Time Stamps

• 02:44 What makes this patient different from others with similar symptoms or diagnosis?
• 07:28 Does your covering team have the tools to follow up on tasks and information they need for success?
• 16:06 Is the handoff updated?
• 18:26 What information about goals of care and prognosis should be communicated to the night team, especially for critically ill patients?
• 22:41 What are we still uncertain about?
• 25:30 Closing thoughts

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Show Notes

Question 1: What makes this patient different from others with similar symptoms or diagnosis? 

• The goal of the handoff is to provide tailored medical care. 
  • Think beyond the chatbot version of your contingency plans. 
• Chest Pain
  • The chest pain example demonstrates a more broad framework that can broadly be applied to other problems.
  • Framework
    • What makes this patient different? Suspected etiology?  
      • Ex 1: L main disease, awaiting coronary angiography tomorrow
      • Ex 2: Normal coronary angiography, severe anxiety
    • Next steps for evaluation
      • Ex 1: Evaluate at bedside. Repeat troponin and EKG. 
      • Ex 2: If no change, then no need for in-person evaluation. If change in quality, repeat EKG and troponin and evaluate at bedside. 
    • Empiric treatment recommendations 
      • Ex 1: Maximize nitroglycerin drip. 
      • Ex 2: Trial hydroxyzine or Tums. If those do not work, trial nitro. 
    • When you should escalate the problem to a consultant
      • Ex 1: If Chest pain persistent despite nitro drip then reach out to the cardiology fellow to discuss cath lab activation overnight. 
      • Ex 2: If newly anginal, EKG changes or troponin elevation, reach out to cardiology fellow.
• Altered Mental Status
  • Be very specific about what altered means. 
    • Neurologic exam that day as well as baseline (when they were well)
    • Mental status exam that day
      • Are they conversational? 
      • Do they doze off during speech? 
      • Are there hallucinations? 
  • Provide multiple layers of recommendations for management of hyperactive delirium. 
    • Are there any tips to help with reorientation like family members, music, etc. 
    • What medications have worked in the past? 
    • What medications have caused side effects? 
    • Are there IV or IM options if reorientation and oral options are not available?
• Pain
  • It can be really distressing to the night team when there is nothing to offer. 
  • Discuss what is available – oral opioids, NSAIDs, acetaminophen. 
  • Have a low threshold to reassess pain at the bedside!

Question 2: Does your covering team have the tools to follow up on tasks and information they need for success?

• Think about whether you could carry out your recommendations overnight and what the barriers might be. Try to reduce them as much as possible.
• GI Bleed 
  • If asking to follow up a CBC, make sure that there is a consent, type and screen and IV access. 
• Procedural Complications
  • Ask your procedural colleagues about expected complications and when to call overnight.

Question 3: Is the handoff updated? 

• It may seem like a no-brainer, but updating the handoff is really important. 
• Think through the other questions in this episode and see if anything needs to be added. 
• Outdated information can be just as dangerous. Sometimes the most important update is removing information that is no longer pertinent like recommendations for a resolved problem.

Question 4: What information about goals of care and prognosis should be communicated to the night team, especially for critically ill patients?

• Goals of Care
  • You don’t need to have everything wrapped up by sign-out. 
  • Letting your night team know that it’s a complicated situation is helpful in and of itself. 
  • Starting the conversation during the day will give the patient and family time to process in case complications or progression occur overnight.
• Prognosis
  • Prognosis is really challenging, but if you have information then it can be helpful to pass along to your night team. 
  • The example discussed in this example was a patient who likely would not be liberated from a ventilator.

Question 5: What are we still uncertain about? 

• Acknowledging uncertainty can help the night team triage better. 
• Being aware that there is uncertainty can prompt the team to rethink preliminary diagnoses, especially if the patient isn’t responding appropriately to treatment.

Closing Thoughts

• Be generous to yourself and others. Every complication cannot be forecasted. 
• If something came up the prior night then try and figure out how to keep it from being a problem tonight.

