Night call

At the University of Virginia, we use a night float system instead of a standard call schedule.  Depending on the level of training, each resident is scheduled for 2 or 3 weeks of nights per academic year.  The week starts on Friday with a 24 hour shift, with the incoming night resident starting at 7 AM, as for a normal day shift.  The resident is responsible for the night duties until 0700 the following morning.  The last 6 nights of the week start at 1730 and end at 0700 the following morning.  Thanks to the 24-hour shift at the beginning of the week, the outgoing night resident has the following Friday through Sunday off from clinical duties.

A Wednesday night

1730   The two night residents have reported to the “Big Board” for assignments.  I have been assigned a cardiac room.  Eric has been assigned to start one of the pediatric cases left over from the day.  I take over OR 3 where the case is a aortic root replacement.  The patient is still on cardiopulmonary bypass.  I receive report from Steven.  The patient is a Marfan’s patient who has had a previous aortic valve replacement.  After receiving report, I ensure that all of the medications are ready to take the patient off bypass.  I then check in with the attending in the room, Dr. Sanders, to confirm the plan.  

1800   The patient is ready to come off bypass.  We begin the long process of volume resuscitation and hemodynamic support.  This is the most tenuous period of the case as the patient’s physiology changes rapidly.  The patient underwent deep hypothermic circulatory arrest, so she will have a coagulopathy worse than normal cardiopulmonary bypass.   This will necessitate increased use of fresh frozen plasma, platelets and cryoprecipitate in the operating room.

1900    We are reaching the conclusion of the case.  The surgeons are happy with the surgical field, the patient appears to be clotting appropriately and we are beginning our closure.  I have called report to the post-operative ICU. 

1930   We arrive in the ICU.  One of the anesthesia intensivists, Dr. Groves, is the ICU attending for the night.  She is present in the ICU room as we discuss the hand-off of care with the ICU resident, fellow, attending, and RN. 

2000   We get a short break before an emergent exploratory laparotomy due to post-operative bleeding is posted.  Simultaneously, an emergent craniotomy has also been posted.  Eric has decided to take the craniotomy while I take the laparotomy.  Since we have 2 operating rooms active, the first call resident, Bob, is still in house.  We always have one more resident in the hospital than the number of active operating rooms.  The extra resident is necessary to hold the consult pager and be available for emergencies, “codes,” etc.

2030   Both emergent cases have arrived and are ready for transport to the operating room.  Just prior to induction for the laparotomy, there is an overhead page for a stat caesarean section.  Very quickly, Bob and Eric go the 8th floor to assist.  I quickly induce the anesthetic for my case, and our attending runs upstairs for the section. 

2045   My patient is quite sick and hemodynamically unstable.  Her hemoglobin prior to arrival in the operating room is 5.  I quickly placed a large introducer catheter into her internal jugular, and begin transfusing her packed red blood cells.  The surgeons begin their part of the case.

2200   We have transfused over 10 units of blood products.  The surgeons feel they have obtained adequate hemostasis and have started their closure.  I call report to the Surgical Intensive Care Unit. 
Meanwhile, both the craniotomy and emergency ceasarean section went well.  A potentially difficult airway in the pregnant patient was secured safely.  The baby was delivered quickly and was not in distress.  The craniotomy was also completed safely.

2300   All of the OR rooms are now finished.  With no rooms running, the first call resident, Bob, is able to go home.  During all of the cases, several preoperative assessments have piled up.  Eric and I start gathering information on the late postings.  We will see the patients in the morning.
Earlier in the evening, a liver transplant was posted to start at 0600.   Our plan will be to help the day team by placing all of the necessary central venous lines and arterial lines.

0600   The patient for the liver transplant has arrived.  We were fortunately able to grab some rest prior to this case.  We greet the patient at the front desk, explain our anesthetic plan and take her back to the operating room.  After inducing our anesthetic, we spend the next 45 minutes placing multiple lines. 0645   The weekend day coverage has arrived to take over the case.  After discussing the patient and transferring care, Eric and I leave to get some rest.

Josh Smith, CA3