Tips for Surviving Hospital Call Shifts?
November 16, 2010 4:39 PM   Subscribe

How do you survive 30 hour call shifts on a busy general internal medicine ward?

As the medical student, I'm first to be paged by nursing staff for all concerns on my ward. I'm responsible for around 30 patients, with back up from a resident covering all other wards and screening in the ER. I'm also responsible for new admissions.

I have no control over scheduling, work environment, etc. I do get the next day off (post-call), but otherwise am already working 12+ hour days on the ward. This is short term, for this rotation anyway, but is still hard to handle.

Looking for advice - tips, tricks - on how to function 24 hours in!
posted by narcissus_and_ambrosia to Work & Money (15 answers total) 9 users marked this as a favorite
I'm not a physician or nurse, but have worked in hospitals for quite a while (including a lengthy stint as a patient advocate). My best advice is to find out what the nurse (particularly if she is experienced) thinks should be done for the patient. If you work in a hospital that is using SBAR for physician/medical student contact, he or she will tell you right up front what they believe should be done.

Usually, this will be what actually needs to be done. Do a gut check (does anything feel ~wrong~ about this?), and if the gut checks out, do what the nurses recommend. The nurses are the ones with the patient, and if they are experienced they have probably seen this problem dozens or hundreds of times before.

If you're feeling indecisive at 24 hours in, this could be a big help, and a boon to the patient.
posted by jeoc at 4:53 PM on November 16, 2010

This technique ("What do you recommend?") garnered me a lot of goodwill and helped me learn a lot in my first year as a patient advocate. In some ways, being a patient advocate is a little like being a medical student. You don't really know what the hell you are doing, but everybody expects you to fix stuff anyway.
posted by jeoc at 4:55 PM on November 16, 2010

posted by Mach5 at 4:59 PM on November 16, 2010 [2 favorites]

Try to round with the nurses on each shift (hopefully it'll be 12-hr shifts) and ask if they have any concerns about their patients or need any orders written. It also helps if you let the nurses know what the tentative plan is for that patient.
posted by TorontoSandy at 5:03 PM on November 16, 2010

I wish I could help you but can't recommend anything that doesn't involve pharmaceutical intervention. I don't think you should have to work 30 hour shifts or that you should have that responsibility as a med student.

However, this physician and proponent of controversial long hour shifts for learning medical professionals claims that small amounts of sleep don't help but showers do. Good luck.
posted by red_lotus at 5:12 PM on November 16, 2010

Thirty hour shifts sound nasty--I'm surprised they still make you do that. My worst rotation was on a surgery service that was similar, if not a little worse. Eighteen hour days 6 days a week with "24 hour call" that would start about 0430 hrs one day and end about 1700 hrs the next long as "the team" (which usually meant an exhausted senior resident) felt that you'd done enough work, otherwise you'd get another few hours of stuff to do, get home at 2300 hrs and be back the next morning at 0430. IT WAS NOT FUN.

How do you get through? I don't know the exact answer to that as I suspect it's different for everybody. For myself, I constantly reminded myself of three things: 1) I was there to learn as much as I could about taking care of other people, (2) I was there to do what I could, in my power, to make my patients' lives better, and (3) it wouldn't always be like this. Of the three things I tried to keep in mind, I think the third thing was what ultimately carried me through: IT WON"T ALWAYS BE LIKE THIS, IT WON"T ALWAYS BE LIKE THIS.

Gotta take it one day at a time: eat when you can, sleep when you can, shit when you can. Always smile and always ask for more and, in truth, one day it won't be as bad as it is now.

Good luck.
posted by FredFeral at 5:31 PM on November 16, 2010 [1 favorite]

I'm a nurse. I've had residents do "I'm going to bed now rounds" on my patients and it helps a lot.

I had a cardiologist tell me once that a nurse woke her up to report a patient's arrythmia, and she replied, "Well, get the defibrillator ready," and went back to sleep. She knows this because she got chewed out for it in the morning, but she did not remember it.

Your question may be more about how to function on zero sleep than how to get sleep though. I don't have much to offer except caffeine.

And always go see the patient yourself. It will be tempting to rely on someone else's report. That will lead to trouble.

Drive carefully on the way home.
posted by SLC Mom at 5:31 PM on November 16, 2010 [1 favorite]


No, but it'll be like this for a while. Residents do this for at least three years after medical school.

