First month of general surgery residency on night float. Tips please!!

[bob123451]

So I guess i'm the lucky intern who gets to start there first month of residency on night float covering the three surgery services (Vascular, General, Bariatrics, Colorectal and scattered cases of subspecialties like plastics, Onc and Thoracic) at my community hospital. I have been getting some tips from my senior residents (Load the boat) but I wanted to reach out to ya'll and see what advice you can offer. Please feel free to brain dump anything and everything to help me survive this month and hit the ground running. Any specific pocket manuals I should buy? I know for medicine there's the mass gen pocket medicine. Is there anything like that for surgery that's worth investing into? I won't be responsible for the ICU as they have their own night float intern, but i'll be covering the floors. I am pretty familiar with our EMR which is Meditech. Really just worried about the specific orders and actions for situations that arise at night. My official first day on nights will be sometime early next week.

Thanks for tryna save me guys!

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[dr zaius]

I found the book Surgery On Call to be pretty helpful.

Grit your teeth and always be nice to the nurses...even when the pages are really dumb. They can always make it worse.

Go see the patient. You'll rarely regret it.

Never be afraid to bump it up the chain. If you're concerned or stumped, ask for help.

Stay organized. Make a to do list at sign out. Run the list with yourself multiple times through the night.

Make note of everything you order so you follow up on it. If things are busy you can and will forget about it (which is why you should run the list frequently).

Document EVERYTHING.

You don't have to have an answer for everything. If a patient's family arrives at 11pm and wants to know minor details of the patient's care plan, it's OK to say you're the night guy. That's much better than taking a wild guess, being way off, and causing a riff between the patient and primary team.

There are more pearls out there. When I'm less tired I will try to add more.

 

[bob123451]

Please do, these are helpful. Thanks!

 

[bob123451]

Just to clarify, is this the Surgery On Call by Lange? Or On Call Surgery:On call Series? The book is from 2005/6. I just want to confirm before I order it.

 

[tiedyeddog]

I second making a list at sign out. Put check boxes beside each task you need to have done and when it is done put a check in the box. Try to review the list whenever you have time or every hour or two at at least.

I know it sounds stupid but at least Google putting in peripheral ivs. I got calls all the time about not being able to get an iv from a nurse so I would just go do it myself or even get the ultra sound if I needed it.


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[SouthernSurgeon]

1. Be systematic. I don't care if you are smart and think you can remember 57 different things in your head. You WILL forget stuff. Important stuff. Developing an organized system (i.e. box checking) to ensure you get stuff done is critical.

2. Don't be afraid to call. I've never been upset at an intern for calling me. I've been upset at them for not calling. It doesn't even matter if you know medically what is appropriate to do for the patient, there are some important things that we as chiefs just need to be informed about.

3. Go see the patient. We have a saying that you can tell when someone is practicing "call room medicine" - i.e. just blindly putting in orders in response to the EMR vitals or the nurses pages. Don't be that guy.

4. First step in your development as an intern is learning SICK from NOT SICK. I don't expect you to know that at that point, but keep that question in mind as you see people.

5. Your chief likely has a very different priority list than yours. That's okay. You're micro-focused and detail oriented at the moment and that's what we want. You should be focusing on urine outputs and k levels. Just don't be surprised when it seems like your chief's focus is elsewhere. He/she is probably thinking about 2-3 big picture items for the patients that will really drive their care in one direction or another. If you can pick up on your chief's priorities it may help you get on their good side

6. Speaking of good sides. Try to get on the nurses' good side. They can add a lot more pain to your life than you can add to theirs. Be collegial and professional.

7. The pocket on call books are fine or whatever but a bit generic and honestly somewhat dated. Low UOP doesn't always need a bolus, even on POD0. You'll learn as you go. I don't think there is any one magical resource it's just a matter of gaining experience.

 

[ProfMD]

1) Keep a list of to-do items with check boxes. Add to it as your call night goes on. This should include labs/images/etc that have been ordered that need to be followed up on.

2) Have a low threshold to call your senior. Do not call until you have seen the patient yourself.

3) Go see every patient. In short order, you will figure out which ones you can handle by phone, but right now this is none of them. If you get called, see the patient.

4) Document everything. If you get called and see a patient, throw a note in the chart about what you saw, what you were thinking, and what you did.

5) Be nice to the nurses. They can make your life a lot easier, or a lot more painful.

6) If you get called for a consult, say yes and see the patient.

7) If you are calling another service for a consult, make sure you have seen the patient and can provide pertinent history, physical, and reason for the consult.

8) Have an algorithm in mind for common calls (fever, chest pain, low urine output, tachycardia, etc).

9) Always remember that it can be a pulmonary embolism.

10) Remember that internship is temporary. In the beginning you will feel like you know nothing. This will get better.

