Do we need to do it all?

A patient presented to an academic centre with hepatic encephalopathy and decompensated liver disease with a Hb of 54 and pancytopenia on a background of worsening NASH cirrhosis. She is febrile and tachycardic in addition to being confused. She has had multiple contacts with the GI service and several medical admissions as well, with the last admission being 6 weeks ago. There is concomitant hyponatremia and anemia from liver disease. After a few tests are back, a consultation is made to the Internal med service on call. The Resident asks if ammonia has been drawn, lactulose been given and a paracentesis performed. The platelet count is 39. The INR is 2.0. You have already given fluids, antibiotics and arranged for blood transfusion. You have even obtained some X-rays and a bedside US to document ascites worsening. All emergent bloodwork is either drawn or pending and resuscitative measures are well underway. A debate ensues that you may not have referred a well worked up patient as the paracentesis is missing, the lactulose is not given and the ammonia is pending. You kindly explain that this is normal practice to make a referral after you feel your job is done. The Medicine resident goes on to say that in his experience ER physicians do all these things and points out that you are the exception as most of the ones he has seen refer patients after all this is done. What would you do in this situation? A nearby nurse gestures you to hang up the phone and do what has been asked of you. Thoughts?

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