The Phone and Consults

On the medical ICU, one of the fellows is always carrying the "phone," which is a bit like a hot potato. The fellow carrying the phone is the main gateway for patients to be admitted to the ICU. The emergency department calls us with new patients who have medical critical care needs, from sepsis and hypotension to respiratory failure to neurologic catastrophe. In fact, the phone fellow often spends his time hovering between rooms in the ED, stabilizing patients and determining whether they need to come to the unit or not. We also get a good number of floor consults for inpatients who are looking a little sicker. These consults require a lot of clinical intuition and judgment. From a resource-management standpoint, I can't take every patient into the ICU so I have to tease out those who can be managed on the floor and those who cannot. Often, I will make several interventions to figure out the safest disposition for a patient. Sometimes, I will round on them hourly to get a sense of where things are going. Occasionally, this means that I get into arguments with the emergency department or primary team about what is appropriate, but I try to be reasonable in determining how to allocate our limited beds. Surprisingly, gut feeling and instinct plays a lot into it. I've written before about the clinical gestalt when physicians see a patient. Some people just "look sick." They appear frail, tenuous, or fragile. Others may have vital sign or lab abnormalities but look "stable." You have to take these clinical impressions with a grain of salt, but sometimes, they turn out to be the right decision. When I decide someone needs to come up to the ICU, I work closely with our nursing supervisor and bed control to get them upstairs as soon as possible.