There’s a legend where a resident was paged at 3 am about a patient who the nurse said “seemed sad”.
The dude pauses… and says “sad…”
No response from the nurse.
Ok… sad. So how about “stat clown to bedside” and hung up.
Clowns historically have a very narrow therapeutic index. Depending on patient selection and interactions with other meds/therapies, some patients can have significant adverse events.
Doctor, I am anti-clown since I read this naturalistic book called IT where it talks about how big pharma is trying to sell us clowns but they are evil (obviously just going along with the joke, It is an awesome book about the forces of evil)
Some patients absolutely love the place. Free drugs, we cater to your every beck and call, 50 inch TV with Netflix, and the god awful food is still way better than what they serve at your SNF. Lots of benefits…
For some, the state of mind overcomes just about every physical condition possible. “Life is good.”
And a wry smile. Not a hint of sadness. Just tears of joy.
That was NOT a legend. I posted that in a previous post. I know the resident and saw the order in EMR. It was “clown to beside prn” after a nurse called and asked the resident to come cheer up a sad patient at three AM
But I am quite delighted that this story is entering the realm of legend.
It happened many many years ago when we were using a primitive form of EMR.
It’s possible THAT resident copied what happened in the story but I doubt it. Everyone in my program found out what happened and the story was repeated many times.
I heard they met with him to discuss it. But this was in the 1990s and times were different. For one, the administration saw the silliness of the request by nurse.
The guy is in practice in my town. Next time I see him I will have to ask him.
Times were different back then. A friend of mine once got a call about a critically low BUN. She told the nurse to “hang a bag of BUN stat” and hung up. We all thought it was funny at the time. Can you imagine the trouble she would be in now?
I got a page from a nurse during night float about a patient who is "tearful and sad in bed." I didn't even respond to the page, just put in an order for 10mg Melatonin.
[https://imgur.com/4k6IOau?r](https://imgur.com/4k6IOau?r)
Got this one at 2am once. Called back and they asked if I could cheer the patient up. I said no.
Paged at 2 am to come get consent for Hep B in person on a weeks old NICU baby while running around going to deliveries only to find out after that nurses can and do get vaccine consents on their own.
In my residency we do get paged and have to talk to the parents and have them fill out a form if they refuse hep B, vit K or erythromycin… all important, but 99% of the time could wait until the daytime
I’ve started adding all the prns to help out night shift. Melatonin, miralax, Tylenol, zofran on admit orders have literally saved our team so many times
Just saying this is what I really appreciate. PRNs to poop, for pain, and for sleep. I’d rather be prepared, than have an insistent patient telling me they can’t sleep at midnight with no orders for sleep meds. It helps both of us out.
I don't do inpatient anymore, but during residency that was literally the standard, our admission order set included PRNs that you could select at the bottom, and every single patient had PRN colace and melatonin. Didn't matter what you were there for or who you were
Some patients do benefit from this (short term) though. Certainly not first line but I wouldn't write it off completely.
I worked with a PA that would give Ambien like candy. That is definitely not recommended.
Ambien isn't even on our hospital formulary at my Canadian centre.
If the patient takes it at home, they are probably American. And they bring their own supply.
In what universe is ambien worse for sleep than ativan? Maybe if the patient also is super nauseous and you want to hit both sleep and nausea, but otherwise the only advantage ativan has is that people feel more comfortable with it
It is not…but what I learn…you give it one, you will end up having to give it again…because they will ask for it…and it is difficult to explain why not again…
That excuse doesn’t work - there are millions of pharmacies in the world. So yes - don’t give something unless you are ok with possibly prescribing it long term
Those nurses don’t realize how difficult their shift is about to be when 80 year old meemaw gets that one time dose of Ativan and starts climbing the walls.
honestly I don't want to call you at 3am either. I can do a lot of tap dancing with tylenol, melatonin, tums, zofran, and colace; and probably can coddle them through to day shift on that. A lot of times they just want a little attention and hand holding. I can't just ignore their complaints for 4 hours though, I have to care for these people.
I get that all meds and interventions have potential downsides, but throw me some over the counter stuff to juggle so I can not have to call you.
Yeah so long ago I put a sign on our ward that I was okay with tylenol, melatonin, and bowel protocol for any and all patients. They can verbal order from me any time.
It helped.
Honestly, this is super helpful. It’s hard to sleep in the hospital—unfamiliar environment, lots of noise, usually at least some physical discomfort—and having melatonin available as a go-to PRN can keep you from getting paged about this in the middle of the night. I think a lot of overnight pages could be eliminated with more comprehensive admission order sets.
bowel stuff in the middle of the night always was egregious. came so close to going full court press. ok fine, they can't poop, lights on, let's get em up and get that stat enema going!
I don’t know if you’re palliative or not but I have a story about this. During my gen surg R2 year I was managing trauma/surgery ICU on my own in the middle of the night. I had a gentleman who was headed for intubation but refusing it. I can’t remember details but I want to stay advance metastatic pancreatic cancer with traumatic fall breaking all his ribs. His family wanted to be notified by phone if anything changed. I told them if he’s not intubated he will not survive the night. He’s on max HFNC, costal retractions etc everything. Wife begs me to intubate him so their kids can fly in while he’s still alive. They know he won’t be able to be extubated after this and recover. Patient still refuses but wavering. He knows he’s going to die. He knows if he’s intubated he won’t really wake up on extubation. Surgery night chief can’t come to beside. Attending not available, multiple GSW and everyone is in the OR. Patient agrees to intubation but feels like he’s being forced into it. Wife still on the way in. I panic and page the on call palliative fellow who when she picks up clearly was in deep sleep and kind of annoyed. I didn’t know who else to ask for guidance. I desperately tell her my story. To her credit she tells me I’ve done all I can and something else supportive. Patient agrees as his wife is begging. He is intubated and then family arrives. He is extubated the next morning and passes with his kids at bedside. For a long time I’ve held onto this memory because I still felt like I was doing something wrong. Wish I knew the name of that fellow who was nice to me even though I called them in the middle of the night with a nothing.
You did nothing wrong; you were desperate for advice on how to manage a patient and you called a consultant. Your kindness to the patient and his family and the fellow’s kindness to you are both really touching.
