Night Float weekend

[Gfliptastic]

I just finished Night Float for this weekend. I'm posting as a curiosity although there will be some gripey-ness to it. Cuz I am wondering aside from putting a body in the hospital, is there an actual learning purpose to night float? Theoretically/ideally speaking.

Giving an intern the Ancom phone and getting signed off 64 patients from the many teaching services to receive multiple phone calls from nurses at all three nursing shifts (their 3-11, 11-7, 7-3) w/ 3 different sets of eyes on their patients. Night Float for us is 8pm to 10am and I found ZERO value to it.

Things I learned.

~ You have no time to assess any patient complaining of pain and if you try to be conservative w/ PRN narcotics, the patient/nurse will fight you about it till you give in and you pretty much become a glorified drug deal. I feel like I pushed probably a sum total of 1gm of IV dilaudid by the end of the shift.
~ If one nurse signs off a completely irrelevant symptom (i.e. a COPD exacerbation patient w/ R ear pain), that will continually be signed off on remaining shifts and 3 separate phone calls will be made.
~ So I DID learn to somehow be in these nursing sign-outs. Not literally, but unless you finally tell one nurse, "please only call me if the patient is febrile, tachypneic, or desats" that irrelevant symptom persists. And they make their snippy little notes in their notes, "Pt still complaining of ear pain. MD does no new assessment."
~ You sign off on more things than you have time to think about sometimes. Which is scary but somewhat necessary when your Ancom is going crazy. Those veteran nurses know what to do, but they Jedi mind trick you. "I have a patient w/ [this], can we order [that]? I can put it in for you. Spell your last name. Thanks doc!"
~ You are a "fire fighter" of the wards. Get a "fire" put it out. Move on. Which is not all that great. As much as you do want to be a "better doctor" you can't. If COPD patient were my daytime patient I'd want to fully "work up"/treat her ear pain. But you literally have an Ancom ringing in your pocket every 3 minutes and my census is 64. It's ONLY the "big stuff" otherwise it would be insanity. You sign it off to the relieving intern at the end of the shift, go home and sleep.
~ You can become quite delirious 8 hrs into it which is potentially where medical errors can be made. Fortunately none of mine were serious. For example, I needed to renew a mitts and wrist restraint order, which I completely did, not knowing I was in the WRONG patient's EMR. So the requesting nurse calls me back 30 mins later and asks why I didn't renew it. I explain I did. Only to see I did for another patient who's EMR I was in while talking to the nurse.

Point of all of it is (before I keep adding to that list which I could) to illustrate how medical learning is completely NOT happening when an intern (3 days into residency) is suddenly given a 64 patient census for 14 grueling hours overnight.

I anticipate a response like: "Well, you are learning how to acutely manage patients" so...that I can teach MY intern next year on Night Float which will eventually insulate me from it, if I decide to become a hospitalist w/ an overnight at a teaching hospital or actually an internist who does mostly OP.

If you read this or respond to it thanks lol

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[Dral]

Sorry, but at least you're done for now.

I loved night float. Mine was at the VA. We had a room with a leather couch, computer, and catered dinner every night to that room. I just used to lay there and watch adult swim all night.

Which is good...it was the VA. One Friday night I think I got called three times the whole night.

 

[Perrotfish]

I just finished Night Float for this weekend. I'm posting as a curiosity although there will be some gripey-ness to it. Cuz I am wondering aside from putting a body in the hospital, is there an actual learning purpose to night float? Theoretically/ideally speaking.

Giving an intern the Ancom phone and getting signed off 64 patients from the many teaching services to receive multiple phone calls from nurses at all three nursing shifts (their 3-11, 11-7, 7-3) w/ 3 different sets of eyes on their patients. Night Float for us is 8pm to 10am and I found ZERO value to it.

Things I learned.

~ You have no time to assess any patient complaining of pain and if you try to be conservative w/ PRN narcotics, the patient/nurse will fight you about it till you give in and you pretty much become a glorified drug deal. I feel like I pushed probably a sum total of 1gm of IV dilaudid by the end of the shift.
~ If one nurse signs off a completely irrelevant symptom (i.e. a COPD exacerbation patient w/ R ear pain), that will continually be signed off on remaining shifts and 3 separate phone calls will be made.
~ So I DID learn to somehow be in these nursing sign-outs. Not literally, but unless you finally tell one nurse, "please only call me if the patient is febrile, tachypneic, or desats" that irrelevant symptom persists. And they make their snippy little notes in their notes, "Pt still complaining of ear pain. MD does no new assessment."
~ You sign off on more things than you have time to think about sometimes. Which is scary but somewhat necessary when your Ancom is going crazy. Those veteran nurses know what to do, but they Jedi mind trick you. "I have a patient w/ [this], can we order [that]? I can put it in for you. Spell your last name. Thanks doc!"
~ You are a "fire fighter" of the wards. Get a "fire" put it out. Move on. Which is not all that great. As much as you do want to be a "better doctor" you can't. If COPD patient were my daytime patient I'd want to fully "work up"/treat her ear pain. But you literally have an Ancom ringing in your pocket every 3 minutes and my census is 64. It's ONLY the "big stuff" otherwise it would be insanity. You sign it off to the relieving intern at the end of the shift, go home and sleep.
~ You can become quite delirious 8 hrs into it which is potentially where medical errors can be made. Fortunately none of mine were serious. For example, I needed to renew a mitts and wrist restraint order, which I completely did, not knowing I was in the WRONG patient's EMR. So the requesting nurse calls me back 30 mins later and asks why I didn't renew it. I explain I did. Only to see I did for another patient who's EMR I was in while talking to the nurse.

Point of all of it is (before I keep adding to that list which I could) to illustrate how medical learning is completely NOT happening when an intern (3 days into residency) is suddenly given a 64 patient census for 14 grueling hours overnight.

I anticipate a response like: "Well, you are learning how to acutely manage patients" so...that I can teach MY intern next year on Night Float which will eventually insulate me from it, if I decide to become a hospitalist w/ an overnight at a teaching hospital or actually an internist who does mostly OP.

If you read this or respond to it thanks lol

1) Where is your senior?

2) Is your senior also night float or is (s)he on call?

3) What is your maximum possible census (if every bed was full)?

4) Are you doing admits too?

5) Are you running any of these order by your senior? What percentage of them?

6) Is night float always this many patients per Intern or does your staffing level go down on weekends?

 

[calvnandhobbs68]

This is insane...64 patients? Try half of that and that would be a more normalish number to handle. What you're describing is downright dangerous.

and yeah, where is your senior?

 

[gutonc]

This is insane...64 patients? Try half of that and that would be a more normalish number to handle. What you're describing is downright dangerous.

and yeah, where is your senior?

I don't know, that seems pretty typical. When I was an IM intern on NF, at the Uni we had 5 teams, 12 pts max, 1 intern and 1 senior, cross-cover and up to 8 admits a night (usually split with the senior unless s/he was a total asshat). At the VA there were 5 teams with 16 pts max, 1 intern doing X-cover, the other doing admits. The surgery interns had it worse. 1 on Trauma/Emergency Gen Surg (basically every ED consult plus trauma), 1 covering all the other "Gen Surg" services (Transplant, Surg Onc, Hepatobiliary, colorectal, Foregut), 1 more covering all the other sub-specialty services (Ortho, Uro, ENT, Plastics) and 1-3 covering the 3 surgical ICUs (otherwise covered by a PA or an R2) with variable in-house and home call backup.

 

[sluggs]

You are an intern with a ton of patients. If you can't find a way to learn from them and help them, there is something wrong with you. Start an IV. Look at labs and X-rays. Ultrasound a patient. Talk to a patient. Teach yourself.

 

[DeucesHigh3]

You are an intern with a ton of patients. If you can't find a way to learn from them and help them, there is something wrong with you. Start an IV. Look at labs and X-rays. Ultrasound a patient. Talk to a patient. Teach yourself.

I must disagree somewhat. At least 90% of what NF is teaching me are the normal starting doses for hydralazine, ativan, duonebs, melatonin, benadryl, dilaudid, zofran, and tylenol (which, of course, are right on the order screen anyway). The other vital skills I'm acquiring are how to renew a normal saline order that fell off, order an AM lab someone forgot, play telephone operator for nurses who can't parse the on-call rubric, and figure out how much a pt's/RN's desire for a PRN would conflict with the day-team's notes.

We're essentially just triage for about 15 cookie-cutter overnight issues... anything more interesting gets left to the day team, and anything more dangerous gets whisked away to the MICU.

 

[pulmoblast]

This is what you do as a nocturnist hospitalist...trust me when you are paid $120/hr for stupid phone calls like this you won't mind it that much

 

[DeucesHigh3]

Oh I'm sure I'd love it in that case. But alas, we're making $14-15/hr pre-tax...

