On Call

Tomorrow I'm on call, and I thought I would clarify what that means.

I always thought that when you were on call, you brought your pager home and went into the hospital if you were paged. I was very wrong. What being "on call" means is that between 12:30 p.m. and 4:30 a.m. my team admits any patients who have to come into the hospital (only on the Medicine service, though, surgical pts are admitted to the Surgery team on call). 95% of the patients we admit come through the Emergency Room.

So this is how it happens: my senior resident gets a call from the ER that someone needs to be admitted. That person might have a serious pneumonia, or bowel obstruction, or they are vomiting blood, or cellulitis, or any number of other medical problems. (Very sick and unstable patients are admitted to the ICU). Anyway, the senior resident calls the intern on our team, who grabs me, and we go down to the ER and interview the patient. After that, we write some admission orders, which includes practical information like where the patient will go, how often their vital signs should be taken, what meds they will take, what they can eat, etc. I then have to write a complete history, a write-up of their physical exam, and then a discussion of the patient's diagnoses and what I intend to do so make them feel better. Right now when I'm on call, I admit two patients and "follow" them until they are discharged. The morning after they are admitted, I present their story at the patient's bedside to the rest of my medical team, and we discuss the plan. Every morning after that I give my team an update and we make any changes until the patient goes home.

The last time I was on call, I admitted my two patients and was done with my work around 3:30. At that point, I went to the on-call room where there are some beds, and slept for a few hours before rounds at 7.

In spite of the lack of sleep, being on call is usually fun. It's exciting, it's busy, it's unpredictable. In some ways, it's a lot like fishing. Early in the night it's pretty low key, you're waiting for something to happen, and then a call comes from the ER. Our team admits around 10 patients per night, and I'm only really involved for two, so when someone else admits a patient, it's just like when someone your fishing with catches a big one right next to you. There's more certainty on call than when you go fishing, because it's almost a certainty that I'll admit a patient. Then when you get a call, there' s a little time to wonder what's on the end of the line. Even after you've learned a little about the patient from the ER team, you really don't know what to expect until you meet them.

This brings me to one of those dirty little secrets in medicine: the more sick the patient is, the rarer their condition, the more exciting that patient is. I try to be very careful with my language, but if you ever hear a doctor or medical student say they have a "very interesting patient", that patient is either very sick, has a very rare disease, is unique for some other reason (like they were injured in a very unusual way, for example), or some combination. The last time I was on call one of my patients had a very rare skin and muscle disorder along with diverticulitis (a potentially serious infection of the colon). There's definitely part of your brain that is trained by medical school to think, "sweet, this guy has dermatomyositis! Are those Gottron's papules?!" Dermatomyositis is not usually a life-threatening illness, but thinking something like "wow, that woman has necrotizing fasciitis!" is a bit more troubling because it is often fatal. You see the problem.

In medical school we learn about disease so that we can help real people, but there is something about that learning that depersonalizes patients. Every medical student wants to see a case of necrotizing fasciitis, but no medical student wants any person to have necrotizing fasciitis. I resolve this dilemna by reminding myself that disease is inevitable, and that if it is to exist, I should know about it. The key is to remind yourself that it is the patient who has the disease, not the other way around. That doctors have to remind themselves of this seems ridiculous to people outside the medical profession but it frequently happens.

As I mentioned, I'm on call tomorrow, so I need my sleep tonight. I'll post again soon.