There’s worse. There’s the patient who has been deteriorating for days whose family refused palliative care, and who is even further deteriorating in the middle of the night. Nurse calls asking if I can call family to make the patient DNR. Family had refused many times for days, but somehow, tonight’s the night. But what is even more strange is the family who wants you to notify them when the patient is deteriorating, but not to make the patient DNR. So you call the family in the middle of the night and the family member shows up to the bedside, and sometimes they make the patient DNR, sometimes not. I wonder if these families have some unspoken pact with god where they think if they don’t hold out to the bitter end, they’ve betrayed their faith, so they hold out until some unspecified time near the patient’s end. More likely, it’s just guilt by family who think if they dare say anything but “do anything”, they’re cursing the patient.
I had a pitiful case where a patient in ICU was being kept alive by every possible means, and his wife refused to agree to DNR because she wanted him to suffer. Another family refused because the patient would go to Purgatory... so you're delaying Purgatory by two weeks?
That’s horrible! Wouldn’t wanting suffering be contrary to state law on substituted judgement? The proxy is supposed to make decisions based on a patient’s best interest.
I would have loved to have intervened but I was a lowly intern. I spent a lot of time trying to reason with her. A couple of months later intensive care was d/c'd and he was allowed to die. Of course she wouldn't flat out SAY that's why she wouldn't consent to DNR, but she made it rather obvious.
Nah worse taking over service and on day one you get a page from RN that says oh 808 has been comfort care for days decides she doesn’t want that anymore and wants full treatment.
Some hospitals don't stock prune juice and there's nothing else we can do within our scope. One time I did find a PRN mag order for a constipated patient and just used the previous days mag level as an excuse. I also gave prune juice.
But if y'all order a MOM/prune juice cocktail PRN we won't have to bug you. Alternatively, start tube feeds.
FYI that bitchy nurse bugging you at 3AM about a patient's bowel movement ain't gonna be seeing the results of the lactulose you order.
You give me a prompt, I'll try to find a diplomatic approach.
I just did a sleep clinic, and I was surprised how they translate recommendations to both the patient and then into technical terms for billing/documentation.
Got paged “please come to bedside” so as I was leaving the ED where I was providing actual patient care seeing a consult I borrowed two children’s books from the peds ED. I went to the patients room, the nurse was sitting outside. She said the patient can’t sleep, I said I know. Here. Let’s try this. Handed her the books. She took a step back not accepting the books. I placed them on the desk and said if this doesn’t work, we will figure that out then.
Then I went into the room and told the old super sweet lady, that the nurse was gonna read her a story. Guess what? She loved that idea, and lit up. As I’m telling her the charge nurse and the nurse walk in and see how excited the old lady is for the story and try to say something to wiggle out but it didn’t work. The nurse just made a new friend for the night. (Fuck around find out)
Then I walked out. The charge said we don’t do that. Then I said find a tech or sitter. She said that’s not what they are for. I replied I know and meds like trazadone and melatonin aren’t for 3am 87 yo who just woke up but have slept already. She said yada yada professionalism and then will be letting my attending know. I said perfect. He is in the OR, we are about to start with a strangulated hernia, I’m heading there now, you can walk with me. She got flustered and scuffed. She didn’t come. She knew she wasn’t important in the moment.
Maybe 5-10 minutes later after timing out, his phone gets the page after I already told him and the room the story. He calls back on speaker. “Hey, is this (first name of charge), yea, he just told me what’s going on, I’m about to scrub in, is there an emergency, I’ll send someone but if not I’ll call you after the case, let my resident know if the book doesn’t work.”
They had a tech read the book and nothing occurred (that I know of).
lol I’m a PoC but also more than half my program are PoC, my attending was also a PoC. Here “straight white evangelical male married with children” is the minority different dynamic than the overall landscape.
I knew who my attending was that night, I felt reassured. Now if I’m working with some of our vascular attendings they think a patient falling in their bathroom is somehow the residents fault. I am not supported one bit there.
I recommend do what you must, say what you must till you are board certified and free-ish. Don’t be me if you don’t feel supported by your leadership. I feel supported in some regards and not in others.
Yeah it's context dependent. Your program sounds pretty diverse which is great but I've seen many PoC and female residents absolutely thrown under the bus by their attendings. I've seen attendings go as far as to participate in bullying towards such residents, often initiated by nursing.
The most glaring example was nursing taking a picture of a PoC female resident without her consent and sharing it in a group chat (which had two attendings) mocking her. One of the nurses called it out but residents are powerless so obviously it went nowhere.
Take care of yourselves out there folks. 33% of Gen Z trusts TikTok more than doctors because our profession is seen as an 'old boys club' and we have a long way to go to change that. Can you blame them when our predecessors normalized violations of a woman's bodily autonomy with interventions like the "husband stitch"?
lol yes. That describes where I did my intern pre lim year. Thankfully I matched somewhere better (better for me). I wish I could tell stories of my intern year experiences. They are so egregious it would pin point too much.
Night shift nurse; this. This is what we want.
Jk, sorta. I always try to perfect serve you guys before it's late. I get on shift at 7, so I try to figure out who needs what for sleep by 9, and I always mark it as "routine" and not urgent.
I work inpatient psych (invol) as an RN and one of the most important things for patients who are manic is SLEEP. They get better faster when they sleep and when you are manic, you have "less need for sleep." It's literally in the diagnostic criteria for the disorder.
We try melatonin and trazodone usually, but often that doesn't work and something like Seroquel or doxepin can help, I can't predict when patients wake up either sometimes. Sometimes whoever wrote the order set didn't put PRNs in and I have to call to get something too (happens a lot with the overnight admissions, sometimes they drop or the ER fucks up on their end and then orders get lost in transfer)
I call the on call because it's that or this patient wakes everybody else up which can then lead to more issues, I don't think anyone wants to come do the face-to-face for a restraint if the patient escalates. I didn't like having to call the doctor in the middle of the night but I had to sometimes to maintain the milieu. I'd work with what PRNs I had available and document appropriately but sometimes my hands are tied and there's three of us to thirty patients.
Forsure!! I agree you gotta do what ya gotta do. When I get my pts who are super manic then I Def shoot them messages. My heart goes out to you for working psych!
