Surviving Night Shift

[Backpack234]

How do you survive stretches of night shifts? I have to do 3-4 per month and still not sure if it’s better to cluster them together or only do 1-2 at a time.

Also noticed after a shift, I come home and sleep as soon as I can, but then wake up a few hours later. It’s tough to get a full 8 hours of sleep even if I waste the entire day.

Anyone have any tips or tricks to getting through nights?

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[JacobMcCandles]

Try to group them in 2s if you do 4 or all 3 in a row if you're only doing 3. I come home and sleep until about noon and then wake up and get back on a normal schedule. Make sure you have 2 days off any nights.

 

[Interpolfanclub]

Try to group them in 2s if you do 4 or all 3 in a row if you're only doing 3. I come home and sleep until about noon and then wake up and get back on a normal schedule. Make sure you have 2 days off any nights.

Pretty much what I do. I've told our scheduler I don't want more than 2-3 in a row. If I'm doing 4 that month it's 2 and 2. If it's 3, then 3 in a row usually. Sometimes 2 and 1 which is also fine. I never do 4 in a row. The first few mornings I take CBD oil to sleep most of the day then caffeine. The last morning I usually try and wake up by 2p if I get off at 7am then slam coffee and generally cowboy up to get through it. But nights suck.

 

[Tenk]

If you have trouble sleeping after a night shift you can actually try not clustering them and ending a normal stretch on a night. That way you go to bed, get a short nap, then go to bed at normal time that evening and good to go back on days.

 

[southerndoc]

Blackout shades and a quiet room with white nose (or a good ole fashioned fan) are a must.

Also, I find that I do better if I split my sleep when doing nights. Instead of sleeping 5-8 hours straight, I'll sleep for 3 hours, get up and run a few errands/mingle with the family, and then go back to sleep for another 3-4 hours. As odd as it seems, I feel more refreshed this way as compared to sleeping straight through. Night 2 is always the worst for some reason.

 

[RustedFox]

I don't survive nights; they survive ME.

- Night ranger for the past year.

 

[Backpack234]

I don't survive nights; they survive ME.

- Night ranger for the past year.

Whoa whoa whoa. What are you? A nocturnist? How much can I pay you to work at my shop?

 

[GonnaBeADoc2222]

The one major perk of my job is that I don't work nights.

 

[RustedFox]

Whoa whoa whoa. What are you? A nocturnist? How much can I pay you to work at my shop?

It just kind of happened. As long as I never work that 7am-4pm shift, it's cool. 12 hour shifts, 10 shifts a month. Minimizes a LOT of nonsense. I'll write creatively (RustedFox Rants: Night Ranger Edition) if y'all want.

 

[Jabbed]

Black out curtains, eye mask, +/- ear plugs are a must.

I’ve stopped trying to switch over to a full nocturnal schedule (ie, sleeping the entire day). After driving home and crying in the shower, it’s like 8am by the time I’m actually going to bed. I don’t set an alarm. After my first night I’ll usually wake up around 1 or 2, but by the fourth night I’m waking up at 4p. I’ll then do whatever around the house and try and nap for 2 hours before my shift.

What really sucks is trying to recover from night shifts. I’ll wake up at 3a screaming for at least 2 or 3 days following my stretch of nights.

My gut instinct would be just to do them all in a row to get them out of the way, but I think that it would be much easier to recover from 2 night shifts than 4.

I really hate nights…

 

[CoolDoc1729]

How do you survive stretches of night shifts? I have to do 3-4 per month and still not sure if it’s better to cluster them together or only do 1-2 at a time.

Also noticed after a shift, I come home and sleep as soon as I can, but then wake up a few hours later. It’s tough to get a full 8 hours of sleep even if I waste the entire day.

Anyone have any tips or tricks to getting through nights?

