By - anon3644
*you gonna learn*
I think they’re talking about admissions, not administrators.
Wait I know the topic was admissions and not admin (I misread it too) but that sucks and you should name and shame once you’re out of there.
What medications do you take?
It’s in the computer
What’s that surgical scar from?
I don’t know you’re the doctor
You had a MRI at crosstown hospital?
Yeah but I wanted to come here for a second opinion
What did they say was on the mri?
Well something about my kidney bleeding
Your…kidney is …bleeding?
Can I have pain medicine?
Altered mental status,
“UTI” in asymptomatic patient,
Family can’t take care of them,
Mild electrolyte disturbances,
Same alcoholic here for the 7th time,
“Chest pain” with 1 negative trop - admit to medicine,
“Medical management” of a surgical patient with maybe diabetes on metformin,
Post op patient being dumped on medicine with no sign out possibly with shit hitting the fan,
Literally any admit where you don’t have the specialty you need on call,
Shitty transfer dump from outside hospital,
“Bilateral LE cellulitis”,
“Intractable nausea and vomiting”,
“Mass found on CT” (it’s outpatient workup),
“Diarrhea” in the patient that ran out of Oxy 20mg Q4H “PRN” that always seems to have them stolen,
All the fucking direct admissions
I didn't know you were on call with me last
Fave chief complaint: weakness
Failure to thrive from the nursing home is the worst one.
"Altered mental status. Baseline A&O 0, but she looks even more 0 today."
What? Why on earth would that get admitted?
So they could thrive again
Shoot, I hit a rough patch of depression and my go-to response to "how've you been" is usually "surviving; not thriving" ... so you're saying there's a cure?!
Yah it's called TPN c'mon bruh. Get you self some of that gud stuff. Then you'll be depressed and thriving
Shit I was still stuck on the ol' TCB protocol: **T**akin' **C**are of **B**usiness, and being paid 1.5x more than the normal rate when the amount of time spent working exceeds what's contractually expected.
It sounds like you’ve never worked at a VA
Intractable nausea, vomiting, and abominal pain that’s only relieved by hot showers in chronic weed use. “I’ve been smoking weed every day of my life for years, it can’t be that.”
Cannabanoid hyperemesis is my most HATED admit. It requires a full work up to r/o potentially serious causes because intractable abdominal pain in an adult should strike fear in all physicians. The diagnosis is so unsatisfying for both you and the patient. They typically don’t feel much better until a good week or two of not smoking, and telling them that it’s the weed (which let’s face it, is relatively harmless in the grand scheme of things) they’ve been using for 10+ years without issue always makes them feel like you’re stereotyping them and not really trying. I HATE IT HATE IT HATE IT.
These are getting admitted to you? They usually are younger folks with a benign abdominal exam and normal labs. I hiit them with haldol (droperidol now that we have it again), IVF, capascian cream, reassess and discharge from the ED.
No obs unit in our ED :( if they say they can’t keep food down then they’re admitted as OP in bed
I don't usuallt obs them either. Treat, give them something to drink, if they don't puke it back up in the next hour or two they go home.
Pls come work at our ED!
Big if true.
The teenagers get admitted every time
This but now make the patient 16 with an attitude. Welcome to Peds
Had a patient with cannabinoid hyperemesis and the only thing that worked for her was thorazine. Woof.
Mine is dizziness & giddiness 😄
How about hitting a gym?
Then they decide they wanna leave 2 hours after you finish admitting them
Personally triggered by this, and these bullshit admits because they wind up being so much work for so little learning.
Disposition nightmares too
Made my day
This. This. This.
For God’s sake, I just wish info and data were shared or all readily available with patients.
Then there’s problems with the damn eMR being the eMR we collectively chose (with a few health services as notable hold-outs).
Remember when we wanted EMR so we could have access to the patients EMR and now the EMRs don’t communicate … so helpful
EMRs can and DO communicate with each other all the time. There is a standardized protocol they use to transmit patient data between each other (HL7) that has been around since the 80s.
The problem is that in order to pass the data back and forth, the EMRs have to be manually configured to broadcast to, and listen for each other. There have been a couple of attempts at making a centralized national repository of patient data that every healthcare entity could access/update, but those have mostly fizzled out for various reasons.
The latest, and most successful push has been by Epic (care everywhere) where organizations can communicate the data freely between each other as long as they are both on epic. And with this we see the reason why past efforts have failed. Orgs don't want to share their patient information, because it makes it too easy for patients (clients, who represent $$$) to move between orgs. Epic has basically strongarmed their customers into sharing the info, which is great for orgs that use Epic, but they're creating a pay-to-play ecosystem that only benefits their customers.
