EM Doc: *Cringes before picking up the phone*
“Hey…it’s Dr. SaltySweet from the ED. I have a placement patient for you…”
Admitting Doc: *Cringes. Sighs. Shakes head.* (This is all one smooth motion, typically.)

I know you dislike calling your (usually) friendly neighborhood hospitalist for the “placement patient” about as much as the receiving hospitalist dislikes receiving that call. However, I would argue that you should never be making that call in the first place. Let me explain.

One of the most dangerous cognitive errors we can make as physicians is premature closure. This is the concept that when the “diagnosis” and disposition are decided, the thinking stops and one disengages from the diagnostic reasoning process. As a hospitalist, I see this happen all too often to patients who are characterized as “placement patients” in the ED. Once the premature closure occurs, the work up frequently comes to a grinding halt. When the patient is labelled as a “placement” in the ED, the admitting physician may be deleteriously biased about the patient before even seeing him or her. As a result, the admitting physician is at higher risk for glossing over important details about the case due to anchoring bias and diagnosis momentum. As you might imagine, this does not promote optimal patient care. On occasion, it can even be dangerous.

As a former EM fanatic myself, one of the reasons I ultimately did not pursue emergency medicine was because I enjoyed continuity of care. I (usually) like knowing what happens to my patients and following them through their hospital courses. As a hospitalist, I have watched the hospitalizations of innumerable “placement” patients play out which is a perspective that EM physicians do not have by nature of their jobs. Sometimes these “placement” hospitalizations are very boring, but that often is not the case. Unfortunately, I have seen “placement” patients unintentionally misdiagnosed and/or misrepresented as more stable than they actually were due to premature closure. I have witnessed these patients become quite ill during their hospital courses through no one’s fault; they were just sick. On a side note, I contend that you should chart check your admitted patients at least once to see if you were correct or incorrect in your initial clinical reasoning and treatment approach; being wrong often feels just the same as being right when you do not see the effects of your actions.

In my career, I have cared for “placement patients” with missed spinal cord injuries, infections, fractures, and intracranial bleeding to name a few diagnoses. I have seen “placement patients” go into respiratory failure and/or shock. I have seen “placement patients” die. I am not saying any of this to place blame, but rather, to contend that physicians should consider looking at the “placement patient” a little more closely before admitting them upstairs. Ask yourself if you might be missing something. Keep your eyes, ears, and “Spidey sense” open. Roll them over and look at their backs and bums; you might be surprised by how many wounds and ulcers you find. You might even find Fournier’s gangrene!

All of this is why I want to educate young EM physicians on why you are doing patients a disservice when you label them as “placement patients” at the very beginning of their hospitalizations. These days, I cringe when I am called about a “placement patient” because I know there is likely more to the story than meets the eye. These patients have illnesses and social situations that are decompensated enough to land them in an emergency department and warrant admission to the hospital. They are not healthy people. They often are (unintentionally) very good at hiding occult illness that later becomes, well, not so occult. Lastly (and this is the superstitious, non-evidence-based part of me speaking), I swear calling someone a “placement patient” brings bad juju into the equation.

In closing, please remember that these so-called “placements” are human beings who are spouses, significant others, parents, brothers, sisters, aunts, uncles, friends, etc. to someone. I would not want my mom or dad labelled as a “placement” if they were admitted to the hospital, and I suspect most of you would feel the same way about your own loved ones. I challenge you to reframe how you evaluate and treat these “placement patients.” Keep an open mind and do not anchor on the idea that the only thing wrong is that they need “placement.” It is almost never just that. Ask yourself questions like: My patient is debilitated and can’t walk, but WHY is that? WHY is it that they laid on the ground for 3 days and could not get up? WHY is their potassium 2.8? WHY do they have altered mental status? Is there something reversible that I can diagnose and treat? In the end, you will do yourself and your patients a favor by reframing how you think and talk about them. Even if your patient truly just needs “placement,” find a more creative and fact-based way to present the patient to your admitting doc. Everyone will be happier, and arguably, safer!

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