Thursday, June 14, 2012

My First Call

My first call as an intern began at 7:30AM. I started out feeling optimistic, even sort of looking forward to it. Ha.

My spirits started to fall when I got my first admission of the night. It was a Russian-speaking guy on dialysis who had chest pain and shortness of breath. Because he spoke no English at all, we called for the translator, who took about an hour to show up.

Me: “How are you feeling, sir?”

Russian patient: [string of Russian]

Me: “What did he say?”

Translator: “I don’t know.”

Russian patient: “Nyet!”

Apparently, because he didn’t have his false teeth, he had become unintelligible and even the translator couldn’t understand him. It was kind of a challenging situation. We got him into dialysis and hoped for the best.

My second patient of the night was a homeless, alcoholic, heroin addict with hepatitis C. He also had chest pain and shortness of breath. I noticed when I was examining him that he had a heart murmur, which I mentioned when I presented my H&P to my resident Susan. She went in to examine him herself:

Susan [accusingly]: “OH MY GOD, this guy has a HUGE systolic ejection murmur.”

Me: “Yeah, I mentioned—”

Susan: “This is the LOUDEST MURMUR I’VE EVER HEARD. You could hear it in the hallway.”

I got another patient at that point, a diabetic guy with diplopia (double vision). After examining the patient, I decided that he had a lateral rectus muscle palsy, probably caused by an infarct to the sixth cranial nerve. I thought I was totally clever figuring out the diagnosis and started feeling somewhat confident in myself.

Me: “I think the patient has a cranial nerve VI palsy.”

Susan: “Yeah, that’s REALLY OBVIOUS.”

I admitted one more patient, which gave me a total of four for the night. The other intern only admitted two patients and the sub-intern admitted two, but I didn’t get any chance to pat myself on the back, thanks to continual disparaging remarks from Susan.

Susan: “Man, I am so tired. I forgot what it was like not to get sleep during call.”

Me: “You usually get sleep during call?”

Susan: “The interns I had before you were really good.”

Well, gee, thanks. It was only my second freaking day.

My confidence dropped to about zero at some point during the night. I kept getting paged about questions on my patients that I had no idea how to answer. I knew they were easy questions, but I just didn’t know the answers. I kept paging Susan to ask her, and I could tell she wasn’t happy with me. It got to a point where if the question wasn't all that important, I just made something up. Some questions I got:

"Doctor, your patient's blood sugar is 62 but she's NPO for a biopsy. What should we do?" Uh....

"Doctor, your patient's blood sugar is 405. What should we do?" Uh....

"Doctor, your patient's BP is up to 195/82. Do you want to do something about that?" Uh....

"Doctor, you wrote for an ADA diet, but you didn't say how many calories. How many calories do you want?" Uh....

By around 3AM, I wanted to strangle anyone who called me "Doctor." I still felt ridiculous returning my pages as "Dr. McFizz" and it also felt ridiculous that nurses who knew about 100 times as much as I did kept saying, "Doctor, what do you want me to do?" (If you are a nurse reading this, please just tell the poor interns on their first call what to do. You know that you know.)

I found some comfort in eating massive amounts of junk food. During the call, I ate a big bag of Doritos, cracker jacks, gummy worms, and a giant bottle of Coca Cola. I felt sickened by how much junk I ate. Yet the moment of putting the food into my mouth gave me just a tiny jolt of pleasure in my otherwise miserable existence.

At about 5ish AM, we finished our admissions for the night. I hadn’t slept at all but I was oddly awake. It was probably all the adrenaline.

Susan: “We’ve got some time before you need to pre-round. Why don’t you go sleep for an hour?”

Me: “Nah, I’m sure my pager will go off and just wake me up right away.”

Susan: “If you have an opportunity to sleep, you should take it.”

So I set off trying to find the call rooms. They were in some hidden, undisclosed location, and I failed to find them. I finally went to the resident lounge and lay down on the couch. I dozed off eventually and woke up about two minutes later when my pager went off.

I may not have felt tired, but my brain was definitely sluggish. When Susan asked me to order a transthoracic echo (TTE) on a patient, I went to the file cabinet of forms to order the echo.

Me [opening file cabinet] “What the hell was I looking for again?”

I checked my notes and remembered I was looking for the echo form.

Me: [after searching for a couple of minutes] “Damn, what was I looking for again?”

I did eventually, miraculously find the form. Of course, it couldn’t be that easy. I couldn't figure out what box to check to just get a normal TTE. The options seemed to all be words I didn’t understand. I checked the wrong box, naturally, and when Susan found out, she acted like I was the biggest idiot in the world. I maintain, years later, that there was no way for me to have figured out how to fill out that form on my own.

My organization paid off somewhat. I made checklists of everything, so I couldn't forget to do anything. Our attending even commented that I was very organized. Of course, I was a little jealous of everyone who seemed to remember everything about their patients on zero sleep and no checklists. My co-intern never wrote anything down. I don’t even think he had a pen.