Even epic’s sharing is like 1/10th of the functionality I would expect from a 21st century emr. You see some garbage format of the other hospital’s notes, labs are hidden in the deepest darkest corner. It’s dramatically more difficult than results that were obtained at your own hospital.
I agree. Part of that is due to the customizability of each instance of EMRs. Everyone wants things tailored to their workflow/billing/legal requirements, which makes the sharing of their data a little messy.
It would be nice if everyone agreed on a standard, but that would need to come down from the govt. There were some financial incentives in the ACA for hospitals to participate in shared data warehouses, but nobody signed up for those for the reasons I stated before.
Exactly! idk how the FBI can have a better robust system for criminals vs. hospitals for patients!?! Well monies and power 😂 lol
The 21st Century CURES act provisions on information blocking will finally force EHR vendors to provide APIs to access a standardized medical record set… so Epic’s play to control all the data will come to an end.
Interesting! I'll have to read thru the bill, but from my first glance it looks like Epic is still in the clear. From what I'm seeing it seems like this is just requiring EMRs to share their patient data with each other without holding anything back. Epic already does this (although their data structuring is so unique that it makes it really difficult for other systems to interpret/integrate data between them), but I'm glad to see the doors are closed to them creating the Epic-verse
I'd love to see a free central data warehouse.
They will be required to provide data to any other health system in a meaningful and standardized way. The standards aren’t completely worked out yet, but if they structure their data in a unique way that isn’t easily integrated into other systems, that may not be sufficient to comply with the law as it is eventually implemented.
Here is the current timeline for implementation:
I’m clinical informatics - trying to change that! \^.^
Well, it’s been like 15 years and every EMR is still fundamentally designed for billing and not medicine.
Let’s all quit pretending anyone gives a shit about patients medicine or doctors
Then design an implantable chip like dogs have so we can scan that. It links to the blockchain where a particular patient has their information stored. Would require a massive network of server farms, but hey…. so does what we do now.
At the very fucking least force states to have a central database for patient data. We have 4 hospital groups in our town, can’t see anything from one another. It’s bullshit and costs the system so so much
Lol “implantable chip”, people won’t even get vaccines
I know, I know. I’m just tired of poor historians and spending so much of my day trying to track down their histories and images. You’d think people would care AT LEAST AS MUCH as I do about their own health.
It’s so frustrating, a lot of it is poor health literacy. I’ve had a few patients on GDMT who didn’t even understand they had a heart problem.
Omg , you nailed it . THEN STAY AT THE OTHER HOSPITAL
That’s the one time my voice raises (slightly) at patients. You got all your workup done at this hospital 1 mile away but decided you needed to come here..
People legit think everything is "in the computer". To be fair, at this point the digital record should be that developed. But its also insane that such a majority of people have zero idea about THEIR OWN problems, and will pound medications without knowing what they are.
I once saw a guy in the ED who was a diabetic on insulin for years. He didn’t know what insulin was. He didn’t know what *diabetes* was. He thought blood pressure and blood sugar were the same thing. It’s just not fair that people like that somehow make through that many years of life against all odds.
I personally like the process of admissions in itself. It's the horrific time crunch it inevitably brings to everything else I'm supposed to be doing that I hate.
That’s why I like nights at my program, we only get like 3-4 admits on average so it’s lots of time to think and pontificate 🥸
Idk, if I spend more than an hour on an admission, then I’m doing something wrong or just wasting time
It gets better as an attending. You can just tell them to do a finish the workup and hang up. They'll whine to administration but you'll get used to that also.
If it's an ER provider I like and trust I'll take their calls immediately.
If it's one that I don't I finish what I'm doing and call back 15 to 20 minutes later. Usually those 15 to 20 minutes gives them time to do something they should have before calling me. So it all works out in the end.
We get so many admits where they haven’t even drawn the labs yet lol it’s terrible
How? Do they think they can dispo patients without that information?
How do the attendings accept them is the better question
Same! I’m a nurse and I really enjoy new admissions. Talking to the patients, explaining things the doctor has ordered, and helping them be more comfortable in the hospital.
The issue is this takes time and it makes you late on everything else you have to do with your other patients. So you end up in a time crunch, and everyone is unhappy bc they had to wait so long for XYZ and stuff is delayed or missed. 😣
I wouldn’t mind admissions at all if it didn’t throw a wrench into following a timely care plan for your other patients.
It’s been a while hasn’t it?