 

[pulmoblast]

Set a countdown timer ending June 30 the year you finish residency. It will help immensely. But watch out and be alert on these stupid cross cover shifts...once I was being paged incessantly for a patient feeling "cold" on his eyebrow. I hauled my ass over there to scream at the nurse and happened to walk past the room. This guy was hemiplegic - in hospital stroke - when i confronted the nurse - she said he wasn't complaining of anything else over the intercom system

 

[Law2Doc]

Mostly what you learn from being alone on the wards at night is to be where the buck stops. The guy in charge. That's when you stop being a peon and start being a doctor. It's a big confidence builder to get good at these overnight stints and by the end of the year you will be doing a lot more than just what the nurses want. It teaches you to make good decisions and be confident in them. Once you get out in practice you'll be calling all the shots so best to have windows where you are doing it now. Yes the nurses may beat you down with multiple shifts of the same inane (this could wait until the morning) requests and yes some want you to knock out their patients with meds so they can just sit an do soduko. You'll learn how to play this game correctly eventually and realize who you answer to (hint -- it's not the nurses).

The hardest thing to appreciate when you start is that "medical learning" is not the stuff you were learning in med school -- this is. That's all stuff you'll forget and never use. The confidence of keeping 65 patients alive for the night is something you'll keep.

 

[Gfliptastic]

1) Where is your senior? ICU

2) Is your senior also night float or is (s)he on call? Senior is available but with junior in ICU. Junior is admitting, and does supervision of us. 2 interns. 1 w/ float phone for the 6 teaching teams. 1 w/ cardiac care phone and assisting w/ overnight admissions.

3) What is your maximum possible census (if every bed was full)? Float/teaching floors = 74. Cardiac team = 24.

4) Are you doing admits too? Not if you are the intern w/ the float phone, for obvious reasons

5) Are you running any of these order by your senior? Always possible! What percentage of them? Confidence dependent. I checked 35% probably, but my personality does tend to gravitate toward confident autonomy. I KNOW that is really dangerous, but that's who I am. Honestly it would have been 0% but I knew/understood when a proper answer was needed!

6) Is night float always this many patients per Intern or does your staffing level go down on weekends? I believe it was a "banner" weekend since we hit cap and even overcapped (via designed loophole), but I believe it's usually 80% of this amount.

Answered. If it sounds dangerous, I will make an addendum that we have that nocturnist hospitalist if the **** really hits the fan I suppose. I believe we CANNOT admit any patient at all w/o an attending physician (which sounds sensible). I barely saw him. And BTW, I had attendings calling me, like wanting special "favors" for their patients lol I sure as hell listened more intently than a nurse.

I do also believe this is normal. Where I did my IM core, it was about the same except there was only 5 teaching teams. And similarly where I did some electives.

Honestly, either phone rings about the same amount, since I agreed w/ my co-intern to switch hit this weekend. Got about >25 calls w/ CCU cover phone. Got >35 w/ float phone. Sleep was absolutely NO option. Which differed from my experience on surgical night float (as a medical student). I could get about 3 hrs of sleep if I was lucky. Which I rarely was. As soon as I laid down and drifted off - TRAUMA alert!

This is institutionalized hazing. But today most of the juniors and seniors were quite proud and congratulatory. Although it was basically started w/: "Hey, you survived!"

 

[Doctor Bagel]

Answered. If it sounds dangerous, I will make an addendum that we have that nocturnist hospitalist if the **** really hits the fan I suppose.

Can an intern on his/her third day of work really know when the *** hits the fan? I know that this is normal and all, but it scares me that you would be on without a senior resident. Sure the hospitalist is there, but it sounds like there's a prohibition on contacting them unless it's really urgent. With the 2011 duty hours changes, the interns at the program I trained at had essentially a month of more senior supervision before functioning autonomously. In my medicine months back in 2010 (pre duty hours changes), we still always had a senior with us on any internal medicine months even overnight. I believe night float in internal medicine consisted of a senior and an intern, not merely an intern.

Regardless of safety, you are learning stuff on this rotation even if it's not textbook medicine type of stuff. You're learning time and people management skills, which are critical. You're also learning how to recognize when the *** hits in the fan. My only worry is that you might miss it the first time.

 

[Gfliptastic]

Well I will say, "****" we are discussing will literally get a page for a FAST team (known elsewhere I've been at as Rapid Response Team). So I'm not quite sure if our levels of **** are the same??

Calls made to intern float phone consist of the following: "Should I give Y her metoprolol, since her HR is 120?" "Z is complaining of pain 2 hrs after I gave a q4 PRN dilaudid. Do you want to give some or hold off?" "L is desat'ing to the low 90's, can you assess?" "I need a restraint order renewal" "D has a temp of 101 after I gave PRN Tylenol, can you assess?" "K's BP is 85/60, should I hold off on the Vasotec?" Anyone who was a senior, do you want phone calls from your intern for this stuff??

If they desat below 80, become unresponsive, become apneic, go into V-fib, the intern float phone isn't getting a phone call. That's a FAST team. If you are imagining the episode of Scrubs where 3 interns are running a code and the patient dies, there is way too many fail safes for that to ever happen. For a code where I am, I'm there to smash chest. That's it and only it. If the senior and junior residents get stuck in an elevator, the FAST team has done a zillion codes, I doubt the intern would have very much say.

You DO answer my original post tho. I guess I did (and will when I start my actual 2 weeks of Night Float next Mon) learn time and people management skills.

 

[Perrotfish]

Well I will say, "****" we are discussing will literally get a page for a FAST team (known elsewhere I've been at as Rapid Response Team). So I'm not quite sure if our levels of **** are the same??

Calls made to intern float phone consist of the following: "Should I give Y her metoprolol, since her HR is 120?" "Z is complaining of pain 2 hrs after I gave a q4 PRN dilaudid. Do you want to give some or hold off?" "L is desat'ing to the low 90's, can you assess?" "I need a restraint order renewal" "D has a temp of 101 after I gave PRN Tylenol, can you assess?" "K's BP is 85/60, should I hold off on the Vasotec?" Anyone who was a senior, do you want phone calls from your intern for this stuff??

Honestly? In June I want the Intern calling me on every example you gave. Definitely not in the second half of the year. Maybe not on the second ward month. But right now I want that Intern telling me what he's about to do and why he thinks its a good idea for every call.

The issue is that at this point in the year I don't know that you have an adequate differential for what you're being called on. You might, but many Interns don't early in the year (I didn't). With the exception of the restraints every call you just described could have a much more serious etiology than the one the nurse is obviously thinking of, and while you may have considered and adequately ruled out all of them I think there's at least a good chance you might be missing something on one of them. When someone calls and asks about giving metoprolol to someone with a HR or 120 I want you to ask 'why is her HR 120?'. What's her rhythm? Is it compensatory for something? What's her clinical history and vitals? If they have a fever I need to know that you know when a fever is (chemo, hardware) or is not (known sepsis on abx, POD1) clinically important before you just give a PRN. Even the restraints: they're renewed every 12 hours for a reason. Do you know why you're tying this patient to her bed? I know you know a lot of that, but if you knew all of it and could apply it consistently you wouldn't need an Intern year or a Senior in the hospital to supervise you.

Obviously you're going to need to work within the system you're in, but you described a system where you do have supervising seniors and are allowed to call them more than you're calling them. You should be using your Seniors liberally. Good rules of thumb until you've finished at least one month of wards (including at least 2 weeks of night float)

1) If you think you might need to call, you need to call.
2) If you are writing orders without assessing the patients and reading their notes, you are overwhelmed and need to call.
3) If you're not sure what you're seeing, you need to call
4) If you are sure you don't need to call but anyone else on the clinical team is expressing any doubt about your management (nurse, RT, janitor, I don't care) you need to call


I really can't emphasize #4 enough. In time you will need to start standing your ground, but your first ward month is not when you push back against the rest of the clinical team without involving your senior. In that situation even if you're right you're still going to be considered to be offensive and wrong.

BTW your comments above about what is and is not serious do not sound like someone who really understands how serious a patient can be without being ICU material. The time that we save patients is not when we're coding them. Seriously, look up survival to discharge rates for patients who code in the hospital. What we go into medicine for is that magical window in between when your patient begins to develop something serious and when they begin to crump enough for them to call the FAST team. Bacteremia and sepsis but not shock. Renal failure and hyperkalemia but not arrhythmia. MI but no tissue death. Pulmonary hemorrhage while you can still tamponade it with CPAP. The real learning of night float is not time management or people skills. Its to learn how to pick out those needles in the haystack of calls.

 

[normtheniner]

Honestly? In June I want the Intern calling me on every example you gave. Definitely not in the second half of the year. Maybe not on the second ward month. But right now I want that Intern telling me what he's about to do and why he thinks its a good idea for every call.

The issue is that at this point in the year I don't know that you have an adequate differential for what you're being called on. You might, but many Interns don't early in the year (I didn't). With the exception of the restraints every call you just described could have a much more serious etiology than the one the nurse is obviously thinking of, and while you may have considered and adequately ruled out all of them I think there's at least a good chance you might be missing something on one of them. When someone calls and asks about giving metoprolol to someone with a HR or 120 I want you to ask 'why is her HR 120?'. What's her rhythm? Is it compensatory for something? What's her clinical history and vitals? If they have a fever I need to know that you know when a fever is (chemo, hardware) or is not (known sepsis on abx, POD1) clinically important before you just give a PRN. Even the restraints: they're renewed every 12 hours for a reason. Do you know why you're tying this patient to her bed? I know you know a lot of that, but if you knew all of it and could apply it consistently you wouldn't need an Intern year or a Senior in the hospital to supervise you.

