taking call as a new intern: when to call the senior?

If you ever think "Should I call my senior?" then you might want to for your first few calls. After that, then when you feel like you have no clue on what is going on. Most of us are expecting a lot of calls in July, so don't feel bad on calling if you have questions. Now if you are calling on things like the dose of Tylenol, or what should I do if this patient is constiated, then you might want to rethink all of this....

lfcdoc said:

I'm on call tomorrow and it's my first day as an intern. New hospital, new system, and first day as a 'doctor'...I'm definitely not feeling very qualified at this point. One thing I'm really wondering is what is the threshold for when I should be calling my senior?

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early and often...

jd

Midwest Medic said:

If you ever think "Should I call my senior?" then you might want to for your first few calls. After that, then when you feel like you have no clue on what is going on. Most of us are expecting a lot of calls in July, so don't feel bad on calling if you have questions. Now if you are calling on things like the dose of Tylenol, or what should I do if this patient is constiated, then you might want to rethink all of this....

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That last sentence is funny..

DeLaughterDO said:

early and often...

jd

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indeed.

If you ever think "Should I call my senior?" then you might want to for your first few calls. After that, then when you feel like you have no clue on what is going on. Most of us are expecting a lot of calls in July, so don't feel bad on calling if you have questions. Now if you are calling on things like the dose of Tylenol, or what should I do if this patient is constiated, then you might want to rethink all of this....

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i tell interns to call me for anything. i'd rather hear about "it" and its nothing, then to not hear about "it" until the patient codes!

Midwest Medic said:

Now if you are calling on things like the dose of Tylenol, or what should I do if this patient is constiated, then you might want to rethink all of this....

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Sorry, meant CONSTIPATED!!

Midwest Medic said:

Sorry, meant CONSTIPATED!!

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I'm pretty sure there is a post on another thread in the EM forum linking to an article about how sales of Metamucil are up... maybe I could recommend this for you as well?? Especially if you feel the need to yell it out to everyone else. It must truly be bothering you!!

jd

call you senior for anything you have a question about, even tylenol and constipation if you have a question about it.... better to look dumb than do something dumb.

shorrin said:

call you senior for anything you have a question about, even tylenol and constipation if you have a question about it.... better to look dumb than do something dumb.

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Just remember that just because it seems simple, it might not be. We had a telephone call to our peds ward from one of our chemo patients. Kid had fever and the intern just told the mother to give them tylenol and everything would be OK.

Well, kid was neutropenic (ANC=0) and febrile. Fortunately, the mother called the oncologist. We've had similar things happen with our sickle cell patients in pain crisis develop fever and cough. Intern gave them tylenol.

Call us, please call us. That's what were there for. Especially in July.

Ed

edmadison said:

Just remember that just because it seems simple, it might not be. We had a telephone call to our peds ward from one of our chemo patients. Kid had fever and the intern just told the mother to give them tylenol and everything would be OK.

Well, kid was neutropenic (ANC=0) and febrile. Fortunately, the mother called the oncologist. We've had similar things happen with our sickle cell patients in pain crisis develop fever and cough. Intern gave them tylenol.

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I hear stories like this all the time, and I know I shouldn't comment since my first call isn't until this weekend, but WTF is wrong with interns like this? It's so hard to believe that you could get an MD, and still think that this would be appropriate.

edmadison said:

Just remember that just because it seems simple, it might not be. We had a telephone call to our peds ward from one of our chemo patients. Kid had fever and the intern just told the mother to give them tylenol and everything would be OK.

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Im not even in med school yet, I know better than that.

Tired said:

I hear stories like this all the time, and I know I shouldn't comment since my first call isn't until this weekend, but WTF is wrong with interns like this? It's so hard to believe that you could get an MD, and still think that this would be appropriate.

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I think it's almost scarier that you can't see how this could happen. Of course, with the information presented to you in the way it was, it was clear to see that it was a stupid decision. And making the decisions isn't the hard part it's all- it's trying to make sure you have the proper information to make the decision. That's the difference between step 2 and real life.

nutmegs said:

I think it's almost scarier that you can't see how this could happen. Of course, with the information presented to you in the way it was, it was clear to see that it was a stupid decision. And making the decisions isn't the hard part it's all- it's trying to make sure you have the proper information to make the decision. That's the difference between step 2 and real life.

