Sunday, April 23, 2006

Are You the On-Call Doctor?

A Medley of Call Night Antics

7pm
nurse: are you on call tonight? Oh good, I've got the sister of Patient XXX on the phone and she wants to know what is going on with him.

Note to all relatives of people who are in the hospital: If you want to get in touch with the primary physician or the primary team taking care of your mother/father/brother/sister/cousin, please call in the morning. Early is better than late. Some physicians have afternoon clinics so they will not be available. Others, like surgeons, will be in the operating room and so will be harder to reach. If you call at 7pm chances are the physician you talk to will have very little detail on what the primary doctor is thinking and why they are doing what they are doing. Call in the morning. Early.

call from nurse at 2:30AM:

nurse: Hi, the patient has a foley catheter in place and is scheduled to have it taken out at 6am. Can I take it out now?

No. Unless there is imminent danger to the patient or others, it is never a good idea to change management plans at night when the primary doctor is not available. The doctor on call is covering all the patients in the hospital and does not know each patient well enough to make the best decision on management issues that are not critical at that point in time. This holds true for other noncritical management decisions, such as "should we change from an intravenous fluid with a little sugar in it to fluid without" or "do you really think we should do the orders Dr. X wrote earlier?" If Dr. X wrote it, and Dr. X is the primary physican caring for this patient who knows the patient well, and I am only the physician on call, and it is not a life or death issue, YES, you should follow the order that Dr. X wrote. I'm not going to second guess someone who knows the patient better, who may know certain details about the patient or his/her social situation, or past medical history that may affect why they order what they order. Medicine is an art and every physician has their own "style" of management. It's not my place to adjust another physician's style if it does not affect patient care.

call from the nurse at 3AM:

nurse: Hi, I have a patient here, Mr. X, who is wandering around. Could we get an order for Ativan?

Ativan is a sedative that can effectively knock someone out for the night. In elderly patients (majority of the hospitalized population), Ativan tends to be a suboptimal choice of sedative because of its side effects. Unfortunately, a number of them end of receiving this at night, even those that may not really have needed sedation in the first place - it's main purpose in certain situations is to ease the workload of the nurse. And unfortunately, physicians order it more often than needed, because if the nurse asks for it, and if the nurse isn't happy with your refusal to order it, they will call you. Again -- and again -- and again. Or worst, get mad, and the on call physician will be guaranteed many a sleepless night. From our point of view, it is extremely easy to just say yes, give Ativan if you would like to, but it's really not in the best interest of the patient or the primary team, who will find an extremely groggy patient who can't urinate in the next morning. It's much tougher to drag your butt out of bed to see the patient and assess the need for medical intervention, but it really is in the best interest of the patient. Most nurses are reasonable. If you see the patient, decide the medication is not indicated and discuss the situation with them, they are OK with not using a sedative. Some like getting their way. Like the nurse last night. Page #1: Patient had a little dementia and didn't want to stay in bed. I was in the middle of admitting a new patient and said that I would be up shortly to see the patient. Page #2: another nurse restating the same situation. Repeated my answer. Page #3: A third nurse stating that the patient was now agitated and threatening to leave. 3 in the morning, 3 pages, 3 nurses, 3 requests for ativan, all in 30 minutes. So I go to see the patient. He's standing in the hallway by himself, NOT agitated, NOT angry, NOT threatening to leave. The man is very pleasant, definitely advanced dementia with really poor short term memory. Based on the interaction, there was no acute need for sedating the patient. Tried to discuss this with the nurse, and had all three nurses in the wing crowding around describing how agitated the patient was and how he was climbing up and down and pulling things. Giving them the benefit of the doubt, as nurses are at the bedside and see more of the patient than we do, and given the fact that I was definitely not going to hear the end of it if they didn't get some sort of medication order, we compromised on a medication with less side effects that was to be used only if the patient was agitated. Riiiight... I'm sure it got used as soon as I left the floor. What can I say? There's only so much you can do... (Disclaimers: There are definitely situations where ativan is extremely useful, even in elderly patients. And not all nurses are like the nurses described in this situation - most of them are great.)

Worst phone call to have to make while on-call: calling the family of a patient you don't know who has passed away overnight.

2nd worst phone call: calling the coroner, who grills you with questions about the deceased patient that you just met. You sound like an idiot as you stammer and try to flip through the chart quickly to find the answers.

Time for bed.

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