hearing off service residents bitch about the ER because they haven't spent the time there in the capacity as a EM resident. There are stupid docs in every specialty and smart docs that occasionally do something stupid....You know what? Never mind. Answering this post is a waste of time. You either get it or you don't.
 

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I have to say, one of the important things I have learned as a senior resident about ER is: learn to move at the pace of the particular ER. If you are on the receiving end of the dumping call at shift change, just take a deep breath, and smile, CUZ THERE IS NOTHING YOU CAN DO ABOUT IT...

In my few years as housestaff I have served many different roles in the ER and lets just say, at my hospital's ER, my program's VA triage, and at a local private ER where I moonlight, things all work differently, and at different speeds. Some shifts I can't do **** but see pt's door to door and phones just ring off the hook and I have to beg, drag, coerce, name-drop and downright get in the face of people to get them to do their **** (today at the VA i saw 10 straight chest pains in the morning shift because the heart station people just decide it's a good day to take off a day, I had to do 3 stat EKG's myself because the RN's at the VA "are not qualified to do EKGs" and transport a patient to radiology for stat CT for suspect dissection when pt transport is on an hour "smoke break"... how ridiculous), sometimes things just go real smoothly and the 12 hour shift passes fast. I must say, as a triage physician (which ER docs really are... they are there to assess how sick people are, not to follow-up ****), people should be in, get their acute intervention and consult they need that particular minute, and either move up or head for dispo... you will understand why nobody like "ER is the hospital's parking lot" philosophy, but it all end up inevitably happens when things gets busy and the hospital is full and have to clear a bed for patients or when consultant haul their asses to come down.

Look at it the bright side... If they call you at 6am for an admission of a not-so-sick patient that has been parked in the ER for 8 hours, at least be glad that all the labs are collected and that they didn't wake your ass up at 4am (which they could have done)... You will appreciate it on Febuary when **** hit the fan. :)
 

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Mumpu said:
Wish we had pitbosses. It's up to the ER chiefs to hand out the admits and most calls happen after the change-of-shift board rounds. Just another bug on my long list of beefs with emergency medicine (giving fluids before checking orthostatics and giving antibiotics before drawing cultures is up there too).
Are you an intern? You sound like one. Just for your few comments, are you opposed to fluids in a frankly hypotensive patient - or would you rather they fell and hit their heads when they get stood up (while hypotensive) for their orthostatics? Secondly, what is the utility of blood cultures? Do some research and you will find out the utility is very low. Still, nonetheless, we do them (oftentimes just because IM - apart from other groups, like GS and Ob - will bitch like children if they're not drawn).

I am glad that I am done with residency, because, where I was at, I had an IM2 lose his **** - just go NUTS - because I didn't get a UA and urine culture on a patient. This was not before antibiotics, and the pt did get blood cultures. Instead of just writing a two-line order, he made a big deal of showing how lazy he and his colleagues have become. One of the med/psych guys (who was there before the EM residency started) said that it was night and day between the way it was and the way it is - now, there is NOTHING left to do. There is no acute thinking that has to go on for the IM residents, because all blood has been drawn, all tests have been ordered, and all radiology is done. Anything a patient needs acutely they get - if flow cytometry is indicated, that can wait until the next day or Monday, since that won't change their acute problem. Anything else arcane or subspecialized that the patient may need that IM decides on can wait until the next day.

In your "long list of beefs", do you consider when you cap? I waited until after 4am more than once so that the overflow resident would get the admission, instead of screwing the on-call teams (no matter how whiny they were).

If your biggest issue here is getting more than one patient at once, you need perspective. How do you think it will be in practice? You should be happy for the challenge of multitasking now, instead of having to figure it out that the faster you get it done, the earlier you get to go home to your family (when you are in practice).
 

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I have much to say, but like others, it seems like a waste to write it all. In summary: do multiple months of ED (like I was forced to do, b/c I wasn't categorical) and be the guy/girl working your tail off and making lightning quick decisions about who stays and who goes, and then see if it is that easy to complain.

-S
 

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i've paid my dues working one of the busiest municipal ERs in the US, and i know what it is like being in trenches. just a few thoughts ;)

1. it's wrong to be bagging on the ER people. everyone's workin' hard.

2. yo Mumpu, your problem is administrative. you guys should be sittin' with the PD of your program to institute a senior admitting resident in the ED. it's got a lot of perks. helps the ED with extra hands. streamlines admissions and relations with the ER. teaches the IM resident valuable lessons on triaging and admissions criteria. admitting teams yell at one of their own instead of at a an ER resident (teaches fair play). patients actually move out of the ER quicker making ER, admitting teams, and the patient happier.

