nilesh patel july 22, 2009 st. joseph’s regional medical center em conference

Nilesh PatelJuly 22, 2009

St. Joseph’s Regional Medical CenterEM Conference

OBJECTIVES

Review techniques to effectively communicate with consultants

Highlight the DO’s and DONT’s of speaking with consultants

Learn how to navigate the difficult consultant

REALITY

EM physicians frequently deal with consultants by phone

Variety of consultants…Different expertise Develop your own method Bottom Line

We need to effectively communicate with our consultants

This is an under-taught art of EM

CORE COMPETENCIES

Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism System-based Practice Osteopathic Philosophy and OMM

WHAT’S AT STAKE?

Job security Job satisfaction Patient care

EVERYTHING!

THE PROBLEM

EM physician Stress/Heavy patient load Fatigue Work-up

Consultant Inconvenient times Stress/Heavy patient load Fatigue

The Interaction Phone conversation…disconnect

COMMUNICATION

Effective speaker

Effective listener

Accept feedback

PATIENT CARE

SOME EXAMPLES GONE BAD

Symptomatic anemia pt—missed transfusion

SAH pt—received IV Heparin

Trauma pt (glass in brain)—not seen

SBAR

Situation

Background

Assessment

Recommendation

SITUATION

Introduce yourself Chief complaint

Example Hi Dr. Rizzo. This is Nilesh Patel calling from the

ER. I have Mr. Jones in the ER today. He is a 26 y/o male who presents from NJDC with vomiting and diarrhea for 4 days.

BACKGROUND

HPI Pertinent PMHx/Meds/PSHx Vital signs Pertinent physical exam findings Labs and Imaging results

EXAMPLE

Mr. Jones has had non bloody vomiting and diarrhea for the past 4 days. No fevers or abdominal pain.

He has a pmhx of severe CP, multiple other medical problems and is nonverbal. PSHx of the abdomen includes PEG placement.

On vitals, he is afebrile but tachy to 120 with a bp of 120/70 On exam, he appears volume deplete. His mucous membranes are

dry, heart tachycardic, with diminished cap refill. His abdomen is completely soft, non-tender with normal bowel sounds.

His labs show a normal CBC, normal lytes except a Bun of 40 with a Ct of 1.3. His K is also low at 3.0 with no EKG changes. His abdominal xray shows no evidence of obstruction but is also a limited film.

ASSESSMENT

Treatments administered Diagnosis

Example We have given Mr. Jones 2 liters of NSS as well as IV

K+ replacement and anti-emetics. My assessment is that Mr. Jones has a gastroenteritis with resulting dehydration and electrolyte abnormalities. He may also have colitis. I do not think he has a bowel obstruction or appendicitis because his abdomen is non-tender.

RECOMMENDATIONS

Disposition Other suggestions

Example My recommendation is we admit Mr. Jones to any

medical floor, continue with ivf rehydration and antiemetic therapy and reassess his response.

THE DO’S

Do be professional Do be organized Do speak your consultants’ language Do highlight important information Do be concise Do have a plan

May lay out plan early in conversation

PEARLS

Get to know your consultants Respect your consultants Make the proper referrals Know when to back down; when to stand up

& stick to your guns You have to “sell” the case The “prn” phone call

THE DONT’S

Don’t be rude Don’t keep consultant waiting on phone Don’t be indecisive/disorganized Don’t say “I have no idea what is going on” Don’t lie

DIFFICULT CONSULTANT

Be respectful, prepared, and honest Remember appropriate patient care takes

priority Silence can be golden Stick to your guns when necessary Take the high road Go to a third party if necessary—attending,

administrator

YOU MAY HAVE HEARD THESE…

“This patient seems low risk to me” “I have known this patient for years” “There is not much that can be done for this

patient” “If this patient is admitted, they may get a

nosocomial infection” “This sounds like a social admission”

TELEPHONE TIPS

Introduce yourself Be concise and organized Lay out expectations…Know why you are

calling Review patient with attending prior to phone

call Be honest

CASE 1

CC: SOB HPI: 82 y/o female presents with SOB and

cough for 4 days, fevers. SOB worse with walking. Positive cough, chest pain with coughing. Positive nausea, no vomiting

PMHx: CHF, DM, CAD, COPD Meds: Diovan, Lasix, Insulin, ASA, Plavix,

Spiriva SHx: Former heavy tobacco use

CASE 1

PE VS—T102, 115, 24, 120/70, 93% RA HEENT—MM mildly dry Lungs—crackles at L base with scattered wheezing

Labs WBC—16.5, N80, B8 Na—129, Bun—35, Ct—1.8

EKG—sinus tachy, nonspecific ST/T changes CXR—positive LL infiltrate

CASE 2

CC: Chest pain HPI: 40 y/o male presents with acute onset of

substernal chest pain. Pain pressure-like, radiates to L shoulder. Positive associated sob. Pain relieved upon presentation to ER, lasted for 4 hours.

PMHx: HTN, Gout Meds: Norvasc, Atenolol SHx: Positive tobacco use FHx: Father with MI at 51

CASE 2

PE VS—T98.7, 90, 20, 160/90, 99% RA Normal

Labs Normal

EKG Sinus, T inv V2, V3, V4 (no old ekg)

CXR Normal

CASE 3

CC: Weight loss HPI: 54 y/o male presents with weight loss

over the past couple of months. Positive urinary frequency.

PMHx: none Meds: none FHx: Mother, brother, sister all with DM

CASE 3

PE VS—T98.7, 85, 16, 130/80, 99% Exam normal

Labs Finger stick 370 SMA 7 normal except blood glucose, AG 7

UA with moderate glucose, no ketones

SUMMARY

Effective communication skills Patient care Have a technique Do’s Dont’s