Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Monday, June 24, 2013

On Call 2: The Feel of Call

For those who didn't read my previous "On Call" post, this is a series of essays, or maybe chapters, that I wrote during and shortly after residency, with the plan, never realized, to publish them as some sort of book.

I wasn't sure what to post about today, so I thought I'd try another installation of On Call. This one is about what it's like to take call, rather than incidents that occurred during call. It's a little dated-notes were handwritten, for example. And bear in mind, it was written for a lay audience, so most people reading this won't need some of the included explication.

It's lighter than the previous chapter I posted, and it's a little long, but I hope people can still relate to it.

The Feel of Call

I’ve written a lot about what happens on call, but I haven’t mentioned much about what call feels like. It’s a different experience than a regular workday, and nothing is quite like it.
As a medical student, I sometimes had to stay very late, and I did some overnight shift work, but by coincidence, I only had to do overnight call twice, and both times I got to sleep most of the night.  At the time, I found it impossible to stay up all day and night.  And I worried about what I would do once I started residency, when I would have to stay awake.  I was afraid I would collapse into a blubbering heap somewhere around 3am.
But when I actually got there, something changed.  As a medical student, most of the time I just felt like an observer, with no real power to do anything, because I couldn’t order medications or tests even if I knew what to do.  So I never quite felt like “my” patients were really my responsibility.  But when I became a resident, suddenly, the responsibility was all mine, and even though it was scary, it was no longer impossible to stay awake.  It felt like my job, and no one else’s.  And in the morning, I felt like a hero.
And it didn’t feel like I expected it would.  I thought it would be like a horribly boring class, where you fight to keep your eyes open, or like my surgery rotation, where I would fall asleep during an operation, standing up, with one eye open, holding the retractors (this is called “waterskiing”), and alternate which eye was open in an attempt to appear awake.  
Instead, when I was on call, I would feel like I was working more and more slowly, and I sometimes couldn’t think of the next word in a sentence.  But it never felt like I would grind to a halt, just like I would keep going in that slow-motion way, and if I didn’t expect my normal standard of work, if I allowed myself to be weird and a little slow, I could keep going indefinitely.
The mindset also makes a difference.  If you start out looking for the first opportunity to lie down and get some sleep, you’re in for a very grumpy call, because you end up resenting every page and demand that’s made on you.  Most of my later calls were like this.  But if you start out with the assumption that you’re not going to sleep at all, you don’t really mind all the demands on your time-that’s what you’re there for-and if you do get some sleep, it feels like a bonus.
There are some things I do to get ready for call.  They started out as practical preparations, but eventually took on the feel and significance of a ritual.
On a weekday call, I’ll come to work in ordinary work clothes (I’m a psychiatrist, so I don’t normally wear a white coat).  I bring the following items with me to work: 

Set of scrubs
Extra pair of scrub pants
White coat
Crappy long sleeve t-shirt
Change of clothing for the next day
Two clean sets of underwear
Two extra pairs of socks
I also make sure to wear comfortable shoes.  

I keep what I refer to as my “Call Bag” at work.  It’s a medium sized makeup bag, pink, with elephants on it, which contains shampoo, soap, deodorant, a toothbrush, toothpaste, dental floss, and a comb.  I rarely sleep on call, but I do make an effort to shower, as early as possible, although I usually don’t get around to it until 6 AM. I can’t stand how grungy I feel after a night’s work, and showering gives me a bit of a boost-helpful if you haven’t slept.  It also lets me take a break from the demands of the night, although there’s always the worry that I’ll get paged in the middle of my shower.  To avoid this, I sometimes leave my pager outside the bathroom, so I won’t hear it.  Then I worry that I won’t hear it and I’ll forget to check it when I get out of the shower.  
The thing about call is, you can never really relax.  You could get paged for just about anything, at any time.  And psych patients do really weird things, like the guy who peeled off the sealing part of a ziploc bag and inserted it into his penis, where it got stuck (the nurse said, “You’ll need a flashlight, and a gentle touch”).  Or the mentally retarded woman who pushed a wadded up piece of paper into her ear. 
When you’re lucky enough to get some sleep, you keep waking up and wondering if there’s something wrong with your pager, and that’s why it hasn’t gone off.  Then you page yourself, just to be sure.  

