SUGGESTIONS FOR NIGHT FLOAT RESIDENTS
I finally graduated to 2nd year of my IM residency. My first rotation was night float. Night float is hard and it really tests you. As a night float resident, you are just working, sleeping and eating!
The cases which you see as a night float resident in a community hospital varies widely. Now I am more comfortable admitting a drunk alcoholic patient than admitting someone for the CCU team. Our Hospital is not equipped to handle urgent cardiac cath. So, we have to decide about possible transfer to a hospital which can tackle Coronary cath. We admit a lot of NSTEMI and Arrhythmias. There is a cardiologist on call every night but he is at HOME and resting. It's hard to reach them and as a resident you can only pray for the patient in some situations. So, whenever I am admitting any patient for CCU for gray zone troponin or non-specific EKG changes, I give the patient Aspirin, Ticagrelor and Full dose anti-coagulation. I can not take the risk. I call the attending and he normally agrees with my approach. In short words, I am just scared to admit patients for CCU.
My advice for night Float
1- Whenever the nurse calls you, ask the name of the patient and the name of the admitting physicians. Some times, they call you for patients who are not teaching. It safes times!
2- Try to as polite as you can with the nurses but do not prolong your talk over the phone as it will waste your time and energy. Try to keep it short and straight to the point.
3. Whenever the nurse calls and you want to put in the orders, put them as soon as possible. Otherwise, you will forget and the nurse will give you a call again which will waste your time.
4- Be aware of the sick patients in Intermediate care unit and the CCU patients. Always ask the floor seniors to let you know about the sick patients when they are signing out. Also, if the nurse calls you for a patient and tells you that the patient is not doing good, kindly go to the floor and assess. Otherwise, patient might end up in a rapid response or code blue.
5- Whenever you are admitting a patient, go and speak with the ER nurse yourself. Sometimes, Nurses are busy and have too many patients or they are just feeling lazy and do not want to work. Talk to them and tell them about the orders you need them to follow as soon as possible eg. troponin 4 and FLUID BOLUSES. Tell them to follow some orders and ignore the rest.
6- Follow important labs and radiology of all the patients you are admitting. Try to look at the Xrays and CT scan yourself. Do not wait for the prelim reports or the official report. As a physician, you need to learn the acute stuff in the radiology.
7- LACTIC ACID, ABGs (if Respiratory therapist does not do it, do it yourself and take it to the lab. It takes 5 minutes to get the ABG result) and CMP (LFTs) are your friends. Order them in all patients. They will guide your overnight management
8- So in our hospital, we carry our pager, the pager of the floor residents in his protected time, the night float phone and the team on-call phone. It gets crazy. One day, I was being paged and called every 5 mins from the 7th floor. My misery lasted for 1 hour. It was getting ridiculous. I lost my calm! So, I get the call from the same nurse who talked to me twice in the last 20 mins. She told me that patient has TPN and IVFluids running and patient has just one IV access. I checked the orders and there was no order for IV fluids. I told her that she needs to know her orders and asked her what is wrong with 7th floor tonight. I was mean. Then I suggested that all the nurses on the floor need to calm down. Sometimes, I think that some of the nurses do not realize that we are extremely busy in ED doing admissions and we may not have the luxury of the time to waste on unnecessary things
9- So, when you are on call, the nursing supervisor will call you for administrative stuff especially if there is a VIP patient in the ER. Be professional and tell them that you need to discuss everything with your attending. Once you have the backing of your attending and once you do the documentation of your communication with the attending, call the supervisor and tell them that you are NOT going to do what they are suggesting.
10- You will definitely lose your temper overnight. You will call a lot of people STUPID during your rotation(but never on their faces). And the next day, the Floor teams will also blame you for STUFF which they are supposed to do and follow. Your job is to just keep the patient alive till you sign out. I really do not like my colleagues when they start blaming each other for patient related matters. Once the patient is yours, it's your responsibility. Once you sign out, it is their responsibility.
