As an intern, you will typically have about 2 weeks of Nightfloat, (NF)
typically divided eually between !offitt (during your "#$$ %onth) and &F$' (during your () %onth)* (+cept for very, very rare circu%stances in which you %ight be asked to help ad%it a patient with the resident NF, your pri%ary ,ob as -ntern NF is to handle the cross.cover for all of the %edicine patients (e+cept the patients cared for by the on.call tea%(s)*) /his allows the on.call interns to focus on ad%itting* 0ou will typically be given a nu%ber of patient care.related tasks (e*g* checking vitals1eyeballing pts, checking labs, etc) to do* 0ou will also be the pri%ary physician to assess and proble%.solve when any of the patients you2re covering has a change in clinical status* /his can be a scary thing (particularly if you2re doing NF early in the year), but re%e%ber that you always have a resident NF there to back you up, as well as -#"1##" residents* 0ou should never feel alone3 4e%e%ber that the night (and the week15 days1whatever), no %atter how harrowing, 6-77 co%e to an end* 0ou will %ove on to so%ething else, and you will greet the nightfloat with tre%endous relief and happiness when 08" are the one on call trying to ad%it and cross.cover at the sa%e ti%e* Intern NF, Typical Night Arrive 9 :;<=.5p% Figure out who the interns on-call are (at Moffitt, 2 teams are on call M-F, 1 team on weekeds at !F"#, 1 team is on call e$ery night% Figure out who the &esident NF is (on 'mion under (shift)%* The resident NF will arri$e at +,-.pm* $et signout, pick up cross.cover pager(s) /ontact the on-call interns (usually pager0o1 works 0est% to ask for signout* 's a courtesy, offer to meet them where they are to get signout* 2ick up the cross-co$er pager(s% o 't Moffitt, this is the Intern NF pager (33--&4FF%, which stays in the resident room in a small wicker 0asket when you5re not there o 't !F"#, these are the Intern (') and (6) pagers, carried 0y the on-call interns until you arri$e* 7ist your na%e and pager as -ntern NF on the white board in the resident roo%* !ee (!ignout) section under ("eneral Tips and 'd$ice,) 0elow !ake your /o )o 7ist 6efore the on-call interns arri$e to sign out, get ready to organi7e the To 8os (see (Making a To 8o 9ist) under ("eneral Tips and 'd$ice,) 0elow% >atient #are 9 5;?@p%.:;?@a% (or 5a% on weekends) /ompleting (To 8o) Tasks, triaging and managing patient pro0lems &ignout in A! 9 A;?@.:;?@a% (or 5a% on weekends) &eporting 0ack to the primary teams on the e$ents of the night Attend 4esident 4eport (optional but encouraged, :;?@.5;?@a% !.F e+cept /hurs) "eneral Tips and 'd$ice :ating and sleeping o 't Moffitt, (ating; you are gi$en an allowance for eating on NF (;+<night%* The caf= (2 nd floor% is open until 11pm* >n-call teams will often meet for ice cream around 1.,-. or 1.,3? @ Aoining up with them, if you ha$e time, is always nice @ makes you feel less lonely in the sometimes lonely world of NF* For late night hunger pangs, there are $ending machines on the 2 nd floor as well (to your 9:FT, away from cafeteria, from the ele$ators%* &leeping; you are assigned a call-room, listed on one of the 0ulletin 0oards in the resident room, along with the door code which you5ll need to get in o 't !F"# (ating; The caf= closes 0y Bpm, 0ut the resident lounge (on the 2 nd floor 0y the chapel% gets stocked with food at +pm* Food items usually include 0asic stuff like fruit, crackers<granola 0ars, cookies, chips, water* !ometimes there are microwa$ea0le foods like Cuiches and peanut 0utter and Aelly* &leeping; you are assigned a call-room in the 0asement, which you access $ia the sensor attached to one of the cross-co$er pagers 4nderstand and anticipate the $ariety of nights that you will e1perience on NF, o Most often, there5s a solid 0ackground of calls for stupid scut stuff (filling out '>!es, restraint orders, diet orders, etc etc%, mi1ed in with a smaller num0er of potentially real medical stuff (0leeding, dropping #ct, !