When 5 PM rolls around, after my regular workday, I begin my ritual.  I go into my office, and change into scrubs, with the crappy long-sleeved shirt underneath.  I prefer my VA (Veterans Affairs) hospital scrubs, which are blue on one side (left-right), and green on the other.  It’s more cheerful than plain green or blue, like a harlequin.  And someone invariably asks me if I know my pants are two different colors.   
Incidentally, I don’t work at a VA hospital.  But I did my medical school neurology rotation in one, and I stole the scrubs from there.  This is what medical students do.  You get bragging rights for every pair of scrubs you steal.  And different hospitals have different color scrubs, so you end up with quite a collection, which you generously give away to all your non-medical friends, as if to say, “Oh, I don’t need those.  I’ve worked in so many hospitals, I have more than enough.  And I can always get more, because I’m a doctor, and you’re not.”
 I change my socks in a vain attempt to minimize the smelly feet effect.  It amazes me just how much my feet smell, even to me, by the end of a call.   I put my wallet in the back pocket of my scrub pants, and I clip my pager to the front of my pants.  Then I put on my white coat.
More than anything else, the white coat makes me feel like a doctor.  In medical school, you get a white jacket, a sort of Good Humor number, and this differentiates you from the real doctors.  You don’t get to wear a long white coat until you’ve graduated, and if you put one on before that, it feels illegal, like you’re impersonating a physician.
So when I put on my white coat, I’m accepting the mantle of a doctor’s responsibilities.  I look like a doctor, and I’m prepared to act like one.  But I tell myself secretly that I’m wearing my doctor costume.  I never really believe I’m up to the task.
The next thing I do is fill the pockets of my coat.  The upper pocket on the left side receives a 2x3 medication reference, and Maxwell’s handbook, which has stuff like normal lab values, advanced CPR protocol, and an eye chart. These kinds of books are referred to as the “peripheral brain”.  I clip my ID onto the outside of that pocket, and clip several pens-at least two-and a penlight, to the inside.  I need at least two pens, because sometimes I have to write something while the patient is signing a legal document, and it saves time not to have to wait for him to finish.  Also, I don’t like using the same pen as the patients, who often haven’t bathed in quite a while.  A third pen is helpful, in case one of the others runs out of ink.  You write a lot on call.
The lower right hand pocket gets my phone, and the lower left-hand pocket gets my keys, a bunch of progress note paper (the kind that goes in medical charts) folded lengthwise, a reflex hammer, the Sanford Guide to infectious disease treatment, which I never use, but which no good resident should be without, and my psych card.  These last two are also part of my peripheral brain.  I don’t really need the psych card, which is a laminated card with information pertinent to psychiatry.  I pretty much know everything that’s on it.  The only use it has for me is at 3 AM, to focus me when I can’t remember what comes next in a Mental Status Exam, which is a kind of physical exam of the mind.  It includes such information as the patient’s mood, whether she is suicidal or hallucinating, and how clear her thinking is. 
The last thing I do in my ritual is drape a stethoscope around my neck, and assume my on-call posture.  I take a deep breath, let it out, and slump under the weight of the stethoscope, everything that’s in the white coat, and the planet of responsibility on my shoulders. I shuffle out of the room, arms dangling loosely at my sides, hound dog expression on my face, head bowed, dreading the night ahead of me.