SimulD said:
...be the guy/girl working your tail off and making lightning quick decisions about who stays and who goes...
3. disposition should be on your mind as soon as that patient hits the door.

totalbodypain said:
...Sometimes I get that chest painer with nl ekg and multiple factors to the admissions resident and he or she is willing to help keep an eye on them till the trops come back and sometimes they just tell me to call back when the labs are back...
4. you SHOULD be keeping an eye on the troponins anyway. amongst other possibilities, that patient COULD be having a LCx/OM STEMI that is not evident on standard surface ECG (could try posterior leads though), in which case you need to mobilize the cath lab and not be talking with the IM resident. your assessment of ACS is NOT complete until the evaluating doc has reviewed the biomarkers. ;)
 

totalbodypain

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True, I follow CE's like a hawk till there back. I have seen some incredible time bombs but when everything comes back negative, the patient is stable, in a monitored bed and has gotten all the acute interventions that I am going to give (ASA, Plavix, B blocker/heparin if indicated), then chasing the admitting resident down to admit often becomes one of my least important tasks...But your over all point is taken. Thanks for the clear up...
 

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totalbodypain said:
Come to my hospital (3rd busiest inner city ER in the country), start from scratch with 2-3 patients per hour trying to figure out which ones are getting ready to crump on you, which ones are seekers, which one's are full of s..t, which ones can go home and which ones are beligerant and likely to take a swing at you if you get too close while the rigs just keep coming in, switching from a med to surg to gyn problem between patients all the while not having a chance to take a leak let alone eat, read, go to a drug rep lunch or take a crap for that matter, then you can tell me you have a beef with how the ER is dumping the patients....
Amen to that. We all went to medical school, we all work our asses off. I cant understand the logic behind thinking that some people become geniuses and some people become *******es immediately after graduation from medical school. In the ER, we deal with a much, much greater diversity than any other specialty. We see and deal with crap that you will never see on a ward or nice cozy office. We constantly deal with abuses from jerks in other specialties who only judge us by our knowledge of their specialty and seem to have forgotten basic manners they were supposed to learn in kindergarten. We don’t complain about it because we love what we do. No other specialty has as much challenge and excitement and as many opportunities to immediately save lives as we do. And the “triage physician” remark is just complete ignorance. No physician follows a patient home and takes care of him 24/7 for the rest of his life. We all play a part in helping people lead longer and healthier lives. Just because you “follow” a patient one hour every few months or so in clinic doesn’t make you anymore important in his healthcare than the physician, not triage nurse, who is saving that patient’s life when he has the MI, or CVA, or is septic, or has a traumatic head injury, or just has a laceration to repair or has broken his fifth metatarsal, or whatever. We’re all on the same team.
 

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Ahh, the IM vs EM debate....I probably shouldn't get into the middle of a thread that started out as an (self-admitted) rant from an IM resident on an IM forum, that is now starting to show signs of degeneration, but oh well.

Apollyon said:
Secondly, what is the utility of blood cultures? Do some research and you will find out the utility is very low. Still, nonetheless, we do them (oftentimes just because IM - apart from other groups, like GS and Ob - will bitch like children if they're not drawn).
Are you serious? Blood cultures have no utility? How about the chance of identfying the organism causing the fever, hypotension, or whatever in your pt and thus allowing you tailoring your abx therapy appropriately? I'd really like to see this "research" you speak of.

I don't think Mumpu was implying that the EM residents are lazy, vengeful, whatever, but it can be very frustrating to get those calls for admissions at 7:45p (right before night float comes on at 8pm) from the ER on pts that have either been there all day, or barely meet admission criteria as it is. Part of the problem, as previously mentioned, is triage. But at my program, the ER has a policy where the residents are not allowed to sign out their pts to the next resident at the end of their shift. So the options become a)hang around waiting for tests, scans, etc to come back and therefore be forced to stay way past the end of your shift or b)admit to medicine. Guess which one gets chosen most of the time?
 

kungfufishing

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Ehrenstein BP. Jarry T. Linde HJ. Scholmerich J. Gluck T. Low rate of clinical consequences derived from results of blood cultures obtained in an internal medicine emergency department. [Journal Article] Infection. 33(5-6):314-9, 2005 Oct.

Kennedy M. Bates DW. Wright SB. Ruiz R. Wolfe RE. Shapiro NI. Do emergency department blood cultures change practice in patients with pneumonia?[see comment]. [Evaluation Studies. Journal Article] Annals of Emergency Medicine. 46(5):393-400, 2005 Nov.

Leonard P. Beattie TF. How do blood cultures sent from a paediatric accident and emergency department influence subsequent clinical management?. [Journal Article] Emergency Medicine Journal. 20(4):347-8, 2003 Ju



There's plenty more.
 

Apollyon

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Hova2005 said:
Are you serious? Blood cultures have no utility? How about the chance of identfying the organism causing the fever, hypotension, or whatever in your pt and thus allowing you tailoring your abx therapy appropriately? I'd really like to see this "research" you speak of.
Are YOU serious? You can't be, since you don't know how rarely useful blood cultures are.

You see one of my colleagues pointing out multiple studies, which you apparently were unable or unwilling to look for.

Are you a student? At most, you too couldn't be more than an intern if you didn't know this. Do some research and save some face.
 

Renovar

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kungfufishing said:
Ehrenstein BP. Jarry T. Linde HJ. Scholmerich J. Gluck T. Low rate of clinical consequences derived from results of blood cultures obtained in an internal medicine emergency department. [Journal Article] Infection. 33(5-6):314-9, 2005 Oct.