I am a weekend nocturnist and my husband works on the days I am off, so I am used to nights but I also completely switch to day shift between stretches so that I can take care of my small children. I work 3-4 stretches of 3-5 nights per month, depending on staffing and how many weekends are in the month, usually a total of 13-14.
I am fairly religious about getting up early on the first day of a stretch, so that by afternoon I am able to take a nap. I am used to the schedule, so i sleep all day after my shifts despite broad daylight and the kids running around the house. After the last day of the stretch I try to wake up by 2-3 pm and do something outside to kind of reset the clock. All this has worked well for me for the past 7 years.
What wakes you up midday? Is it anything that can be fixed , or you just wake up? I find having the ceiling fan on to be fairly vital so I don’t get too warm, for example.

 

[Backpack234]

The one major perk of my job is that I don't work nights.

VA?

 

[Mount Asclepius]

I’m a nocturnist. I think it’s important to minimize the number of times switching back and forth as that’s the most disruptive part. I do larger blocks of nights (occasionally 4-6, but typically 7 in a row). I completely switch to a night schedule when working. Then I switch completely back to days when I’m off work. I follow a fairly regular schedule for both. I come home post shift and stay up a few hours unwinding. Then sleep a full 8 hours straight just like I would at night before getting back up with a short ‘morning’ prior to heading into a shift.

The transition back is the worse part, which happens typically twice, but sometimes 3 times per month. I sleep for around 4-6 hours and then force myself to get up. I’m usually a little groggy that first day off on short sleep. I then head to bed early and typically sleep around 10 hours the following night prior to resuming a normal day schedule for my block off work.

 

[sloh]

Black out curtains, eye mask, +/- ear plugs are a must.

I’ve stopped trying to switch over to a full nocturnal schedule (ie, sleeping the entire day). After driving home and crying in the shower, it’s like 8am by the time I’m actually going to bed. I don’t set an alarm. After my first night I’ll usually wake up around 1 or 2, but by the fourth night I’m waking up at 4p. I’ll then do whatever around the house and try and nap for 2 hours before my shift.

What really sucks is trying to recover from night shifts. I’ll wake up at 3a screaming for at least 2 or 3 days following my stretch of nights.

My gut instinct would be just to do them all in a row to get them out of the way, but I think that it would be much easier to recover from 2 night shifts than 4.

I really hate nights…

Crying and screaming

 

[Groove]

I work 5-6 overnights a month. I request for them all to be blocked and grouped together with no 24h turnarounds to day shift (I can do swing). I personally can't stand doing 2-3 nights twice a month like most of our group, it just wrecks my body. I don't mind it when they are blocked, even if I have them all in a row (which I do). I would just rather get them all out of the way once a month and never have to worry about them again until next month. As for sleeping...blackout shades, keeping the room at 68 degrees, my SO will set up a gate to the bedroom so the dogs can't bother me, etc.. I used to take ambien which I think is a fantastic sleep aid but I ran out several months ago and haven't bother to get a refill so I'll usually take 10mg melatonin, 50mg Benadryl and 1200mg valerian root. If I'm getting off at 6am, I don't go straight to bed, I kind of wind down and get in bed around 8am or 8:30am and usually can sleep until 2-3pm. My last day, I sleep 3-4 hours and get up dragging through the day and then try to go to bed at a decent hour so I can transition. I generally feel horrible for 3 days, no matter what I do after a stretch of nights.

 

[emdoc799]

My experience is on par with other posters. You need to most closely simulate nighttime for your body. This means as dark environment as possible, I use blackout curtains and an eye shade. White noise as well. Cool the room and turn the fan on. About an hour prior to going to sleep I take one 25mg doxylamine (Costco has a bunch of these for under $10) after my first overnight which is when there is the greatest need to adjust. After one or two more nights I may not take it because I’ll be adjusting back to days shortly.

Other things that help are getting in some intense aerobic exercise and drinking lots of cold water.

 

[emergentmd]

Best way to survive nights is to Not do them.

Luckily throughout my 15 yr career, I probably did a total of 10 true overnights. I did do some wingman shifts done at 2am which is not too bad b/c I get 4-6 hrs of real night sleep.

