night float

 Night shift is like a nonstop final exam. Remember how waiting for the test score was sometimes harder than studying for the test? Nights is a series of problem-solving exercises, where you have to come up with your best explanation and plan, then leave the building. You come back twelve hours later, and like it or not, the answer is up in public view. The rest of the residents and attendings on that service have had all day to think about it, and the official position is out: you got it right, or you missed this or that diagnosis or test or medication, and everyone knows.
I need a handbook, something like “Medical Spanish for Dummies,” maybe “How to Break Bad News in Three Easy Steps.” Last night was the worst test ever: a CT scan so bad I had to look at it three times before I completely realized how bad it was (and then radiology was overwhelmed, and perhaps felt I’d used up my quota of over-the-phone consults, and couldn’t read it for me till two hours after I needed it). After a few bad experiences early in the year, there’s a couple of conversations I try to avoid having with patients: being the first one to tell them they have cancer, especially as a consultant; giving bad news in the middle of the night; giving bad news without a family member available for support. So I looked at the CT another three times, to see if I could get out of it, and I couldn’t. How do you tell someone, You’re going to die within the next few days; I could try to stop it, but you really don’t want me to. And then, in the textbook scenarios, the patient is supposed to have something to say to that: questions, denial, grief – something. When they don’t say anything except, OK – you can’t even really try to comfort them, because there’s nothing left to say.
As if that wasn’t bad enough, then I felt obliged to call their family and explain the momentous decision we’d made. No one answered the phone, so I thought I had escaped at least that difficult conversation. Then, ten minutes before the end of my shift, the family got my message and called back; so I did have to tell them. I could have deferred it to the primary service (we were just consultants), or to the daylight team that I had already signed out to, but although I try not to be the one giving bad news (I think I’m still too junior to be the one making life and death pronouncements), I despise doctors who dodge their responsibility, and let days go by without telling patients and families the bad news that the medical team already knows. I was the one who’d read the scan, talked to the primary service and my attending, and had the discussion with the patient. So I talked to the family, on the phone (even worse than in person; another rule from medical school – don’t give bad news over the phone), stammering and repeating myself and hiding in a forest of medical details. They understood me, though; the only question was, how long do we have?
(And how do you answer that question, anyway? I’m in the business of trying to keep people alive. I’m not really familiar with how things go when we decide to give up. All I could do was make a guess, and warn them that I could be off by several days in either direction.)
So then I had to go home, and try to sleep, and wait to come back in the evening and find out –if the radiology attending agreed with our preliminary reading of the scan (what if I had made all these dramatic statements, and been wrong on the diagnosis?); if the surgery attending agreed with my assessment of how bad the prognosis was; if discussion with the family in the light of day changed the decision about whether to intervene or not. I couldn’t decide whether to wish that I had been flamingly, humiliatingly incorrect on all points, and the patient would do better than I thought, or that I was correct, with all that implied for patient.
I was right.
I don’t feel any better.

Finally, I’ve figured what is so fatiguing about night float. The shift is only 12 hours, so we actually spend less time in the hospital per day this way than usual. But no matter how hard I try to believe that it’s a normal day (at night), it’s impossible to completely ignore the fact that I spend two days in the hospital, but go back each evening on the same day that I started. So I spend less than a day at home, and two days at the hospital. . . or something like that. Anyway, overnight feels like a longer, more significant length of time than a day.

Plus, of course, the inevitable 2am disaster; I can almost set my clock by this one, and usually from the same floor (admittedly the busiest surgery floor, so it’s not really their fault). The only question is how big of a mess it’s going to be: can it be handled on the floor, does it require moving to a step-down unit, or all the way to an ICU, and how many times am I going to have to call people at home to inform them of developments before things quiet down?

I didn’t want to ask for help because it would be a confession of weakness. But my patient was dying, really dying, all of a sudden, out of nowhere, and I didn’t know why, and I didn’t seem able to do anything to stop him. I figured it would be even worse if he died because I didn’t ask for help. So I did. I don’t know what’s worse, that I was weak enough to ask, or that the person I asked didn’t really know any more than I did, and didn’t do any more than what I was about to do anyway. The patient survived, mostly thanks to the nurses, and due to what they and I did before the help arrived. I guess it’s good, in a way. I’ve proven to myself that I can get through anything (with the right nurses). I need to stop using the comfort blanket of asking senior residents for help. If I could just not get so worried by my patients dying, or trying to, that I can’t seem to think straight. . . and why do they always do it at 3am, when I can’t think straight anyway?

