starting on night float

[Radignator]

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My first rotation of the year will be on night float and I'm feeling kind of apprehensive about it. I don't know all the scheduling details yet, but as I understand it, it will be just a senior resident and myself covering the whole hospital.
I saw a few good threads on this in the past, but wanted to make a new one for this year.


Any general advice on what to do and how to cross cover a ton of patients most effectively?

Any specific topics that I should try to have fully memorized? ie ACLS

Are programs generally understanding of the limitations of a new interns, or is it more likely to be a trial by fire type of experience? Same question in regards to the nursing staff.

What can I do to be the best night float intern possible and make a good impression (and not screw up) from the beginning?


Any and all advice would be greatly appreciated.

 

[Bostonredsox]

Your answer to every floor nurse question first month of residency on nights should be "let me go over this with my senior and ill call you back".

 

[VentdependenT]

You will not run a code as an intern unless there is already another one tying up Sr.

Make sure to get signout in terms of "If this happens then this is the most likely cause." Code status and allergies important.

Your Sr will layout and help with orders w/up of your patients.

Be nice to nurses.

Just enjoy rest of 4th yr. Nothing can prepare you now. Let the rubber meet the road. Remember that intern is glorified secretary.

If there is any question run it by Sr. Dont blow stuff off. "oh its probably gerd. Just rpt vitals in an hour. just get a CT head."

If there is altered mental status: first thing you do is ask for point of care glucose. physical exam. review last note, labs, vitals now.

Cant piss: check post void residual, if high put in foley. physical exam: wet vs dry. review last note, labs, vitals now.


Fever work up if not done (lung, pee, blood, fungal if imm comp) physical exam. make sure its not anaphylaxis from some abx. review last note, labs, vitals now.


SOB: cxr and physical exam, consider PE, CHF (how long they been poundin granma with fluids), RAD, PNA. review last note, labs, vitals now. Consider ABG. Do not just throw a dude on a face mask or NRB and not try and find out why.

Chest pain: markers,ekg. physical exam. review last note, ekg, tele, labs, vitals now.

Get my drift. Rule out and treat the acute crap that kills inpts.

Give pain meds. Avoid nsaids in old people. Avoid natcotics in fat people. Avoid benzos unless withdrawing from etoh or OD on sympathomimetics.

ABD pain. physical exam. review last note, labs, vitals now. call surgeon 😉. consider upright kub for obstruction or perf if you cant tell by physical.

Cant sleep: trazadone

Gramps is having a freakout session: haldol + benadryl. make sure his bladder isnt full of piss as the etiology.

All this stuff is 90% of what you will get called in NOT including ridiculous stuff.

ADCVANDISML bro.

 

[gutonc]

Your answer to every floor nurse question first month of residency on nights should be "let me go over this with my senior and ill call you back".

Beep! Wrong.

The correct answer is: "I'll come see him/her, talk to my senior and get back to you."

The #1 most important skill you need to learn in residency is to tell "sick" from "not sick". You can't do that over the phone, by looking at the EMR, or talking to your senior (or the nurse frankly). You need to go to the bedside to do that, especially when you're on NF and they're not "your" patients. There are obvious exceptions to this rule ("Mr. Jones was admitted for a GI bleed and doesn't have a CBC ordered for the morning" is a good example) but in general, especially at the beginning, go to the bedside.

The #2 most important skill you need to learn in residency is which nurses you can trust to appropriately assess patients and call you for "real" issues. This is easier to do if your patients are geographically localized in the hospital (I usually only have to cover 2 floors at night...I've been doing it for years and know 80% of the night nurses). Again, you need to go to the bedside to compare what you were told over the phone with what the reality is.

Night nurses come in 3 basic flavors:
1. Fresh grads who don't know their head from their ass. They're actually not that dangerous because they're going to be as scared as you are and, while they'll keep you busy with dumb pages, will also let you know when people are truly ill (as well as when they're not).
2. Dumb/lazy/dangerous nurses who haven't been promoted to days after whatever period of time and have just given up. These are the ones that will make your life hell. They'll page you for BS just to be mean and won't bother to tell you that the tele tech called and Mrs. Smith in 409 is in VFib.
3. Good, smart, experienced nurses who choose to work nights because they get paid more or have to work less for the same pay, and appreciate working free of administrative BS (most of them hate it as much as we do). These are your friends. One of the Charge nurses on the floor I cover is an old battle ax who'd been doing nights on the BMT/Leukemia service for over 30 years. She's cranky, ornery and I believe everything she tells me. She also reins in her nurses and has them batch the BS FYI pages until 0600.

