Emergency Medicine · Year 3 · from Emergency Medicine

Case 3: Difficult Consultant Communication - Getting the Admission

Patient Demographics

  • Age: 45 years
  • Sex: Female
  • Occupation: Small business owner

Clinical Scenario

Situation: It's 11 PM. You have a patient with diabetic ketoacidosis requiring admission. The medicine resident you're calling seems reluctant to accept the patient because they're overwhelmed with admissions. You need to effectively advocate for your patient.

Patient Summary

One-liner: 45-year-old female with type 1 diabetes presenting with DKA (pH 7.18, glucose 480, bicarbonate 10, AG 28) triggered by UTI, now on insulin drip and fluids requiring ICU vs. step-down admission.

Initial Call (Ineffective)

ED Physician: "Hey, I have a DKA for you in room 8."

Medicine Resident: "What's the pH?"

ED Physician: "7.18"

Medicine Resident: "That sounds pretty bad. She probably needs the ICU."

ED Physician: "I don't think she needs ICU, she's mentating fine."

Medicine Resident: "Well, she's pretty sick. I'm already overwhelmed tonight. Can you call the ICU?"

ED Physician: "The ICU won't take her if she doesn't need it. Can you just come evaluate her?"

Medicine Resident: "I really don't have time. Can she wait until morning?"

Problems with this call:

  • No structure
  • No clear communication of urgency
  • No anticipatory planning
  • Became adversarial
  • No resolution

Effective Consultation Call

Using 5 C's of Consultation:

1. Contact: "Hi, this is Dr. Johnson from the ED calling about an admission. Is this the medicine resident covering admissions? Great. Do you have 2 minutes?"

2. Communicate (SBAR):

  • S (Situation): "I have a 45-year-old woman with DKA who needs admission tonight."
  • B (Background): "She has type 1 diabetes, good compliance usually, but developed a UTI over the last few days and missed a few insulin doses. She presented with nausea, vomiting, and abdominal pain."
  • A (Assessment): "She has moderate-severe DKA. Her pH is 7.18, glucose 480, bicarb 10, anion gap 28. She's currently mentating well with a GCS of 15 and hemodynamically stable on fluids."
  • R (Recommendation): "I've started her on an insulin drip per protocol and aggressive IV fluids. She's had 2 liters so far. She needs ongoing monitoring and protocol management. I think she's appropriate for a step-down or close monitoring floor bed rather than ICU given her mental status, but I'd like you to evaluate and help determine the right level of care."

3. Core Question: "Can you accept this patient for admission to your service for DKA management?"

4. Collaborate: "What else would be helpful before you see her? I can have the labs trending, and I'll make sure she's ready for transfer when you're able to evaluate."

5. Close the Loop: "So to confirm - you'll see her in the next 30-60 minutes, and we'll plan for step-down admission pending your assessment. I'll call you if she worsens. What's the best number to reach you?"

If Meeting Resistance

Medicine Resident: "I'm really overwhelmed tonight. Can this wait?"

Effective Response: "I understand you're busy, and I appreciate that. Unfortunately, she does need admission tonight - she has an anion gap of 28 and is on an insulin drip that needs to be managed inpatient. She can't safely go home or wait until morning.

Let me help make this easier:

  • She's stable and won't need much immediate intervention
  • I've already started the insulin protocol
  • Her first set of repeat labs is pending
  • I'll have everything documented and ready for the transfer

When do you think you can evaluate her? I can help prioritize if needed."

If Significant Disagreement

Escalation Pathway:

  1. Clarify the disagreement: "Help me understand your concern about admitting her."
  2. Find common ground: "We both want her in the right level of care. Let me share more about why I think step-down is appropriate."
  3. Offer alternatives: "If you're concerned about acuity, would you be more comfortable with a monitored bed or ICU evaluation?"
  4. Escalate if necessary: "I think we may need to involve our attendings to figure out the best plan for her."

Key Principle: Escalate to attendings if there's true disagreement about patient safety - this isn't "going over someone's head," it's patient advocacy.

Documentation

Consultation Note:

"11:30 PM - Medicine consulted for admission Spoke with Dr. Smith (medicine resident). Patient information communicated including presentation, labs (pH 7.18, AG 28), current management (insulin drip, IV fluids), and clinical stability. Discussed appropriate level of care - agreed patient appropriate for step-down given hemodynamic stability and intact mental status. Medicine resident will evaluate within 1 hour. Patient will be transferred to step-down unit pending their evaluation."

Outcome

12:30 AM: Medicine resident evaluated patient, agreed with step-down admission Admission: Medicine step-down unit Hospital Course: DKA resolved within 18 hours, transitioned to subcutaneous insulin, discharged day 2

Teaching Points

  1. Structure your call: 5 C's or SBAR - don't just "dump" information
  2. Lead with the ask: Make it clear you need an admission (not a question)
  3. Provide relevant information: Not the whole story, just what's pertinent
  4. Collaborate, don't combative: You're on the same team
  5. Offer to help: "What can I do to make this easier?"
  6. Document everything: Including discussions about disposition
  7. Escalate when needed: Patient safety comes first
  8. Understand their constraints: Consultants are often overwhelmed too

Additional Tips for Effective Consultation

Before the Call:

  • Have all relevant information ready
  • Know what you're asking for
  • Review the patient yourself

During the Call:

  • Be concise but complete
  • Be professional regardless of response
  • Clarify expectations

After the Call:

  • Document the conversation
  • Follow up if recommendations not followed
  • Close the loop with the patient

Clinical Image

Image Description: Diagram showing the SBAR (Situation, Background, Assessment, Recommendation) communication framework used for structured healthcare communication and consultant calls.

Attribution: Image from Institute for Healthcare Improvement. Educational use. Source: http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx

All cases for this lecture as Markdown