Obviously you're going to need to work within the system you're in, but you described a system where you do have supervising seniors and are allowed to call them more than you're calling them. You should be using your Seniors liberally. Good rules of thumb until you've finished at least one month of wards (including at least 2 weeks of night float)

1) If you think you might need to call, you need to call.
2) If you are writing orders without assessing the patients and reading their notes, you are overwhelmed and need to call.
3) If you're not sure what you're seeing, you need to call
4) If you are sure you don't need to call but anyone else on the clinical team is expressing any doubt about your management (nurse, RT, janitor, I don't care) you need to call


I really can't emphasize #4 enough. In time you will need to start standing your ground, but your first ward month is not when you push back against the rest of the clinical team without involving your senior. In that situation even if you're right you're still going to be considered to be offensive and wrong.

BTW your comments above about what is and is not serious do not sound like someone who really understands how serious a patient can be without being ICU material. The time that we save patients is not when we're coding them. Seriously, look up survival to discharge rates for patients who code in the hospital. What we go into medicine for is that magical window in between when your patient begins to develop something serious and when they begin to crump enough for them to call the FAST team. Bacteremia and sepsis but not shock. Renal failure and hyperkalemia but not arrhythmia. MI but no tissue death. Pulmonary hemorrhage while you can still tamponade it with CPAP. The real learning of night float is not time management or people skills. Its to learn how to pick out those needles in the haystack of calls.

This makes me feel a little better. I feel like I've been calling my senior for almost everything. It's hard because I feel like they probably think I don't know anything.... the only thing I do to combat this (at least while I've been on night float) is to ask the senior why we're doing X intervention and then go back to the resident physician room on the unit and read whatever I can about what just happened. I feel like I'm learning a lot, I just wish I could feel like I knew enough to make bigger contributions to care.

 

[Siggy]

This is insane...64 patients? Try half of that and that would be a more normalish number to handle. What you're describing is downright dangerous.

and yeah, where is your senior?

Pfft. I did an intern year last year at a county hospital and we had 5 teaching teams that capped at 20 patients, 2 hospitalist teams (uncapped, but normally around 15) and 2 NP teams (stable patients that either need IV ABx or placement issues). The on-call senior was spending most of the night handling the ICU patinets and chiefing admissions with the attending from the med students.

So 2 interns handling cross coverage calls for easily 100 or more patients. There were times I was getting paged about every 10 minutes.

To the OP, you're probably learning more than you think right now. You're learning how to handle common issues and, gradually, learning to do it on your own without having to run every order by someone else.

 

[Gfliptastic]

Perrotfish I get your post. Honestly, that's what I would like to do, but that's also not very realistic w/ the patient load. Which is why we hand it off to day team. Which is part of my handoff. I tell the day intern, "Your patient spiked a temp of 101 @ 00:40, I gave Tylenol." <---It's that intern's job to do what he or she wants to do w/ that info. Sorry, gotta pass the buck. I am handing off 65 patients.

Spiking a temp, there might be something behind that worth digging. Being tachy, all those situations, those are very well and good and the essence of medicine. For the daytime intern who has 6 patients. And 14 hours to figure it out. NOT the intern who is floating w/ 65 patients while the phone rings every 5 minutes. I mean, the whole original objective of the post was essentially that. To state I did not feel any medicine learning was being accomplished while the stupid Ancom and a dozen nurses/patients allow no time.

For example, I had the same Uptodate article about alcohol withdrawal open at 12:30am as I did at 8:05am sign out. Because the nurse of the patient who was going through alcohol withdrawal had my Ancom ringing every 15 minutes, after I originally went to see him. (I turfed that one up to the senior the 3rd time his nurse asked me for even more Ativan). But another patient yanked out his PEG. And gal desat'd (Also got help for that). And an H/H dropped so I had to order blood. And I had hypothermia guy. Mild brady lady. I can go on and on. The best part of my day was giving that Ancom to the next victim.

Everything you describe is for the daytime interns. And I completely agree w/ you. But I respectfully disagree (as an intern to an attending) because that's not possible on Night Float. Like I stated in the original post. You are a fire fighter. Get a fire, put it out. You don't have time to discern if it was arson or accident. What caused it. There's a fire literally every 5-10 minutes. GOOD LUCK!

 

[calvnandhobbs68]

Which is exactly why an intern covering 65 patients is a dangerous situation, whether it's commonplace or not. There's a huge potential for mistakes, especially when your only senior is in the ICU dealing with his/her serious problems there. We also don't do coke anymore so we can stay awake for three days straight, just cause it happens doesn't mean it's a good idea.

 

[Perrotfish]

Which is exactly why an intern covering 65 patients is a dangerous situation, whether it's commonplace or not. There's a huge potential for mistakes, especially when your only senior is in the ICU dealing with his/her serious problems there. We also don't do coke anymore so we can stay awake for three days straight, just cause it happens doesn't mean it's a good idea.

It is tough for me to give advice to this guy because I literally have never seen a system even close to this, and between med school and residency I rotated through 8 different hospitals and 7 different Pediatric programs. I've seen an R3 do the job he's describing and cross cover 80 patients she didn't know, but it was considered a capstone rotation for residency. I've frequently seen an Intern cross cover a team of 20, which is what I think the upper limits of safe is. I have once seen day Interns cover up to 40 patients without real supervision, but they since changed the system for being unsafe. I have never heard of a new Intern doing anything like what this guy is doing at night.

I tell the day intern, "Your patient spiked a temp of 101 @ 00:40, I gave Tylenol." <---It's that intern's job to do what he or she wants to do w/ that info. Sorry, gotta pass the buck. I am handing off 65 patients

I don't know what to say other than that

1) If something that you were called on turned out to be serious, when the Intern gets there in the morning I promise it will be too late to fix it

2) If something turns out to be serious, I promise they will blame you. Not the senior. Not the system. Not the nurse. You.

Call often. If only to spread the blame around. If you can do nothing else sign out your management to the senior every 2-3 hours. Set an alarm in your phone so that you always do it. It can take 5 minutes to run the list, and once the Senior knows about your management he's at least on the line for it with you.

 

[DrZzZz]

It is tough for me to give advice to this guy because I literally have never seen a system even close to this, and between med school and residency I rotated through 8 different hospitals and 7 different Pediatric programs. I've seen an R3 do the job he's describing and cross cover 80 patients she didn't know, but it was considered a capstone rotation for residency. I've frequently seen an Intern cross cover a team of 20, which is what I think the upper limits of safe is. I have once seen day Interns cover up to 40 patients without real supervision, but they since changed the system for being unsafe. I have never heard of a new Intern doing anything like what this guy is doing at night.



I don't know what to say other than that

1) If something that you were called on turned out to be serious, when the Intern gets there in the morning I promise it will be too late to fix it

2) If something turns out to be serious, I promise they will blame you. Not the senior. Not the system. Not the nurse. You.

Call often. If only to spread the blame around. If you can do nothing else sign out your management to the senior every 2-3 hours. Set an alarm in your phone so that you always do it. It can take 5 minutes to run the list, and once the Senior knows about your management he's at least on the line for it with you.

I also worked (as an intern) at a hospital with night float system similar to Gfliptastic. I regularly covered 60-75 patients as an intern on medicine night float. The scariest parts of Gflip's situation to me are 1) that his/her only senior is in the ICU and 2) that he/she is on night float as an intern in July.
At my place, no interns were on night float until August (or maybe September?) so they at least got a little footing in being a doctor for the first time and knowing the hospital system a little better. Also, I had 2 seniors on night float whose only responsibilities were managing the admission grid, doing said admissions, and aiding the night float intern. Then there was another senior in ICU if **** really hit the fan. When I had a really sick patient I was uncomfortable with or unsuccessful in managing, I had a senior readily available. As much as I hated dealing with the 9,000 pages asking for colace, tylenol, AM lab orders, and other crap the day team should have dealt with, I loved night float because it made me actually feel like a physician (getting to manage patients on my own much of the night). And despite not having time to really read up on various things, I learned a hell of a lot managing patients at night when they were desatting, going into A-fib, dropping BPs, etc. That being said, I am so glad to never have to do it again.

 

[Gfliptastic]

Now that I've had a whole weekend to socialize (and yes, finally have a drink) I am doing a complete 180. Based on perrotfish's previous post. Night Float might not be a conducive environment to learn medicine, but I am being given an opportunity to have a bigger census than the day floor team interns (capped at 10), and not have to do all the "physical" work (like proper SOAP notes and dictations). And I need to make any attempt to reach the "ideal". Ideal being, what any overnight hospitalist might do at a non-teaching hospital any given night. Carrying that many patients. Not getting overwhelmed. Not being a "band-aid" hoping no one gets worse before the next shift.

