Freeze Frames: A Night on Call
An essay about learning how to learn, and forgiving myself for making mistakes
My first few essays here will be from the archive of my writings. I first published this essay on my previous platform on August 25, 2021, and am now reprinting it with some minor edits.
93. That is how many pages I got on the most stressful night of the month (yes, we do still use pagers).
Starting my intern year of residency on night shift was one of the more nerve-wracking ways to begin – each night carried something new, from clinical challenges like how to approach and manage post-operative fevers, to the seemingly mundane, like figuring out the correct dosage for pain medications and how to order insulin.
Mostly, things turned out alright. But that night, something seemed to go wrong with every patient on my two double-sided lists.
Barely a few hours after sign out, I was called to the post-op care unit by a nurse who told me that one of my patients had a systolic blood pressure of 60 and was not responding to vasopressors. I had never met this patient before, but a systolic of 60 was enough to send a cold rush through my veins, so I stopped what I was doing and ran downstairs. As soon as I got there, I saw the monitor reading 53/36. I went over and tried to talk to the patient, but she didn’t know any English and seemed to be mumbling in Russian. This clearly wasn’t the time to call a translator and wait as they painstakingly took down every detail of the patient’s PHI.
I looked up at the monitor again, trying to come up with a plan. This time I wasn’t even able to process the numbers I was seeing.
I panicked. I immediately called the ICU resident before I had a chance to think about what was going on. All I had done was order stat labs, and tell the PACU nurses that the patient needed an arterial line – but I couldn’t do an arterial line without supervision. The PGY2 (2nd year resident) and ICU PA arrived and I started to tell them about the patient, all the while trying to silence my pager, which was going off non-stop, until halfway through my presentation the nurse interrupted me and said, “Wait, this patient didn’t have a thyroidectomy. She had a bypass.”
Turns out when the nurse had called me upstairs, I had written down the information on the wrong line on my list, so that when I was telling the PGY2 about the patient, my facts were completely jumbled up. If my skin was any lighter, I would have gone red in the face.
If my skin was any lighter, I would have gone red in the face.
All I could hear was the echo of my senior resident telling me the week before, “You have to know your patients.” He was right at the time, and he would have said the same thing if he had heard me now. I wanted to smack myself in the face for making such a stupid mistake. I wanted to throw my pager out the window for clouding my judgment, and then I wanted to smack myself in the face a second time for allowing my judgment to get clouded just by its incessant beeping.
My patient ended up going to the surgical ICU – and even though I hadn’t understood what was going on or how to address the situation, at least I had done the right thing in calling for help.
Barely two hours later it happened again, when I went to check on a patient who was post-op from an angiogram. He was sweating and moaning in pain, but his pulse exam was exactly the same as it had been previously. An nurse practitioner (NP) from the primary team showed up and ordered him dilaudid for the pain.
This time, I actually examined the patient, but it was hard to tell where he was tender because he was yelling so much about everything. “I’m just in pain, why can’t you see that!” he shouted at me.
The NP gave me a knowing look.
I knew these kinds of patients were easily dismissed. The sweating, his discomfort, could all have been secondary to pain – it definitely wasn’t the first time he had called us for it. But still, something didn’t feel right. I ordered labs and asked for vitals, which showed that his blood pressure was low. Now I was really worried. I called my senior resident, and while waiting for him, tried to see if the patient had any groin or abdominal tenderness or swelling that could indicate bleeding.
By the time my senior got there, the pain medication had kicked in, the patient’s blood pressure improved, and his exam was non-focal. He seemed to be fine.
But then 30 minutes later, his Hemoglobin came back at 6.5 – a huge drop from 11.3 just that morning. We got an urgent CT scan that showed a huge retroperitoneal hematoma - bleeding in his back. He got 2 units of blood. I was right.
But before I had any time to process the case, or reflect on if I had handled the second situation better than the first, my pager went off again.
A girl in 10/10 abdominal pain wasn’t feeling any better with Tylenol or pushes of dilaudid. Maybe I could give her Toradol? I hoped so, because I couldn’t think of anything else that would help.
802A had a fever to 100.7, but because it seemed low, I held off on doing anything. In the morning I would learn that I should have done a full fever workup, and that any first-time fever after surgery is potentially concerning.
A post-op gastrectomy patient vomited blood. He was clammy and pale, and didn’t look good.
A man with an AV fistula started bleeding from his arm.
And every 5-10 minutes, I would get a page about putting in a diet order, changing the parameters for a medication, or morning labs.
As a medical student, I used to love the busy nights. These were the nights I would hope for and look forward to, because it meant I could do something, or learn something. Now, I longed for those days when I could take a back seat and just watch the chaos unfold in front of me.
Now, I longed for those days when I could take a back seat and just watch the chaos unfold in front of me.
A few nights later there was another crisis. An overhead page was called for vascular surgery to come to the Pediatric ICU, where there was a patient who had just had a vascular procedure done a few hours before. Of course, it took me forever to get to the PICU because half the building was closed off for construction. As I wandered through the halls, going up staircases and then doubling back, I tried to run through possible scenarios in my mind, but since I had never met this patient before, trying to do that felt futile. All I could think was – if the PICU, where there are multiple critical care doctors and nurses with much more experience than me, is calling for help from the surgical team, won’t they be disappointed when I show up.
I finally found the room at the end of the hallway where dozens of people were crowded around a bed. When I asked what was happening, someone said “he’s hemorrhaging.” I waited for someone to summarize to me what had happened and what interventions had been tried so far, but no one did. Maybe they could tell I was just the intern, and were waiting for the real surgeons to show up. I wanted to ask more questions, but I couldn’t even figure out who was running the room. I felt like a deer in the headlights – and with my widened eyes being the only facial feature visible behind my mask, I’m sure that’s exactly what I looked like.
I called the vascular fellow. The first thing she asked me was what his pulse exam was – of course. How could I not have thought to check pulses? Why hadn’t I examined the patient at all?
I checked – he had strong DP and PT pulses.
While waiting for her to arrive, I tried to piece together other bits of information about the patient from what I could see and hear. Information I would store in my head and try to make sense of at a later time. But then, I just stood there and watched the boy shiver, his eyes closed, as his mother held his head and stroked his hair, looking terrified.
But then, I just stood there and watched the boy shiver, his eyes closed, as his mother held his head and stroked his hair, looking terrified.
The rest of the night, I was preoccupied, because again, just like with the hypotensive patient, I hadn’t done anything. Both times, I froze. I hadn’t even thought to examine the patient until prompted – both times. Why hadn’t it occurred to me to examine the patient? A history and a physical are the first things we learn, and they are constantly drilled into our heads throughout our training. When you’re stuck, you go back to the basics – that’s how you figure out what’s wrong and what to intervene on. And a good H&P is one of the few things I could actually do. So why didn’t it occur to me? This is the question I asked myself the rest of that rotation.
Now, thinking back, it was probably naïve to have expected more of myself as a two week-old intern. I kept thinking, if I can’t get into the habit of thinking like a surgeon, how will I possibly get better? But we learn in stages, and if the worst thing I did was call for help before working up the patient myself – well then, at least I called for help.
After all, there must be a reason that surgical training takes five years.