He has a ton of patients to see, write notes on, call people, etc but gets interrupted to do admissions which can take a long time
The moment you feel like a competent doctor on top of the day’s work, the admissions hammer comes down hard
I don’t know about other places, but at the hospitals I’ve worked at the ED always hammer pages us and dumps all the admits at the same time that they’ve been holding for hours because it’s shift change and they want to clear the list for the oncoming doc. We as residents don’t have the ability to say no or to tell them to stop doing it like that so we just suffer in silence.
Back in med school, the residents called it "the VA ED special".
The pump and dump
This is super true. Or they’re held until just before the nurses shift change because nurses don’t want to hold admissions for the oncoming crew too, and a lot of times it’s easier to hold someone for as long as possible if they’re an easy patient so they don’t have to take a train wreck instead.
We call it the end of shift bolus. Worse at the VA.
What workup did you do?
Oh not much but they need to come in.
Come in for what? Are they stable? Is prelim workup done?
No, but they just need to come in.
No they don’t. Do a workup.
But it’s shift change, I don’t want to hand off this many waiting.
Too bad, sounds like you should’ve done a workup hours ago when they got here then.
As the year goes on we have gotten more salty and pushed back hard. Our attendings don’t actually care. A valid admission is a valid admission but they’ve lost their appetite for collecting rock gardens on behalf of the ED.
The best is when they say “oh, the hospitalists don’t want this one so you need to admit them”. Oh do we? Is their PCP one we admit for? No? Then we ain’t admitting shit. Usually followed by a swift and angry message from the attending to the admitting hospitalist team chewing them out yet again for thinking we suddenly got stupid and forgot who we admit for.
"Are you refusing an admission? I need to talk with your attending."
The attending always caves because it doesn't bother them and you'll just staff it with them tomorrow anyway.
Yea we like that part. Our attending will message and ask what workup they did. We tell them how little was done. He won’t even reply.
That’s the universal code for “I’m going to call them and tell them to fuck off until they can produce an actual assessment”
It’s kinda nice running a hard capped service with attendings who actually try to fill it with things beneficial to our time and not just a rock garden
Glad that's been your experience. It very much was not mine as a resident.
At our program, if it’s past 4-4:30 then they have you staff with a hospitalist on long call or if it’s really late with the nocturnist.
All of our admissions are accepted by a hospitalist first before pushed to us. Depending on that hospitalist it could be something good or bad. There are certain hospitalists that know if it’s going to a resident team then it will be the most soft admission with nothing done and a very obvious situation where it’s 90% psych/social with little to no medicine to learn. I imagine this is a phrase every where but a lot of these attendings will say it’s a good “resident patient”. Also, a lot of the hospitalists will send these kind of folks to our clinic when they discharge because again good resident patients.
Consult for our patient in the Ed for “inability to swallow.” After talking to her I think she’s just very dehydrated. 3L fluid later she is drinking water without issue. I go to the ED Resident, she’s able to drink liquids now.
ED resident: she needs to be admitted, she’s been here too long.
Me: admitted for what?
ED resident: inability to swallow.
Me: I just watched her drink a glass of water. Have you tried giving her anything and seeing if she can actually swallow?
ED Resident: I haven’t seen this patient. I just got signout that she can’t swallow and she has been here too long to send home. You need to admit her.
Me: We’re not admitting her.
We did not admit her. I think they talked medicine into an obs admit and she went home the next morning because she didn’t need to be admitted in the first place. But throughput metrics were better so success?!?
These admits are not as bad as an attending because 1) you get paid and 2) when the same ER provider calls you for an admit 3 hours later and is upset to find out the hospital is full or the service is capped, you get to make a shocked pikachu face at em.
Our attendings will definitely keep a patient in the hospital 1-3 days longer than is indicated then become frustrated when our patient in the ED can’t get a bed upstairs for 36 hours, without even the slightest realization of any connection between those two scenarios.
We don’t use the term “hammer page”, but staff do do that here.
That stuff is infuriating, just like the page for needlessly stupid stuff that should’ve been learned within days of starting or during school.
It (?unnecessarily) adds to the workload of having to everything, even blood work, venous access and sometimes asking for or doing your own observations.
Admissions suck because:
1. Patients change their stories between teams. They’ll tell me one thing from the ED, tell the specialist something different, and the IM team something else totally different.
2. Depending on which side you’re on, you either see the patient at their worst before they’ve been tuned up, or you see them afterwards and think “hmm they don’t look so bad why am I admitting them”. So you think the ED is overselling them while we think you’re minimizing.
3. Specialists that won’t admit their own patients because they don’t want to do any scut work.
4. “Hey while you’re down here can we talk about this other guy I’m going to admit? Workups started but he’s definitely coming in regardless”. Trust me, I hate it when my attending makes me do this too.