Behind The Scenes YouTube Interview

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Transcript

Dr. Maria Rosasco:  I cannot tell you the number of times that I have activated a code stroke, because of anisocoria or weakness or a facial droop that is not new. For example, I had a case relatively recently and the nurse had found them to be altered and they had a left-sided facial droop. And so I activated a code stroke and it ultimately turned out that they had had an old stroke and in the morning the provider had said, ah, sorry, that’s old. Their daughter told me that they’ve had a facial droop for a long time, but it hadn’t made it into the chart. And so I wasn’t able to determine that this was old and the patient didn’t know. 

Dr. Shreya Trivedi: That was Dr. Maria Rosasco, a nocturnist. You may remember her voice from the memorable July Stories episode last year. She is the queen of storytelling and she has so many more stories that we draw upon to all learn how to give better signouts and particularly contingency planning. Welcome to CoreIM, and I’m Dr. Shreya Trivedi. And I’m joined by, 

Dr. Taylor Cox: I’m Dr. Taylor Cox. An attending at Mt. Sinai Hospital. Shreya, I reached out to you about handoffs and contingency planning because during my chief year I was constantly hearing feedback about handoffs, and I was struggling with how to coach others. It’s very easy to give too much information and not enough information all at the same time. 

Dr. Shreya Trivedi: It is so hard! So when you reached out do this episode. I was like heck yes. I am always up for a good educational challenge. But yeah as you mentioned even as we put  together this episode, we realized just the challenge that it was. Ideally we wanted to come up with a clean, neat formula or framework on contingency planning. Every patient is different and every hand off is unique. 

Dr. Taylor Cox: Yeah on top of that, we couldn’t find any practical studies except for IPASS to help guide us, so we decided to interview the people on the receiving end of signouts, the nocturnists.

Dr. Shreya Trivedi: Yeah, and I’m so glad we did because I’m a big believer in hearing their stories and empathy for these stories of receiving not so ideal contingency plans can be so powerful and practice changing.

Dr. Taylor Cox: And of course this is by no means comprehensive… but from conversations with a few people on receiving end of signouts… (some we did not include on air in the episode), there were five themes and questions to ask yourself that really stood out.

Dr. Shreya Trivedi: We think these 5 questions will be a good foundation to continue to build on. And even if you are seasoned at signouts, we can all use reminders in different ways– especially in the context of some of the very real and humbling stories.

What makes this patient different?

Dr. Shreya Trivedi: The first and most important thing that came up with contingency planning is thinking through what makes this patient different from all the other patients with similar symptoms or diagnoses.

Dr. Maria Rosasco: In my mind, the main value that the day folks can provide is to help me do bespoke medicine. What I really need that only the day person can provide is this really specific critical context and synthesis that lets me provide really specific care to patients. But if it’s too general, I think of that as sort of like the chatbot version of the contingency. If a problem, do the standard thing. And I think it’s much more helpful if you’re going to give some direction to deviate from sort of the standard care.

Dr. Taylor Cox: I know that I’ve written or verbally signed out a lot of “If chest pain, get EKG. If febrile, then culture.” But Maria brings up a good point, these contingencies are already the immediate reactions our colleagues are gonna have overnight. 

Dr. Shreya Trivedi: Yeah, so takeaway is to really think through what makes the management of this patient’s symptoms different from typical management. And we sat down Dr. Aaron Troy, a cards fellow at Hopkins and he has a framework with which he approaches his contingencies. Now it doesn’t cover everything but its a good start – and the first question being what makes this patient unique with regards to this symptom? 

Dr. Taylor Cox: Second, what’s the empiric evaluation if the symptom occurs? 

Dr. Shreya Trivedi: Third, what empiric therapy if the symptom occurs?   

Dr. Taylor Cox: And fourth, at what point would you escalate care and how would you escalate care? 

Dr. Shreya Trivedi: Lets hear how he applies that approach to two different patients admitted for to a very common symptoms, chest pain.