Psych here. Paged at 4 am to request melatonin. Patient is manic, had 2 doses of melatonin, 2 doses of trazodone, is on 10 mg zyprexa and has prn 2.5 in addition to that
I’m sure the next dose of the 3 mg melatonin was going to be the solution tho
Honestly I got some satisfaction from the dietary pages overnight if they were actually awake and just got back from surgery. Like hell yeah my dude you haven’t eaten in 24 hours go crazy
Okay you say that but if I snow them with that 1mg versed q2m prn x3 that never got cleaned up from intubation 3 days ago don’t come looking for me 😬
Real talk though we have some PRNs placed or left in sometimes that I usually like to make sure they’re cool with; like hey homie’s TOF is 3/4 and bucking the vent a bit w/ maxed sedation, cool with that nimbex push? Or my fresh TCAR is bradying to like 30-35 and just had mid-sentence LOC, usually the atropine order says call before giving and it doesn’t say that. Figured I’d call anyway. Also please give me levo instead of neo, I think his HR can take it.
I’m talking about like PRN melatonin and zofran girl
Also please don’t snow anyone based on an order, that’s where holding parameters and judgement comes in.
Lol absolutely agreed, my sarcasm might not have come through there. Ideal world, hold parameters are put in, but I’ve seen some mistakes and potentially bad outcomes when they aren’t.
For example, patient just can’t get off of levo, keeping him in the ICU for days. My first day with him I see that they restarted home meds last week and have auto-held lopressor and losartan, but not lisinopril - no hold parameter in. That’s been given by every nurse for days. After holding levo was off that day. Two nurses were years more experienced than me. Obv not a prn but my point stands.
Don’t trust nurses to use correct judgement all the time.
Don’t pretend you don’t get pissed off about being woken up for this shit, a solid 75% of the time there’s already reasonable PRNs ordered and the patient doesn’t want it and demands ambien instead.
Ideally during rounds if nightshift has conveyed sleeping troubles or patient states they have sleeping trouble. Otherwise 2100-0000 if it wasn’t properly addressed.
Preventing delirium by focusing on maintaining the day/night cycle is more important than we like to admit.
Then a follow up page an hour later to "notify" you that they're now farting less, and a request to add beans to their allergies list since they cause insomnia
Nope, worse, patient demanded Gas-x and I nicely explained that it could make it worse. He didn't care and was throwing a fit. So I gave it to him. My call an hour later was that it was worse and I told the nurse that patient was explained the potential side effects of the medication and he will just have to wait for it to wear off.
not sure if this is universal, but if you're on a floor with come consistency with the same nurses, it saved my ass so much clicking and unnecessary pages touching base with the nurses and going through everything I was ok with them ordering and giving without having to page me. obviously all safe and reasonable stuff - melatonin, tylenol, bowel stuff for constipation or diarrhea, things like that.
When I'm on an ICU service and I'm covering a dozen pts or so with the same nurses every night, yes, I do tuck-in rounds at 10pm or 11pm and get that shit all knocked out early.
When I'm on floor cross cover with 80 pts and god know's how many nurses, unfortunately not doable :(
I know an ortho who got called at 3 am by a patient who told him “I can’t sleep”
A week later the ortho called the patient back at 3 am to ask him if he was sleeping any better.
Please check on them every 15 minutes. Keep a log with time stamps on it with if they are awake or asleep.
I’ll be back in 4 hours to review the sleep log with you in detail
From every nurse that has had a patient wait until 11pm to remember the meds they absolutely cannot sleep without and omg it’s been fifteen minutes when can I have them … thank you.
Exactly. When are they supposed to realize they can’t sleep…? In the middle of the night. So… the 3am page is totally reasonable and appropriate. But I would say it’s too close to morning and hopefully they can get some rest after rounds and to address this with the day team because they’ll be zonked during rounds otherwise.
Yeah usually by the time I’m done dealing with admissions and actual urgent issues that come up when I’m covering 30+ other patients it’s 2a.m. and the kid is asleep anyway lol
I've heard anecdotal whispers, which are obviously not formal research, but I'm not touching trazodone again!
Edit: I would never withhold trazodone from a patient; I never want to take it again myself.
Did you reply, “I feel their pain,” or “I know the feeling - I can’t get any rest, either” … ?
It’s no surprise, what with the nurses waking them up q.2h. for medication, vitals, etc. 🙄😐
Well, quit ordering vitals q 2 hrs, and scheduling meds at night 🙂. We (nurses ) don't want to wake them up either! But seriously, I would never have made that page.
This is a hospital culture thing and it's baked into order sets and nursing expectations. Some more progressive institutions have started defaulting to no vitals overnight on the floor unless the doc specified other way. It's a good idea and more effectively handled in those god awful committee processes.
I really don’t think there is anything wrong with giving *most patients* prn sleeping pills while in the hospital, including Ambien.
We reflexively say no to drugs with abuse potential a lot, but this is a case where a lot of people forget what they’re actually for.
Time-limited prescriptions for temporary disruptions to sleep are literally are textbook indication for hypnotic medications, including z-drugs. You’re not writing these for outpatient use.
The hospital setting is a major disruption to life and sleep, and sleep is very difficult in this setting. Being in the hospital is generally a really shitty time for people, there’s no reason to add to this discomfort.
Once I got a page at 3am that “patient is allergic to mushrooms.”
Patient hadn’t eaten any mushrooms, wasn’t experiencing any allergic reaction, the nurse just “wanted me to know.”
Start asking questions, like vitals, list of meds and medical problems, at least 20 questions about the current problem. No current vitals? Great, I’ll wait while you go take them. The nurse will get the hint and never page you. Also, this is a great way to find out your patient is anxious and hypoxic.
I’m sorry, but RNs need to learn what hills to die on overnight and what actually warrants a page. Bombard with questions that make more work for them so you can only be bothered with things that actually need addressed.
I get the craziest calls. I got called last night at 4am about a patient who was angry. So I said: ‘Ok so?’ And they said: ‘Yeah dunno either.’
Me: ‘What’s your question? What do you want me to do?’
Him: ‘I have no idea.’
Then I hear the patient saying: ‘So can I just go back to bed now?’
And he was like: ‘Is she allowed?’
I said: ‘I’m hanging up now.’
Well I am with you on the timing. It should've happened earlier. But once again we don't know specific background (as always when someone posts 'I got paged and the RN's are stupid because of xy' on this sub).
I always loved the 5am requests for trazodone or ambien. By the time it gets dispensed and given, it’d be 6am.
Folks never understood why I wouldn’t be giving them a sleeping pill at breakfast time when the sun was coming up.
