Hospital/Night float pearls/tips...

[NRAI2001]

I feel like a lot of night float/hospital medicine is learned from trial/error and experience...I thought it would be great to have a thread with pearls of wisdom or general educational type of questions us interns and residents could ask eachother.

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[NRAI2001]

When it comes to prn control of HTN overnight what are you reccs? At our hospital it seems that Hydralazine 5mg or 10mg IV is the go to medicine at our hospital... any other good reccs from your experience? The other meds we often use are enalapril and labetolol?

 

[Doctor4Life1769]

When it comes to prn control of HTN overnight what are you reccs? At our hospital it seems that Hydralazine 5mg or 10mg IV is the go to medicine at our hospital... any other good reccs from your experience? The other meds we often use are enalapril and labetolol?

You should try to at least entertain a differential prior to just giving prn BP meds.

 

[galactus]

want to decrease the pages at night? When the nursing shift changes at 7pm, do a quick round with the patients and ask the nurses if they need anything from you. made my page frequency drop in the middle of the night

 

[jonb12997]

I liked to shoot through around 830 or so. Once the night nurses had a chance to get sign out, assess their patients, and check all the orders. Dramatically reduced calls.

 

[JustPlainBill]

No pearls of wisdom here...just a memory of a page at 0345 with the nurse saying," Doctor, the patient in 745?" " Yes"..."Well, his vitals are stable..." Thinking -then why the hell are you paging me? -- " but his eyes have rolled back in his head and he's not responding. What do you want me to do?".....yep, another busy night at Chateau Parkland.....

Good luck, guys...glad my night float time is but a dim memory....

 

[JustPlainBill]

So -- just some things I used to do --- and remember, hospital work is NOT my forte -- I was always thinking, "What am I missing? Am I about to shove this patient over the edge? Is there anything in the chart/vitals that's significant that I'm missing? What do I do if this guy crashes?" ---

1) I would always ask,"Who's my sickest patient?" when taking checkout -- and round on them first to eyeball 'em -- if I felt they were bad sick or I hadn't seen them before, I'd ask the day shift sign out person to go see them with me so I could get an idea as to their normal mentation, etc.

2) For the ones that are sick, after rounding on the census, I would wander over to the ICU and chat with the resident's there -- let them know about my sick one's, see what they felt and casually give them a heads up, that way it wasn't a surprise if I needed to call them in the middle of the night -- sometimes, they'd offer to watch them peripherally with me. Once, I had a guy who was herniating and had started to become stuporous -- I called the ICU to evaluate and the resident didn't even bother eyeballing the patient, he looked over the chart while we were talking and flat out said,"He's ours as of now, I'm coming down with the intern, start the transfer paperwork". just like that -- none of the kids-in-the-sandbox games that you usually get at Parkland.

3) keep an eye on vitals, once you know the patients -- I'd check them usually last time at midnight/1AM and then again when I woke up from my nap at 5:30AM
4) Screw the "I'm going to study and read up on my patients" BS -- bring a good book or movie and some Fruity Pebbles -- you're working nights and will have trouble remembering stuff.
5) I also used to call the attending around 10PM to run the list with them and see if there were any specifics they wanted -- some appreciated it, some didn't.
6) Do not be afraid to call your attending -- I would rather get chewed out for calling than have a patient crash and now I've got to explain what happened and why I didn't call -- again, I had a bad residency experience so YMMV.
7) Admits -- a good chart review helps immensely, take your time and go through the ED note and previous chart history
8) Know where your floor pharmacy is -- sometimes they can help with medications that you're unsure of or have information that's not available elsewhere -- a box of Einstein Brothers Bagels ($20) with some cream cheese goes a long way towards ensuring goodwill --- also works with ICU types.
9) Don't be afraid to hang around IM types, you can learn good stuff that way.
10) Don't be afraid to cruise the ED (via EMR) and see if any of your clinic patient's are in the ED and see who looks like they may need admission -- if so, you can get ready before you get paged -- if they get discharged, great -- if not, it may take until the AM and the day shift can get it.
11) MAKE the dayshift give you immediate action drills/meds for patient's that are quirky or unstable -- don't guess since you don't know their thought process -- and don't let them give you some mealy mouthed BS either --


Anyway, not a lot of medicine, but that's the way I ran my service.

