As I mentioned in my last post, I am currently on night float, and my responsibility is to cross cover all of the patients on the floor. I've learned some really important things over this last week and a half on night float.
1) Patients, especially really sick patients, get even SICKER at night
2) My upper level residents are great and always willing to help me out no matter WHAT time I call them
3) Cross coverage can lead to many issues that remain un-resolved and may actually impair patient care
This post will focus on dealing with the last point the most. As many people are now aware, residencies are required to adhere to an 80 hr work week for their residents (thank goodness for that!) But, there are some logistics issues with this that make it difficult to come up with the "perfect" system where both the residents are happy, doing good work, and patient care is not being compromised. The way things are set up at many hospitals to make sure the 80 hr rule isn't violated is to keep residents from taking overnight call, and instead having a cross-coverage come in and watch the patients. This is not a bad system in that in decreases the work load on the residents during the day allowing them to work better and more efficiently when they are at work. Everyone needs rest. BUT, the shortfall to this system is when the patients are signed out to cross-coverage without adequate information passed along to the night float, or even any other cross-coverage that occurs on other days/weekends as well. Little things get missed and not passed on from person to person which may end up adding to a big problem. Some things are avoidable, and other times when a patient starts to crash in the middle of the night, nothing could have been done to prevent it. My point is for those situations where SOMETHING could have been done earlier.
To make a comparison here: at my medical school, the on-call team actually admitted patients overnight, and cared for their own patients as well, while a nightfloat took care of all the other patients on the floor. Here, at this hospital, the on-call team does not stay overnight, therefore a nightfloat covers all the inpatient teams and admissions are also done by nightfloats. Both systems have their shortfalls and benefits. First is that with the second system, residents get more time off to make sure 80 hrs is not violated, and they are well rested and in a good state of health the next day for week. The shortfall is that every night, ALL inpatients are taken care of by a night-float who is not intimately involved with the patient's care. With the first system, residents are tired the next day after being on call all night, but at least their inpatients were taken care of by the actual team making sure that their issues are well known to the team. But, on the other hand, all the other teams' patients are covered by a nightfloat, so still the same problem exists. There really is no way to resolve this issue since a nightfloat coverage is needed otherwise EVERYONE would have to stay EVERYNIGHT to cover for their patients. It seems the best thing would be to make sure everything that needs to be done, followed up, etc be done PRIOR to the team leaving and not leaving tasks like that to be done by night float. A good, informative sign-out document should be passed on so that night-float knows what's going on with the patient if he/she gets called in the middle of the night.
I wonder how other programs have addressed this issue, or maybe this is just a problem across the board now with the 80 hrs. So that's my issue for the day. Soon, I'll be back on days, and no longer have to sleep in a coffin during the day and will hopefully get to see the sunlight!
Monday, July 16, 2007
Wednesday, July 11, 2007
Becoming a Vampire
Well, after some time on the wards, which turned out to be a great two weeks learning experience, I have now changed my rotation to nightfloat. I essentially work 8:30 PM-7:30 AM for the next two weeks. My job is to cross cover (ie: take care of all the inpatient teams) and keep the patients alive until the primary team gets back in the morning.
My first night was from hell. The pager did not stop going off until about 3 am. And even after that, I barely had time to sit down and think. That was offset by last night which was much smoother. I had plenty of time to do the work I needed to do, respond to intermittent pages, and even do a little reading! Yes, reading up on disease management etc. is NOT an easy thing for an intern to fit into the schedule. One must be SUPER efficient to actually be able to get some reading done, or have a nice, calm, night. That being said, I hope I didn't just jinx myself.