 

[armybound]

call you upper level

 

[rigid]

To add to some things

- Treat every patient like you want your family to be treated, do not cut corners
- Double check everything, asking for something to be done and it actually happening are two very different things
- Never dismiss a Nurses concern, they are seeing this patient for hours at a time and they usually know when something is up
- To add to above, do not ignore an irregular vital sign (be especially wary of respiratory rate)
- When a surgical patient has a non-surgical issue (rapid AF, hypoxia, whatever) its probably being driven by the surgical problem (eg that pleural effusion may be coming from a sub-phrenic abscess)
- You only get one chance to make a first impression, unfortunately this is yours
- Don't ever be forced/bullied into doing/charting something you're uncomfortable with

 

[dr zaius]

1) Keep a list of to-do items with check boxes. Add to it as your call night goes on. This should include labs/images/etc that have been ordered that need to be followed up on.

2) Have a low threshold to call your senior. Do not call until you have seen the patient yourself.

3) Go see every patient. In short order, you will figure out which ones you can handle by phone, but right now this is none of them. If you get called, see the patient.

4) Document everything. If you get called and see a patient, throw a note in the chart about what you saw, what you were thinking, and what you did.

5) Be nice to the nurses. They can make your life a lot easier, or a lot more painful.

6) If you get called for a consult, say yes and see the patient.

7) If you are calling another service for a consult, make sure you have seen the patient and can provide pertinent history, physical, and reason for the consult.

8) Have an algorithm in mind for common calls (fever, chest pain, low urine output, tachycardia, etc).

9) Always remember that it can be a pulmonary embolism.

10) Remember that internship is temporary. In the beginning you will feel like you know nothing. This will get better.

I feel like these are super important. In particular for #8, for the first few months of intern year I carried around a check list, algorithm, and ddx for common problems such as those stated. I found this helpful because it's very easy to forget to order something or think of an important item on the differential when you're getting paged constantly.

 

[DoctwoB]

In addition, remember what will kill your patients and keep those in mind. Most increased 02 requirement is not a PE, most "heartburn" is not an MI, most tachycardia isn't an acute bleed, but these things always need to be on your mind anytime you get a call about or see a patient. All things aside your first job at night is to keep people alive to the morning. MI, PE, CVA, bleeding, infection/sepsis are in the differential until proven otherwise.

Also agree that resp rate is an underused (and poorly charted) vital sign. Tachypnea usually means badness is happening. Likewise, rigors, even in the absence of fevers, are often an early warning that badness is coming.

 

[TypeADissection]

Good luck young doctor. Welcome to the team. It totally totally sucks! No just kidding (but not really). I'm gonna pass along what was told to me three years ago when I started out on night float as a "glorified medical student in a suddenly longer white coat." My only two goals for intern year were: 1. Be the best information gatherer in the hospital (the time for decision making will come later) and 2. Learn to identify sick vs not sick. The latter can actually be sometimes more difficult than it sounds but it'll start to come together. It'll actually never be easier than your intern year. See the patient, report it up the

 

[deleted547339]

In addition, remember what will kill your patients and keep those in mind. Most increased 02 requirement is not a PE, most "heartburn" is not an MI, most tachycardia isn't an acute bleed, but these things always need to be on your mind anytime you get a call about or see a patient. All things aside your first job at night is to keep people alive to the morning. MI, PE, CVA, bleeding, infection/sepsis are in the differential until proven otherwise.

Also agree that resp rate is an underused (and poorly charted) vital sign. Tachypnea usually means badness is happening. Likewise, rigors, even in the absence of fevers, are often an early warning that badness is coming.

Not a surgeon, but feel like this is related.

RR is the one vital sign you can't really trust a nurse to ge accurately, they will all magically be 16 or 20.

 

[HighPriest]

1. - Be as aggressive as possible to the nurses. Let them know right up front that you're a doctor and you're in charge. It's like being in prison, you need to make an example of someone right away.

2. - When you get a consult, always sound like the person on the other end is wasting your time. this will make you seem confident.

3. - When you write a new prescription, if you don't know the dosing just guess. The pharmacy gets paid to fix that.

4. - If a senior resident asks you something about a patient, always ask him or her if they read the note. Mention that all of that information is in there.

5. - If you're not getting at least 6-7 hours of sleep at night, it's because the floor nurses are screwing with you. See point #1.

6. - If you feel that another provider - especially a senior resident on another service or an attending - did something that you wouldn't have done, make sure you badmouth them. it's the only way they'll learn. Mention in your note that they probably made a mistake.

7. - Everything you order from radiology or the lab should go stat. You will have a lot on your plate, and you don't want to waste time waiting for some jerk to do their job.

8. - Patients come to you because they need to be told how to take care of themselves. Most people are incapable or surviving without your advice. You are their shepherd. Remember that.

9. - Reading is for children. You simply won't have time. Plus, this is residency. It is your attending physician's job to teach you, and they know it.

 

[tiedyeddog]

1. - Be as aggressive as possible to the nurses. Let them know right up front that you're a doctor and you're in charge. It's like being in prison, you need to make an example of someone right away.

2. - When you get a consult, always sound like the person on the other end is wasting your time. this will make you seem confident.

3. - When you write a new prescription, if you don't know the dosing just guess. The pharmacy gets paid to fix that.

4. - If a senior resident asks you something about a patient, always ask him or her if they read the note. Mention that all of that information is in there.

5. - If you're not getting at least 6-7 hours of sleep at night, it's because the floor nurses are screwing with you. See point #1.