 

[Doctor4Life1769]

I generally agree, except I never cruised the ED list. I always had the mentality of "not my problem until they page me" - what's the point anyway? It's not like I'm going to click on the patient's name and see what they're there for and what's the work up been at that point. The less I know the better and if they contact me, I'll worry about it then. Most of the time the private patients are discharged with close follow-up (unless they clearly need admission, a lot of times the ED will call and ask if I want to admit or just DC with outpt follow-up if it's a soft call) and it's the unassigned patients that are called for an admission on those call nights.

My junior residents and a few of my co-residents; however, would cruise the list.

I always contacted my attending when a patient needed to be transferred to the ICU or if the patient passed away (even if it was expected). I generally didn't call unless I was in a bind or if the attending wanted to be called. A lot of mine didn't want a call unless I needed it or if they went to ICU/passed away. I always called for OB admissions.

 

[Bacchus]

want to decrease the pages at night? When the nursing shift changes at 7pm, do a quick round with the patients and ask the nurses if they need anything from you. made my page frequency drop in the middle of the night

Like X100. I noticed a considerable difference when I did this.

 

[Bacchus]

When it comes to prn control of HTN overnight what are you reccs? At our hospital it seems that Hydralazine 5mg or 10mg IV is the go to medicine at our hospital... any other good reccs from your experience? The other meds we often use are enalapril and labetolol?

I often go with lopressor and then hydralazine. I don't use labetalol unless on OB usually. I did vasotec a time or two, but my patients often already have an AKI going on.

 

[Bacchus]

You should try to at least entertain a differential prior to just giving prn BP meds.

Agreed. My intern once told me about a patient who was anxious/rowdy (not wanting to put the CPAP mask on) on the floor and was going to order a 1X Ativan dose. I asked if the intern saw the patient. The answer was no. So, instead of giving the ativan we went to the floor. Within 5 minutes I had the patient on a NTG drip for flash pulmonary edema and had called the ICU attending (as a heads-up) and had an ICU resident come see the patient to help me.

It may seem benign, but you should usually go see the patient if there is anything that doesn't seem "routine."

 

[Doctor4Life1769]

Agreed. My intern once told me about a patient who was anxious/rowdy (not wanting to put the CPAP mask on) on the floor and was going to order a 1X Ativan dose. I asked if the intern saw the patient. The answer was no. So, instead of giving the ativan we went to the floor. Within 5 minutes I had the patient on a NTG drip for flash pulmonary edema and had called the ICU attending (as a heads-up) and had an ICU resident come see the patient to help me.

It may seem benign, but you should usually go see the patient if there is anything that doesn't seem "routine."

It's pretty amazing, isn't it?
I always tell my interns to go see the patient. If I'm not doing anything I'll join 'em. Makes for some good education time too.
Surprised your nurses caught it in a somewhat timely manner. Some of our nurses only notice it too late and the pt then needs a tube and inodilator with ICU admission.

 

[Bacchus]

It's pretty amazing, isn't it?
I always tell my interns to go see the patient. If I'm not doing anything I'll join 'em. Makes for some good education time too.
Surprised your nurses caught it in a somewhat timely manner. Some of our nurses only notice it too late and the pt then needs a tube and inodilator with ICU admission.

I feel it was around 7pm, haha.

 

[cabinbuilder]

I would always check with the nurses around Midnight before going to lay down. I can live on 4-5 hours of sleep so they ususally left me alone if I covered all the bases before hand.

I would also go through the ER prior to laying down, I would rather do an admission at 11pm than 4am any day.

