A couple of weeks ago I was on call in the ICU and I was called by a 2nd year resident. “Mr. Miller isn’t well and has desaturated repeatedly.”
How was I supposed to reply?
“Thank you for the information, good night.”
Obviously, the way this piece information was presented neither helped me, the patient or the poor guy on the other side of the phone.
When you wake up your boss during the middle of the night, you should be a little more prepared than someone, who calls 911.
So what can you do to make your boss happy at 3 AM in the morning. Let’s try these six steps:
1.Acknowledge: It’s OK to be afraid.
That shows you care and is a clear sign that you will be a good doc. Just put the fear aside for a second and think this over.
2.Remember: It is your goal to help the patient.
So try to focus on the problem you want to solve. Before you call your boss, gather as much information about the patient and the problem you are trying to solve. Don’t wake anybody up at night before you haven’t done your homework! (if you have time for that, of course)
So in this case the patient has dyspnea:
- Do a quick physical (Quick timeout: Don’t ever call anyone to look at a patient you haven’t examined , yet.)
- Look at the vital signs
- Lab values
- Blood gases
- X-ray
- ECG
3. Make up your mind, what is the problem here?
Come up with two or three differential diagnoses.
What has to be done next:
- Further diagnostics?
- Pleural tab?
- Diuretics?
- Non-invasive ventilation?
- Intubation?
4.Decision time:
Once you structured your thoughts and you have made up your mind, you have to decide whether to consult your boss.
How do we know whether to call him or not? That greatly depends on his personality. But when in doubt, I would always call him. And don’t worry, if you present the case, as written above, he will be content.
It is better to wake somebody up during the middle of the night than to be responsible for someone’s death.
5. When you call him: Have a clear purpose in mind.
What is your intended outcome of this telephone conversation? The goal must be one of the following:
- him answering a precise question
- him choosing from options you gave him regarding further work-up
- him deciding whether he wants to take a look himself.
He was treated with 10.000 units of heparin and the echocardiogram showed distension of the right heart.
Even though he has a history of colon cancer 7 years ago without metastasis, my approach would be to go ahead and treat him with rescue lysis therapy.
Would you agree with me on this , or would you like me to contact the cardiothoracic surgeon?”