Selling your Patients and Beating "The Block"

[NinerNiner999]

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I know that as EM docs we all face difficult consults and admits from time to time, but I am curious how difficult some of your hospitals are out there regarding seeing your patients for admission workups. I know that at my institution it is often difficult to get sick patients on the floors and that I spend a fair portion of my shifts anticipating tests that will be palatable selling points for consulting services to entice them to pay my patients a visit.

Have many of you experienced the block by medical or surgical services and their constant turfing back and forth? I have had patients wait up to 10 hours to be seen and admitted to the floor, often times going through three or four different services before someone is willing to take them. I get silly responses like "well, why don't you order a mag and phos and tell what they are before we admit your chest pain patient with ST elevations" and my personal favorite - "He's well known to our orthopedic service, but I really need plain films and a contrast CT of his leg before I come down to tap his knee. Oh what? His creatinine is 1.6? Why don't you get him into IV contrast range and call me when you have his scans."

How much should we do in the ED for our consult services before we are no longer performing tests we need as emergency docs?

 

[DrQuinn]

At my institution (Univ of South Florida) it is very resident-dependent, but often we can just pull the "put your attending on the phone" card and they will balk immediately. Some of the upper-level residents, however, we can trust, like the vascular fellows or the hand fellows, since they are technically "surgery attendings." When it comes down to the medicine residents, basically if the patient meets inpatient criteria, they'll get admitted. It can be a little frustrating but it seems at your place its a little tougher. At my hospital, its a 70/30 mix of resident patients to private patients. I absolutely love dealing with the private hospitalists, they are so nice when they come down to the ED and they will take everything (with insurance).

 

[Scrubbs]

Its very institution dependent for us (we work at 5 hospitals). At the 2 community places its super easy to get a medicine admit - we have to call the attending for acceptance before we tell the residents. Attendings see admissions as money instead of work, so we generally don't have a problem. Surgery is a different story b/c we go through the residents. If I feel really strongly about someone, I just call the attending to get the admit.

Our academic hospitals are a little trickier. We go through a triage resident for medicine admissions, which means you have to have all your ducks in a row to get the person in. As far as I'm concerned, a 60 year old diabetic with h/o MI coming in with CP - EKG changes or not - is coming in for a rule out. I don't really care what the Mg and PO4 are!

Oh, and I don't know how everyone else's departments are, but Ortho NEVER admits (even if its blatently an ortho patient or a bounce back from surgery 2 days ago). Also, most of our surgeons don't really like surgical patients. They'll come up with 900 reasons why the patient with CT confirmed appy is really a medical patient. Frustrating sometimes, but what we all learn to deal with and around. 😉

 

[deleted6669]

worst surgical turf ever...
80 yr old guy with obvious small bowel obstruction with all evidence to support
surgeon: he's vomitting too? I want gi to see him first and if they think I should come in I will...
gi: "what the hell?"(comes in confirms sbo)
guys surgery is delayed by hours. pt goes to o.r. and ends up loosing FEET of previously viable bowel tissue.

 

[Eidolon6]

As a medicine resident, I have admitted a number of patients for some "dire problem requiring admission" and subsequently discharged them less then 12-18 hours after their admission often without any definable (or required) intervention because the ER doc could use flowery language and laboratory embellishments to get his patient admitted.

More often than not, we get dumps from other services, esp. surgery and psych, after they've refused the patient in the ER. But our trump card is the middle of the night "emergent" surgical consult where the surgery resident gets to admit his mistake and take the patient to the OR and explain to his attending why he refused to see or admit the patient in the first place.

Some of the worst ER docs I've dealt with are in the private hospitals where they play the game of "What single lab test will get my patient admitted to medicine?!?"

The fact of the matter is...it shouldn't be a sell. When you call me...have your facts straight, do a reasonable ER w/u, tell me what you are thinking, and fight the friggin' urge to be lazy if you can dispo the patient without having to admit them (that one really boils me). For the most part, we want what's best for the patient (which may or may not be getting them out of the ER as soon as possible (depending on your locale)). The other thing is, if a patient falls on the fence....before you admit, call a consult (medicine consults do exist) and have them look at the patient and decide for themselves....that way as the treating ER doc, you have a second opinion if you decide to let the patient go home versus putting them in the house for a questionable indication.