6. Admissions always disrupt time-sensitive tasks.
\*looks at #3\*
\*backs away slowly\*
Fucking #4. Sometimes I feel like I’m given 1 admit just to trap me. Before I even get in the room, “hey, I actually have 2 more I want to talk to you about, and Dr. B and Dr. C have something too I think”. Like why the fuck did 1 become 6? Also, give me time to chart review them. We’re not having a discussion on the patient if all I have is what you’re telling me
This! I’m having my residents talk to ED to get signout to learn, but you better believe we chart check together before they chat. And I always tell them only talk about the patient we were given, never accept anything else - any other admits gotta go through the Hospitalist admit teams.
Admissions and ICU consults are by far the most time consuming part of the job of an internal medicine resident. For the majority of your hospitalized patients, you chart review, examine the patient, do team rounds, come up with a plan of care and hopefully get them closer to discharge. Plus, if they're there any longer than 2 days, unless they have a sudden decompensation/decline overnight, they're usually pretty straightforward as to what you need to do to get them out.
Admissions are often starting from scratch, especially if they've never been to your hospital. Piecing together the HPI, figuring out what meds they're actually taking vs what's listed in the computer which has like 3 different doses of coreg and metoprolol, thoroughly examining the patient, forming a differential and subsequent plan of care/further investigative workup. It's just a lot to do, especially when it's getting close to end of shift and you get a complex admission you know is going to take you at least an hour.
Ok so imagine you’re painting a fence. However the person you’re painting the fence for is SUPER particular in how you paint the fence down to the hue of the color and thickness of the paint.
THEN imagine someone calls you and says they have 3 more people who want their fence painted and your employer demands you start painting all fences and get the painting supplies ordered within an hour of getting called.
So you go see the three different people and find out what color they want their fence painted, the details on how it should be done, their preferred brand of pain, if they have any issues with their fences and so on until you have the details and start painting their fence. But as soon as you start painting those fences the first person who’s fence you were painting calls you and tells you the paint you used got in the gate hinges and you need to fix it NOW. So you stop painting whatever fence you’re on and go fix his gate. While you’re fixing his gate the 2nd fence you agreed to starts dripping paint on the owners grass so you have to leave and go put a tarp down. Then once you do that and go back to finish up the first fence you get 2 more calls about fences that need to be painted. Then once you get their fence history you realize it’s 6pm and you worked through lunch and still have 6 fences to paint but now the night time painter is taking calls for painting admissions and owner complaints so you can focus on getting your fences done so you can go home. And by the time you finish your fences up it’s 8-9pm.
Then you face the cruel reality that you’ve gotta be back at work at 6am to relieve the night time painter and start your 24 hour fence painting shift.
THAT is the insanity of residency and admissions.
I too have a preferred brand of pain.
Jokes aside, as an incoming intern, this is very enlightening
Would you musculoskeletal or nerve pain? Perhaps mental or cardiac pain? Oh you want zero pain? Sure intubate and sedate then.
You get to go home ?
>details on how it should be done, their preferred brand of pain, if they have any issues with their fences and so on until you have the details and start painting their fence. But as soon as you start painting those fences the first person who’s fence you were painting calls you and tells you the paint you used got in the gate hinges and you need to fix it NOW. So you stop painting whatever fence you’re on and go fix his gate. While you’re fixing his gate the 2nd fence you agreed to starts dripping paint on the owners grass so you have to leave and go put a tarp down. Then once you do that and go back to finish up the first fence you get 2 more calls about fences that need to be painted. Then once you get their fence history you realize it’s 6pm and you worked through lunch and still have 6 fences to paint but now the night time painter is taking calls for painting admissions and owner complaints so you can focus on getting your fences done so you can go home. And by the time you finish your fences up it’s 8-9pm.
>Then you face the cruel reality that you’ve gotta be back at work at 6am to relieve the night time painter and start your 24 hour fence painting shift.
>THAT is the insanity of residency and admissions.
These types of days usually turn into 16-24 hour shifts for me...pgy3 painter
Dear Sisyphus, why do you have such dislike for that boulder your pushing?
LOL just fucking wait to see what patients you are assigned
In residency, you get paid shit. You get paid the same shit to do two admissions or ten admissions. In most real life work, you get paid for the work you do. Do more work, get paid more.
Because patients don't know how to answer simple questions
"So when did you start taking Plavix?"
"Around the same time my Son got his new Job"
"ok..when was that?"
"Well he didnt like his old job, hes much happier now"
"Was it more than 6 months ago?"
"I need to go to the bathroom"
“Can you find me the hallmark channel?”