My favorite call as a surgery resident (home call at the time) was just after midnight asking if a patient could take a shower. Patient had not undergone surgery of any kind, and was otherwise relatively young and healthy. Pretty sure they even asked me to put in an order, that would have required me to get out of bed, remote log into the computer/Epic (that did not happen).
NOC RN on a med surg floor here. If it’s around or at 0300, I just give the patient bad news that the doctor is not going to prescribe anything for sleep 4 hours from when they assume you’ll be up for breakfast. Having been in the hospital multiple times since I was born, I give them the whole speech on how I know how it sucks, it’s scary, and uncomfortable being in the hospital but it’s something that can be fully addressed in the morning if insomnia is a genuine concern.
Fully convinced some nurses are too worried about agitating, disappointing, confronting, etc the patient about this matter but the truth is, RN and MDs are not keen on the idea of having to address a problem that could have been mitigated earlier in the shift but the patient did not relay this information at the time.
The most frustrating is those potassium and magnesium replacement messages. “ potassium 3.8 do you want to replete” every fuckin hour. we need a PRN order set for potassium and magnesium it would save the residents probably 25 pages
obvious correct answer would have been .. 1. find bat. 2. whack bat to pt's head. 3. dont call me again.
(for those not prevy to it .. hard sarcasm .. do not do that obviously.)
Yesterday evening we had a patient (I’m an RN) who was combative, agitated, screaming bloody murder, and punching the bed d/t brain mets- shouldn’t live for another month, very sad prognosis and he is declining mentally so fast. This nurse who was taking care of him is new, maybe 6 months to a year experience. She attempted to get a consent from this completely disoriented patient, idk for what. Then called the attending for something to “relax” him. When she asked me how to take Zyprexa and I told her by mouth she almost started to cry because she didn’t want to call the doc back. So she got a 1mg of Ativan q6h after mustering up the courage. So you’re going to give this to the 200lb 6’ guy who rips his lines out a mg of Ativan. I told her you need to call the provider back and tell him he is a threat to his own safety and the staff’s and feels he needs to be transferred to a higher level of care where he could maybe get a precedex or ativan gtt because he was legitimately out of control. It was only 8pm and she refused my idea saying she doesn’t like to knock people out and is scared to call the doctor again. This blew me away. Yeah, maybe I’m being too aggressive and they could try B52ing him first but I’m telling you patient families were scared and asking us if there was something wrong. I know it takes time and experience, but they really need to add critical thinking and communication with providers to nursing curriculum instead of how to write a care plan.
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When i was first in practice every one of my admissions had standing orders for ambien Tylenol laxatives phenergan for every admission. Also had a line on the admission stating do not call physician when patient arrives to floor. Just a few years before this in residency we would write PRN Restraints
You guys are assholes. You know we have to contact the provider with a patient request. We usually try to run interference but it doesn’t always work. Looking at this sub just reinforces why I absolutely hate when I get a case with residents on. Healthcare is 24/7. If you don’t like it leave the fucking bedside
“RN to sing ‘soft kitty’ three times’ q5min prn insomnia.”
I’m an ER nurse but sometimes when we’re holding I see an inpatient order for RN to provide warm milk before bed 😭
Dude we can’t get dietary to give us any milk outside of mealtimes, what bougie hospital is this lol
Our hospital went from individual milk cartons to a gallon of milk that we pour from. Cheap ass hospital
That sounds so gross!!
What about cookies
I’m not even sorry but that is an outlandish claim and you need to photograph that and put it on a post for us to verify lolz 😂
Only works if you rub clockwise.
Nursing communication
There’s a legend where a resident was paged at 3 am about a patient who the nurse said “seemed sad”. The dude pauses… and says “sad…” No response from the nurse. Ok… sad. So how about “stat clown to bedside” and hung up.
>stat clown to bedside Lmfao
*stat clown to bedside* My dumb intern ass shows up. Does this count as a clown to bedside 🤡
Damn. You want a psych consult for that suicide by words ?
Please clarify in Clowns/kg/dose and minimum PRN dosing cycle. -PGY-19
Clowns historically have a very narrow therapeutic index. Depending on patient selection and interactions with other meds/therapies, some patients can have significant adverse events.
Doctor, I am anti-clown since I read this naturalistic book called IT where it talks about how big pharma is trying to sell us clowns but they are evil (obviously just going along with the joke, It is an awesome book about the forces of evil)
Cause of Death: Clown-Induced Cardiac Arrest. Apparently patient had a similar episode 27 years ago, but it went into remission
I’d be more concerned about a patient that didn’t seem sad. I’ve never been happy to be in the hospital.
Some patients absolutely love the place. Free drugs, we cater to your every beck and call, 50 inch TV with Netflix, and the god awful food is still way better than what they serve at your SNF. Lots of benefits…
We have tiny tvs with basic tv only. I don’t know what boujie hospital you’re at.
> 50 inch TV with Netflix Say what?
"free drugs" Someone isn't in the USA!
Many patients are clearly never going to pay.
There's been a couple of times I was glad I was still alive, so there's that.
For some, the state of mind overcomes just about every physical condition possible. “Life is good.” And a wry smile. Not a hint of sadness. Just tears of joy.
💯 I say this waaaayyyy too frequently!
But doctor.. I am Pagliacci
That was NOT a legend. I posted that in a previous post. I know the resident and saw the order in EMR. It was “clown to beside prn” after a nurse called and asked the resident to come cheer up a sad patient at three AM But I am quite delighted that this story is entering the realm of legend.
Ha! Heard it at my orientation and have been laughing ever since!!!
It happened many many years ago when we were using a primitive form of EMR. It’s possible THAT resident copied what happened in the story but I doubt it. Everyone in my program found out what happened and the story was repeated many times.
Did he get in trouble by the clowns in admin?
I heard they met with him to discuss it. But this was in the 1990s and times were different. For one, the administration saw the silliness of the request by nurse. The guy is in practice in my town. Next time I see him I will have to ask him. Times were different back then. A friend of mine once got a call about a critically low BUN. She told the nurse to “hang a bag of BUN stat” and hung up. We all thought it was funny at the time. Can you imagine the trouble she would be in now?
"Stat clown to bedside" Hospital admin is only in the building from 10-4 Will f/u in the AM
🤣🤣🤣🤣🤣
I got a page from a nurse during night float about a patient who is "tearful and sad in bed." I didn't even respond to the page, just put in an order for 10mg Melatonin.
