Dispo Comes First

In Samuel Shem's House of God, the Fat Man teaches his eager interns this important adage: dispo comes first. That appears to be the modus operandi of the emergency department. Immediately upon seeing a patient, one must decide where that patient goes next (or, more uncouthly, how to get that patient out of the ED). The entire course of care in the ED is centered around that: either gathering the appropriate tests to prove that the patient needs to be admitted or figuring out the diagnosis and treating the symptoms so that the patient can go home. On all services, "disposition" is the ultimate goal: patients cannot stay in an acute care hospital forever, and they must be stabilized to transition to the next step: to a nursing facility, shelter, home, or even another service. In any case, this process is accentuated in the ED for several reasons: the ED is always just a temporary step, that beds are scarce, and that the ED can do everything (critical care, obstetrics, eye exams, surgical and medical stabilization, orthopedics) but it is inefficient to keep a patient in the ED because no one will need all of those services at once (except polytrauma, I suppose). The ED runs like an ICU; it offers high acuity services and time spent there is valuable and expensive. Once an appropriate disposition is identified, it is a boon to patient, hospital, and community to clear them out of emergency.