Hi everyone! Hope everyone is settling into the year well and getting ready for autumn. Myself, Alec and one of our M4s (Jasmine Scripp) decided to write down a few high yield points about how to excel during the night float month. Seeing as we’re only into the third month at the new hospital I figured some reflection about our experiences may serve a purpose to those taking the dive the rest of the year. What I really liked about this opportunity was the chance to have the perspective of three different levels all in one spot. Enjoy!
- Find a system to keep track of the patients you admit, cross cover and any MET calls you need to follow up on through out the night. By now each of you likely have a system to keep yourselves organized, now is the time to rely on your experience. For me, as I’m sure most people know, it has always been a notebook I can keep in my white coat to manage the flow of information, which is often fast.
- Your intern and medical student are invaluable members of the team; learn to incorporate them into patient care and they will learn quickly. Eventually they will be managing many problems on their own which allows you time for other issues.
- Having said that, it’s important to establish that any help is readily available. Not only should this be stated, it should be shown through action. Reach out from time to time to see how your colleagues are doing. Actions speaking louder than words.
- Check the batteries of all your pagers/MET phone at the beginning of the shift.
- Call attendings if you are unsure
- Call consults if you are unsure
- When called to the ED try to go quickly and then place orders to have them moved to the general floors in a timely fashion. Bergan Mercy ED is often busy so getting in orders to have patients moved to the floors is a high priority for the RNs and MDs that work there. You will quickly realize this as well.
- This is important; the time it takes for patients’ to move from the ED onto the floors is often pretty wide. It can takes minutes to close to an hour. Remember that when you contact the patient they effectively becomes yours, which means that while they sit in the ED you must be aggressive and cognizant of any orders they may need immediately as opposed to when they arrive on the floor. This usually is pain control, fluid orders and antibiotics. Even though you place orders into EPIC in the ED, they will be “signed and released” by the floor RN — if any of those orders cannot wait, then make sure the ED staff knows to enact them ASAP.
- Make sure you follow up on your patients when they arrive onto the floors. I often talked to the floor nurse in person to make sure he/she understood the plan for the patient and to address any concerns he/she may have. Probably saved some pages this way but most importantly I hope I relieved any uncertainty
- During these calls it will be you, the ICU charge and the floor nurse to address a potentially acute complaint a patient may be having. Drop what you are doing to go to the bedside and evaluate.
- You will deal with a broad set of complaints, regardless of your plan of action, remember to ask if the ICU charge and floor RN understand the reasoning behind them. I also made sure they were comfortable and to know they could touch base with me anytime throughout the night. Once again getting everyone on the same page is a great reliever of anxiety in the middle of the night, especially if a patient is sick. Everyone is trying to provide effective care.
- If you order labs/imaging on a patient, follow up on them.
- Nurses may contact other consulting services or even the primary team for a patient they called you to evaluate. Obviously these doctors know more about the patient than you do and respecting that is important. At the end of the day though, you are physically in the hospital which means if there is something that does not seem right it is your responsibility to contact the right people or move the patient to the appropriate setting.
- Write a MET call note to communicate your plans with the day team.
- When people are admitted in the evening they enter a hospital that is no longer full of the hustle and bustle we grow to expect during the day time. I refuse to have any of my patients uncertain of why they are there and what the plan is. I made sure that before I left any of my patients I asked them two important question “Do you know what the plan is?” “Do you have any concerns?” Once again I’m sure this reassurance saved me a few pages throughout the night.
- At the end my notes I put this acronym down, ADDC stands for Access Diet DVT Prophylaxis Code status. Don’t forget this stuff.
- But also commit
- Night rotation is demanding. You work long, stressful hours and your day-night cycle is often lost. Remember to pace yourself to last the entire month. On your off days reach out to friends, go to the park, spend time with loved ones. As MDs we survive by knowing ourselves and subsequently by knowing what we need to do to be OK. Now’s the time to use that insight
- Don’t eat junk food all month 🙂 (hard I know)
- Get sleep when you can on your off days, you earned it!
- PROTIP: I liked to plan some events throughout the month, things I really liked to do, maybe dinners or movies to have something to look forward to. It broke up the month for me.
(Tips on how to be an effective supervisor and a few words to interns)
1. Teaching, not doing. The first time putting in orders, admitting patients, discharging. Etc. can be a great learning opportunity so teaching how to do these things properly can be beneficial. Sometimes it’s easy to do everything for intern/student to save time or even help relieve the pressure off of them, which is appreciated but then they still don’t know how to do those tasks in the future.
2. Making interns/medical students feel like a member of team rather than an inconvenience.
3. Keeping a positive environment so that interns/students know that it is okay to be wrong as long as you continue to learn from mistakes and practice with patient safety as the number one priority. This allows an environment in which everyone feels comfortable contributing.
4. Interns/students should form an assessment and plan and defend it. I think this is most important as it requires that they think critically about all aspects of patient care and learn with each patient.
5. Informing members of the team if you make changes throughout the day (i.e. Stopping or decreasing fluids). Following these changes helps with whole patient management and enables progress toward independent decision making.
Jasmine Scripps (M4)
- Bring snacks – it’s a long night and having something to nibble on helps. Cafeteria closes at 2 PM, so the only place left at night at Bergan is Subway.
- Hydrate up – chances are, you haven’t been drinking enough water while running around all day with your team. When in doubt, the blue water machine on the 2nd floor is quality.
- Chargers are important – computer and phone both. Nothing drains your battery like waiting around doing UWorld questions (or checking Facebook).
- Extra pens help everyone – and yours will normally be borrowed and never returned. Plan accordingly.
- One on one teaching is lit. Your residents are the best in-the-moment teachers. Don’t miss out on learning opportunities where you can gain some insight on pt management. It also helps for shelf exams (if that helps convince you).
- Ask to be involved – the intern is figuring out how to manage these things, the senior is responsible for everyone. They won’t always remember to invite you along or text you. Ask to go, stick with them for at least the early part of the night. You may be able to participate more than you thought.
- Read up on what’s going on. Especially for new admits. You never know if something you check on UpToDate will impact the assessment and plan.
- Talk to patients. They have important information! It is great practice now, and will be even more useful for checkout in the morning.
- If someone tells you to go to sleep, you can go to sleep. You aren’t a failure or weak for needing some rest. You were on all day before this.
- Don’t bail either. Just because you want to study or are tired doesn’t mean going to the call room at 9 or after 1 admit is acceptable.
- Be part of the team. Offer to look up information. Ask questions if you want to know something else for the history. If you are unsure of a finding, ask someone to check it out with you. Even if you are wrong, you learn something.
- Night staff are all heroes. Treat them with respect and kindness, and you will reap the rewards. They know where to find almost anything, who to call, and where the Martti is kept.
- You are already here in the morning for rounds. You are the expert on what happened overnight. Help your team by rounding on your pts earlier and finishing your notes before check out, so that you can be available in case your fellow med students or residents need you. Your notes will be very valuable for the whole team.
- Have fun! This isn’t punishment. This is a right of passage and a small preparation for what you will get when you are a resident. Take it in.
Hope this was helpful everyone!