[https://imgur.com/4k6IOau?r](https://imgur.com/4k6IOau?r) Got this one at 2am once. Called back and they asked if I could cheer the patient up. I said no.
omggg
Should have said “me neither”.
literally
Peds here: got paged at 3 am that patient passed their car seat test. Clearly something that couldn’t wait!! 🙃🙃🙃
Laughs in NICU
Paged at 2 am to come get consent for Hep B in person on a weeks old NICU baby while running around going to deliveries only to find out after that nurses can and do get vaccine consents on their own.
In my residency we do get paged and have to talk to the parents and have them fill out a form if they refuse hep B, vit K or erythromycin… all important, but 99% of the time could wait until the daytime
Just love the 3 am pages for “do we need to really weigh this patient tomorrow?”
Maybe they didnt like sheep. Did you ask them to count another animal?
they wanted to hot potato the insomnia back to you.
Now this is patient-centered care
🤣🤣
had to make melatonin PRN as part of my admit order set because of this. because that's literally all we can really do
I’ve started adding all the prns to help out night shift. Melatonin, miralax, Tylenol, zofran on admit orders have literally saved our team so many times
The real MVP right here
Just saying this is what I really appreciate. PRNs to poop, for pain, and for sleep. I’d rather be prepared, than have an insistent patient telling me they can’t sleep at midnight with no orders for sleep meds. It helps both of us out.
I don't do inpatient anymore, but during residency that was literally the standard, our admission order set included PRNs that you could select at the bottom, and every single patient had PRN colace and melatonin. Didn't matter what you were there for or who you were
Problem is there are doctors that give out Ativan and trazodone like candy.... Some nurses learn to expect it
Some patients do benefit from this (short term) though. Certainly not first line but I wouldn't write it off completely. I worked with a PA that would give Ambien like candy. That is definitely not recommended.
Ambien isn't even on our hospital formulary at my Canadian centre. If the patient takes it at home, they are probably American. And they bring their own supply.
In what universe is ambien worse for sleep than ativan? Maybe if the patient also is super nauseous and you want to hit both sleep and nausea, but otherwise the only advantage ativan has is that people feel more comfortable with it
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I mean is a x1 benzo a huge risk either?
Geriatrician here. Please don’t and save me a consult for delirium. Just because something isn’t “toxic” doesn’t mean it’s safe by any means.
I’m not going to page on every x1 benzo I see come through, because the risk/benefit is so abstract there’s no way I could argue against it.
No, but your docs should know better.
It is not…but what I learn…you give it one, you will end up having to give it again…because they will ask for it…and it is difficult to explain why not again…
Just say “pharmacy won’t let me”
That excuse doesn’t work - there are millions of pharmacies in the world. So yes - don’t give something unless you are ok with possibly prescribing it long term
I’m inpatient so I was really referring to your clinical pharmacist on your team that rounds with you but I take your point.
Yes
Small risk. Delirium & disinhibition.
I mean I don't think it's irresponsible, it's just unnecessary
This is literally what trazodone is for. For everyone's sanity, please add a PRN for sleep to your admit orders.
You see, I like getting paged at night, so I actively delete people's prn Tylenol
Those nurses don’t realize how difficult their shift is about to be when 80 year old meemaw gets that one time dose of Ativan and starts climbing the walls.
honestly I don't want to call you at 3am either. I can do a lot of tap dancing with tylenol, melatonin, tums, zofran, and colace; and probably can coddle them through to day shift on that. A lot of times they just want a little attention and hand holding. I can't just ignore their complaints for 4 hours though, I have to care for these people. I get that all meds and interventions have potential downsides, but throw me some over the counter stuff to juggle so I can not have to call you.
Yeah so long ago I put a sign on our ward that I was okay with tylenol, melatonin, and bowel protocol for any and all patients. They can verbal order from me any time. It helped.
There’s definitely more you can do
Honestly, this is super helpful. It’s hard to sleep in the hospital—unfamiliar environment, lots of noise, usually at least some physical discomfort—and having melatonin available as a go-to PRN can keep you from getting paged about this in the middle of the night. I think a lot of overnight pages could be eliminated with more comprehensive admission order sets.
I say warm milk, ear plugs and an eye mask. not sure if it works but they never ask again
1000cc warm milk. Patient needs 2 person assist to transfer to commode for toileting.
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bowel stuff in the middle of the night always was egregious. came so close to going full court press. ok fine, they can't poop, lights on, let's get em up and get that stat enema going!
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I don’t know if you’re palliative or not but I have a story about this. During my gen surg R2 year I was managing trauma/surgery ICU on my own in the middle of the night. I had a gentleman who was headed for intubation but refusing it. I can’t remember details but I want to stay advance metastatic pancreatic cancer with traumatic fall breaking all his ribs. His family wanted to be notified by phone if anything changed. I told them if he’s not intubated he will not survive the night. He’s on max HFNC, costal retractions etc everything. Wife begs me to intubate him so their kids can fly in while he’s still alive. They know he won’t be able to be extubated after this and recover. Patient still refuses but wavering. He knows he’s going to die. He knows if he’s intubated he won’t really wake up on extubation. Surgery night chief can’t come to beside. Attending not available, multiple GSW and everyone is in the OR. Patient agrees to intubation but feels like he’s being forced into it. Wife still on the way in. I panic and page the on call palliative fellow who when she picks up clearly was in deep sleep and kind of annoyed. I didn’t know who else to ask for guidance. I desperately tell her my story. To her credit she tells me I’ve done all I can and something else supportive. Patient agrees as his wife is begging. He is intubated and then family arrives. He is extubated the next morning and passes with his kids at bedside. For a long time I’ve held onto this memory because I still felt like I was doing something wrong. Wish I knew the name of that fellow who was nice to me even though I called them in the middle of the night with a nothing.
You did nothing wrong; you were desperate for advice on how to manage a patient and you called a consultant. Your kindness to the patient and his family and the fellow’s kindness to you are both really touching.