Kennedy M. Bates DW. Wright SB. Ruiz R. Wolfe RE. Shapiro NI. Do emergency department blood cultures change practice in patients with pneumonia?[see comment]. [Evaluation Studies. Journal Article] Annals of Emergency Medicine. 46(5):393-400, 2005 Nov.

Leonard P. Beattie TF. How do blood cultures sent from a paediatric accident and emergency department influence subsequent clinical management?. [Journal Article] Emergency Medicine Journal. 20(4):347-8, 2003 Ju



There's plenty more.
Wonder why all those above are published in the EM journals. Though I am certain there are some that are published in medical journals as well.

With that being said, current IDSA, ACP and ATS recommendation guidelines (aka standard of care) of treatment of meningitis, inpatient pneumonia and sepsis have been obtaining blood (and whatever other relevant) samples prior to antiobiotic initiation.

http://www.journals.uchicago.edu/CID/journal/issues/v39n9/34796/34796.html
http://www.journals.uchicago.edu/CID/journal/issues/v26n4/ap63_811/ap63_811.web.pdf
http://www.thoracic.org/sections/publications/statements/pages/mtpi/commacq1-25.html
http://www.ihi.org/NR/rdonlyres/5A927540-D8F2-44E7-83B4-3B17270A4ACB/812/SepsisGuidelines.pdf

Low yield doesn't mean you shouldn't do it.
 

Apollyon

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Renovar said:
Wonder why all those above are published in the EM journals. Though I am certain there are some that are published in medical journals as well.
Infection is an EM journal? 2/3 is not "all".

I wasn't saying "don't draw them" - I was saying that losing your **** because they weren't drawn is not the end of the world, nor not nearly the biggest problem.
 

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Swaydaa said:
Unless the earth rotated in the wrong direction we will always have terrible ER admissions. In my opinion, ALL ER programs should be 4 years with intense surgiacal and medicne exposure/rotations during the first 2 years. It may seem like a "long" residency, but these people are deciding who gets a $5000 room per night VS. going home with close follow up for nothing.
Don't get me wrong, I have many friends who are in ER and they are excellent at addressing acute problems/interventions....they are protecting their own assses...and have every right to do so. Just wish their sphincter tone was a little more relaxed!!!!

Maybe once you've done your ED rotation you'll have a new appreciation for what we do.
 

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"But at my program, the ER has a policy where the residents are not allowed to sign out their pts to the next resident at the end of their shift"

-------------------------------------------------------------------

THAT is ridiculous. So much so that I cannot believe it. I have never heard of a program in the country that does that.
 

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Renovar said:
Wonder why all those above are published in the EM journals. Though I am certain there are some that are published in medical journals as well.
They're published in emergency medicine journals because the question being asked is an emergency medicine question, namely do we need to be drawing cultures on every patient admitted from the ER with pneumonia. And the annals article was done as a joint project between the depts of internal medicine, infectious disease, and emergency medicine, there's no emergency medicine bias. certainly agree that septic or any real sick patients should have cultures drawn. But the practice of doing this as a firm policy for every pneumonia is yet another reason patients get hung up in the ER for hours and hours prior to being admitted. I have had numerous times when I am admitting my afebrile, otherwise stable asthma patient for persistent wheezing, and the admission chest XRay shows a ?infiltrate that the radiologist officially reads as pneumonia. And there are alot of other potential scenarios. Sure, if me and the nurses were doing nothing else this might only take a few minutes. but the reality is even with effective multitasking on a busy night (with multiple resusces going on) it might take literally hours to get to it not to mention you're torturing a patient who might be a real tough stick. And with the literature stacked up against it's usefulness, you have to ask why.
 

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Apollyon said:
Are YOU serious? You can't be, since you don't know how rarely useful blood cultures are.

You see one of my colleagues pointing out multiple studies, which you apparently were unable or unwilling to look for.
the Kennedy et. al. article from Annals of Em. Med. is pretty informative.

of 414 pt.s admitted with CAP, 29 (7%) had true bacteremia. 4 (1% of all, but 14% of bacteremia) were resistant to empiric Rx. Most of these cases was MRSA. in this study, more than half of all staph bactermia was MRSA.

some thoughts...
1. we routinely perform lots of tests with lower yield than this.
2. study population was in years 2000 to 2001. multi-drug resistance (as well as community MRSA) has been on the rise.
3. this is compelling data that we need to be more discriminatory about how to maximize the yield of blood cultures. establishes that this subject needs more study, but is NOT a solid argument for excluding routine blood cultures.
4. CMS and JCAHO core quality guidelines still requires blood cultures.
5. pts. who are "hard sticks" are often hospital freq flyers and definitely would be in the high risk group for drug resistant bugs.

P.S. sorry people here are ragging on EM. people on the receiving end of admissions are always gonna b*tch (hence the beauty of medicine SARs, so IMs can rag on each other). :p

P.P.S. if you or your beloved was admitted for pneumonia, given a 7% chance of true bactermia, would you want blood cultures? ;) on second thought, this is not a fair question, since you're a doc, you'll by nature be in a high risk group for drug resistant bugs. but on the hypothetical condition that if you were not a doc...
 