As for ortho, I am with you guys. Medicine takes all the hip fractures, geriatric fractures, or anyone with diabetes or even a remote history of lung disease. The problem with ortho training is that they don't have weekly (or daily) morbidity rounds where they get to round with the medicine teams (on their former patients) to see how their ineptitude has caused overt harm to innocent people.

 

[ERMudPhud]

I know that as EM docs we all face difficult consults and admits from time to time, but I am curious how difficult some of your hospitals are out there regarding seeing your patients for admission workups. I know that at my institution it is often difficult to get sick patients on the floors and that I spend a fair portion of my shifts anticipating tests that will be palatable selling points for consulting services to entice them to pay my patients a visit.

Have many of you experienced the block by medical or surgical services and their constant turfing back and forth? I have had patients wait up to 10 hours to be seen and admitted to the floor, often times going through three or four different services before someone is willing to take them. I get silly responses like "well, why don't you order a mag and phos and tell what they are before we admit your chest pain patient with ST elevations" and my personal favorite - "He's well known to our orthopedic service, but I really need plain films and a contrast CT of his leg before I come down to tap his knee. Oh what? His creatinine is 1.6? Why don't you get him into IV contrast range and call me when you have his scans."

How much should we do in the ED for our consult services before we are no longer performing tests we need as emergency docs?

Unfortunately you work at an institution where medicine and surgery have tons of power and EM has little if any power. That is the price you pay for working at an institution like JHU. At places where EM has more power the more typical practice is that if the EM attending feels a patient needs to be admitted to a particular service then they get admitted to that service unless they are seen and refused by the attending. With this increased power comes some increased responsibility since it is up to you not to dump all kinds of crap into the hospital. In a way though its easy. Since the clear cut admits get admitted with little fuss or time it gives you more time to focus on the less clear cut cases and hopefully not have to just punt them in.

There are some things you can do to help yourself. Instead of looking for the magic test that will get your patient admitted concentrate on giving a clear/concise history and more importantly how that history and whatever workup you have so far leads to a specific differential list that requires admission. If your admitting service asks for further tests ask them which items on your differential will be conclusively ruled out and what results would allow the patient to go home(i.e. "so if the Mg is normal they can take their elevated ST's home with them?") If they can't answer you than the patient should come in and get the rest of the work up as an inpatient. The problem of competing services trying to turf to each other is one of my favorites. I explain to both services why the patient isn't going home and then tell them to discuss the case with each other and tell me who is taking the patient. Pancreatitis with gallstones, choledocolithiasis, nonoperative ICH are just a few examples of the many diagnoses where this turf war happens.

Most importantly, get your attending involved. It should be easier for them to explain(not sell) to the admitting services why they should be admitting the patient. Also, log the time you call the first admitting service, when they finally came to see the patient and when and where the patient finally got admitted. That way when the hospital administration starts crapping on your EM director about why the ER is always so backed up he can present them with a long list of patients who clearly needed to be admitted along with the times that the admitting team was called and the time they saw the patient. If the lag is in hours you may have the ammunition you will need to institute a policy of the admitting service seeing the patients up on the floor and not in the ED. That's how it is where I work and where I trained and we loved it. It also spurred the admitting teams to hussle down to the ED if they wanted anything done before the patient went upstairs. In the end it was good for us, good for patient care (they didn't languish in the ER) and good for the admitting teams. The admitting teams ended up liking it because now instead of us constantly badgering them to hurry up and admit the patient they could prioritize patients based on severity of illness. A stable patient with probable endocarditis might not get seen on the floor for several hours but since they've already been cultured and treated there isn't much that needs to be done right away anyway. Meanwhile the borderline COPD'r who isn't doing so well gets immediate attention and no one is parked in the ED waiting for the admitting team to show up.

Finally, tell ortho you can't imagine how a contrast CT( or even plain films) of the leg is going to change the need to tap a clear cut effusion seen both on physical exam and ED u/s. Furthermore, that in the interest of patient care and the expeditious diagnosis of a septic joint you would be glad to tap the joint for them unless they really want to come right down and do it. Then tap the damn joint. You might also point out to them the physiology underlying creatinine clearance and that you could buff the patient in the ED for a day or two and barely change the creatinine.(since they forgot all renal physiology right after they scored 260 on step 2) Even if you did manage to buff his creatinine from 1.6 to 1.4 it probably wouldn't change his risk for contrast nephropathy.

