Night time is all about triage. When you get three pages exactly at the same time, which one do you answer first? Two interns calling you, who do you answer first? Two consults in the ER, which one to see first? Two attendings to call, which one goes first?

More complicated: An admission in the ER, and an ICU consult which is probably nothing – but you won’t know for sure till you look for yourself. A floor consult which probably needs surgery, and an ER admission which probably doesn’t need surgery – again, nothing for sure. An ER consult which needs surgery, and an ICU patient with a pressure of 60/40 and no lines.

Sometimes, like the ICU patient whose vital signs are not compatible with long-term survival, it’s easy to figure out where to go first; and the attending will just have to get woken up an hour later to hear about that patient in the ER. More often, it’s not that simple; you have to trust the interns to give you an accurate picture of the consults they’ve seen, in order to figure out which ones get priority. And if you don’t get the right picture from the interns, it’s still your fault, because if only you trained the interns better, or asked better questions, or listened to them more carefully, you wouldn’t be missing the important facts.

As a rule of thumb, I tend to rank vascular above general surgery. Vascular patients are more likely to have strokes and heart attacks, and if there’s something wrong with them, they’re liable to bleed much more dramatically than general surgery patients. Also, lack of blood supply, to any object, is likely to be irreversible faster than most cases of peritonitis.

Strangely enough, the resident I mentioned in my last post, one of those guys who always gives off an air of glacial calm, which I would give anything to achieve, passed me in the hall this morning: “You’re sick of nights, aren’t you? I know. It was the scariest month of my life.” Not sure whether to be happy that after all he too was disturbed by the level of responsibility, or dismayed by further proof that all the people I admire are in truth as clueless and scared as I am – suggesting that I’ll never achieve that state of calm, because it doesn’t actually exist.

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