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Nilesh Patel July 22, 2009 St. Joseph’s Regional Medical Center EM Conference.

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Presentation on theme: "Nilesh Patel July 22, 2009 St. Joseph’s Regional Medical Center EM Conference."— Presentation transcript:

1 Nilesh Patel July 22, 2009 St. Joseph’s Regional Medical Center EM Conference

2 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

3 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

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

5 WHAT’S AT STAKE?  Job security  Job satisfaction  Patient care  EVERYTHING!

6 THE PROBLEM  EM physician  Stress/Heavy patient load  Fatigue  Work-up  Consultant  Inconvenient times  Stress/Heavy patient load  Fatigue  The Interaction  Phone conversation…disconnect

7 COMMUNICATION  Effective speaker  Effective listener  Accept feedback


9 SOME EXAMPLES GONE BAD  Symptomatic anemia pt—missed transfusion  SAH pt—received IV Heparin  Trauma pt (glass in brain)—not seen

10 SBAR  Situation  Background  Assessment  Recommendation

11 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.

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

13 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.

14 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.

15 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.

16 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

17 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

18 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

19 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

20 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”

21 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

22 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

23 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


25 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

26 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

27 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

28 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

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

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