Saturday, July 21, 2007

Night float: "MD aware"

Last night I was on night float--this time, a one-time thing, to give other night float interns a night off. Today, I'm spaced out and headache-y. Some of the other interns are getting together for dinner and drinks tonight, and I should go, but I feel as if I can't bear to talk to anyone or go anywhere. Instead, I'm sitting in my apartment while Ms. Dr. Hemodynamics is on call. I'm listening to KCRW on the internet, writing this after cooking myself some dinner.

I'm not sure when the concept of night float was invented, but it's become a lot more common with work-hour restrictions for residents. In overnight call systems, when residents literally lived at the hospital (hence the word "resident"), "call" meant not only admitting patients to the hospital but also cross-covering other residents' patients.

Now, the interns and residents on call stop admitting after a certain point in the evening, and a nighttime team takes over both admitting and cross-coverage. In our hospital, the night float interns respond to the problems of patients already in the hospital. The night float residents admit new patients who are coming in overnight.

That means that as an intern, I was answering pages from nurses for some large number of patients--I didn't want to know exactly how many. Something in the range of 50 or 60 or 70, I think, but I never counted; I just answered pages.

Some of these pages seemed simple; this patient wanted medicine for back pain, while that one wanted something to help him sleep. But for me last night, anything but the simplest and heavily chart-documented chronic back pain warranted a visit (was it new? where was it? was it a kidney infection or a spine infection? or just from sitting in a hospital bed for days?). Help with sleeping required at least a chart review (how was the patient's kidney function? liver function? what had they taken in the past? any psychiatric issues?) to try to figure out whether the easiest choices might make them crazy or dangerously sedated.

Then there were the pages that went something like "[Patient name] down to 90/56". A drop in blood pressure can be truly ominous: it can be a sign that someone has a new serious infection, or an acutely failing heart, or new internal bleeding. But the majority of overnight pressure drops last night were probably mostly caused by something simple: sleep.

One of my more alarming pages about low blood pressure last night was solved by turning on the lights and talking to the patient and listening to her heart and lungs with my stethoscope. When that was done, she was at an average blood pressure, and I was convinced by her quick wake-up and easy return to coherence and consciousness that she'd been doing fine all along. The unfortunate effect of this kind of evaluation: when the number on the screen means a nightmare for me, that's the end of sweet dreams for you. On the other hand, it's better than getting a bag of unnecessary IV fluids.

Some reasonable proportion of us, if we had telemetry monitors hooked up to us at home every night, would be setting off alarms all the time. But even when nurses are reasonably sure that this kind of normal situation is why the pressure is low, they need to page the doctor anyway. In the nursing note, they have to make note of abnormal vital signs, and they write something like "BP down to 89/56 during night while pt sleeping. MD aware."

As with my first night on the MICU, I was once again grateful for my hospital's well-educated and experienced nurses. In one case, a renal fellow talked to me about the patient in some detail in the late evening, and then checked back in with me in the morning about how the plan had gone. I explained that we'd stopped the fluids, and why; the fellow was pleased because this is what she'd called to recommend.

"Actually," I said, "the nurse called when the labs came back, and said we should stop the fluids, and I said that sounded like an excellent idea." The fellow laughed, and praised me for listening to the nurse.

I said, "I try to do what the nurses tell me, probably... mmm... 85% of the time." She laughed again: "Sounds about right," she said.

The rest of the 15% is complicated, and it's rarely due to some error on the nurse's part. More often, it has to do with differing priorities. For instance, since the nurse is hearing the patient complain all night, and is sick of answering the call button again and again, the nurse might be more ready to want the patient to get a sedative medication for sleep. Often, this is informed by knowing that a particular medication is given all the time, and knowing that a particular patient is medically stable, and knowing that it's really hard to get good sleep in a hospital.

On the other hand, for people with complex medical problems, a lot of these medications can be frightening for the doctor to prescribe, and if I can avoid prescribing them, I will. The most satisfying visit last night was with one of these patients, who had many medical issues. The patient and the nurse wanted a sedative to help him sleep. The idea was worrying to me, since all I knew about the patient was a list of medical problems, and the drugs I knew best each had some possible bad interaction with at least one of those problems. I was doing some other things, and took a while to come up to evaluate the patient, probably to the annoyance of the nurse and the patient. But by the time I got there, the patient was asleep without my help. (The ideal solution for this situation is for the doctor who is taking care of the patient by day to anticipate this problem and suggest a possible sleep medication for the night float intern to prescribe if necessary--but it's July, and that kind of hand-off is a ways off.)

The most frustrating thing about night float was one of the things that makes night float systems worrying to most people who think about their risks and benefits: hand-offs. I got some less-than-totally-informative descriptions of what was going on with some of the patients I got called about overnight. And on my end, hopefully just because it was my first night, the system I was using to keep track of overnight events turned out to be much-less-than-excellent, and I fear that I may not have handed off all the information I should have.

But looking at the hospital computer system from home, it looks like everyone is OK for now. The people I worried about didn't get the kind of labs drawn that would suggest problems (like arterial blood gasses, which are drawn for people in respiratory distress). A tentative sigh of relief: night float is over, and the day has come.


nicole said...

You have confirmed what I have always suspected, my b.p. means that I am almost dead. I feel remarkably lively despite that. Perhaps it is all the bolstering I get when I go to the doctor, "I wish I had your blood pressure," they say. Hmm.

Anonymous said...
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Anonymous said...

Please check my blog of March 22, for a description of our Triggers program. It relates directly to this topic.

Precordial Thump said...

We used to joke with the nurses who'd ring us in the middle of the night to assess a completely well patient with an aberrant number on a chart to remember to write in the chart - AC,DC.

"Ass covered, doctor called".