As a first year resident, I would interview and examine all the patients admitted to the hospital on my call. This means I would ask patients all about what’s bothering them, including their symptoms, medical history, medications, allergies, substance use, and a bunch of other stuff, followed by a physical examination. Once that’s done, I would  have to write up the results. This is called an H&P, or History and Physical Examination. 
My hospital has a form for most of this information, and eventually, you develop a method for getting through it quickly. For example, where the form asks about the patient’s tympanic membranes, or eardrums, I write, “Not visualized”, which means I didn’t look. Where the form asks about the rectal examination, I write, “Patient refused”, which means I didn’t offer. After all, if I came to the hospital because I was depressed I’d refuse to have someone stick their finger up my ass.
There are also a lot of abbreviations. Lungs are CTA or Clear to Auscultation. Hearts have RRR or Regular Rate and Rhythm. Eyes are PERRLA, or Pupils Equal and Responsive, Reactive to Light and Accommodation.
Psychiatric patients experience SI, HI, and AH, or Suicidal Ideation, Homicidal Ideation, and Auditory Hallucinations.
“58 ♀ h/o HTN, DM2, NAD, c/o SOB x2d” means “A 58 year old woman with a history of high blood pressure and type 2 diabetes, in no acute distress, complains of shortness of breath for 2 days.”
The need to record so much information in so little time is one reason doctors have such lousy handwriting. Mine was always bad. The left-handed boys in my second grade class used to make fun of my handwriting. But it got worse in medical school, and by the middle of my PGY-1 year, even I had trouble reading it. (By the end of my first month of residency, I also had a prominent callous on my right middle finger, which was not present before my residency). One shortcut I resort to is leaving off the ends of words. For example, the word, “presenting” would trail off into “presen-----. I would just think, “Eh, they know what I mean.” 
The first part of an H&P is the Chief Complaint (CC). This is the patient’s stated reason for coming to the hospital. You learn pretty quickly how to elicit this information. Or, more accurately, you learn how not to ask for it. 
You don’t say, “What brought you to the hospital?” because the answer, very often, is, “An ambulance”, or, “My brother-in-law”.
You don’t say, “Why are you here?” because the patient will either feel attacked, or have flashbacks to Philosophy 101.
Instead you say, “What happened that made you decide to come to the hospital?” At 3AM, this doesn’t flow so smoothly.
Usually you end up summarizing what the patient says. For instance, “I broke up with my boyfriend. We dated for 3 years. And we thought about living together, but it never quite worked out. He’s a great guy, but it just wasn’t right. So since then, oh, that was 3 days ago, or was it 4, no, it was 3, because I remember the Sopranos was on that night, I’ve been sleeping a lot, and having trouble getting out of the house. I don’t have that many friends anyway, but now I don’t want to talk to them, or I stay on the phone with them too long. What was the question again?” is recorded as, “CC: Depressed Mood s/p B/U with BF”, or “Chief Complaint: Depressed mood status post breakup with boyfriend”. 
You want to find out how the patient is sleeping. To do so, you never, ever, ask, “How have you been sleeping?” because this will get you a 10 minute response about how the patient had sleep problems as a kid, and a year ago he had problems but they got better, and his uncle Fred has sleep apnea and is hooked up to a machine when he goes to bed.
Instead, you ask, “How many hours do you sleep each night?” Even this is time-consuming territory, because the patient will proceed to tell you how many hours he slept as a kid, and a year ago, and fewer hours than uncle Fred, who’s always tired in the mornings. You need to get really specific, like, “About how many hours have you been sleeping each night in the last 2 weeks?” This can also elicit a lengthy reply, but it’s the best you can do.
Another thing that’s time consuming is that many patients, at least the ones who aren’t “frequent flyers” in the hospital, think that the admission interview is a kind of psychoanalytic psychotherapy. They want to tell you their dreams and all about their childhoods, and how they have low self esteem, and that their depression is anger turned inwards. 
This kind of information is vastly important when you’re seeing a patient twice a week for psychotherapy. But for a patient you’re only going to see this once, it’s a useless waste of your time, and you really don’t give a shit.

In fact, the whole attitude you develop towards call, as a resident, has to do with the conflicting goals of call. The hospital’s goal is to get you to do as much work as possible. Your residency program’s goal is to get you to learn the things you need to be a competent doctor. And your goal is to do as little work, and get as much sleep, as possible. Yes, you want to learn things, and yes, you understand that you’re a cash cow, but you’re also human, and you have basic needs, like sleep.

