Your First Night Running the List...

Cut to the Chase: General Surgery Survival Series, Post 32

For PGY-2s, and the interns reading ahead

You read all twenty-six charts at home last night. You can give the creatinine on anybody on the list, including two people who went home this afternoon.

It’s your first night as the senior on this service, and the phone that comes with the job has a crack across the screen that nobody is going to fix. A little after nine, your intern calls to ask whether the woman in 11 can have something for nausea.

You say yes and name the drug before she’s done talking.

She had one more thing. It started with also.

Everything you read was true when somebody wrote it. Whatever is true now reaches you through her, from rooms you won’t walk into before morning.

At six the attending will ask what happened overnight. Most of your answer will be decisions made by someone a few months into residency, about patients you know only on paper. That’s the right thing to be anxious about.

Before you split up, sit down and ask which two or three patients she’s worried about and what it is that worries her. Review what to do if her worries happen. Then see them yourself while it’s quiet, so you know how they looked when they were fine.

“Call me for anything” sounds generous, and it leaves her the hardest decision of the night to make alone.

Tell her what gets a call, plainly enough to repeat back: anyone going to the unit or getting blood, anyone she’s seeing a second time, and anything she can’t explain, whatever the numbers say.

Interns save the worry that didn’t seem worth its own call. It comes out last, said quickly, where it’s easy to drop if you sound busy.

You’ll sound busy. There’s a man downstairs who’s been waiting an hour for you to feel his belly.

Answer what she opened with, and she takes the call as finished. Most nights, so do you. So let her get all the way to the end.

Ask what she wants to do before you tell her what you’d do. If her plan is safe, let her run it, even when yours is a little better.

Safe means that if she’s wrong, you’ll find out in time to fix it.

Tonight it’s a man a day out from a colectomy who hasn’t voided in the twelve hours since his catheter came out. She thinks he’s dry and wants five hundred of LR and another look in two hours.

The fluid passes that test. Two more hours on his bladder doesn’t, so keep her plan and add one step: “Fluid’s fine. Scan his bladder before you hang it, and call me with the number.”

The scan finds eight hundred. The nurse drains it, and when she calls back with the number she’s already holding the fluid. Nobody told her to.

Swap your plan in every time and she finishes the year without finding out whether her own read holds up, and neither do you. She also stops bringing you plans, and every decision on the list becomes yours, made about patients you haven’t seen.

One call will be her outside a room, asking how long she’s supposed to listen before she says a time. Answer it as carefully as you’d answer a falling pressure.

End every call with the same question, including the ones about nausea: “Anybody on your list you haven’t called me about?” It takes ten seconds, and it’s the only question all night that lets her hand you a patient without a reason attached.

A phone that hasn’t rung since ten means a calm floor or an intern who has decided you’re expensive, and from the call room there’s no telling which. After a couple of quiet hours, go find her.

One of my first nights running the list, my intern was a former nurse from that floor. By eleven she had called me nine times.

The ninth was about acetaminophen. I told her she didn’t need me for that and hung up before she’d finished saying okay.

She didn’t call again.

At sign-out she read me the night in order. Fourth, between a potassium and a fall with no injury, was a man on a morphine pump after an open ventral hernia repair.

His nurse found him at half past four, hard to wake and breathing eight times a minute. The intern stopped the pump, gave naloxone, watched him come around, and wrote a good note.

Everything she did was right. His creatinine had doubled since the operation, though, and the naloxone was good for about an hour against morphine his kidneys weren’t clearing.

We walked in a little after six to find him asleep again, saturation in the high eighties. He spent a day in the unit on a naloxone drip and came back fine.

I hadn’t been annoyed with her at eleven. I was nervous about the list, and over the phone that sounded exactly like annoyance.

Keep your voice level on the ninth call of the night. She can’t hear the difference between scared and annoyed, and she’ll decide about the tenth call from what she heard.

Before the rotation ends she’ll call you at three about a woman she can’t explain. She’ll start with what’s bothering her and finish with what she wants to do.

There won’t be an also.

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What to Read Next: Post 33, “The Overnight Consult.” Every call in this one came from your own intern. The next one comes from downstairs, about a patient who isn’t on anybody’s list yet.