Wednesday, January 2, 2013

Home call pages

When I was a resident, we took call from home. Considering we had to work the entire next day after being on call, the attendings would tell the nursing staff that they shouldn't page us in the middle of the night about unimportant things that could wait till morning. But they still did, because that's life.

A few of us were complaining about it during lunch one day, and an attending sitting near us in the cafeteria overheard. She came over to us and said, "The nurses shouldn't be paging you about unimportant things like that."


"I'd like you to write down every single page you get every time you're on call," she told us. "And then hand it in to me.

"You mean just the inappropriate pages?" I asked.

"No, all of the pages," she said.

"When it's 2 in the morning, you want us to find a piece of paper and write down what the page we just got was for??" a flabbergasted resident asked.

I get that she was trying to help and meant well, but creating extra work for residents in the middle of the night was not helpful. We might have been more on board if we thought there was absolutely any chance that this measure would result in any changes. The nurses didn't respect this attending any more than we did.

Needless to say, none of us started writing down every single page we got.


  1. I take it your pager couldn't just save the pages?

    1. They weren't text pagers, so it only recorded the number, not what it was for.

  2. This is still very nice of her. And yep, useless.

  3. OK, nursing point of view. I don't think that physicians should be called in the middle of the night unless it is essential - nearly a code situation. However, sometimes it is their own fault for failing to think ahead. Ok, so you want me to do a Hct 2 hours after the blood infuses. That will be about 3 a.m. Hct is 24%. What do you want me to do with the results? Shall I assume - without an order - that you want another unit to follow? Shall I stand idly by until you make rounds? Or shall I call you with the results? Then, there is the 2 a.m. fever. That's right, you did not leave me an order for Tylenol. What happens when I give the Tylenol without an order and discover the next day that you are concerned about this patient's liver function? Also, in this patient who has not previously had a temp, do you want me to culture him up or just medicate him? In the ICUs, much of this stuff can be done without a direct physician order, but the floor nurses are constrained by needing an order for everything. Including Colace. So, a little advanced planning on the part of the MD should save those pesky phone calls.

    Now, at the risk of making this post even longer, I will admit that there are some nurses who get perverse pleasure out of calling a doc at night and waking her/him, sometimes with only borderline necessity. They seem to be aggrevated that the doc is "sleeping while working" and the nurse has to be awake, so the doc should as well. I don't get these people. Finally, there are the docs who are so incredibly nasty when they are called that the nurses are afraid to call them, even with true emergencies. With the advent of nocturnists (hospitalists who work at night and, theoretically anyway, are awake and available all night), this problem should pretty much go away for attendings; it will always be there, I fear, for residents. Tricia

    1. Sorry, I meant to add that as well-meaning as this attending was, no one is going to give up that extra 5 min of sleep to document pages. Anyway, look at that list in the morning. Huh? What does that say? Mr. who needed what for ... huh? Tricia

    2. It could be the physician's fault, although it very likely is not the fault of the physician who's actually being called.

      One thing I've noticed though is that there's some point during the night when nurses get bored and start flipping through charts and noticing things. Like that a patient has not had a BM in two days. Yes, that's important, but not at midnight or even at 10PM.

    3. Re: those who think the doc should be up working at the same time as the nurses (and thanks to Anon on behalf of all docs for NOT feeling this way):

      This makes me feel sad. I could perhaps understand this if we both worked the same 12h shift, but by the time I get called (in-house) at 3 a.m. I've been on shift for 20 hours. Honestly, I'm not that sharp at that hour. I've had to apologize for falling asleep on the phone ("I'm so sorry, but I think I just fell asleep while you were talking. I want to hear what you need...would you please repeat what you just told me?"). Better to let the only in-house doctor catch a few minutes of sleep so s/he might have some chance of thinking clearly during the early morning code. Even an hour of solid nap/sleep is better for my cognition than the same sleep broken into segments.

      I know nursing is very, very hard work, but I must admit that I felt tremendous regret for not more seriously considering a career in nursing when I met my first OB RN during 3rd year of med school and learned she made enough money to live on during three 12 hour shifts per week. I wondered if I had made a mistake in choosing medicine. Both physicians and nurses are, of course, prone to burnout, but it seems each field has its distinct advantages.

    4. Yes, Fizzy, you are right. It is not the physician who forgot to order something who gets that 2 a.m. phone call. It's the poor resident who may have last seen the patient on 6 am rounds, if then, and who has no idea what or who you are talking about.

      If a nurse is calling in the middle of the night with something stupid, they might be just following ridiculous administrative rules. Administration tells nursing that all 'unusual' signs or occurrences need to be reported to the physician immediately - without fail - And documented as such. I frequently banged my head against the administrative wall about this. UO dropped to <30 cc per hour? Sure, call the doc. No BM in 2 days? I don't think so. I would call a doctor only if I could reasonably answer the question, "What is the doctor going to do with this information for this patient right now?" and I would make a mental note to grab the resident before rounds and tell her. My efforts, though appreciated by the docs, were unappreciated by administration and the oncoming shift. Actions like this were considered as turfing responsibilities.

      PGYx - I get it! We do get to that livable salary much sooner than you do, and - I will admit - with far less work to get there (not less patient work, though, especially once we are there!) IMHO -- and I know I will get grief for this -- medicine is more of a 'calling' than nursing, at least for some people, like me. You know, that whole "follow your dream" thing. In order to make it through the rigors of med school and residency, I think you need to be truly committed. Maybe committed only to paying back those med school loans, but committed. It used to be that physicians had more autonomy and the additional 6 or 8 years or more of sacrifice were worth it in the end for the rewards of money, respect, and autonomy. Truly, I am not so sure that those rewards are there anymore for physicians, which is where the committment really comes in.

      Yes, you guys often do fall asleep during these nighttime calls and sometimes you say truly bizarre things! "Doctor, are you sure you want me to give IV Lopressor to the bradycardic patient with a systolic BP of 70? ... No, there is no lawnmower in the hall. ... Doctor, you really need to wake up. ... No, I don't think you are awake yet doctor." You had better hope that the nurse on the other end can talk you through it! Tricia

  4. As a resident I hated the 2 am calls that started "I was just looking through the chart and..." Nothing urgent ever came of them. Ever.

  5. I ALWAYS were down the pages - the number, time, and reason. So I always sleep with paper and pen handy. This is helpful with handover, and helpful in the morning to make sure I didn't write a to-do note and forgot about it (I usually have a to-do note, and I usually forget about it by morning).

    So I don't understand the distress over writing down a page, as I always do it anyway. Even a Tylenol order.