Dr. Aaron Troy: You might write chest pain. Patient has un revascularized left main disease and is on board for cath in the morning. If the chest pain is worsening, evaluate them at bedside. Repeat the troponin in EKG and start and maximize the nitro drip. If there’s ectopy on telemetry, persistent chest pain on nitroglycerin or any vital side and changes would page the fellow and ask about activating the cath lab overnight. For another patient’s chest pain who you’ve fully evaluated and you’re less worried about. You might write something like chest pain, patient with negative coronary angiography this morning, and known severe anxiety if similar to the reported exam above, no need for in-person evaluation. If there’s a change in quality, would repeat the EKG and troponin and assess at bedside. Could consider trying as needed hydroxyzine or Tums. If that’s not working, try sublingual nitroglycerin. If the chest pain is newly anginal, there’s a positive troponin or EKG. At that point, I would page the fellow.

Dr. Taylor Cox: I think the first line of both really does a good job identifying what makes them different than your average patient with chest pain, specifically knowledge of their coronary arteries. It then breaks down next steps for evaluation if chest pain happens, empiric treatment and when you should be escalating the problem to a consultant overnight. 

 Dr. Shreya Trivedi: Yep, that was all solid. And because practice is so important lets apply how we can be more specific all too common scenario the “altered” patient.

Dr. Taylor Cox: Yeah, the phrase “altered” can mean so many different things. 

Dr. Shreya Trivedi: Yes this is a soapbox I care a lot about. I also cringe when I see notes that doesn’t comment on their altered more specifically. Can they hold a conversation? Are they dozing off during speech? Are they having more issues with hyperactive delirium? Are they seeing things?

Dr. Taylor Cox: Yeah, and we heard a ton of stories while preparing for the episode where workup was missed because the sign out wasn’t specific about how exactly they were altered… and so the covering person couldn’t recognize that something was different.

Dr. Shreya Trivedi: And then on top of that, leaving helpful recommendations on treatment options. What type redirection works usually? Is there a family member who wants to be reached to help with redirection? If we are at the point of meds, what meds to try?

Dr. Maria Rosasco: So if they have previously received anti-psychotics for their behavioral disturbance, what’s worked? What’s caused unintended side effects or undesirable side effects? What doses have worked? Often this is an urgency or an emergency and I might not have the luxury of time to sort of mine the chart for all of this information. 

Dr. Shreya Trivedi: So I think this 1st concept is really tailoring your handoffs, which can make it difficult to teach and learn. You have actively ask yourself what should I communicate that is specific and different about this patient.

Does your covering team have the tools and information they need?

Dr. Shreya Trivedi: So the first question was to ask yourself what about this patient makes them unique that i should communicate. Maria had a great story that brings up the second question to ask yourself, which is “does the covering team that we are handing off to have the tools they need to follow up on what I’m asking of them,” in other words, did we set up the night team for success? And there are a lot of examples to unpack this and we narrowed it down to 2 high-yield examples. Let’s hear the 1st one!

Dr. Maria Rosasco: A patient was admitted with a lower gastrointestinal bleed and was asked to pull up the CBC and transfuse as needed and their hemoglobin had been in the 10 to 11 range and the person signing out to me said, I really don’t think it will meet the transfusion threshold, but I’m just checking one more tonight for my own peace of mind. And of course the hemoglobin was 6 and this person was having a significant amount of bleeding overnight. But the problem was that because the person during the day had been sure that they would not reach a transfusion threshold, they did not have a blood consent and the patient had dementia, they could not consent for themselves. They also did not speak English as a first language. Their healthcare proxy also did not speak English as a first language and in fact spoke a rare dialect of a particular language for which we do not have an interpreter on staff. And so I was in a position where I was asked to follow up on this lab, but it was non-actionable this contingency. I didn’t have the tools that I needed to do what needed to be done.

