Common PM&R Overnight Calls / Pages

[dc2md]

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I remember 2 years ago when I matched. One of the immediate worries (and especially as July 1st approached) was taking overnight call. Would I know what to do? Thankfully LSU has home call (the nurses seem less likely to page you if they know you're outside the hospital). But the core question (and fear) I had was, what kinds of things do we get called on.

I have to preface this by saying I get VERY few pages from the nurses at our hospital. Either they're very competent, or are neglecting my patients overnight. Actually, they record "insignificant" problems in a notebook for us to see the next morning when we arrive (that saves quite a few calls).

But I just got paged with a problem so I'll put it down here. Hopefully, other residents will list their common calls/pages and what they do/did. This can be very informative both for the scared incoming PM&R residents, and the current ones too.

1) Fever (in 16yo T1 ASIA A SCI)

This time (102.6). Other vitals fine. I got CBC, portable chest xray, blood cx x 2 different sites, cath UA C&S. Gave 650mg tylenol x 1 (forgot to write standing order before). No sputum to cx. No wounds to cx. On lovenox for quite awhile, so less likely DVT.​

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[PMR 4 MSK]

I've found after-hours calls fall into three categories: 1) the parameters you set up to be called, such as BP, temp, HR, etc. Keep the pt in mind and write orders specific to the pt and you'll save yourself and others calls.

2) You forgot to order something such as a med or lab draw.

3) Something is wrong and they want or need a doctor to address the problem. Take this VERY seriously! Going in after hours is a PITA, but unless you are very confident that personally examing the pt will not change anything, and you really, really trust the nurse, go in. The pt and nurse will appreciate it, the attending will be proud of you, and you might save a life or prevent a complication. Put the pt first, your inconvenience second.

This is only a small amount of time on inpt rotations (although it may seem longer). You'll be and become a much better doctor if you set your threshold for going in low. And while you are driving in at 1 am, remember all the home calls you take vs the in-house calls you could be taking.

 

[Xardas]

I remember 2 years ago when I matched. One of the immediate worries (and especially as July 1st approached) was taking overnight call. Would I know what to do? Thankfully LSU has home call (the nurses seem less likely to page you if they know you're outside the hospital). But the core question (and fear) I had was, what kinds of things do we get called on.

I have to preface this by saying I get VERY few pages from the nurses at our hospital. Either they're very competent, or are neglecting my patients overnight. Actually, they record "insignificant" problems in a notebook for us to see the next morning when we arrive (that saves quite a few calls).

But I just got paged with a problem so I'll put it down here. Hopefully, other residents will list their common calls/pages and what they do/did. This can be very informative both for the scared incoming PM&R residents, and the current ones too.

1) Fever (in 16yo T1 ASIA A SCI)

This time (102.6). Other vitals fine. I got CBC, portable chest xray, blood cx x 2 different sites, cath UA C&S. Gave 650mg tylenol x 1 (forgot to write standing order before). No sputum to cx. No wounds to cx. On lovenox for quite awhile, so less likely DVT.​

Add more...

Calls for inpt rehab are not that much different than floor calls for a medicine ward in internal med.. Since you survived your internship it shouldn't be that much worse. While medicine wards have a higher percentage of sicker patients rehab wards require you to cover more patients at once. So its a wash.

You did pretty much the right things there, just don't start antibiotics until you know whats going on!

in your case:
Other things you may want to check on that are very important are: skin - cellulitic processes are common, and worse, infected pressure ulcers. Check all IV line sites or even the old line sites, as phlebitis is a common problem. Lastly don't forget asking a nurse about bowel problems - c. diff is always lurking.

when in doubt, call your attending. And as PMR4msk put it best, go see the patient in person!

 

[topwise]

I agree that PM&R night calls are pretty similar to the calls I got as a medicine intern. The only caveat is that you need to watch out for patient-specific problems (which I guess is true in medicine too, though). For example, a call about a BP of 160/90 might not be a big deal in a standard medicine admit, but it's definitely cause for alarm in a quadriplegic patient. A medicine intern probably wouldn't know that, but hopefully all of us do.

 

[PMR2008]

This is excellent information for all of us starting this summer. What are the top 5 reasons to be called on the rehab floor? I am guessing they are the same as on general med floor but I would like to hear it from you guys.

 

[RUOkie]

What are the top 5 reasons to be called on the rehab floor?

The answer to your question is "it depends"

On a general acute rehab floor: falls, fever, pain, change in mental status.

SCI/TBI units: anything goes.

As a doc in a rural setting with a general acute rehab unit, I get night calls very infrequently, but when I get them it is usually important (I have trained my nurses well😀

As a senior resident covering a SCI unit at the VA (we did week long home call) I got a call from one of our great nurses. He said (at 2am) "doc, come in here and look at this wound, he is bleeding" I said, pack it and get his regular doc to see it in the morning. He replied "I said get here, NOW!" I drove in (very quickly) to discover an arterial bleeder from a decubitus ulcer. The patient had eroded his gluteal artery and had surgery 30 min later. The key is to listen to the nurses, and when you are at all concerned, go it and eyeball the patient. As you age, you will learn when you don't need to go in; but early on, sleep less and learn more.

