Surviving Intern Year: Taking Call

One of the things that intimidated me the most about moving on to residency was the thought of taking “call.” Am I really expected to be awake and functional for 24+ hours in a row? How often will I have to be on call? Are there different types of call? Will I be able to sleep on my call shift?

First things first, figuring out what type of call you’ll be expected to cover. There are two main types “Home Call” and “In House Call” .

Home CallYou are allowed to go home after your standard work shift and take pages/calls at home. Usually you have home access to the EMR or the hospital allows for verbal orders so you can take care of new medications, changes in diet orders, reviewing labs etc from home. If taking home call you are still required to drive in to the hospital to evaluate a patient if there is an acute change and to see any new consults. Some benefits to being allowed to take home call are that in theory you can spend more time at home. It is possible if you leave work at 5pm you may not be called back in to the next morning at 5am. A downside to home call is that “post call” days are not factored into the schedule. Some days you may have no calls at all and other call days you may have to return to the hospital 3 times to see a consult and be kept awake all night responding to pages.  Another downside to home call you have to use your best judgment to use the information you receive over the phone to determine if a patient requires an in person evaluation. (When in doubt: GO SEE THE PATIENT)

In House Call: This is usually a 24 hour shift  which requires you to stay at the hospital for the entire duration of your shift. After your shift is completed you have a designated “post call” day where you are given time off prior to coming back to the hospital. Pros of this type of schedule is that when you’re off  work you’re really off, all your time spent at  home should be uninterrupted by work matters. Another benefit is if you have a “slow” night its possible to get a decent amount of sleep and that means you can spend your post call day doing something rather than resting/recovering from your shift. A downside to this schedule is long hours guaranteed away from home. If you have a spouse, children or pets, you know that it will likely be about 30 hours before you can see them again. Another potential negative is if you are a “black cloud” and have a super busy call shift, the last couple hours of the shift can be emotionally and physically draining. A busy call shift can also derail your sleep pattern for the remainder of the week as you are trying to catch up and make up for lost hours of sleep.

In my experience at  the military facilities I have rotated through, the general surgery service has a small patient volume. So when it comes to taking call, there aren’t enough patients or enough patient turnover to warrant having an in-house General Surgery team overnight. Additionally these hospitals don’t accept traumas, and there is only one OR on call team, which means we do home call when at my core site. When I rotate at other hospitals on busier services (Trauma, ICU, transplant) I’m expected to do in house call. Different services within the same hospital can have different expectations, but typically you are expected to be able to evaluate a patient within 30 minutes regardless of if you are doing home or in house call.

Regardless of which type of call you are expected to take, I strongly encourage all residents to make a “call survival kit”. Long hours in the hospital can be disorienting and demoralizing and having a few key items can drastically improve how well you feel at the end of a shift.

  1. Blanket. Hospitals are frigid places to be. There is a reason that there are blanket warmers and Bear Hugger machines to be found dispersed throughout the patient care areas. Typically hospital call rooms are bare bone versions of dorm rooms, with beds made up with just a flat and fitted sheet and a pillow. When you’re tired and just want to crawl into bed for a 2 hour “sleep” before meeting the team for AM rounds there is nothing worse than being buffeted by the relentless hospital AC. Sure you can seek out a spare blanket, but just make things easier on yourself and keep a thin blanket rolled up in your desk or locker. I take things a step further by having a sweatshirt and sweatpants to throw over my scrubs for an extra layer of warmth.
  2. Phone Charger/Power Bank. Most hospitals I have worked in are basically designed like a bomb shelter and phone service can be hard to find. With my phone constantly searching for signal, my battery runs down very quickly. Its hard to be on call when you don’t have a phone that is functional. Be sure to keep a phone charger handy to prevent going off the grid.
  3. Tooth Brush: for the good of yourself and the good of your patients please have a travel tooth brush and tooth paste available.
  4. Eye Drops/Glasses/Contact Case: props to you if you can wear contacts for longer than 12 hours without feeling like there is sandpaper under your eyelids. For the rest of us I recommend always having glasses available so you can give your eyeballs a break when you’re on your 23rd consult and you can barely see straight anymore.
  5. Change of socks & underwear: some times you just need to feel refreshed. Don’t underestimate a change of clothes to feel a little more human.
  6. Snacks: pretty self explanatory. While it is easy to fall into the habit of justifying poor food choices while on a busy shift, you will be much better off if you pack healthy and nutritious snacks (think nuts, veggies and hummus, fruit, etc.)
  7. H20: try to prioritize water earlier in your shift. I find its often late morning-afternoon that I get super busy and all of a sudden its 8pm and I haven’t had anything to drink other than coffee.
  8. Medications: if you take any prescription medications pack a couple of doses into a travel pill case to have on you in the event you have to stay in the hospital longer than anticipated. I also recommend having over the counter medication for aches/pains/headaches, acid reflux, and for cough/cold symptoms.
  9. Resources: There is nothing worse than being woken up when on call  and your brain isn’t awake enough to catch an abnormal lab, ask appropriate questions, or give a simple order. I try to document on my patient list during sign out anticipated problems (Nausea, low urine output, increased pain medication requirements), and that way I can formulate a plan ahead of time as to what my next step may be. When I started my intern year I had a small reference guide with common doses of medications and a “To-do” list depending on the patient’s complaint to help guide my decision making. Additionally I keep a notepad and paper right next to my phone so I can copy down all the information while I’m trying to process it.
  10. A Book: now you may think you want to use your free time to catch some sleep, but if you’re anything like me its hard to turn off your brain long enough to fall asleep when you’re always on edge waiting for the next call or consult. I have a non-medical book in my bag at all times so I can decompress and clear my mind.

Lastly, just relax. I was very intimidated by the thought of being on call because often times it can feel like the weight of the world falls on you. One of my first overnight shifts when I was the only resident on trauma services I responded to a rapid response on a post surgical patient who was hemorrhaging from his wound. I called my attending frantically while I was at bedside holding pressure on the wound thinking he would want to come evaluate this patient immediately. Instead he asked me what I planned to do. I told him I wanted to pack the wound tightly to provide compression, get stat labs, transfuse the patient if his hemoglobin was below 7 and monitor for hemodynamic instability. My attending agreed with my plan and hung up. It is a very daunting feeling when you realize you are the person in charge of making decisions. What if I didn’t convey how serious I thought the situation was? What if I’m missing something? What if he rapidly deteriorates? An hour later I got a phone call from my attending. He had been chart checking the patient and had seen the patient responded appropriately to the 1 unit of blood he had been transfused and his vitals had stabilized and told me ‘good job’. Ultimately at the end of the day, although you might physically be the only resident in the hospital or the only provider responding to a code, help is not far away. There is always someone you can call. Being on call and being put in these stressful situations is ultimately what allows you to grow and become confident in your clinical abilities as you progress through residency.


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