6. - If you feel that another provider - especially a senior resident on another service or an attending - did something that you wouldn't have done, make sure you badmouth them. it's the only way they'll learn. Mention in your note that they probably made a mistake.

7. - Everything you order from radiology or the lab should go stat. You will have a lot on your plate, and you don't want to waste time waiting for some jerk to do their job.

8. - Patients come to you because they need to be told how to take care of themselves. Most people are incapable or surviving without your advice. You are their shepherd. Remember that.

9. - Reading is for children. You simply won't have time. Plus, this is residency. It is your attending physician's job to teach you, and they know it.

Brilliant.


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[SLUser11]

4. - If a senior resident asks you something about a patient, always ask him or her if they read the note. Mention that all of that information is in there.

This was my favorite.

Regarding #1, I must admit that I sometimes start trouble between the OR nurses and new female fellows for fun....did you hear what she said about you guys? She said "I'm a doctor and they are nurses. I write orders, and they FOLLOW orders." Then when I asked her if she was nervous they would retaliate, she said "they don't have the guts to try anything." Helps get me through the long cases. Haven't tried it on female interns yet.....

 

[Gastrapathy]

You are in a community hospital so this might be realistic: walk around to the floors and ask if they have anything for you right before you put your head down. You can even tell them that you are checking on them because you plan to close your eyes for a couple hours. Even on NF, a 2-4am power nap is really good for you.

You may get the chance to do some surgery cause there are fewer upper levels around at night. Get in there.

 

[kchan99]

7) If you are calling another service for a consult, make sure you have seen the patient and can provide pertinent history, physical, and reason for the consult.

This is for "Advice for Interns on Night Float." If you're calling another service for a non-emergency consult on a patient that you've admitted, please start your H&P first. Your H&P doesn't need to be finished; it only needs to be viewable to your consulting team in the EMR. Your HPI helps the consult resident in providing info that may not be given during your conversation, esp. when part of the history was obtained from someone accompanying the patient who may not be there by the time the consult resident sees the patient.

 

[Winged Scapula]

This is for "Advice for Interns on Night Float." If you're calling another service for a non-emergency consult on a patient that you've admitted, please start your H&P first. Your H&P doesn't need to be finished; it only needs to be viewable to your consulting team in the EMR. Your HPI helps the consult resident in providing info that may not be given during your conversation, esp. when part of the history was obtained from someone accompanying the patient who may not be there by the time the consult resident sees the patient.

This also applies to ATTENDINGS on night float/regular duties etc.

I cannot tell you how often I get a consult and there is no note from the admitting physician. I get that they like to dictate their note and it takes a few hours to transcribe but if that's the case, please actually leave some sort of note or hey, maybe even call me rather than let the ward clerk try and figure it out. It might just help me evaluate how soon I need to see the patient.

 

[Danbo1957]

It might just help me evaluate how soon I need to see the patient.

Well, I see a real systemic issue here, maybe not completely resolvable; but... If you were the Medical Director how would you like to deal with this?

 

[Winged Scapula]

Well, I see a real systemic issue here, maybe not completely resolvable; but... If you were the Medical Director how would you like to deal with this?

I would enforce the Medical Staff rule which says, "all consults are to be made physician to physician".

It would also eliminate ward clerks calling back line numbers during off business hours, leaving messages (which are not routed to the doctor on call) and thinking that "counts" as consult "called". If you haven't TALKED to someone, then the consult is not completed.

 

[Danbo1957]

Yep. "Physician to physician" oral consult, required here in academic medicine.

 

[deleted547339]

I would enforce the Medical Staff rule which says, "all consults are to be made physician to physician".

It would also eliminate ward clerks calling back line numbers during off business hours, leaving messages (which are not routed to the doctor on call) and thinking that "counts" as consult "called". If you haven't TALKED to someone, then the consult is not completed.

I feel like requiring face to face consult isn't necessary. It's kind of a rule that is only necessary if people can't place nice and act like grown-ups. If my secretary calls ortho for a femur fracture, that's pretty straight forward; if my secretary calls you with an appy, that's pretty straightforward; secretary calling hospitalist for chest pain rule-out? fine. If I have one of your post-op patients that doesn't feel great and is borderline, that needs the two of us to talk it out on the phone. The problem is that if you have a lazy ER doc or hospitalist service, the privilege will be abused and someone ruins it for everyone.

 

[Winged Scapula]

I feel like requiring face to face consult isn't necessary. It's kind of a rule that is only necessary if people can't place nice and act like grown-ups. If my secretary calls ortho for a femur fracture, that's pretty straight forward; if my secretary calls you with an appy, that's pretty straightforward; secretary calling hospitalist for chest pain rule-out? fine. If I have one of your post-op patients that doesn't feel great and is borderline, that needs the two of us to talk it out on the phone. The problem is that if you have a lazy ER doc or hospitalist service, the privilege will be abused and someone ruins it for everyone.

You're right - most of the time it isn't required.

But its been taken advantage often enough that its annoying.

BWT, @Danbo1957 its required here too, at every hospital I have privileges at. They just choose not to enforce it.