Tales of Survival: Bellevue Night Float Routine

May 5, 2017

1024px-Bellevue_Psychiatric_Hospital_old_buildingBy Olivia Begasse de Dhaem MD, Palak Patel MD, Shreya Trivedi MD

Peer Reviewed

Hypotension in a patient with a pericardial effusion, sustained tachycardia in a post-MI patient, hypoxia in a patient with metastatic cancer… the Bellevue night float intern pager can get frantic. After trial and error, our group of interns have come up with a cohesive routine to balance the strain that night float forces on our circadian rhythms, eating habits, work pattern, and social life. Given the paucity of information on night float well-being in the literature, we decided to share our positive experience to help guide future night float interns.

We stress integrating five beneficial activities: early identification of sick patients, physical fitness, healthy eating, educational activity, and intern communication and support. As the number of rapid responses or issues that arise overnight can be unpredictable, the following is more of a suggestion than a strict schedule.

As soon as we arrived to start our shift, we first made sure that everything was set up before getting hammer-paged. One intern would fill a jug of water for each of the co-interns, else we could go without a sip of water on some busy nights. It was also crucial to have an efficient system to organize the sign-outs and double-check that the labs that were being signed out had actually been ordered. We additionally restocked rapid response kits in the 17N workroom. Finally, we rounded on the sickest patients at the beginning of our shift and informed nurses on the symptoms to monitor for and the plan. Involving the nurses in our team made our night much smoother and ensured safer patient monitoring.

During the first wave of downtime on quieter nights, we exercised in the workroom to upbeat music. We varied our exercises between yoga, pushups and sit-ups, cardio, and dancing. We used bed sheets from the linen closet as surrogate yoga mats. Needless to say, our attending was jealous (or at least amused). Standing up to answer pages became part of the workout, as did squats, lunges across the workroom, and steady runs up and down the stairs between the 15th and 17th floors. We also learned a great deal from each other, including the traditional Indian dance Garba. This fitness routine was critical, as most interns spend their nights sitting in front of computers for hours and standing in bad postures during rounds, all the while fatigued from the chest compressions administered during the most recent code.

During the second wave of downtime, we bonded over sharing our brown-bagged food, which we tried to keep on the wholesome, healthy side. We ate minimal carbs to avoid its sedating effects. Bringing our own food helped us save money and acquainted us with different cultural cuisines. One intern kept pushing for her warm, caramelized, Belgian waffles and chocolate; another had a good laugh each night as we tried his surprisingly spicy food; the third, the most reasonable, shared her steamed veggies. After EW rounds, we took turns picking up coffee, almonds, and other healthy snacks, as frequent snacking rather than large meals increased metabolism and prevented sugar-highs.

We refrained from napping overnight in order to keep a consistent sleep schedule. Any potential extra downtime was dedicated to education or research. While residents and medical consult were always available to answer our questions, we discussed clinical pearls relevant to our patients amongst ourselves and with our attending. At times, we also talked out common overnight management calls, changing the scenarios to fine-tune our clinical decision-making. Anion gap of 20 and blood glucose of 300 in a type 1 diabetic? Make sure you start IV fluids before insulin to avoid inducing hypovolemic shock from fluid shifts, since water follows sugar intracellularly. Then remember to bridge appropriately between the insulin drip and long-acting subcutaneous insulin once the patient can tolerate PO.

As interns, we worked as a close-knit unit. We knew that even when things seemed to be falling apart, we were always there for each other. If one intern was swamped managing post-rapid response patients, another would help to assess their hypoxic EW patient with hemoptysis. We had good laughs and meaningful discussions together. Maintaining social interactions with the outside world was difficult, but Bellevue night float gave us the feeling of being part of a team and enabled us to develop close friendships within the hospital.

During our time off during the day, we mostly slept and prepared food for the night. If we had an extra hour before the start of our next shift, we would catch up with friends or family, or take a walk by the East River.

Covering patients was sometimes challenging. At the same time, it made us more comfortable taking care of sick patients, more efficient at figuring out our patients’ stories, and brought us closer as we relied on each other for help and support. The most crucial element for our well-being on night float was our team spirit. It enabled us to build lasting friendships, create fun memories, and learn valuable lessons, all while taking care of each other and ourselves.

Dr. Olivia Begasse de Dhaem is an internal medicine resident at NYU Langone Medical Center

Dr. Palak Patel is a resident psychiatrist at NYU Langone Medical Center

Dr. Shreya Trivedi is an internal medicine resident at NYU Langone Medical Center

Peer reviewed by Amar Parikh, MD, Internal Medicine, NYU Langone Medical Center

Image courtesy of Wikimedia Commons

 

 

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