I tried to outsmart myself and asked to do nights for 2 months during one summer believing I could just go home/sleep 6hrs/be ready to spend time with the kids while cutting down to 10-12 shifts/mo equalizing pay due to overnight bonuses. I was badly mistaken and 2 wks into it, I was miserable/family miserable. We have a big house, lots of rooms, I slept in our media room with sound machine, no windows, completely black. Didn't matter. I only got 3-4 hrs max then went into the "Tired but can't sleep mode"

If you do not have a nocturnist, then find someone who wants to do nights and pay them $500 or whatever it takes. If you are obligated to do 3 night shifts a month=$1500/mo=18K/yr= BEST money you will ever spend. Pick up an extra 5-7 dy shift throughout the yr and you would be even.

Your happiness/longevity/family environment will thank you for it. Trust me. Looking back, I would be willing to pay $1k/shift.

 

[Backpack234]

Best way to survive nights is to Not do them.

Luckily throughout my 15 yr career, I probably did a total of 10 true overnights. I did do some wingman shifts done at 2am which is not too bad b/c I get 4-6 hrs of real night sleep.

I tried to outsmart myself and asked to do nights for 2 months during one summer believing I could just go home/sleep 6hrs/be ready to spend time with the kids while cutting down to 10-12 shifts/mo equalizing pay due to overnight bonuses. I was badly mistaken and 2 wks into it, I was miserable/family miserable. We have a big house, lots of rooms, I slept in our media room with sound machine, no windows, completely black. Didn't matter. I only got 3-4 hrs max then went into the "Tired but can't sleep mode"

If you do not have a nocturnist, then find someone who wants to do nights and pay them $500 or whatever it takes. If you are obligated to do 3 night shifts a month=$1500/mo=18K/yr= BEST money you will ever spend. Pick up an extra 5-7 dy shift throughout the yr and you would be even.

Your happiness/longevity/family environment will thank you for it. Trust me. Looking back, I would be willing to pay $1k/shift.

Somehow it seems like you've had the most ideal career of any of us on here.

 

[emdoc799]

Somehow it seems like you've had the most ideal career of any of us on here.

Agree. If I brought this idea up to my group they would laugh hysterically.

 

[emergentmd]

Agree. If I brought this idea up to my group they would laugh hysterically.

How is this even out of the norm? Most docs I worked with were happy to pay the night guys a stipend/shift. Even if the group could not agree, why can't you Venmo them outside of the group?

Everyone has a price to do nights, heck I do too. Eventually someone would take it and from my experience its typically $250-750 typically from the younger guys.

 

[CajunMedic]

Mine are all blocked together in 4s. I'll have 4 either 11-2300, or 12-0000, then 5-7 days off, then another stretch of 4 1900-0700, off for 7-10 days, then my final run of nights. On the first day, I tend to stay up kind of late, get up around 11-12, run errands, then back to bed and get up 1700-1730. Once I get through that first night, I try to minimize caffeine and heavy meals when I get off. I'll take some Melatonin and put on my white noise app. Room is dark and cold as possible. On the last day, I'll go to bed when I get off, and then get up around 1400 to get back on a day schedule.

 

[Backpack234]

How is this even out of the norm? Most docs I worked with were happy to pay the night guys a stipend/shift. Even if the group could not agree, why can't you Venmo them outside of the group?

Everyone has a price to do nights, heck I do too. Eventually someone would take it and from my experience its typically $250-750 typically from the younger guys.

Maybe if we had a nocturnist they might take it? But I’ve offered up to 1k per shift. Even asked other docs to name their price. And nobody took it. Solo nights here are just that bad.

 

[RustedFox]

Maybe if we had a nocturnist they might take it? But I’ve offered up to 1k per shift. Even asked other docs to name their price. And nobody took it. Solo nights here are just that bad.

How bad?
Give us a real idea.

 

[Groove]

Maybe if we had a nocturnist they might take it? But I’ve offered up to 1k per shift. Even asked other docs to name their price. And nobody took it. Solo nights here are just that bad.

Same… We have a 10$/hr shift diff for nights and our average is around 270/hr for days but we only have one nocturnist at the moment. I think we’d have more of our young docs step forward to fill nights if our diff was greater but it’s hard getting everyone on board at a CMG where they take the diff out of the day docs pot. All I can do is suggest ABEM nocturnists that I meet while PRN at our outlying sites. I suggested one recently that is currently getting credentialed at our academic site so hopefully we get another one soon…

 

[Backpack234]

How bad?
Give us a real idea.

