The Spin

Reposted today from 2008. Always applies though!

What is one of the most important skills a doc learns while working in the ER? The “spin”. This is in addition to the obvious (and boring) skills of multitasking and learning the actual medicine. This skill (or lack thereof) can make a good ER doc into an ineffective one or a mediocre one into a dispositioning god.

What is the “spin”? Well, it is something that Bill O’ Reilly hates. The ER could also be called “The Spin Zone”. Why? Well, the fact is that many cases do not have indisputable objective physical findings, lab results, X-rays, or CT scans. Those cases are easy: “Yeah, Dr Surgeon, the kid has a WBC count of 15k and the CT shows appendicitis”. No spinning needed.

Basically the spin is how you make your clinical suspicions into presentations that other doctors have a hard time arguing about. The more nebulous the case, the more spinning you need to do. The cases where someone just “looks sick” or your “spidey sense” is tingling that something bad is going on require some spinning. The old lady who is generally weak and you are afraid if she goes home at 1am that she will fall and break something or be found unconscious the next day by relatives needs spinning. Rarely do you need to overtly lie. Remember however, you are doing this because you are worried about the patient and want to make sure they are safe – you don’t do this because you are lazy and don’t know what the hell to do with them.

How to spin:

1. Tell the doc on the line something that will concern them. Now, this varies from doc to doc mostly depending on their specialty. Surgeons care about white counts and things like lactate levels and rebounding of the abdomen. Pulmonologists care about pulse ox’s, chest X-rays and ABG results. Pediatricians care about respiratory rates, “tugging” of accessory chest muscles, and colour. GI docs get worked up about haemtocrits, stool colour, and naso-gastric tube contents. You don’t need to lie – even if something is even slightly abnormal, you can emphasize it when you mention the clinical picture to them – “yeah, I know the hgb is 8.5 but she looks pale and is very weak” – would be the way to describe a lower GI bleeder that you are sure they are going to want you to send home. Gynaecologists are more likely to respond to ” she went through 30 pads today and is lightheaded – although I agree that her hgb of 8 is not that bad. I am worried what it will be in 8 hours”.

2. De-emphasize things that don’t concern you. This is done to prevent PMD’s from asking you to call random consults before they are willing to admit the patient. This is especially important at night. DO NOT emphsise the “dizziness” in a dehydrated patient with vomiting unless you want the PMD to ask you to call the neurologist in at midnight for a stat consult. Use words like “lightheaded” and “weak” – they sound more general. PMD’s handle that. They don’t like things that sound like potential strokes.

3. Use the family and the patient to your advantage. Tell the doc ” the family is not comfortable taking them home” – this works well for the elderly or little kiddies. Likewise you can always use the “she lives alone and there is no one to help take care of her with her broken humerus for the next few days. ”

4. Frighten the doctor. If a patient had a previous episode of whatever they are in for and had a bad outcome, like perhaps a cardiac arrest or got intubated, use it! “Yeah doc, I know she looks pretty good but last time she had a COPD exacerabation she got intubated”.

5. When all else fails, but you still don’t want to send the patient home, have them wait overnight in the ER and tell the doc they can swing by before their rounds. Many times as soon as they come in and see the patient, no spinning is needed since they now are actually looking at the patient and the need to admit is obvious!

12 Responses to The Spin

  1. Dr. Bearemy says:

    Spinning is definitely an art. Too much and you’ll loose credibility.

  2. ERP says:

    Indeed. If you spin too obviously you lose your cred and everyone thinks you are an idiot. Spin too little and you can never get those tough cases admitted.

  3. Dr. J says:

    In the end, do whatever it takes for you to go home and sleep that night. I’d rather have a hospitalist think I’m a pansy liar than go home and be snippy with my wife, kick the dog, and lay awake hoping that patient didn’t come back 4 hours later looking like hell.

  4. Jamie says:

    Now I know why my husband kept getting admitted every time he had pneumonia. One time he didn’t seek care soon enough and ended up almost dead, having to be shocked back, and then intubated and in ICU for a while. I hadn’t ever thought about the fact that a previous bad outcome would make him more likely to be admitted when it was borderline.

  5. Sara says:

    DO NOT emphsise the “dizziness” in a dehydrated patient with vomiting unless you want the PMD to ask you to call the neurologist in at midnight for a stat consult.

    Thanks a lot!!! :-)

  6. ERP says:

    LOL Sara, that is EXACTLY what happened the other night when my PA overemphaised the dizzy factor in an old dehydrated lady!

  7. Sara says:

    And I was thanking you because ER docs who work in my hospital don’t seem to understand that….a syncope in an old patient taking four anti-hypertensive drugs? “Call neurology!” Position-related vertigo associated with nausea and vomiting? “Call neurology!” Cephalea that completely disappears fifteen minutes after intamuscular ketorolac? Just guess………

  8. Rogue Medic says:

    Even in EMS, spin is an important skill. Knowing the different medical command doctors. Knowing what to say to get them to order something that the patient appears to need. Knowing what to say to get them not to order something that the patient appears to need to avoid. At the same time avoiding presenting a false picture of the patient.

    The same is true for presenting the patient to the triage nurse/charge nurse, who will be deciding if the patient goes to triage, to a hall bed, to a monitored room. The nurse has the advantage of actually being able to see the patient at the time you are presenting this information.

  9. ndenunz says:

    I don’t know, but to me, telling me the family doesn’t want to take their loved one home makes me want to dig in my heels more and not admit them. I just know I’m going to get a call from Utilization Review the next day if the person gets admitted.

  10. Emma says:

    This is very true, and it applies to *everything*. I tend to find I spin the same patient a slightly different way to everyone I speak to – my registrar, my consultant, the physios, anaesthetics, everyone I ever refer to, radiology (especially radiology), even sometimes the nursing staff. It’s really just a way of persuading them to do what you need them to do.

  11. Dr. Grumpy says:

    Whatever Sara said.

Leave a Reply

Name and Email Address are required fields. Your email will not be published or shared with third parties.