Many kinds of "call"

I didn't realise until now that there are many kinds of call. It turns out, the overnight kind we all think of when we hear "on call" is more precisely long call. If you are on long call, it means your service is admitting patients. On my current service, the interns cap out at 4 patients each and the senior resident doesn't stay all night.

While on long call you also cross-cover the patients on other services. If something happens to a patient admitted to another service over the night, you will get the page instead of them. Of course, this also means that your patient's problems will be handled by others when you are not on call.

The day after overnight call you are post call. Interns usually leave by noon because they were working all night. The senior resident will finish any remaining management on the patients for that day. Unlucky for the medical students: afternoon conferences are still required even if you're post-call.

The second day after long call you are on short call. You admit one patient early in the day.

The day before your long call, you are pre-call. Your service doesn't admit any new patients in anticipation of the new load during long call.

Another good question: what does it actually mean - "admitting" a patient? Well, it means the ED or another hospital has determined a patient needs care in your hospital. When your service accepts the patient you get a one-liner about their major symptom (chief complaint). Then you go and examine the patient, ask lots of questions and come up with several possible reasons for their illness (differential diagnosis). You also come up with a plan of how to manage each of the patient's problems. Usually the intern will see the patient first, then the senior resident, then the attending. The intern writes up an admission note and the attending co-signs it.

Each day in the hospital the intern (and med students) will pre-round on the patient, then the interns, resident and attending all round on all the patients together. They discuss progress and complications that occurred overnight and how to continue or change the management plan. The intern and the senior then spend the day organising that care and documenting it.

That's life on general medicine, inpatient. I'll post some stories about my first patients soon.

Live from the OR

Once upon a time I did a post composed of live blogging from the ER. I thought I would replicate the concept tonight by giving you an idea of what a transplant case looks like for me.

11:07 - consent is obtained and I receive an email. I am now aware that a donor liver is expected to arrive for a patient and the surgery should occur sometime today.

17:48 - I find out the donor liver is not expected to arrive until after 10pm, that means an overnight surgery is likely.

21:11 - I call the main OR desk and they indicate a lines-in time of 11:30pm. That means the incision won't happen before 00:30am.

23:50 - I arrive at the hospital to change into clean scrubs, prep some dry ice for samples and start the paperwork.

00:18 - I head down to the OR to check on the progress. They are just finishing the echo and still have to place the radial line.

00:37 - Incision. I draw two purple tops and collect 10cc of urine. I leave the OR and head to the lab to centrifuge the samples and put them on dry ice.

01:26 - Back in the OR to observe

02:51 - Anhepatic phase begins. This is when the patient is no longer connected to his old liver and not yet connected to the new one. I draw samples and put them on ice to process later.

03:29 - Reperfusion. This is when the new liver is connected and circulation through the liver is restored. All the preservatives and biochemical waste from the new liver cause the patients heart to struggle briefly. When well-managed and with a little luck this can be short-lived and uneventful. Tonight, reperfusion goes smoothly.

03:59 - I draw samples and bring them and the pre-reperfusion samples up to the lab to process. Sometimes I stay in the OR until close, but tonight I'm hoping to catch a few hours sleep before class. If the close is within two hours of my shift ending, I will be able to draw the closing samples and leave. If not, I will have to stay until 2 hours post-op.

04:40 - The surgeons have closed, the operation is complete. This was a very short surgery, which is good for the patient, but bad for me. I now have to stay until 6:40 to do the 2 hour post-op samples.

04:50 - Follow the patient up to the SICU to get immediate post-op samples. Run back to the lab to finish processing samples already collected.

05:30 - Email an update about the surgery and schedule for post-operative draws through POD4 to the research group.

06:30 - Head over to the SICU to check in with the nurse and get the 2 hour draw.

06:45 - Head back to the lab to leave the samples on ice (the girl coming in at 7 will process it), head home to catch a three hour nap before class at 11.