>6%, and not unusually one patient who is acti$e and potentially sick or decompensating* 8> N>T #:!IT'T: T> /'99 D>4& &:!I8:NT >N NF E#:N !>M:>N: ":T! !I/F >& D>4 8>N5T FN>E IF !>M:T#IN" I! !:&I>4!, >& 8>N)T FN>E E#'T T> 8>* The >N9D way that you can screw up as an intern is 0y N>T calling for help when you should ha$e* Dour residents will e1pect to hear from you ' 9>T, 0oth on NF and on the wards in the first few months* o &arely, you will ha$e a night when multiple patients are crashing* &est in the knowledge that these nights are truly rare, and when they happen, you and your resident may well end up working as a team with one of you at the 0edside of each patient, since, after all, you can only 0e in one place at one time* o &arely, you will ha$e a "9>&I>4! night when the calls, e$en for scut, will 0e few* :nAoy them as much as possi0leG !ignout o 8o N>T, under any circumstances, try to 9:'&N all of the patients as they are signed out to you* The key things to listen for are these few things, 2eople who the primary team identified as sick, who may crash o$ernight* If time permits, talk 0riefly or round on these folks with your resident NF when he<she arri$es, so that you know what to anticipate* 2eople who ha$e had any cross-co$er issues (this is good 0oth 0ecause people who ha$e 0een acti$e during the day<e$ening often will continue to 0e so and, if nothing else, you5ll 0e the one communicating what happened to the primary team in the morning%* Dou should make sure you understand any notes that ha$e 0een Aotted down 0y the cross-co$er interns* To 8o tasks for you (often +pm<MN<CHh la0 checks, f<u on consultant recs, etc%* These should 0e written on the signout sheet anyway, so if you don5t go through these with the on-call intern signing out, no 0ig deal* o Ask the people signing out to you to filter their signout for the above details 9 Bust tell %e about the people who are sick or who have been active 9 so that you don2t get overwhel%ed* Making your To 8o 9ist o 6efore the on-call interns arri$e to sign out, get ready to organi7e the signout* "et a fresh sheet of paper and make a few categories, 9ist of the floors where medicine patients usually are 't Moffitt, 13M, 139, 1.!, I-I/4, Misc floors 't !F"#, ?', ?/, ?8, 36 9a0s<radiology o 's the on-call interns are signing out (or after they lea$e, when you look 0ack through the signout sheets%, write down the name and team of the patients that you ha$e To 8os for* For e1ample, if the on-call team tells you to check I<> on Ms* !mith on team 6 in 13M at MN, put down (Team 6, !mith, I<> at MN under your (13M) list* If it5s a la0 check, try to figure out when the la0 is due (typically la0s take an hour or so to get results once they5re drawn, so check for +pm la0s around Ipm%, then write down the pt5s name, team, and time to check la0 under your 9a0s category* o /aking =.C@ %inutes %ake this list at the beginning of the night will save you /8N& of ti%e during the night, since you2ll get your /o )os done in the fewest a%ount of tripsD also, you2ll be less likely to forget to do one of your /o )os, which are all buried in a huge stack of papers* o 's you get calls to fill out forms or e$aluate patients during the night, you can easily add the pt5s name (and team% to your To 8o 9ist 2atient care o 'nticipate a lot of pages early on in the e$ening and lots of To 8os early on in the e$ening* !tupid cross-co$er scut stuff usually dies down after 12-1 'M* o Try to make sure 0y I,-. that +pm la0s you5re supposed to check ha$e actually 0een drawn, if they5re not pending in the computer* 2hle0otomy draws are only C2h, on the e$en hours* o ' word on $er0al orders, Jer0al orders are accepted at Moffitt in emergency situations (the nurse will ask for your name, then will lea$e a sticker in the order section of the chart for you or the primary team to sign later% Jer0al orders are not accepted on any floor at !F"# o Ehen paged 0y the nurses, the first Cuestion to ask if which team the patient is on* This will help you find the patient in a 0ig stack of sign-outs* !uggestion, (/arry a copy of the roster of the