My first night on call in the cardiac intensive care unit

So this morning, after surviving my first call night in the CCU, I was beginning to get giddy. I started to think about the relieved, victorious?, humor-packed entry I was going to write as soon as I got home. But then, as I was about to leave the hospital, I realized that the handbag that I had brought with me to the hospital to help me carry all my stuff was missing. I walked the halls for about hall an hour, a bit resigned to having misplaced it, but sure that I would find it eventually. After not finding it on any of the hospital floors I had visited, and almost ready to go home to deal with it later, I realized that not only did I have my wallet in that bag, but also my house and car keys. At this point, nearly 32 hours had rolled by since I had last slept (and only 4 hours that night because of the anxiety of starting call!), and the adrenaline rush that had kept me going through my call night had warn off. I crossed the halls frantically looking for my bag again - with the amazing ER nurses springing into action to look into every nook and cranny of the place - but finally had to admit to it being gone. Exhausted now, with all the emotions/stresses of the night catching up with me, I walked the two blocks to my friend's house and broke down the minute she opened the door. Half an hour later, I had a warm breakfast in my belly (the first food in nearly 20 hours), and - with the $100 my friend lent me - was meeting a locksmith in front of my house. I collapsed in bed 34 hours after pulling myself out of it the day before.

Now, after a 5 hour nap, I'm a bit more calm and rested, and can actually write a bit about my first call night in the CCU.

It had been an intense night. There were probably several moments throughout the night when intense doubt about my own capabilities and motivation overwhelmed me in a way I've never experienced since starting medical school. Probably the one thing that best sums up my experience is the moment this morning when -after being at the hospital for more than 27 hours- I realized I hadn't peed since I had left my house!

CCU is probably our busiest rotation, with many critically ill patients, and multiple new admissions and discharges every day. Despite trying my best to prepare myself the day before, I started the day off completely overwhelmed. I had 6 patients to pre-round on in the morning, and because I received them only the night before, I had not had a chance to catch up on their complicated histories. Furthermore, due to the new resident work hour restrictions (laws that prevent residents from working more than 80 hours a week), I was not allowed to enter the hospital until 6am. That meant that I had 90 minutes to gather relevant information about my patients, meet and examine them, understand their medical care and management, and write my notes before rounds. And I knew that I had to try to do that, because as soon as rounds ended, I would be admitting new patients and eventually cross-covering for the entire ICU list of 28.

So for morning pre-rounds, I did exactly what we had been taught not to do and what patients absolutely hate about staying in the hospital: I ran into their rooms, asked them a few quick questions, tried to cut them off as soon as they tried to make any conversation, and ran out about 2-3 minutes later, promising to come back and finish our discussion later (which, I never had a chance to do).

Rounds were embarrassing. All of our patients are, by default, cardiac patients, so at first glance, they all seem the same. I had just skimmed over the files of 6 of them and tried to catch up on their individual hospital courses, and within 10 minutes it was all a blur. Which one Ideally, I would have taken a deep breath and focused my mind before each presentation, but whenever I tried to, my mind would just go into a panicked blank. I was doing such an incredibly terrible job, that my stomach was cramping up.

The rest of the day and night, I was playing constant catch-up, constantly feeling as if I just needed that "one more thing" to completely overwhelm. My residents were great. I was covering 8 patients during the day, while he was covering me and 3 other interns and a total of 28 patients. For the night and evening, it was just me and a new resident, admitting patients, and covering for all 28 patients. Every time I stopped to write something or catch up on a bit of work, my pager would go off. Often, the questions/requests the nurses called me about were not simple things I could just answer, and I would watch my night slip by out of my grip with every new page.

I started to subconsciously label every encounter with a time value: if something was going to take less than two minute of my time, it was as if I had won the lottery. There was the patient I admitted who was transferred from an outside hospital at 9pm. He was brought with a paper chart of nearly 200 pages, which appeared to have been freshly printed and then dropped on the floor and restacked in completely random order. It took me nearly an hour just to go through his chart, and another hour to gather a history from his anxious family. During the night, while my resident was busy covering half of the patients I should have been able to cover, I was kept busy finishing my admissions, answering random pages, and responding to urgent calls about new onset delirium, chest pain (not a light matter in the cardiac intensive care unit), sudden onset of severe pain with abdominal distention, and an acute drug rash that burned, itched and covered my 91 year old patient's entire body. Between there were the calls for the agitated patients, the need for clarification of orders I had not written, etc. I had to control my impulse to complete a task or thought instead of jumping up to immediately return every page, or I would not get anything done.

...And then there was dictation. I have never before dictated in my life and the experience has always paralyzed me in fear. In our orientation, they had told us that we needed to dictate the admission note for each new patients, and also write one in the chart. They suggested that we put a skeleton note in the chart and add more details to the dictated note. Unfortunately, as became clear during my first attempt at dictating, the part of my brain that regurgitates information is quite separate from the part that actually thinks. And when I am tired and stressed, the part of my brain that thinks does not seem to connect well with the part that speaks. I stumbled, swore, and um'ed my way through the first dictation, forever thankful for the rewind button, trying desperately to calm down and think clearly. For my next notes, I wrote all the information in detail and mindlessly read off my notes as fast as I could.

There were a few really good things that happened as well. I never yelled at (or got yelled by) a nurse. I seemed to be able to hide my stress well from everyone but the residents. I was able to answer a page calmly, walk in to a sick patient's room and logically think through whatever crisis was going. I didn't hurt or kill anyone, and I even had a patient's family come up to me in the morning and thank me for spending the night taking care of their brother. Small things, I know, but after a night like that, one has to hold on to every silver lining.