Pee

Time I got paged this morning: 5am
Hours of sleep I got: 3.25
Time I waited for my patient to pee: 8hr 37min
# 12oz coffees I drank in that time: 2
# times I peed in that time: 3

Liver #2

I went to bed excited because we had consented another patient for our liver transplant study. The OR schedule said they would induce the anesthesia at 10:30am, so I hit the sack just before 2 with my alarm set for 9. At 4:46 my pager goes off. They are inducing now. I head straight to the OR where I find out that this is expected to be a tricky case. I have had 3 hours of sleep and haven't eaten since 8:30pm the previous night. I emerge from the OR at 10:30am, put the samples on ice and head straight to Einsteins for a large coffee and a honey wheat bagel with honey almond smear. Never tasted so amazing.
The surgery itself was longer than the last one I observed, but they didn't have to use any blood products and were able to extubate before sending the patient to the SICU. It speaks to the skills of the surgeons and anesthesiologists in managing the anatomy (surgeons, no blood) and physiology (anesthesiologists, not acidotic).
The patient was awake when I went up to the SICU for the 2 hour post-op samples; the family was there too. It's really kind of fun when you can say you were in there with the patient the whole surgery.
I left the hospital around 2:45pm and was kind of dragging this afternoon, but I just had some coffee and a chocolate chip cookie. Nothing like caffiene and glucose to keep yourself on point.
There's another harvest this afternoon. If they keep the liver in house there's a chance I'll have another surgery this evening, although it looks like the graft is of poor quality, so I may get some sleep instead.

Don't tease me!

(18:21) I get the email that there is to be a liver transplant at 20:30.
(20:07) I get the page that says the transplant will begin 21:00.
(20:14) I get the page that says the transplant has been canceled.
(22:00) I go out dancing instead.

Turns out carrying a pager in a club makes you attractive. A law student asked for my phone number.

Cirrhotic liver. The kind you take out, not put in.

Yet more trauma

It started off well. I was studying in a coffeeshop when my trauma pager went off. It's silly, but I felt a little cool reading the page out to my friend and booking it out of there.

"Class 2 M, Go cart vs truck, blunt, 115/78, not intubated, unk GCS, ETA 8 min"

It turned out the patient was pretty much ok - just a closed tib/fib fracture. He had been transferred to our hospital mostly because of questionable change in mental status, which it became quickly clear was not the case.

On my way back to my car to drive home and contine studying (well, doing write-ups on clinic patients) the pager goes off again (in front of more people!).

"Class 1, M, ATV vs tree, blunt, 123/80, intubated, GCS 3, ETA 10 mins."

It turned out ATV vs tree was actually fell-off-the-back-of-moving-pickup-truck. For those non-medical folk, GCS of 3 is very bad. It's a scale of 3-15 based on eye opening, movement and vocalization. A 3 means you have none of the above. He displayed from priapism (look it up if you don't know), indicating decreased sympathetic tone. On CT he had an impressive skull fracture and significant uncal herniation.

While eating a delayed dinner, the pager again beeps.

"Class 2, M, dirt bike accident, GCS 15, not int, in ER"

Five minutes later...

"Adult, class 2, motorcycle accident, left ankle lac, 148/68, HR 118, GCS 15, ETA 5mins"

My first overnight

It's the morning of my first overnight in the hospital. I was here from 10am-4pm on Sunday getting samples for anesthesia and working on charts for cardiology. When I checked my email on arrival at home, I found out there was going to be a liver transplant that evening. I took a quick nap, ate some food and headed back to the hospital. I spent the night in the OR, pestering the anesthesiologists with questions and asking for samples. Did you know that post liver transplant the person will have no gallbladder? I spent the wee hours of the morning processing the blood and urine. I just returned from putting it in the -20/-70 freezers. In less than two hours I have trauma/burn rounds, after which I will run home to shower/change into professional dress and return to the hospital for noon conference and trauma clinic. At about 6pm I will be able to go home and crash. And you know what? It's fantastic fun!

First pages

This weekend brought the first liver transplant since I started taking anesthesia call and the first trauma page on my trauma block.

For anesthesia, my friend J was on call of the intra-op samples (I'm jealous) but I've been going in to the surgical ICU every day to take blood from the arterial line and urine from the Foley for processing. I'm sure there will eventually be a liver on my watch and I'll get to go into the OR.

For trauma, I booked it down to the trauma bays to watch the team take care of a young adult with an open tib-fib fracture from a motorcycle accident. I was hoping July 4th would be a heavy trauma weekend, but so far - not so much. Let's hope it gets busier over the next two weeks.

Ok, so I realise that my hoping for livers and trauma requires that people get sick and that it makes me a tad bit of a bad person. But really, these things are going to happen; I just want them to happen here (as opposed to in OH or some other place that I am not).