Sunday, December 13, 2009

The triage owl....the musings and thoughts of a night coverage triage hospitalist

It is sunday, 2 AM. I'm in my office, with a cellphone directed to the admitting line, where my role is to receive the calls from any external medical center wishing to transfer a patient to our institution for evaluation and treatment. I have 2 pagers as well, and of course, my direct office extension.

This activity is called the Nocturnal Internal Medicine Triage Officer, which basically is a medical-administrative job as said above. You accept and coordinate transfers from any external medical center, and triage them to the appropriate medical subspecialty. After you accept a patient, and you consider the patient should be admitted, let's say, to Hematology, then you get connected with the Hematologist on call and give report so that the patient can be admitted under their service.

As well, you take all the calls from the Emergency Department (ED) transferring patients to Internal Medicine, where you do the same thing; help the ED staff to triage the patients to the appropriate service; help the ED residents to determine the required acuity of care (regular floor, telemetry, ICU) and as well the appropriate specialty.

You want to ensure that the patient gets the best standard of care; and even if our Internal Medicine staff are tremendously bright, knowledgeable and insightful, if a patient benefits from being on a primary subspecialty service, then that is the best; for example - a lung transplant patient or a patient with a congenital heart disease with Eisenmenger's, etc. What is most important is always to look at the situation this way: "if this patient would be me or my mother, who would I prefer her to be taken care from"....a bright internist with limited subspecialty knowledge, or a bright subspecialist that wrote the "State-of-the-art" on that very particular disease last week (which is the kind of colleagues I'm fortunate enough to interact with)", and if needed can always get an Internal Medicine consult on board.

Appropriate triaging impacts patients in many ways: they can get different standards of care depending the service where they go to; the length of stay is minimized in subspecialty services that have an increased comfort level discharging patients that based on their experience are stable enough to be followed as outpatient; the patient can get procedures done earlier; the subspecialist's experience can as well mandate an earlier work-up. Remember, your eyes can see what your brain knows. That means a lot in Medicine. We as internists know a lot of everything; but a subspecialist knows a lot of a particular thing that generally goes well on top and beyond our knowledge and that is fine; they did an additional 2-3 years of fellowship plus an extra 1-2 years of further fellowship (so in general 3-5 years more than our training). I feel very proud of being an Internist and a Pediatrician. I harbor with pride my FAAP FACP titles (which may seem pompous, selfish and arrogant, but it is not; it is important as the letters are designed to identify my area of expertise); however, I recognize that there are limitations to our knowledge, and I start a work-up, have a perspective of things, but at some point, it is the subspecialist expertise which will help the patient the most.

Of course, most patients will end up in the Internal Medicine service. The difference will be depending on their medical complexity whether will be triaged to a "teaching" service or a "non-teaching" service. This is an academic medical center, so residents will take care of patients supervised by a staff; in the non-teaching service, a hospitalist will take care alone of all the patients.

In addition, you are the staff at night to help the Internal Medicine consult resident on call with questions and see patients that need urgent evaluations, particularly pre-operative assessments. For the pre-operative evaluation we do "assessments" and "determine the medical optimization" of the patients; we "optimize" them as much as we can from the medical standpoint. We do not "clear" patients; this is a common misconception; in our large outpatient preoperative clinic (IMPACT - Internal Medicine Preoperative Assessment, Consult and Treatment) we write at the end of the note..."the patient is optimally prepared for surgery" or " not optimally prepared...".

You track all the admissions and transfers. We have organized and know all the details of each single admission - where it comes from, which service is taking care of the patient, who wrote the history and physical, what floor and bed the patient is at, which service will take care of the patient in the morning, who is the responsible staff.

Essentially, from the medical operations standpoint this is one of the finest and most sophisticated way that patient safety in transitions-of-care has evolved into.

There is variation from night to night. I have been kept awake from 5pm until 8am non-stop. Tonight, it is a quieter night. So quiet, that I decided to write a new post.

I realize that yesterday it was the most sacred day in Mexico, the Day of the Virgin of Guadalupe, or the "dark skinned lady from the Tepeyac" as people refer to her. It was as well the second night of Hannukah; the first one fell on Shabbat - so it is a special celebration. Last night (saturday night), the menorah was lighted after singing Eliyahu anavi. It is a religious weekend. I feel blessed and enlightened as I'm able to work in good health and spirit, and able to help people, both our patients (even if I'm just coordinating their transition of care, are MY patients) and my colleagues. As always....primum non nocere

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