4 AM

In light of my recent post outlining my thoughts on the "work above all else" culture of medicine, I thought I would take you through the stages of a typical call night. Given the new work hour rules, this could mean different things to different people. What I will describe is the traditional 30 hour call that has long been a part of medical training (now 28 hour call for 2nd and 3rd year residents).

The morning of your call day is spent just like every other day. You pre round and then round formally on all your team's patients. If you are the intern, you will likely actually pay attention during all of rounds that day. On the traditional medicine team, each intern is responsible for half the team with the upper level resident overseeing everyone. You can imagine that it is not uncommon as an intern to enter a transcendental state where your body remains still but your mind is 2 continents away when you arrive at a patient's room that is not yours. A call day changes this because after everyone leaves that evening, you will be managing the patient through the night. Best to actually have some idea of what is going on if the nurses are going to page you when a patient starts circling the drain.

Next phase is lunch and then getting work done in the afternoon. Again, this is not much different than ordinary except you are likely to start admitting new patients. If your team is high functioning and generally humane, the non call members of the team will take the first few admits since you have to stay all night. If you have made enemies amongst your team or work with people looking to make you their enemy, then its time to pony up and take your punishment. Trying to admit new patients while discharging others and getting all your other work done is not fun, but we have all done it. Having a really rough afternoon in this regard can mean one of two things. You have either already exhausted the sick population around your hospital, or it is the tip of the iceberg that is about to sink your ship.

This brings us to the night portion of your call. For new interns, this is the part known as "I'm so scared I crapped my pants." For the rest, this is "another night stuck in this stupid place." You will know if that precious commodity known as sleep will be enjoyed by midnight. Still working at midnight equals no sleep. Caught up by midnight equals possible to catch a few hours. This rule of midnight is based on my experience and is nearly flawless.

Next up on your schedule is the dreaded hour known as 4 AM. This is rock bottom if the rule of midnight has stated that you are still awake and working. Though tired at other portions of your 30 (so sorry, 28) hour call, this is where you will feel physically and mentally beat down to the max. Personally, 4 AM is usually associated with a wave of nausea, inability to sit more than one minute without my eyelids drooping, and deep desire to end anyone's life that stands between me and the closest bed. This is where the men are separated from the boys. Many a med student's career has crashed and burned at 4 AM as they have totally lost it and submitted to the weariness. I've had multiple med students downright refuse to do work at this hour. Some have even just gone home without even asking, never to show up again. There is nothing glamorous about making it through this phase of the guantlet. There is only survival.

If indeed you do have the mental fortitude to survive, then the hour of 5AM is when the glow of hope appears on the horizon. With only one hour until everyone else arrives, you can now begin to effortlessly push away work with the time old adage of "I think that decision is best made by the primary team." Nurses know this phrase well. They also know that all decisions except for those that are emergent will be pushed off until 6AM once that phrase appears and the hospital grinds to a screeching halt. For the resident, it is now time to grab whatever catnap possible, round on your patients, and get the heck out of there. One more 4 AM between you and freedom (aka the end of residency) is now gone.