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Well, could you offer me a scenario about how such a thing could occur? Because it seems to me that, prior to ordering Tylenol, the intern would need to go through a couple of steps:

1) Not look at the chart/EMR
2) Not realize they are covering Heme/Onc, or not realize the patient is on Heme/Onc
3) Not look at the sign-out list
4) Not see the patient
5) Not question the RN further about the patient
6) Not consider the differential of fever in a hospitalized patient

Look, obviously I've been around a little bit, and yes I've heard these stories. Usually it involves waking up the intern from a deep sleep, the intern refusing to get out of bed, and the RN not pushing him/her to do their job. If this is what happened (my bet, anyway), it represents a gross dereliction of duty, and I have second-hand knowledge of two different interns being fired for exactly this scenario.

What I don't understand is why people make this choice.

I've taken more than a little call the last two years, and I have a lot more coming up. No matter how f-ing tired I get, I can't imagine snapping out a half-asleep verbal order before I even take the time to consider which patient we're talking about. I get it, people make mistakes, but most don't make this mistake. That's why I don't get it.

To the OP: Ask lots of questions. You will slowly get an idea of what you can handle. Even then it doesn't hurt to double check if you're not absolutely comfortable. We have a lot of responsibility, but it is not our responsibility alone. Use your resources!

1) when your myasthenic patient gets somnolent with labored breathing
2) when your stroke patient starts cheynne-stoking
3) when your patient with leg pain gets tachy laying in bed

post-call #2: internship officially takes 7 days to become un-fun.

Tired said:

Usually it involves waking up the intern from a deep sleep, the intern refusing to get out of bed, and the RN not pushing him/her to do their job. If this is what happened (my bet, anyway), it represents a gross dereliction of duty,

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Mmm I've noticed I don't remember being paged or my verbal orders because I go right back to sleep afterwards. My pager lights up, I read the number, feel for the keypad, and dial it in the dark. If it is a patient I don't know, then I have to flip on the light and look at the signout. But still it takes 4-5 minutes of arousal to add things to memory. I've heard that is why we don't remember waking up 5-6 times per night even though we do.

lfcdoc said:

I'm on call tomorrow and it's my first day as an intern. New hospital, new system, and first day as a 'doctor'...I'm definitely not feeling very qualified at this point. One thing I'm really wondering is what is the threshold for when I should be calling my senior?

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I just had my first overnight call and quite frankly, I called my senior for everything. I tried to have plans in mind and I think she actually just went ahead with all of my plans with a couple of extra things so nothing I did was actually wrong, maybe just not complete. Still, we're right out of medical school and I think that's what should be reasonably expected July 1st. She was very friendly and encouraged me to call stating very clearly that's HER JOB. If your resident complains or seems less than thrilled with you calling so early in the year, I think that's completely inappropriate.

Until you get the swing of things, always call your resident.

I've seen some unbelievable things from interns....
Giving enema/suppositories in POD#1 sigmoidectomies --> pt got anastamosis rupture
2 liter bolus in pt with heart failure for hypotension --> pt developed cardiogenic shock
etc, etc, etc...

Always go to the patient when paged as an intern.
Always assess the patient
Always review the chart
Always formulate a plan
And then call the resident and run in by him/her

Leforte said:

Always go to the patient when paged as an intern.
Always assess the patient
Always review the chart
Always formulate a plan
And then call the resident and run in by him/her

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great advice.

as someone stated earlier, many residents were either chosen to be on wards/icu at this time of year, or personally chose to be on at this time of year. i.e. we expect to be called by the intern. there's likely nothing too big or small to call about at this point.

and if a senior gets upset, oh well, that's on him/her. your duty is and always will be to the patient.

Leforte said:

2 liter bolus in pt with heart failure for hypotension --> pt developed cardiogenic shock
etc, etc, etc...

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If a patient with heart failure (I'm assuming we are talking systolic) is hypotensive and gets fluid, I'm guessing the fluid bolus didn't put them into cardiogenic shock. Probably put them into pulmonary edema.


sorry, just the critical care part of me coming out

I have to agree with Mman.

you're not the only one with the issue. Just lucky that on my first call I'll be paired with my senior on the floors. So he knows I'll be obnoxious

For me, I'm trying to read up the wash man intern guide to help me with some of those smaller things.

I'd rather piss off my senior and be safe than assume I know something and cause some problems.

Mman said:

If a patient with heart failure (I'm assuming we are talking systolic) is hypotensive and gets fluid, I'm guessing the fluid bolus didn't put them into cardiogenic shock. Probably put them into pulmonary edema.


sorry, just the critical care part of me coming out

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Yep - post-op pt got rapid pulomonary edema, heart stress, MI then cardiogenic shock, Transferred to CCU and ended up with the balloon pump for just under a week, but recovered fine.

so my july 4th wasn't so merry

Only one on my team covering our pts. Get there early. Take one of my co-interns patients who I'm somewhat familiar with. He H&H drop and I'm told she needs a transfusion. Fair enough. I try to call the senior resident who should be in the hospital and I get no response. Finally call the attending and told to order 2 units.