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On a different tack, there is an invaluable book I bought called The M&M Files: Mortality and Morbidity Rounds in Emergency Medicine, and there was a point in there that was reiterated on the EM forum that speaks directly to the OP: as you approach the end of your shift, become more conservative (ie, more testing and more admitting) instead of succumbing to your fatigue. There is also the component of disposition and to not dump work on a colleague.

Really, bringing a patient in virtually always is the better part of valor, and EM docs will take **** from IM residents (and interns) that will bitch about doing their job, as long as the right thing happens.
 
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Geez... I understand and respect how busy ERs get. Re-read my original post: I was specifically talking about a patient whose A/P written at 10 am says "admit to medicine" and who does not actually get called to the resident until shift change 8 hours later, along with four other patients. It can't be a concidence that a bolus of 4-5 admits comes around shift change every day, can it? All the wards people (be it IM or surgery) ask is that you call as soon as know you are going to admit, spacing out the admissions so they can all get an appropriate level of care from the primary team.

As for blood cultures, how many D-dimers and CTPEs have you ordered today in your ER? How many troponins have you sent? A febrile ill-appearing patient needs blood cultures. If you give them levo 500 prior to drawing cultures, you may have just cost the primary team a micro diagnosis and forced them to unnecessarily use a too-broad antibiotic. If a patient presenting with syncope stood up and fainted when you tried to do orthostatics, tell me -- you just saved someone the expense of 24-48 hours of tele.
 

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Perhaps our program is the exception, but we dont produce big dumps like that (I'd say no pun intended, but it was pretty good).

I routinely get blood for cultures prior to ABX and so do the majority of my resident colleagues. I think a lot of the replies about blood culture yield had to do with the tone of Hova2005's post.
 

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This thread is beginning to degrade into an "us vs them", and I hope it won't continue to do so.

Much of the literature that our EM colleagues are referring to are specifically discussing patients with pneumonia. I'd like to remind both my EM and IM colleagues that it is very well known in both the EM and pulmonary literature that blood cultures in pneumonia are not very helpful. However, patients with pneumonia are a small minority of patients who end up getting admitted to the medical service. Of course there are many patients with CXR's that are read as "question of pneumonia" by the ER radiologists that end up actually being atelectasis, effusion, or just chronic changes -- if there's a concern for infection but the source is not clear, those patients should have cultures done - not just assume that there's a pneumonia present. In other words, if it's not a "slam-dunk" pneumonia, and there's a concern about infection, these patients should have blood cultures drawn before their antibiotics. Sure it won't change their management in the ED, but it does change their management on the floor or in the MICU. As for getting a hard time from the ER staff, it takes about 5-10 seconds to order blood cx, urine cx, and sputum cx, so I don't understand why this should really be a point of contention in an infected/septic patient.
 
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It wasn't even a question of doing or not doing cultures, but the sequence. For whatever reason, antibiotic drips tend to outrun the culture bottles on the way to the patient.
 

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Mumpu said:
It wasn't even a question of doing or not doing cultures, but the sequence. For whatever reason, antibiotic drips tend to outrun the culture bottles on the way to the patient.
Well duh.

Show me the data that culture bottles outrunning antibiotic administration saves patients, and I'll make sure the bottles get the nod when I've 12 patients to carry, 2 nurses to do all the scutwork, and not enough time to take a s*!&.
 

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AJM said:
This thread is beginning to degrade into an "us vs them", and I hope it won't continue to do so.

Much of the literature that our EM colleagues are referring to are specifically discussing patients with pneumonia. I'd like to remind both my EM and IM colleagues that it is very well known in both the EM and pulmonary literature that blood cultures in pneumonia are not very helpful. However, patients with pneumonia are a small minority of patients who end up getting admitted to the medical service. Of course there are many patients with CXR's that are read as "question of pneumonia" by the ER radiologists that end up actually being atelectasis, effusion, or just chronic changes -- if there's a concern for infection but the source is not clear, those patients should have cultures done - not just assume that there's a pneumonia present. In other words, if it's not a "slam-dunk" pneumonia, and there's a concern about infection, these patients should have blood cultures drawn before their antibiotics. Sure it won't change their management in the ED, but it does change their management on the floor or in the MICU. As for getting a hard time from the ER staff, it takes about 5-10 seconds to order blood cx, urine cx, and sputum cx, so I don't understand why this should really be a point of contention in an infected/septic patient.

AJM has the real point here. Proper management of a patient with suspicion of infection would include acquisition of blood cultures, ideally before the administration of antibiotics. Now you can find a journal article that says the sky is purple and humans really breath helium...so having a bulletin board war using obscure B-rated journals up against peer reviewed guidelines is bit folly and frankly stupid. In other words, its the ER's job to do the proper evidence based and guideline supported initial steps in diagnosing and managing the patient acutely for the suspected diagnoses, keeping mind the patient's further care during admission and the inpatient admitting service handles the rest.

Having worked on the floor and in the ER for a while, now the ICU I have few observations as to the rights of the parties involved.