I was thinking that every Ancom call/request should mean something. Anything! If a pt is feeling pain, say a leg or foot and is really requesting a PRN push of dilaudid ahead of schedule, I need to consider what might be causing that pain. Maybe they are s/p knee surgery a month ago, but are admitted for UGI bleed so anticoagulants are currently held. So maybe it's a DVT! I need to at least consider it, based on the situation and rule it out. Order up a d-dimer & possibly a US. At least do SOME critical thinking. Maybe nothing happens, but at least I am showing I'm not just blindly going through the routine. I AM thinking. Plus, I'm a freshly minted intern. Who is going to fault me for thinking?

Anyways, what a difference some R&R makes!

 

[Crayola227]

It's not like I've read everything Perrotfish ever wrote, but so far everything he has said has been 100% true and wise and makes me feel like living again. All interns would be wise to heed his advice.

 

[Crayola227]

For the record, I loved night float. But I did it after having ICU and wards under my belt.

I learned a lot because everything was either nothing or something. Meaning, since my job wasn't doing all the routine stuff to work up a patient and treat them, it was like either like BOOM! melatonin, done
or I was called for scary (to me as an intern) stuff

Like I would assess if the obstructed patient was getting acute abdomen
What to do with the guy in resp distress who won't keep bipap on
I actually like the challenges of pain management
I perfected PRN order sets for all kinds of stuff making all those orders way easier
Only admit and sig event notes to write, and the admit notes could be pretty sparse, I didn't have to do much of the workup just stabilize patients and start w/u for the day team, but it's not like I had to fix fix the patients

I carried around a book from the EM Resident assoc book EM's Top Clinical Problems which helped me a lot on my EM rotations, very algorithmic so using that I could at least be confident I did a good differential and diagnostic work up for anything scary or dangerous, an EM attitude helps (my only job is to keep these patients alive for day team w/o totally ****ting on their plan).

I had a similar situation as the OP, but more like 40-50 patients, the senior was away in the ICU, and changed mid rotation so they could be more or less helpful, but they were always very easy to call, but not get bedside
Reasonable admit cap, all admits staffed with an attending in person

I learned to be more efficient in assessing patients, problems, reviewing chart notes, writing admits, and I spent a lot of time problem shooting with the nurses. If they were really scared about a patient and there was nothing I could do, I would just sit with them outside the patient room while they thanked me for my reassuring presence (Jesus God! I'm an intern and I'm being appreciated for doing nothing other than sitting with a nurse or patient?! Why can't days be like this?)

Like Perrotfish said, blame shift! It's always great if you can start a sentence with "The senior or the attending told me..."
I would just add that you will never go wrong getting off your butt and going bedside. This will make the nurses happy even if you have no idea what to do to fix their problem, and When you're asked, "Did you see the patient? How did they look?" You want to be able to say yes. Major ass-saver.
Anything that comes up, if it is at all possible to just lay eyes and hopefully hands on the patient, you will be better off, that's true even and maybe especially if that doesn't change management or outcome.

 

[Law2Doc]

Honestly? In June I want the Intern calling me on every example you gave. Definitely not in the second half of the year. Maybe not on the second ward month. But right now I want that Intern telling me what he's about to do and why he thinks its a good idea for every call.

... You should be using your Seniors liberally. Good rules of thumb until you've finished at least one month of wards (including at least 2 weeks of night float)

1) If you think you might need to call, you need to call.
2) If you are writing orders without assessing the patients and reading their notes, you are overwhelmed and need to call.
3) If you're not sure what you're seeing, you need to call
4) If you are sure you don't need to call but anyone else on the clinical team is expressing any doubt about your management (nurse, RT, janitor, I don't care) you need to call
....

Absolutely agree with this IN THE FIRST MONTH. You know squat and your seniors know you know squat. If you make bad rookie decisions its actually the senior who is going to get torn a new one by the attending the next morning, so s/he ought to be pretty open to you calling for help when needed. But I think once you get past the first few night float weeks you need to start to carefully pick and choose when you make calls. If the patient is crashing absolutely make a call. If you can answer your questions with Epocrates or a call down to the pharmacy, don't make a call. And so on. The timing of when those training wheels come off is likely a bit different for every intern and in every specialty. But in large part this is what separates out the solid interns from the weak ones.

 

[Law2Doc]

.... the only thing I do to combat this (at least while I've been on night float) is to ask the senior why we're doing X intervention and then go back to the resident physician room on the unit and read whatever I can about what just happened. I feel like I'm learning a lot, I just wish I could feel like I knew enough to make bigger contributions to care.

Bear in mind that your plans aren't supposed to be made and implemented overnight. That's really the day teams job, when they round with the attendings and figure out the plan of care. Overnight your job is really just to keep the patients alive and kicking and in more or less the same condition they were signed off to you. If you can do that you are making a huge contribution to care.

 

[Law2Doc]

Which is exactly why an intern covering 65 patients is a dangerous situation, whether it's commonplace or not. There's a huge potential for mistakes, especially when your only senior is in the ICU dealing with his/her serious problems there. We also don't do coke anymore so we can stay awake for three days straight, just cause it happens doesn't mean it's a good idea.

First, I doubt all residents did coke even when it was in vogue. Second, with duty hours nobody is staying awake 40 hours in a row anymore. But the couple of studies out there haven't borne out that morbidity or mistake rates are any different with the shorter hours. Third, whether covering 65 patients is dangerous kind of depends on the acuity. In my intern year we carried multiple pagers and cross covered, but many of those patients were stable, about to be discharged types, who would be asleep in bed by 10 pm, and rarely coded.

 

[Doctor4Life1769]

Well, if there isn't coke being done, there certainly could be adderall being done

I kid.

 

[Crayola227]

First, I doubt all residents did coke even when it was in vogue. Second, with duty hours nobody is staying awake 40 hours in a row anymore. But the couple of studies out there haven't borne out that morbidity or mistake rates are any different with the shorter hours. Third, whether covering 65 patients is dangerous kind of depends on the acuity. In my intern year we carried multiple pagers and cross covered, but many of those patients were stable, about to be discharged types, who would be asleep in bed by 10 pm, and rarely coded.

I hate when people bring up that morbidity and mistake rates aren't any different
sure, maybe not for the patients, but what about for the residents?
meaning, do the work duty hours positively affect M&M of the residents?
I can think of so many car crashes, needle sticks, abused drugs, gastritis, divorces, quit jobs, cheating spouses and resultant STD testing and treatment, and the like that happened to residents because they just plain worked too many hours

The studies have definitely shown an improvement in resident QOL
Not that that should have any importance whatsoever

Now, if we can figure out how many patient QALYs are lost due to patient hand offs versus resident QALYs gained by not dying in car crashes or suicide due to exhaustion, we may decide that the life of the 30 year old resident might be worth, say, that of like three 85 year olds
I'm not being mean, seriously, let's bust out the calculators and make this about QALYs

 

[Law2Doc]

I hate when people bring up that morbidity and mistake rates aren't any different
sure, maybe not for the patients, but what about for the residents?
meaning, do the work duty hours positively affect M&M of the residents?
I can think of so many car crashes, needle sticks, abused drugs, gastritis, divorces, quit jobs, cheating spouses and resultant STD testing and treatment, and the like that happened to residents because they just plain worked too many hours

The studies have definitely shown an improvement in resident QOL
Not that that should have any importance whatsoever

Now, if we can figure out how many patient QALYs are lost due to patient hand offs versus resident QALYs gained by not dying in car crashes or suicide due to exhaustion, we may decide that the life of the 30 year old resident might be worth, say, that of like three 85 year olds
I'm not being mean, seriously, let's bust out the calculators and make this about QALYs

Have you worked a month of night float shifts? You aren't always less tired. Most people cant effortless will themslves to sleep in the daylight for the first few days, and you never catch up. On call you could sometime grab an hour of sleep. And you'd generally get a post-call day to recover. With night float, since it's a shift you are expected to work the whole night, and they generally don't even give you a call room. My bet is people crash their cars and stick themselves, and get divorced or have cheating spouses, just as frequently under this new system if not more. IMHO the only people who think a night float system is better are those who didn't have the opportunity to do both over the course of their training.

 

[Doctor4Life1769]

NF sucks balls.
I warn my interns that I become progressively meaner as the weeks ensue and to minimize their **** towards the last few days of the week. I'm usually good at the start of the week and my tolerance for bull**** is generally good.

 

[Crayola227]

Have you worked a month of night float shifts? You aren't always less tired. Most people cant effortless will themslves to sleep in the daylight for the first few days, and you never catch up. On call you could sometime grab an hour of sleep. And you'd generally get a post-call day to recover. With night float, since it's a shift you are expected to work the whole night, and they generally don't even give you a call room. My bet is people crash their cars and stick themselves, and get divorced or have cheating spouses, just as frequently under this new system if not more. IMHO the only people who think a night float system is better are those who didn't have the opportunity to do both over the course of their training.

