This whole home call concept takes some getting used to. One of the major lessons I learned last year was how to be on the spot: if a patient’s sick, you don’t wait to get called, you keep walking by. If you do get called, you give some preliminary orders (oxygen, fluid, ekg) on the phone, and then get over there so you can see for yourself. And you don’t leave in five minutes; if there’s nothing else urgent, you stay around to see how things go; work on the computer, make some calls, but stay handy for a little bit. And of course the cardinal lesson in medicine: trust no one, neither those junior to you nor those senior. Everyone lies; verify it for yourself.
Now I have to reverse that. I’m getting a little better at jumping wide awake in the middle of the night, so the intern calling doesn’t have to repeat himself ten times. But you have to have all the answers – maneuvers, tests, medications and doses – completely memorized; that’s the only way they’ll come out coherently at (ahem) 3am. (How about my attending for president? He’s really good with the 3am phone calls. And I’m sure he’d come up with a more practical healthcare policy than the politicians have.)
The worst part is not being there. I have to trust the intern (fortunately the ones I’m working with are quite competent) to assess the situation correctly; without seeing things for myself, I have to figure out the key information, and think of things to ask about that the intern may not have considered. Then we come up with a plan, he hangs up to go do it – and I’m supposed to go back to sleep, instead of lying there worrying about whether either of us missed something, whether the patient is going to get worse before our treatments take effect, whether I misjudged the significance of a piece of information, whether I told him the wrong dosage on a medication. If I were in the hospital, I’d keep looking over the labs, ekg, chest xray, till I felt more confident. But I can’t keep calling the intern to go over things again.
(A bonus last week: in desperation, I dredged up a treatment I’d read about as of historical value only, but it was the only thing available or applicable for this patient. Not fun to play that card from long distance, but next morning the patient was nearly all better. I don’t know whether that old-fashioned trick did it, or whether he wasn’t as sick as we thought. Remind me not to read the historical section of the textbooks, it leads to unsettling decisions.)
Going back to sleep is also tricky. After getting called, I spend the next couple hours unable to sort out whether the phone ringing and the patient deteriorating are happening in my dreams or in real life, and I can’t shake the feeling that it’s really high time to get up and go to work, no matter what the clock says. I used to react the same way to pages at night on call, so hopefully this will get better with time.