Transfer Center I

Before being a fellow, I was vaguely aware of the hospital's "transfer center." As an intern and resident, patients transferred from outside hospitals would magically appear, and I would have to leaf through packets of handwritten notes to try to figure out what the outside physician was thinking and determine the plan of action going forward. I knew there was an accepting attending and expected a transfer summary (though somewhat like unicorns, these were mostly fictional). But I was never privy to the process of how these patients got here.

Now as an ICU fellow, I have daily conversations with the transfer center. Staffed by well-seasoned nurses, the transfer center fields phone calls and inquiries from community physicians and other hospitals hoping to send their patients to Stanford. They triage patients and if a patient sounds like they have a medical ICU need, they give the ICU fellow a buzz.

For us, it feels a bit like a chore. We are busy with our mounting census, admitting patients from the emergency department, and responding to codes. Having a long phone conversation trying to tease out whether a patient needs to come over can be a bit of a burden. But I've realized in my interactions with the transfer center that they really help make things pain free.

A victim of a near-drowning has been in the intensive care unit at a large community hospital. The settings on his mechanical ventilation are pretty much maximized; he is requiring 100% oxygen and significant pressure to keep his lungs open. He developed acute respiratory distress syndrome, pneumonia, septic shock, liver failure, an ongoing gastrointestinal bleed, and kidney failure. He's on continuous renal replacement therapy, blood transfusions, and broad-spectrum antibiotics. The ICU doctor over there calls me because he does not know what else to do for this patient. Can he send the patient over for further management?

I declined the case. I felt that he was too tenuous to transport. With his ventilator settings and three vasopressors, I did not think he would survive a helicopter flight or ambulance ride. Furthermore, I couldn't think of any additional therapy we had that they hadn't tried. I talked to one of our cardiac surgeons to make sure ECMO (extracorporeal membrane oxygenation) was not an option, and then I told the outside physician that bringing him over would subject him to serious risk without a clear benefit.

A patient with alcoholic cirrhosis and known esophageal varices goes to a local emergency department because she is vomiting blood. Her blood pressures and hemoglobin are quite low and she's rehydrated, transfused, and started on some medication drips. Although that facility has an 8 bed ICU, they do not have a gastroenterology or interventional radiology consult service. After hearing about this, I took the patient. They needed a higher level of care which we could provide. When they arrived, I had our gastroenterologist scope her, place a few bands on a bleeding esophageal varix, and I sent her out of the ICU the following day.

Stay tuned - more stories to come.