You only got me there because yes, I do have to admit, I'm an oddball. Or maybe not. I did a lot of EM where the schedule was more like what you're describing, and in med school we had " long call" days and post call. Maybe I didn't experience that to the extent you're describing, but the random sleep schedule changes get me WAY WAY WORSE than just switching to being up all nights for a month. I felt ****ty for like 5 days then I was golden. Even as a nightowl I couldn't will myself to sleep during the day at first as I had been entrained out of that. I'd love for Michael Rack to chime in here, but otherwise I'd say I'm pretty knowledgeable about circadian rhythms and the like, and I'm truly a night owl wired where I think the other 10 months of day rotations are what I imagine nights are like to everyone else, it's miserable shift work you learn to adapt too. Nightfloat is my natural hour, so I should my opinion on the awesomeness of the hour isn't really generalizable (I still stand by what I said of its educational value). I'm planning on being a nocturnist for my circadian cycle (although yes the challenges of family, work/life balance, and difference what you actually do day vs night shift might have sway on that). It'd be great for my wallet and sleep though, I gotta tell you.

My friend works at a program where every month he has like a week of nights or long call or some weird thing in their 5 week rotations. The whole week is miserable because it always takes a week to really adjust to any major change in sleep/wake cycle, and by the time that happens at all (never does it long enough to I guess) he has to do figure out what the hell to do to turn back around that weekend before days. He switches to days more easily since that's how most people are. My program the senior is long call every Friday on wards and ICU months (and that's most of the months). I dunno, my body/brain likes the same wake/sleep cycle for as long as it can have it, one day off schedule a week isn't a killer, q3 or 4 sounds like hell on Earth, even if I had an 8 hour sleep interrupted once by a page, I wouldn't trade that for the reliable shift work of nightfloat. I want to be awake at work and asleep at home, if I have to be in the hospital I'm going to "enjoy" being awake rather than getting half assed interrupted naps. One week in 5 sounds like hell. I'm happy to just bunch together all the similarly timed shifts together into lumps, that way after I go through the pain of ****ing with my clock for a week I can at least ride the wave until it's time to change again.

I'm just expressing my experience, which as you point out, I can't really say I fully understand the old system but whatever I hear of it I like less.

Residents may be more exhausted on a nightfloat month, but supposedly that facilitates better hours the rest of the year. Again, QALYs, I think it's a gain for residents.

Or whatever, 80 hr work week restriction rules, that is the one thing I would step out of the shadows to fight the "Man" on IRL if they try to go back to the Dark Ages of Residency Work Hours. Whatever had to happen to night coverage to make that happen, I actually don't care about QALYs for all the jokes I made. I would sacrifice the lives of one 30 yo resident and 3 85 yo for that QOL. The quality adjusted life years refer to quality as a measure of function that allows one to contribute to society, while the word quality is in it, it is not the same as quality of life. QALYs are a financial public health measure. I'm a selfish renegade who shouldn't even practice medicine by many standards, because I would trade some QALYs for QOL years for me and my resident dawgs yo. And there's even physician assisted suicide. The tide is turning towards quality not quantity on all fronts. Before long, people will be living shorter, happier lives. My signature pretty much captures why I'm cool with these trends.

 

[Crayola227]

What I didn't throw out there is that most of the docs I know either know jack about or just don't bother with sleep hygeine. It doesn't have to be a matter of willpower, Michael Rack will tell you, there's a lot of science we're not using to help us out.

In fact, the only real issue I have with residency is the biological laws of sleep that it violates. I'm cool with starving, holding in my piss, being pissed on, being almost celibate, seeing FB pics of my peers at the pool with their infants while my uterus shrivels, and spending 99% of my waking hours in the hospital. It's when I can't wake and sleep at the same time and get a straight 8 that I have objections.

 

[Doctor Bagel]

What I didn't throw out there is that most of the docs I know either know jack about or just don't bother with sleep hygeine. It doesn't have to be a matter of willpower, Michael Rack will tell you, there's a lot of science we're not using to help us out.

In fact, the only real issue I have with residency is the biological laws of sleep that it violates. I'm cool with starving, holding in my piss, being pissed on, being almost celibate, seeing FB pics of my peers at the pool with their infants while my uterus shrivels, and spending 99% of my waking hours in the hospital. It's when I can't wake and sleep at the same time and get a straight 8 that I have objections.

It's true that we very strangely ignore the evidence we know about the importance of sleep hygiene. One idea that goes around in medicine that drives me crazy is the notion that you somehow get better at sleep deprivation the more you do it, like training for an athletic event. I don't think sleep works that way.

About night float, though, and the duty hours changes, the one thing I think it did that lowered quality of life in the programs I saw was the length of everyone's days. IMO, working 12 hour days 6 days a week is super miserable. I'd much rather have some shorter days coupled with a call day (and a post call day!) in there. Night float is OK. The long days, though, are miserable. Our interns went from having periodic overnight weekend call and one long day a week (7:30 am to 8 pm at the earliest) to two long days a week. The medicine interns went from having one overnight call and one long day in a 5 day period coupled with 3 pretty short days to all long days except your day off. The peds residents supposedly do 6 12 hour day shifts their whole life. I think that makes it way harder to have a life outside of work. Also, those long days in my program often went well after 8 pm -- your shift ended then but if you got 2 to 3 admissions/consults in your 3 hour short call period, you'd be stuck late writing them up and of course still coming in to start your day at 7:30 the next morning.

 

[Crayola227]

True true, Dr. Bagel, about those long call days.
And I have this great quote from somewhere about this idea of getting a "tolerance" for sleep deprivation

Not my words, I'm sorry I saved this verbatim and didn't note the author, but not plagiarism as I do not claim them as my words:, re: similarities between alcohol intoxication, sleep deprivation and perception of performance:
"How it works in medicine is a matter for research, but how it works in other fields is similar to how it works with habitual alcohol abuse: as you acquire experience at performing while impaired (e.g. driving drunk) you build a baseline of “normal” which includes your impaired behavior as perceived by your impaired judgment. Since the ability to recognize poor performance is degraded before the ability to actually perform, especially for tasks for which you have trained extensively, your self-perceived performance may actually improve. Thus the common opinion that “I actually drive better after a few drinks.”"

 

[Crayola227]

Dr. Bagel (I can't get over the cute cat avatar named Dr. Bagel)
The schedule you describe sounds like it has its appeal.

I think now, that whatever is the form of dysfunction/torture that you're first initiated to is likely to remain as the one you prefer, unless there's some other compelling thing (I love nightblock!), but all these systems sound appealing and disgusting in their own unique ways

I want to go back to shaman days, I would have died in childbirth before now I'm guessing (might have been a relief) but otherwise
if I were a shaman, I would just stay up all night and eat herbs to get a headchange
and work might be ritual cutting or something, but it might not be as painful as being a modern MD and work could be just shaking sticks and drinking nasty concoctions, and we could close the hospitals
people argue there would be all this suffering if we did that, but the most ancient form of medicine was euthanasia, it's not like they just had to let people suffer if they couldn't heal them (there's more than one way to harm & heal, word)

Just a weird little daydream I have sometimes when I'm on long call

 

[Law2Doc]

You only got me there because yes, I do have to admit, I'm an oddball. Or maybe not. I did a lot of EM where the schedule was more like what you're describing, and in med school we had " long call" days and post call. Maybe I didn't experience that to the extent you're describing, but the random sleep schedule changes get me WAY WAY WORSE than just switching to being up all nights for a month. I felt ****ty for like 5 days then I was golden. Even as a nightowl I couldn't will myself to sleep during the day at first as I had been entrained out of that. I'd love for Michael Rack to chime in here, but otherwise I'd say I'm pretty knowledgeable about circadian rhythms and the like, and I'm truly a night owl wired where I think the other 10 months of day rotations are what I imagine nights are like to everyone else, it's miserable shift work you learn to adapt too. Nightfloat is my natural hour, so I should my opinion on the awesomeness of the hour isn't really generalizable (I still stand by what I said of its educational value). I'm planning on being a nocturnist for my circadian cycle (although yes the challenges of family, work/life balance, and difference what you actually do day vs night shift might have sway on that). It'd be great for my wallet and sleep though, I gotta tell you.

My friend works at a program where every month he has like a week of nights or long call or some weird thing in their 5 week rotations. The whole week is miserable because it always takes a week to really adjust to any major change in sleep/wake cycle, and by the time that happens at all (never does it long enough to I guess) he has to do figure out what the hell to do to turn back around that weekend before days. He switches to days more easily since that's how most people are. My program the senior is long call every Friday on wards and ICU months (and that's most of the months). I dunno, my body/brain likes the same wake/sleep cycle for as long as it can have it, one day off schedule a week isn't a killer, q3 or 4 sounds like hell on Earth, even if I had an 8 hour sleep interrupted once by a page, I wouldn't trade that for the reliable shift work of nightfloat. I want to be awake at work and asleep at home, if I have to be in the hospital I'm going to "enjoy" being awake rather than getting half assed interrupted naps. One week in 5 sounds like hell. I'm happy to just bunch together all the similarly timed shifts together into lumps, that way after I go through the pain of ****ing with my clock for a week I can at least ride the wave until it's time to change again.

