The ED consultant insists a patient is 'medical' and must be admitted under you. After reviewing, you believe the patient is primarily surgical. The ED consultant becomes confrontational. How do you handle this?

Question

A 72-year-old woman with abdominal pain, vomiting and a lactate of 4 has a CT showing small bowel obstruction with a transition point. The ED consultant has referred her as 'AKI and electrolyte disturbance' and is refusing to re-refer to surgery, raising her voice in front of nursing staff.

Accepted Answer

I would use **SPIES**.

**Seek information** — I would review the patient myself: history, observations, the CT report and the surgical opinion if one has been sought. I want facts, not impressions, before any conversation.

**Patient safety** — a lactate of 4 with small bowel obstruction is a time-critical surgical pathology. Irrespective of the disagreement, this patient needs IV access, fluids, NG decompression, analgesia, antibiotics if perforation suspected and an urgent surgical review. I would initiate that resuscitation now.

**Initiative** — I would invite the ED consultant to step away from the bedside and have the conversation in a side room, calmly. I would acknowledge the pressures they are under, share the imaging findings, and propose a **joint bedside review with the surgical registrar** so the decision is made on clinical grounds, not specialty turf.

**Escalate** — if the disagreement persists, I would phone my on-call medical consultant straight away. This is exactly what consultants are there for. If patient safety is at risk because of the delay, I would also inform the site manager.

**Support** — I would protect the nursing staff who witnessed the exchange, debrief them afterwards, and complete a **Datix** focused on the system issue, not the individual. I would reflect on the encounter in my portfolio and, if appropriate, request a professional conversation with the ED consultant through educational channels rather than informally.

Conflict with ED consultant over an inappropriate medical referral

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