I seriously suggest asking the residents at your hospital how they do it. Not only will they have actual information to share with you, they'll also be able to talk to you about the local culture, i.e. how particular physicians in particular wards handle things. Different members of your house staff are going to expect different things from you. When you do go on to residency, I'd immediately connect with your R2s and experienced nurses for tips.
posted by valkyryn at 6:09 PM on November 16, 2010

I'm due to start my internal medicine rotation in a few months. I've been reading The Nerd's Guide to Pre-rounding, and it seems somewhat helpful. YMMV.

Good luck, you'll get through it and onto greener pastures with better hours! :)
posted by greatgefilte at 7:00 PM on November 16, 2010 [1 favorite]

Working for 24+ hrs definitely sucks. Contrary to what many assume, I don't think it gets easier to be up for 24 hrs straight. As you get older, working for 24hrs becomes increasingly difficult. Sorry ... but it's true.

But ... I do think that you will get better at being on call. First of all, you will become much more adept at asking the right questions over the phone. When you do your tuck-in rounds you will learn how to put out fires before they start. Saving you even a few phone calls. Also depending on where you are working, over time you will come to know the nurses and if you treat them well, they will advocate for you and help you get some rest. (They might wait and then pool all of their questions into a single phone call, or wait until you are next awake to ask you nonurgent questions.)

The biggest change will come as your anxiety levels start to come down a little bit. By far, being on edge about all of your patients all of the time is the most exhausting component of medical student/resident life. As each of these things start to fall into place, you won't drain yourself as much when you're awake and you'll also manage to decrease the number of phone calls.

I guess I do agree that it will get better overall. But working for 24 hrs is hard for everyone. Your body is still going to be angry at you. Post call arrhythmias perhaps? muscle cramps maybe? post-call diuresis (have you ever peed so much)? Treat yourself well on your post-call days.

Also as a word of encouragement I think that internal medicine is one of the worst specialties for call. I'm still doing busy 24 hr call as a staff, and I pity the internal medicine team.

Other little tricks - shower if you can in the morning. Brush your teeth, wash your face. Don't ever apologize for eating lunch or dinner. Change clothing. If something is so urgent that you don't have time to use the washroom - they're paging the wrong person! (This might change when you're staff, but by then you will be far more jaded!) Don't apologize for being tired - caffeine helps a bit, but is no replacement for sleep. Remember that 24hrs is a long time to be working, but it's not forever. You will go home. And do what you can to get your colleagues out as early as possible when they're post-call.

Also, perhaps a bit off topic - never make important life decisions at 0400. You can go ahead and increase someone's labetalol, but don't try to decide where you want to specialize!

Hope this helps - good luck
posted by commissioner12 at 7:01 PM on November 16, 2010 [1 favorite]

Ooh, one specific thing that I just thought of that's mentioned in the book -- make sure to be exhaustive with prophylactic orders. Sennakot + docusate for all, acetaminophen PRN for pain, dimenhydrinate (or ondansetron if possible!) PRN for nausea/insomnia, and some other ones that I'm forgetting.
posted by greatgefilte at 7:04 PM on November 16, 2010 [1 favorite]

Third year med student here - s/p medicine and surgery rotations. I don't drink coffee or soda, or take any pharmacologic remedies. I found that wintermint chewing gum and drinking lots and lots of water were the things that helped most staying awake on busy overnight calls. Stay moving as much as possible, if you won't be able to sleep.

Also, keep in mind that as a medical student, your duties on paper may look worse than what is actually expected of you. Even if it is as painful as you say, you will get through this.
posted by honeybee413 at 9:12 PM on November 16, 2010

It seems quite a lot for a med student to be first-call for 30 patients. To make things more manageable:

Have less patients:
--Check that you are covering the same amounts of patients that previous students have. Find out what the cap is for interns and make sure you aren't exceeding that.
-- Dispo: Are there any chronic patients with disposition hang-ups that your team can transfer to a non-teaching hospitalist team or be discharged to medical respite?
-- Less admissions: are there admissions that do not belong on the medicine service?

Get less calls:
-- make sure vital parameters are appropriate
-- have PRNs in place for fever/pain/nausea/vomiting/constipation. have prophylaxis and/or second-line PRNs in place, e.g. anti-emetics for chemo patients with nausea refractory to original PRN. BPH meds for urine output.
--anticipate orders ahead of time, e.g. "please resume regular diet when patient returns from OR."
-- make sure orders have nursing calls set appropriately to consult teams. for example, some places it is routine for surgery/IR to be first call for drain output problems rather than primary medicine team.
-- don't order unneccesary labs in the afternoon (or ever).