current medicine teams, so that you can identify a pt5s team num0er<letter 0y intern or su0-i*) !uggestion, (>nly when I ha$e located the patient do I ask them whatKs going on*) /his ensures that you2ll actually hear what they2re saying* Make a note with the time L issue on the signout each time you5re paged !uggestion, (Ehen lea$ing notes on the sign-outs, try to use a non-0lack pen* ItKs easier to pick out what youK$e written, it distinguishes 0etween you and the on-call intern when youKre e1plaining in the morning what happened*) o Ehen the nurse is calling regarding a change in the patient5s clinical status, your ne1t Cuestion should 0e, (Ehat are the $italsM) Ask for a F"77 set of E&* o /heck the signout section ('nticipate 2ro0lems) to see if the team has any d1 or r1 ad$ice for you* o /onsider what additional information or inter$ention might 0e helpful to ha$e the nurse get started while you5re on your way to see the patient (e*g* get an :F", call for a /N&, put the pt in Trendelen0erg if hypotensi$e and altered, call &T% o !tart thinking through your differentials, get additional information or help as necessary, while you5re on your way @ re%e%ber that it2s A76A0& best to err on the side of calling your resident earlier rather than later3 o !uggestion, (Ehile itKs always 0est to see the patient for most issues, I do gi$e $er0al orders for things that are $ery straightforward (e*g* last night a nurse called 0ecause a sta0le, 2--year old patient had recei$ed am0ien ? mg and still couldnKt sleep, so I ga$e a $er0al order for additional 'm0ien ? mg without seeing the patient%* o For any maAor management decision, inter$ention, or change in pt5s clinical status, you should lea$e a 0rief note (e*g* (:$ent Note)% in the chart o !uggestion, (Ehen nurses or pharmacists ask me to change management<meds that are not urgent or wonKt change anything o$ernight, I defer to the primary team and tell them that IKll pass their concern<suggestion on to the primary team*) &esident 0ack-up o Though it may not feel like a glamorous Ao0, you will learn a tremendous amount on NF, particularly in terms of how to triage and manage patients who are getting sick* Ehile you should certainly do your 0est to assess the patient and come up with your plan for what to do ne1t, when in doubt, call your resident3 o The resident NF is your primary 0ackup howe$er, don5t forget that there are always multiple senior residents who can help you, on-call medicine or cardiology residents, I/4 residents !igning out to the primary teams in the 'M o Try to 0e 0ack in the resident room 0y H,-. or Bam (especially in the 0eginning of the academic year% to gi$e signout to the primary teams* o Feel free to let people know if there was so%ething unclear, %issing, or wrong in their signout* Bust as %uch as you2re learning how to cross.cover, they need to learn how and what is appropriate to sign out to NF* -f you do it in a constructive, diplo%atic way, they will thank you for it* !uggestion, Make sure to pro$ide feed0ack in the morning* If there were notes that were really helpful, acknowledge that* If you felt that they signed out something without making it clear what was to 0e done with that information, also let them know that, so that they can impro$e in the future* >ne thing that I ga$e feed0ack on was when people asked me to check results (especially of radiology studies% without letting me know what I was looking for or how the plans would change*) o If interns ha$en5t arri$ed 0y B,-.am on weekdays (e1cept Thurs% or +am on Thurs<weekends, you should lea$e their signout in a marked spot in the resident room (usually on or near the white 0oard%* 9ea$e your name and pager O in case they want to contact you with details Morning &eport o Dou5re e1pected to go to (&esidents5% Morning &eport, which happens at B,-.- +,-. on e$ery weekday e1cept Thurs* :nAoy the opportunity to hear some cool cases and how the residents are approaching them* (Dou may also end up cross co$ering on one of the pts presented later on in the weekG%