Tips for intern on night float?

[NewSurgeon]

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Hello all,

So, July 1st is almost upon us and I found out that I will be starting on night float - as I have never done night float on a surgery service while in med school, I am a bit nervous. I was wondering if anyone had any tips for surviving on my first service 🙂 ?

 

[Dr.LeoSpaceman]

• Go see the patient...for essentially anything.
• Make a list of things that need to be done, and check it neurotically.
• Document. Document. Document. If you go see a patient who is having an issue, write something (even if it's very brief) in the chart.
• Be kind to the nurses, and respect their opinions/concerns.
• No, seriously: Go see the patient.
• Call your senior with any questions. Even if it seems stupid. Better to have an irritated senior than a dead/injured patient. However, learn from the times when you do call. It's not a stupid question the 1st time you call...but it may be the 3rd time you do.
• When you call, have a plan. Yes, your senior is going to tell you what they want done. But 1-2 years from now, it's going to be you getting those calls for "What do I do?" You need to start developing those skills of clinical judgement and autonomy from day 1.
• Did I mention going to see the patient?

 

[Smurfette]

To add to the above:

~ Get sign out from the team(s) you are covering and keep a list of stuff you need to do (i.e. post op checks, labs, check CT results, etc.). Check them off when completed. If something is not done(!?!), be ready to explain why to your seniors in the morning.
~ Give sign out in the morning to the team(s) with the results of the tasks you did overnight, significant overnight events and important details on new admits and consults.
~ ALWAYS "load the boat" if a patient is deteriorating. Your senior needs to know, and you need back up.
~ If you have never seen or done something before, ASK how it's done or have someone show you. Do not be the intern who makes things up.
~ Find out where these places are in the hospital: your call room, your senior's call room, bathrooms, supply closets, cafeteria/snack machines/food sources.
~ If you are going to try to take a nap, first cruise by the nursing station(s) and see if anyone needs a med renewed or if the nurses have questions on a patient. The goal is to take care of stuff now to spare you the pages later. It works.
~ Have you seen the patient yet?

 

[greg1184]

Know who your upper levels are when you start your night shift. If your program is like mine chances are you will have midlevels who handles consults/admissions and a senior resident in house. Do not hesitate to bump up anything that you feel uncomfortable with... especially in July. It is far better than if you fail to bump up things and you do something wrong (by omission or comission). Even now at the end of June I still bump up things.

 

[rigid]

There is no shame in having to look anything up - like drug doses. Also never be bullied into doing something you aren't comfortable doing, having said that at night time the nurses can be your best ally or your worst nightmare so do your best to not offend them.

 

[Dr.LeoSpaceman]

Know who your upper levels are when you start your night shift.

This is an important point. By ACGME rules, you have to have a supervisory resident/attending in-house. However at some programs (like mine) that person may be a resident/fellow from a completely different service. For instance, since we have an in-house trauma team, that senior is technically the in-house supervisor for the night float even though the NF is going to call the responsible chief/fellow for their service who is at home. It's good to know who else you have as a backup, just in case you get into a situation where you need immediate help and your senior is 15 minutes away.

 

[HighPriest]

100% agree with all of that.

My small addition: understand your place in the machine. You're a cog, just like everybody else. As an intern, you just happen to be a less revered cog that does a massive amount of relatively less important work. That work is nonetheless vital to the machine.
Why do I think that's important? Because you're going to get irritated at some point with the amount of TTD you get at checkout. You're going to wonder why the day team didn't do more of it. You're going to wonder why your senior sometimes seems to get more rest than you do (he probably isn't, but it will seem that way at some point). You're going to head to every nurses station, speak with every nurse, and still get called 5 minutes after you lay down for a 2 a.m. Colace order. Some of the nurses, no matter how well you treat them, are not going to trust you simply because you're an intern. You're going to be afraid to call someone senior to yourself at some point, whether that fear is justified or not, but you're still going to have to do it. You're going to feel yourself becoming more and more competent, and then you're going to have some situation make you feel like a fool.