Some nights have been admittedly good. 8 after midnight kind of nights. But the random chance of the perfect storm of 5 elderly weakness, 2 lacs, drunk kid mvcs, and a stemi walking in all within 10 minutes of each other when you’re solo covered is a lot higher than at my last gig.

Did I mention you should switch jobs and come here?

 

[RustedFox]

elderly weakness

All day, every day. I hate these guys the most.

 

[Rekt]

All day, every day. I hate these guys the most.

I've lost my tolerance for this. Do some nonsense labs that will be totally normal and discharge them back to wherever they came from. I tell family my hospitalists want a reason for admission and weakness isn't one of them. Follow up with your pcp to discuss placement options.

 

[cyanide12345678]

All day, every day. I hate these guys the most.

Elderly weakness and elderly dizziness. Both complaints are just absolutely the worst.

 

[oldtown]

Elderly weakness and elderly dizziness. Both complaints are just absolutely the worst.

These are doubly bad chief complaints when the patient shows up with their overnight bag and/or family just dropped them off and drove away

 

[sloh]

Same… We have a 10$/hr shift diff for nights

Jfc only a fool would take that lmao

 

[GonnaBeADoc2222]

"He's 92, but he's just sooooo tireddddd."

Usually the UA will have some BS leuks or bacteria and I'll send home w Keflex and everyone is happy at my fake magic.

 

[RustedFox]

"He's 92, but he's just sooooo tireddddd."

Usually the UA will have some BS leuks or bacteria and I'll send home w Keflex and everyone is happy at my fake magic.

I'm going to catch hell for saying this, but these boomers need to pass on.

We're just carrying caskets.

Bring back the Eskimo funeral.

I've said to all my friends that I am seriously considering walking into a national park and not walking out at age XX if it seems right.

 

[CoolDoc1729]

I'm going to catch hell for saying this, but these boomers need to pass on.

We're just carrying caskets.

Bring back the Eskimo funeral.

I've said to all my friends that I am seriously considering walking into a national park and not walking out at age XX if it seems right.

When they are whining about the long wait times and the floor is dirty and why can’t they just have a bed and they came by AMBULANCE… I say I’m sorry , there’s just too many of you and not enough of us… the other day I told someone the days of unlimited medical resources are oooooovvvver… it quiets it down in the not at all private side room where we do “waiting room dispos “ now ….

 

[RuralEDDoc]

I'm going to catch hell for saying this, but these boomers need to pass on.

We're just carrying caskets.

Bring back the Eskimo funeral.

I've said to all my friends that I am seriously considering walking into a national park and not walking out at age XX if it seems right.

Absolutely. Why does everyone need to die in an ICU in a blaze of glory? Or worse, survive and die three months later covered in bed sores? No thanks.

 

[RustedFox]

When they are whining about the long wait times and the floor is dirty and why can’t they just have a bed and they came by AMBULANCE… I say I’m sorry , there’s just too many of you and not enough of us… the other day I told someone the days of unlimited medical resources are oooooovvvver… it quiets it down in the not at all private side room where we do “waiting room dispos “ now ….

Yep.
One thing that COVID has done is signal to the corporate overlords that it's totally okay to treat and street from the "vertical flow area", and all privacy be damned. And it's usually these entitled, whiny boomers that demand "a private room, both here and upstairs".

 

[CajunMedic]

Absolutely. Why does everyone need to die in an ICU in a blaze of glory? Or worse, survive and die three months later covered in bed sores? No thanks.

I have absolutely zero qualms about having goals of care and hospice conversations. More than once, I’ve been asked by family “what would you do?” My standard response has been: “take them home, we can make them comfortable, let them die in peace in their own bed, surrounded by their loved ones. Not stuck in here in the middle of this chaos.” It’s worked well so far.

 

[emergentmd]

"He's 92, but he's just sooooo tireddddd."

Usually the UA will have some BS leuks or bacteria and I'll send home w Keflex and everyone is happy at my fake magic.

