Six months. He had me at six months. You know the guy. You hear those words every shift. My ED brain turned off once I heard he had had the pain for six months. I always ask what was different that prompted him to come to the ED, but the answer rarely changes my plan. You, my friend, are going home.
I am interested in disposition, not diagnosis. The definition of disposition has to do with placing or disposing of something. It might sound harsh, but getting rid of our patients is what we do all day.
We have a family medicine residency at our hospital. They rotate through the ED, and I have burned an analogy into their brains: We are driving on the freeway with a car full of patients. The car has four or five seats; sometimes we have a van and carry a few more. Either way, we are looking for an off ramp.
I can drop a 20-year-old woman with dysuria on the corner and get back on the freeway. I will stay on for a couple more exits if the patient is pregnant and then drop her off. I am not going to drive her all the way home, but I'll stay on the freeway until I find her exit. She might get picked up by the hospitalist or the intensivist, or she might walk home from the ramp. I have more room in the car once she is out, and I am going to get back on the freeway as soon as I can.
I explain to residents that we are disposition-driven, not diagnosis-driven. I remind them that they will be working things up when they go out into the community, but we in the ED are working for a disposition and ruling out the worst things. There are no outpatient D-dimers and people with chest pain driving themselves over from the office to be checked out. We think PE or ACS and work backwards. It has to be that way.
The Disposition Guy
Back to my patient with six months of pain. Somewhere along the line, patients have gotten the idea that all the stuff they need is in the hospital. They think that the smart doctors and all the latest technology is at their disposal there. They have often already been to Stanford or UCLA or some other tertiary care center and have had numerous specialists try to solve their mystery. Then they come to see me: the disposition guy. I am polite and try to let them down easy, but they have the wrong guy. I will make sure nothing bad or dangerous is going on, but I'm not keeping them in my car for long.
Granted, making a diagnosis contributes to the treatment and disposition, but it isn't always necessary. I tell the residents we admit patients for only two reasons: when we know what's wrong with them and when we don't know what's wrong with them. Sick or not sick, in or out, as the saying goes.
A buzzkill is someone or something that makes people less happy or excited about something. I have realized that most of what gets to me on a shift, what makes me less happy or excited, is a disposition killer. The pandemic, specifically the COVID-19 test, is right at the top. Transfers are disposition killers, for sure, especially when the need for specialty care is borderline. Combine transfer with COVID, and you get a dead and buried dispo. Geriatric psychiatric patients, folks with chronic pain, kids needing specialty care—the list is endless.
It is usually a sign that your dispo is about to code if you are calling a case manager or social worker. The patient who came in from home but now “can't walk?” The discharge papers you just printed might as well be stamped with a big red DK.
How's your EHR working out? I know we have all gotten used to them. Perhaps they are not killers. But let me remind you that they are the undisputed champion of dispo delay. You'll agree if you remember when we used paper. We just had an addition to our EHR discharge process. Why break what's already broken? I do not know. But we now have to deal with a few extra clicks and blanks, nothing intuitive or helpful, just more steps before discharge.
I like to teach, and I enjoy our residents. It's rewarding, and I have a sense of duty and desire to pass along what was given to me. But let's face it: An intern in the department, especially one from another specialty, is a dispo assassin.
But sometimes everything clicks into place, and it feels like the department is running smoothly when the dispos line up. But it feels like the system is out to get me when they don't. The funny thing is that the other definition of disposition has to do with temperament or emotional outlook. My goal is not to let the death of my disposition affect my disposition. Otherwise, it's going to be a long shift.
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Dr. Harmonis an emergency physician at Marian Region Medical Center in Santa Maria, CA. Read his past columns athttp://bit.ly/EMN-SameShift.