Sleep when you can:
-- take naps if possible
--avoid bright lights and caffeine on post-call mornings.

Delegate tasks to the appropriate person. Depends what is appropriate at your hospital, rather than doing it yourself get:
Wound care nurse to do dressing changes, dietitian to set diet, pharmacy to do medication reconciliation, coagulation pharmacist to titrate coumadin, social worker to help communications with family, discharge nurse to set follow-up appointments, nurse to do ambulatory sats.

Go home if you have no work to do:
--if you are not admitting and all your patients are stable, some places allow you to sign-out to cross-cover early in the afternoon. where I work, several tasks are reasonable to be signed-out to another person (f/u PM labs, PM groin check).

Of note, starting next year, the ACGME guidelines will be pushing 16-hour maximum work-hours for interns.
posted by alex3005 at 9:56 PM on November 16, 2010 [1 favorite]

Other posters have given you excellent tips for increasing your efficiency and minimizing night-time phone calls. Here’s my 2 cents about managing the physical and mental aspects of sleep deprivation. You’ve likely heard some of it before, but it may bear repeating:

1. Sleep when you can. This doesn’t just apply to call nights – if there’s nothing happening on the ward during the day, find a spare call room and take a nap. If there’s another med student around, try to spell each other off on alternating days. If your resident is not pro-nap, consider memorizing some helpful facts beforehand so that you can say something like, “I checked the follow-up labs; Mrs. S’ creatinine level is stabilizing” when you appear back on the ward. (Obviously this is not recommended if there is actual patient care to be done.) Don’t forget to set an alarm, and keep your pager on!

2. If you don’t have time to sleep, at least take a shower – it provides a sort of mental break between yesterday and today. Change your socks afterward – nothing is more demoralizing than sticking your feet back into last night’s cold sweaty socks.

3. In the middle of the night, food is key. I used to keep Jello, a chocolate bar, and a bottle of Coke in my call room. I would have a big gulp of Coke before giving any orders over the phone; if I had to actually go to the ward, I would eat half a chocolate bar on the way there. The snack became a psychological cue to wake up and start thinking, as well as a little reward for getting out of bed.

4. Pay attention to your body. After a few bad shifts, you’ll be able to predict – and hopefully manage – your body’s responses to sleep deprivation. For example, I get a horrible nauseous gnawing feeling in my stomach sometime between 4 and 6 am; this can be treated with ranitidine. From 7:30-10am, I am giddy, silly and amped up – this is a great time to speed-round on patients, and a moderately bad time to hold serious discussions with their families. If I’m still up by 2 pm, I become filled with irrational rage – this is a terrible time to do pretty much anything, so if we were still rounding, I used to concentrate on keeping a nice neutral facial expression and being super-duper helpful (handing patients’ bedside charts to the attending, being ready with the order sheet to transcribe stuff – the usual med student jobs) so that the whole ordeal could be done with as soon as possible. Finally, I found that upon leaving the hospital, my relief would occasionally manifest itself in ridiculous sobbing – based on my observations of other med students and residents over the years, this is kind of normal, so don’t feel bad if it happens to you. Obviously your own physical responses will vary, but knowing what is coming can really make it a lot more bearable.

5. Make life as easy as possible for yourself. This means things like having a Call Kit packed with a travel toothbrush, toiletries, ibuprofen and extra socks so that you don’t have to run around collecting stuff each time you’re on call. It also means actually sleeping post-call, and getting up early enough in the afternoon that you’ll still be able to go to bed early again that night. Try not to do anything you don’t have to on post-call days – the day is meant for sleeping and taking care of yourself, so give yourself a pass on housework, dentists’ appointments, and social obligations.

Take care, and best of luck! You will actually sort of get used to it after a while -- or at least, sleep-deprived will become your new norm, and you will learn to cope with it.
posted by TheLittlestRobot at 2:00 AM on November 17, 2010 [2 favorites]

Stay away from sugar, caffiene and carbs- essentially anything that screws at all with your blood sugar. I've done more than 48 hrs aware and this seriously makes a difference.
posted by filmgeek at 10:27 AM on November 17, 2010

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