 

[southerndoc]

I have to admit, I have it made at my program. With most patients, we put in an admission request into the computer, receive an infogram a few minutes later, then call the admitting resident and give report. The resident sees the patient upstairs -- not in the ED! Only the consulting services like surgery, ortho, neuro, etc. see the patient in the ED.

I have to admit that I rarely have to argue to get an admission. The only time I do have to argue is when I talk to a private attending, which is rare because most admit to the university service or admit anything you think needs to be admitted.

On another note, how many of you absolutely hate trying to get an admission for a patient you don't think needs to be admitted, but your attending is telling you to admit? It's hard to sell a patient when you yourself aren't sure the patient needs to be admitted. This happened to me the other night. Neither I nor my senior resident thought a patient needed to be admitted, but an attending did.

 

[ERMudPhud]

On another note, how many of you absolutely hate trying to get an admission for a patient you don't think needs to be admitted, but your attending is telling you to admit? It's hard to sell a patient when you yourself aren't sure the patient needs to be admitted. This happened to me the other night. Neither I nor my senior resident thought a patient needed to be admitted, but an attending did.

So ask the attending why you think the patient needs to be admitted. Then explain why you think they don't need to be admitted and see what they have to say. That way you will already have run through the conversation you are going to be having with the admitting team. If you are still not convinced tell the attending to call the patient up. I did that once or twice during residency. I wouldn't recommend it as a frequent tactic but if you truly think the admit is bogus go for it but expect to get a crappy evaluation in return.

 

[southerndoc]

So ask the attending why you think the patient needs to be admitted. Then explain why you think they don't need to be admitted and see what they have to say. That way you will already have run through the conversation you are going to be having with the admitting team. If you are still not convinced tell the attending to call the patient up. I did that once or twice during residency. I wouldn't recommend it as a frequent tactic but if you truly think the admit is bogus go for it but expect to get a crappy evaluation in return.

Guess I'm just too new to argue my stance. I will try that next time.

 

[ribsandbbqbeef]

A lot of it also has to do with who the ER resident is and who the medicine resident is. Medicine admitting residents generally know which ER residents give "real" cases to them and which ones like to "dump" cases; so depending on who's calling him for the consult, he may or may not give them a hard time.

On the flip side, some medicine residents just try to bounce virtually everything for whatever reason and no matter how convincing your case may sound, you'll still have a hard time admitting.

My attending told me that as long as we do what we are supposed to do and have worked the patient up adequately, we call medicine to TELL them they have an admission, not ASK them if we can admit to them. It's the ER doc's decision whether the patient should be admitted. If the medicine service refuses or disagrees, that's fine since different training backgrounds may have different perspecitives on the problem, but then it's up to the medicine service to discharge the patient from the ED since they are refusing the admission.

But instead of this "tougher" way of thinking, I usually like to take the middle ground. If I think a patient needs to be admitted early on in the workup (even before all the labs are back), I call medicine service and curbside them my case to give them a heads up. If they think that it probably will not become a medicine admission, they usually will say what consult to get. I get the consult and if it's negative, then medicine has nothing else to say since I did everything they wanted. But this way, you're not wasting time waiting for all your labs and scans to come back before you call for consults....

~ribs

 

[The White Coat Investor]

On another note, how many of you absolutely hate trying to get an admission for a patient you don't think needs to be admitted, but your attending is telling you to admit? It's hard to sell a patient when you yourself aren't sure the patient needs to be admitted. This happened to me the other night. Neither I nor my senior resident thought a patient needed to be admitted, but an attending did.

I hate that.

 

[docB]

I had a pt when I was a resident who needed a social admit (homeless, too weak to walk, mild dehydration, incontinant, etc.) The policy at my hospital was to admit to the PMD (of course) and if there wasn't one to admit to either IM or FP depending on the med rec number. I checked all these things out and called the IM tern. I said I was real sorry but the guy had to come in and the guy was his. The intern argued to no avail. Then he comes up about 20 min later and says "Hey, this guy is FP. He has an FP PMD." I reply, "No, he was seen by that doc in house once so that's not his PMD and even if she was that FP attending is part of a group that the medicine dept is contracted to admit." He sulks off. He returns 30 min later and says, "This guy goes to FP because his med record number is even." I reply, "No, you're reading the wrong number. This is his MRN and it's odd." Intern gives me look of resignation and I could help but add, "And if you'd just done the admit when we first talked you'd be done by now."

 

[Apollyon]

Yesterday, had an interesting patient, and something germane to this thread.

