Greetings from your friendly emergency medicine department internist! For those of you who don’t know me, I am an internist and medical director of the ED hospitalist service aka “Gold Medicine.” As someone who was completely in love with emergency medicine prior to realizing that I was someone who enjoyed continuity of care (for the most part!), being an internist/hospitalist in this great department is the best thing ever for me. This department is full of incredible faculty, staff, and residents, and you should be proud to be a member of it. You will learn so much, and from good people.

As an internist, I have a perspective that is a bit different from those of the other faculty in this department. I want to be a resource for all of you, as I know internal medicine patients can be quite challenging at times. I would love to know of topics that you would like for me to write about on this blog and/or teach about in didactics. If I approach you with follow up on a patient you admitted to my team, I am doing it because I think it would be a good learning opportunity for you to see what happens after admission, particularly because some of these patients can still be quite ambiguous when you release them to the “upstairs world” (the rest of the hospital, outside the ED) as I call it.

For the new interns, I would like to give you some tips on how to call your internal medicine colleagues for an admission. People generally want to hear the “bottom line up front” (BLUF). When you call for an admission or consult, immediately tell us you that want to admit a patient and for what reason. Then give a concise summary that includes the patient’s age, gender, relevant PMHx, the high points of the patient’s presenting symptoms and events, and relevant labs and imaging. I don’t want to hear about a patient’s normal alk phos or RDW, and if an admitting doc is grilling you on such obscure details, then, well, they are being unreasonable. We do not want to hear a meandering stream of consciousness presentation that leaves us scratching our heads and wondering if you know what is going with your patient, so please be prepared when you call. Be sure to have easy access to any other pertinent information so you can quickly answer questions asked of you. If you remember nothing else from this: BLUF.

One of the best ways to peeve an admitting or consulting physician is to grab them while you see them in the ED and say “Hey I have this patient I need to admit” and then know nothing about your patient as you try to tell your consultant about the patient on the fly. Another way to frustrate an admitting or consulting physician is to call on a non-crashing patient before pertinent labs or imaging are resulted—especially things that could actually change management and even admitting team. Yes, it is important to be efficient, but sometimes you can be premature in calling for an admission and that is not good either.

Remember that until a patient has a bed slip, that patient is your responsibility. Replete that potassium (and please check a Mg++ level in your profoundly hypokalemic patients and replete accordingly). Bolus that patient with DKA who is dry as a bone. Get those antibiotics in that septic patient. Do that LP on the encephalopathic patient with a fever who has no other obvious source of infection. Order the head CT on that encephalopathic patient who you think is in alcohol withdrawal—you’ll catch some subdural hematomas along the way for sure. Place a central line in that shocky patient who needs pressors or inotropes ASAP. Remember that in the ED, you are going to be able to accomplish many patient care tasks much more quickly than will happen on the floor or even in the ICU. You will save lives or at least prevent further morbidity by being proactive.

We are all here to take excellent care of our patients who also happen to be mothers, fathers, brothers, sisters, sons, daughters, fiancés, aunts, uncles, friends, etc. to someone. This can be difficult to remember when a patient is being “difficult,” combative, “non-compliant,” or downright disrespectful—but when this is the case, remind yourself that there is usually a reason they are acting in such a way. As one of my favorite authors, Gregory Boyle, puts it in his book Tattoos on the Heart: “You stand with the least likely to succeed until success is succeeded by something more valuable: kinship. You stand with the belligerent, the surly and the badly behaved until bad behavior is recognized for the language it is: the vocabulary of the deeply wounded and of those whose burdens are more than they can bear.” Those words truly changed my perspective in dealing with these “difficult” patients, and perhaps I can talk about this more in depth at a later date.

Lastly, just remember that we truly are all in this together. Thank goodness there are so many types of docs with different interests, gifts, and talents. Be the better person and always be respectful, even if the person on the other end of the phone is being rude and grouchy. Make friends with your fellow EM residents but also make friends with residents in other specialties; the personal and professional relationships you foster in residency will often last a lifetime and that is just the coolest.

I leave you with the words of Leslie Knope (my alter ego): “What I hear when I’m being yelled at is people caring loudly at me.” I just hope that you don’t get too much loud caring as your intern years begin and as your residencies progress! : )

Until next time,

Dr. McGee