TL;DR...for your first month on NF (and on any new service frankly), if you get paged, go see the patient. Get your sick/not sick radar calibrated early and figure out which nurses you can trust. It's going to make the next 3 years (and career) go much more smoothly.

 

[jdh71]

My first rotation of the year will be on night float and I'm feeling kind of apprehensive about it. I don't know all the scheduling details yet, but as I understand it, it will be just a senior resident and myself covering the whole hospital.
I saw a few good threads on this in the past, but wanted to make a new one for this year.


Any general advice on what to do and how to cross cover a ton of patients most effectively?

Any specific topics that I should try to have fully memorized? ie ACLS

Are programs generally understanding of the limitations of a new interns, or is it more likely to be a trial by fire type of experience? Same question in regards to the nursing staff.

What can I do to be the best night float intern possible and make a good impression (and not screw up) from the beginning?


Any and all advice would be greatly appreciated.

Most places do not just throw you to the wolves. Your senior will be your backup and there will be others docs in the house, probably a surgical resident or two, and probably at least one person in the ED. It is scary, but, it will also be an opportunity for a lot of personal growth, so try and keep the bigger perspective when it gets to feeling overwhelming, even when it doesn't feel like your learning or doing ok, you are. Run lots of stuff past your senior, they expect lots of questions, and will expect it first month. It will be difficult but try not to let the nurses bully you, they will try, be polite and let them know you will get back to them or put an order in the computer once you've spken with your senior if you are unsure of anything or uncomfrotable with something the nurse wants.

Ok, and this will be a pain in the ass, but first month GO SEE the patient for anything but a straight forward med order. You don't have to do a million dollar exam and history, but if you're called about an issue, tell them you'll be right over, talk face to face with the nurse, speak breifly with the patient, make sure they are not actively dying, and then page your senior to come help you out with the assessment, while you wait for the senior look over the chart - PMHx and that day's note + labs/images should be helpful.

I hesitate to give a big list of common calls and what you should do about them (though I think I have done that once or twice around here in the past - I know others have), because I kind of want you to think about it and learn how to come up with your own plans from your own experience. By the end of the year, you'll have your own treatment algorithm for common night nurse calls.

You'll be given a checkout list of some kind. Make note on there of EVERY call and EVERY intervention, so that when you check out to the AM team they will know you started a dilt gtt on an afibber who wouldn't slow down with IV pushes.

You'll be fine. We all were nervous, and we all come out the other end better doctors for it.

 

[jdh71]

ADCVANDISML bro.

who does that anymore?

just plug things into the order set

 

[gutonc]

who does that anymore?

just plug things into the order set

I was thinking the same thing. If this is something you have to deal with, you chose the wrong residency program.

 

[jdh71]

Beep! Wrong.

The correct answer is: "I'll come see him/her, talk to my senior and get back to you."

The #1 most important skill you need to learn in residency is to tell "sick" from "not sick". You can't do that over the phone, by looking at the EMR, or talking to your senior (or the nurse frankly). You need to go to the bedside to do that, especially when you're on NF and they're not "your" patients. There are obvious exceptions to this rule ("Mr. Jones was admitted for a GI bleed and doesn't have a CBC ordered for the morning" is a good example) but in general, especially at the beginning, go to the bedside.

The #2 most important skill you need to learn in residency is which nurses you can trust to appropriately assess patients and call you for "real" issues. This is easier to do if you're patients are geographically localized in the hospital (I usually only have to cover 2 floors at night...I've been doing it for years and know 80% of the night nurses). Again, you need to go to the bedside to compare what you were told over the phone with what the reality is.

Night nurses come in 3 basic flavors:
1. Fresh grads who don't know their head from their ass. They're actually not that dangerous because they're going to be as scared as you are and, while they'll keep you busy with dumb pages, will also let you know when people are truly ill (as well as when they're not).
2. Dumb/lazy/dangerous nurses who haven't been promoted to days after whatever period of time and have just given up. These are the ones that will make your life hell. They'll page you for BS just to be mean and won't bother to tell you that the tele tech called and Mrs. Smith in 409 is in VFib.
3. Good, smart, experienced nurses who choose to work nights because they get paid more or have to work less for the same pay, and appreciate working free of administrative BS (most of them hate it as much as we do). These are your friends. One of the Charge nurses on the floor I cover is an old battle ax who'd been doing nights on the BMT/Leukemia service for over 30 years. She's cranky, ornery and I believe everything she tells me. She also reins in her nurses and has them batch the BS FYI pages until 0600.

