Preface, 2008: I wrote most of these On-Call reports during the second year of family practice residency, mainly because I had more time to digest and process events than other years. At my program, our call frequency never decreased but our responsibilities shifted each year. Interns got pounded with running Labor and Delivery and admitting all floor patients, while second-years covered ICU/NICU and performed "special ops" such as checking up on people who were crashing on the floor. Third-years were responsible for overseeing their juniors, and this meant their either a) worked harder than ever, making sure their juniors did a good job and nobody got yelled at the next day, or b) disappeared into the call room and allowed the juniors to suffer, unattended.
I was on-call last night, but I'm feeling strangely lucid this evening, after a good, long nap, so I thought I'd give you a flavor for what happens on call. (I've changed some of the details about the patients, to protect confidentiality.)
6am to 5pm: Just because you're on call doesn't excuse you from your day job! I rounded on the kids and babies hospitalized on the wards; admitted M.S., a 12 year-old girl with insulin-dependent diabetes mellitus in diabetic ketoacidosis (DKA), to our intensive care unit; went running down to the Pediatric clinic to see patients; wolfed down lunch at the cafeteria; then finished the afternoon off in my own Family Practice clinic, seeing my own patients. I'd hoped to squeeze in a catnap before the evening started, but it wasn't meant to be.
5pm: To Labor and Delivery for board rounds. At our hospital, the first-year resident runs L&D, and begins call by reviewing each patient's status, whether they be in labor, preterm labor, or hospitalized for control of the diseases that complicate pregnancy, such as gestational diabetes or preeclampsia. This used to be my job, and it's an odd feeling to see the new intern taking command of the role I used to occupy.
5:30pm: To the Intensive Care Unit (ICU) to review the status of all the patients there. As a second-year resident, I'm in charge of the ICU and the Neonatal Intensive Care Unit (NICU) while on call. This means I'll be admitting patients to those units and managing problems that arise during the night. M.S., the girl in DKA, is doing better but still requires glucose checks every hour and blood draws every four hours, and she's not very happy about it. The rest of the ICU is filled with critically ill adult patients, including Ms. G, a woman with multiorgan failure who requires a ventilator to breathe.
6:00pm: The most important activity on call: dinner! Our senior resident has brought in burritos so we don't have to suffer through yet another cafeteria meal. Yum!
6:30pm: The first delivery of the night! I am called to attend the delivery because the mother received narcotic pain medications immediately prior to starting to push, and this can result in a baby born who doesn't want to breathe properly. This is not an emergency, but it requires an extra set of hands to resuscitate the infant. Again, I feel an odd twinge as I watch the first-year resident deliver the baby, because that used to be my job....Oh, and the baby came out pink and crying, thank you very much!
7:45pm: To Medical Records to sign about 30 charts. If you spend enough time on call, you'll phone in hundreds of verbal orders to the various wards, and these verbal orders have to be signed in person within two weeks. This generates the dreaded "stack" in Medical Records.
8:15pm: I'm called to the ICU because Ms. G has died. She had made the decision not to undergo CPR if she were to pass away. Apparently her blood pressure had dropped steadily throughout the afternoon, and then her heart slowed down until it stopped beating. I gave her one last examination and made the death pronouncement, never the happiest moment on call but part of my job. I indulge in a moment of reflection upon the cycle of life, having run from a birth to a death in less than two hours.
8:45pm: Down to the Mother-Infant Unit to evaluate a baby who is breathing too fast. Usually newborns room in with their mothers, but every so often a baby develops a fever, acts abnormally fussy, or develops rapid breathing or other kinds of respiratory problems. This little boy's nostrils flare when he inhales, and his little chest heaves to take a breath. I order some lab tests and an x-ray, and have him moved to the intermediate nursery for observation.
9:15pm: Another delivery--this time I'm called because the baby is expected to be a big one, and we're getting ready for a possible shoulder dystocia. When this happens, the baby's head delivers easily but the shoulder gets stuck behind the mother's pubic bone. It's a life-threatening situation for the baby and doesn't happen all that often, but because we see a lot of mothers with gestational diabetes, a risk factor for the event, the possibility is always at the back of our minds. Luckily this baby delivers easily and cries right away. The birth weight is well over nine pounds, so we all breathe a sigh of relief.
