night float

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.

I’ve been reading some of the never-ending controversy in the medical blogosphere about the 80-hr week (some are talking about 57hrs as though it’s a definite development; that had just better not be true). I thought I’d add a slightly different perspective:

Today I worked about 14 hrs – came in an hour earlier than I was supposed to, and left an hour later than I was supposed to; not bad for a surgery intern. At the end, I walked away from a sick patient who will likely to go the OR tonight, I’d guess around midnight. When I left, he wasn’t acutely decompensating; his pressure had stabilized and he didn’t need to be intubated, yet, although there were more lines being put in. I had admitted him; he was one of the traumas that came in all together, and by the luck of the draw, the triage information was inadequate, and the senior residents went with patients who seemed sicker, but turned out to be in better shape. So I’d worked him up, admitted him, followed him for several hours. Then I was told to leave, while his final outcome was still unclear: could we handle him nonoperatively, or would he require one of the now nearly legendary trauma ex-laps (exploratory laparotomies)? (legendary because so many blunt trauma injuries are now managed with just observation or angiography)

If I had thought that I would get to participate if I stayed for the surgery, I would have stayed eagerly. But I knew that the senior resident in-house would get to do anything that was the least bit interesting about him; just because I’d admitted him didn’t mean I’d get to do anything meaningful in the surgery. So I left.

I don’t know which came first, shift work, or the attitude that seniors get all the cases. I’d stay more if I thought I’d do more. As it is, I’m sorry to miss seeing exactly how it plays out, but since I wouldn’t see the inside of him anyway except from a distance, I figure sleep is good, and I’ll hear in the morning exactly how many hours of borderline pressures, and how low of a hemoglobin, it took to get him to the OR, or not.

My plan for the last night of March was to keep things quiet, get some sleep, and study up for a laparoscopic procedure that I had been semi-promised on my new service the next day. Semi-promised, as in, “X procedure. . . you do know how to do that, right? [alarmed] Have you ever done one of those?” Me: “Oh yes, sure – at least, I did one.” So every time the junior residents saw me, they egged me on to make sure I did the case, and every time the chiefs saw me, they expressed skepticism over the wisdom of the plan, coming off of nights, a complicated patient, and so on, and reassured me that one of them could do it if I couldn’t. Needless to say, after a very few of these conversations, I was quite determined to do the case no matter how tired I was. After all, in three years, as a chief, I’ll need to be able to operate after being up 24 hours or more, not to mention what is likely to happen in private practice. (That’s how I persuaded myself I wasn’t needlessly endangering the patient.)

Of course, the night wasn’t quiet. I had shared responsibility for one patient, and individual responsibility for another patient, who both crashed and went emergently to the OR at the same time. My particular patient was bleeding dramatically – the kind where you transfuse massive amounts of blood, and the hemoglobin comes back lower than when you started; and when you open in the OR, the floor gets covered with blood. I did my best to do hands-in-the-pockets, and thanks partly to that, and to the fact that it was actually a straightforward case – the only thing to do was give blood and go back to the OR – and to the attending turning up quickly when called, the patient did just fine. But even after the OR, I still had to spend a lot of time in the patient’s room, talking with the nurse, doublechecking orders and labs. So I slept for maybe an hour altogether, and had no time to study for the case.

Fortunately, after four hours of mandatory lecture, the case was delayed for a little while, so I had a chance to go read. It was good I did, because the way I had assumed the procedure should be done was incorrect, and there was a fair amount of background material which I ought to know, and which it made me feel much more confident to face the attending, having read. The case went fairly well; as in, it took twice as long as it ought to have, and there was a slightly larger blood loss than usual (usual being 20cc, that’s ok). It was complicated, for me, by the presence of a new medical student. She did her absolute best to keep the camera in focus and to follow my movements; but the result was that it bounced worse than any other med student I’ve seen this year; and when I already felt a little unsteady on my feet, and was trying to do the most delicate maneuvers I’ve tried yet, laparoscopically – it was all I could do not to snap at her. But as in the parable of the unforgiving debtor, what could I say, when the attending was silently putting up with my infuriating slowness and blundering?

