Sink or Swim: Call and The New Intern

(I had call on my first night as an intern almost two years ago and as of last week I am officially and forever done with call. It’s been a long two years and I won’t miss it. I’m working the 11PM to 9AM shift in the Emergency Department this month and I marvel at how good I feel getting seven hours of sleep every day. It’s also pretty nice having a regular job again with a schedule that I can make plans around. Here are some random observations about call with a little advice thrown in for those of you who will be starting intern year in just two short months.-PB)

No Atheists in the Call Room

Despite having scoffed at religion for your whole life, disdained the faith of your parents, and professed to only believe what can be experienced by the senses, on your first night of call you will find yourself praying the universal prayer of the new intern, “Please, God, don’t let anything happen tonight.” Later, as you gain more experience, you will grow to despise call because you like to sleep. As a brand-new intern however, not only will you be too tense to sleep even if you could but your twice-weekly call nights will be anticipated with a profound sense of dread and a yearning for the simpler days when your only responsibility was to pass a measly test every couple of weeks.

Objectively it shouldn’t be that bad. Your program will point out that you are never really alone. A senior residents is always likely to be in-house with you and you can always call your attending at home if you get in over your head. No doubt this is true but as the last of the People Who Know What They are Doing leave for the night, the hospital becomes a lonely, threatening place full of patients who seemed friendly enough during the day but have now become half-dead ghouls, swaying precarioulsy on the knife edge of life, ready at any moment to shuffle selfishly off their mortal coil.

Unfortunately, you have been left you in charge of a certain number of patients and they expect a reasonable number of them to be alive when they return in the morning. If not, you’ll look like an idiot. The patients will be dead and beyond any worries. Kind of makes you regret not paying attention to ACLS in medical school. As if you were ever going to be in charge of a code.

Relax and remember the French Hooker Rule.

No matter what they want, you can only give them what you can give them. Nobody is expecting you to run the hospital. It runs on autopilot most of the time anyways. All you have to do is be attentive to your duties, make decisions that you are comfortable making, get to all the codes and if you don’t know what you’re doing, get out of the way of the people who do.

Listen to the Nurses

As you gain more experience, you will tend to roll your eyes at some of the pages you get at 3AM. You need to be polite but sometimes it’s hard to keep the “You woke me up to tell me that?” tone out of your voice.

“Dr. Bear, this is Cindy on Five South, Mr. Jones in room twelve just had a five-beat run of V-tach.”

“How’s he doing now?”

“Fine, he’s asleep and his vitals are stable.”

“Um, thanks.”

Keep in mind that she has to call you. It’s part of her protocol even though she knows more about Mr. Jones than you do, knows he has a list of life-threatening conditions that reads like the PDR, and knows perfectly well that he’s probably not going to die tonight. If on the other hand she asks you to come up to see him, well, usually it’s her long experience telling her that things are heading south and they are going to need a decision maker at the bedside. So while the tendency for a new intern is to panic and over-react to everything, even agonizing over the choice of simple pain medication renewal order, take a cue from your nurses, they know it’s July, they know you’re new, and they know you need a little guidance.

This does not apply at the VA, of course, where after five o’clock you can see tumbleweeds blowng down the corridors and the nurses vanish to some secret nurse’s lounge and are not seen until morning. I was on call there one night and a patient coded and died without anyone thinking to call me. I only found out in the morning when I walked into his room with a cheerful “Good Morning” only to see his lifeless body, endotracheal tube still in place, equilibrating with room temperature. Some people pre-write skleleton notes before they round and fill in pertinent information as they go. In this case, “Patient was without complaints,” while a completely true statement, would not quite have captured the flavor of the situation.

Stay Hydrated

Pure anecdote on my part but caffeine is over-rated. I used to drink a lot of Diet Cokes on call but it just made my jittery and, for lack of a better word, edgy. I’ve cut back considerably lately and I’ve found that good old-fashioned honest fatigue is better than the lying, cheating alertness you get from caffeine. I seem just as tired after a four or five Diet Cokes as if I just drink water, the only difference being that I yawn a little more with water.

It’s more important to stay hydrated. You can easily get mild dehydration if you’re running around all night which can be all the difference between being just tired and being physically ill. Drink water.

Oh, and avoid eating crappy food on call. Greasy fried food or sweets are going to follow you the whole night. Unfortunately, the hospital gets a good deal more casual at night and there are always cookies of doughnuts laying around somewhere. Better to have a turkey sandwich or something with some protein in it. My experience is that I always felt better on call if I ate light.

Stay Motivated

The definition of eternity is the time between midnight and five AM. If you look hard enough you can almost see the clock hands moving backwards and no matter what you do, it’s always just a little after one. In fact, it will be one AM for hours. Your brain will cry for sleep and you will be totally uninterested in the mundane crap that fills a lot of your night. At the same time your most ferverent wish will be that it’s all mundane crap. No two ways around it, call, like most of intern year blows with the power of a thousand hurricanes.

But you’re there. You’re stuck. There’s nothing to do but suck it up and make the best of things. If you have a few good friends in the same predicament you can even have a lot of madcap fun on call. Just hang out with people with a sense of humor who can appreciate the ridiculousness of the situation.

