super bummed

[Pinner Doc]

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I'm An ER intern currently rotating off-service in the surgical ICU. Our call nights are set up so that we're always on call with a senior resident. There is a "SICU pager" that the nurses page when they have questions, issues. In addition, every resident and intern has his or her own pager.

Interns are definitely encouraged -- but not required -- to carry the SICU pager when on call with a senior. I'm definitely cool with that-- it's a great chance to stand on my own two feet.

I was on call last night with a second year surgery resident (my senior). I was carrying the SICU pager, and I was psyched to have gotten several straight hours of sleep during the night. However, around 4am I got a page from my resident saying that he was out managing one of our patients who had spontaneously gone into SVT.

I went out to join him. All was under control, so I asked him how he had known about the patient-- I hadn't been paged. Basically, the nurses had paged him directly. In fact, it turns out he had received at least five pages over the course of the night from various nurses.... who took the time to look up his personal pager number, rather than page me at the default SICU resident pager.

I'm not a fool. I haven't made any huge -- if any! -- mishaps in the ICU this month, and I think it's pretty evident that I want to be involved in the medical decision making and learn how to manage these patients. When I heard that they were directly paging him instead, I felt sucker punched. I've really been trying so hard... and I feel so unnecessary!

Advice? Has anyone been in the same situation? Does this ("this" being intern year) get any better? 🙁

 

[nsap102]

Same thing at my program. It's not uncommon, especially for ICU RN's to directly page the Resident. I asked a couple of SICU RN's once why they do this. They said it is because if they page the intern, s/he will say "ok...I'll check with my resident and get back to you" so for the RN's they are just bypassing the middle man so to speak.

Best thing to do is to establish rapport with the RN's. Furthermore, they'll need to get to know your professional ability.

Sometimes its not a bad to idea to speak to some of the RN's. Tell them that once they were students...on the learning ladder and now you're standing in the same shoes they once stood in...and that you'd appreciate it if they paged you first. Granted, it may be an inconvience for them at times, but you've got to learn some how.

 

[gutonc]

I've had this experience both as the intern and the resident. It usually happens for 1 of 4 reasons.

1. They don't like the intern or they like the resident more (FWIW, this can happen in reverse as I've been paged as the intern when a particular RN didn't like my senior at the time)
2. They think you're just going to run it up the chain of command anyway so they page the resident to avoid the extra step
3. They think you're an idiot.
4. They suck.

It's probably 1, 2 or 4, may be #3 but unlikely. You just suck it up and move on. Your resident (assuming s/he trusts you) should be the one to tell the nurses to page you first.

 

[Pinner Doc]

The chain of command theory makes the most sense to me. If I have an LVAD patient with new onset chest pain (as I did the other night), I *will* page my senior. But in a teaching institution, interns should at least have the chance to think on his/her own feet.

 

[Faebinder]

Your senior needs to grow some balls and tell them to page you first... but in all honesty.. the SICU is not for interns... that's the general agreed mentality of surgical residency. You help manage the SICU but you are not IT.

 

[jdh71]

OK. While I do hear what you are saying, I think your perspective is 100% bass ackwards. You are making this about you this isn't about you, this is about an unstable patient with SVT in an ICU - I think I could easily argue that it would be malpractice to make the intern first call in such a situation. Do what's best for the patients (you know those people who are sick and in the hospital who expect the best care possible) and let your ego slide. You will have plenty first calls in the next three years following this internship - take the oppourtunity to learn and not mope

 

[Pinner Doc]

OK. While I do hear what you are saying, I think your perspective is 100% bass ackwards. You are making this about you this isn't about you, this is about an unstable patient with SVT in an ICU - I think I could easily argue that it would be malpractice to make the intern first call in such a situation. Do what's best for the patients (you know those people who are sick and in the hospital who expect the best care possible) and let your ego slide. You will have plenty first calls in the next three years following this internship - take the oppourtunity to learn and not mope

I totally hear what you are saying, and I agree... it was more compounded with the fact that he had been paged about 4 additional times for other matters. It's cool now, though. I think I was post call, tired, and took it personally.

PS- I may be an intern, but I'm pretty sure I know what a patient is.

 

[dragonfly99]

Like being paged all night constantly by nurses for stupid things ( = most medicine calls as an intern!).

I would just bring it up with your senior (not during or right after taking care of a sick patient). Ask if he could ask the nurses to call you first if it's not something like the patient is crashing. At my hospital the intern pretty much always gets called first, even in the ICU, but it's expected the senior res. will be in close proximity. Maybe you just need to hang with your senior all night so he knows you are interested.

You can talk to the charge nurse or other nurses in a very nice way (nonaggressive) and ask that you be called first. The other option is go hang out on the floor, so you are THERE and not sleeping in bed when the action happens. I pretty much never slept except maybe between 3 and 5 a.m. when I was an intern on call. They can't "not contact you" if you are already there.

Your senior resident might have thought he was being nice to you, since you're an off-service ER intern and he might not have realized how interested you are. You can honestly just tell him you want to immerse yourself in this experience and don't want to miss any learning opportunities, and ask him what he thinks you can do to become a little more involved.