Radio call for inbound 39 male DM, "no radial pulses but a strong carotid" (these guys give weak reports here), "high" on glucometer. Into ED, lethargic, strong pulses (systolic 200), covered in stool, retching. Glucose is 726, ketone (+) to 1:8, with ABG 7.41/42/103/2/26/96, lactate 3.8, and a gap of 18, osmolarity of 326. That's right - nl pCO2, bicarb, and pH. DK(A) vs. HONK. With his retching, gets an NG, that returns dark red blood, and lavages to clear with coffee grounds. Afebrile, nl CXR, H&H10.4/34, WBC8.5.

Call the MICU, they've got a full boat, but she's working with me. Guy's gap closes, his glucose comes down, he gets 6L of fluid. He's still complaining of some abdominal pain (which he's had for YEARS). Got Protonix IV when the first lavage came out.

Repeat CBC (after 6L) is virtually the same, with H&H unchanged. White count is up to 13, but still afebrile. Pt is stable for the floor, and MICU resident agrees. The admitting resident (who is IM-2, just like the MICU resident), absolutely FLIPS, whining and crying and saying "He can't come to the floor - he needs a unit", reinventing the wheel, saying, "Is this a Mallory-Weiss, and did it perf?", and I said, "If it was Boerhaaave's, he would be sick as stink, and, he's not - he just has the abdominal pain". I tell him about the ABG (again), and he says, "it (the pH) could be compensated", and I said, "with a normal pCO2 and bicarb?" He doesn't say anything to that, and says, "He could be hemoconcentrated - the H&H might be artificially up" (and my response - after 6L of fluid?) (Oh, I forgot - when I called the pt. in, I told the resident that the insulin drip was still on, and, before I could say the SQ had been given, he says, "Why? Why is the drip still on?" At our hospital, an insulin drip can go to the floor, no question, no problem, but that wasn't even germane.)

The MICU resident is in a bind - she has no beds, and this guy is a soft unit candidate. She says her fellow is going to LAUGH at her, and balk at taking him. But, she says, she can't TELL the floor resident that he has to take the patient. Moreover, sight-unseen, the floor resident called the chief resident (IM), saying "this patient sounds unstable". The floor resident says, "Did you call GI? Does he need an emergent scope?", although the MICU resident had TOLD HIM she had already spoken with the GI fellow about this patient, and that he didn't need a scope right now.

By this time, with all the wringing of the hands, the new attending has come on, and he is no BS (Major, USA MC, in Iraq this time last year, Haz-Mat, on the one of 4 federal disaster medical teams in the US that is based in this state, and volley firefighter to boot), and he says, "CXR. shock panel, and we'll go from there. If there's free air in the mediastinum, we're done".

As has happened before, I forgot to pass the code pager off, and, when I returned at 1:30, the patient 1. still has a floor bed assigned 2. is still in the ED. I didn't even WANT to know what the deal was.

My attending says, "He's (the floor resident) early into his second year, unsure, it's not a problem", and I said, "Well, the MICU resident is 2nd year, too, and she's a LOT more squared away". But this guy (despite the mandate this year that IM CANNOT decline an admission) still tries to block every one, anyway.

 

[Annette]

DKA on the floor? The nurses would be going nuts with q1-2 hr bs!!! And it wouldn't get done. This is better patient care? You guys are comfortable with this patient on the floor? Having no ICU beds can not be an issue. Send the patient to a hospital with an open bed, then!

And you all want to be able admit patients to medicine without medicine seeing them first???

Yes, blocking admits and bad admits are VERY resident dependent. The best we can do is what we think is best for the patient. You think a patient is stable enough to go to the floor, when the medicine resident is so busy they can't get to the ed? Well, you had better be prepared to take a lot of crap should that patient crash. I get my butt to the ED asap when I get called for an admit. I hate when the ED has had a patient for over 4 hours when it was obvious the patient was going to be admitted in triage, then complain when I delay the nurse from packaging the patient up so I can do a 10 minute H+P!! Most of the ED residents where I'm at do a great beginning workup. However, a few of the residents blithely ignore the patient and go stright for dispo. It ain't pretty when an ICU or CCU patient ends up on the floor. I often pray for the patients those residents send home!

 

[Sessamoid]

And you all want to be able admit patients to medicine without medicine seeing them first???

Need I remind you that in the world after residency, practically all patients (floor and ICU) get admitted without their primary seeing them first, or even at all the same night?