Sometimes you will give an order on the phone, then roll over and think. If you have ANY difficulty sleeping, you probably need to see the patient. I follow this plan even now. 2 days ago I drove to the hospital at midnight for the first time in a year because of a bad feeling after speaking with a nurse. My patient was in uncompensated heart failure and is now in the ICU.

 

[Ludicolo]

This thread is causing bad flashbacks. So very glad I don’t do inpatient anymore.

In retrospect I was called in probably most often due to fevers, other abnormal VS (newly increased or decreased BP or HR), falls, chest pain/SOB, acute changes in mental status. Also - difficult family members causing disruption on the unit at night. Loved getting called that one. 🙄

Echo the advice from the other attendings here. If there is a shred of doubt, see the patient. Know your medicine.

Oh, to clarify something Xardas said: don't call your attending if you haven't evaluated the patient yet.

 

[topwise]

Some of the extremely important pages I've gotten recently:

Not that long ago, I was paged to look at a patient's "bleeding" wound. I was in the middle of eating lunch in the cafeteria, so I asked if it was urgent or if I had time to finish eating. I was told I needed to come STAT. I threw away my food, raced over to the unit, and the wound wasn't even bleeding.

I was driving home and got paged while I was on the freeway. Since I didn't feel comfortable fumbling with my pager and headsets while driving 80MPH, I got off the freeway to return the page. It was from a nurse, asking me if I had signed restraints on a patient. The chart was right next to her and she chose to page me rather than just open it up to see that I had, in fact, signed it.

I was woken up at 5AM to be told that a patient had a blood sugar of 201 and there was no sliding scale.

I was woken up at 4AM to be told that somebody had come in to adjust a patient's air conditioner and he was angry they had disturbed him.

I usually get woken up around midnight or so to be told certain patients can't sleep and they need sleep meds (or MORE sleep meds).

The best page ever at midnight: being called to let me know that the patient's urine osmolality had come back from the lab. I was like, "What the hell am I supposed to do with that in the middle of the night??"

In summary, it's not exactly brain surgery.

Sorry, just had to vent....

 

[Hemisphere]

that really is a list of pages to be proud of...

just goes to show you the quality of the pages depends on the quality of the nurses... if they are cool or if they feel like they have to be up all night so u do to...

i was so nervous my first night on call alone as a PGY-2 covering rehab... cos as pgy-1 I did a hard-core medicine year, coded patients or rapid responses every call, rotated through the MICU where I was on call alone as well as a pgy-1, but for some reason starting a new gig new place just makes u nervous.

the main thing is just relax, u've gotten where u are cos u can HANDLE things.
also, you aren't REALLY alone. attendings are going to expect you to call them and ask questions at the beginning of the year. If you work in a hospital attached rehab, even better you can consult medicine or curbside other services, show them an EKG to double-check yourself or whatnot.

Here are examples of some decent issues:

1) called for fevers (do basic fever work-up as suggested above if not already done - main thing make sure vitals are stable and they are not crashing, if they are send them out of the rehab unit pronto) ps. u are much more likely to get in trouble (legally and from your superiors) for not sending someone out who is sick than for sending someone out seemingly a little to healthy.

2) shortness of breath (put on O2, check vitals and o2sats, give supplemental oxygen, check a portable chest xray, give LASIX if its fluids, give some nebs if they are wheezing, if pain is pleuritic or high suspicion for PE (primary team forgot to put on DVT prophylaxis) r/o CT PE protocol, although check if kidney function is stable, if not do a V/Q scan.)

3) Chest pain (do the work-up to r/o MI if one hasn't been done recently, check EKG, compare it to the old one, troponins x 3)

4) cardiac arrest: lol just kidding this has never happened to me when on-call as rehab resident, happens maybe once per year... calm down... it's not your fault it happened (hopefully), they are already near death and u are just trying to bring them back. call code or 911 start CPR if not DNR, BLS, ACLS until help arrives, etc.

5) fingerstick glucose too high/too low... basic medical issues etc. which u probably learned how to work-up in medschool and honed by practice during PGY-1

6) combative/agitated patient: if psychotic (hallucinating, etc) think atypical antipychotic to help them calm and sleep: think seroquel or low dose of risperdal. order bed alarm/frequent checks by nursing (q 15 minutes) or restraints only if absolutely necessary. 1:1 supervision if available if patient is getting up without assistance with poor safety awareness and at risk for falls.

