IM PGY1 First Night on Call

[aurab]

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I know someone just started PGY1 in IM had a terrible night thinking that that night was the worst night so far in her medical training.

Could any of you in PGY2 or PGY3 ruminate any horror experience you had during your first night on call in PGY1?

Aurab64

 

[Bobblehead]

Here's an interesting story. There was an intern in our program assigned to our 10 bed MICU along with a 2nd year resident. It was his first day of internship and nearing the year's end for the 2nd year resident. Things had been fairly light that month. However the day started off with 5 open beds. By the next day we had admitted 3 active GI bleeders of which only two had acceptable access, a morbidly obese asthmatic without access and someone getting over a pancreatitis flare. Two of the GI bleeders got central lines. The third was turfed as he was "stable" with a pair of peripheral IVs. Then we had two old patients turn into vent disasters. The first was someone who had been transferred too late to us from an outside facility to "save" but had lingered on for weeks. She ended up having peak pressures in the 80s which we couldn't bring down. When the pulmonary fellow on call came in he couldn't get her pressures down either but said he almost killed her making some vent changes while we were working on another access nightmare in an old patient.

At least after 3 central line kits, the ultrasound and discarding the micropuncture kit (did I mention this one was coagulopathic?) we got a femoral line into the patient. Of course this patient also ended up being the second airway nightmare. She had previously been intubated over a bronchoscope to correctly place the ETT because she had such a difficult airway. She was oxygenating poorly so while the fellow was there we ended up taking another look down her airway to discover that the tube had of course migrated.

Throughout all this the poor intern had to take histories, write the H&P and was running back and forth through the unit trying to figure out whether to put the stethoscope on his chest or the patient's. The morbidly obese asthmatic was the last admission and arrived near midnight. The woman had no neck. And with the ultrasound we were unable to locate an IJ or EJ on either side (and while the next day's call team scoffed vindication came in the form of a VIR placed central line days later--no one in the ICU was able to establish access).

The woman with the high peak pressures ended up dying around 3am with a rather upset family (but a successful autopsy request). Of course this caused us even greater problems as we had an open bed and were immediately notified that we would be receiving an outside hospital transfer (which thankfully did not arrive until the next morning).

The intern was eventually sent to get an hour of sleep between 5 and 6am before morning pre-rounds had to start. And he actually came back the next day..

Just remember, it can ALWAYS get worse.

 

[UTSouthwestern]

When I started out in internal medicine, I had a similar situation with my first call being on the MICU on the first day of my intern year. We don't cap the ICU admissions, for obvious reasons, so we took 14 admissions that night, of which 8 were legitimate (AMI, GIB, decompensating CF). We covered three ICU's (MICU, CVICU, SICU) on separate floors and by we I mean myself and a second year resident with little confidence in her abilities.

All three GI bleeders required bedside scopes and immediate transfusions, but thankfully, only one had access issues and I was able to put a L subclavian cordis into her. Two out of the three MI's were unstable and came in simultaneously. We stabilized one while the other one went emergently to the cath lab with tombstone T's and an SBP of 50. That guy came back on IABP (great for the intern who knows jack about anything, much less a balloon pump) and coded twice later in the evening before finally stabilizing.

The worst was the 19 year old CF patient with intractable pseudomonas pneumonia. Difficult airway (small, high, and anterior) but success using just the stylet with a strand of silk tape tied to the other end, to get between the cords, then threading the ETT over that contraption. Able to ventilate thereafter but she was already septic and requiring Levophed and vasopressin infusions. Family let her go two days later.

Don't even talk about the existing patients. All told, we ran 9 codes that night, with two chest tubes, multiple central line placements and art line redos, and I didn't have time to write even one procedure note, much less an H&P. I was exhausted, terrified at times, but exhilirated in the end because not one died on my first watch. I finished my H&P's, progress notes, and procedure notes by 5 pm the next day and walked out of the hospital feeling pretty damn confident . . . and promptly fell asleep at the wheel and ended up back at the hospital with bruised ribs. Finally made it home at 11 pm to sleep and was back in the ICU by 4 am.

It wasn't pretty, but I never had confidence issues after that month and I wear my gray hairs from that day with pride.