The admitting physician has rights:

1. The right to admit the patient
2. The right to request evaluation of a patient in the ER prior to admission
3. The right to notify a receiving MD/team of a likely admission in a timely manner.
4. The right to be respected as a colleague and not be hassled by housestaff or other MDs posing as NFL linemen trying to block all possible admissions.
5. The right to perform initial diagnostic and treatment maneuvers based on best evidence available.
6. The right to defer longer term decision making to MD assuming responsibilities for definitive inpatient care.

The receiving physician has rights:

1. The right to accept the admission
2. The right to know of and review the requested admission and examine the patient themselves in a timely manner
3. The right to make alternative arrangements for a patient whose admission may not be necessary but f/u is
4. The right to a clear and concise review of the patient's presentation and acute management
5. The right to request alternative service evaluation for admission if chosen service is not deemed appropriate.
6. The right to request specifics from ER physicians admitting the patient to their service before the patient is officially dispositioned as an inpatient(i.e. antibiotic and acute lab choices, if not already performed, etc)

Here is my last point, then I am done. If anyone in the ER or on the floor is "too busy" to provide proper, evidence based and uniform care to a patient or patients...then it is that person's responsibility to call for help to do the right thing...e.i draw the blood cultures yourself, get the charge nurse to hang the antibiotics if the patient's nurse can't/won't do it. This argument about the ER being so busy that proper care can't be delivered is crap. Half-assed care is as good as no care at all, and is likely more dangerous.
 

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Eidolon6 said:
obscure B-rated journals

3. The right to notify a receiving MD/team of a likely admission in a timely manner.
Although a good post, I just have these two points. First, the "Annals of Emergency Medicine" is not a "B-rated journal" - unless you consider EVERY specialty-specific journal (the Green journal, Pediatrics, Journal of Trauma, and so on) that is NOT NEJM or JAMA to be a "B-rated journal".

Secondly, when I was at Duke, it happened enough that I stopped doing it - trying to tell the receiving team of a likely admission - they (mostly PGY-2's in IM) did NOT want to hear about patients unless they were ready to be admitted - period. Even then, a few of the "brilliant PGY-2's" would indeed use all of their brains to fight EVERY admission - it was amazing how so many patients could be either 1. not sick enough 2. TOO sick or 3. not appropriate for IM. A bitterly amusing point would be the MICU consultant - a PGY2 IM peer of the admitting resident - saying, "This patient does NOT need the unit".

Oh, and, for the IM folks - "the patient doesn't have a diagnosis - do they need to be admitted?" is NOT the right response.
 

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Qtip96 said:
4. CMS and JCAHO core quality guidelines still requires blood cultures.
I haven't seen the actual notice but I did just receive this week an email from the ID folks at my hospital saying that CMS had just dropped blood cultures from their inpatient pneumonia guidelines.

I posted most of my response to the sister thread over on the EM forum but one other thing to add. If Mumpu is still in Colorado then I have some first hand knowledge of how things work there. Don't forget its July and the learning curve for the ED folks is a steep as it is for everyone else. I can remember some of my first PGY-3 shifts where you are truly responsible for all your own patients and it can be a large number or PGY-4 shifts where you are responsible for all the interns, students, and PGY-2's patients and it is an even larger number. EM really is sometimes about triage and priorities. If you are still learning the job and if you are nearly overwhelmed one of the lower priorities may be calling up the relatively stable medical ward admits especially if they've already received whatever treatment they are going to need for the next few hours. Calling up the MICU, SICU, peds, OR admits, managing new traumas or resuscitations, and getting the minor/urgent care stuff out the door becomes more important. This is even more true if the admitted patient, as is often the case, doesn't have a bed to go to anyway. To this day if the admitted patient has no where to go I make sure they have everything they need done for the next few hours and then if I'm crushed or the hospitalist is crushed or if its 3:00 AM then I don't rush to call up the patient. I'll let the hospitalist sleep or tell him to call me back when he catches up with his other work or whatever. Once the new team comes on at shift change you have a chance to catch your breath and go finish the stuff that got left behind which is usually; 1. stable admits still waiting for a bed, 2. lacs still well within the window for primary closure, and 3. D/Cing the drunks who have been sleeping it off all shift. As the year progresses your ED residents should get more efficient and comfortable and hopefully won't do it as often but there will still be times when they fall behind and the stable ward admits waiting for beds won't get called up in a timely manner. Just as the pace and workload of internship may seem overwhelming to you at times but in the end serves to make you a better, more efficient physician, your overwhelmed, inefficient ED colleague is also becoming a better doctor.
 

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One thing I forgot to add.