So in contrast to my last post, where I was having difficulty deciding on whether a plan of action was just too much for a patient, I had an interesting experience from the opposite perspective the other night. One of my patients actually was going downhill, and FAST. We were running out of options on the floor, and decided the patient probably needed to be transferred to the ICU for further managment. At this point, we had to think about what was our best plan of action. This patient was 90+ years old, but the family wanted FULL CODE status. The patient also had severe dementia making it difficult for us to establish was a baseline mental status was, although according to the daughter and the nurse, by the time I saw the patient at his/her worst, he/she was apparently well below baseline. My resident and I both felt that an ICU transfer should be done since the patient was full code, but the odds were not in the patient's favor of survival. On the other hand, the family insisted we do "everything we can" to save the patient's life. I can't pass any judgement on issues such as these for a few reasons. First, I have never been a family member in this particular situation so I wouldn't know how I'd react myself. Second, I don't have enough experience as a physician to compare to other situations where another patient's status was similar, and an outcome had already been established. That being said, I felt that this patient probably would be best managed without invasive treatment, do everything we can minus full code, and provide comfort care if it came down to that. This is opposite to what the family wanted. So of course, without any other advanced directive, this patient had to be transferred to the unit and most likely required intubation and a host of other invasive treatment modalities.
That was just one piece of my first night as a night float. On top of that, this occured 10 minutes BEFORE my shift should have ended, which means I ended up staying at the hospital much later than I anticipated. I hope all turned out well for the patient and the family, but I'm not quite sure what happened.
On a happier note, I did get to go to the Charles River to watch the fireworks display last week! It was beautiful. Even despite the rain, and the cold weather, we managed to have a good time and enjoy the company around and the show. Boston truly has some spectacular scenery. I also got to spend some time out by the pool on Sunday on my day off. That was nice. During the end of my last year of medical school, I managed to spend many hours by the pool, or on the beach in the carribean, and 3 weeks of work in the hospital under flourescent lights has already managed to rid me of my tan and make me look like a ghost, or better yet, a vampire since I'm now awake all night- and sleep during the day (but I promise I do NOT sleep in a coffin!!!)
My first night was from hell. The pager did not stop going off until about 3 am. And even after that, I barely had time to sit down and think. That was offset by last night which was much smoother. I had plenty of time to do the work I needed to do, respond to intermittent pages, and even do a little reading! Yes, reading up on disease management etc. is NOT an easy thing for an intern to fit into the schedule. One must be SUPER efficient to actually be able to get some reading done, or have a nice, calm, night. That being said, I hope I didn't just jinx myself.
So in contrast to my last post, where I was having difficulty deciding on whether a plan of action was just too much for a patient, I had an interesting experience from the opposite perspective the other night. One of my patients actually was going downhill, and FAST. We were running out of options on the floor, and decided the patient probably needed to be transferred to the ICU for further managment. At this point, we had to think about what was our best plan of action. This patient was 90+ years old, but the family wanted FULL CODE status. The patient also had severe dementia making it difficult for us to establish was a baseline mental status was, although according to the daughter and the nurse, by the time I saw the patient at his/her worst, he/she was apparently well below baseline. My resident and I both felt that an ICU transfer should be done since the patient was full code, but the odds were not in the patient's favor of survival. On the other hand, the family insisted we do "everything we can" to save the patient's life. I can't pass any judgement on issues such as these for a few reasons. First, I have never been a family member in this particular situation so I wouldn't know how I'd react myself. Second, I don't have enough experience as a physician to compare to other situations where another patient's status was similar, and an outcome had already been established. That being said, I felt that this patient probably would be best managed without invasive treatment, do everything we can minus full code, and provide comfort care if it came down to that. This is opposite to what the family wanted. So of course, without any other advanced directive, this patient had to be transferred to the unit and most likely required intubation and a host of other invasive treatment modalities.
That was just one piece of my first night as a night float. On top of that, this occured 10 minutes BEFORE my shift should have ended, which means I ended up staying at the hospital much later than I anticipated. I hope all turned out well for the patient and the family, but I'm not quite sure what happened.
On a happier note, I did get to go to the Charles River to watch the fireworks display last week! It was beautiful. Even despite the rain, and the cold weather, we managed to have a good time and enjoy the company around and the show. Boston truly has some spectacular scenery. I also got to spend some time out by the pool on Sunday on my day off. That was nice. During the end of my last year of medical school, I managed to spend many hours by the pool, or on the beach in the carribean, and 3 weeks of work in the hospital under flourescent lights has already managed to rid me of my tan and make me look like a ghost, or better yet, a vampire since I'm now awake all night- and sleep during the day (but I promise I do NOT sleep in a coffin!!!)
Subscribe to:
Posts (Atom)