I'm just expressing my experience, which as you point out, I can't really say I fully understand the old system but whatever I hear of it I like less.

Residents may be more exhausted on a nightfloat month, but supposedly that facilitates better hours the rest of the year. Again, QALYs, I think it's a gain for residents.

Or whatever, 80 hr work week restriction rules, that is the one thing I would step out of the shadows to fight the "Man" on IRL if they try to go back to the Dark Ages of Residency Work Hours. Whatever had to happen to night coverage to make that happen, I actually don't care about QALYs for all the jokes I made. I would sacrifice the lives of one 30 yo resident and 3 85 yo for that QOL. The quality adjusted life years refer to quality as a measure of function that allows one to contribute to society, while the word quality is in it, it is not the same as quality of life. QALYs are a financial public health measure. I'm a selfish renegade who shouldn't even practice medicine by many standards, because I would trade some QALYs for QOL years for me and my resident dawgs yo. And there's even physician assisted suicide. The tide is turning towards quality not quantity on all fronts. Before long, people will be living shorter, happier lives. My signature pretty much captures why I'm cool with these trends.

1. Call as a med student isn't the same. You might think it is at the time but you have no clue how sheltered you are from certain things.
2. Because of the 1 day off in seven rule you are in fact forever shifting your sleep cycle during long night float shifts.
3. again with call you might actually get a quiet night and sleep in the call room once in a while. With night float since its a work shift you generally are expected to work the whole time, as your sleep time is in the daylight.
4. Honestly a lot of us who lived through both regimes AS A RESIDENT can tell you with certainty that you were less tired on the non call days under the call system. Night float you are like a zombie months on end. So the latter is more dangerous in terms of driving, sticking, marriage. All you guys who graduated med school into the night float system got hosed. You just don't know how bad because you don't have the other to compare it to.

 

[Crayola227]

1. Call as a med student isn't the same. You might think it is at the time but you have no clue how sheltered you are from certain things.
2. Because of the 1 day off in seven rule you are in fact forever shifting your sleep cycle during long night float shifts.
3. again with call you might actually get a quiet night and sleep in the call room once in a while. With night float since its a work shift you generally are expected to work the whole time, as your sleep time is in the daylight.
4. Honestly a lot of us who lived through both regimes AS A RESIDENT can tell you with certainty that you were less tired on the non call days under the call system. Night float you are like a zombie months on end. So the latter is more dangerous in terms of driving, sticking, marriage. All you guys who graduated med school into the night float system got hosed. You just don't know how bad because you don't have the other to compare it to.

Call or ED as a med student was no where the same because of stress level, my hours of sleeping and waking were still long and strangely chaotic, however I can't say how that was similar to the old system at all really, just didn't like the randomness

Nightfloat at my program:

4 weeks once for the whole year
7 pm to 7 am Su-F
so you have Friday day, eve, all of Saturday, and Sunday am off, basically weekends off, not one day in seven that month
3 admits overnight, cross cover 40-50 patients I think
I developed these great PRN order sets and went over that stuff with day team and nurses so they were tucked in tight for that stuff
I like being awake that hour. I was told I looked more awake at 7 am after nightfloat than I did at 7 am for days on wards
I stayed up the whole shift. I napped only if I was bored and tired of studying when my admits were capped and the patients tucked (I had a talent for tucking)
I slept during the daylight fine, but I know my sleep medicine so it was fine (melatonin, trazodone, literally almost light tight room with lightblocking curtains, facemask, earplugs if needed, a sunrise simulator to wake me for night, coffee at the right times, and I didn't turn around to days over the weekend)

I liked working on my own with a good senior to call down from ICU
staffed all pts with hospitalist

The seniors have a slightly different experience with call than me, obviously. ICU is brutal for them, long call 7 am to 7 pm 6 days a week.
On wards they would have to do overnight call Friday

I probably can't fashion the system you're thinking of in my new gen intern brain
Outline for me like a calendar so I know what hours I would hypothetically be working under the old regime
q4 never really meant anything to me, and I never really got how it was explained in a way that I could imagine waking and sleeping week to week
It would be great actually if you wanted to teach me, I think the noobs should preserve the knowledge of what the old system was for posterity (I hope it stays the old system)

Somehow Dr. Bagel explained it where it sounded like doing those long call days spread throughout meant shorter days on the other days

Why does one month of nights make you a zombie for months? You mean the month of nightfloat adjusting, then the next month of days switching back, or that the nightfloat system means longer sustained hours over pretty much all the rest of the inpt rotations? Or all of that? I jus don get it I's a baby

 

[Crayola227]

I usually hear so much enthusiasm about the nightfloat system except from older residents

I told Dr. Bagel that both systems seem to have diametrically oppsoed costs/benefits, so it seems a wash, and maybe you just like either the torture system you were initiated into unless there's some other quirk at work (I am circadian-ly wried to be a vampire)

 

[Law2Doc]

I usually hear so much enthusiasm about the nightfloat system except from older residents

I told Dr. Bagel that both systems seem to have diametrically oppsoed costs/benefits, so it seems a wash, and maybe you just like either the torture system you were initiated into unless there's some other quirk at work (I am circadian-ly wried to be a vampire)

except in the case of the rare person like yourself who is fine with medically controlled sleep hygiene control, blackout shades and a daylight simulating machine, the single call shift followed by a Post call day is better tolerated. Bear in mind that there are more than one form of call, and the long call short call system Doctor Bagel was referencing isnt what all of us had. I took call back when 30 hour shifts were allowed. During your call day you came in like normal but didn't leave until after morning rounds the next day, but then had the whole day and night off as a post-call day. So between a post call day and the one day off in seven (and the fact that you maxed out on duty hours pretty quick when you were doing 30 hour stints) you actually had a few opportunities to come up for air each week. The days you were not on call were normal days (get there in early am, leave around dinner time). 30 hours only seems bad until you do it. You get a bit tired during the wee hours but then get a Second wind and are fine. No interns I trained with wrecked their cars, but once end a while people took naps at the hospital before hitting the road. I wouldn't recommend long commutes, though.

I think to some extent it's like taking off a bandaid from a hairy part of your body. Call is just yanking it off in one quick pull -- hurts at the time but then you're back to normal. Night float is pull it off very slowly over time, never really getting back to normal.

 

[calvnandhobbs68]

Call or ED as a med student was no where the same because of stress level, my hours of sleeping and waking were still long and strangely chaotic, however I can't say how that was similar to the old system at all really, just didn't like the randomness

Nightfloat at my program:

4 weeks once for the whole year
7 pm to 7 am Su-F
so you have Friday day, eve, all of Saturday, and Sunday am off, basically weekends off, not one day in seven that month
3 admits overnight, cross cover 40-50 patients I think
I developed these great PRN order sets and went over that stuff with day team and nurses so they were tucked in tight for that stuff
I like being awake that hour. I was told I looked more awake at 7 am after nightfloat than I did at 7 am for days on wards
I stayed up the whole shift. I napped only if I was bored and tired of studying when my admits were capped and the patients tucked (I had a talent for tucking)
I slept during the daylight fine, but I know my sleep medicine so it was fine (melatonin, trazodone, literally almost light tight room with lightblocking curtains, facemask, earplugs if needed, a sunrise simulator to wake me for night, coffee at the right times, and I didn't turn around to days over the weekend)

I liked working on my own with a good senior to call down from ICU
staffed all pts with hospitalist

The seniors have a slightly different experience with call than me, obviously. ICU is brutal for them, long call 7 am to 7 pm 6 days a week.
On wards they would have to do overnight call Friday

I probably can't fashion the system you're thinking of in my new gen intern brain
Outline for me like a calendar so I know what hours I would hypothetically be working under the old regime
q4 never really meant anything to me, and I never really got how it was explained in a way that I could imagine waking and sleeping week to week
It would be great actually if you wanted to teach me, I think the noobs should preserve the knowledge of what the old system was for posterity (I hope it stays the old system)

Somehow Dr. Bagel explained it where it sounded like doing those long call days spread throughout meant shorter days on the other days

Why does one month of nights make you a zombie for months? You mean the month of nightfloat adjusting, then the next month of days switching back, or that the nightfloat system means longer sustained hours over pretty much all the rest of the inpt rotations? Or all of that? I jus don get it I's a baby

7pm-7am Su-F does not typically mean you get all of Friday off. Most systems that means you work sunday night through friday night and get saturday night off (so only one "day" off). So what you really worked was Su-Th.

Nights are different at every place. Some places you get one day off/week but get a week off somewhere during night float month (that same place you work 14 hour nights instead of 12 hour nights though). Some places you do a week of nights on every floor month you have (so cover that service at night).

In regards to your question about call and short vs long day, short and long days get adjusted because you no longer have someone there every day who is "on call" that everyone else can hand their patients to in the afternoon. So instead you're arbitrarily designating a "long" person every day and you're short a resident because someone is on nights. Before the long person was just...the person on call. That increases the frequency of everyone else having to do long days or just makes everyone else do 12 hr days/6 days a week depending on how your program works and how long the night vs day shifts are.