Dr. Taylor Cox: This story really hits home for me because I’ve both been in the situation where I’m trying to cobble together a type and screen… get IV access, get consent overnight… And I’ve also forgotten to tee all of this up for my overnight team. 

Dr. Shreya Trivedi: I think we’ve all been there and do give yourself some grace if this happens – We are juggling so much. Moving onto the second example of does the covering have all the info they need– its actually about complications post procedure.

Dr. Taylor Cox: Yep and for that we set down Dr. Margot Hedlin, a nocturnist whose voice you may remember from our At The Bedside segment.

Dr. Margot Hedlin: There are plenty of times that we’re monitoring someone after they’ve had a procedure, so it’s really helpful to know what the expected complications are and how do you manage them. So for example, at this hospital, we do a lot of hepatic artery embolizations to cut off the blood supply to certain tumors in the liver. It is very common for people to have pretty severe abdominal pain and for people to have fevers after that procedure is done. Those are not complications that the interventional radiology team usually wants to know about. Those aren’t complications that you usually need to start antibiotics or get a scan for, but that’s not something I would’ve known the first couple of times that I covered a patient who had just gotten that particular procedure. 

Dr. Shreya Trivedi: Yes! This was honestly one of the most practice changing parts. I recently was on service, IR called for sign out about a patient post a percutaneous nephrostomy tube and said we expect it to be bloody since they biopsies a likely urothelial CA while in there and those are really friable. Usually i’d be like okay thanks but remembering Margot’s storym I said “Wait just in case the night RN gets worried and calls coverage, at what point should they reach out or get further workup of the bloody output” and she gave such clear recs and sure enough when the night coverage got paged, IR did not get woken up in the middle of the night unnecessarily and patient did not have go through extra imaging.

Dr. Margot Hedlin: And that’s something that as a day person you have access to the consulting teams in the way that the night person does not. Sometimes something is a little bit worrying to me, but I’m not sure if it’s worth waking somebody up at three in the morning, but when it’s 4:00 PM and you’ve got the GI fellow’s cell phone number, I think people will appreciate being asked for clarification if you sort of say that the goal of this is to make sure we know what to call for overnight and what we can manage on our own.

Dr. Taylor Cox: And just like altered mental status, another all too common pain points is pain management. 

Dr. Shreya Trivedi: Haha, nice pun!

Dr. Taylor Cox: I think it can take a lot of time to search through the chart and gather all of the information that you need to manage pain overnight if there’s not a clear plan in place. 

Dr. Shreya Trivedi: Yep so how we can be more specific in our pain contingencies for patients we know much better than the covering person?

Dr. Maria Rosasco: And I think that at night I want to be faithful to the pain plan and the boundaries that you have worked really hard to establish during the day and to try to help you and the patient work towards the goals that you set together. But sometimes that’s hard to do without a little extra information. I receive a lot of signups that say something like avoid IV opioids overnight. And okay, yes, but I need more information because if the patient is saying they have pain and IV opioids are off the table, then help me understand what’s on the table. Can they get an extra dose of something else? What’s worked before? Can they get an oral opioid? Can they get some type of adjunctive agent? What can I offer them? 

Dr. Shreya Trivedi: Yeah you know it can hard to receive those pages from nurses that the patients requesting more things for pain. To be honest, this was actually a bit morally distressing for me when I was an night intern to have nothing to offer these patients because yeah I want to adhere to the boundaries that the day team set and do a good job for them.

Dr. Maria Rosasco: I received a pretty good contingency, which was a patient who had a history of opioid use disorder and alcohol use disorder and was admitted with alcohol induced pancreatitis. And the contingency said that the goal was to work toward discharging home in the next one to two days. And to that end, they asked to avoid additional doses of IV opioids overnight if there were pain for additional doses of oral opioids. And they gave some specific doses. And that’s a really helpful contingency because it helps me align with your goals and what the patient is working toward. But in this case, I got the page and I gave an additional dose of oral opioid and then I got another page about an hour later that said, Hey, this is patient’s having a lot of pain still can we give them something IV? And so I said, let me come to the bedside. And I went to see this patient and she said, something feels totally different. I’m in excruciating pain, something feels wrong, and the patient was peritoneal and it turned out that they had had a perforation. I think that to me this contingency was excellent, but it was also a good reminder that I’m not beholden to it.