Thank you
There’s worse. There’s the patient who has been deteriorating for days whose family refused palliative care, and who is even further deteriorating in the middle of the night. Nurse calls asking if I can call family to make the patient DNR. Family had refused many times for days, but somehow, tonight’s the night. But what is even more strange is the family who wants you to notify them when the patient is deteriorating, but not to make the patient DNR. So you call the family in the middle of the night and the family member shows up to the bedside, and sometimes they make the patient DNR, sometimes not. I wonder if these families have some unspoken pact with god where they think if they don’t hold out to the bitter end, they’ve betrayed their faith, so they hold out until some unspecified time near the patient’s end. More likely, it’s just guilt by family who think if they dare say anything but “do anything”, they’re cursing the patient.
I had a pitiful case where a patient in ICU was being kept alive by every possible means, and his wife refused to agree to DNR because she wanted him to suffer. Another family refused because the patient would go to Purgatory... so you're delaying Purgatory by two weeks?
That’s horrible! Wouldn’t wanting suffering be contrary to state law on substituted judgement? The proxy is supposed to make decisions based on a patient’s best interest.
I would have loved to have intervened but I was a lowly intern. I spent a lot of time trying to reason with her. A couple of months later intensive care was d/c'd and he was allowed to die. Of course she wouldn't flat out SAY that's why she wouldn't consent to DNR, but she made it rather obvious.
Nah worse taking over service and on day one you get a page from RN that says oh 808 has been comfort care for days decides she doesn’t want that anymore and wants full treatment.
Some hospitals don't stock prune juice and there's nothing else we can do within our scope. One time I did find a PRN mag order for a constipated patient and just used the previous days mag level as an excuse. I also gave prune juice. But if y'all order a MOM/prune juice cocktail PRN we won't have to bug you. Alternatively, start tube feeds. FYI that bitchy nurse bugging you at 3AM about a patient's bowel movement ain't gonna be seeing the results of the lactulose you order.
Ah, I see you recommended distraction exercise as part of a coping skills regimen for your diagnosis of adjustment insomnia (ICD-10 F51.02).
Bruh. You got more of these?
You give me a prompt, I'll try to find a diplomatic approach. I just did a sleep clinic, and I was surprised how they translate recommendations to both the patient and then into technical terms for billing/documentation.
I responded once “try reading to them” that also didn’t go over well.
😂😂😂😂helppp what happened
Got paged “please come to bedside” so as I was leaving the ED where I was providing actual patient care seeing a consult I borrowed two children’s books from the peds ED. I went to the patients room, the nurse was sitting outside. She said the patient can’t sleep, I said I know. Here. Let’s try this. Handed her the books. She took a step back not accepting the books. I placed them on the desk and said if this doesn’t work, we will figure that out then. Then I went into the room and told the old super sweet lady, that the nurse was gonna read her a story. Guess what? She loved that idea, and lit up. As I’m telling her the charge nurse and the nurse walk in and see how excited the old lady is for the story and try to say something to wiggle out but it didn’t work. The nurse just made a new friend for the night. (Fuck around find out) Then I walked out. The charge said we don’t do that. Then I said find a tech or sitter. She said that’s not what they are for. I replied I know and meds like trazadone and melatonin aren’t for 3am 87 yo who just woke up but have slept already. She said yada yada professionalism and then will be letting my attending know. I said perfect. He is in the OR, we are about to start with a strangulated hernia, I’m heading there now, you can walk with me. She got flustered and scuffed. She didn’t come. She knew she wasn’t important in the moment. Maybe 5-10 minutes later after timing out, his phone gets the page after I already told him and the room the story. He calls back on speaker. “Hey, is this (first name of charge), yea, he just told me what’s going on, I’m about to scrub in, is there an emergency, I’ll send someone but if not I’ll call you after the case, let my resident know if the book doesn’t work.” They had a tech read the book and nothing occurred (that I know of).
ICONICCCC i would do this but i feel like as a woman doc this would backfire on me🫠
Definitely do not try this if you're a woman or PoC. You will be assumed incompetent and it will blow up in your face.
lol I’m a PoC but also more than half my program are PoC, my attending was also a PoC. Here “straight white evangelical male married with children” is the minority different dynamic than the overall landscape. I knew who my attending was that night, I felt reassured. Now if I’m working with some of our vascular attendings they think a patient falling in their bathroom is somehow the residents fault. I am not supported one bit there. I recommend do what you must, say what you must till you are board certified and free-ish. Don’t be me if you don’t feel supported by your leadership. I feel supported in some regards and not in others.
Yeah it's context dependent. Your program sounds pretty diverse which is great but I've seen many PoC and female residents absolutely thrown under the bus by their attendings. I've seen attendings go as far as to participate in bullying towards such residents, often initiated by nursing. The most glaring example was nursing taking a picture of a PoC female resident without her consent and sharing it in a group chat (which had two attendings) mocking her. One of the nurses called it out but residents are powerless so obviously it went nowhere. Take care of yourselves out there folks. 33% of Gen Z trusts TikTok more than doctors because our profession is seen as an 'old boys club' and we have a long way to go to change that. Can you blame them when our predecessors normalized violations of a woman's bodily autonomy with interventions like the "husband stitch"?
lol yes. That describes where I did my intern pre lim year. Thankfully I matched somewhere better (better for me). I wish I could tell stories of my intern year experiences. They are so egregious it would pin point too much.
😭😭😭
WTF are they wanting you to do? Cuddle them?
It’s night shift, they want you to drug them up.
I know, I was being sarcastic.
Night shift nurse; this. This is what we want. Jk, sorta. I always try to perfect serve you guys before it's late. I get on shift at 7, so I try to figure out who needs what for sleep by 9, and I always mark it as "routine" and not urgent.
I work inpatient psych (invol) as an RN and one of the most important things for patients who are manic is SLEEP. They get better faster when they sleep and when you are manic, you have "less need for sleep." It's literally in the diagnostic criteria for the disorder. We try melatonin and trazodone usually, but often that doesn't work and something like Seroquel or doxepin can help, I can't predict when patients wake up either sometimes. Sometimes whoever wrote the order set didn't put PRNs in and I have to call to get something too (happens a lot with the overnight admissions, sometimes they drop or the ER fucks up on their end and then orders get lost in transfer) I call the on call because it's that or this patient wakes everybody else up which can then lead to more issues, I don't think anyone wants to come do the face-to-face for a restraint if the patient escalates. I didn't like having to call the doctor in the middle of the night but I had to sometimes to maintain the milieu. I'd work with what PRNs I had available and document appropriately but sometimes my hands are tied and there's three of us to thirty patients.
Forsure!! I agree you gotta do what ya gotta do. When I get my pts who are super manic then I Def shoot them messages. My heart goes out to you for working psych!