As a second and third year resident, I would page the first-year, let him or her know I was available and not to hesitate to page me, because I’d rather be woken up and know what’s going on, than not know.  I started doing this after a well meaning first-year resident let me sleep all night while he tried to manage a patient he didn’t realize was in withdrawal delirium, and who subsequently died as a result.  That was the last time I slept on call.  
I would also let the first-year know that if I appended my pager ID number to a page I sent her, it meant I just wanted to talk to her.  But if she simply got a 4614-the Psych ER extension-it meant there was an admission.  And I would remind her that I sometimes forget my own rule in the middle of the night and not to count on it.
When I get the chance, I take myself out to dinner, to the local diner.  The food is lousy, but it’s close by, and they know me by now.  I read while I eat.  Nothing professional.  I’m much too resentful for that.  Just fiction that I have on my phone.  I also read whenever I have some down time.  Over the course of all my calls, I got through The Scarlet Pimpernel, Tartuffe, Wuthering Heights, Tom Jones, Elektra, and parts of The Wind in the Willows, Peter Pan, and The Origin of Species. It’s not that I had a lot of down time. It’s that I took a lot of call.
By the time midnight rolls around, I can’t stand the way my feet smell.  By 4 AM, I can’t stand the way the rest of me smells.  I don’t go to the call room until it’s light out, because that involves crossing a dark, deserted street.  For a while, there was a security guard at the door who would keep an eye on you as you crossed, but then the hospital decided it would be cheaper to close that entrance during the night, and bye-bye security guard.  
 When I finally get to the call room, which is an apartment owned by the hospital, all I want to do is get cleaned up, but I check in all the rooms and closets to make sure there’s no one lurking. Lots of people have access to the call room, and many forget to lock the door on their way out.
And sometimes there are people there, sleeping or showering.  Mostly from Orthopedics.  And one  mysterious resident has filled the closets with enough stuff to live there for a month.  
I grab two towels from the closet and hope they’re clean.  I also grab a flat sheet, which will substitute for a robe.  I turn on the heat in one of the rooms, so I won’t freeze when I get out of the shower.  Then I take my disgusting, ugly, and uncomfortable flip-flops out of the closet, where I will leave them for posterity when I become call-free.  I leave my clothes in the room, shut the door, and step into the bathroom.  
This room has not been cleaned since I’ve been a resident.  The hospital’s housekeeping is supposed to clean it, but they don’t.  I know they don’t, because there’s a piece of something that strikingly resembles a large booger on the cold water tap, and each time I’m there, while I avoid touching it, I check to see if it’s still there.  And it always is.  I don’t remove it myself because I’ll be damned if I’m gonna clean the call room, and also because it’s evidence of the continued filth.  The floor also tends to be wet, and I offer a brief prayer to Athena that it isn’t urine.
Because it’s dangerous to walk to the call-room in the middle of the night, some of the residents, myself included, have taken to sleeping, or at least resting, in one of the residents’ offices on the inpatient units.  Several of these rooms are carpeted, so it’s not too uncomfortable to sleep on the floor.  I leave a sleeping bag in one of these offices, as does another resident from my year, and we have a deal whereby each uses the other’s rolled up bag as a pillow.
Some time toward the end of my PGY-2 year, I had to stop this practice.  One night, I got to lie down for 45 minutes or so.  Despite my exhaustion, I find it difficult to sleep on call, even when I have the opportunity, because I’m so keyed up, and it takes me something like 30 or 40 minutes just to doze off.  So I had just fallen asleep when I got paged-not an unusual event.  I got up and realized I was itching all over.  I looked around to see if I could identify lice, or something, then I thought better of it and got the hell out of there.  I abandoned my sleeping bag, and only retrieved it when I could manage to get it at the end of one day, and rush it home at arm’s length to toss in the laundry.
After that night, I tried lying down on the desk in the room once or twice, and then gave it up.  Ultimately, when I had a little down time, I would go to another resident office on that floor, which has no carpeting, and a desk that’s actually a ledge attached to the wall, so forget about lying on it.  I would end up sitting back on one of the two desk chairs in that office, and putting my feet up on the other.  This was a problem because both chairs were on wheels, and to prevent them from slipping all over the place, I had to lean up against one of the walls and kind of angle my head towards the desk.  Believe it or not, once or twice I managed to doze off in this position, to which I attribute my now chronic neck pain.  But at least I didn’t itch.
