Newman's Notions | April 2019 | FREE
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A hospitalist primer

Learn hospital medicine from A to Z.

A is for Admission. Admissions are the basic unit of hospitalist existence. Some are legitimate, some more questionable. Admission guidelines are key for managing the census and have been around as long as hospitals. The first English-language criteria, from 1536, excluded “Hedge-creepers” and “Mylchers” from admission. My hospital will take a Mylcher, but only if he has good insurance coverage.

B is for Beds. Bed management is essential to maintain hospital efficiency. Having all your patients in beds on one unit is important, but as the hospital fills, this gets increasingly more difficult. It then becomes like a sliding-tile puzzle where there are 15 squares filled and one open space and you have to move the tiles to get them in order, except there are 17 tiles and no open spaces.

Illustration by David Rosenman
Illustration by David Rosenman

C is for Calm. It is essential to maintain your cool when the admissions are coming and the patients start crashing. This is best stated by the classic House of God aphorism, “The first thing to do at a code is check your own pulse.”

D is for Discharge. The sine qua non of a hospitalist service is the discharge. The safe discharge of a satisfied patient in a timely manner is the holy grail of hospital medicine. Sadly, it sometimes doesn't happen (see “Top 10 Reasons Not to Discharge Your Patient” in the September 2011 ACP Hospitalist).

E is for EMS/ED/EHR/ETOH/ESRD/EPO/EBV/EGD/ERCP/EMG/EEG/ECT/EKG/EF/ECMO/EXP. We've all had that patient, right?

F is for Fragmented Care. A risk of shift work and hospital medicine is the fragmentation of care. The only way to deal with this is by open communication and solid transitions of care and handoffs between hospitalists and to outpatient care.

G is for Grand Rounds. It's easy in the course of events to focus only on patient care. But you have to stay educated. Whether by social media, journals, CME courses, or noon lectures, make sure you stay informed. (Plus there's nothing like grand rounds for a free lunch and a nap.)

H is for Hospitalist, of course. The fastest-growing specialty, hospital medicine has spread across the world from Japan to Brazil.

I is for Iatrogenic. From the Greek word for physician, iatros, this is disease caused by us. It's the wrong medicine, or wrong-side surgery, or even surgery on the wrong patient. This should not be confused with its cousin, nosocomial, which is caused by the nosocomium, or hospital, environment itself.

J is for Joint Commission. The Commish is on the way! Everyone is prepared, except you. Time to take a vacation!

K is for Vitamin K. Named for “Konsumption” factor, it's our favorite fat-soluble vitamin. Vitamin A is cool, because you can overdose if you eat too much polar bear liver, and vitamin E has a great publicist. Vitamin D is really essential for bones but dull. So vitamin K rules. But in the era of the new anticoagulants, our obsession with vitamin K and its inhibitors may be coming to a sad close.

L is for Lean methodology. Lean methodology (not named after Dr. Lean) comes from manufacturing, especially in the automobile industry. The focus is on value, value stream, flow, pull, and perfection. This approach works well in analyzing ED admissions or PACU discharges. The only thing that may not be lean is having too many participants in a meeting working on a lean project!

M is for Meetings. You have to love them. They seem to come in quanta of 30 and 60 minutes, with the dreaded day-long or multiday retreat always looming on the horizon. If you have 20 minutes of work for a 60-minute meeting, remember nature abhors a vacuum. The material will expand to fill the allotted time, leading to a low-density output. End it when the work is done, and give everyone back their time.

N is for Newman's Notions. No self-promotion here!

O is for Outpatient. This is the ideal place for any patient workup, according to hospitalists at least.

P is for Patient. The core value of the Mayo Clinic is “The needs of the patient come first.” This is true wherever you practice. If it isn't about the patient, then something is wrong.

Q is for Query. The documentation nurses are on your heels again. Why do you keep writing altered mental status, urosepsis, and bacteremia? It would be easier just to learn the basics. But more fun to complain.

R is for Readmission. The unscheduled readmission (aka the bounceback) is often a failure in the system but is sometimes unavoidable. Penalizing readmissions may lead to a paradoxical increase in mortality (see “Readmission Impossible” in the June 2018 ACP Hospitalist).

S is for Sarcoid. The patient is a mid-40s African-American woman with an abnormal chest X-ray. Years of multiple-choice tests have primed this as a reflexive response: sarcoid. So when a patient with this actually shows up, how come you miss it?

T is for Transfer. It's 5 p.m. on a Friday and the transfer requests start rolling in. Or a surgical service has decided that the patient they have had in for 15 days needs no further operative intervention and would be “best served on medicine.” Some people like service transfers, especially from the MICU as they come with orders and admissions notes in hand. However, those same patients are sicker with a longer length of stay. It's a tradeoff.

U is for Unpredictability. Like a heart rhythm that is regularly irregular, the hospital shift is predictably unpredictable. Embracing this concept an important step toward survival in the world of hospital medicine.

V is for Vaccine. This has been a good year for influenza vaccine, though last year was not. Make sure you get yours and give it to your patients. And don't forget the pneumonia vaccine. With the inexplicable rise of the anti-vaxxers, let's all be thankful for Edward Jenner and Jonas Salk.

W is for Wash Your Hands! The simplest of safety measures, but physicians are not the most compliant in this regard. Just do it! I placed a sign in the staff bathroom “All Employees Must Wash Their Hands Before Handling Patients.”

X is for X-ray. Interns from the pre-EHR era would spend hours a week chasing down films that had been stashed in odd places by other services. Now it's just a click of a button. Sadly it's often just the report physicians look at, not the actual image. Look at your patient's X-ray (and EKG)!

Y is for Yeast. It grows everywhere. So look in your patients' mouths and intertriginous regions. And for our ornithological readers, thrush is the Vermont state bird.

Z is for ZZZ. Your patients want sleep meds, but they either don't work well or have side effects. You should order the sleep enhancement protocol. But when you get home after a run of night shifts, don't forget your own protocol: Get exercise, eat well, and most important, get those ZZZs.