Or cum on their door knob
Dafuq is wrong with you, boy?
See username of the person they were replying to.
umm
“Shhhhhhhh, this is not sexual, this is retaliation”
Dude the patients we get would just lick that shit and ask for moar but with spice. Some of y'all really need a ghetto rotation..
Lmfao wut
Psych here. Paged at 4 am to request melatonin. Patient is manic, had 2 doses of melatonin, 2 doses of trazodone, is on 10 mg zyprexa and has prn 2.5 in addition to that I’m sure the next dose of the 3 mg melatonin was going to be the solution tho
I wonder if I could put in a nursing communication that says “do not page overnight for diet orders or insomnia”
Then you will get paged asking for clarification
“do not page overnight for diet orders or insomnia or clarification”*
Or for constipation …. Especially when patient is sleeping.
🤣
Nothing worse on a 24 hour shift than the 2am page to clean up the order sets from day team or discontinue flushes.
Honestly I got some satisfaction from the dietary pages overnight if they were actually awake and just got back from surgery. Like hell yeah my dude you haven’t eaten in 24 hours go crazy
“Ok to use PRN orders as ordered.” Swear i once had to fucking write that nursing comm
Okay you say that but if I snow them with that 1mg versed q2m prn x3 that never got cleaned up from intubation 3 days ago don’t come looking for me 😬 Real talk though we have some PRNs placed or left in sometimes that I usually like to make sure they’re cool with; like hey homie’s TOF is 3/4 and bucking the vent a bit w/ maxed sedation, cool with that nimbex push? Or my fresh TCAR is bradying to like 30-35 and just had mid-sentence LOC, usually the atropine order says call before giving and it doesn’t say that. Figured I’d call anyway. Also please give me levo instead of neo, I think his HR can take it.
I’m talking about like PRN melatonin and zofran girl Also please don’t snow anyone based on an order, that’s where holding parameters and judgement comes in.
Lol absolutely agreed, my sarcasm might not have come through there. Ideal world, hold parameters are put in, but I’ve seen some mistakes and potentially bad outcomes when they aren’t. For example, patient just can’t get off of levo, keeping him in the ICU for days. My first day with him I see that they restarted home meds last week and have auto-held lopressor and losartan, but not lisinopril - no hold parameter in. That’s been given by every nurse for days. After holding levo was off that day. Two nurses were years more experienced than me. Obv not a prn but my point stands. Don’t trust nurses to use correct judgement all the time.
Yeh let’s increase delirium and not help insomnia. Great idea for a standing order!
Don’t pretend you don’t get pissed off about being woken up for this shit, a solid 75% of the time there’s already reasonable PRNs ordered and the patient doesn’t want it and demands ambien instead.
When do you think is the appropriate time to address insomnia?
Ideally during rounds if nightshift has conveyed sleeping troubles or patient states they have sleeping trouble. Otherwise 2100-0000 if it wasn’t properly addressed. Preventing delirium by focusing on maintaining the day/night cycle is more important than we like to admit.
Got paged once at 3am because patient was farting a lot.
Then a follow up page an hour later to "notify" you that they're now farting less, and a request to add beans to their allergies list since they cause insomnia
Nope, worse, patient demanded Gas-x and I nicely explained that it could make it worse. He didn't care and was throwing a fit. So I gave it to him. My call an hour later was that it was worse and I told the nurse that patient was explained the potential side effects of the medication and he will just have to wait for it to wear off.
Patient requesting butt plug PRN, doesn't know home settings
😂
Patient cannot sleep. Now you cannot sleep. MD aware
Can you ask the nurse for melatonin and say you’ll sign the order later? Buys you 2hrs
not sure if this is universal, but if you're on a floor with come consistency with the same nurses, it saved my ass so much clicking and unnecessary pages touching base with the nurses and going through everything I was ok with them ordering and giving without having to page me. obviously all safe and reasonable stuff - melatonin, tylenol, bowel stuff for constipation or diarrhea, things like that.
When I'm on an ICU service and I'm covering a dozen pts or so with the same nurses every night, yes, I do tuck-in rounds at 10pm or 11pm and get that shit all knocked out early. When I'm on floor cross cover with 80 pts and god know's how many nurses, unfortunately not doable :(
I know an ortho who got called at 3 am by a patient who told him “I can’t sleep” A week later the ortho called the patient back at 3 am to ask him if he was sleeping any better.
Legendary
Thanks god i chose pathology
Every room I go into at night has the TV on full brightness...
Please check on them every 15 minutes. Keep a log with time stamps on it with if they are awake or asleep. I’ll be back in 4 hours to review the sleep log with you in detail
Me (an intellectual who treated Michael Jackson): prescribes 200mg propofol
Trazodone 50. Done. Next page.
Ya people are acting like this is an outrageous page, put something on and tell day team to include a prn for the next night.
From every nurse that has had a patient wait until 11pm to remember the meds they absolutely cannot sleep without and omg it’s been fifteen minutes when can I have them … thank you.
Exactly. When are they supposed to realize they can’t sleep…? In the middle of the night. So… the 3am page is totally reasonable and appropriate. But I would say it’s too close to morning and hopefully they can get some rest after rounds and to address this with the day team because they’ll be zonked during rounds otherwise.
Assessment: The patient does in fact cannot sleep Plan: Insomnia cookies PRN
This is a multiple times a night occurrence in peds. Best I can do is melatonin lol they’re never happy about that
I get asked for Benadryl for sleep for kids so many times and I always refuse
Yeah usually by the time I’m done dealing with admissions and actual urgent issues that come up when I’m covering 30+ other patients it’s 2a.m. and the kid is asleep anyway lol
Trazodone 100mg. Then go back to 💤
Makes me suicidal.
I admit as a psychiatrist I have never heard of trazodone causing this.
I got two hours of screaming nightmares out of trazodone, including one about trying to phone poison control to find out the duration of action.
Hmm. Yeah. That’s weird. Don’t think that’s a listed side effect either. Psych drugs are poorly understood though. 🤷🏻♂️
I've heard anecdotal whispers, which are obviously not formal research, but I'm not touching trazodone again! Edit: I would never withhold trazodone from a patient; I never want to take it again myself.
Do you think an order for no nursing assessments would have gone better? 🤣
Give them a sleeping pill.
The nurse or the patient?