Now, I round on all my patients and meet with my attending tell her about everything. Sign out to the on call intern and leave the hospital. About an hour I leave the hospital I'm getting paged like crazy from the floor with the transfusion patient and told she's coding and I need to be up t here. I told the nurse that Ive left and signed out to the oncall resident and give the pager #.

Somehow it feels like I'm doing something wrong.

Bevo said:

Somehow it feels like I'm doing something wrong.

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I don't know but something just tells me you should've stayed until you knew that patient was stable and that somebody definitely was there to take over the care of that patient. I would be a little upset if that was a family member in there and the doctor taking care of them just took off and left just like that.

Better to be safe than sorry. Your senior residents expect you to call for lots of problems at the beginning of the year.

no, when I last saw the patient which was at she was stable came back to her later still stable. spoke with my attending again in person, she had seen the patient and told me to go home. It had been a good 4-5 hours from my first encounter with the patient without any issues.

It wasn't like she was unstable like she could crash at anytime. Her vitals didn't show any issues. Her repeat H&H showed that her hb and hematocrit had gone up.


If I'd assume that every patient I have is gonna crash and that I shouldn't leave then I'd never leave the hospital.

The nurses didn't call any of the on call residents. Even after I had asked them too. I spoke with the resident intern as well. Found out the senior call resident who was on call was my senior resident. I fubbed cause the pager # was actually a phone # (I had never called it, i just tried to page it with no response). So my bad on that and I don't carry around a printed paper with who is on call. Lessons for next time.

As for not contacting my senior - we treated the holiday like a weekend, so only 1 member of the team was there, me. I had assumed that my senior on my team was home. Had he been there(i.e. a regular work day), he would have been my first phone call. When I spoke to him about it he was suprised that he wasn't called or paged by the nurses. He would have assumed to have been notified but was not.


Either way, checked on the patient this AM. Wasn't a code blue they called me for. They had called for a rapid response cause her beatbeat shot up into the 140s. They had given her some ativan and something else I can't think of right now.

I spoke with attending about it and said I hadn't done anything wrong. That this patient has had similar episodes in the past 3 weeks. She believes that high dose solu-mederol the pulmonologist had ordered for her might have caused her to start rebleeding into her lungs. Not sure. She wasn't sure either.

I know about the patient, but since I dont normally follow her, I only listen to what is being said during rounds. So I was not intimatly knowledgable about her long hospital course. Ya, maybe I can get faulted for not spending the hour or so to read through and go through her ?? week hospital stay. She had been stable this whole week.

Yeah, I got a few lessons learned from this and luckily nothing disastrous happened with the patient. Had she died would it have been my fault? No. Regardless of the mechanism behind her tachycardia.

I've been wondering if it could have been related to the blood transfusion trying to read up on the various types of transfusion reactions. Don't think it was it. Maybe it was the rate of the transfusion that shocked her system. I'm not sure.

You may label me what you will. As doctor for 3 days now, I had a trip up. I communicated with my attending about the patient's situation on two occassions. I had signed out and told the on call resident about my patient. It was a big suprise to me.

You may label me what you will. As doctor for 3 days now, I had a trip up. I communicated with my attending about the patient's situation on two occassions. I had signed out and told the on call resident about my patient. It was a big suprise to me.

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don't worry - and please don't feel the need to defend yourself here. i felt for you as i read your [very long] post...i simply appreciate you sharing your story, and feel bad that you now may feel like you can't (and others might feel that way as well) since your actions were questioned.

it's tough being a [new] intern - you're donig a great job so far, adn please keep the stories coming

nabeya said:

I don't know but something just tells me you should've stayed until you knew that patient was stable and that somebody definitely was there to take over the care of that patient. I would be a little upset if that was a family member in there and the doctor taking care of them just took off and left just like that.

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Really? You stay after sign out a lot because you have a "funny feeling"? What a lot of crap. Either you're a crappy resident, or a pre-clinical med student who thinks you know more than you do.

For my fellow new intern, the only way you could have avoided this situation (and I'm only saying this because a similar situation, though far less serious, happened to me last night) is to go around to every ward where you have patients, and give them the pager number of the person covering your patients, and telling the charge nurse you're leaving.

I started doing this today for the first time, and it's the first time I didn't get paged fifteen times in the evening after I got off.