I’ve mentioned the ghosts before – memories of other times when things went wrong. They’re starting to add up now, so whenever I have a really sick patient, there’s usually an analogous memory, where things didn’t turn out well. I don’t know whether it’s good, to have those to make me paranoid and anxious to check into every possible explanation or treatment option, or whether knowing the answer to those old puzzles sets me thinking down one track, unable to see what might be different about this time.

No matter how much trouble I have with a rotation, I always get nostalgic for it during the last few days, and uneasy about leaving to do something different. Strangely enough, I feel the same way about night float, the rotation that everyone in the program loves to hate.

Despite the difficulties of switching your schedule around by twelve hours, to the exact opposite of everyone else’s, and then having to stay awake for conference on odd days (and in my case, wake up for church on Sunday), night float has its benefits. We own the night. There’s a sense of empowerment in surviving the worst rotation of the residency (and having nearly all of my patients survive it, too). If I can do this – since I have done this – I can do anything. (So, ok, every one of the chiefs was more than annoyed with me on at least one occasion, and I managed to say something idiotic to just about every surgery attending in the program, but still – only two chiefs were upset enough to chew me out a day or two later, and no attendings have sent angry messages by intermediaries. . . ) No individual service will ever be harder than handling all the services at once, alone, at night. There is no phone call that will not be easier for not having to wake the recipient up for it (whether calling a family with bad news, or an attending about a new patient).

Not having to preround in the mornings; not having to sign in with a team; not having to round with the attendings. . . At night, as long as you get the work done, you are your own boss.

I like the hospital at night. There’s a sense of camaraderie among the staff stuck there. A lot of ancillary services and radiology tests aren’t available at night, but the ones that are available are easier to get: if you’re ordering a CT at night, the techs understand that there’s a good reason, and it gets done reasonably soon.

Coming off nights, the schedule change is one of the worst things about the whole arrangement. On the other hand, for the last month I’ve spent nearly every night dealing with the sickest patients on the service I’ll be switching to, so there won’t be the usual disorientation of picking up a new list of patients and trying to become immediately expert in all their idiosyncrasies.

But whether I’m feeling nostalgic for the lonely freedom of night, or glad to be done with the crushing responsibilities, it’s only two months till I’ll be doing this again. And by that time, the weather will be better, and there will be a lot more traumas; which will make that month about twice as bad as this one. . .

Night time is all about triage. When you get three pages exactly at the same time, which one do you answer first? Two interns calling you, who do you answer first? Two consults in the ER, which one to see first? Two attendings to call, which one goes first?

More complicated: An admission in the ER, and an ICU consult which is probably nothing – but you won’t know for sure till you look for yourself. A floor consult which probably needs surgery, and an ER admission which probably doesn’t need surgery – again, nothing for sure. An ER consult which needs surgery, and an ICU patient with a pressure of 60/40 and no lines.

Sometimes, like the ICU patient whose vital signs are not compatible with long-term survival, it’s easy to figure out where to go first; and the attending will just have to get woken up an hour later to hear about that patient in the ER. More often, it’s not that simple; you have to trust the interns to give you an accurate picture of the consults they’ve seen, in order to figure out which ones get priority. And if you don’t get the right picture from the interns, it’s still your fault, because if only you trained the interns better, or asked better questions, or listened to them more carefully, you wouldn’t be missing the important facts.

As a rule of thumb, I tend to rank vascular above general surgery. Vascular patients are more likely to have strokes and heart attacks, and if there’s something wrong with them, they’re liable to bleed much more dramatically than general surgery patients. Also, lack of blood supply, to any object, is likely to be irreversible faster than most cases of peritonitis.

Strangely enough, the resident I mentioned in my last post, one of those guys who always gives off an air of glacial calm, which I would give anything to achieve, passed me in the hall this morning: “You’re sick of nights, aren’t you? I know. It was the scariest month of my life.” Not sure whether to be happy that after all he too was disturbed by the level of responsibility, or dismayed by further proof that all the people I admire are in truth as clueless and scared as I am – suggesting that I’ll never achieve that state of calm, because it doesn’t actually exist.

Sorry for the shortage of posts. Night float doesn’t leave a lot of energy for talking.

Last year I was in awe of the junior residents on call. So much responsibility, and they handled it so coolly. Sometimes I saw the stress, but they covered it pretty well. I wanted to be like them.

