On Call

Tonight I am on long call. I arrived at the hospital at 6:30 am this morning which requires me to leave home at 5:00 am. I will be on call through 3:00 - 4:00 pm tomorrow. All in all it is a 20 + hour shift. We have on call rooms where we can sleep at the the hospital. However taking care of the patients through the night takes priority over sleeping. When we are on call we get all new patients admitted to our service. We are responsible for anyone who comes into the hospital during the the time that we are on call. This is when we get new patients. 

You never know what you are going to get when you are on call. It could be a seizure, congestive heart failure, stroke, myocardial infarction, pulmonary embolism, COPD, pneumonia, etc. Sometimes you get a patient that has an unknown etiology and you have to try to figure it out. Often the patients will have multiple co-morbidities. When a patient gets admitted to our service my senior resident decides who is going to get the patient. My team is made up of 2 3rd year medical students, 1 4th year medical student, 2 interns and 1 senior resident. We take turns getting new patients. The senior resident will page me when it is my turn and give me a basic description.

For my 1st patient tonight the senior resident page me and when I returned the call she said; "you ready?" "this is a 66 year old male with a chief complaint of left lower extremity swelling who presented to the ER. He is in room 601." That is the info I get and I go from there to work the patient up and figure out what is going on. This patient had tripped and fallen about 2 1/2 weeks ago and noticed that he had some swelling near his groin. There was not much associated pain. He could walk fine. He did not want to mention it to his wife because he had a big hunting trip scheduled and he did not want her to not let him go. He went on the hunting trip which required a lot of driving and a lot of sitting waiting to shoot elk. Upon returning home he noticed that the swelling was still present, but he continued to wait hoping it would go away. He woke up this morning and noticed that the area was warm and the swelling had not resolved so he called his primary care physician who immediately instructed him to go to the hospital.

Even before I went to see this patient I had a basic diagnosis figured out. My basic thought was that the patient had either cellulitis (infection) or a deep vein thrombosis (DVT). Both can be very serious and both can result in death if not managed correctly. Upon seeing the patient I ordered a venous doppler ultrasound to see if a DVT had formed. Sure enough he had a massive DVT that most likely resulted from the fall he had over 2 weeks ago. This basically helped me rule out the cellulitis. I started the patient on lovenox which is an anticoagulant (blood thinner). I also had to adjust his other medications for his chronic conditions which include hypertension, diabetes, hyperlipidemia. Once I got the patient all worked up and "tucked in" I paged his primary care doctor and let him know what was going on. He was glad to hear that I had managed the patient correctly and he did not have anything to add or change. He will be in to see the patient in the morning. This is how it works.