TL;DR...for your first month on NF (and on any new service frankly), if you get paged, go see the patient. Get your sick/not sick radar calibrated early and figure out which nurses you can trust. It's going to make the next 3 years (and career) go much more smoothly.

beat me to it

 

[VentdependenT]

who does that anymore?

just plug things into the order set

All ICU orders at UL are paper. Surgeons refuse to let it go paperless. I crank out my ED admits on paper. I can do it 4x faster than on computer. Every other floor paperless.

Jewish hospital: massive tertiary care center: paper.

Epic is coming. Old dudes are scared.

 

[VentdependenT]

I was thinking the same thing. If this is something you have to deal with, you chose the wrong residency program.

Too late

 

[gutonc]

All ICU orders at UL are paper. Surgeons refuse to let it go paperless. I crank out my ED admits on paper. I can do it 4x faster than on computer.

With order sets and note templates, I generally spend about 15-20 minutes total computer time with each admit (that includes reviewing the 73 meds that the NH gomer is on with the CNA who accompanied him). But I've been doing it since internship on the same EMR in the same hospital system so I've got a pretty good workflow.

Epic is coming. Old dudes are scared.

They'll get over it. They always do. When we switched to inpatient Epic in the middle of my intern year, the attendings were all pooping their pants over how horrible it was going to be. 3 weeks later, nobody says anything. Same for when we went to CPOE. "OMFG ;alksdf;oqidjf;lakf, CPOE is the devil!" A month later...they can't imaging living without it.

Besides, isn't that what residents are for?

 

[Radignator]

A lot of great advice in here, thank you all.

 

[Bostonredsox]

Beep! Wrong.

The correct answer is: "I'll come see him/her, talk to my senior and get back to you."

The #1 most important skill you need to learn in residency is to tell "sick" from "not sick". You can't do that over the phone, by looking at the EMR, or talking to your senior (or the nurse frankly). You need to go to the bedside to do that, especially when you're on NF and they're not "your" patients. There are obvious exceptions to this rule ("Mr. Jones was admitted for a GI bleed and doesn't have a CBC ordered for the morning" is a good example) but in general, especially at the beginning, go to the bedside.

The #2 most important skill you need to learn in residency is which nurses you can trust to appropriately assess patients and call you for "real" issues. This is easier to do if your patients are geographically localized in the hospital (I usually only have to cover 2 floors at night...I've been doing it for years and know 80% of the night nurses). Again, you need to go to the bedside to compare what you were told over the phone with what the reality is.

Night nurses come in 3 basic flavors:
1. Fresh grads who don't know their head from their ass. They're actually not that dangerous because they're going to be as scared as you are and, while they'll keep you busy with dumb pages, will also let you know when people are truly ill (as well as when they're not).
2. Dumb/lazy/dangerous nurses who haven't been promoted to days after whatever period of time and have just given up. These are the ones that will make your life hell. They'll page you for BS just to be mean and won't bother to tell you that the tele tech called and Mrs. Smith in 409 is in VFib.
3. Good, smart, experienced nurses who choose to work nights because they get paid more or have to work less for the same pay, and appreciate working free of administrative BS (most of them hate it as much as we do). These are your friends. One of the Charge nurses on the floor I cover is an old battle ax who'd been doing nights on the BMT/Leukemia service for over 30 years. She's cranky, ornery and I believe everything she tells me. She also reins in her nurses and has them batch the BS FYI pages until 0600.

TL;DR...for your first month on NF (and on any new service frankly), if you get paged, go see the patient. Get your sick/not sick radar calibrated early and figure out which nurses you can trust. It's going to make the next 3 years (and career) go much more smoothly.

My apologies, I assumed it was obvious you saw the pt before you spoke with your senior. Because if an intern ever said to me the nurse called me pt is complaining of chest pain my answer has been what did you think when you saw him? Oh I didn't go see him. Them why are you talking to me now? The nurse could have just called me directly if it was known you weren't going to see the pt in between. Go see them. Assess. Then call me. Well go over it. Then you can call the nurse back.

That was what I meant.

 

[rokshana]

and document, document, document....if you go see the pt and you do something (ordered imaging, labs, ekg, rapid response called and so on) write a quick cross cover note. 1. it will let the day team know that something sig occurred overnight and if there is anything pending to follow up and 2. if anything occurs later, there is something to document that the issue was addressed.

 

[theneh]

writing or typing short floor call notes is essential. it helps day team figure out why you decided to change narcotic dose or D/C some medication. it also helps you think and cover all the bases when addressing the issue. As a senior I'll admit, i have gotten lazy doing this unless it's a serious event, but every legitimate floor call should have a note by the intern.