Saturday, June 23, 2012

On Call: Memories

   Every now and then I like to write about some of my memories of my medical training and lifelong career. And one of the most memorable parts of both that training and work life is the on call duty. There is nothing quite like being on overnight call duty. The nature of that service changes as the doctor's life advances.
   My first memories of being on call over night arise from my medical school years. Medical students usually don't take overnight call until at least junior year and mostly it is entirely in the senior year clerk ships. Of course the junior student is entirely in a learning phase. He/she is there to participate in the care of a patient from the very beginning of that patient's admission and to learn from it, but the student is totally supervised by first an intern and above that a resident and above that an attending. Therefore, the student is not responsible for major treatment decisions, but is responsible for the first history and physical for that patient and then for various basic procedures such as starting IVs or putting down nasogastric tubes and such.
   I have a very strong memory of my on call nights during an obstetrics clerkship at St. Joseph's hospital here in Milwaukee when I was a senior medical student. We were on call every other night -- that is 24 hours on and then 24 hours off for the one month rotation. This schedule was hard and often during the night hours, if we had no women in active labor, the nurses would let us take one of the empty labor rooms and sleep during the night. There was only one problem. One of the very active staff obstetricians at St Joe's Hospital was Dr. Jack Klieger. He practiced there for probably 40+ years and had a huge patient base. He was a stickler when it came to educating the students. He felt that if you were on call, you were on call. You should not be sleeping. If you didn't have any women in active labor to follow, you should be reading about obstetrics or studying. So when one of Dr. Klieger's patients would come in and near delivery so that Dr Klieger was expected in the department to perform the delivery, the nurses would come and wake us up and give us a little time to make ourselves presentable (Dr. Klieger expected  a white short jacket and dark slacks or skirt,  with everything pressed and crisp, etc). I will say though that if you had a patient with Dr. Klieger, he was an excellent if demanding teacher and you learned a lot, often getting to help with if not actually do the deliveries toward the end of your rotation.  At the end of your 24 hours on that rotation, you went home and had something to eat, maybe put a load of laundry in, and then collapsed into bed.
     I remember that at Milwaukee County General Hospital there were no on call rooms for women medical students and I think there was even a shortage for women interns and residents. There were fewer women in medical school in those days and not all locations provided for their women students. You had to figure out where you might be able to catch some shut eye if there was any chance to do this during the night. Sometimes you could find an empty patient room and the nurses were always willing to let you use it. We didn't have beepers then so you had to let the operators know where you would be and then try to sleep under those circumstances. Actually you were so sleep deprived that usually you could fall asleep almost anywhere.
      One night I was on call at the VA hospital during a rotation there. The senior student got called first for problems on some of the non medical and non surgical floors, such as the psych floor, or the rehab unit floor. The senior was expected to go and assess the situation and then determine if any of the regular medical interns or surgical interns needed to be called to see the patient and if it was serious enough to transfer them to one of the more active care units. I recall one time getting called to the psych unit by the nurses there. I don't even remember the reason for the call -- it was a rather trivial problem that I was able to handle easily. But I will never forget entering that locked unit. It is in the middle of the night and to save money a lot of the lights in these unused corridors are turned off and just emergency lighting shines along the long halls. This psych unit was a locked unit so I had to hit a buzzer and get buzzed in (ie someone somewhere way off down the hall and around the corner would hit a button and the door would unlatch.) As I went through the door and entered the long dark hall, not knowing exactly which way to go to bet to the nurse's station, a deep voice from behind me said, "Well, hello sweetie!" and then some expletive descriptive words were applied to me. A man sat on the floor, just out of reach of the automatic door. He appeared a bit unkempt and wanted to continue his rather inappropriate commentary. I just hurried off down the hall. There were other patients awake along the corridor, but at least the comments I got as I went further into this ward were more what I was used to: "Hey, doc. How you doin' tonight?" Taking care of the vets at the VA was always enjoyable for me. In general they were great guys, very grateful for anything you could do for them. Many of them had been raised in a Wisconsin rural setting, and were even farmers after their return from WWII. As a group they did not know that I was not yet a doctor. So I received all of the respect and admiration that a doctor would receive. On top of that they thought it was great that a woman was becoming a doctor and they paid me even more respect. I remember one saying, "I want you to take care of me, Doc. I figure if you're here, and being a woman and all, you must be a very good doctor."  This particular on call encounter on the psych ward fortunately was an aberration.
     I took my internship and residency at Mount Sinai Hospital in Milwaukee, where I had served some clerk ships as a senior. My husband had taken a job in Milwaukee, so I was limited to this city for my training. The only other medical internship and residence was out at Milwaukee County Hospital and I knew that that was a tough residency. On many of the services, the call of every other night. Since my husband is 8 years older than me, I knew that we would plan to start our family during my training. How could I possibly be engaged in a tough residency with frequent call and have and raise children. So I made a choice. I knew that the Mount Sinai residency was less powerful but it had much less frequent call, every third night and sometimes every 4th night. So I made the choice -- less powerful residency but easier life. I was fortunate that many of the attending staff at Sinai knew me from when I did my senior clerk ships there. Therefore, they were comfortable with letting me take care of the patients, writing orders and making many of the treatment decisions. But there was also time during the day to read and study. I learned well enough to pass my Internal Medicine Boards the first time, whereas many of my friends out at County Hospital didn't pass their boards because they never had time to study and broaden their knowledge to be able to correctly answer the sometimes esoteric board questions.
