Same shift, different day: Disposition killers just won’t… : Emergency Medicine News


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Six months. He had me at six months. You know the guy. You hear these words every shift. My ED brain turned off once I heard he had the pain for six months. I always ask what made him come to the ER, but the answer rarely changes my plan. You, my friend, are going home.

I’m interested in the disposition, not the diagnosis. The definition of disposal has to do with placing or removing something. It may sound harsh, but getting rid of our patients is what we do all day.

We have a family medicine residency at our hospital. They’re turning around in the emergency room, and I burned an analogy into their brains: we’re driving down the highway with a car full of patients. The car has four or five seats; sometimes we have a van and carry a few others. Anyway, we’re looking for an exit ramp.

I can drop a 20-year-old woman with dysuria around the corner and get back on the freeway. I’ll stay a few extra outings if the patient is pregnant, then I’ll drop her off. I won’t drive her home, but I’ll stay on the freeway until I find her exit. She could be picked up by the hospitalist or intensivist, or she could walk home from the ramp. I have more room in the car once she gets out, and I’ll be back on the highway as soon as possible.

I explain to the residents that we are focused on the disposition and not on the diagnosis. I remind them that they will fix things when they go out into the community, but we at the ER work for a disposition and exclude the worst things. There are no outpatient D-dimers and people with chest pains walking out of the office to get checked out. We think PE or ACS and work backwards. It must be so.

The layout guy

Back to my patient with six months of pain. Somewhere along the line, patients got the idea that everything they need is in the hospital. They think smart doctors and all the latest technologies are available to them there. They have often already been to Stanford or UCLA or another tertiary care center and many specialists have tried to solve their mystery. Then they come to me: the disposition guy. I’m polite and try to let them down easily, but they’ve got the wrong guy. I’ll make sure nothing bad or dangerous happens, but I don’t keep them in my car for long.

Certainly, making a diagnosis helps with treatment and disposition, but it is not always necessary. I tell residents that we only admit patients for two reasons: when we know what’s wrong with them and when we don’t know what’s wrong with them. Sick or not sick, inside or out, as the saying goes.

A buzzkill is someone or something that makes people less happy or excited about something. I realized that most of what happens to me during a shift that makes me less happy or excited is a disposition killer. The pandemic, especially the COVID-19 test, is all the way up. Transfers are disposition killers, for sure, especially when the need for specialist care is borderline. Combine transfer with COVID, and you get a dead and buried dispo. Geriatric psychiatric patients, people suffering from chronic pain, children requiring specialized care, the list is endless.

It’s usually a sign that your dispo is about to code if you call a case manager or social worker. The patient who came from home but “can no longer walk? The discharge papers you just printed might as well be stamped with a big red DK.

Available Killer

How does your EHR work? I know we all got used to it. They may not be killers. But let me remind you that they are the undisputed champion of available delay. You’ll agree if you remember when we used paper. We just had an addition to our EHR discharge process. Why break what is already broken? I do not know. But now we have to deal with a few more clicks and blanks, nothing intuitive or helpful, just more steps before dumping.

I love teaching and I appreciate our residents. It’s gratifying and I have a sense of duty and the desire to pass on what has been given to me. But let’s face it: a department intern, especially an intern from another specialty, is an available assassin.

But sometimes, everything clicks into place, and it feels like the department is working well when the devices line up. But I feel like the system is there to get me when they don’t. The funny thing is that the other definition of disposition has to do with temperament or emotional outlook. My goal is not to let the death of my temper affect my temper. Otherwise, it will be long.

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Dr. Harmonis an emergency physician at Marian Region Medical Center in Santa Maria, California. Read his past columns on


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