 

[JustPlainBill]

Agreed. My intern once told me about a patient who was anxious/rowdy (not wanting to put the CPAP mask on) on the floor and was going to order a 1X Ativan dose. I asked if the intern saw the patient. The answer was no. So, instead of giving the ativan we went to the floor. Within 5 minutes I had the patient on a NTG drip for flash pulmonary edema and had called the ICU attending (as a heads-up) and had an ICU resident come see the patient to help me.

It may seem benign, but you should usually go see the patient if there is anything that doesn't seem "routine."

did you ever get chewed out for doing that? I would always try to give people a heads up as to what was coming at them (or us) and my program attendings, save one, interpreted that as a lack of confidence/medical knowledge -- had a very sick patient that I was considering transferring to the ICU one night-- septic from LE cellulitis, on vanc/zosyn, tachy, approaching hypotensive, not responding to antipyretics, stuporous, on high flow mask on the floor -- I called the service attending at 2350 to let them know I was considering requesting a transfer on this one figuring he'd appreciate the heads up, we got one going south on us -- yeah, no -- that turned into a conversation with my advisor that they had a PGY3 who didn't know how to manage a fever ----

 

[Doctor4Life1769]

did you ever get chewed out for doing that? I would always try to give people a heads up as to what was coming at them (or us) and my program attendings, save one, interpreted that as a lack of confidence/medical knowledge -- had a very sick patient that I was considering transferring to the ICU one night-- septic from LE cellulitis, on vanc/zosyn, tachy, approaching hypotensive, not responding to antipyretics, stuporous, on high flow mask on the floor -- I called the service attending at 2350 to let them know I was considering requesting a transfer on this one figuring he'd appreciate the heads up, we got one going south on us -- yeah, no -- that turned into a conversation with my advisor that they had a PGY3 who didn't know how to manage a fever ----

Lol, the attending sounds like he came from my old anesthesia program.

 

[Bacchus]

did you ever get chewed out for doing that? I would always try to give people a heads up as to what was coming at them (or us) and my program attendings, save one, interpreted that as a lack of confidence/medical knowledge -- had a very sick patient that I was considering transferring to the ICU one night-- septic from LE cellulitis, on vanc/zosyn, tachy, approaching hypotensive, not responding to antipyretics, stuporous, on high flow mask on the floor -- I called the service attending at 2350 to let them know I was considering requesting a transfer on this one figuring he'd appreciate the heads up, we got one going south on us -- yeah, no -- that turned into a conversation with my advisor that they had a PGY3 who didn't know how to manage a fever ----

Never. It'd be viewed oppositely... effectively recognizing the limitations of med/surg, tele or step down I/II and planning ahead to avoid drastic complications. I did luck out because the ICU attending on call (I called the operator to ask who it was) is someone I'm on a texting basis with. I've actually talked to our ICU folk more about pediatric patients than adult patients. We don't have a PICU but still manage to admit often higher-than-we-should acuity to the peds floor (IMO). If I think something is going to go wrong and I want to let the out-of-house pediatric attending know about it, I will every once in a while slip in, "Oh, BTW, Dr. X is the intensivist tonight. He or she will manage kids over age X but no one younger. (or no peds at all)" I do that to get a point across because I'm the in-house provider (with RR backup, obviously).

 

[Bacchus]

I would always check with the nurses around Midnight before going to lay down. I can live on 4-5 hours of sleep so they ususally left me alone if I covered all the bases before hand.

I would also go through the ER prior to laying down, I would rather do an admission at 11pm than 4am any day.

Just date it after midnight

 

[Doctor4Life1769]

I would always check with the nurses around Midnight before going to lay down. I can live on 4-5 hours of sleep so they ususally left me alone if I covered all the bases before hand.

I would also go through the ER prior to laying down, I would rather do an admission at 11pm than 4am any day.

