It’s 3 AM and I’m on call. I’m about to go home, but I’ve become addicted to Snood, up here in the surgery resident’s lounge. My pager went off just as I had willed myself to play ony one more game…

It was Nick, the intern on call. “Mr. Morris is having increased work of breathing,” he said. My heart jumps just a little bit. “I don’t hear any ronchi or rales, but he’s a little bit wheezy. I gave him a nebulizer treatment and he’s feeling better.” I relax a little. Nick continues with his clear presentation, “I checked an EKG and it’s unchanged and we just got a chest x-ray.” He’s on top of things, I think to myself.

At least Mr. Morris isn’t dying. Nick starts to run through a differential of what he thinks might be wrong, and I help him think through the options. “PE,” I hear Nick say. “Should we get a doppler?” I affirm my knowledge and hear myself tell Nick, “Well, we already have a doppler that shows bilateral clots in his lower legs. We put a filter in last week, and just today, he has become therapeutic on his coumadin. There’s not much we would do for him if he did throw a clot that we havn’t already done.”

I continue my logic…”If he is simply struggling with his COPD, you can give him one or two more nebulizer treatments as long as he’s not tachycardic.” Wait, I think to myself, he doesn’t have an AV node, his heart is paced. Could he be having an MI? CHF? I tell Nick, if the chest x-ray looks identical to the last one, then I think we’re done, you’ve treated him. If he looks wet, then I’d check cardiac enzymes, give him some lasix, morphine and nitroglycerin.

I’m proud of myself for thinking clearly at 3 AM. I’m thankful that Nick is a pretty smart intern and flattered that he called. He’s probably scared, but he’s doing everything right. That’s how you learn on call, is to get called to the bedside to see patients. My job is easy in comparison. Once Nick gathers all the facts, I have the leisure to think things through. “Thanks, I call you if I have any more questions,” he tells me. I like being an R2.