Monday, July 9, 2012

Home call and ACGME

As everyone in medicine knows, there are rules in place to keep tired residents from harming patients. When I was training (and perhaps still), you were not allowed to work for more than 30 hours in a row. Only 30 hours in a row. Because when you've been awake 29 straight hours, you're feeling fab and totally capable of caring for patients.

Home call is an exception to the rule. If you're taking call from home, you are not post-call the next day. Even if you had a really rough call and got zero sleep, you still have to put in a full day of work the next day. And if you're doing home call for a whole weekend, you could potentially get zero sleep the entire weekend and yet still be caring for patients (with very little back-up).

I was told by an administrator that there are some protections in place. If you're on home call, but you manage to spend 30 straight hours in the hospital, you must leave. But here's the catch:

If you leave the hospital during that time for any reason, the 30 hours restarts.

So say you run to the food cart outside to grab a sandwich, the 30 hours restarts. Say you step outside to vomit from exhaustion, the 30 hours restarts. The person literally said that to me.

Of course, this makes absolutely no sense.... the reason for the 30 hour rule is to protect residents (and thereby patients) against fatigue, so you're not less fatigued if you leave the building for five minutes. You've still been awake 30 hours. It's not like they're protecting us against some toxic chemical that's in the hospital that will kill us if we're exposed for 30 hours in a row, but if we get some fresh air we'll be okay.

For those of you residents who do home call, what happens when you've had a really rough call with no sleep?


  1. We have guidelines for call conversion (due to our union negotiations) so that our home call gets "switched" to in-house if we end up in the hospital for four hours straight with one of those hours after midnight, or if we get called in between midnight and six am. That means we technically get to leave the next day at 10am. Which, if we're on our inpatient service, usually does happen. But, if we're on an outpatient rotation and have clinic scheduled.... Well... That's kind of another story.
    - MM

    1. The coverage issue is always a problem. Who covers if you leave post-call? Is it the attending? (yeah right) Or is it the other residents? If it's the other residents, the residents might prefer to just suck it up on post-call days rather than have to constantly be covering.

    2. In my program the attendings cover when residents are post-call. They are accustomed to working their asses off as much as (or sometimes more than) the residents.

  2. I was in the group that had some years under before the 80/30 rule and some years after it.

    We switched to nearly entirely home call except for interns. I got called just as much at home as I did for in-house call. It blew chunks...

  3. If we are on home call and we don't sleep, we tell our PD, who finds a way to get us coverage for either the AM or the PM clinic so we can sleep.

  4. Don't tell anyone, and make sure the cameras arent watching, when you go out to that taco truck for lunch.

  5. I HATE our system. You get to leave at noon the next day if you were up past 1AM physically in the hospital that couldn't be done at a later time. Up until 12:45 and then answering floor pages all night? WOrking a full day the next day. Busy doing stuff until midnight and then dictating it all until 2AM? Up until midnight because technically the dictations could be done later. Your attending says there's a consult to see at 1AM but you can see it in the morning before rounds so you have to see it at 4AM to get rounds done? WOrking a full day.

    If, by some miracle, you actually do get to leave at noon, you need to find someone to cover your afternoon stuff for you. Cases can generally go uncovered unless they're with certain attendings, but clinics need to get covered. So you have to pull someone out of their afternoon cases to cover your clinic and it builds a lot of resentment.

    Also, we're on the honor system, so some people abuse it a little bit, I think. You're supposed to show xrays from the night before at trauma signout at 6:45 and they have times on them, but the way around that is to claim you were dealing with soft tissue injuries of the hand after 1AM. (the trauma attending comes to signout, the hand attending doesn't, neither does the spine attending but a spine consult would require xrays) But some people are curiously perpetually postcall when they have afternoon scoliosis clinic...

    I will go to my grave believing this system exists to screw me over.


  6. We get declared post-call if we stay in the hospital past midnight or if we get called in after midnight. On our post-call days, if we would normally have clinic that day, it is not scheduled. Then if we don't meet criteria for being officially post-call, it gets opened for random last minute (annoying mostly) appointments. And yeah, all of this is a little silly, because you can be up all night at home and it doesn't matter at all unless you set foot in the hospital.

  7. Weekends are the worst. With no other residents to cover, whether you are up all night in hospital or out, you still have to be back at 8:00 to preround before the attending comes in. They say they would be flexible, but I have yet to experience that. Any hint that I might actually need to sleep after 36-48 hours of constant awake on call has previously been labeled lack of dedication to patient care and my education. This from healthcare professionals who claim to know how human brains work.

  8. I think his interpretation is incorrect. My understanding is that you have to have at least six hours off between that shift and the start of your next. We used to do 24 hour shifts, then go to a.m. clinic. We had to be out of the hospital by 1 p.m. so we could go back on call at 7:00.

  9. Jeez this is awful. We really get the post call day - almost always.

    But we don't do home call. I thought that was a curse and kept comparing to other programs...but now, not so sure.

  10. Call in sick. Or wait until someone senior to you sends you home sick, because you are going to kill someone if you stay.

  11. We just have to have 8 hours in between shifts. So if you stay till midnight, you come back at 8 and start working the rest of the full day. If you stay until 7 a.m., you are basically post-call since by 3 p.m. there are usually enough coverage to staff all the OR cases. One of the perked anesthesia is that there is usually some way to rearrange the OR staffing if something changes with the schedule.