-“what? Ma’am, how long have you been taking Plavix & Xarelto?”
good IM admissions at a reasonable pace so you can actually learn is great
when you get slammed with a bunch of placement issue admissions from the ED with little to no educational value it gets frustrating AF
Now think about how frustrated we feel seeing them in the ED knowing we have to admit them because of policy.
no shade on the ED - I know you guys dont want to hit us with them
It essentially takes the day you have planned and adds 45 min to an hour of time sensitive work right into the middle of it. The unpredictability is what is so frustrating.
Cause often they're bullshit admissions that add unnecessary work to all the other bullshit we have to deal with
Sometimes bullshit admits are simply human beings that can’t quite go home for a variety of reasons. Everyone’s least favorite is the altered and not at their baseline old person with very concerned family…ED uses the equivocal urine to get them admitted but it’s not their fault either. Until we have better social services and outpatient medical services that can actually see people in a reasonable amount of time, this will continue. The ED and medicine floor will just continue to get dumped on by society at large with minimal recourse.
I fought it as an R2. As an R3 I just listen to the ED sign out, nod, "yep sounds like they ain't goin home, what were admission dx were you gonna use? Ehhh, I'm gonna get torn a new you-know-what if we use failure to thrive again, and doesn't sound like they can cooperate with a workup for weakness enough to avoid an unnecessary sedated MRI, what else can we use... oh wait you said their XYZ was barely abnormal? Yeah sounds like a great admission for XYZ!"
Note: if it's in the patients best interest to set firm boundaries and kick out, I'm all for that. But only one of the many attendings I've ever worked with really had my back on dispo-ing clearly inappropriate admissions. And for a lot of these patients, especially at the VA, if we admit them we can stabilize things a little, maybe prevent a bit of neglect or harm to them or family overnight, let family cool down and take them home or get them into the right facility way faster. Our social workers and case managers suck at the VA,, and having a dumb admission sitting around gets them off their butts better than anything else I've tried.
Bc it's tedious, long, and boring.
And bc it's easy to criticize the next day.
"Hey. you missed this on admission."
Ok but there were 99 other things to do. Sorry I missed that one thing that one thing that you are now making into a huge deal even though it has no real effect on patient care, just bc it's related to some inpatient metric that will affect our bottom line, blah blah blah.
Admissions come in a few flavors:
1: Sick patients that you can fix
2: Sick patients you can't fix (end stage cancer, cirrhosis)
3: Well patients who thinks they are sick
4: Chronically ill patient with non-specific complaints and negative workup
5: Old person who is weak
6: Syncope/chest pain
Option 1 is stimulating and rewarding. Option 2 and 3 is exhausting and time intensive. Option 4 and 5 is frustrating and repetitive. Option 6 is almost never "high risk" even though the ED thinks it is.
oh you sweet summer child
its a huge chunk of work of taking care of a patient in a hospital
the general public
Your about to sign out in 2 hour or soon. Admission pager goes off patient is being admitted for AMS. You chart check 80 something year old with dementia with no documented baseline brought in from nursing facility. You go down to Ed and somehow from ems transport to Ed all their paperwork is lost so you got no med rec, no pmhx. Call the facility put on hold forever until you finally reach someone they tell you nurse for patient left already no one knows anything. Workup shows some elevated mild elevated white count, chest X-ray shows maybe possible early infiltrates, u/a is borderline dirty, pan ct scan shows shit tons of random findings where you got no old image to compare to and no history to work with. You go talk to patient and their complete out of it Ax0 0-1 and every question you ask they say yes it hurts here too. You start some abx and fluids and sign out to night team so you can figure this shit out tomorrow morning. In the morning attending gets upset and tells you not every old patient with AMS is UTI. Your day repeats 😭
Well at least you started abx lol
XR shows possible early infiltrates, UA is borderline dirty and patient has a white count. Would the attending prefer if you withheld antibiotics and the patient ended up in the unit overnight?
A large part of medicine is managing risk and this is a those situation where the risk of withholding a little Ceftriaxone outweighs the potential benefit.
Also when the patient cannot provide a history, can you really call it asymptomatic bacteruria?
In general an admit takes a lot of time. You have to take a full history, do a med rec, put in orders, start a work up, add the patient to your sign out list. And if you’re doing a surgical subspecialty, this is on top of everything else you have to do. IM generally has caps to the number of patients on their service, but for a surgical specialty and admit is 1-3 hours of unexpected extra work added to your day. Every Gyn Onc patient I admit takes 2-3 hours. They are always sick as shit, they always need a work up for a serious problem, they always have a complex treatment history and medical history, they’re always on a shit ton of meds, many got half their care at an outside clinic that I have to look up notes for and piece together records, so between seeing them, writing their note, putting in orders, doing a med rec, starting work up, adding them to our list, it’s pretty much always 2-3 hours. Also it is not considered acceptable in most scenarios to push an admission to the next team. If an admit comes at 4 and I get off at 5, I’m going to be there until 6-7 finishing it.
