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The sun has set, and your colleagues have retreated home. Four members, including yourself, stayed behind to keep the fire alive. The chief resident and attending surgeon are sweating in the operating room (OR) #6 attempting to control a duodenal hemorrhage refractory to endoscopic intervention and embolization by interventional radiology; tensions are high, and massive transfusion protocol is activated. The intensive care unit surgery resident is actively resuscitating bed #2, multisystemic trauma with an open abdomen that suddenly coded.

You just triaged three emergency department (ED) stat consults, deciding to prioritize an elderly female presenting in septic shock with imaging demonstrating obvious pneumoperitoneum. Running down the northeast stairwell, you scroll through electronic medical records on your phone to review the patient’s surgical/medical history. Suddenly, your hospital phone buzzes. The floor intern is frantically describing a bariatric patient who is postoperative day #3 from her bypass, acutely tachycardic to 140, and febrile to 102 and complains of chest pain.

As you explain the most appropriate labs and imaging modality, the ED hallway screens flash red/black. Trauma alert is activated, and your pager once again screams for your attention. GUN SHOT WOUNDS, TRAUMA UNKNOWN, INTUBATED, 5 MINUTES. You silently shout profanity down a hallway cluttered by empty beds, carts, and mobile X-ray devices and force yourself to take a deep breath. You remembered that you were not alone.

You call the operating room front desk to deliver an SOS message to OR #6 and sprint to the trauma bay. At least 13 other healthcare colleagues are looking to you for instructions. You have done this before, and this is only another Tuesday night. You identify yourself and initiate crew resource management to prepare for the worst-case scenario.

General surgery call is inherently chaotic; our job is to embrace and organize the chaos. Here are the practical tips that will help you become an effective general surgery resident.

Utilize the EMR: The hospital electronic health/medical record system has the function of creating and managing a private list of patients. Document and keep a clear list, electronic if possible, so it is not lost in the chaos. This list should include new consults, patients with worsening clinical status, and patients with pending tasks. Actively review this list throughout the night to follow up and progress patient care. This list will also serve as your sign-out list to respective colleagues in the morning.

Triage every new patient brought to your attention. You will learn and hone this skill with endless hours in the hospital. Always prioritize the sickest patient first. This obvious fact often eludes the junior residents during real-life applications because not all tasks are created equal. Patient care comes before nonurgent documentation. If documentation is required to facilitate operative intervention, it is acceptable to abbreviate. Assessment/plan may say nothing more than “Patient presented in septic shock with pneumoperitoneum of unknown origin. Ongoing resuscitation. Broad-spectrum antibiotics. Plan for emergent operative intervention.”

Follow the hierarchy and ask for assistance. Always notify the upper level before making any critical interventions. Know your limit; if you are preparing to tackle a task for the first time, always call for backup to bring experience and safety to the scenario. The presence of senior/chief residents will also shield you from moments where others are critical of your decisions. Asking for help when tasks become overwhelming despite your best efforts at triaging and prioritizing is a sign of maturity and taking responsibility for patients.

You are never alone. Even if all other surgical residents appear to be occupied and unavailable, there are other healthcare providers in the hospital. Ask your ED colleague to help facilitate tasks such as line placements, start resuscitation, initiate antibiotic therapy, or call for critical consults such as cardiology for perioperative risk stratification. Be respectful and courteous to emergency department colleagues; they know how to reach just about every service in the hospital and will return the favor when you need their assistance.

Keep a sterile sharp instrument on hand. General surgery residents should be ready to wield a blade at a second’s notice. Many reversible causes of acute life-threatening deterioration require invasive intervention, and no one should be more prepared to do so than you. Tension pneumothorax can be relieved merely by entering the thoracic cavity with a finger.

Finally, remember to breathe and always prepare for the worst-case scenario. If the surgeon in the room is panicking, so will everyone else. Take control of every battle and exude confidence through preparation and experience. The sun will always rise in the morning, and reinforcement will be here to relieve you of your duties.

FormalPara Pearls

  • Follow the chain of command and notify your upper level resident before making critical decisions or interventions. Senior residents bring experience and safety to foreign scenarios, which will protect you.

  • Organize the chaos by maintaining a private electronic patient list in the EMR for call shifts. Include patients with pending tasks, new consults, and those with deteriorating clinical status.

  • Actively think ahead to prepare for the worst-case scenario. In high-stress situations, others will naturally look to you for leadership and guidance. Remember to breathe and learn to keep a calm demeanor.

  • Maintain a friendly relationship with your emergency room colleagues. They will appreciate your kind attitude and readily come to your aid when requested.

  • Keep a sterile sharp instrument handy. Few things are more frustrating than opening up the sterile thoracotomy set and not having a blade for initial incision.

  • Triage your patients and your tasks; always prioritize actions that advance patient care. Develop this skill to improve efficiency.

  • Know your limit, and do not be afraid to ask for help when overwhelmed.