I managed to get out of the hospital by 1:30 (30 hours), which was a bit of a miracle. The cross cover sign-out guy was really nice and he was like, "Go home! Enjoy your night and get some sleep!"


  1. I have my first nights the last week of August this year (start 1st job at start of August) so this post terrified me. How do you treat high BP acutely?

  2. Mr Mobius -- I've seen IV labetalol used before, but there are other options too. It depends a bit on the type of patient. If I remember correctly, they liked to use nicardipine on the stroke service, though it beats the heck out of me why there and not on the medicine service.

  3. I had the exact same first call as you, except I had a nice resident, and that made all the difference.

  4. This med student is taking note of the fact that he'll never have to do a 30 hour call as an intern...

  5. gah, worst post to read since I'm starting intern year NEXT WEEK!! :(

  6. I wish my hospital had a program where nurses can volunteer to orient med students to the hospital (where items are located, the workflow dynamic, meds most commonly dispensed by the pharmacy, important phone numbers, etc.) prior to them starting. I think it would improve the lines of communication and it would give med students a nice, solid foundation. Oh well, maybe some day.

    1. That is actually a great idea that would promote collaboration...suggest it to the administration and to the individual unit RN managers. There are so many "little" workflow issues that would decrease frustrations on both sides.


    2. Thank you for the feedback. I've been on the fence about suggesting it, but maybe I will after all. :)

  7. PS- mobius.. depending on what the patient is currently on and if their heart rate can tolerate the lowering effect of a beta blocker, I have seen metoprolol or labetalol used (IV push) Hydralazine may also be used as a prn IV push dose. You have to be really careful with the hydralazine especially, however, because it can lower a BP quite substantially so the parameter is usually to give if SBP is over 180. (labetalol is typically for an SBP over 160) I've seen Nicardipine drips used when the SBP was over 200, usually, but that's my hospital.

    I also feel I should point out that some nurses are brand new, too, so you can't always rely on them to offer suggestions.

  8. Ugh. I'm having flashbacks to my nights of call. Being that clueless is just awful -- and I completely agree - most of the time, you know the patient issues are not a big deal, but you just don't know the answer and you feel like an idiot. When a patient is acutely ill, you usually have back-up (or at least, very legitimate reasons to call for back-up), given that seniors want to know when a patient has acutely decompensated. It's the ward crap that keeps you anxious throughout the night!

    Also, regarding the treatment of high BPs, we see a ton of people in emerg who check their BP at home and come to the ED panicked about a BP of 190 or something. The general thinking in emergency medicine is that you don't drop asymptomatic high BPs rapidly, as you could cause ischemia to the brain or kidneys that are used to a higher BP. If there's no evidence of end-organ damage such as kidney failure, ACS or stroke/encephalopathy or an ICH/SAH, It's best to lower gradually with an oral agent, which their primary care physician can take care of. I usually just reassure the patient, get them calmed down, take the BP again (usually it's lower -- regression to the mean). If it's still really high, i might start them on the oral agent myself and give them a prescription and have them follow up wiht their own doctor, which is more to make myself feel better. Again the adverse events from hypertension take years, not days, to develop, and patients will not bleed into their brains from one episode of BPs above 190.

    Just my two cents.

    ER MD

  9. I'm a nurse in the NICU...and I tend to only help residents/interns if they ask for help/don't act like a jerk. We had an intern once who tried to educate me on what a pneumothorax in a 600g baby would look like (duh--this is MY job, I know this!) He's now 4th year (he's doing a med/peds residency) and he still goes around acting like we as nurses know nothing. The intern who came up to me and said, "Hi, I'm Kate, and I know nothing. Do you mind helping me out," has been the favorite intern (now 2nd year resident) on our unit. We're more than happy to work with her anytime because she appreciates that she has a lot of education and head knowledge, but this is our area of expertise!


  10. man, that takes me back. my first call as an intern (on my first day) was in the NICU. not only did i know nothing because i was an intern, but i had also never done anything even remotely similar to NICU in med school either, so it was a brand new world. oh, and this NICU had no senior residents or fellows taking call in house, so it was just me and the nurses and the RTs and 60 babies. the nurses and RTs SAVED MY LIFE. every question of "what do you want to do doctor?" was returned with, "hmm, well what do YOU think we should do?" and i survived. so did the babies.

  11. Medstudents at our hospital are not allowed to give orders by phone, and computer-orders are not processed until signed off on by staff or resident.

    When I was in my last year as medstudent/clerk:
    Pager goes off at 3am: "Your patient has a blood sugar of 18" (mmol/L)
    Me: "Can you give him 5 units of X insulin?"
    Nurse: "We can't take orders from a medstudent."
    Me: ".... so why did you page me?"

    Another favourite:
    "Your patient with TB has a temperature of 39.5C. We are going to give him Advil."
    Me: "Uh... thanks for letting me know?"