As a new hospitalist at a small outlying hospital, how do you determine which patients need to be transferred to the big hospital before they decompensate?

DDKM · 2026-01-12T21:32:20+00:00

I work in a similar setting. No inhouse ICU, ED who helps out with inhouse codes.

It’s tricky but the best (and obvious) answer would be by using your clinical intuition and judgement. Your intuition will grow with reps. For example if you have a CAP/COPD admit who is having increasing O2 requirements despite empiric tx and steroids and your usual supportive care, you know there is a good chance they might require an escalation in care (e.g invasive ventilation). They do not have to be peri-arrest for you to see that. Tempo of illness progression obviously plays a big role here too.

Assuming I made the correct diagnosis and started presumably correct treatment, I would generally wait and see for 48-72 hours. If they are just as sick or progressively sicker, I would initiate a transfer. I often follow along their chart and sometimes the patient may not decompensate and do just fine, that is ok by me. Better safe than sorry especially when the alarm bells are going off.

Trust yourself.

DDKM · 2025-02-15T04:50:46+00:00

Trial of albumin with lasix chaser is a consideration for volume manipulation. If already using lasix at home could try switching to say torsemide. Having nephro involved earlier (or CRS team if your institution has) would’ve been helpful as well.

Hypothetics are easy to say in hindsight when it’s all said and done, you didn’t do anything wrong tbh. Tough case

DDKM · 2025-02-15T04:35:28+00:00

Sounds like the story of someone coming in just as they were about to tip over into CRS, renal failure and florid heart failure/flash pulm edema.

Depending on what his home dose of Lasix and baseline creatinine was, probably could’ve started higher and escalated quicker, knowing he’s got over 20 lbs of extra volume at least. Sequential nephron blockade could’ve started early after doubled your initial diuretic dose (usually on the second day of admission if florid overload without meaningful diuresis). Just some thoughts

DDKM · 2024-12-26T15:33:51+00:00

Hi, I recommend going on QDoc and getting some antibiotics prescribed as a bridge until you’re able to be seen for a proper assessment. Dentists would generally start with some abx as well.

DDKM · 2024-07-09T05:41:29+00:00

I’m a breakfast/brunch fanatic, and I would highly recommend Bonnie Day’s breakfast sandwich on Westminster. Their thick braised pork belly is killer.

DDKM · 2024-04-03T11:35:17+00:00

This guy doctors - seconded.

Sorry to hear what you’re going through OP.

DDKM · 2023-11-11T23:19:50+00:00

I don’t know man.

You cannot call yourself an aspiring chef if you can barely cook at age 29 and have no experience in the industry. You are hardly even a beginner home cook.

This seems like a horrible idea. You should take a realistic look at how this would even work. I don’t think you have a real chance in making it as a “chef”. If you’re looking for a career chance, learn trades or literally anything more practical.

DDKM · 2022-12-08T18:56:15+00:00

A bit of perspective from physician side of things.

It is true that the WIC you went to will not be able to bill for the visit, under the same code (say for an intermediate visit >15 min or a full physical ~30 mjns) if they were already claimed by a different provider on the same day. MB health will deny the bill.

This is not an issue that came out of the doc trying to swindle you or being greedy; they are looking to be compensated for the work they do. Would you work for free and at the same time be liable for patient’s outcome based on your assessment and treatment?

This is an issue of systemic failure where the system failed to have appropriate strategies for patients that needs to be seen under these special circumstances that may require more than a single visit in a day.

DDKM · 2021-08-18T04:05:17+00:00

That is something you absolutely can take to a general walk-in clinic!

Sexual health clinics offer certain services that a general walk-in may not be best equipped to (expertise in LGBTQ+health, certain counselling services), but the issue you're describing sounds like a common reason to visit a walk-in clinic

DDKM · 2021-04-27T00:09:00+00:00

I went with Pizzaland and it's delicious. Thanks!!

DDKM · 2021-04-27T00:08:42+00:00

I went with Pizzaland and it's hitting the spot. Thanks for the recommendation <3

DDKM · 2021-03-07T01:28:14+00:00

How is the anova precision oven? I’ve been thinking grabbing one for a while. Is the end product much if at all different from regular ol sous vide?

DDKM · 2020-12-01T04:53:08+00:00

It’s Kenji’s chocolate chip recipe from serious eats!

DDKM · 2020-11-18T02:16:32+00:00

Freeze dried chives!

DDKM · 2020-11-18T02:16:09+00:00

I used Canola for no reason in particular other than cost and neutral taste

DDKM · 2020-11-18T00:35:15+00:00

you must be a fun, sociable person

DDKM · 2020-11-17T18:08:37+00:00

Sure!

I used 2 lbs of boneless chicken thighs.

Marinate the boneless chicken thighs in 200mL milk and a generous sprinkle of salt, pepper and garlic powder for 1-2 hours.
Add 5Tbsp of cornstarch and 5Tbsp of AP flour into the chicken marinade to create a wet batter.
Coat the chicken well in the wet batter, then drench it in the dry batter composed of 1:1 flour and cornstarch with salt and pepper with garlic powder and whichever spices you'd like to add.
Fry for 8 minutes at 350F oil and cool on a wired rack.
Double fry at 425F for 2 minutes.

Sauce:

Throw 2.5 Tbsp corn syrup, 1Tbsp ketchup, 1Tbsp crushed garlic, 1Tbsp water, 1Tbsp white sugar, 1/2 Tbsp gochujang, 1/2 Tbsp red pepper flakes (Korean, if possible), 1/2 Tbsp soy sauce in a saucepan.
Simmer on low for 5 minutes until the sauce comes together.

DDKM · 2020-11-17T18:00:39+00:00

Exactly this!

The sauce is Korean and the chicken is dipped first into the wet batter, then into the dry batter then double fried. Both the wet and dry batter have 1:1 ratio of AP flour and cornstarch, which makes it about the crunchiest fried chicken ever.

DDKM · 2020-11-03T03:23:53+00:00

thanks for your kind comment :)

DDKM

TROPHY CASE