Monday, July 4, 2011

Tales from Intern Year: Cross Cover

Top 10 Most Annoying Cross Cover Sign-outs

(Just for review, sign-out was when the day teams handed their patients over to me for the night, along with a little blurb about the patient, what could possibly go wrong, and things that need to get done overnight.)

1. The "do my dirty work" sign-out

"I want you to check the cardiac enzymes."
"Okay. And what should I do if they're positive?"
"Hmm.... good question. I guess you should heparinize the patient."
"Okay, is he guaiac negative?"
"I didn't check."
"Damn it, are you signing out to me a rectal exam to do???"

2. The "be the bad guy" sign-out

"This patient is really drug-seeking. Try not to give him morphine."
Later that night...
"Doctor, Mr. K is asking for morphine."
"The team told me not to give it to him so no morphine."
"Doctor, Mr. K said, 'I want to talk to that doctor who won't give me morphine'."
"I'm not talking to him!"
"He said the team misunderstood--"
"Just give him 1 mg of morphine. I don't have time for this."

3. The "mission: impossible" sign-out

"Make sure this CT gets done."

How do you "make sure" a CT gets done? I tried calling the tech and the radiology resident (neither of whom were easy to reach) and all I got was a vague assurance that it would "probably be done that night". Then at 9PM, I ask the nurse to see if it was done. It wasn't. The reason? The patient refused. If I wanted to get it done, I'd have to go try to talk the patient into it, then fill out a new requisition form and have it faxed, then call the CT tech and explain why the CT was so emergent that it needed to be bumped up on the schedule. Guess whether that CT got done?

4. The "check this lab that I'm not going to order" sign-out

About a quarter of the labs I was asked to check on never seemed to get drawn. If it seemed like an important lab, I would go ahead and reorder it. But PM labs could get drawn any time during the evening, so I felt silly chasing down a random chem panel, especially when there weren't many instructions for what to do with it. By the time I feel absolutely sure that it was an actual oversight and not just a late lab, it seemed like it would make sense to just wait another 8 or so hours till the morning instead of sticking the patient twice.

5. The sign-out that assumes that I know more about the patient than the team does...

"If the patient has a fever above 101.5, you can consider switching the patient from cipro to zosyn."
"What do you mean, 'consider'? Consider based on what? Based on my many years of experience in infectious disease?"
"Well, if the patient...... uh, just switch them to zosyn if they have a fever."

6. The "wrong info" sign-out

The most common thing to go wrong was that the room number is wrong. This was annoying if I needed to go see the patient, but especially if they told me to look up a consult. I hated having to run all the way across the hospital to find a patient's chart and then discover the patient wasn't where they said he was.

One night I had a patient where they gave me the wrong med record number. That was awful, especially since they wanted me to follow up cardiac enzymes on the patient. I was beginning to get upset that they weren't coming back, when I noticed that the record number was wrong. Ugh. If they spelled the patient's name wrong too, I would have been in big trouble.

7. The "no instructions" sign-out

"Here, this intern gave me this sign-out to give to you. The only thing to do is check the CBC on this patient."
"And what should I do with the CBC? Why are they ordering it? What's the cut-off for transfusion?"

8. The absent sign-out

Several times one team just never signed out to me. This mad me really furious, because I was getting calls all night on patients I knew nothing about. This is almost criminal.

9. The "too much to do" sign-out

"Yeah, so I need you to follow up recs from cards, pulmonary, renal, and rheum on these five patients. Also, I need you to check enzymes and an EKG on this patient, then discharge him if they're negative... you also should go talk to the family and let them know the results, also you need to check a chem panel and CBC on every patient on my list, if this patient rules in, you need to heparinize him and call cardiology, and if this other patient has an abscess on his MRI, I need you to call neurosurgery and tell them to urgently make sure to see the patient."
"That's it?"

10. The "five-page long" sign-out

"Sorry, I have a lot of patients... this is going to be painful."


