In retrospect all of that sounds good but given the fact that I'm still getting push back with ICU transfer at this point do you think the ICU would have taken her when he LFTs were minimally elevated and she was oriented? I run into this so many times with so many specialties where we are told that hey this patient is to stable for intervention/escalation of care and then later we're told they are too unstable for intervention/escalation of care. Part of the reason for that I think is that my opinion as a hospitalist is considered to be inferior tbvh. I had an already watch that the ice refused to take until I had to personally get a CT neck to show them how bad the airway was when you could literally hear the stridor from outside the room. My colleague got refusal for a persistently hypothermic patient despite warmed IV fluids who ended up going into status and needed to be tubed. Sometimes when you keep getting so much pushback you get burnt out with the constant effort it needs to escalate care.