 

[Wordead]

except in the case of the rare person like yourself who is fine with medically controlled sleep hygiene control, blackout shades and a daylight simulating machine, the single call shift followed by a Post call day is better tolerated. Bear in mind that there are more than one form of call, and the long call short call system Doctor Bagel was referencing isnt what all of us had. I took call back when 30 hour shifts were allowed. During your call day you came in like normal but didn't leave until after morning rounds the next day, but then had the whole day and night off as a post-call day. So between a post call day and the one day off in seven (and the fact that you maxed out on duty hours pretty quick when you were doing 30 hour stints) you actually had a few opportunities to come up for air each week. The days you were not on call were normal days (get there in early am, leave around dinner time). 30 hours only seems bad until you do it. You get a bit tired during the wee hours but then get a Second wind and are fine. No interns I trained with wrecked their cars, but once end a while people took naps at the hospital before hitting the road. I wouldn't recommend long commutes, though.

I think to some extent it's like taking off a bandaid from a hairy part of your body. Call is just yanking it off in one quick pull -- hurts at the time but then you're back to normal. Night float is pull it off very slowly over time, never really getting back to normal.

My impression is that postcall days after call are way better than nightfloat.

However, several specialties have switched to "home call" systems where if you have to come in, you come in (which can be most nights at a busy hospital) but it doesnt count as inhouse call so you DONT get a postcall day. So basically you get screwed coming and going - come in all night but dont get a postcall day. So night float seems like a huge improvement.

 

[Law2Doc]

My impression is that postcall days after call are way better than nightfloat.

However, several specialties have switched to "home call" systems where if you have to come in, you come in (which can be most nights at a busy hospital) but it doesnt count as inhouse call so you DONT get a postcall day. So basically you get screwed coming and going - come in all night but dont get a postcall day. So night float seems like a huge improvement.

home call only works for a handful of specialties. You always need someone in the wards/ICU for medicine and surgery. So it's either night float or in house call.

 

[Gfliptastic]

Forgot to follow up on my own thread. (See no f/u. Bad intern! )

My 2 weeks is over. No one died. Not blind luck either, I got my s*** together in the sink or swim of NF. No one was even maimed, so I do want to pat myself on the back. In fact, I took a conservative approach after awhile. Like threw out sepsis work ups for febrile, tachy overnight pts w/ an upward trending WBC like melatonins for all those "insomniacs". Stat CT's on altered folks who weren't altered at 10pm, etc. I learned some stuff. Not anything that is going to help me on my first ITE next week, but what the hell, I probably wasn't going to study hard for that anyways. I consider it a "baseline" so I might as well go as low as I can go LOL

And my eval from the hospitalist attending said I was average intern but he saw potential since I could almost do an entire admission on my own.

However, in all it's irony, I miss NF. Cuz now I have a mess load of dictations to do. Notes for everything. Documentation out the wazzoo. My pager goes off now. (Never did when I had the ASCOM in my pocket). And working up my own patient? Boo! lol

I thoroughly enjoy being a "normal" person tho. Wake up in the AM go to bed in the PM. I don't have Night Float (weekend) until September so let it ride baby!

 

[Crayola227]

7pm-7am Su-F does not typically mean you get all of Friday off. Most systems that means you work sunday night through friday night and get saturday night off (so only one "day" off). So what you really worked was Su-Th.

Nights are different at every place. Some places you get one day off/week but get a week off somewhere during night float month (that same place you work 14 hour nights instead of 12 hour nights though). Some places you do a week of nights on every floor month you have (so cover that service at night).

Good point. Night float at my program pretty humane and cush compared to most of what I hear out there.
You're right, it was until Thursday, but weird since I didn't leave until Fri AM and then had to sleep/ But I got to have a great Friday and Saturday night!!
12 hours -- sweet. On ward mos you could get shorter days, but f*ck that I liked regular schedule and getting an extra bit of time on weekend, and the total number of hours a week was less. No getting trapped in the hospital for BS, where you're about to sign your pager out at 3pm (yay early day!) then 2 min beforehand get a page the family wants an hour long heart to heart. (don't mind family chats, but sometimes I want out the door.....)
Every floor month having only 1 week nights then switching back to days would f*ing kill me. Need to avoid that. If it's a 4 or 5 week rotation, say 5, then out of 2 blocks
wk 0 (last rotation's night week, zombie nights adjusting)
wk 1 - zombie days from coming off night on last block
wk 2, wk 3, wk4 - feel good regular schedule
wk 5 - zombie nights adjusting
wk 1 next rotation - zombie days coming off nights

So in this scenario spanning 7 weeks, assuming the day weeks of the block are clumped together uninterrupted
you spend 4 weeks of it just adjusting to changes in sleep schedule
why bother doing night float in this scenario over any other way you could do nights? the only advantage is your census gets a week of care from its primary team - but isn't that person crosscovering other teams? and vice versa? so you gain little in continuity to get a perpetually zombified resident
then you guys are right, better sprinkings of staying up all night through the month because an isolated night off schedule isn't enough to seriously f*ck with your circadian rhythms

In regards to your question about call and short vs long day, short and long days get adjusted because you no longer have someone there every day who is "on call" that everyone else can hand their patients to in the afternoon. So instead you're arbitrarily designating a "long" person every day and you're short a resident because someone is on nights. Before the long person was just...the person on call. That increases the frequency of everyone else having to do long days or just makes everyone else do 12 hr days/6 days a week depending on how your program works and how long the night vs day shifts are.

Mmm, don't quite get it.
I think what I described above shows how teams can have their short days be short, the long days are only so long, all the ward teams put together are lacking a senior and intern for dedicated nightfloat block, but as I said the rewards are that people wake and sleep the same times and aren't necessarily trapped 12 hours every day (just long call days)
ah, now I see what you mean, the team long call days happen more often under this system? still confused
I never could wrap my brain around scheduling as a med student because I couldn't look up the senior/intern schedules, I just came and went when they said and they would talk about their day off before it would happen, that was it, and so then on interviews it was really mind-boggling to hear these systems, all these things are pretty complicated (IMHO, I guess I'm not the brightest crayon in the box... hehe, get it?)

so can you give me a Sunday to Saturday style schedule of what the old system looked like as far as when you would theoretically get to work and leave?

I figured it out better as an intern what was up, so I know how my program does it, and it isn't so scary, but going elsewhere I dunno
Our program say ward team 1 was ready to leave at 3pm
the "long call" resident we signed out to was team 2 and would be admitting to 7, when night float showed up
any other poor bastards on the ward teams still there that late would sign their stuff out to the nightfloat, plus the long call resident on team 2
Lots of handoffs that way yesssss
The benefit was on wards when it wasn't a call/admitting day q4 you could go home early (unless clinic day yuck)
Ward months a lot of 12 hour days, but a lot of days home 3-5pm
Got to sleep at wake at almost the same time every day, the senior was stuck with an overnight not often so being a senior on ward not bad
@michaelrack - sleep doc, what do you think?

My impression is that postcall days after call are way better than nightfloat.

However, several specialties have switched to "home call" systems where if you have to come in, you come in (which can be most nights at a busy hospital) but it doesnt count as inhouse call so you DONT get a postcall day. So basically you get screwed coming and going - come in all night but dont get a postcall day. So night float seems like a huge improvement.

Word on this one. I thought this was an attending style of doing call, residents do this? or is it like specialty residents do this?

Forgot to follow up on my own thread. (See no f/u. Bad intern! )

My 2 weeks is over. No one died. Not blind luck either, I got my s*** together in the sink or swim of NF. No one was even maimed, so I do want to pat myself on the back. In fact, I took a conservative approach after awhile. Like threw out sepsis work ups for febrile, tachy overnight pts w/ an upward trending WBC like melatonins for all those "insomniacs". Stat CT's on altered folks who weren't altered at 10pm, etc. I learned some stuff. Not anything that is going to help me on my first ITE next week, but what the hell, I probably wasn't going to study hard for that anyways. I consider it a "baseline" so I might as well go as low as I can go LOL

And my eval from the hospitalist attending said I was average intern but he saw potential since I could almost do an entire admission on my own.

However, in all it's irony, I miss NF. Cuz now I have a mess load of dictations to do. Notes for everything. Documentation out the wazzoo. My pager goes off now. (Never did when I had the ASCOM in my pocket). And working up my own patient? Boo! lol

I thoroughly enjoy being a "normal" person tho. Wake up in the AM go to bed in the PM. I don't have Night Float (weekend) until September so let it ride baby!