Laugh it Off

You’re going to make mistakes. Your not going to know what to do in a lot of situations. Everything is going to be difficult at first and being a real doctor is going to be nothing like you expected it to be when you were a pre-med those many long years ago but pretty much what you expected as you counted your last days of irresponsibility in fourth year. Every day and every call night will bring some secret humiliation but you have got to let it go. Don’t internalize the inevitable criticism. Sure, you’re worthless and weak, a real danger to the patients, and a jibbering, ignorant intern monkey but we’ve all been there, man. It will get better.

I promise.

21 thoughts on “Sink or Swim: Call and The New Intern

  1. Good Post. When I read the phrase, “intern year blows with the power of a thousand hurricanes” I laughed out loud. That is good writing.

  2. My fondest memories of internship is being paged at 2 am from nurses in an unattached wing of the hospital a quarter mile from the call room with a heavy Philipino accent that couldn’t be understood over the phone.


    Nurse: “Doktor, patient in room 408 have Peeber (fever)”

    Me: “Tell me more”

    Nurse: “Doktor, patient in room 408 have peeber, One OOO Twoooo point por”

    Unable to ascertain what the patient was admitted for, what meds they were on, what the concerns were, I would have to trudge the quarter mile to go figure it out. Most of the time the patient would have a known condition that would cause the fever and already have orders on the chart explaining what to do (get blood cultures, give tylenol, etc.)

    What a year. Many more people would crack if they had not invested 4 ungratifying years and 150K for the priviledge of getting to do it.

  3. I didn’t write skeleton notes until this last rotation. Now I try to get in and out as fast as I can since most of the time the patient tells the resident and attending something completely different from my note. I try to avoid “no complaints” though since most patients always have at least one.

  4. Love the blog – but what is up with the new obnoxious pop up ads for SPA SERVICES? Or did my computer just hiccup something random?

  5. I think it’s an interstitial ad. Pay it no mind. If they become too much of a pain I’ll shut them down.

  6. They miss you over at the FM forum at SDN. Apparently the program that gave you YOUR intern year is planning on reviving its FM Residency.

  7. “In this case, “Patient was without complaints,” while a completely true statement, would not quite have captured the flavor of the situation.”

    P. Bear, you truly have a gift with words. I think I’ve learned more about what to expect from you than I have from any other single source (“House of God” comes a close second).

    Thanks for the blog, and as always, please keep it up.

  8. The VA is a strange and unusual entity. The neurosurg resident was putting in a ventriculostomy on night and i was answering his pages. The VA was calling because they had a post op laminectomy patient and they couldn’t find the orders. come to find out, he had been on their floor for EIGHT hours. What the hell were they doing all that time? How in the heck can you have a patient for eight hours and just now figure out you don’t have any orders?
    I didn’t know about the super secret nurses lounge, somehow it is now all becoming clear.

  9. You crack me up. (I love to come here and see what mischief you’re up to.) Thank you very much for telling that bit about nurses HAVING to call in the middle of the night because of protocols, etc. Once, as a rookie, I had an intern tear me a new one because I woke him up in the middle of the night for a patient with a heart rate which wouldn’t get out of the 30’s. Now granted, the patient was asleep and in no distress, but dang it, it was the CCU. (And the French Hooker Rule is just too frigging funny. I don’t know how you come up with this stuff…)

  10. On the hydration and caffeine:
    Your right, this is very key. I would limit myself to Mountain Dew Code Red, 40oz a night. I would gradually pour it from the bottle into a small cup of ice chips. I would sip slowly throughout the night. As it melted, what I drank was probably 2/3 Mountain Dew and 1/3 water.

    GI prophylaxis is also important. Never go on call without some Zantac. It prevents that vague cramping stomach unease that comes around 4am.

  11. Great post – it takes me back a few short years to those awful days of call. I loved the bit about the VA especially. Isn’t it funny that VA’s everywhere are exactly the same?

  12. Hi Dr. Panda Bear,
    This post brought back some disturbing yet strangely fond memories. Nice writing. I’m going to blogroll you, if you don’t mind.

  13. I enjoyed this post and give you all so much credit for overcoming obstacles, persevering and accomplishing your goals. You Docs certainly have paid your dues. 🙂

  14. Hey Panda, Regarding the patient that was dead in the VA. It could have been my uncle. He served In Germany during the Korean war. However he told everyone he was a combat soldier in Korea. After discharge he managed to get into the VA system with a 10% disability, later haveing it raised to 30%. He was a parasite to the system, about 6 months before they found him stiff, he told me he had a heart attack and he had to hit himself in the chest to get his heart started. After hearing of his death all I could think of is why didn’t you hit yourself in the chest again.

  15. Wow. Pure gold. Brings back a Kodak moment from my first week of internship, when my co-intern was told about a patient’s decreasing renal function.

    Nurse: “Dr. H, Mr. X’s urine output for the last six hours was only 50 cc’s!”

    Mike H: “Yeah, well, I haven’t peed in two days, but no one cares about that!”

    It took all of us at least 15 minutes to stop laughing…

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