Night Float: Assume the Position

Night Float.... 14hrs of cross-covering somewhere between 50-70 patients that you only hear a one-liner about before assuming responsibility of them for the night. We can divide these patients into two main categories: asleep, and awake.

Luckily, a lot of them will be sleeping for most of your shift. But that doesn't stop the nurses from calling you- for medication clarification (including questions they know you can't possibly answer, like why the primary team switched one medication for another sometime during the day), order clarification ("I don't see a time for the pre-meal finger stick glucose checks. What time did you want those done? You should clarify the order." It's 11 o'fucking clock! You think this can't wait for the day team, who will be here, in the day, when the patient is actually eating?!?), medication list cleanup ("So I was reviewing the medications and I noticed that the patient has 2mg IV Dilaudid as needed for pain, and also 4mg IV Dilaudid as needed for pain. Can you just delete the 2mg Dilaudid order? I think it would look neater that way." WHO CARES if they have two PRN pain orders?), to ridonculous requests ("I noticed this patient has not had a bowel movement in 3 days. The primary team wrote orders for stool softeners but not an enema. Do you want to write an order to try an enema now?" Side note: it is like 11pm and the patient is asleep.)

Ok, second category: unfortunately, a lot of these patients are going to be awake. You get paged about the fact that some of them are awake like it's a problem (as in, the nurse asks for a sleep medication to give the patient because she wants the patient to go to sleep so she can comfortably ignore them and go back to shopping for shoes on zappos). You get paged about pain medications. You get paged about breathing treatments. You get paged anytime somebody falls down, and you have to go evaluate them. ("You fell off the commode in the dark? Did you hit your head? Did you hit your head???") You have to run and evaluate anyone having chest pain, shortness of breath, bad headache/abdominal pain/random other complaint. The patients you are cross-covering are scattered in different wings between the 4th and 12th floors. And your pager is going off incessantly. There were several times that my pagers were going off simultaneously WHILE I was returning another page. That's another thing- you're carrying three pagers, like little beeping grenades, just waiting for them to go off at any minute.

Alright. Highlights from my weekend of night float:

1. Patient admitted for chronic pain exacerbation spent 15 minutes yelling at me about how the Emergency Room doctors had given him too much morphine the night before when he was being admitted to the hospital ("Y'all fucked up, BIG TIME!") and how in general we, as a hospital, as a whole, suck. Here's a thought: he probably got too much morphine because he was harassing the ER nurses for more pain meds. Anyway, after debasing the hospital, and being rude to me, he managed to offend everyone else in the room by accusing us of "tricking" him and putting him on a psychiatry ward rather than a general hospital ward, saying, "Oh I know crazy- this mind is STRONG [points to his own head]- don't even TRY to play mind games with me!!! I know this floor is full of nut jobs- including THAT one!" [gesturing obviously over to his hospital roommate. Who was sitting in bed, alert and not crazy at all, with family at bedside. All of whom heard this and glared.] I later found out from his nurse that he also accused me of being a psychiatrist, masquerading as a medicine intern. No comment. Anyway, why was I called in the first place? He wanted more morphine. OF COURSE.

2. The electronic medical record went down for "maintenance" for 4 hours on Saturday night. Hilarity ensued when we had to write STAT orders. I had completely forgotten how to write paper orders. The nurses had to guide me through step by step.
"Ok, first you write the date. The date. That's not the date. Ok, then the time. Yes... then the order. Yeah. And don't forget to specify if it's routine, urgent, or... ok, that's ok, it's still legible. Good, now sign it. Sign it. Do you know your PI#? Ok, good, you're all done. ...what do you mean 'where does it go now?' We fax it down to the pharmacy. Where did you think it went? Ok... ok, nevermind doc. Thank you, thank you...BYE."

3. The best: the fake AMA patients. Unless a patient is under a psychiatric hold or for whatever reason doesn't have mental capacity, they are free to leave the hospital at any time. But if they are leaving against medical advice, they have to sign the AMA (or "Against Medical Advice") departure form. Sometimes certain patients, ohhhh let's just say the kind who have a substance abuse history and are on chronic methadone/actively using heroin/abusing a ton of painkillers at home, will "threaten" to leave AMA. When you ask why, they will throw out a litany of complaints... that inevitably leads to their "pain not being addressed", and they will suggest that if they could get that 12mg IV Dilaudid push, they might just be able to be persuaded to stay the rest of the night.

Even though I'm complaining a lot, I got very lucky since no one coded, had chest pain, stopped breathing, or otherwise had a medical calamity on either my shifts. Thank you, hospital gods, for shining your fluorescent rays of mercy upon me.