      On call at Sinai was typical of on call duty at most hospitals. Our call rooms were on the 6th floor of the old building end of the hospital They actually were three rooms at the end of the hall of the Psych ward. Now this psych ward was not like that which I described at the VA hospital. These psych patients were quiet and well behaved. The ward was not a locked ward. And they slept during the wee hours of the morning. I can still remember be sound asleep and that phone ringing. The hospital operator would be on the other end. If the call was not extremely urgent, she would gently try to bring me awake. Even a young person, as I was then, being suddenly awakened from a sound sleep would likely be a bit discombobulated at first. The kind operator knew this and would talk me through it. She also didn't want me to just turn over and go back to sleep which was a real danger. If the call was a Code Blue, however, there was no time for such ministrations by the operator. She would just say, "Code, doctor, in the ICU. You got it? Go!" I can remember running down those stairs to the ICU thinking and running through code procedures in my head on the way. Running a code was one of the more demanding things that we did as house staff. That separated the women from the girls and the men from the boys. I had a very good relationship with the ICU nurses who did these types of procedures regularly. So they were often a great help. They knew the protocol inside and outside and often had the next medication ready to go before I even thought to ask for it. Looking back, those were times when I most felt like a true doctor, even during my training.
     Recalling these time, puts me in mind of one of my fellow residents at Mount Sinai. That was Dr. George Levisman. He was young Jewish man from Argentina, a quiet man, who stayed on at Mount Sinai for a cardiology fellowship. I regarded it very fortunate if he was in the hospital on call when I was called for an emergency. He was the most unflappable doctor I have ever worked with. The patient could be crashing in the worst way, and he just proceeded in a soft voice, directing the emergent situation like a master. He had a quiet little sense of humor during regular work hours that was so refreshing. I miss George very much. He went to California, completed his fellowship, and worked out of Cedar Sinai in Beverly Hills. Unfortunately he developed color cancer and died at a very young age. It is interesting that writing these memories called him back to my mind. What a great guy!
     After my training, I immediately entered practice with the Milwaukee Medical Clinic in Milwaukee, WI where I practiced Internal Medicine for 34 years. On call comes into play during our practice years as well. We had a call rotation for the weekends. During that time I would be covering for my partner internist's patients if they had emergencies. Some of this duty involved answering patient's phone calls. Other duties involved admitting people who had come to the emergency room and whose doctor I was covering for. Then I would be responsible for examining them, forming a diagnosis (though the emergency room physician had often already figured out was going on,) and then beginning treatment and monitoring the patient for how the treatment was helping. Sometimes I would have to call in specialists to contribute to the treatment. On Sunday I would make rounds on my partners' patients who were already in the hospital as well. And sometimes I would arrange to see patients who called that were sick, either at the clinic if it was open, or I would meet them in the emergency room and take care of them, prescribe antibiotics for their infection or whatever was required.
     During these early years, perhaps the worst annoyances of call were the patient phone calls. Sometimes they could be quite ridiculous. The notorious example was the one where it is 2:30 in the morning: "Hello, this is Doctor Smith calling you back."
     "Doctor, I can't sleep."
     I usually felt like saying, "Yuh, well now I can't either." But I didn't say that. I would talk to them a little bit and try to find out what was going on that led to this phone call in the middle of the night.
     Often patient's thought that we were just sitting somewhere waiting for their phone call. They had no idea that we were asleep ourselves and that we had to work the taking care of other patients in the office the day of our night on call and the next day. This would result in ridiculous calls in the middle of the night, to try to make an appointment the next day, or to cancel an appointment. Well, you can just use your imagination knowing what you know about people. Needless, to say being on call could be very annoying dealing with some of the requests intermixed with taking care of very sick patients at the hospital.
     As the years went by during my practice, on call improved considerably. We hired a cadre of phone nurses who worked in shifts to cover a lot of these nuisance phone calls. That meant that when we were awakened it was usually for a significant problem. Then we arranged call schedules where we covered for each other even during the week. And on weekends, we divided the days up so that our exposure was only for one 24 hours period of time, then someone else came on duty.
    Toward the end of my practice years two things happened that seemed to balance each other out. First, as I grew older, if I was awakened during the night by a phone call or had to go in to admit a patient, I often found it difficult to go back to sleep when I was back in bed, or back home. This meant that most nights on call I would lose much of the night of sleep even if not working the whole time. Also my husband worried about me if I had to drive into the hospital in the middle of the night. The neighborhood around the hospital was changing and he feared that I might run into difficulty either on the way, or in the parking lot at the hospital. Also sometimes the winter weather made the roads difficult to maneuver and he worried about me. Therefore during my last years in practice, sometimes he would get up and drive me into the hospital and wait for me. Wasn't that a great thing to do? But during those last years, hospital practice changed. We had a hospitalist there on call, and they would take the admission, work it up and start treatment and report back to us at home. So there were many times that we did not have to go in during the night and we could take over the patient's care in the morning. All of these things began to make on call duty easier. And it was a good thing, because I was getting older and handling it less well.
     For any aspiring doctors out there, I would say that most specialties usually still require some off hours work, some more than others. Patients do not get sick by the workday clock. So almost all doctors will need to be available and to serve on call times. But there is some special feelings about being there for your patient when they are most in need of you. It is one of the great rewards of a medical practice. It just is not easy, that is all. 

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