Finally, I had to leave late in the evening, signing out a rather unstable patient to the new night float. The intern on this month is one of the program’s characters. He’s ten times as competent as I am, and I completely trust him to take care of my patients. The trick is that his good care will be quite unorthodox, and I’m sure I’ll be in for some surprises when I get back in the morning and see what his management has been overnight. And then I’ll have to explain to my chief and attendings, who will somehow hold me responsible for all events. Ah well. Have to let go sometimes.

Time to go read a little bit; we’ve been warned of pimping sure to occur tomorrow, and having been warned, it would be unforgiveable to be unprepared.

I spent a large part of the night, in my capacity as plastic surgery consultant, watching the trauma team and the neurosurgeons handle a stream of disasters. I would get a perfunctory consult, because of a broken orbit or zygomatic arch, or maybe a few small lacerations, but I wasn’t about to take up the time to look at the patient or sew things neatly while the neurosurgeons were discussing how fast they could get the subdural or epidural hematoma into the OR. Then there was the poor guy who came in with his face streaming blood and an unstable airway which took the longest time to get control of. I stayed around, because I figured with his face looking like that, there would be a plastic surgery consult forthcoming. When we finally got to the CT, everyone was amazed to see that the bones were just fine (though not much else was). Which was ok with me.

I continue to admire and take notes on the senior residents’ manner of handling emergencies. Hands in pockets seems to be a ubiquitous theme, and a practice which I will have to adopt. It seems to promote a certain shoulders-back, distanced-enough-to-think-calmly stance, which I could use. (Not, you understand, when there’s any thing which actively needs to be done. The point is to keep your hands still if they’re not needed. One thing I learned quickly as a medical student is that you should not put your hands in your pockets as a student on a surgery rotation, because it implies that you’re uninterested, and not available to do things like rectal exams, foleys, and cleaning up whatever messes need cleaned up.) Pockets, and standing at the foot of the bed, where you can survey the situation and not get in the nurses’ way, and standing still, rather than pacing back and forth.

At the beginning of the year, I got a long way by pretending to be a doctor – and here I am, actually a doctor, feeling like one, and acting like one without having to pretend. So I think for next year we’ll go with the same plan: pretend to be a junior surgery resident, calm, unfazed, knowing what to do next, and hopefully within a few months it will be true.

I’m 3/4s done with The ICU Book, which will have to do for now. Tomorrow night I plan to sleep as much as possible, and then the same all day; which will hopefully help me to flip my circadian clock 180 degrees within 24 hours. The only good thing about this entire scheme (surgery residency and all) is that I seem to be good at falling asleep anywhere, anytime, at the drop of a hat. Being at night and having a bed are nice if they happen, but not necessary.

Jesus, I am so grateful to be doing this. Answering pages tonight, I was just happy that I get to be answering pages about surgery patients. In general, I am interested in what’s happening with them, and I’m familiar enough with most surgical situations to be able to give glib answers to questions. I am glad I get to take care of surgery patients. Life is good.

And then, of course, I get to sew people up, too. I had a guy with the most complicated facial lacerations I’ve seen yet. It took me an hour and a half to finish. I think I did the best possible job with them. As messy as they were, he’s not going to be pretty, but hopefully not too horrible either. I bit my tongue and managed not to console him with the observation that scars look good on guys. He was the nicest trauma patient I’ve met in a while – apologizing for giving us trouble, promising to turn his head however I needed him to, not complaining the least bit about the needles, and saying thank you every couple of minutes.

I learned something else about professionalism this week: it doesn’t mean just staying late when you have an assigned service to finish taking care of, but also even when you’re on call and there’s still something to finish. I haven’t been that late this week, just late enough to have to be sure that I’m not rushing through a job because I want to get out. I keep remembering earlier in the year, when I saw one of the senior residents whom I respect the most stay four hours late after a call shift to keep an eye on an ICU patient whom he was afraid might get overlooked and crash without continued TLC.