When I started as an attending, hated these cases. Had to go through all the differentials, full work up, then after everything was negative spent more time trying to figure things out.

Learned quickly that this is a population that will not sue you if you try your best.

So I just pan lab them, CT head, EKG, CXR, Trop. When they come back and everything negative, I ask the pt/family do you want to admit or go home. If I get any blowback on admission, I just tell the hospitalist that pt too weak to go home/family refuses to take them home and if they continue to refuse, they can come and eval the pt for D/C. This always gets them admitted.

 

[GonnaBeADoc2222]

When I started as an attending, hated these cases. Had to go through all the differentials, full work up, then after everything was negative spent more time trying to figure things out.

Learned quickly that this is a population that will not sue you if you try your best.

So I just pan lab them, CT head, EKG, CXR, Trop. When they come back and everything negative, I ask the pt/family do you want to admit or go home. If I get any blowback on admission, I just tell the hospitalist that pt too weak to go home/family refuses to take them home and if they continue to refuse, they can come and eval the pt for D/C. This always gets them admitted.

Agree. These are pretty easy patients for me as well.

 

[Groove]

When I started as an attending, hated these cases. Had to go through all the differentials, full work up, then after everything was negative spent more time trying to figure things out.

Learned quickly that this is a population that will not sue you if you try your best.

So I just pan lab them, CT head, EKG, CXR, Trop. When they come back and everything negative, I ask the pt/family do you want to admit or go home. If I get any blowback on admission, I just tell the hospitalist that pt too weak to go home/family refuses to take them home and if they continue to refuse, they can come and eval the pt for D/C. This always gets them admitted.

I'm kind of similar but try to flesh out the primary reason for the ED visit right off the bat. Usually with these old geezers, there's a secondary gain for the family bringing them in and more times than not he/she is "overwhelming" the care givers at home or they "need a break" for a few days. I always try to identify what's really going on and if there's truly enough resources at home. If not, you can always sell it to medicine as some sort of "inability to carry out ADLs" and would certainly qualify for CM/SW assessing the home situation for additional resources. Some have enough resources but they are in that quasi "failure to thrive" (state of body/state of mind?). I lay it to them straight on those cases... "We can admit you for this....but you won't be going home. You will be going to a SNF/REHAB facility until you are hopefully strong enough to go home. Is that what you and your family want us to do?" Some elderly patients shut that down very quickly and can't be talked into it by family members which makes my disposition extremely easy and I always tell them "Hey listen....we tried. He just is not ready for that step and nobody can make that decision for him. Why don't you guys continue the discussion at home and even bring it up with his PCP in the next 2-3 days? If he suddenly becomes ready...we're always here." Most families are pretty kosher with that approach.

I don't think I've ever been worried about someone in their 90s suing or even family being able to successfully mount and generate a lawsuit that would not seem absurd to most jurors once they start looking at the age and comorbidities of the pt.

I don't even do as exhaustive a work up in this patient population as I once did...as long as they've got a reasonable family member with them. I tell them "Look...we can focus on X, Y or Z but the more things we focus on, the more problems I'm going to find. I promise you I can run enough tests to find SOMETHING wrong enough to keep you in this hospital. If that's what you want....then so be it. Most of these pt's just want to be in their own bed and family is reasonable and just wants them to be comfortable. I do a little "shared decision making" and discussion/blurb in my note and that's it. Hell, when I'm in my 90s someone please do the same for me.

 

[BoardingDoc]

Agree. These are pretty easy patients for me as well.

Yeah, I feel they're pretty straightforward. They get a grampagram/grammagram silver/gold/platinum (CBC/CHEM/UA +/- cxr/trop/ekg/head CT depending on tier). BS AKI/UTI/whatever? Admit. Dispo done. All normal? PT/CM consult for placement. If it's past 5p, admit for PT/CM.

Hospital completely full and you can't admit for PT/CM and they're one of the completely demented, constant "help me!" or "NURSE!" screamers? Zyprexa until that stops for the night.