Dr. Taylor Cox: The patient’s whole hospital course just changed and it’s great that Maria went to the bedside and readdressed even though she had a very good, specific contingency. And while this episode is written mostly with the goal of improving sign outs to your covering colleague, I do want to pause briefly and highlight how important it is to trust your own intuition and clinical judgment if you’re the covering person and something seems off to you. 

Dr. Shreya Trivedi: Right, that was a good story on both giving and receiving end of sign out! So this one may not need to much of summary because I think the stories are so powerful in and of themselves but whether it be following a hemoglobin for a GI bleed, or signing out a patient post-procedure. I think we can set our colleagues for success if we ask ourselves will they have everything they need to follow up on things or the info they need should things are to arise. 

Dr. Taylor Cox: And I’m sure there are so many more! We would love to hear what examples you have and put together a collection of more specific contexts to think through so we can make sure our night teams have all the information that they need. 

Absent/Stale Sign-Outs

Dr. Taylor Cox: Ok so the third question is quite simple but you’d be surprised often this comes: its the Q of asking “Did I update my handoff today?” 

Dr. Maria Rosasco: I was working nights and I get a page that a different patient was hypoxic. They had been on room air and now they were on two liters nasal cannula. The nurse said they didn’t have any respiratory symptoms. And so I pull up the chart and I look at the contingencies and there is one and it says this patient has COVID, they’re on room air. If they become hypoxic then start dexamethasone. And I think on its face, this contingency is okay, they are telling me what they have forecast to possibly happen, what is the likely diagnosis and given me some guidance for therapeutics. And so I order the dexamethasone. And only later did I realize that this contingency was stale, that this was over three weeks old, that this diagnosis of COVID was a long time ago and probably no longer relevant to their hypoxia.

Dr. Shreya Trivedi: Oh man, I can feel for both sides here — on one hand, there’s so much stuff to do during the day but man, 3 weeks of not updating contingency is a bit extreme. 

Dr. Taylor Cox: But actually Shreya, yeah this is a no brainer, but you know for me… this is one of the biggest problems I see… 

Dr. Shreya Trivedi: Really?

Dr. Taylor Cox: Especially with less active patients. Their handoff still has information about their urosepsis from 3 weeks ago. Especially those people waiting rehab for weeks and of course, one night they inevitably get septic. Then the handoff  has really old information that may no longer apply. 

Dr. Shreya Trivedi: And of course, if the covering doesn’t do their due diligence, patients can get real harm and unnecessary testing or treatment done. So this is a quick question to think which is my sign out outdated or what do I need to take out? And sometimes the most important update we can do is just removing things that shouldn’t be there anymore. 

Critically Ill Patients

Dr. Shreya Trivedi: You know, we were talking all about contingencies and Margot also brought up how critically ill patients need more than just contingency planning for their medical problems. So the fourth question is asking yourself what prognostic information and goals of care information what would be important to pass along?

Dr. Margot Hedlin: It’s very common that I hear like, oh, the patient’s healthcare proxy is on board, but the patient’s daughter is not even knowing. Obviously can’t, not all day teams are going to be able to wrap up a difficult situation with a pretty bow, but at least knowing that there is sort of conflict within the family or that the patient is capacitated, but kind of on the verge of becoming too sick to make their own medical decisions. Just knowing that I’m walking into a situation where there might be a little bit of difficulty when it comes to those conversations is helpful to know.

Dr. Taylor Cox: Margot brings up something that I think I’ve definitely felt… which is a bit of shame if everything is not wrapped up in nicely by the time of sign out.

Dr. Shreya Trivedi: Which is so hard to do and I think what’s worse is maybe not being explicit about things that are still up air or more commonly what I’ve seen is people just omit where things stand with goals of care and then the covering team has to go digging in the chart.