That is all a part of the machine. Everything said above is excellent advice that I guarantee every resident, surgeon or otherwise, wishes they had adhered to just a little more than they did. (and I'm not saying these rules weren't followed. I'm saying that when you're in the $#!T, cursing your R4 under your breathe and wondering how nursing schools spend their recruiting time, you can lose sight of the bigger picture.)

Eventually things start to become more evident.

The day team busted their rumps for way longer than their recorded hours dictate, and they're relying on you to mop up. You'll be in the same spot someday. Your Sr. resident is as busy or busier than you dealing with admits, surgery, and ICU patients, and someday that'll be you. The nurses changed shifts, or one of them was helping a patient when you came by, and they're trying to do right by their patients by double checking their med orders. Some nurse had a bad experience with an intern, and she doesn't trust you now. But in a year, she may be your biggest advocate. Your senior resident is just as tired as you, so sometimes he's an ass when you call. Or, if he's just an ass, remember not to be that guy when you're in that position. But either way, all that matters is that the patient gets what he needs. And finally, everybody feels like a fool at some point, staff, resident, or intern. It just happens less often with experience.

Keep the outside perspective in mind. <--wow, that was shorter.

 

[jasb66]

As an ex-intern that started night float in my program when the new rules came into effect in 2011, I think I have a few things to say. We did around 4 months of night float as interns. My program now has been randomized to the intervention group on the FIRST trial, so there will be no more night float this year.

- Never ever assume anything. Trust everyone, but recheck everything. An intern's excuse starting with the clause "I assumed that..." gets immediately destroyed in my program.

- You are a doctor now. It is July and you are making a doctor's decision in the middle of the night. You aren't 110% sure about the decision. Odds are you will be wrong about your decision. Stop, read, bump, ask, confirm.

- Accept that you are completely fallible and many times clueless as a fresh intern. You will commit mistakes. Never, ever lie about anything or deny your mistakes. Finding about your lie will mark you for good and no one will trust you completely ever again.

- It is okay to say "I don't know". State that you will find out as soon as possible.

- You are training to become a surgeon. Taking care of the floor at night is part of that. But in a quiet and easy night, do what a surgeon must do: go to the OR, at least to observe. My juniors and seniors would be surprised when I showed up in the middle of the 2am trauma laparotomy/lap appy/dead viscus/incarcerated hernia. Yeah, I am night floating the n=4 patient bariatric MIS floor, and all is good and charming there. Thought I could take a look at what you guys are doing. Maybe I can scrub in, maybe I can close, always leaving the myriad of pagers to the circulating nurse and KINDLY asking her/him to call and rely pages instantly to you - scrub out as needed, which is usually the case because you pretty much ALWAYS have to see and lay hands on the patient. But in a quiet night you can score a sweet case. I would do this above sleeping, all the time.

- If you are doing an entire rotation of night float, I'd recommend to change your sleep cycle. Become a vampire. Breakfast is after checkout, lunch at midnight (try getting lunch with junior - they will appreciate this in the middle of their consult-slammed night), dinner (bacon Texas toast treat for me) after early AM rounding on your patients or after sign out. I placed my mattress into my walk-in closet with the AC on and it was pitch dark, cold and cozy when back home from hospital. Banged 7-8 hours of quality sleep before having to show up again to hospital.

- Stay away from napping at night if you desire to change sleep cycle. Instead read for ABSITE, a text book, shadow/help your junior with whatever you can, fool around the nurses station, or go to the OR. The night float fragmented sleep won't be fulfilling or recovering for you to function at 100%. Unless you want to sleep 10+ hours a day.

- You will get pretty close to hating some of the night nurses. Show no emotion about these feelings you will certainly have. To the opposite: be a charm, please, listen, smile, and acknowledge. It is pretty damn hard to do this, but it will be all in your great benefit. Life will be so much easier.

- Be neurotic about checking your boxes in census. Importantly, during sign out, recheck your already checked boxes to highlight night events. Avoid calls from day teams about events when you are getting ready for bed at 10AM. Spare these annoying (for them) calls also by neurotically documenting everything. My night notes would be one-liners of event, assessment, and plan discussed with (...).

Hope some of it helps and good luck.