If you’re wondering why you haven’t heard from me in awhile, it’s because I went directly from the Potassium Repletion rotation, which I absolutely despised, onto internal medicine wards. I am not sure why it is called a “wards,” rotation, but basically it’s the same thing I did in med school – rotating on an internal medicine team. I actually finished my “IM” rotation two weeks ago and have since been on an obstetrics service catching babies, but that’s a story for another time.
I’m behind. Residency is hard. Leave me alone.
When the previous intern signed out to me – giving me the rundown on all the patients on the service, plus some tips on how things work – I made a joke about how my only job on the CCU was to replete potassium. She smiled and said, “you definitely do a lot of that here too!”
Ha. She knows nothing. I only had to replete potassium about 13 times on medicine, which is about 103948 times less than on the cardiac care unit.
The way my hospital here admits patients to a medicine team was designed by a 5-year-old using crayons and Tinkertoys. It is so absurdly complicated, and so completely opaque and nonsensical to an outsider, that I will not even attempt to explain the basics of the system here. The only thing you need to know is that every four days I was required to stay overnight in the hospital.
For my fellow EM interns who already completed their medicine block, “long call” was benign. Most of the work gets done during the day before the sun goes down, and most people have gotten at least five or six hours of sleep every time. However, because your solipsistic narrator has the luck of this guy:
…I received exactly zero sleep on all three of my long call nights. A primary reason for this is a concept familiar to every doctor in the universe: the 3 AM page.
The 3 AM page is special in that it doesn’t have to happen at 3 AM. It always comes in the ten to twenty seconds immediately after you’ve fallen directly into REM sleep from total body exhaustion. The harsh tones of the beeper causes an almost physical pain.
There are three varieties of the 3 AM page.
1) The FYI page. The purposes of this page is quite obvious: to alert you, as the primary provider, to something nominally important. Usually this is a lab result, or a vital sign change. An example: “FYI: Patient Smith morning potassium level 3.4.”
YES I AM PERSEVERATING ON THE POTASSIUM THING SHUT UP.
The FYI page is great when it’s lunchtime and you’ve been waiting with bated breath all morning to find out about the potassium. It is not great at 3 AM, when it is lunchtime for the night shift nurses but the absolute dead center of REMland for you.
Early on in my rotation I met the FYI page with uncontrollable fury and rage, destroying two patient lists and a ballpoint pen in my anger. Later on I acquired a psychological disorder known as “learned helplessness,” which is pretty self-explanatory. Once an animal believes they cannot escape a negative situation – the original experiment used mild shocks on dogs, which is horrible – they just lie there and take it instead of trying to identify a solution to their problem. They give up trying.
As an example: My idiot dog, Tiller, often exhibits learned helplessness. In pursuit of bunnies to murder, he often wriggles under the deck at my parents’ house. Because he is a fatass, he then gets stuck. Instead of trying to weasel his way back out, he tries a few times and then just lies there and whines until we pull him out by his hind legs like an enormous chubby sausage.
Anyway. Here’s Tiller. He may be a helpless murderer, but he is very cute.
The exact page for which I established my own learned helplessness was the following:
“FYI: Patient Smith had a bowel movement on the floor.”
When I read that, awakened from a fitful twilight/fake sleep from the sound of the pager, I just busted out laughing, completely alone in the call room. It was at that precise moment that I decided I was helpless to prevent these pages.
2) The Pain Control Page. The purpose of this page is to remind you at the most unwanted time that you are an idiot, although this is a hardwired lesson that I have never once forgotten in residency. One of the unwritten tenets of hospital medicine is that if you forget to write an order for some kind of pain medication “PRN” (meaning “as needed”), you will be paged for a pain medication at 3 AM, guaranteed.
“Patient has a headache, no PRN order written, can he get PO Tylenol? Thx” is a standard pain control page. Miraculously, this page appears regardless of whether or not the patient is experiencing any discomfort at all.
The pain control page is infuriating because it represents a personal failure. If only I had written the order for Tylenol, I would be aggressively sleeping right now.
(As an aside, “aggressive sleeping” is a thing I made up. It only happens when you are running at least a twenty-hour sleep debt. When you fall asleep – usually instantly – you go directly to Stage IV deep sleep, which I’m told resembles being dead. Upon awakening you are horribly confused and have no idea where you are or what time it is. Also you sweat a lot, hence the aggressive terminology.)
3) The STAT page. The STAT page is the only message I can receive during the night that will inspire anything other than either helplessness or immediate resentment and rage. The STAT page means “call back immediately” and may or may not include any additional information.
As you might imagine, the STAT page should only be sent during times of emergency, such as when a patient is decompensating and needs immediate intervention. For instance, I received the following STAT page during my last call night (I’ve changed a couple details for privacy reasons):
“STAT, Rm 10399, pt developing sudden shortness of breath, currently satting 87% on 15L face mask x849522”
That page means, “your patient is about to die, please call me.”
That’s a reasonable STAT page. When you get a STAT page like that at 3 AM, the flood of adrenaline is so powerful that you’re instantly awake. Which is good, since you’re about to sprint down the hall with the looming possibility of potentially Doing Things around the corner.
Unfortunately, sometimes that STAT designation is abused. Sometimes it is abused in conjunction with a total lack of context:
That’s a STAT number-page. A number-page is when someone pages you to call them back (that’s the x938492) without any information. Every doctor reading this is nodding with distaste because we universally despise the number-page. When paired with a STAT, I assume the nurse is too busy preventing my patient from being imminently dead to type anything out, so I call back immediately, adrenaline now going at DEFCON 1. With that in mind – it’s about 3:30 AM, by the way – the following interaction occurred:
ME: “Hi, this is Nate the medicine intern, returning a page, what’s this about?”
NURSE: “Hello Doctor, the patient’s family would like to speak with you.”
ME: “… what? Who? What are the vitals?” (We are trained to ask this last question in medical school when responding to a stat page.)
NURSE: “His vitals are stable. The patient’s wife would like to speak to you when it is convenient.”
ME: “…Like… right now? Why?”
NURSE: “No, in the morning on rounds is fine. She just wanted to let you know.”
Remember that I have enough epinephrine flowing through my veins right now to hulk-smash my way through a military checkpoint. It took every ounce of kindness I possess, which on a good non-sleep-deprived day can fill a shot glass, not to slam the phone down screaming in rage.
This is why I never slept on a call night.