How would cruising the ER list impact when you did an admission?
Are you guys calling up the ED and going "yo, my man, if you're thinking of admitting patient X, she's our pt and pls let me know now than at 3 or 4am. K, thx bai!"

I just don't see the point but perhaps I'm missing something here?

 

[Doctor4Life1769]

Never. It'd be viewed oppositely... effectively recognizing the limitations of med/surg, tele or step down I/II and planning ahead to avoid drastic complications. I did luck out because the ICU attending on call (I called the operator to ask who it was) is someone I'm on a texting basis with. I've actually talked to our ICU folk more about pediatric patients than adult patients. We don't have a PICU but still manage to admit often higher-than-we-should acuity to the peds floor (IMO). If I think something is going to go wrong and I want to let the out-of-house pediatric attending know about it, I will every once in a while slip in, "Oh, BTW, Dr. X is the intensivist tonight. He or she will manage kids over age X but no one younger. (or no peds at all)" I do that to get a point across because I'm the in-house provider (with RR backup, obviously).

Y'all admitted kids too?
We only do adults.
My attendings here also appreciate when we give them a heads up, so that they aren't surprised and are aware of what happened and why we transitioned to higher level of care.

 

[Bacchus]

Y'all admitted kids too?
We only do adults.
My attendings here also appreciate when we give them a heads up, so that they aren't surprised and are aware of what happened and why we transitioned to higher level of care.

Call scenarios:
1) Worst: an active labor comes in while admitting an adult and pediatric patient
2) Best: there's a mid-level admitting for peds and no one goes into labor and I admit 1-2 adults at night.

 

[Doctor4Life1769]

Call scenarios:
1) Worst: an active labor comes in while admitting an adult and pediatric patient
2) Best: there's a mid-level admitting for peds and no one goes into labor and I admit 1-2 adults at night.

Hopefully there's nights where y'all aren't admitting.

 

[galactus]

Call scenarios:
1) Worst: an active labor comes in while admitting an adult and pediatric patient

Man glad I'm not in residency anymore lol. Hated those ICU admits + active labor (your continuity) while on night float.

 

[Doctor4Life1769]

Man glad I'm not in residency anymore lol. Hated those ICU admits + active labor (your continuity) while on night float.

Our policy is to admit the laboring OB and hit up the privates who were managing the pt in clinic and they come in. If they can't, then we call up the backup person from home. We don't manage both laboring pts and hospital pts the entire night like that while on night float. We also hit up OB residents so they're aware.

 

[cabinbuilder]

How would cruising the ER list impact when you did an admission?
Are you guys calling up the ED and going "yo, my man, if you're thinking of admitting patient X, she's our pt and pls let me know now than at 3 or 4am. K, thx bai!"

I just don't see the point but perhaps I'm missing something here?

We as residents when on call helped the ER doc from 7pm-12am since it was 17 rooms and only 1 ER doctor. Many times there was patient that took time to work up/be seen but pretty much knew they would be an admission especially if they had a private doctor and were very old. Also, our hospitalist was all about making money so he would admit EVERYONE that came close to criteria. Most times we could just admit and let him know. Where I did residency it was not uncommon to have 8-10 admissions a night so if I could get ahead of the game and start writing orders to get them admitted and do the H&P later. No such thing as a "cap". It was just one resident on call for the whole building.

 

[JustPlainBill]

Y'all admitted kids too?
We only do adults.
My attendings here also appreciate when we give them a heads up, so that they aren't surprised and are aware of what happened and why we transitioned to higher level of care.

Never. It'd be viewed oppositely... effectively recognizing the limitations of med/surg, tele or step down I/II and planning ahead to avoid drastic complications. I did luck out because the ICU attending on call (I called the operator to ask who it was) is someone I'm on a texting basis with. I've actually talked to our ICU folk more about pediatric patients than adult patients. We don't have a PICU but still manage to admit often higher-than-we-should acuity to the peds floor (IMO). If I think something is going to go wrong and I want to let the out-of-house pediatric attending know about it, I will every once in a while slip in, "Oh, BTW, Dr. X is the intensivist tonight. He or she will manage kids over age X but no one younger. (or no peds at all)" I do that to get a point across because I'm the in-house provider (with RR backup, obviously).

