/UCEM
Referring patients to inpatient teams (even for FUCEMs) can be daunting, so here is a sure-fire way to get your patient admitted regardless of lunar cycle, system wide constipation, snobby inpatient sub-sub-subspecialists, and PGY1 first week on the job IMGs. ISBAR is for simps. The Utopian College of Emergency Medicine prefers the far superior BARIS handover tool as as an evidence based method to improve 4hr KPIs – the only metric that matters in ED. Bed status be damned – your patient will be admitted after using this handover tool. I will use the example of Mr Patient, a 75yo man with an intermittent heart block who is stable but needs admission to a ward with telemetry pending a pacemaker.
Background
Always start your clinical handover with prose. As soon as the inpatient registrar picks up the phone, your goal is to impress them with your impressive command of England. Some eastern FUCEMs use haiku. This is from legendary FUCEM G. Lucas.:
A long time ago, in a land far far away, Mr Patient was born at term to Ms Mother and Mr Father, an apprentice plubmer by trade, who took a day off work to attend the emergency delivery as Mrs Mother failed to progress in her labor...A full history includes the birth history, travel history and all details of your patient’s life. If you are uncertain about the relevance of Mr Patient’s marital fidelity, do include it as well – there is no such thing as lack of detail in a patient’s background. UCEM advanced trainees approaching fellowship would do well taking a collateral history from Mr Patient’s wife’s boyfriend. Personaly I would also include the patient’s circadian preference and sleep wake cycles just to be sure.
Assessment
This is your time to shine. The most detailed history of presenting complaint, clinical examination, and panel of investigations will impress the most snobbish of inpatient subspecialty registrars. The trick is to leave the listener with a sense of wonder and amazement about the broad list of differentials you are teasing them with. Never mention any differentials when detailing your assessment of the patient. The idea is to give vague hints with random positive and negative findings from unrelated differentials in a mixed order. Like a good cocktail, you need to mix the HOPC, examination and investigations thoroughly. Remember you are trying to make the registrar do all the heavy thinking and diagnosis over the phone without seeing the patient – this avoids you from having any medicolegal liability and puts the responsibility of decision making on them. “Decision for [treatment] by [registrar].” will be documented in the notes formally.
He had an episode of feeling dizzy (avoid using the terms vertigo or lightheadedness as it is too specific) while watching TV and came to ED with some minor chest pain. It is sharp but at times dull and occasionally radiates to his shoulderblades. I asked him to take a deep breath and he said it only hurts when he takes a deep breath lying down. Because of this, I did a D dimer which is still pending. The triage nurse noted he pointed at his upper abdomen when she asked about chest pain, so i've added on a Urinary Porphorins to his UMCS - which was done as part of my screen for infection. There is a possible exposure to ticks as he went camping in Louisiana wetlands one month ago. Did I mention his COVID test was negative? It was just a rapid point of care swab so I sent a formal PCR just to be sure. The epigastric pain did not radiate up to his throat and he did not have any burning sensation. He tells me he has never had a colonoscopy. There were no night sweats or weight loss reported, but I am still worried because he is old and may benefit from a PET scan, whole body MRI, and bone marrow biopsy as an inpatient. On extended history he tells me that he is an instagram influencer and went to Chernobyl which has recently opened to visitors to take selfies in the Zoolander 'derilique' style. Thus, a faecal uranium pathology sample has been sent and should be back in 2-3 weeks - your name has been attached to the request to follow up the results. His psoas sign is negative. The vitals signs show a systolic blood pressure of 142, diastolic of 85 and a MAP of 98. Saturating 98% on room air and 99% on 2L nasal prongs. I also checked his blood pressure on both arms while explaining that a dissection could cause him to suddenly die. He did become quite anxious, and by the time i measured his left arm, his blood pressure was 182. Hence the CT aortogram on the RadiologyViewer - I couldnt see a dissection, but a formal radiology report is pending and I was hoping you could have a look at the scan. The chest is also clear with no unilateral crepitations, RV heave, or cardiac friction rub audible.Notice how I have left the best for last? The inpatient registrar is now hungry and desperate for any mention of an ECG. But it’s never a good idea to put yourself out there too much. Have some standards. Bonus points for throwing in some random life threatening differentials – the mark of a true professional.
Paramedics said his heart rate dropped to 40bpm in the ambulance but the telemetry in the cubicle looks sinus rhythm and not slow, but on closer inspection appears wide in nature. Then go into a full in depth systematic review of the ECG. There is a "M" shape (calling it rSR' is too technical and frowned upon) in V1 and is quite wide. I think the PR interval looks like it is 4, maybe 5 small squares. The S wave in the lateral leads appear slurred as well. Acute right heart strain can cause that so im wondering if I should also order a CTPA. Recommendation
Always stress the fact that a patient the specialty registrar has never seen before will appear in the ward under their bed-card and name. If the registrar (rudely) interrupts you and asks about resus status, the answer is always “FULL RESUS” – there is no time in Utopian EDs to look up advanced care directives or talk to patients about things as mundane and elective as resuscitation status and goals of care.
I have booked a bed in the cardiology ward as I think he needs an admission to fix his slow heart rate that was documented by the paramedics. I think you need to see him as soon as possible and address his presenting complaint as he will be transferred to the ward within 30 minutes - the bed manager has organized a bed and I will document this handover to you in the medical record. He is for FULL RESUS.Identify
At this stage, the receiving registrar should have stopped talking or asking any questions – stunned into silence by your amazing gestalt and clinical acumen. It is common for them to ask who they are talking to. Always ask who their consultant is, and offer to call them directly.
It's [insert name here], calling from ED. Who's the cardiologist on today btw? ... Oh no worries I can call her if you would like. I've got her number. ^That’s the secret right there. It is proven to reduce barriers to admission by 80%.
Situation
If you have followed this guide to the letter it should be unnecessary to explain the situation. The inpatient subspeciality team would either already be down in ED at this point, or practically begging for the patient to be sent up to the ward as soon as possible. However, if you do reach this part of the conversation (usually after about 20-30 minutes), do enlighten the inpatient registrar of the situation:
There is a 75yo man requiring and admission for a pacemaker for a trifascicular block. He presented after having three presyncopal episodes and is currently asymptomatic. Trops are negative, there are no red flags, and he is stable to be seen upstairs in the wards.Further Reading
Now that you have mastered the FUCEM way of making referrals, consider the following article:
www.emtldr.com 
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