Earlier this year SDN member bob123451 was the lucky intern starting residency on night float covering multiple surgery services—vascular, general, bariatrics, colorectal, and a number of subspecialties—at a community hospital. Understandably nervous about jumping in with both feet, he reached out to the SDN community for advice. The following tips may be helpful, should you find yourself in the same boat.
• Keep a list of to-do items with check boxes. Add to it as your call night goes on. This should include labs/images/etc that have been ordered that need to be followed up on.
• Have a low threshold to call your senior. Do not call until you have seen the patient yourself.
• Go see every patient. In short order, you will figure out which ones you can handle by phone, but right now this is none of them. If you get called, see the patient.
• Document everything. If you get called and see a patient, throw a note in the chart about what you saw, what you were thinking, and what you did.
• Be nice to the nurses… even when the pages are really dumb. They can make your life a lot easier, or a lot more painful.
• If you get called for a consult, say yes and see the patient.
• If you are calling another service for a consult, make sure you have seen the patient and can provide pertinent history, physical, and reason for the consult.
• Have an algorithm in mind for common calls (fever, chest pain, low urine output, tachycardia, etc).
• Always remember that it can be a pulmonary embolism.
• Remember that internship is temporary. In the beginning you will feel like you know nothing. This will get better.
• The book Surgery On Call was pretty helpful.
• Go see the patient. You’ll rarely regret it.
• Never be afraid to bump it up the chain. If you’re concerned or stumped, ask for help.
• Stay organized. Make a to do list at sign out. Put check boxes beside each task you need to have done and when it is done put a check in the box. Try to review the list whenever you have time or every hour or two at at least.
• Make note of everything you order so you follow up on it. If things are busy you can and will forget about it (which is why you should run the list frequently).
• Document EVERYTHING.
• You don’t have to have an answer for everything. If a patient’s family arrives at 11pm and wants to know minor details of the patient’s care plan, it’s OK to say you’re the night guy. That’s much better than taking a wild guess, being way off, and causing a riff between the patient and primary team.
• For the first few months of intern year I carried around a check list, algorithm, and ddx for common problems such as those stated. I found this helpful because it’s very easy to forget to order something or think of an important item on the differential when you’re getting paged constantly.
• I know it sounds stupid but at least Google putting in peripheral IVs. I got calls all the time about not being able to get an IV from a nurse so I would just go do it myself or even get the ultrasound if I needed it.
• Treat every patient like you want your family to be treated; do not cut corners.
• Double check everything: asking for something to be done and it actually happening are two very different things.
• Never dismiss a nurse’s concern; they are seeing this patient for hours at a time and they usually know when something is up
• To add to above, do not ignore an irregular vital sign. (Be especially wary of respiratory rate)
• When a surgical patient has a non-surgical issue (rapid AF, hypoxia, whatever), it’s probably being driven by the surgical problem (e.g. that pleural effusion may be coming from a sub-phrenic abscess)
• Don’t ever be forced or bullied into doing or charting something you’re uncomfortable with.
Want more tips? Have some you’d like to add? Visit the original thread discussion here.
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