Clinical pearls picked up along the way...

[SERENITY NOW]

I just got out of a great conference that had some excellent take-away learning points, and I thought to myself, "you know, everyone should be able to hear this... its really good stuff!"  Since I enjoyed writing the residency blog (link in my signature below) but have since finished residency and now have even more free time, I figured it might be fun to start up a new thread.  A thread where we can all share the worthwhile learning / teaching points that we tend to stumble upon as we study, work, interact with colleagues / consultants, and go to the "state of the art" conferences around the world.  We are certainly all exposed to endless resources and constant learning, but you know how it is... its somewhat rare to stumble upon a speaker, article, lecture, website, textbook, or what have you, that is just "top notch"and worth sharing... those are the kinds of things I'd like to include in this thread.  I want this to be open for everyone, students and professional PAs alike; if any of you learn something out there on your journey that you think is worth sharing, please share!  It could be links to specific resources, or simply your take-away learning points / notes on the topic written out.  In a bit I'll be writing up post #1 on the conference I went to today as an example.  Let me know if you all think this would be worthwhile.  

-SN

 

[SERENITY NOW]

Excellent Conference!  

The conference I went to today was a whole day dedicated to two topics:  consulting and presenting.  They emphasized that these are trainable skills that are rarely taught in school (nor residency), and instead is something that most people learn through trial and error... lots and lots of error.  Trust me, when first starting out, this is often one of the most anxiety-provoking things for people.  You'll feel overwhelmed with a complex patient, you'll know that you need help, but won't know how exactly to go about finding that help, nor how to word your request for the help.  You might start out by fumbling through a presentation with your supervising doc, who will quickly loose focus if you don't keep it concise, and they might just say "run it by the specialist", or "just admit the patient".  When you start out, its really hard to do this!  What are you supposed to say over the phone to the specialist?  What kind of answers are you looking to hear?  What if the hospitalist refuses the admission?  There are so many more questions than answers when you first start out, and it can be overwhelming at first.  The point of this conference was to help break down the process into steps, just like everything we do in medicine... steps of the ABCs... HnP...  consulting/admitting... etc.

 

Part 1:  Steps in the consultation or admission process

Step 0 - A) Before even calling the consultant, formulate your clinical question or request for them, and know what it is you need from them.  You are going to have a much tougher time interacting well with consultants if you are unprepared and haphazardly ending up always saying, "I'm just calling to run this by you", without a specific request in hand.  There are specific reasons for consultation / admitting and you should be aware that your reason should fit one of these.   

Step 0 - B) Still before calling the consultant / admitting hospitalist, anticipate the things they will want to know, try to look them all up so you can be prepared.  Anticipate their blocking points (typically for admission).  More on this later.  

You send out the page, and they call back.  

Step 1) Introduce yourself.  "Hi this is Serenity Now the PA covering Mt St Elsewhere emergency dept"

Step 2) Get their info (it can't be documented in chart, "spoke with ortho" - you need specifics.)  "Who am I speaking with?"  Confirm they are the service you need and they cover the area you're addressing (i.e., a private orthopedist in the community, confirm they can see peds).  

Step 3) Right at the get-go, tell them your clinical question / clinical problem / the reason for the call.  "I'm calling to admit this patient in room 15, Ms Jones, for sepsis with pyelonephritis".  Do NOT start the call with the classically taught student presentation format, "This is a 51 year old woman with a pmh of htn, gout, gerd, anxiety, right big toe fracture, insomnia, migraines, dentalgia, who presented with a few days of headaches, sweats, back pain, chills, abdominal discomfort, body aches, burning with urination.  Denies drug use.  Denies past surgical hx etc etc......  aaaand I think they have sepsis with pyelonephritis warranting admission.  You want to start immediately with the whole point of your call, and only then do you get to the case presentation.  If you ever find yourself on a rotation or specialty where you are covering the consult phone, you'll notice very quickly how it can get infuriating when people drone on and on without getting to the point.  It is so much more helpful to the consultant to have a frame of mind with which to hear the presentation.  

Step 4) Present the case.  Each case presentation is really unique and dependent upon the clinical situation - an ortho presentation should look different than a cardiology presentation etc - still, there are some common rules of thumb.  Case presenting is certainly a skill in and of itself, and has its own steps as well:

Again, start with the chief complaint to frame it.  "A chest pain patient"

Age and pertinent medical history.  "45 years old with a PMH of DM, HLD, and smoking"

Very brief / pertinent HPI and exam - "Describes typical CP with onset 3 hours prior to arrival and had been constant until resolution with nitro.  They're otherwise well appearing and their vitals are normal."

Pertinent workup results.  "EKG showed some T wave inversions in the inferior leads, troponin elevated to 0.7."

Address the things they'll being thinking about and might use to try to block the admission.  "No prior caths or stress test done, but last time in ED her prior troponin values were normal.  Creatinine normal.  the T wave inversions are new as well"

Since you've addressed everything they need to know and they can't refuse the admission, tell them other relevant details, like things still pending in the workup, other important info about the patient (non-english speaking, DNR/NI, neuro deficits at baseline, etc as relevant)

...And just like that, you've successfully consulted on or admitted your patient in a way that makes everyone happy, and the patient gets what they need!  