9:45pm: Oh dear, things are picking up in the Emergency Room. The senior resident tells me we've got four admissions to do! I run back to the intermediate nursery to check on the fast-breathing baby. I don't like the way he looks at all--still heaving and flaring, and breathing far too fast to feed safely--so I write orders to have him admitted to the NICU. He looks a bit yellow to me, so I add a bilirubin level to his labs.
10:00pm: Down to the Emergency Room to admit a 56 year-old man with coronary artery disease and worsening chest pain. This is called unstable angina and it buys the gentleman a trip to the ICU with two full pages of orders! The senior resident is admitting two patients who need to go to surgery that night, and the first-year resident is admitting a woman with severe lupus and poor kidney function. It looks like Grand Central Station in the ER! The good news is: we've filled all the beds in the hospital, so hopefully things will slow down for the rest of the night.
11:30pm: The lab results are back on the NICU baby...everything looks fine, except the bilirubin is a bit high for being only 9 hours old. I notice that his mother's blood type was O-positive, and his blood type is B-positive. When you have this combination, there can be an incompatibility between the mom's blood and the baby's blood that causes the baby to break down blood cells rapidly. The accumulation of broken-down blood cells can cause severe neonatal jaundice, or elevated bilirubin, which is a condition requiring treatment because excessive amounts of bilirubin can get deposited in the brain, and cause irreversible brain damage. Neonatal jaundice is a difficult diagnosis, because you have the severe cases at one end, and the normal and harmless cases, which are far more common, at the other. The trick is to tell them apart. I order another bilirubin level at 3am and a Coombs test to see if there is an incompatability between the maternal and infant blood types. At least the baby's breathing is beginning to settle down. I think we'll be able to feed him in a few hours.
1:00am-3:30am: After going back to the ICU to write notes, finally...NAPTIME! I doze for a while on the sofa in the resident's lounge. Every hour, I get a page about M.S.'s glucose level, and have to phone in orders to adjust her insulin infusion, so it's not an uninterrupted sleep, but it's more sleep than I ever got as first-year, so I'm not complaining.
3:30am: Time to go back to work. I swing past Labor and Delivery, where things are settling down after another delivery. The first-year is caught up on her work, so there's nothing I can do to help her. She's got a few questions about her admission, however, so we chat for awhile, and then I send her off for a nap. Even ten minutes of rest is helpful on call.
4:00am: Did I mention I have to round on the Pediatric service today? This is part of my "day job" but I've combined it with my call night so I can get a day off this week. It sounds crazy, but between the resident's call requirements and our responsibilities to the inpatient services of the hospital, we could end up working every single weekend if we did not do our rounding on call. I can start early with the NICU babies because I can examine them while they're sleeping. It's not like waking someone up out of a sound sleep. Their notes are tedious, however, because every drop of formula that goes into them, and every drop of urine that comes out of them has to be accounted for, and divided by their weight in kilograms...I'm telling you, it's advanced mathematics when you're doing it at 4am!
7:00am: I've seen all the babies, now I run upstairs to the Pediatric ward to start seeing the older kids. On the way, I swing by the ICU to see M.S., whose lab results have been improving throughout the night. She's really sleepy after being woken up hourly overnight, poor kiddo. At this moment, I'm grateful for the fact that the hospital filled up last night. Usually we'd be finished up a half-dozen more admissions at this hour.
8:00am: Time for the Morning Report. Every day, the Night Float team (weekdays) or the call team
(weekends) present the patients they admitted to the residents and staff who are beginning their day. It's an old-fashioned tradition, but it shows off the versatility of our program. In larger hospitals, each service--Internal Medicine, Surgery, Pediatrics, Obstetrics--would be covered by their own set of residents, but at our hospital, the residents cover everying, so the Morning Report is equally interesting to all of us.
9:00am: Back upstairs to round with the Pediatric attending physician. We talk about all the patients on the ward, then go to see M.S. in the ICU. There's a fair amount of running around to do, looking at x-rays and calling the lab, so it takes a long time.
11:30am: Finally done with the ward, I go down to the NICU to round with the neonatologist. It turns out that the baby I admitted last night does have a blood-type incompatibility with his mother, so he's at high risk for developing serious jaundice. Dr. Yaeger has already started phototherapy on the baby, which is like a tanning booth for infants. Light helps the body get rid of the extra bilirubin, so it's a reasonable treatment, but it's funny to see the baby lying under two spotlights, with nothing but an eyeshade and a diaper on. Dr. Yaeger takes one look at my bleary eyes, and very kindly sends me home. Done!
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