In Colorado it is nurses not beds that limit the bed supply. There are almost always available beds but no nurses to staff them. If the hospital is full they will often call in extra nurses for the next shift which means suddenly a bunch more beds open up and those admits sitting in the ED all day suddenly get beds at shift change. In the ideal world we should call up the admits as soon as possible but unfortunately it doesn't always work that way and they don't become a priority until they get a bed. Then they suddenly DO become a priority because anytime you can move somebody out of an overcrowded ED it opens up a bed for a new ambulance. ED overcrowding is one of the reasons the IOM is so concerned about the state of EMS in America and why one of the proposals to improve things was to board patients waiting for beds in the hall on the medical floor, their ultimate destination, and not in the hall in the ED. At least that spreads the pain
 

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Apollyon said:
Although a good post, I just have these two points. First, the "Annals of Emergency Medicine" is not a "B-rated journal" - unless you consider EVERY specialty-specific journal (the Green journal, Pediatrics, Journal of Trauma, and so on) that is NOT NEJM or JAMA to be a "B-rated journal".
Infection and Emergency Medicine Journal are not, in my experience, A-level journals to which major practice shifting evidence based observations are published. I concur that Annals of Emergency Medicine is the one that I would agree has a stronger reputation but Renovar's post provides guidelines using compiled evidence and peer review from organizations more germane to this topic and a single study in even A-level journals of does not always constitute grounds for major practice shift....for example not getting blood cultures in the ED because of one's misguided belief based on a few throw-away journals that they do not assist clinical care.

As for complaints against IM housestaff, all of the experienced IM/CCM folks in this forum could level and equal number of valid complaints against our ER colleagues about bad dumps or being frankly lied to over the phone, etc. but for what benefit....think Israel vs Lebanon here...there will be no winner.
 

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Apollyon said:
Although a good post, I just have these two points. First, the "Annals of Emergency Medicine" is not a "B-rated journal" - unless you consider EVERY specialty-specific journal (the Green journal, Pediatrics, Journal of Trauma, and so on) that is NOT NEJM or JAMA to be a "B-rated journal".
Infection and Emergency Medicine Journal are not, in my experience, A-level journals to which major practice shifting evidence based observations are published. I concur that Annals of Emergency Medicine is the one that I would agree has a stronger reputation but Renovar's post provides guidelines using compiled evidence and peer review from organizations more germane to this topic and a single study in even A-level journals of does not always constitute grounds for major practice shift....for example not getting blood cultures in the ED because of one's misguided belief based on a few throw-away journals that they do not assist clinical care.

As for complaints against IM housestaff, all of the experienced IM/CCM folks in this forum could level an equal number of valid complaints against our ER colleagues about bad dumps or being frankly lied to over the phone, etc. but for what benefit....think Israel vs Lebanon here...there will be no winner.
 

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Eidolon6 said:
Infection and Emergency Medicine Journal are not, in my experience, A-level journals to which major practice shifting evidence based observations are published.
Granted. You're right.

Eidolon6 said:
As for complaints against IM housestaff, all of the experienced IM/CCM folks in this forum could level and equal number of valid complaints against our ER colleagues about bad dumps or being frankly lied to over the phone, etc. but for what benefit....think Israel vs Lebanon here...there will be no winner.
In the book A Little Book of Emergency Medicine Rules, rule #13 is "No admission is appropriate if you are on the receiving end." In the ED, we're (unfortunately) used to it.
 
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ER is spot on. Basically it comes down to this: the hospital I'm at right now badly needs an obs unit. About half of my admits are discharged within 24 hours of admission and a large proportion of these are still in the ER at the time of discharge. One could argue that if a patient never went to the floor, they never had to be admitted per se in the first place -- what they needed was a place to stay and some focused care. Managing patients in the ER is a PITA -- the patient load per nurse is too high to provide anything resembling expedient care.
 

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ERMudPhud said:
. . . beds open up and those admits sitting in the ED all day suddenly get beds at shift change. In the ideal world we should call up the admits as soon as possible but unfortunately it doesn't always work that way and they don't become a priority until they get a bed. Then they suddenly DO become a priority because anytime you can move somebody out of an overcrowded ED it opens up a bed for a new ambulance.. . .
Agreed there are many reasons on both sides for the "war" between IM residents and EM RESIDENTS. We need to give each other a break. We do jobs the others are not trained to do. The patients need BOTH groups. The idea of a "pitboss" sounds very helpful.

If these admits waiting for the bed can be called to the admitting service, all the paperwork can be done while the patient is waiting, saving the admitting team a crush of patients all at once.

As for the blood culture issue, the triage nurses are usually pretty sharp about picking out the truely ill patients, and they get blood cultures when they get the other labs. It is rare that it makes a hugh difference, but when it does, it REALLY does.
 

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ERMudPhud said:
In Colorado it is nurses not beds that limit the bed supply. There are almost always available beds but no nurses to staff them.
not just in Colorado my friend, this unfortunate scenario is everywhere! ;)
truly, quality of care is as much determined by the number of nurses per bed as the quality of the docs.

