PM&R doctor

An Internist’s Guide to STAT Overnight Pages

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PM&R doctor

At 7:30pm: So what’s the discharge plan for this patient?
Follow up: Remind the nurse that you’re the overnight resident and haven’t been attending case management rounds, so you imagine the patient will likely be discharged whenever he or she is medically cleared.

At 9:17pm: Family wants to speak with you. They’re very upset.
Follow up: Greet the family warmly. Summarize the patient’s course in broad medical terms, as you were told in the brief sign out. Explain that while this is your first time meeting the patient, he or she appears rather comfortable. If family is still upset, agree that the resident taking care of the patient is likely incompetent and offer to call Patient Advocacy for them.

At 10:31pm: Patient wants to go off the floor to smoke.
Follow up: If this is the VA, this is really more like an FYI page. If you’re not at the VA, approach the patient and offer a nicotine patch that they will inadvertently refuse. Remind the patient to come back after their smoke so that the vascular surgery doctors can see him/her and give final recommendations.

At 11:02pm: Can you discontinue the duplicate glucose tablet order?
Follow up: Explain politely that glucose tablets are automatically ordered every time that you adjust the patient’s insulin, but you are certainly happy to help ensure that the patient does not overdose on glucose tablets while inside the hospital.

At 12:26am: Vital Signs HR 71, BP 132/68, 99% on RA.
Follow up: Call the nurse back and thank them for waking you up to report normal vital signs on a stable patient with cellulitis.

At 1:48am: Patient is having chest pain.
Follow up: See the patient. Find out that the chest pain is actually epigastric burning that radiates up the chest towards the mouth. Do an EKG so you feel like a real doctor. Beg the nurse not to send a troponin. If you’re feeling especially smart, write an event note that mentions coronary vasospasm and in-hospital cocaine use on the differential.

At 3:12am: Can you change Gabapentin to 300mg by mouth twice a day for renal dysfunction? Thanks, Pharmacy.
Follow up: You don’t have to know why this otherwise healthy patient is taking Gabapentin. Log into the computer and try to change the dose, but find out that the order is locked because the pharmacist is in the chart. Flag this as a note in your signout to remember to go back in ten minutes.

At 3:13am: Pharmacy needs you to change the Gabapentin order. Patient is upset.
Follow up: Go back into the order. Pharmacist is still in the order. Call and ask the operator to connect you with inpatient pharmacy. Wait on hold while listening to your institution’s hold music, knowing that this melody will haunt you in your dreams.

At 3:16am: Can you change the Gabapentin order? Thanks, Pharmacy.
Follow up: You’re still on hold trying to talk to them. Take some deep breaths. When you’re finally connected, thank the pharmacist for their vigilance and ask if they can change the order for you to cosign. They do so. You are finally done with Gabapentin for the night.

At 3:51am: Patient is refusing to drink any further GoLytely.
Follow up: See the patient. Explain that while you empathize that the drink is wildly uncomfortable, we would all love to see him stop pooping blood. Remind the nurse not to mix red Crystal Lite into the gallon of liquid.

At 4:34am: Can you please order a nystatin powder for the patient’s groin?
Follow up: Order the Nystatin. Wonder why his groin was being examined at this hour and why this didn’t come up during day shift.

At 5:06am: FYI, your patient is on non-rebreather.
Follow up: See the patient. Turn down the oxygen to find that the COPD patient is actually satting 93% on room air. Explain to the nurse the difference between face mask and non-rebreather. Ask another nurse to teach her how to administer a nebulizer treatment. Exchange looks of exasperation with the patient before you leave.

At 6:32am: Patient’s BP is 102/58. Should I hold Atorvastatin?
Follow up: Call back and advise that Atorvastatin does not have blood pressure holding parameters.

At 6:34am: Patient’s BP is 102/58. Should I hold Metoprolol?
Follow up: If you feel like it, call back and explain that Metoprolol Tartrate has little effect on blood pressure and should really only be held in cardiac patients with significant bradycardia. Hang up the phone and stare at the clock and count the minutes until sign out at 7am.

At 6:34am: Patient’s BP is now 123/78. Should I still hold Metoprolol?
Follow up: Repress your urge to scream. Call back and skip to the part where you say that, yes, it’s safe to take it. Hang up the phone and hope you don’t get called into a Morbidity and Mortality conference in two months.

At 6:36am: Is patient medically cleared for OR today? Thanks, Orthopedics.
Follow up: Stare at the patient’s chart. Remember that you’re only an overnight resident who has never done a formal cardiac pre-operative evaluation before. Call orthopedics to tell them you’re not sure but you’re going to go ahead and order an INR for them.

At 6:56am: Code Blue, MICU Room 5.
Follow up: Even though the interns have already shown up for sign out, grab your stethoscope and run downstairs. Stand awkwardly at the perimeter watching the senior run the code. When a nurse asks if you can hop in line for compressions, explain that since you’re in residency, you haven’t exercised in over two years, so you don’t think you can adequately compress one third of the patient’s chest diameter. Listen to the nurse scoff at you and recall that you probably deserve that one. Maybe you should buy a bike on Craig’s List after all.

At 7:03am: Hey, I’m ready for signout. Thanks, –Intern #506
Follow up: Stare at your pager during the above code. Shed a tear. Put your pager away and look at the clock. Then continue to watch the code, feeling useless, until everybody starts to leave and you can finally return to the room for signout

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