And here I am now; I don’t think I’m as cool as they were. In fact, I can see it, when there are senior residents around at night for other things; they look at me out of the corner of their eye. I’m not doing anything exactly wrong, not wrong enough to be stopped; but I’m more excited/nervous/antsy about all of this than the guys ever let on. (I’m upset that my patients get sick, become permanently handicapped, die, and I can’t stop it; I don’t know how not to be nervous with these things at stake.)

There is one resident who to me is the epitome of a good doctor: he’s very serious, smart, thinks everything through, and is always willing to put in extra hours to make sure that things get done right. I remember him, on night float, staying hours late in the morning to make sure everything was settled. This morning, I was pleased to be able to do the same thing. A patient came in right before everyone’s shift change, seriously ill. Several different surgical services needed to coordinate to get him in the OR. Although everyone agreed that he needed surgery urgently, it was a little more tricky to decide what exactly was wrong with him, or what precise procedure we could do to fix it, or which surgery team ought to start the proceedings. I’m not sure how much I actually contributed; but my attending was the one making the most concerned statements about not losing time; so I stayed, and called the OR to encourage them that even though I couldn’t quite tell them who the surgeons would be or what the exact title of the procedure would be, they needed to get a room and provide certain equipment. And then I stayed with the patient, as other people had to come and go, and got him up to the OR, and explained his problems to anesthesia. (My commitment to patient care did not quite cause me to scrub in; they would have let me, but an unworthy desire to sleep overcame my passion for knowledge. . .  or something like that.) It wasn’t a big deal, but I was satisfied that even though I’m not yet as cool and collected as the guys I admired last year, I can go the extra mile too.

And as they say, nobody’s died on my shift. . . so far. So I guess all the other problems are small in comparison to that accomplishment. I must be doing a couple things right.

The week was fairly quiet: only a few cases to go to the OR at night, no remarkable activity in the ICU, no dramatic traumas. I was figuring that my white cloud had stuck with me; and indeed it was remarkable how all the arrests on the floor, and all the gunshot wounds for trauma (which it’s part of my responsibility at night to assist with) should all happen during the daytime for a solid week.

Of course Friday night that all changed, and I was completely swamped, to the extent of almost recklessly leaving things unfinished with one patient in order to hurry off to the next, leaving large jobs for the interns to do alone that normally I would help with, and being quite curt in my discussions with patients (completely contrary to the rules of don’t interrupt, and don’t ask closed-ended questions). Once again, though, everyone survived quite nicely (except for the one patient who, sadly, was not expected to; so I am not too cast-down about that death), and not too many anxious families were mortally insulted. The only lucky thing about the night was that the hospital was suddenly smitten with an excess of empty ICU beds, such that no critical patients had to wait to get in the ICU, which was very convenient.

I am developing a great respect for one of the surgical ICUs in particular, whose nurses are so used to having imperious attendings stroll through handing out orders, and then disappear out of range of pages, that they commonly put in all the orders themselves as verbals; and I find them taking care of all kinds of scut for me, and correspondingly ridiculously pleased when they see me putting in housekeeping orders on my own. This is also the only ICU in the hospital in which the nurses are actually excited when something dramatic happens, and all join in happily for bloody bedside procedures; unlike even the other surgical ICUs, where they don’t mind blood and commotion, but prefer peace and quiet.

On the other hand, I am getting quite frustrated with the medical ICU, where the nurses are certainly competent, but have a very different set of priorities. They will not call to tell me that the patient’s urine output is drifting pretty much to zero for a couple hours on end, or that the blood pressure is creeping steadily down to 80. They will however call to say that the potassium is 3.5 (lower limit of normal) or that the troponin (cardiac enzyme, marker for possible ischemia) is 0.12 (lower limit of abnormal); or that the patient’s lungs sound wet, even though their sats are fine. I wish I knew a tactful way to tell them that I would appreciate being told about borderline blood pressures and urine outputs, in addition to the labs; but I can’t come up with any statement that doesn’t sound insulting (as in they’re not doing their job properly) or lazy (I don’t always have the time to walk through the unit every 1-2 hours to check the numbers for myself).

Also on the score of good news, I have a delightfully competent intern to work with. She is remarkably good at assessing things on the floor or in the ER, and calling me only at appropriate times. Also, she is good at procedures – nearly better than me, I am obliged to say.

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