Saturday, August 1, 2009

Night float

Our department chair decided at some point that the people on night float shifts--interns who cover the medicine patients overnight, and residents who admit new patients coming in after the regular teams have stopped admitting--should have a teaching session. And so we met this morning, all the night float residents and interns. I've been doing a pinch hitter sort of job, in which I do overnight medicine consults and also support the night float interns; next week I'll be doing admissions. The relationship among all of these people is an odd one. Except for me (because I spend a reasonable amount of time checking in with my early-in-the-year interns and backing them up in various medical crises), we are mostly working alone. But we see each other through the night, crossing paths in the hallways or sharing a workroom for an hour here or an hour there.

In our conference this morning, we started talking about a patient. It turned out she'd been admitted two days prior by one of the admitting residents. An ICU resident on call overnight came down to evaluate her when we thought she might go to the ICU, and spent a good long time afterwards thinking about the patient's situation. In a workroom, thinking aloud, getting excited about some ideas about the patient's situation, the ICU resident talked to another nightfloat resident, and had pitched her theory to a couple of us. One of the interns had been called a couple of times to go see her overnight, and I'd gone to back him up for some of the hairier calls, and I had helped arrange the patient's possible transfer to the ICU before we decided she was OK to stay on the regular medical floor.

In conference, then, the admitting resident presented the case, but the group started talking about it in an engaged and interested way, because so many of us had thought about the patient, cared for the patient, or heard about the patient already. I'd seen the admitting resident a couple of nights before and had talked about this patient even then, because the resident was excited about the admission. She wasn't too busy and with an interesting case to think about and read about, she got the chance to do real medicine instead of setting up a holding pattern to be handed off to the day team. I'd spent a long time thinking about the patient when I was trying to figure out whether she should go to the ICU. And the nightfloat intern had spent a lot of time seeing the patient because of multiple problems over several nights, trying to figure out which of the calls represented real crises and which ones didn't.

I was reminded of another time I was in the ICU and a patient came in with an unusual problem; within a couple of hours, cardiologists, pulmonologists, and oncologists had mobilized for procedures and studies, teams were passing the chart back and forth as they worked on plans and notes and recommendations, and people kept buzzing in and out of our MICU team rounds to give updates on the latest detail of the plan. A cardiology fellow showed up and so did an echo tech, and within an hour of us asking for the study, there was a detailed echocardiogram and an attending reading it. Someone else was planning for a biopsy. One consult team was calling another consult team to help work out details.

"This is when I love being at a teaching hospital," I said quietly to one of my fellow residents, as our intern was presenting data and we were watching out of the sides of our eyes as one of the consult teams was bustling about nearby. "These moments of this massive mobilization of expertise, all of these people with this insane amount of training, coming together for one sick person. It's beautiful."

Overnight, the hospital often seems like it's in a holding pattern. We try to keep people alive until care can be advanced during the day. So it was a surprise to me to find myself in conference with a little bit of that teaching hospital feeling: the feeling that there were all of these smart and engaged and caring people watching the progress of one sick patient and sometimes being a part of her care, wondering how it would turn out, wondering whether she would come to the unit or stay on the floor, wondering whether she'd get sicker or better, hoping for the best.

The senior admitting resident had come up with a long set of possibilities for what might explain the patient's symptoms, and ordered a bunch of tests right away to start sorting them out. The ICU resident was pitching an obscure diagnosis but one with some credibility; though I wasn't buying it, I had to give her props for zeroing in on a particularly striking lab value which I had skimmed over. I was pitching another theory, but at the same time telling the intern to cover for gram-negative infection, which was actually a counter-move to anticipate what could happen if I was wrong. The attending, writing a note in the morning when we emerged back onto the floor from our conference, thought we were all wrong, was stopping the antibiotics I'd told the intern to start, and had another theory entirely. But we all had opinions without certainty, which meant that we really listened to each other, and we all had a sense of suspense:

"Poor lady," said the attending, "I haven't seen a case like this for a while";

"I really think the team should start treating now, even without knowing everything!" opined the department chair;

"I know what you mean, but they could get in trouble with that in other ways," said the chief resident, deferential but firm;

and the intern, new to it all, was listening to the primary attending with eyes much brighter than his fatigue should have permitted, truly a part of this thing that we all had spent so much time working towards, and which he had finally just joined a few weeks before.

We felt ourselves to be a part of a community of highly trained people, late at night when others are asleep, part of the world of doctors as doctors themselves hope for and imagine it should be. A team of experts and people becoming experts, mobilizing, caring, theorizing, arguing; and at the same time, perhaps above all, walking briskly down the hall towards the patient's room after getting a page from the nurse about low blood pressure.