 

[Annette]

Yes, and that makes me very nervous!

 

[Eidolon6]

Much like ER residents learning to "sell" the patient, medicine residents have to both learn the "sell" and the "block". IM docs often have to sell their patients to less than eager consultants as well as block bogies from the ER. For blocks, the art is forcing the ER to avoid the path of least resistance all of the time and if possible, provide feasible alternatives to admitting a soft admit (part of this involves being a good internist and knowing what you are talkin' about).

For example, the Heme/Onc fellow accepted a patient the other day from an ER doc who was just sure a patient with a history of esophageal cancer that had been successfully treated had known bilateral pleural effusions despite a BNP of 1000 w/ a history of heart failure, without evidence of hypoxia, respiratory distress, fevers, chills, chest pain, etc. His only complaint was orthopnea/PND. So what are the possible options for this patient? A) admit them overnight to the hospital so they can get a thoracentesis and go home the next day and charge them for it. B) do a thoracentesis in the ER and send the fluid for the appropriate studies as dictated by the oncologist, check a post tap CXR, watch the patient for an hour and send them home C) consider diuresis and establish a f/u appointment with the oncologist in a few days for possible thoracentesis.

The ER doc insisted on admission on a completely stable patient with mild symptoms of heart failure, who was not on diuretic therapy, and the Heme/Onc guy, to his credit, accepted the patient knowing that he couldn't trust the ER to get it right had he refused him and laid out a reasonable plan for follow-up. Me, being the resident, had to admit the patient, do a quick thoracentesis and tell the patient that I could send him home that night, but he'd be charged for the admission (at least a 23 hour observation) in the midst of more pressing things. He chose to stay for the f/u of the tests run on the fluid. I didn't mind doing it...but it was avoidable and the patient could have been in his own bed, his pockets still a little heavier.

The frustration is that we could block a lot more admits, but we choose not to because a lot of us fear that it is better if we do it ourselves. The excuse that the "ER f*#@ed up again" doesn't fly. We also quickly learn which residents and attending we can trust. A good deal of us have notches on our belts and sharp memories of those that have sold us (or tried to sell us) the hooker w/ a heart of gold. Having done at least 3 months of ER in my residency so far, I can definitely understand the ER docs frustrations, but I have also witnessed their lax approach to admission especially to medicine and ICU services. If its not a slam dunk on the initial dish, then it is totally reasonable, especially for a seasoned internist or resident to ask whether there is a safe way to keep the patient out of a hospital bed and still treat or palliate their problem. If thats a block (or attempted block), then so be it....I will continue to do it and will fight when I know I'm right.

 

[Sessamoid]

Yes, and that makes me very nervous!

Then I can expect you in to see the patient immediately any time I call to admit one of your patients? 😉 I'd love that!

 

[aphistis]

For what little it's worth from a dental student, this is a great thread. Solid arguments from both sides, and it's stayed civil to boot. Why can't the rest of the world be like y'all EM folks? 😉

 

[Apollyon]

DKA on the floor? The nurses would be going nuts with q1-2 hr bs!!! And it wouldn't get done. This is better patient care? You guys are comfortable with this patient on the floor? Having no ICU beds can not be an issue. Send the patient to a hospital with an open bed, then!

And you all want to be able admit patients to medicine without medicine seeing them first???

Yes, blocking admits and bad admits are VERY resident dependent. The best we can do is what we think is best for the patient. You think a patient is stable enough to go to the floor, when the medicine resident is so busy they can't get to the ed? Well, you had better be prepared to take a lot of crap should that patient crash. I get my butt to the ED asap when I get called for an admit. I hate when the ED has had a patient for over 4 hours when it was obvious the patient was going to be admitted in triage, then complain when I delay the nurse from packaging the patient up so I can do a 10 minute H+P!! Most of the ED residents where I'm at do a great beginning workup. However, a few of the residents blithely ignore the patient and go stright for dispo. It ain't pretty when an ICU or CCU patient ends up on the floor. I often pray for the patients those residents send home!

1. The gap was closed.

2. At Duke, everyone - everyone - acknowledges that DKA can be handled on the floor, if it isn't severe. In my prelim program (Elmhurst), I managed several DKA's on the floor (compounded with occasionally incompetent nursing). The q-hourly fingersticks weren't a problem. More than one time, when I was prelim, CCU/ICU players were managed on stepdown. We were able to muddle through easily enough. One guy DID die, but I was in clinic (I had called the code before clinic, but then he coded again). That was a guy that the dingus critical care fellow had said his mantra - "You're doing everything we would be doing".