Leforte said:

Until you get the swing of things, always call your resident.

I've seen some unbelievable things from interns....
Giving enema/suppositories in POD#1 sigmoidectomies --> pt got anastamosis rupture
2 liter bolus in pt with heart failure for hypotension --> pt developed cardiogenic shock
etc, etc, etc...

Always go to the patient when paged as an intern.
Always assess the patient
Always review the chart
Always formulate a plan
And then call the resident and run in by him/her

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AND, ALWAYS write a note, esp. on x-cover.

thats what our chief told us. I have my first call this week and with my team senior.

sepsis said:

AND, ALWAYS write a note, esp. on x-cover.

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I hate it when the cross-cover guys don't write notes when they see my patients. Half the time the signout they give is less than stellar, then later in the day I'm scratching my head at some of the orders they wrote.

I also hate it when, instead of writing for one-time meds, they write it as prn orders. Just because the patient had pain the night after surgery doesn't mean they need a dilaudid prn order on their chart.

Started my medicine prelim in the CCU, overnight call on my first day! At this hospital, there's no CCU resident overnight: I am the only one from my team who stays. Cards fellow is on call from home, MICU senior available for questions. And I carried the code pager. Scariest night of my life!! I mean, a fresh intern, first day at new hospital, left alone in the CCU?!

irinka217 said:

Started my medicine prelim in the CCU, overnight call on my first day! At this hospital, there's no CCU resident overnight: I am the only one from my team who stays. Cards fellow is on call from home, MICU senior available for questions. And I carried the code pager. Scariest night of my life!! I mean, a fresh intern, first day at new hospital, left alone in the CCU?!

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Heh my first intern run was in CCU as well. I felt most comfortable there more than anywhere else when someone arrested... in my first few weeks I would just stand in the corner while the nurses did ABCs and DC cardioversion while I said 'yeah... uhh.. lets do that,,, nice work team'. In the more general wards (or unfortunately in my experience, anywhere EXCEPT ICU and CCU) arrests are alot more stressful.

More back on topic as an intern ending his year I call a senior when;
Patient crashing/dying
MI
Pulmonary oedema etc.

After I've managed the situation acutely. If difficult situation - eg classic CP with ECG changes consistent with NSTEMI (eg. new onset TWI) in patient with bleeding problems post op, I'll obviously ring the senior before giving antiplatelet treatment, more so to cover my ass if he bleeds out. Also things like new onset AF when you are on call and covering other doctor's patients, some people like different treatments and get pissed when you start them metoprolol, or sotalol etc (I had this issue a few weeks back on surgical evenings with a new onset AF HR 150-170, BP being maintained appropriately [for now] in an 80+ year old, attending didnt want to start rate control as he 'didn't like polypharmacy'... (he wasn't on any cardiac drugs, otherwise had a bunch of other meds) lol. ok

Purifyer said:

If difficult situation - eg classic CP with ECG changes consistent with NSTEMI (eg. new onset TWI) in patient with bleeding problems post op, I'll obviously ring the senior before giving antiplatelet treatment, more so to cover my ass if he bleeds out.

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And sometimes they get pissed because you changed the Darvocet prn (which was making them itch) to TC3 prn (which didn't). Learned the hard way today that just because everyone else is happy with you managing the little things at 2am yourself, there are those attendings out there who want you to talk to them about everything, no matter how small or what time it is.

Leforte said:

Always go to the patient when paged as an intern.
Always assess the patient
Always review the chart
Always formulate a plan
And then call the resident and run in by him/her

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This sounds nice - but made me smile when I consider the nearly 100 pages (no joke) I got last night on cross cover at the very busy county hospital where I'm at.

RogueNine said:

Im not even in med school yet, I know better than that.

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Want a cookie?

jonnylingo said:

Want a cookie?

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What kind?

Always go to the patient when paged as an intern???? Are you f-ing kidding me?

Unless the patient's vitals are unstable (or something really terrible is happening), I avoid seeing cross-covered patients like the plague. If I can't figure out what to do based on what the RN tells me (and a lot of the time, it's "continue current plan until the AM"), talking to the patient will not help. And the last thing I want to do is go waste time seeing a patient I don't know and flog over something that should be handled by the primary team in the morning anyway.

Obviously, the above refers to stupid pages. Though if a patient is hypotensive, I'll bolus 500-1000 cc (assuming good EF and pt otherwise asymptomatic) and then wait to be called back...

6 weeks down and haven't killed anyone yet...