 

[RoyBasch]

When I started as an attending, hated these cases. Had to go through all the differentials, full work up, then after everything was negative spent more time trying to figure things out.

Learned quickly that this is a population that will not sue you if you try your best.

So I just pan lab them, CT head, EKG, CXR, Trop. When they come back and everything negative, I ask the pt/family do you want to admit or go home. If I get any blowback on admission, I just tell the hospitalist that pt too weak to go home/family refuses to take them home and if they continue to refuse, they can come and eval the pt for D/C. This always gets them admitted.

First off: I agree with you. This is pretty much my approach exactly.

But I think what can make these cases a drag depends on how agreeable your hospitalist are. I definitely think it’s reasonable to admit someone who lives at home alone who in the ER today is a 2 person assist. Even if there is no acute pathology but just de-conditioning/dwindling, this person can’t manage at home.

A lot of hospitalist though do not seem to think these are reasonable admits.

So now you have a few bad options:

1.)fight/try to get tough with the hospitalist and lose social capital with a fellow staff physician.

2.) dc the patient home and tell the family to just deal with it. Thus losing social capital with the patient and family. Worst case scenario: This may be legitimately unsafe for the patient and they come back few days later with a SDH or hip fracture from a fall. Best case scenario: nothing bad happens to patient but you get a complaint or low PG score.

3.)try to place the patient in a facility directly from the ER. Best case scenario: it’s business hours and this is theoretically possible but takes many hours crushing LOS. Worst case scenario: the family opted for a Friday evening turkey dump (as they always do) and placement is impossible so you are back to option one or two.

At one hospital I work at admitting these patients is a breeze. So the case is fine. At one other hospital it’s very hard and Hence the conundrum.

 

[WilcoWorld]

I'm going to catch hell for saying this, but these boomers need to pass on.

We're just carrying caskets.

Bring back the Eskimo funeral.

I've said to all my friends that I am seriously considering walking into a national park and not walking out at age XX if it seems right.

Absolutely. Why does everyone need to die in an ICU in a blaze of glory? Or worse, survive and die three months later covered in bed sores? No thanks.

Your communities need Palliative Care!

 

[RustedFox]

Your communities need Palliative Care!

If only.
These boomers REALLY think: "Use ALL the medicines ALL the time(s)11!1!"

I hate typing this: In *most* cases, any mention of anything less than a full-court-press ICU stay is met with scoffs and gasps.

I even had one family really suggest organ transplantation for a bedbound dementia patient. I'm 100% sure that they really just felt like it was "taking the old battery out of a toy R/C car (or whatever toy) and putting in a new battery". Simple as that, you know.

 

[emergentmd]

First off: I agree with you. This is pretty much my approach exactly.

But I think what can make these cases a drag depends on how agreeable your hospitalist are. I definitely think it’s reasonable to admit someone who lives at home alone who in the ER today is a 2 person assist. Even if there is no acute pathology but just de-conditioning/dwindling, this person can’t manage at home.

A lot of hospitalist though do not seem to think these are reasonable admits.

So now you have a few bad options:

1.)fight/try to get tough with the hospitalist and lose social capital with a fellow staff physician.

2.) dc the patient home and tell the family to just deal with it. Thus losing social capital with the patient and family. Worst case scenario: This may be legitimately unsafe for the patient and they come back few days later with a SDH or hip fracture from a fall. Best case scenario: nothing bad happens to patient but you get a complaint or low PG score.

3.)try to place the patient in a facility directly from the ER. Best case scenario: it’s business hours and this is theoretically possible but takes many hours crushing LOS. Worst case scenario: the family opted for a Friday evening turkey dump (as they always do) and placement is impossible so you are back to option one or two.

At one hospital I work at admitting these patients is a breeze. So the case is fine. At one other hospital it’s very hard and Hence the conundrum.

I have been lucky to work at a place where the hospitalist took everything.

You have to practice within standard of care and that will dictate what to do. If the hospitals never admit unless they can fix something, then everyone works under this umbrella so discharge. If everyone who are too weak gets admitted, then so be it.