Annette said:
The idea of a "pitboss" sounds very helpful.
yeah, i remember those days fondly(man, it was a LONG time ago). both institutions where I did residency and fellowship had medicine SARs (senior admitting resident) assigned to the ED. it's a great rotation.
in addition to what i brought up before...
1. people on the receiving end of admissions are ALWAYS gonna give the admitting doc horsesh*t (fighting admissions, nit-picking, etc.).unfortunately, this behavior seems more pervasive in medicine culture than in surgery. if a medicine resident calls in the admission, there is less grumbling 'cause a SAR is NOT gonna take any **** from one of their own.
2. it's FUN! tons to learn from in the ED. lots of acute care, codes, etc. you're also an extra brain to discuss the difficult cases with your ER colleagues.
3. you're an extra set of floating hands to help out when needed, so everyone loves you (esp. ED staff and nurses).
4. you get to hear about followups on interesting cases admitted to your IM colleagues, and you can communicate them to your ER buds (good for their learning too). since you're down in the ED, seems less like monday morning quarterbacking, and more like a genuine opportunity for learning.
5. man, like EVERONE is happier, especially the patients, since they get up to their beds faster AND it's better care.

you guys in programs without SARs should bring it up with your PDs! granted, a SAR is only a high yield rotation if the ED at your institution is high volume.
alright, sorry to wax so much! i won't bring it up again. :p
 

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Mumpu said:
ER is spot on. Basically it comes down to this: the hospital I'm at right now badly needs an obs unit. About half of my admits are discharged within 24 hours of admission and a large proportion of these are still in the ER at the time of discharge.
An ER without an obs unit to me is unconcievable!!?
 
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Oh there's an obs. Run by ER. So every order and every drug is an uphill battle.
 

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Qtip96 said:
ugh, that really sucks.

most academic IM programs have a medicine SAR (senior resident) or "pitboss" assigned to the ER to ensure appropriate triage and packaging for admission, and also to assess fitness for the various different services (GMS, cards, MICU, CCU, heme/onc, etc.). it's the job of a good SAR/pitboss to constantly survery the ED for pending admissions to streamline their workup and get a service/bed. it does no one any good ( for ED or IM) for patients to be squatting in an ED bed. looks to me that the ER SAR/pitboss during your block is sitting on his/her arse and not hearing about admissions until signout rounds in the ED. :mad:
I trained in an academic IM-Peds program that did not have such a person. We for the most part (except at our VA) had good EM residents and attendings who did the right thing the majority of the time. (And hey no one is perfect). We really seemed to be able to work together. Now as an attending at a hospital where our ED is a little (ok maybe a lot) lacking I definitely miss it.
 

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An ER without an obs unit to me is unconcievable!!?
Actually Obs units are a relatively recent development in the world of medicine and I would hazard a guess to say that the majority of emergency departments still don't have one. Most high volume places (>60k visits per year) probably have one or are on the way to having one.
 

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Seaglass said:
Actually Obs units are a relatively recent development in the world of medicine and I would hazard a guess to say that the majority of emergency departments still don't have one. Most high volume places (>60k visits per year) probably have one or are on the way to having one.
If you can run them for a profit.
 

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Mumpu said:
It wasn't even a question of doing or not doing cultures, but the sequence. For whatever reason, antibiotic drips tend to outrun the culture bottles on the way to the patient.
Just to clarify on this specific point but time to antibiotic administration for pneumonia has become a big quality assurance point in a lot of hospitals. Bad things happen to people if patients don't get antibiotics within some fixed time period after diagnosis (commonly around an hour). This is why you often see antibiotics given quickly.
 

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As someone that's worked both (or all 3 sides if you count the ICU) of the coin, from my viewpoint a lot of the IM vs. ER tension is simple inexperience. True, the community hospital hospitalist that's getting hammered with the 15th admission that shift isn't going to be happy that it's happening but he's going to be a LOT less pissy on the phone than your average internal medicine intern or junior/senior resident taking the phone call from the ER. He's also less likely to just be generally pissy but may make a more useful suggestion such as "please don't send the patient up just yet as things are absurdly busy up here and if you give me half an hour I can catch up".

The change of shift bolus can be remediated without the IM vs. ER mentality. It will need to come from the top down, however. This usually involves a chief of service to chief of service discussion with various senior level clinical personnel also assisting in setting the new policy. Admissions will need to be processed in a more expedient manner. Rather then venting on the ER person on the phone a coherently worded message to the chief resident and then upwards will likely help with a system wide change.

The other reason that boluses can happen in the ER is a simple lack of time to actually get caught up on the appropriate paperwork. If I'm managing 5 people of varying acuity in the ER at the same time I likely won't have the time to complete the necessary paperwork, review enough of the medical history to give a coherent story and then present the case to the IM admitting person. And if I'm the only one in the ER I can't very well delegate the paperwork to someone else.

This may mean that all the paperwork gets pushed back to the point where all 5 people are relatively clinically packaged and then I sit down to do all of the paperwork at once. This will result in several admissions in a relatively short time-period. The trade-off is that they'll be better packaged than if we were sending them off in a rapid-fire succession to simply clear the bed.

You just can't make everyone happy all the time though. If you try to get people up in a steady stream they're not happy that the paperwork is sparse, various tests haven't been done, etc. If you wait to get all the data they're not happy people are getting admitted too close to one another.

Often it may not be entirely true that the person was "sitting for 8 hours" in the ER waiting to be admitted. An alternative explanation is that the ER was hoping the person would stabilize sufficiently over the 8 hours to avoid the admission. None of the ER physicians I've worked with are out to "get" IM by saving up admissions.