Thank you both -- you just reaffirmed my belief that my residency was toxic and abusive and I wasn't wrong when I made that call ---

For us -- we admitted OB continuity to one community hospital and at the time were running 2 in patient services -- 1 at the community hospital and the other at the county hospital -- basically a 10 minute drive with trying to find parking included in that time.

That meant you had to round on both sets of patients and be ready to roll for admissions -- there was no cap for our clinic patients who could present at either hospital, we took unassigned if we were under about 7-10 patients per intern -- if an OB came in, night float had to either rule out labor or do the admit and then page the intern/resident combination that was on OB that month --- you can see where all sorts of unforseen adventures could occur with this set up....all this was during my intern year ---

by the time I was night float we had closed the community hospital service, we had no OB continuity to speak of and ran 1 service in the county hospital -- usually capped for unassigned when the census was 7-10 per intern with 2-3 per PGY2 (usually 1 assigned to the service) -- it really sucked when you'd get hit with 3-4 clinic patient's overnight (no cap for clinic patients) and a full service handed off by day shift --

I do not miss my inpatient days -- it seems like it was made harder than it had to be with no real teaching being done by anyone --

I recall when I pulled the following stunt --

So while reading through the literature, I noted that Zofran (I think it was) had a prohibition in patient's with long QT, kinda like fluoroquinolones -- I offhandedly raised that question on rounds one day sotto voce while the intern was presenting (I was a pgy2) the case in the hallway -- I knew the attending heard it because I saw their head move towards my voice and a questioning look come across their face.

Next day on rounds, we had another patient put on zofran for nausea and the intern was asked if they'd gotten an EKG as Zofran is prohibited in patients with long QT -- and it took off and had a life of it's own from there --- I'm still chuckling on that one --- but then again, these are the same people who ordered an intern to put in a renal consult when a patients Scr jumped from 0.8 to 1.4 after they had mistakenly had 2 contrast studies in 1 day -- the intern looked a little puzzled and said that we could just hydrate, give them mucomyst and trend for now, no symptoms of uremia but the attending was adamant that a renal consult was needed to figure out the jump in the Scr -- so we happened upon a renal fellow while rounding and the intern and I walked over and stated our request -- the fellow had the same puzzled look and said it was clearly contrast induced nephropathy, fluids and trend -- our attending walked up, requested the consult, was told the same thing, pulled the "I'm an attending card, I want a formal consult" so the fellow put it on the list of "Things to do after I rearrange my underwear drawer" and walked off ---

 

[Doctor4Life1769]

Thank you both -- you just reaffirmed my belief that my residency was toxic and abusive and I wasn't wrong when I made that call ---

For us -- we admitted OB continuity to one community hospital and at the time were running 2 in patient services -- 1 at the community hospital and the other at the county hospital -- basically a 10 minute drive with trying to find parking included in that time.

That meant you had to round on both sets of patients and be ready to roll for admissions -- there was no cap for our clinic patients who could present at either hospital, we took unassigned if we were under about 7-10 patients per intern -- if an OB came in, night float had to either rule out labor or do the admit and then page the intern/resident combination that was on OB that month --- you can see where all sorts of unforseen adventures could occur with this set up....all this was during my intern year ---

by the time I was night float we had closed the community hospital service, we had no OB continuity to speak of and ran 1 service in the county hospital -- usually capped for unassigned when the census was 7-10 per intern with 2-3 per PGY2 (usually 1 assigned to the service) -- it really sucked when you'd get hit with 3-4 clinic patient's overnight (no cap for clinic patients) and a full service handed off by day shift --

I do not miss my inpatient days -- it seems like it was made harder than it had to be with no real teaching being done by anyone --

I recall when I pulled the following stunt --

So while reading through the literature, I noted that Zofran (I think it was) had a prohibition in patient's with long QT, kinda like fluoroquinolones -- I offhandedly raised that question on rounds one day sotto voce while the intern was presenting (I was a pgy2) the case in the hallway -- I knew the attending heard it because I saw their head move towards my voice and a questioning look come across their face.