Yeah, it is impossible to see every patient when paged. I have to complete a minimum of 7 h and p's for the patients admitted from the emergency room per night, plus cross cover fifty or so patients and my only back up is one resident who covers the icu at night. I probably get paged every 10-15 minutes at times and I am still expected to write great orders and h&p's on my seven admits.

It is impossible to see every patient the nurses call you about and do a good job admitting your own patients while on call. I make sure the RN gives me a ton of info about the patient when they call me. I have them look up info in the patient chart, etc. I chart check the patient while I'm on the phone with the nurse, sometimes send them in to do more work (pulse ox etc) and call me back, then I decide if I should see the patient, place an order, etc...

As for "talking to the family" when X covering patients, I avoid this like the plague.

Agree sometimes it would not be possible to see every crosscover patient you are called about. If you are admitting 5-8 new patients/night with full H and P's and have 16 patients on your own team, plus crosscovering 50 more...that = getting paged every 5-15 minutes all night if it's a medicine call.

The problem is you don't want to skimp on going to see a patient who really needs to be seen, and as an intern you can't always judge who needs to be seen. That is why your chief resident and program director will tell you the expectation is to go see EVERY patient, and your a-- will be held accountable if you don't and something bad happens. My rule would be to go see any patient with unstable vitals, any one the nurse wants you to see (though sometimes they are wrong...sometimes not and even if wrong they can burn you bad if they want you to see the patient and you refused). Try to turf routine "talk to the family" phone calls from nurses if it's not your patient...one way to do this is to tell them you are admitting a patient and it might be an hour or two before you can get down there, if the family wants to wait, blah blah. Usually they give up. If it's a seriously ill/hospice/ICU patient then I always would talk to the family even if it's not my patient...it's what I would want for my family member.

Call senior resident or fellow for help about ANYTHING the first 1-4 months of internship, and really throughout the first year. Call them with a plan of what you want to do, and ask if that's OK. If it's something really complicated and patient seems real sick, just tell them the patient is sick and you aren't sure what to do and need help. Only real jerks get mad at you for calling, and ultimately if you get them in the loop they will have to help you and they will become accountable for what happens also, which is how it should be.

I think it really depends on the resident. I am the kind of resident who likes to hear about EVERYTHING that is going on with the team's patients, I want to be in the loop and I HATE it when interns do their own thing and only tell me the bare minimum. It's fine for the interns to be independent if they want to be, that's great! But I still want to know exactly what they are doing and what is going on with patients, ALL the details.

When it comes to crosscover, however I dont need to know every little thing, but if there is the slightest doubt in the intern's mind as to how to handle something, I'd rather you guys err on the side of asking for advice or at least to run your ideas by me, even if you think you know.

Of course this also depends on the intern's ability to discern a simple situation vs a complicated one (which can be difficult to do in the first 4-6 months), and does depend to an extent on the intern's judgement on when to ask and how thorough they are. If an intern is very thorough and has pretty good judgement of when to ask for help, I am ok with not hearing as many crosscover questions. If an intern I'm on call with is sloppy, doesn't think of checking on certain details, and has a track record of not asking for help when they should have, I want that intern to tell me EVERYTHING they do; I will ask them to run everything by me before they do anything, and I will also be double checking everything they do, but there is only so much I can double check if i dont hear about things. Most interns I've worked with fall into the former category, but I have come across 2-3 of the latter and they are the ones who gray my hair prematurely.

I'm a surgical intern, and my first 2 months, I called pretty often when I had doubts. Usually, my chief would just go along with my plan, adding a thing or two here and there. It's not too hard, once you get the hang of it, to manage things at night and keep the service together, even while cross-covering 80-100 patients at the biggest hospital we work at. On every service but our trauma service, interns take overnight call by themselves with upper levels on home call. At first, it was pretty intimidating knowing I'm the only "surgeon" in house for at least 30 minutes until the cavalry can get there.

I'm at one of the busiest, ball-bustingest programs in the country, and my chief this month is the same one from my 1st month. He told me Oct 1st, "You're a real resident now, calling is a sign of weakness. If I hear from you more than once, I'm gonna kick your ass in the morning."

The only patient I've had to call on so far this month was a guy that had a retroperitoneal bleed after a cath. When I saw his Hb drop, hypotension, tachycardia and base deficit of 15, you can bet I was on the phone with my chief. He actually was kinda happy to hear about that one.

Other than that, I've kinda run stuff on my own, and I think it has really made me grow up a lot and really think about my patients, as opposed to being spoon fed at this point. True, there's still a ton I don't know, but after almost 4 months of q3 call, the sense of fear on call is definitely gone at this point.

Im gonna be a new surgical intern in July, so, Im sure all be adding to this thread!