Dr. Margot Hedlin: I care a lot more about people having the conversations than about the conclusion of the conversation. Ultimately, people are not coming to the hospital devoid of all the conflict that existed in their life beforehand. They’re not coming to the hospital having accepted their mortality. At least having had that conversation is critically important because people need time to process this.

Dr. Shreya Trivedi: And sometimes you feel like you didn’t make any progress during the day. But giving patients and/or families time to process will likely make for an easier conversation with the covering team should something arise. 

Dr. Taylor Cox: Right and then with these sick patients, Margot also helped us realize that any prognostic information can be helpful. And it’s really not been something I’ve put a lot of thought into… at least in the setting of handoffs. 

Dr. Shreya Trivedi: I think most people will just communicate is this DNR/DNI or full code, but also giving prognostic information this can be really impactful to share with the overnight team. 

Dr. Margot Hedlin: I have been informed that some folks with pulmonary arterial hypertension, some folks with interstitial lung disease, their chance of surviving intubation and coming off the ventilator is just slim to none. And so that’s really, really important information to have because I don’t want to offer patients a false choice. If someone with respiratory failure who cannot be liberated from the vent is now maxed out on high flow with a non-rebreather over top, hopefully this conversation has happened earlier, but I don’t want to say let’s intubate you with without giving them the chance to say goodbye without giving them the honest information that would shape their preferences when they’re coming to the end of their life. Just because someone has metastatic breast cancer doesn’t mean that they’re dying in a couple of months. There are people who can live with certain kinds of cancers for just shockingly long periods of time, and so their oncologist might have four treatment options down the line.

Dr. Shreya Trivedi: I love these point because maybe the oncologist or pulmonologist has had some comment off hand about prognosis of a patient and now I’m gonna try to incorporate that into the sign out and especially just be open and honest about where things may stood with goals of care conversations, even if  things were not wrapped up in a pretty bow.

Uncertainty

Dr. Taylor Cox: And that last point of everything being wrapped up in a neat bow lends itself nicely to our last question to ask yourself which is, what things am i uncertain that would be good for the night team to not take as a hard and fast on my sign out and be open to rethinking?

Dr. Margot Hedlin: This was a person with metastatic lung cancer who was on a clinical trial for a type of immunotherapy and she’d gotten this clinical trial drug a couple weeks prior and was coming in with just profound hypoxic respiratory failure. I was told it was progression of disease. When I asked about the differential, they said, there’s not really a differential. We’re treating her for everything anyway, and I asked what to do if she gets worse, and they said, turn up the oxygen. So going into the night, I kind of unsurprisingly get a call around 11:00 PM that she’s de-satting on 50 liters, 50% oxygen, and I just sort of, long story short, spent a tremendous amount of time with her. And so I came to the conclusion this was probably due to the clinical trial drug, and in the middle of the night I called the PI for the study. And essentially this really, really shaped the whole discussion because the principal investigator for the study pointed out that this was probably a side effect of the clinical trial, and we stayed in very, very close contact over the course of the night as we tried different, very, very strong immunosuppressant agents.

Dr. Shreya Trivedi: And I don’t want anyone coming away from the episode feeling like they always have to have the answer… that’s just not how medicine works. There is diagnostic uncertainty and patients sometimes reveal themselves at 1-2am in the morning.

Dr. Taylor Cox: Yeah and acknowledging that diagnostic uncertainty can really help the covering team or next person triage.

Dr. Shreya Trivedi: I remember my first year as an attending receiving sign out for a service I was coming onto and the prior attending had actually written “I am actually not sure if what the reason for her tachycardia is but I think it could be…” And I still remember reading that openness in uncertainty in the sign out and feeling like wow I had never seen that in residency and I’m like oh you can say that in sign out?