Gen surg here. I don’t hate consults/admissions to our service. I actually enjoy seeing consults with a surgical problem…it’s why I went into surgery. I hate inappropriate consults, or consults where literally no work up has been done and the ED cannot answer simple questions about the patient, why they’re calling you, or what surgical problem they suspect the patient has. They literally want me to do their job as well as my own for no extra compensation. That’s why.
Most ridiculous example this week: we operated on a guy 6 months ago, he’s been seen in the office twice for follow up, doing great. He shows up to the ED with hiccups. Yes, fucking hiccups. The ED attending hammer paged me during a complex case that I needed to come see him right away because this could be a post-operative complication. Meanwhile, literally no work up. Not a single lab. Not even an XR. ED attending then threatened to call the chief of surgery because I was “refusing to see a consult”.
Did you end up seeing them?
Yup. The best part was that the guy's hiccups were gone when I saw him. I don't think I've ever had so much fun writing a snarky consult note in my life
Did you not have to do an admission as a medical student?
Depends on your specialty. Peds admissions usually aren’t as bad. Since kids are usually pretty healthy, you don’t have to do much in the way of Med recs. They’re admitted for bronchiolitis and need to hang out on high flow for a couple of days, or they have asthma and need q2h albuterol overnight and then can wean down the next day. Parents can be intense, but they are usually like that because they are honestly scared for their kid and want to advocate for what’s best for them, and most of our adult patients would do a lot better if they had someone to advocate for them like that.
Yeah, you get some complicated patients with the NICU special: HIE, trach, G-tube, seizures, spasticity; admitted with need for increased respiratory support and worsening seizures because of a GI bug that then led to aspiration pneumonia, etc. For the seizure aspect of that, continue all home meds and add Klonopin for 3 days 0.1-0.3 mg/kg/day divided BID or TID. If they can’t take any enteral meds while sick, you can convert as many seizure meds as possible to IV, and then do ativan 0.2 mg/kg/day divided q6h. Antibiotics per primary team. Thank you for this interesting consult. Pediatric neurology will sign off at this time. 💃💃💃
I don't know if this has been anyone else's take on this, I didnt see it below. You'll probably notice the same hate for a completely sane with it patient as one who's out of their mind.
Hospitalist medicine at it's core almost makes you hate seeing people show up, because something went terribly wrong, and without admission, they would die. That fact is not always correct because we all have had a BS admission where they would be fine with a tylenol, and the ED just didnt want to spend the time to listen, but still, the need existed. After that, the time starts. Every day that the patient is there is a monument to your diagnosis and treatment. You'll see people brag about how they "got that lady out in like 1 day, friggin ED said sepsis. Sepsis my ass, they were full of shit! (constipated)". Now if they hang out longer, they become a monument to your own failure to diagnose and treat. It may be entirely not your fault or you may be 100% correct in both, but patient's take time to get better, but your metric for quality of work, and reward once you get into the field is how fast you get people out.
If there is no admission, there is no chance for failure, you're just taking care of people already there, with a plan in place. New admit? now's your chance at possibly failing, may luck be on your side regarding your skill, and whether that patient told you everything going on with them.
You'll soon learn about the BS med management consult, or the orthopedic/psych admit which was dumped (because their problem isnt medical, but it is now your problem, and you dont have any way of helping them)
Because it's extra work without extra pay for already overworked residents. That's really all it is.
Not always the case, but a lot of physicians confuse the ED being polite with consults or admissions actually being a request when they are quite clearly a mandate by the hospital by-laws. For all the complaints about unnecessary admissions, it's funny how rare it is for the admitting team to just discharge them from the ED. Everyone's full of big talk until they have to answer to a patient or medicolegal risk.
I do not discharge patients from the ED because I am in no way incentivized to do so.
If I'm going to do all of the work to admit a patient I want them to contribute to my cap. I'm fully aware that the 30 year old with GERD and a heart score of 2 doesn't need to stay, but according to the ER provider they're "really fat" and must have underlying CAD. If you really want that patient to stay then sure, I guess septic grandma is getting transferred later tonight when the hospital is full though 🤷.
It's not so much the medicolegal risk as it is I'm going to get the most out of whatever work I do and that means billing for an admission and having room for one less patient.