  1. It's going to be a good bit worse now with the new intern hour restrictions. At my hospital, the IM schedule has two checkouts in the evening because of the insanity of having a 16 hour work limit but a mandatory 10 hours off. So the primary team checks out to the evening team who then has to check out to another team later on patients they haven't even been called about. It's the worlds most dangerous game of telephone, and it's done in the name of patient safety!

  2. Good post. At our hospital the registrar (Senior Resident?) doesn't sign-out to the intern before we have finished the work on him - like bloods and orders, etc. That means that I often finish only two hours after I was supposed to, but I am sure it does help the tired Intern a lot.

  3. So this is what I have to look forward to. SMH

  4. hilarious. as always. love this blog.

  5. It would have been funny if it weren't so true.

    Juli - I happen to REALLY be enjoying the new intern hours. (I have a slight bias)

  6. On #3, the CT thing, is that really your job? Or is this one of those times when the job is to do whatever you're told? In the hospital where I did clinicals (in nursing school), once the doc ordered a test, it was the RN's responsibility to make sure it got done.

  7. On #3 - at my hospital it was the doc/resident/intern's job to arrange the CT (ie, talk to radiologist, get it scheduled), the nurses would help with paperwork, but sweet talking the radiologist was not part of their job

    #8 is the worst

    actually, limiting work hours can be quite dangerous. more handovers, more chances for errors

  8. Ugh, #1 and #9 are awful, but so true! #3 is truly terrible, "NO, YOU make sure the CT gets done! It's YOUR patient!". I always tried really hard not to dump stuff on the on-call person, and to get as much done on patients as possible.

    And just to throw in my two cents regarding the 16-hour work limit (though I'm probably gonna get burned for this), in Canada, we still have a 24-hour limit, or a home-by-noon on post-call day limit. Frankly, I think 24 hours is reasonable. I'm still able to function after 24 hours, and i really think that you can't replicate the learning that you get when being on-call and having to make your own decisions (even though it's very painful when you're going through it). The problem is actually getting out after 24 hours!

    The 16 hour limit just seems like it might lead to more-- rather than less- medical errors, just through the poor communication. And having worked in the ER, I can say that working shifts just throws off your sleep-wake cycle anyway... It'll be interesting to see how it all pans out.

  9. At my hospital where I just finished medicine, there were four medicine "Teams" - Teams 1-3 were teaching teams, so they had a staff, a senior resident and a bunch of junior residents/medical students on it. These teams had large, extensive team lists, and the senior resident is usually pretty good about handing over lists, and making sure the on-call team knows about the truly sick patients.

    Team 4 is just two staff who tag-team seeing their patients every day. These staff are usually forced to do this as part of their association with the university, so their enthusiasm level is somewhere in the range of "none". They would RUN to handover at five oclock, find the first hapless intern on call, give them the team pager and (I kid you not, I saw this once with my own eyes) say "I don't think there's anyone sick on my team, but you should double check" before leaving for the day. No list, no updates, and a certainty that you could get a barrage of 3 am calls about a warfarin order that needed to get done THAT VERY INSTANT.

    Needless to say, that pager was avoided like the plague.

  10. I'm an RN at a community hospital (no residents) The two statements I hate from on call attendings:
    1."I don't know that patient." WTF doc?! 2."That's Dr.--'s pt you have to call him." Gee doc, you're THE OB-GYN on call for the whole house...--better answer the page or I'll be caalling YOU back!

  11. Just remember, if it's that critical wtf are you signing it out for? If your name is on the test that's ordered thats who they'll go after first if the ball gets dropped. Leaving heavy day work for the night resident is hot garbage. I never assume that the night person will have time to check on my stuff. All you need is to get killed with admissions, never see the call room and suddenlynits like what ct? Whose enzymes? When I have a bad night, if the lab dont call, chances are I'm not lookin. So my rule of thumb is, if something I sign out can't wait til the morning to be dealt with, I'm checking those labs and reports from home.