Next day on rounds, we had another patient put on zofran for nausea and the intern was asked if they'd gotten an EKG as Zofran is prohibited in patients with long QT -- and it took off and had a life of it's own from there --- I'm still chuckling on that one --- but then again, these are the same people who ordered an intern to put in a renal consult when a patients Scr jumped from 0.8 to 1.4 after they had mistakenly had 2 contrast studies in 1 day -- the intern looked a little puzzled and said that we could just hydrate, give them mucomyst and trend for now, no symptoms of uremia but the attending was adamant that a renal consult was needed to figure out the jump in the Scr -- so we happened upon a renal fellow while rounding and the intern and I walked over and stated our request -- the fellow had the same puzzled look and said it was clearly contrast induced nephropathy, fluids and trend -- our attending walked up, requested the consult, was told the same thing, pulled the "I'm an attending card, I want a formal consult" so the fellow put it on the list of "Things to do after I rearrange my underwear drawer" and walked off ---

I consider myself very fortunate and lucky to have left a toxic environment and landed into an environment that is the total opposite. It was something I was worried about when I had to interview for positions. It usually doesn't work out that way, but I thank my lucky (or perhaps unlucky?) stars daily.

Usually if we have a good reason to counter a reason for a consult, the attending will be cool with it. If the renal dysfunction continued to worsen, then we call the consult. We also don't have fellows just private specialists. Only residents in the main hospital is us and the OBs run the OB wing except when we have our privates show up. All Peds goes to the children's hospital and we don't follow them there (thank God!)

 

[Doctor4Life1769]

We as residents when on call helped the ER doc from 7pm-12am since it was 17 rooms and only 1 ER doctor. Many times there was patient that took time to work up/be seen but pretty much knew they would be an admission especially if they had a private doctor and were very old. Also, our hospitalist was all about making money so he would admit EVERYONE that came close to criteria. Most times we could just admit and let him know. Where I did residency it was uncommon to have 8-10 admissions a night so if I could get ahead of the game and start writing orders to get them admitted and do the H&P later. No such thing as a "cap". It was just one resident on call for the whole building.

That's miserable.
We don't have a cap either (regardless of being on call or not - no cap for unassigned, no cap for privates). We fortunately don't have to help out in the ED since they have plenty of physicians and mid levels caring for the pts in the ED.

Where I am, if the ED contacted us for an admission, they were done unless the pt needed an ICU bed that was not avail. The rest of pt care would be on us and when we put in orders or whatever, then they are hands off and the pt is ours. This is why I don't bother with it until I'm paged and I know the pt is mine. If the work up is inadequate, I request for them to complete it and then contact me for admission (if indicated, otherwise, I ask them to finish the work up and I'll still be admitting).

 

[cabinbuilder]

That's miserable.
We don't have a cap either (regardless of being on call or not - no cap for unassigned, no cap for privates). We fortunately don't have to help out in the ED since they have plenty of physicians and mid levels caring for the pts in the ED.

Where I am, if the ED contacted us for an admission, they were done unless the pt needed an ICU bed that was not avail. The rest of pt care would be on us and when we put in orders or whatever, then they are hands off and the pt is ours. This is why I don't bother with it until I'm paged and I know the pt is mine. If the work up is inadequate, I request for them to complete it and then contact me for admission (if indicated, otherwise, I ask them to finish the work up and I'll still be admitting).

No not miserable, just easier to streamline admissions when helping the ER doc. Just took the crash and burn and started on the admission paperwork early so the call night wasn't so hard.