I also remember, ashamedly, one of my patients who died early in the summer, after I’d only been on the service for a couple of days. Back then, I didn’t feel too bad about it. I mean, I was sorry he was dead, but it didn’t seem particularly related to me, because I’d only been seeing him for a day or two. Now, I would feel personally responsible if someone dies on the first day of the month after I join a service. They’re my patients.

Oh – I got my first radial arterial line in. My senior this month is so great. He keeps finding patients for me to try on, and this time he stood there with his arms folded, refusing to put on sterile gloves, saying, “This is your line. You’re not leaving till you get it in.” And it did go in, eventually. I think I’ve been overestimating how deep the radial artery lies. It’s really just under the skin, in a normal-sized person.

Finally, a quiet night. I kept getting pleasantly surprised when I answered my pager: “Oh, sorry, wrong person.” “Can so-and-so have tylenol?” “Can so-and-so have ambien?” “Oh, sorry, wrong person.” Some people hate those mistaken identity pages. I don’t. They feel to me like getting a surprise rebate, or a 50% off coupon.

I even got to scrub in and assist on a case which went really long (three hours after I got there, and more after I had to leave to take care of some things). The attending, whom I hadn’t worked with before, was polite to the assistants, funny, and kept explaining what he was doing almost nonstop, which was terrific. Some attendings hardly talk at all in surgery, and if you do ask a question, they answer under their breath (and behind a mask – almost impossible to hear). Attendings who just chat about what they’re doing in the OR are so much more educational.

There was one patient who developed afib overnight, actually much faster than I’ve seen before. Fortunately he was comfortable the whole time, and I did everything just about right, down to calling the right people at the right time.

Only three more nights of this. I’ve got another three hundred pages to go in The ICU Book. I’m now into the fluids and electrolytes section, which is where I think there’s a hole in my scientific thinking box, because ever since first year med school I get hopelessly lost at this point. I did just barely manage to grasp the mysteries of FeNa (a way to evaluate low urine output which looks like a problem from advanced algebra), but as for hypervolemic/normovolemic/hypovolemic hypernatremia/hyponatremia – I get to about the first level in the branching decision tree on that subject, and my eyes glaze over. Especially since this author starts the chapter out promising to explain a very simple way to approach the whole problem – and then it turns out that the whole evaluation depends on your assessment of the patient’s total body water status, which he himself admits is very difficult to assess reliably, since signs like edema don’t develop until you have 4 or 5 extra liters on board. So basically his simple method boils down to, take a guess about the water status, and then make the rest up from there. (Sorry, non-medical folks, if this doesn’t make sense to you, it’s because it doesn’t make sense to me either.)

At least he gave a very concise explanation of the mechanisms and bad effects of hyperkalemia (high potassium), and what specifically to do about it, which will be very comforting in the future.

I spent all night admitting patients, so much so that I started to feel like part of the hospitalist team – one admission after another. There was one point where I had more than 10% of the ER waiting to be admitted by me individually, plus people already on the floor. At least they were all genuinely sick and deserving admission, which always makes one feel better about it, except that all the attendings were angry at me, for one reason or another, and most declined to answer my pages anywhere near the time I called them. And then I paged them a couple more times, which no doubt didn’t make them any happier. But since I’m sure they were at home either getting ready for bed or in bed, I don’t see why it should take twenty or thirty minutes to call back. Yes. And so on all night. Every time I talk to anyone from this group, it always turns out that I did something wrong, no matter how hard I think about it, how careful and thorough I am – always something wrong, and usually not the thing I’m expecting. At least their patients are uniformly pleasant and polite (except for the one who was trying to leave AMA at 3am).

And the floor they admit to has – nice nurses, but not efficient. The kind who will call you two hours after the fact to tell you about something if it’s important, but immediately if it’s not important. All in all, I am quite ready to be done with this group. They ran through their “things come in threes,” twice by now, so hopefully I won’t have this much to do with them again in the last few days of the month.

(The rule of threes is true, you know. When I got the second call about small bowel obstruction from the ER, I said to myself, I know there’s a third one sitting in one of these corners, I wonder whether I ought to go looking for them? And five minutes later I got called about the third one.)

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