3. This patient did a. go to the floor b. get scoped the next day (not that night) bi. had a NEGATIVE scope, except for some mild gastritis c. not crump - at all.

4. This resident whining and crying had his own colleague - his year - saying that the pt could go to the floor. Moreover, another colleague in the MICU - same year - that I had rotated with last year on cardiology accepted my patient on the ABG and one look at the patient; this was after I was told that a pt on 100% oxygen by face mask couldn't go to the floor, which I didn't know.

As Eidolon6 points out, the block is a two way street - in order to be credible, the IM (usually) person trying to block has to have knowledge on their side. Otherwise, they run the risk of being thought 1. clinically weak/stupid or 2. a slug, which will permeate everything they do.

I didn't admit one patient last night. Had our ED been one as it was before, without EM-trained docs, at least 4 would have been admitted, and multiple consults would have been called. That's what I've noticed, when non-EM trained docs work in the ED. It was clear with a peds critical care doc - no matter what, "call this doc" or "that doc" (cardiology, urology, surgery) happened.

 

[Apollyon]

A) admit them overnight to the hospital so they can get a thoracentesis and go home the next day and charge them for it.

...but he'd be charged for the admission (at least a 23 hour observation) in the midst of more pressing things. He chose to stay for the f/u of the tests run on the fluid. I didn't mind doing it...but it was avoidable and the patient could have been in his own bed, his pockets still a little heavier.

So you had that rarest of creatures - an uninsured patient, who is so because s/he can afford to pay out of pocket, and actually does pay. Some would argue that, if you can pay out of pocket in the US, money isn't a concern for you.

 

[Eidolon6]

44 million and counting, uninsured middle class people and patients. I am insured through my program, however, making what I do now, an equivalent 23 hr admission, had I not been insured, would soak up 1/2 of what I make in a month...for those with an equivalent salary without insurance...thats a big hit.

Anyways, the reality is, insurance or not, the hospital is probably not going to get its due reimbursement (likely a fraction) from an insurance or medicare payor and the patient was inconvenienced when there was an easier way. Again, just citing a recent example, but the principle is there.

 

[Annette]

1. The gap was closed.

2. At Duke, everyone - everyone - acknowledges that DKA can be handled on the floor, if it isn't severe.
. . .
3. This patient did a. go to the floor b. get scoped the next day (not that night) bi. had a NEGATIVE scope, except for some mild gastritis c. not crump - at all.

4. This resident whining and crying had his own colleague - his year - saying that the pt could go to the floor. Moreover, another colleague in the MICU - same year - that I had rotated with last year on cardiology accepted my patient on the ABG and one look at the patient; this was after I was told that a pt on 100% oxygen by face mask couldn't go to the floor, which I didn't know.

As Eidolon6 points out, the block is a two way street - in order to be credible, the IM (usually) person trying to block has to have knowledge on their side. Otherwise, they run the risk of being thought 1. clinically weak/stupid or 2. a slug, which will permeate everything they do.

I didn't admit one patient last night. Had our ED been one as it was before, without EM-trained docs, at least 4 would have been admitted, and multiple consults would have been called. That's what I've noticed, when non-EM trained docs work in the ED. It was clear with a peds critical care doc - no matter what, "call this doc" or "that doc" (cardiology, urology, surgery) happened.

I deleted some parts of the reply for space.

I wholly agree that the block is a two way street. As for the peds crit care doc, could it at all have been due to him/her being PEDS? I trust most of the ED residents, but there are always a few that I wouldn't trust further than I could throw. Same with medicine residents. And the ED's approach is also different than medicine's. You are looking for "does this pt need to be admitted?" Medicine's looking at what is making this person ill.

Didn't realize the gap was closed. Missed that in my reading. However, you must have great nursing staff on the floors. Had a patient die last year on the floor after short acting dose insulin got mixed up with the long acting dose, and the patient wasn't checked on for over 5 hours. The floor nurses are running all the time, and I know for a certainty that q 1-2 hour BS wouldn't be done. They have trouble with q4 vitals! At my hospital insulin gtt=ICU or stepdown. In the not-severe DKA's I'd love to have them in the ED for just a few hours longer then sent to a floor bed off the gtt, but that isn' too feasible either.