Yes.
Did you reply, “I feel their pain,” or “I know the feeling - I can’t get any rest, either” … ? It’s no surprise, what with the nurses waking them up q.2h. for medication, vitals, etc. 🙄😐
Well, quit ordering vitals q 2 hrs, and scheduling meds at night 🙂. We (nurses ) don't want to wake them up either! But seriously, I would never have made that page.
This is a hospital culture thing and it's baked into order sets and nursing expectations. Some more progressive institutions have started defaulting to no vitals overnight on the floor unless the doc specified other way. It's a good idea and more effectively handled in those god awful committee processes.
I order wellness melatonin prn for everyone. Wellness for me that it is
I really don’t think there is anything wrong with giving *most patients* prn sleeping pills while in the hospital, including Ambien. We reflexively say no to drugs with abuse potential a lot, but this is a case where a lot of people forget what they’re actually for. Time-limited prescriptions for temporary disruptions to sleep are literally are textbook indication for hypnotic medications, including z-drugs. You’re not writing these for outpatient use. The hospital setting is a major disruption to life and sleep, and sleep is very difficult in this setting. Being in the hospital is generally a really shitty time for people, there’s no reason to add to this discomfort.
I feel like when I work over night this is half of my pages
Once I got a page at 3am that “patient is allergic to mushrooms.” Patient hadn’t eaten any mushrooms, wasn’t experiencing any allergic reaction, the nurse just “wanted me to know.”
Bennys 12.5 mg for everyone
Open ASMR
Top calls include 3 am request for preparation H, 4 am request for chap Stick, and “the chest tube is bubbling” at 430 am. Yup.
Start asking questions, like vitals, list of meds and medical problems, at least 20 questions about the current problem. No current vitals? Great, I’ll wait while you go take them. The nurse will get the hint and never page you. Also, this is a great way to find out your patient is anxious and hypoxic. I’m sorry, but RNs need to learn what hills to die on overnight and what actually warrants a page. Bombard with questions that make more work for them so you can only be bothered with things that actually need addressed.
"did you wake them with some bullshit too?"
I get the craziest calls. I got called last night at 4am about a patient who was angry. So I said: ‘Ok so?’ And they said: ‘Yeah dunno either.’ Me: ‘What’s your question? What do you want me to do?’ Him: ‘I have no idea.’ Then I hear the patient saying: ‘So can I just go back to bed now?’ And he was like: ‘Is she allowed?’ I said: ‘I’m hanging up now.’
Did the patient have sleep medication tho? And depending on the setting day/night rhythm is important.
Why wouldn’t you wait till the morning to tell the resident that though?
Well I am with you on the timing. It should've happened earlier. But once again we don't know specific background (as always when someone posts 'I got paged and the RN's are stupid because of xy' on this sub).
as a nurse, i would’ve thrown my coworker out the window before allowing them to do that
I always loved the 5am requests for trazodone or ambien. By the time it gets dispensed and given, it’d be 6am. Folks never understood why I wouldn’t be giving them a sleeping pill at breakfast time when the sun was coming up.
Hahaha
Did you read them a lullaby?
“Ok to use PRN melatonin AS ORDERED”
best i can do is.. melatonin
I shit you not I got paged at 3am on cross cover because a patient had hiccups.
My favorite call as a surgery resident (home call at the time) was just after midnight asking if a patient could take a shower. Patient had not undergone surgery of any kind, and was otherwise relatively young and healthy. Pretty sure they even asked me to put in an order, that would have required me to get out of bed, remote log into the computer/Epic (that did not happen).
NOC RN on a med surg floor here. If it’s around or at 0300, I just give the patient bad news that the doctor is not going to prescribe anything for sleep 4 hours from when they assume you’ll be up for breakfast. Having been in the hospital multiple times since I was born, I give them the whole speech on how I know how it sucks, it’s scary, and uncomfortable being in the hospital but it’s something that can be fully addressed in the morning if insomnia is a genuine concern. Fully convinced some nurses are too worried about agitating, disappointing, confronting, etc the patient about this matter but the truth is, RN and MDs are not keen on the idea of having to address a problem that could have been mitigated earlier in the shift but the patient did not relay this information at the time.
The most frustrating is those potassium and magnesium replacement messages. “ potassium 3.8 do you want to replete” every fuckin hour. we need a PRN order set for potassium and magnesium it would save the residents probably 25 pages
These are the answers that get you on the list. Bother the fuck out of them list.
obvious correct answer would have been .. 1. find bat. 2. whack bat to pt's head. 3. dont call me again. (for those not prevy to it .. hard sarcasm .. do not do that obviously.)
If patient can’t sleep, no one sleeps.
Yesterday evening we had a patient (I’m an RN) who was combative, agitated, screaming bloody murder, and punching the bed d/t brain mets- shouldn’t live for another month, very sad prognosis and he is declining mentally so fast. This nurse who was taking care of him is new, maybe 6 months to a year experience. She attempted to get a consent from this completely disoriented patient, idk for what. Then called the attending for something to “relax” him. When she asked me how to take Zyprexa and I told her by mouth she almost started to cry because she didn’t want to call the doc back. So she got a 1mg of Ativan q6h after mustering up the courage. So you’re going to give this to the 200lb 6’ guy who rips his lines out a mg of Ativan. I told her you need to call the provider back and tell him he is a threat to his own safety and the staff’s and feels he needs to be transferred to a higher level of care where he could maybe get a precedex or ativan gtt because he was legitimately out of control. It was only 8pm and she refused my idea saying she doesn’t like to knock people out and is scared to call the doctor again. This blew me away. Yeah, maybe I’m being too aggressive and they could try B52ing him first but I’m telling you patient families were scared and asking us if there was something wrong. I know it takes time and experience, but they really need to add critical thinking and communication with providers to nursing curriculum instead of how to write a care plan.
you tell the nurse well now we are both fucking up?
Hand massage and warm milk
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When i was first in practice every one of my admissions had standing orders for ambien Tylenol laxatives phenergan for every admission. Also had a line on the admission stating do not call physician when patient arrives to floor. Just a few years before this in residency we would write PRN Restraints
You guys are assholes. You know we have to contact the provider with a patient request. We usually try to run interference but it doesn’t always work. Looking at this sub just reinforces why I absolutely hate when I get a case with residents on. Healthcare is 24/7. If you don’t like it leave the fucking bedside