A FEW REHAB SPECIFIC ISSUES TO BE AWARE OF:
-elevated BP: could be autonomic dysreflexia: read about this
-new onset weakness or neuro changes: (make sure it really is "new!" and not patient's baseline, clarify patient's baseline neuro exam when receiving signout or check progress notes from prior. usually check a head CT non-contrast especially if s/p neurosurgical interventions to r/o bleed. call prior team (neurology or neurosurgery to let them know whats going on) and call radiology dept to get a read right away. diffusion weighted-MRI is probably the way to see an acute ischemic stroke, although most centers takes too long to get this done STAT. would call neuro on-call or stroke alert if hospital has such a thing.
-baclofen pump stops working or is kinked: patient with pump has increased tone, etc, read about baclofen withdrawal, check CK, BUN/Cr, likely need tranfer to ICU and pump needs to be inspected or replaced ASAP. can give PO baclofen in meantime.

Annoying pages: (are most common)

patient needs:
-sleeping pill
-pain pill
-laxatives
-re-order med that expired
-patient refused to take a med

Waste of sleep pages:

see above! I can't top that list LOL. generally be nice to nurses and they will try to be courteous when u are on call (hopefully)

DISCLAIMER: THIS IS NOT A COMPREHENSIVE INSTRUCTIONAL GUIDE AND DOES NOT CONSITUTE MEDICAL ADVICE

 

[Hemisphere]

that really is a list of pages to be proud of...

just goes to show you the quality of the pages depends on the quality of the nurses... if they are cool or if they feel like they have to be up all night so u do to...

i was so nervous my first night on call alone as a PGY-2 covering rehab... cos as pgy-1 I did a hard-core medicine year, coded patients or rapid responses every call, rotated through the MICU where I was on call alone as well as a pgy-1, but for some reason starting a new gig new place just makes u nervous.

the main thing is just relax, u've gotten where u are cos u can HANDLE things.
also, you aren't REALLY alone. attendings are going to expect you to call them and ask questions at the beginning of the year. If you work in a hospital attached rehab, even better you can consult medicine or curbside other services, show them an EKG to double-check yourself or whatnot.

Here are examples of some decent issues:

1) called for fevers (do basic fever work-up as suggested above if not already done - main thing make sure vitals are stable and they are not crashing, if they are send them out of the rehab unit pronto) ps. u are much more likely to get in trouble (legally and from your superiors) for not sending someone out who is sick than for sending someone out seemingly a little to healthy.

2) shortness of breath (put on O2, check vitals and o2sats, give supplemental oxygen, check a portable chest xray, give LASIX if its fluids, give some nebs if they are wheezing)

3) Chest pain (do the work-up to r/o MI if one hasn't been done recently, check EKG, compare it to the old one, troponins x 3)

4) cardiac arrest: lol just kidding this has never happened to me when on-call as rehab resident, happens maybe once per year... calm down... it's not your fault it happened (hopefully), they are already near death and u are just trying to bring them back. call code or 911 start CPR if not DNR, BLS, ACLS until help arrives, etc.

5) fingerstick glucose too high/too low... basic medical issues etc. which u probably learned how to work-up in medschool and honed by practice during PGY-1

6) combative/agitated patient: if psychotic (hallucinating, etc) think atypical antipychotic to help them calm and sleep: think seroquel or low dose of risperdal. order bed alarm/frequent checks by nursing (q 15 minutes) or restraints only if absolutely necessary. 1:1 supervision if available if patient is getting up without assistance with poor safety awareness and at risk for falls.

Annoying pages: (are most common)

patient needs:
-sleeping pill
-pain pill
-laxatives
-re-order med that expired
-patient refused to take a med

Waste of sleep pages:

see above! I can't top that list LOL. generally be nice to nurses and they will try to be courteous when u are on call (hopefully)

DISCLAIMER: THIS DOES NOT CONSITUTE MEDICAL ADVICE

 

[dc2md]

excellent list Hemisphere!! i'm gonna compile the posts into one post and see if axm will put it into the "mother of all stickies" sticky. great resource for the newbies.

topwise, i soooo feel for ya. those BS calls would suck! in 8 months of inpt rehab rotations, i've only gotten a couple like that. love hearing other people's pain. LOL.

 

[dc2md]

Thought of another one...actually just got this call an hour ago.

Patient pulled out her PEG tube

-Find out when that PEG was placed. After about a month the track formed from the stomach to the skin should be formed enough.​

-Regardless of the time placed, still replace it with a foley​

-ALWAYS get a KUB with gastrograffin contrast to check placement of foley back into stomach before using the tube for anything (pills or feeds)​

-Then to prevent this from happening again, think about anxiolytics (atarax or benzo), and then abdominal binder with opening either to back or at least a hemiparetic side. Possibly wrist restraints or mittens too​

 

[topwise]

topwise, i soooo feel for ya. those BS calls would suck! in 8 months of inpt rehab rotations, i've only gotten a couple like that.

Wow, that's impressive. I think on almost every call, I've gotten a page that had me practically shaking with anger. On my last call, I went to every single unit before leaving the hospital and politely asked if they had any issues, anything at all, that I could take care of before I left. "Nope, doc, we're good!" So I left.

I didn't even make it to my car before I got a page with THREE order clarifications.