As for the same year resident saying it is ok, there is a vast range of experience in residents of the same year. In my year, there is a guy who practiced for 20 years in Columbia before coming here. And, another cardiologist who practiced for 9 years in Russia. I would certainly trust their assesments over some of the third years. I guess I am also lucky in the we have an ATTENDING in the ICU at all times. They have the final say in unit admissions.

Sessamoid, I'm seriously considering CCM, so I'll be there! If I were going into primary care, it would seriouly depend on 1) how much do I trust you and 2) the work-up you have done so far! I look forward to seeing ya!

 

[ERMudPhud]

DKA on the floor? The nurses would be going nuts with q1-2 hr bs!!!

We did it all the time,with the gap still wide open, when I was an intern. Of course it was the interns job, not the nurses, to check the FS and adjust the drips. Where I was an intern even being vented didn't put you in a unit. I managed plenty of semistable vented patients on the floor. It sucked but that is what happens when resources are stretched to the breaking point or mismanaged.

 

[ERMudPhud]

I hate when the ED has had a patient for over 4 hours when it was obvious the patient was going to be admitted in triage, then complain when I delay the nurse from packaging the patient up so I can do a 10 minute H+P!!

On the other hand I've lost track of how many times I got screamed at by IM residents for calling them before the haptoglobin level or some other equally obscure and pointless test came back.

 

[ERMudPhud]

Then I can expect you in to see the patient immediately any time I call to admit one of your patients? 😉 I'd love that!

That is one of the best things about us having hospitalists. Before they started admitting virtually everyone I would try all kinds of things to pin down the PCP on when they would be seeing the patient. Even going so far as to say that my assessment in the medical record is that this patient is so unstable they need to be seen within 30 minutes or for a few cases telling the PCP I was holding the patient in the ED until they could arrive to accompany them to the ICU.

What was worse was being called to the ICU to stabillize some disaster and when I was done asking the nurse, "So when is his doc/intensivist/CT surgeon/whatever coming in?" and being told "Oh, I don't think he is."

 

[Apollyon]

We did it all the time,with the gap still wide open, when I was an intern. Of course it was the interns job, not the nurses, to check the FS and adjust the drips. Where I was an intern even being vented didn't put you in a unit. I managed plenty of semistable vented patients on the floor. It sucked but that is what happens when resources are stretched to the breaking point or mismanaged.

See? That's Elmhurst for ya! The nurses check the fingersticks now, but the vented stable patients are still on A4.

 

[ERMudPhud]

See? That's Elmhurst for ya! The nurses check the fingersticks now, but the vented stable patients are still on A4.

Do they have 24hour dialysis now or is the treatment for CHF and renal failure still rotating tourniquets and phlebotomy? (I'm not kidding, thats how they were doing it a few years ago)

 

[RuralMedicine]

Have many of you experienced the block by medical or surgical services and their constant turfing back and forth? I have had patients wait up to 10 hours to be seen and admitted to the floor, often times going through three or four different services before someone is willing to take them. I get silly responses like "well, why don't you order a mag and phos and tell what they are before we admit your chest pain patient with ST elevations"

I'm not sure where you practice (or if you embellished a little to make your point) BUT the standard of care for a patient with acute ST elevations is either:
-Cardiac catheterization and to the lab in 2hours or less
OR
-Thrombolytic therapy (providing they DO NOT have lytic contraindications)

Sometimes you have to be a patient advocate in order to ensure that the standard of care is met.

 

[Seaglass]

I think he was being sarcastic.

 

[NinerNiner999]

Thanks Seaglass - I was indeed being sarcastic. I'm glad that this thread has turned out to be as worthwhile as it has become. I suppose the big difference between the REAL world (ala Sessamoid) and residency is the presence of the block in its extreme element. Having worked in community, non-academic ED's in the past, it is amazing how polite and quick-to-admit specialist attendings can be with a phone call, especially when basic workup and obvious historical and physical findings provide a diagnosis for admission - no need for floor labs or other innate details to push them off the fence.

Then again, I suppose those in private practice don't have attendings and chief residents to please or are still "students" trying to pave way for their potential fellowship match. Perhaps they rely on a paycheck based on seeing numbers of patients, or even see the benefit of medical care and a timely workup. We too will rely on patient volume and "moving the meat" to some extent as we practice EM in the private world, and it would be nice to be able to see 30-40 patients in a shift without worrying about wasting time for our 12-15 patients waiting for an admit...

 

[mountebank]

good post.

bump