Consultation

Aka: Consultation, Referral and Consultation

1. Approach: Relationship
   1. Maintain a friendly, collegial relationship with consultants and hospitalists
      1. Approach as a longterm relationship
      2. Socially converse when time and situations allow
      3. Follow-up on shared patients
      4. Learn from their expertise
      5. Treat as partners working for the best interest of the patients (as opposed to adversarial relationships)
   2. Assist consultants when they need help from the emergency department or other consulting services
      1. Assist with order placement, procedure set-up, consent process
      2. Connect them with nursing staff or technicians who can assist them
   3. Acknowledge when "dumping on admitting or consulting services"
      1. Thank them for their help in particularly difficult situations
2. Approach: Consultation (example)
   1. Introduction
      1. Introduce yourself
      2. Write down their name and the time of the phone call
      3. Thank the consultant for their involvement
   2. Frame the Consultation (brief overview)
      1. Subjective
         1. 65 year old female with a history of diabetes and coronary disease
         2. Presents with a 5 day history of progressive exertional Chest Pain
      2. Assessment
         1. I suspect Unstable Angina and
      3. Plan
         1. I would like to transfer this patient to you for further evaluation
   3. Details (pertinent)
      1. Subjective
         1. Anterior, substernal Chest Pain with radiation to both arms, jaw
         2. Associated Shortness of Breath and Nausea. resolved prior to presentation
      2. History
         1. S/p PTCA with DES x2 to LAD in 2012, last echo 1/2013 with 45% EF, no WMA
         2. On Metoprolol, Aspirin, Plavix, Atorvastatin
      3. Objective
         1. Last BP 110/60, HR 95, O2 Sats 93% RA and unremarkable exam
         2. Normal Troponin, unchanged ekg, Chest XRay
      4. Plan
         1. Given Aspirin 325, oxygen, nitro-paste and Heparin
   4. Listen, clarify history and answer questions
   5. Ask specific questions when seeking consultant advice
   6. Summarize your understanding of next steps
      1. We will await RN report and will then obtain Ambulance transport to your facility
      2. I estimate one hour from that time to arrival at your facility
      3. Are there any other measures you recommend prior to transport
   7. Closing
      1. Thank you for your assistance with this patient's care
3. Precautions
   1. Tribalism (or the specialty clique)
      1. Avoid using team cohesiveness (e.g. Emergency providers) to isolate other groups or consultants
      2. Avoid labeling other specialties with negative characteristics
      3. Encourage collaboration and mutual respect
      4. Lin and Brazil in Herbert (2015) EM:Rap 15(12): 6-7
4. References
   1. Sacchetti and Herbert in Majoewsky (2013) EM: Rap 13(9): 4