 

Part 2: "The block"

....Of course, we all know that there are many cases, at least as has been my experience in the emergency department, where it just doesn't go smoothly.  You'll know that the patient is sick enough to warrant admission, or to warrant a specialty procedure, or what have you, but your request for admission or consultation is blocked.  I really struggled with this when first starting out.  I'd think to myself, "well if the hospitalist says admission isn't warranted, I guess there is nothing I can do but discharge them".  Wrong!  I soon found out that while most hospitalists are great, a select few will seriously try to block anything and everything, and if you aren't prepared for that, your patient care will suffer.  What's more, you are definitely still on the hook if there ends up being a bad outcome on a patient you discharge regardless if the hospitalist refuses admission!  

The first step in preparing to counter the admission block is of course, learning the medicine.  The more you know, and the more experience you have, the easier this gets. Aside from this obvious point, the conference went through many of the common arguments used to block admission/consults, and the things you can do to prepare yourself for them.  In each patient you are going to consult / admit, it helps to consider which of these might apply, and prepare yourself before starting the conversation.  The following are the common arguments...

-"this is just the patient's baseline... I doubt there is any acute change" --> always always always look up prior lab values to compare, and past admissions for similar situations.  Don't get suckered into playing the number game if it is irrelevant... "regardless of the unchanged numbers of their WBC (or whatever test they're referencing), the patient sitting in front of me clinically is having an acute problem; its been 2 days and they are now so dyspneic that they can't prepare food and eat, they are tachycardic which they havent been before, and they've been bounced around while progressively worsening so clearly the outpatient plan isn't working."

-"I see no indication for admission" --> when you have an established diagnosis, there often are objective admission criteria that you can look up online (up to date, etc).  One hospital I worked at even had a reference sheet with specific admission criteria that hospitalists couldn't protest since it was all predetermined.  

-"I don't think this is appropriate for my service - its okay for observation unit /or/ it needs to be upgraded to step down / ICU" --> learn ahead of time what each floor's resources are and what is unique about them all.  This takes time to learn... i.e. if the patient needs tele monitoring, how stable their vitals are and if they need q2 hour vitals or q8 hour vitals, etc.  If there is an obs unit, there should be exclusion criteria which often help a lot.  If you keep getting the run around, don't waste time, just say, "its not appropriate for obs; whether it goes to a general medical floor or step down is up to you and your other hospitalist to decide; give me a call back when you've found a bed".  If you play telephone relaying their messages back and forth with both of them blocking, you're just acting like a middle man which wastes everyone's valuable time.  

-"you're missing part of the workup (i.e, DVT ultrasound should be done)- call me back later when its done and I'll admit then" --> we see this often done as a stall tactic when people are going to leave shift and that will stall long enough for their partner to come in and do the admission.  Just say, "regardless if the DVT scan is positive or negative it won't change which bed the pt ends up going to... I'll put in the order for your ultrasound now and the bed request and we will send them up after its been done".  

-"you've already done everything that needs to be done; what do you want me to do when they're admitted?" -->  Regardless of how much or little needs to be done for the patient, if you feel the patient is sick, is too high risk to go home, and meets admission criteria, they need to come in.  Even if it means that all that is being done is serial exams, monitoring, sx control, and a PT eval until the patient has stabilized and is deemed safe for discharge.  

-in the case where you might not necessarily find a specific diagnosis that has inpatient admission criteria, there are some other situations to be aware of as well.  Failure of outpatient treatment, intractible pain after several rounds of IV pain medication, inability to tolerate PO after antiemetics, inability to walk or care for themselves at home especially in elderly patients are all also admission criteria (sometimes only to an obs unit).  Just be aware that these are garbage-can diagnoses that should only be considered diagnoses of exclusion after a really good HnP and workup.  The elderly patient who syncopizes and comes in with severe back pain and bilateral radicular leg pain should not just be admitted for ambulatory dysfunction without a very thorough workup.  

 

Conclusion:

 Clearly this conference was mostly geared towards an EM or FM provider trying to interact with IM and subspecialty services.  I mean no disrespect to hospitalist PAs or subspecialty PAs when I mention all of our frustration with admissions and consults being blocked.  I rotated on many IM and specialty services during school and residency and covered the pagers myself, and I quickly saw their perspective as well - there are so many awful sign outs and inappropriate patients sent from the ER - I know it can be frustrating dealing with the ER as well!  In fact, I'd love it if a hospitalist or subspecialty PA came on here and wrote up a guide to how to communicate and deal with the ER... I bet we'd all learn a thing or two!   I think that learning these things covered in the conference today is all about how to effectively communicate with each other, in the best interest of the patient.  If new PAs come out of school and think its going to happen naturally overnight, they are in for a rude awakening!  It takes time, learning, and practice.  I hope this brief primer can help students think about consulting / presenting in a more systematic and thoughtful manner, and start getting an understanding for the many road bumps that they'll undoubtedly encounter even on day 1 out in practice.  I hope it helps!

[SERENITY NOW]

"Dr. Lorrel Brown covers the basics of shock including how to recognize cardiac shock from history, physical exam and invasive monitoring."

This lecturer, Dr Brown, is one of the best lecturers for cardiology that I've come across online. She has several lectures that I'd highly recommend. Also, in general, this "Louisville Lecture Series" (the internal medicine residency lecture series) offer very nice, high quality lectures mostly geared towards internal medicine, but also easy to apply in other specialties.  http://www.louisvillelectures.org

For other "best of the best" lectures from Louisville - check out http://www.louisvillelectures.org/imblog/2016/7/6/best-of-the-2015-2016-academic-year

 

 

http://www.louisvillelectures.org/imblog/2015/7/2/shock-and-hemodynamics-in-the-ccu-with-dr-brown

 

[EMEDPA]

thanks for doing this. I recently started a post about listing" rules" in your note. I think several of these can help when a hospitalist tries to block an admission." their heart score is XYZ, etc"