I HIGHLY recommend if you have the opportunity to work in the ER beyond your residency requirements that you do so. It's quite enlightening, especially as an internist.
 

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Bobblehead said:
Just to clarify on this specific point but time to antibiotic administration for pneumonia has become a big quality assurance point in a lot of hospitals. Bad things happen to people if patients don't get antibiotics within some fixed time period after diagnosis (commonly around an hour). This is why you often see antibiotics given quickly.
With the Medicare performance improvement initiative you will get dinged if you admit a patient that in any way codes into Pneumonia/Sepsis at the end of stay and do NOT
-Precede your antibiotic with cultures
-Get your antibiotics in within 4 hours of arrival
-Use appropriate antibiotics (Unfortunately in my institution this leads to way overuse of quinolones because it's easy to remember Levaquin is acceptable :rolleyes: I'm not sure how much harder it is to remember Ceftriaxone and Azithromycin are also acceptable)
There are more but those are the most relevant to this point.

Currently you can look up institutional performance online. Eventually they will be reporting individual provider data and it will be the basis for payment in a punitive fashion.
 

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Pretty amazing how many ED folks are cruising the IM forum. Give Mumpu a break, he was just trying to vent a little in a peer forum. If I go into my work room and scream about how much nursing/ED/Surgery/Housekeeping etc... is frustrating me, I shouldn't get dogged about it esp. if those groups are snoooping around in my "sanctuary." Don't tell me ED people don't talk crap about IM folks because you have been doing it on this thread since its beginning. You won't find me over on the ED forums looking for some slight to get into a flame war over. Despite what you might think, defending your honor by putting us down only leads to further degradation of the relationship between the ED and IM.
During intern orientation we had a great talk from the head of our ED. He basically said "You will hate me soon." He told us a story about the early days of CT when it was very difficult to get a CT done on your patient. He said that they usually had to fight the Rads resident tooth and nail to get any CT done, but there was one Rads resident that happily took any CT requests. When they called him, he would say "Send them over because we are radiologists and imaging is what we do." That gave me some perspective. So now when I am on call and I am getting hammered all at once and feeling all toxic, I try to remember that mantra. "I am an internist, admitting people is what I do." Corny perhaps, but it works. Of course, we do not have night float where I am at so I don't have the added stress of trying to get out of the hospital at a decent time. When I go into call it is with several expectations:
1) I am going to cap
2) They are likely to all come at once
3) They are all going to be on death's door
4) I will get no sleep/rest or breaks
So when any of the above does not come true, it feels like a small victory.
 

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Loopo Henle said:
Pretty amazing how many ED folks are cruising the IM forum. Give Mumpu a break, he was just trying to vent a little in a peer forum. If I go into my work room and scream about how much nursing/ED/Surgery/Housekeeping etc... is frustrating me, I shouldn't get dogged about it esp. if those groups are snoooping around in my "sanctuary." Don't tell me ED people don't talk crap about IM folks because you have been doing it on this thread since its beginning. You won't find me over on the ED forums looking for some slight to get into a flame war over.
It happens about twice a month in our forum. Every month.

Anyways, all fora are fair game - unless people do what anesthesia did here on SDN - get a private forum.
 

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Apollyon said:
It happens about twice a month in our forum. Every month.

Anyways, all fora are fair game - unless people do what anesthesia did here on SDN - get a private forum.
Not to mention a fair number of the EM people may be double boarded, have completed one or more years of IM or may just be interested in issues in IM (as medical problems do unfortunately present to the ED ;) ) and therefore reguarly take part in the EM and IM forums.
 

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Loopo Henle said:
Pretty amazing how many ED folks are cruising the IM forum. Give Mumpu a break, he was just trying to vent a little in a peer forum. If I go into my work room and scream about how much nursing/ED/Surgery/Housekeeping etc... is frustrating me, I shouldn't get dogged about it esp. if those groups are snoooping around in my "sanctuary."
Part of the reason I "cruise" is that I like to see the other side of the argument. And I've learned a lot which has helped me get better at negotiating these types of issues.

But I don't think that means I (or another specialist that is lurking) can't weigh in and likewise attempt to share a point of view. If you think that counts as "snooping around in [your] sanctuary, then you might as well go and yell in your work room because that will do about as much good as your last post with your attitude.
 

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bulgethetwine said:
Part of the reason I "cruise" is that I like to see the other side of the argument. And I've learned a lot which has helped me get better at negotiating these types of issues.

But I don't think that means I (or another specialist that is lurking) can't weigh in and likewise attempt to share a point of view. If you think that counts as "snooping around in [your] sanctuary, then you might as well go and yell in your work room because that will do about as much good as your last post with your attitude.
Here is something for all the Uber-sensitive ED types. You will see that the grand majority of posts on this thread are by you. Which probably means: 1) you have too much time on your hands and 2) you have some serious inferiority complex issues that you need to work out. Constantly dredging up this thread to flame IM people is counter-productive. My post above was basically saying why can't we all get along. For some reason this has led to a hail of flames. Fine. You prefer that we don't respect you at all, that is cool with me. Hating/disrespecting ED doc's is really a lot easier anyway.