But agree w/some of the above posts - ultimately most ICU's are not "the intern's show". There's just too much going on w/these patients for an intern to handle alone, so you end up doing more note writing, checking labs, etc. while the senior makes more important decisions, etc. It's that way in MICU also.

 

[jdh71]

I totally hear what you are saying, and I agree... it was more compounded with the fact that he had been paged about 4 additional times for other matters. It's cool now, though. I think I was post call, tired, and took it personally.

PS- I may be an intern, but I'm pretty sure I know what a patient is.

I was post call when I wrote that - didn't mean to be such an as$. My bad.

 

[Blade28]

Agreed that many ICU nurses may just be used to dealing directly with more senior residents (e.g. PGY-2 over PGY-1). In some hospitals PGY-1s aren't even allowed to write initial orders for PCAs, TPN, etc.

 

[carrigallen]

Wouldn't take it to heart. A lot of interns will not make an immediate decision; so nurses are probably jaded about paging the intern pager. Also honestly most good critical care nurses have more ICU experience than interns, and they are usually paging for something serious that needs immediate attention.
If you really want to deal with emergencies in the ICU, hang out in the ICU at night. Then they will just grab you.

 

[DarthNeurology]

I'm An ER intern currently rotating off-service in the surgical ICU. Our call nights are set up so that we're always on call with a senior resident. There is a "SICU pager" that the nurses page when they have questions, issues. In addition, every resident and intern has his or her own pager.

Interns are definitely encouraged -- but not required -- to carry the SICU pager when on call with a senior. I'm definitely cool with that-- it's a great chance to stand on my own two feet.

I was on call last night with a second year surgery resident (my senior). I was carrying the SICU pager, and I was psyched to have gotten several straight hours of sleep during the night. However, around 4am I got a page from my resident saying that he was out managing one of our patients who had spontaneously gone into SVT.

I went out to join him. All was under control, so I asked him how he had known about the patient-- I hadn't been paged. Basically, the nurses had paged him directly. In fact, it turns out he had received at least five pages over the course of the night from various nurses.... who took the time to look up his personal pager number, rather than page me at the default SICU resident pager.

I'm not a fool. I haven't made any huge -- if any! -- mishaps in the ICU this month, and I think it's pretty evident that I want to be involved in the medical decision making and learn how to manage these patients. When I heard that they were directly paging him instead, I felt sucker punched. I've really been trying so hard... and I feel so unnecessary!

Advice? Has anyone been in the same situation? Does this ("this" being intern year) get any better? 🙁

I think that the nurses are using the surgical resident's pager because the "SICU pager" may be carried by an intern who is not as motivated as you OR if carried by the surgery resident he/she still has their own pager. If the nurses assumed that you forfeited the SICU pager to the resident then they would just page him, via his own pager most likely. It seems this is a system error, not a slight by the nurses.

Also, perhaps the nurses just in this SICU routinely page the responsible surgical resident for the SICU and perhaps policy is that the intern also needs to be paged.

Also, this was not a run of the mill in the middle of the night page for tylenol or a supository, it was SVT which needs to be treated quickly so the nurses went with the surgery residents, who do own the SICU basically, and are more able to help in this situation. So, I think the nurses made the right clinical management decision.

However, to involve the intern more there could be a policy that the intern always carries the SICU pager and the nurses are required to also page the intern after consulitng the resident (probably won't happen as nurses focus on patient care rightly, and the intern would be left out of the loop). Or even better there could be two SICU pagers that have the same pager number so you would also call the nurse's station to see what is up.

Realize also that the surgical resident, who will ultimatel get filleted if something bad happens, may have an understanding with the nurses about being called about serious problems first.

In the end if you want to be in the loop on any elective or rotation and are being paged by the "team" i.e. nurses, residents, fellow students, you need to be seen and just be there when the action goes down.

 

[Gastrapathy]

On call in a busy ICU, don't take a long block of sleep. Get up every hour or two and walk through the unit, ask what's up, be there when they turn the patient (this is great roundsmanship, btw, because you demonstrate that you were there without shoving it in their faces), etc. Then not only will you get the pages, you'll get told directly about impending pages, i.e. "you know Mr Smiths HR has been pegged at 150 for a while now, I think its just sinus but I was going to page the resident eventually if it didn't go down". Now you get the EKG in your hand with no resident around, dx flutter and then call your resident to discuss what to do.

 

[AF_PedsBoy]

I agree - I admit I've never had problems with them NOT calling me - it was always the other way around in spades! - but I ended up swinging through the ICU on a regular basis so if they page you too much, sometimes they'll hold off if they know it's not life or death. You don't get any more sleep, but you don't get pulled in three different directions on call. Plus once it ticks over past midnight you can get those notes started, look like a star during rounds, and hopefully it'll get you out of the hospital before the second wind really dies! (I mean you gotta have all the information eventually anyways - may as well have it for rounds!)

 

[Raidergate]

One of the biggest things I've learned as a surgery intern this year is to not give a crap what the ancillary staff think of you and concentrate on what's best for the patient.

That doesn't mean act like a jerk or get into meaningless disputes over things that aren't that important. But, you can't let how you feel about the job you're doing be decided by a bunch of people who have no idea how hard your job is or what it actually entails.