Generally, even when I got to rest for a little while, I’d get paged down to the ER for the 4 AM Xanax run, and that would be the end of my break.  But I absolutely insisted on brushing my teeth before I went down there.  I would walk to the nurses’ station with my “call bag”, shivering, and I would be so exhausted I couldn’t even speak.  But I didn’t want to be rude, because you have to be nice to the nurses.  They can make your life very easy, if they like you.  And if they don’t, you’re in serious trouble.  They must have liked me, though, because my last 2 or 3 calls, they let me use the patients’ shower, so I didn’t have to schlep to the call room.  So I would nod at the nurses, who would giggle and offer me coffee.
Early on, I drank a lot of coffee and Coke on call, until I realized the caffeine didn’t keep me awake, it just made me jittery, so I stopped.  I did eat very strangely, though.  I rewarded myself with Yodels, which I would be ashamed to eat under any other circumstance.  And I would get hungry during the night, but when I tried to eat, I just felt queasy, and my abdomen hurt.  I could never figure out if I was actually more gassy than usual on call, or if I was always that way, but I just didn’t realize it because I was usually asleep when it happened.  
Food is generally available around the hospital.  Doughnuts are ubiquitous, and ER food is up for grabs, if you can stomach stale tuna sandwiches.  Sometimes there are holiday or birthday parties in the ER, where people do shift work, and then there will be all kinds of interesting dishes from different cultures, laid out attractively on the X-ray table.  And one of the assistants on the psych unit makes extra money by selling his wife’s Rotis, which are really good.
The most important foodstuff, though, is water.  You get dehydrated on call.  I think it’s because you’re expending a lot more energy than you usually do during the night, and you’re talking a lot.  No matter how I tried, though, I never seemed to be able to drink enough.
In the morning, or what counts as morning for people who haven’t been up all night, after my shower, I would change into clean underwear, shirt, and scrub pants, but I would wear my grungy scrub shirt on top of my clean one, so no one would dare think I wasn’t on call and ask me to do extra work.  I would also change my socks, again, and my feet would still smell.   
Then I would go to take care of whatever I needed to do before I left for the day.  You were supposed to get your regular work done and be out of the hospital by 11AM-this was the law at the time in New York, and is now throughout the country. 
There’s an art to setting yourself up to leave by 11AM (which often didn’t happen).  You have to see your patients, and on some days, write notes before you go. But the last thing you want to do is get stuck in a prolonged conversation with a psychotic patient. In order to prevent this, I would go into my patients’ rooms around 6 am, whisper to them that I was sorry to wake them, but I’d be leaving for the day, and I just wanted to check on them before I left. I figured that made me sound concerned, rather than in a rush to get the hell out of there. 
If I was lucky, they didn’t wake up, in which case, my note would begin with, “Pt ∅ c/o,” which means, “The patient has no complaints.” If they did wake up, my note would begin, “Pt. c/o feeling sleepy.”
I needed to get out of the hospital post-call. It’s not that I was so tired I couldn’t function. I knew I could. It’s that I just couldn’t stand being there anymore, and if I stayed, I was so irritable I’d end up screaming at someone.
Because call makes you irritable. Even if you sleep, you’ve still been subject to countless demands for the past 27 hours. And it makes you weird in other ways, too.
Sleep deprivation is actually a treatment for depression, and when you’re post-call, you understand why. You’re irritable, but you’re also giggly and silly. You sit at rounds in the morning, and you’re either laughing or snarling. I had a hard time containing my laughter reading my own admission notes, like the one about the paranoid man who was admitted to the hospital carrying a duffel bag that contained 6 enemas, a comb, and nothing else. Or the one about the man who was admitted for calling his neurologist at home and asking for a pair of the neurologist’s underwear.
You also get clumsy post-call. You drop things, and then you can’t stop laughing about it. And you talk too quickly and too much. This is called rapid, pressured speech, and is typical of people who are manic. When you’re post-call, you can empathize.
And your appetite is weird. You’re hungry, but when you try to eat something, you feel queasy. I once got an egg and cheese sandwich with home fries inside it from the fabulous deli around the corner. It looked great. Tasted great, too, but I could only manage one bite.
After my very first call as a PGY-1, I remember feeling so proud of myself for surviving it. I left the hospital around 1pm (I hadn’t yet mastered the art of the post-call escape), and I walked through the park across the street. It was a beautiful summer day, and it was during New York City’s Cow Parade, which was an exhibit of variously painted cow sculptures placed all around the city. There happened to be two in the park, one staring right at me as I left. I looked at it and thought, “If the cow talks to me, I probably shouldn’t be doing this.” But it didn’t.

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