Shoot yeah, nightfloat this early in year is a bit more daunting for sure.
I don't remember your OP and I'm too lazy to scroll up - if you have a decent senior as back up not killing people isn't that hard overnight, at least with gen floor patients, it all depends on how sick the census is and how well the day team tucked them in and signed them out of course, luckily on the gen floor at least, even sick people are pretty resilient. It always amazes me how durable people are, they really do cling to life

I wouldn't call your approach "conservative" if what you meant was playing it safe, I think it would be more appropriate to say it was a "liberal" approach, but that's fine/good for nightfloat, the dayteam that knows the patients can stop and reflect, "do we really need to do this sepsis work up? I'm sure her AMS is a drug SE" NF on the other hand, it great if you can do that, otherwise you're handing out vanc/zosyn and CTs like candy (j/k)
Shoot yes you learned some stuff just based on the examples
F8ck the ITE, you don't go to residency to get better at tests (although you must still do them of course), of course you want to learn the stuff not on the ITE
(although I will say this, DO NOT BELIEVE YOUR PROGRAM that your intern ITE doesn't matter, it doesn't HAVE to matter, but IT COULD hurt/help you depending on factors, so I'm not advocating studying for this thing, but if you think you will bomb it I would try to)
average intern in July in fine, I hope what he meant by saying you could "almost" do a whole admission yourself was just referring to help with A/P and orders to address their problems, you should be working on speed-demoning your history and PE with the patients and your written H&Ps, and when you staff having a good presentation, if not, this is your current goal in life. A lot of interns stress about the quality of their A/P, and yes, that matters, but more important right now is SPEED, caution in not killing people, and a good problem list. Take a stab, but actually better to be more mute appear ignorant than open your mouth suggesting what might sound like dumb plans, that will bite you worse, believe me. If you're a safe intern as far as not seeming a danger to patients, and you get your work done, any deficiency in knowledge they will help you address. If you are a genius and you're too slow, well...... Learning speed right now is what will then allow you the time to think more and look smarter, because it buys you time. So just focus speed, not killing, keep mouth shut, read.

And yes, the glory of NF is near freedom from notes, if that is what ails you.

 

[Law2Doc]

...

so can you give me a Sunday to Saturday style schedule of what the old system looked like as far as when you would theoretically get to work and leave?
...]

When I did night float it was six 13 hour shifts, Sun night 6pm through 7 am through Saturday morning. (on paper if you came and left on time it just fit into the duty hours... 78 hrs If nobody coded during sign out or other morning emergency). so you kind of had weekends off, but really you were there part of every day, ie Saturday morning and Sunday evening.

For call, it was basically Q4 or 5 (so not really tied to the weekdays) but you did, say Mon-Wed 12 hour days (6-6) then Thurs a 30 hour shift, staying through sign out, morning rounds and tidying up a few overnight things, and then post call for the rest of Friday, and thn you worked 12 hours on one of the weekend days (total of 78 hours on paper, except sometimes during the lighter weekdays, especially later in the year, people could carry multiple pagers and cover for each other, so the 12 hours might become 9-10 a few times a week.) but with the call system you'd have a full day off each week not in the hospital, and you only were off your sleep schedule one night a week. And if it was a quiet night and you got a few hours sleep maybe not even that. It was MUCH more lifestyle friendly, even if people get scared by the notion of a 30 hour shift. A 30 hour shift only seems horrible until you've done few, then you realize it's not that big deal and it sops up most of your duty hours for the week to boot. Because of the 80 hour caps, at places that try to maximize manpower ( with 12-13 hour shifts), night float is always going to be more of a torture IMHO.

Obviously in less leanly staffed places with superfluous personnel where they aren't trying to maximize manpower close to the 80 hour cap, life can be better, but you could also draw up a call system that was cushy too in such situation -- I've seen call setups where call wasn't a full 30 hours and I've seen where people got out early more days a week because of floater residents who overlapped in the late afternoons- early evenings ( which sometimes added an additional handoff each day which I personally always thought was a really bad idea). There isn't just one model of call or night float but you have to be cognizant of the fact that with either system the lean programs without enough residents will always have to make things add up close to the 80 hour work week because that's what they are allowed to. And in that setting night float blows -- you'll can be in the hospital at least part of every day for a month or more.

 

[Doctor4Life1769]

Opthalmology is the same way with their "home calls"

 

[Perrotfish]

For call, it was basically Q4 or 5 (so not really tied to the weekdays) but you did, say Mon-Wed 12 hour days (6-6) then Thurs a 30 hour shift, staying through sign out, morning rounds and tidying up a few overnight things, and then post call for the rest of Friday, and thn you worked 12 hours on one of the weekend days (total of 78 hours on paper, except sometimes during the lighter weekdays, especially later in the year, people could carry multiple pagers and cover for each other, so the 12 hours might become 9-10 a few times a week.) but with the call system you'd have a full day off each week not in the hospital, and you only were off your sleep schedule one night a week. And if it was a quiet night and you got a few hours sleep maybe not even that. It was MUCH more lifestyle friendly, even if people get scared by the notion of a 30 hour shift. A 30 hour shift only seems horrible until you've done few, then you realize it's not that big deal and it sops up most of your duty hours for the week to boot. Because of the 80 hour caps, at places that try to maximize manpower ( with 12-13 hour shifts), night float is always going to be more of a torture IMHO.

I disagree with this, or at least I disagree that this is a universal experience.. In my experience 30 hour shift ARE terrifying... to a percentage of residents. One of the things we know about fatigue (well established in military research) is that a persons ability to tolerate a sleep deficit is an intrinsic and mostly unalterable characteristic, like height. Some people simply become incoherent faster with fatigue. By the end of a 28 (really 32) hour hift some residents who are perfectly capable physicians during the day become completely incoherent, while others seem to function at nearly their baseline. Of course, that's not even taking true medical conditions into account. I know quite a few residents with chronic, well controlled migraines who are completely disabled by call days, and who have learned to consider vomiting repeatedly every fourth night to just be a part of life until they graduate. I have found that night shifts, though somewhat crappier for residents who deal with fatigue well, are accessible to a wider range of residents. FWIW I've done both call and night float to get to a 78 hour week and felt I practiced safer and stayed healthier with night float.

Of course, that doesn't have anything to do with the question of why residents should be trapped choosing between these two terrible options.

 

[Perrotfish]

And my eval from the hospitalist attending said I was average intern but he saw potential since I could almost do an entire admission on my own.

One of the things I will not miss about medical training is the way you can kill yourself for weeks, and then your time ends with a **** sandwich evaluation that doesn't include the words 'thank you'.

Anyway, good job. I'm glad you got through it.

 

[Crayola227]

I disagree with this, or at least I disagree that this is a universal experience.. In my experience 30 hour shift ARE terrifying... to a percentage of residents. One of the things we know about fatigue (well established in military research) is that a persons ability to tolerate a sleep deficit is an intrinsic and mostly unalterable characteristic, like height. Some people simply become incoherent faster with fatigue. By the end of a 28 (really 32) hour hift some residents who are perfectly capable physicians during the day become completely incoherent, while others seem to function at nearly their baseline. Of course, that's not even taking true medical conditions into account. I know quite a few residents with chronic, well controlled migraines who are completely disabled by call days, and who have learned to consider vomiting repeatedly every fourth night to just be a part of life until they graduate. I have found that night shifts, though somewhat crappier for residents who deal with fatigue well, are accessible to a wider range of residents. FWIW I've done both call and night float to get to a 78 hour week and felt I practiced safer and stayed healthier with night float.

Of course, that doesn't have anything to do with the question of why residents should be trapped choosing between these two terrible options.

Perrotfish, your posts always rock.

From @Law2Doc post, I don't get how the post call day is so great. Sounds like hours a week and shift hour are the same, with light weekend days, although I see that at a lot of programs, there just isn't as much stuff on the weekend.

The problem as I see it with post-call, is that it's not really a day off. I always see posts like, "what do I do with post call day? the morning's shot (you were at work) so you can nap, get up, then be awake the evening, get crappy night sleep for work the next day because you don't sleep as deep if you overnap. Or you spend post call on the couch zombified and go to sleep sooner. Sounds OK to me, I'll take as much zombie couch time and go to sleep early as I can get in residency, in that case it does look like one of my regular days off anyway. I kid though, because with a real day off you have the eve after work is free although you're tired, sleep in, rested for day off to do stuff, go to bed early and get some sleep.

And then with the kind of call one day every 4 or 5 is still messing with your circadian rhythm, and based on what you're telling me, I'm not sure how much is gained with post call days, except that like many others I love staying up all night, busting ass for a long stretch and then resting a long stretch

Like I told @Doctor Bagel,
post call days and your day off maybe just feel better, and the overnight call wouldn't be bad if it were light
maybe the schedule feels lighter although it sounds weird to the rest of us

Not my words, I'm sorry I saved this verbatim and didn't note the author, but not plagiarism as I do not claim them as my words:, re: similarities between alcohol intoxication, sleep deprivation and perception of performance:
Sleep deprivation:
"How it works in medicine is a matter for research, but how it works in other fields is similar to how it works with habitual alcohol abuse: as you acquire experience at performing while impaired (e.g. driving drunk) you build a baseline of “normal” which includes your impaired behavior as perceived by your impaired judgment. Since the ability to recognize poor performance is degraded before the ability to actually perform, especially for tasks for which you have trained extensively, your self-perceived performance may actually improve. Thus the common opinion that “I actually drive better after a few drinks.”"