I don't get paid to do the ERs job for them. I get paid to admit people.
Honestly, just admitting them is quicker/ less headache than discharging them if youre at the point of having to see them anyway. I'm more likely to discharge patients from the ED on a slow shift when I have time to work out an alternative outpatient plan and then argue more with the ED. Much quicker to just admit observation and discharge next day. The real problem is those patients who never leave the hospital because they're so chronically sick that they'll never feel better than when they came in and have no alternative placement options.
> For all the complaints about unnecessary admissions, it's funny how rare it is for the admitting team to just discharge them from the ED. Everyone's full of big talk until they have to answer to a patient or medicolegal risk.
There are big practical barriers to discharging straight from the ED that has nothing to do with the appropriateness of an admission.
Admissions tend to come in the afternoon, evening, or overnight, and when I was on IM we almost never rounded on these patients until the next morning. A resident team isn't going to discharge directly from the ED without staffing it, and by the time they are staffed the patient is often already upstairs (depending on bed availability).
Plus on IM you tend to get admissions in bunches. Admitting a patient and then discharging them takes more time than just admitting them. It's often not practical from a time perspective.
They just take a lot of time to make sure patient is on all their right meds and getting a good history is hard from a poor historian.
Unpopular opinion potentially but in medicine I hate admissions because attendings press you to give a super long presentation and crazy broad differential when my patient with a positive US, RUQ pain and elevated liver labs clearly has… gallstone pancreatitis. Why are we even talking about anything else? The process could have been a brief interview, some orders, a note, a quick conversation, some more orders, and instead it’s a laborious 100 minute endeavor - a looong drawn out interview with the patient through an interpreter regarding when the symptoms started (not really relevant at this point, is it? They’re here now, we’re gonna treat) and what meds they take at home (again - does it really matter? They’re on metformin but we’re gonna hold it and start sliding scale). I call pharmacy to verify - we decide to hold the HCTZ too iso soft pressures 2/2 to the opiates. Why did I have to call pharmacy then, to verify? Then I spend a while writing my note and presenting. While presenting the attending has me pull up the US and we stare at it blankly for a few minutes together while the attending and resident pretend they can read US (they can’t). We look at the CXR which is completely normal obviously as this person came in for something unrelated but the ED orders CXR on everyone who walks through the door. I’m convinced the door to the ED is an airport scanner that automatically does CXR and head CT non con. The patient takes his ticket to receive 1L NS free of charge w/ admission and then comes to me. I am tortured into reading the CXR for this admission using the ABCDE method. I forget to mention that the ribs for this patient who had no falls, trauma or rib pain look normal and not fractured and the attending reminds me. We discuss how to read CXR for a while. The clock inches toward 5pm and I want to go home. I read EKG for this patient. It looks relatively normal, just like the troponin and the TSH the ED mysteriously ordered. We discuss whether this acute epigastric pain could be related to TSH. My attending says make sure to have this documented in Dc summary for outpatient follow up.
I present my plan and we discuss random parasites to which the patient has never been exposed as a possible cause for his elevated biliary labs. My attending wants to do a full cirrhosis screen on this patient and liver elastography. I send off thousands of dollars of hepatitis tests for my patient that has a gallstone stuck in their CBD. In the end get MRCP, ERCP, cholecystectomy, just like everyone else. I could have told you that 5 minutes after seeing them for 5 minutes. Instead it has taken almost 20x that amount of time. I have learned only that I am frustrated.
When the ED hammer pages you about getting an admit done after they’ve been sitting there for 8+ hr and they just called you
Radiology here so I can only speak of my experience as an intern, but what I really hated is that we had 2 teams that were always close to cap or capped. In theory, we were Q2 admissions, but in practice it was QD. There was never a sense of satisfaction for discharging a bunch of patients because I always knew our team would immediately fill back up regardless of whether it was technically our day to admit or not. By the end of the year I cherished my placement rocks and essentially had no motivation to discharge.
So personally I don’t hate them. It’s so much work fighting the admission, just do the note, drop some orders and move on. So much less work than going to war to try to block a soft admit you can flip and discharge the next day after a period of “observation”
My favourite consults in IM are the grandmas that the ER wants to admit for chest pain. Turns out, even mee maw can get GERD and just about everyone over the age of 65 has a heart score of 4 or higher. So why don't we admit all of them?
The fiestier ones manage to tell the ER provider to "f off" and "I came here to make sure my heart was ok, a little maalox and a sammich" and then they leave AMA. And, spoiler alert, they always end up fine.
It got so egregious that the cardiology department changed the heart score cutoff to 7 or above and even then they suggest cardiology consultation, not necessarily admission, since inpatient provocative testing has been shown to have limited clinical value.