11- My last words for you as a night float resident! "Welcome to the DARK SIDE"
The cases which you see as a night float resident in a community hospital varies widely. Now I am more comfortable admitting a drunk alcoholic patient than admitting someone for the CCU team. Our Hospital is not equipped to handle urgent cardiac cath. So, we have to decide about possible transfer to a hospital which can tackle Coronary cath. We admit a lot of NSTEMI and Arrhythmias. There is a cardiologist on call every night but he is at HOME and resting. It's hard to reach them and as a resident you can only pray for the patient in some situations. So, whenever I am admitting any patient for CCU for gray zone troponin or non-specific EKG changes, I give the patient Aspirin, Ticagrelor and Full dose anti-coagulation. I can not take the risk. I call the attending and he normally agrees with my approach. In short words, I am just scared to admit patients for CCU.
My advice for night Float
1- Whenever the nurse calls you, ask the name of the patient and the name of the admitting physicians. Some times, they call you for patients who are not teaching. It safes times!
2- Try to as polite as you can with the nurses but do not prolong your talk over the phone as it will waste your time and energy. Try to keep it short and straight to the point.
3. Whenever the nurse calls and you want to put in the orders, put them as soon as possible. Otherwise, you will forget and the nurse will give you a call again which will waste your time.
4- Be aware of the sick patients in Intermediate care unit and the CCU patients. Always ask the floor seniors to let you know about the sick patients when they are signing out. Also, if the nurse calls you for a patient and tells you that the patient is not doing good, kindly go to the floor and assess. Otherwise, patient might end up in a rapid response or code blue.
5- Whenever you are admitting a patient, go and speak with the ER nurse yourself. Sometimes, Nurses are busy and have too many patients or they are just feeling lazy and do not want to work. Talk to them and tell them about the orders you need them to follow as soon as possible eg. troponin 4 and FLUID BOLUSES. Tell them to follow some orders and ignore the rest.
6- Follow important labs and radiology of all the patients you are admitting. Try to look at the Xrays and CT scan yourself. Do not wait for the prelim reports or the official report. As a physician, you need to learn the acute stuff in the radiology.
7- LACTIC ACID, ABGs (if Respiratory therapist does not do it, do it yourself and take it to the lab. It takes 5 minutes to get the ABG result) and CMP (LFTs) are your friends. Order them in all patients. They will guide your overnight management
8- So in our hospital, we carry our pager, the pager of the floor residents in his protected time, the night float phone and the team on-call phone. It gets crazy. One day, I was being paged and called every 5 mins from the 7th floor. My misery lasted for 1 hour. It was getting ridiculous. I lost my calm! So, I get the call from the same nurse who talked to me twice in the last 20 mins. She told me that patient has TPN and IVFluids running and patient has just one IV access. I checked the orders and there was no order for IV fluids. I told her that she needs to know her orders and asked her what is wrong with 7th floor tonight. I was mean. Then I suggested that all the nurses on the floor need to calm down. Sometimes, I think that some of the nurses do not realize that we are extremely busy in ED doing admissions and we may not have the luxury of the time to waste on unnecessary things
9- So, when you are on call, the nursing supervisor will call you for administrative stuff especially if there is a VIP patient in the ER. Be professional and tell them that you need to discuss everything with your attending. Once you have the backing of your attending and once you do the documentation of your communication with the attending, call the supervisor and tell them that you are NOT going to do what they are suggesting.
10- You will definitely lose your temper overnight. You will call a lot of people STUPID during your rotation(but never on their faces). And the next day, the Floor teams will also blame you for STUFF which they are supposed to do and follow. Your job is to just keep the patient alive till you sign out. I really do not like my colleagues when they start blaming each other for patient related matters. Once the patient is yours, it's your responsibility. Once you sign out, it is their responsibility.
11- My last words for you as a night float resident! "Welcome to the DARK SIDE"
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