When I finished residency, I could do things most EM docs would never do. Peritonsilar aspirations, perirectal abscess drainage, paracentesis, thoracentesis. Once I figured out no one did them and the time/liability was high, I stopped too.

Just practice standard of care for the community/hospital then everything will be fine. Practice outside, and no one will come to your defense.

 

[The Knife & Gun Club]

The nights are killing me man. Currently i do a run of 5 and a run of 3 every month. 20 shifts total.

I’m a PGY3 so I know it should be hard but damn if I don’t feel like a pile of used diapers after a run of 5 overnights.

 

[RustedFox]

I have been lucky to work at a place where the hospitalist took everything.

You have to practice within standard of care and that will dictate what to do. If the hospitals never admit unless they can fix something, then everyone works under this umbrella so discharge. If everyone who are too weak gets admitted, then so be it.

When I finished residency, I could do things most EM docs would never do. Peritonsilar aspirations, perirectal abscess drainage, paracentesis, thoracentesis. Once I figured out no one did them and the time/liability was high, I stopped too.

Just practice standard of care for the community/hospital then everything will be fine. Practice outside, and no one will come to your defense.

To this end, I find that this sentence is amazingly good advice:

"If the service exists for it, then you're supposed to use it."

 

[emergentmd]

The nights are killing me man. Currently i do a run of 5 and a run of 3 every month. 20 shifts total.

I’m a PGY3 so I know it should be hard but damn if I don’t feel like a pile of used diapers after a run of 5 overnights.

Nights eventually beats most people down. Its just not natural to work against your body's circadian rhythm.

 

[RoyBasch]

When I finished residency, I could do things most EM docs would never do. Peritonsilar aspirations, perirectal abscess drainage, paracentesis, thoracentesis. Once I figured out no one did them and the time/liability was high, I stopped too.

Yeah, it feels strange that I used to do those procedures when I was objectively less skilled (as a med student and resident) and now no longer do them as an attending. But, yeah the time/liability ratio is not favorable. Local standard of care is no ER physicians do them. So, I toe that line.

 

[Groove]

I'll do the PTA aspirations only if they are over 2cm. If less, then I don't even bother and will DC with abx and ENT f/u instructions. I used to do CTAs on all of these to visualize and delineate abscess size but nowadays I can often judge if it's less than 2cm based entirely on exam and I won't even bother with imaging. I have found that I do more of these since working with residents as I do think they need to know how to do them at the bedside.

I never do paracentesis anymore, especially after reading some of that iatrogenic SBP data. What a low yield procedure and most of the time completely impractical in a busy ED, plus it conditions that pt population to perpetually abuse the system and show up over and over again for taps. I might do a diagnostic aspiration if I'm feeling really nice but most of the time I don't even do those anymore. If they are blown up like a balloon and having some mild respiratory compromise then I just stick them in and have GI or IR do it as inpatient. I can't believe I used to sit there for half an hour with vacuum bottles or working up a sweat manually pumping that stuff into a bucket. I won't touch these unless I've got an intern that needs to learn the procedure and "put in their time".

I punt most perianal abscess to surgery unless it's clearly gluteal. I used to try to do some of these in the ED earlier in my career which is why I probably have hearing loss. It's like performing medieval torture. The screams that come out of the room... If I ever come in with one of these please for the love of God let surgery explore under anesthesia so I'm asleep.

I haven't done a thoracentesis since residency I don't think... Completely unnecessary in the ED.

Joint aspirations...usually not. Again, iatrogenic seeding of the joint is not exactly statistically insignificant and I'm much better these days of gauging a true septic joint vs tenosynovitis. Most of those traumatic hemarthrosis knees are going to fill up with blood within 24 hours of you tapping it. If it's a post op knee fogetaboutit. Ortho would count their lucky stars it if you poked a needle in there so they can finger you as the culprit in the lawsuit.

I kind of miss doing some of those cervical injections, trigger point injections, occipital nerve blocks, etc.. but damn...who has the time these days. I almost never have a slow shift where I can do some of those. I used to do intercostal nerve blocks for rib fractures or bad shingles lol...man those residency days seem like ages ago.

 

[southerndoc]

I sedate patients for perianal abscesses.