I love admissions. But I’m a nocturnist ha 😀
I love the process of doing an admission (except staffing because not a fan of presenting), but it really can ruin your workflow especially with a patient that needs to be seen right away. If I didn’t have a list of other patients to staff and see that wasn’t interrupted by the admission then I’d love to do it.
Admitting resident was one of my favorite rotations in residency for this reason.
More admissions = More patients to round on in the morning
They always seem to be dumpster fires and or social shit shows that get dropped on you at the end of shift.
I think registrars don’t hate admissions in general. We hate non medical admissions that we end up doing for social or other reasons where medicine cannot add much.
It's the inconvenience of it. You're finally sitting down, after having rounded for hours, and are constantly being interrupted by pages for new admits, delaying your already existing tasks and adding to your workload
Every residency has different rules. Mine for example, on non long call days ppl admit until 3pm. On long calls you admit from 3-7pm which means on busy days you get out at around 9-11pm depending on number of admissions and acuity etc. Also not all of your rotations will be wards. You will have outpatient clinic, electives, consults (where you don’t have to be primary team which is bless) etc. as a pgy3 we actually did not have that much ward time, with lots of electives outpatient time so it was okay.
Our ED doesn’t even complete a workup before consulting. So, one fun night, they gave me 5 at once, as I’m working through the patients, I say to one patient’s son “does he (the patient) look distended to you?” … the son “I don’t know” . Sure, why would you know what your fucking father looks like, you just live with him at 40 years of age. So, I tap on his belly, super tympanic, run him through the CT (bc why would the ER use their CT machine on this ONE patient), the only use it on everyone else? Come to find out, my dude has a pneumoperitoneum. I’m MICU at the time. This wasn’t even supposed to by my consult. I literally was called for concern of “possible cardiogenic or septic shock” ER attending to me pgy 2 “yea… I dunno what’s going on but his blood pressure is low, he will prkbay need some pressors.”
I called to the ED before the formal CT read and said page surgery. I typically don’t know who I hate more, ER or surgeons, but ED definitely won that night .
Good luck !
Ohhh sweet summer child
ED docs lie, straight up. It is one thing when the patient changes up the story a bit here and there. It is a totally different thing when the ED doc hands off a train-wreck, mangled, borderline cadaver...then you head downstairs and its just a happy, smiling, room air, 80 year old who is being admitted because they are 80.
ED docs also have some weird metric (or something to that effect) where they dont like to have patients at change of shift...so they just dump them at once. They dont seem to care when inpatient shifts change. They dont seem to care that many of those patients could have been admitted hours earlier when it wouldnt be a five-mins until rounds or end of the day admit (lack of beds upstairs isnt a barrier since lots of times my hosp just keeps patients in ED but "admitted") anyway) or that the patient doesnt need to be admitted at all.
If your hospital uses a ED med consult as screening, count yourself lucky. Id much rather depend on people I know and can trust their decision making than ED docs.
And all of it is pretty disappointing since it sucks to be part of that culture thatclashes between services. But ED docs have time and time again, from the very start of residency, let me down in their quality of work.
Lot of bs but ofc that’s when you really help people the most diagnosing and treating the sepsis with relieved family members for example make medicine worth it
Well and the paycheck
Because “Admit to medicine, service X will see patient in the morning” hurts your soul
Not a medicine doctor but I remember working on medicine service as an intern and it was those last minute admits that really get you. It's actually like that on consult services too. The other services always seem to pick the end of your shift to send over all the workup, especially for consults. It almost made more sense at my training hospital to run the consult service Noon to 9 rather than 8 to 6, 85 percent of the consults came after 3pm
“Better the devil you know.” Too many variables that can be a huge time sink.
It’s tedious. Try doing a med rec on 5 patients who have 20 meds. Imagine trying to go through someone’s entire medical history in 20 minutes.
It’s different than when you are a med student. You only have a few patients so you can really spend the time talking to the patient and crafting a good and complete note.
ED call at 6:45 pm when your closed for admits at 7pm - "Hey I got one for you"
Was one of my first med admits as an MS3
Getting home med list is honestly the worst part of it
I used to hate admissions, but by the end of my second year, I got really fast at doing them. It’s like autopilot at this point.
I used to absolutely hate taking in admissions and would fight the ED on dumb admissions.
Then I found out that I’d rather do admissions over rounding/social problems and now working nights & swings (I.e. only admissions and little cross cover)
As a resident, it sucked doing all the work and getting paid nothing.
But now, as an attending (locums for that matter) give me all your shitty admissions. The pay check is well worth it.