Dr. Margot Hedlin: Nothing in medicine is a hundred percent. We’re always working with margins of error. There are always going to be questions about what’s going on, where we’re going, how the patient’s going to do, but I think it’s really important to be honest about what we do and what we don’t know. 

Dr. Taylor Cox: And we have a very difficult job which pulls us in a lot of directions. People are complex, and we just aren’t capable of predicting everything that’s going to happen as much as we might like to. 

Conclusion/Be Generous

Dr. Maria Rosasco: Contingency planning this is sort of like a partnership between day and night. And I think any other partnership, it not only relies on communication, but trust and generosity and trying to remember that not everything can be forecast or planned for and that we’re all sort of trying our best. I think when I was an intern, I worried a lot about contingency planning and signing out and I felt like it was sort of like a bad mark if my sign out sheet had a lot of things on it, and I felt a lot of shame with that. Like I had somehow failed my patients or failed my colleagues to prepare them. And I think the most you can do is if something happened the last night to try to do what you can to get out ahead of it to keep it from happening the next night. If your patient had a rapid response last night for AFib with RVR because they’ve been NPO and they haven’t received their rate control medicines and your colleagues had to work on that overnight, thinking about what can I do today to make sure that the same problems don’t happen again overnight, and to sort of think about where the vulnerabilities of your patients are and response strategies to them, but that it’s not a failure if your patients had activity overnight that you can’t forecast every problem. And that’s what we’re here for. I mean, that’s why we have people caring for patients in-house 24/7.

Dr. Shreya Trivedi: What a beautiful way to close out the episode! Giving each other the benefit of the doubt and to not feel shame if despite your best efforts there were blindspots and things you just couldn’t predict. 

Dr. Taylor Cox: So as a recap the 5 questions we came up with when you are writing sign outs and contingency planning: ask yourself 1) First, what specific info should I communicate about this person? 2) Second, does the next team have all the tools to follow up on what I am asking and information to set them up for success? 3) Third, is my handoff up to date? 4) Fourth, what goals of care and prognosis information do I need to communicate? And 5) Fifth, what things am I uncertain about that I should let the covering team know to help continue to keep a broad differential and management plan?

Dr. Shreya Trivedi: And I am sure there are tons more and we’d love to hear your stories or tips. We are gonna end with one more story from Maria of a really well done and humorous sign out. But before then, thanks so much for joining us. Please do share this episode with your team or colleagues so we can all get better at doing this really hard thing to do and we can all get better at it. And without further ado here is the wonderful Dr. Maria Rosasco and shall I say a very unique sign out she received one day:

Dr. Maria Rosasco: This is an elderly patient who had had a prolonged hospital stay, was being treated for tuberculosis and had during the daytime developed hallucinations, otherwise end of times three, a normal neurologic exam. But they had developed hallucinations and they were specifically taking the form of ghosts. They were experiencing visions of ghosts in the bathroom of their room. And so the person that cured for this patient gave me a great sign out because I don’t really have an algorithm for ghost busting at night. And I think here’s where some specific knowledge about the patient really, really paid off. And this was the knowledge that only the daytime doctor could provide to me, which is that he told me what he did during the day to sort of get rid of the ghosts, which included going into patient’s bathroom and asking the ghosts to leave and then moving the patient’s room and he said these things worked, the patient’s no longer seeing ghosts, so if the ghosts come back overnight, here are the things that you could try. And I had to activate the ghost contingency at night because again, he had ghosts and instead of just medicating the patient I think the daytime doctor had really set me up for success by forecasting that this might recur had given me a lot of really patient specific context, really rich context to go to the bedside with and to treat the patient successfully.

Dr. Taylor Cox: Were you blasting the Ghostbuster theme music as you were walking down the hospital?

Dr. Maria Rosasco: It was really satisfying.

References

• Medendorp NM, Stiggelbout AM, Aalfs CM, Han PKJ, Smets EMA, Hillen MA. A scoping review of practice recommendations for clinicians’ communication of uncertainty. Health Expect. 2021 Aug;24(4):1025-1043.