Killing my circadian rhythms softly: Night Float Adventures.

Remember that principle of "see one, do one, teach one" I was talking about in my last entry? Well, nothing quite exemplifies my residency program's unshakable confidence in its neophyte interns quite like a rotation schedule that has said intern taking care of 80 medical inpatients - that's all the medicine interns' patients - by yourself. Overnight. In the second month of intern year. (Maybe the "see one" part was the one month of rotations and patient interactions during the day??)

Welcome to my life as night float intern, a bizarro universe where my day begins at 7 pm and ends as the sun rises. Judging from my past whining about not being a morning person, a logical reader might posit that this owl-like lifestyle would be a welcome schedule pour moi. However, in a cruel twist of illogical fate, it just so happened that after a month of 4:19 a.m. wake-up calls, I actually had been falling into a pseudo-rhythm of sorts...rolling the rock one inch further up the hill in my Sisyphean quest to become the sprightly morning person who "just can't sleep" past 6 am. Suffice it to say that that rock has now rolled back down the hill with renewed vigor, squelching me triumphantly in the process. My circadian rhythms have not only gone incognito; they're in desperate need of a GPS system (or one of those nifty iPhones that can find out where you are with the touch of a button. Sorry, I'm in San Francisco...got to have the iPhone plug.)


Contrary to what you might think, night float is not in fact the brainchild of cackling, sadistic anti-resident conspirator ghouls haunting the hospital basement. (What, you don't believe in ghosts? Just wait until you've stayed up 7 nights in a row. ) The system was actually designed with an altruistic, noble goal: Let's Help Our Interns Get Some Sleep.


Let's expound on this. See, in the world of yore, hapless Intern X arrived at the hospital at 0600 am, flitting around the hospital floors all day like one of those hyper, in-denial, confused flies that keep hitting the windowpane thinking they're escaping to the sky beyond. She would continue to stagger in a semi-awake fugue state for that night and half of following day and, if all went well, departed at 12:00 noon - capping off a grand total of 30 bed-less and home-deprived hours spent breathing hospital air.


That was then. Now, in today's modern world, we not only have microwaves and TiVo: with night float, we have Intern X going home at a reasonable hour on the - wait for it - same day she came in, thus enabling her to return to her own little converted-closet-aka-you-really-pay-$1500-a-month-for-that-room? and crashing in her own "bed" (using the term figuratively, of course, since said room isn't large enough to accomodate furniture and a human being.) Now, as haggard interns wrap up a 15 hour day, no sight is more gladly welcomed than that of the rested and showered night float as she strides in, valiantly squelching all circadian protestations against starting a workday as the sun is setting. For it is this unlikely superhero who will release the interns from their workday, taking over their patients.



Of course, as the economic principle TINSTAFL (There Is No Such Thing As A Free Lunch) suggests, such a tremendous boon doesn't exactly come without cost. "Cost" in this case refers to that scrappy soldier, that multi-pager-balancing, order-juggling, scrub-clad acrobat, that sensitive soul who, like Atlas balancing the world on his shoulders, takes on the Patients and Their Care when the clock strikes "shift change". This pantheon of intern freedom and sleep enablement is, of course, the Night Float. While the interns snooze soundly at home, she takes on the role of Confused, Bruised Fly for the night, tending to patients while the city sleeps and informercials for arthritis cream play endlessly on TV.

"Night float" is a deceptively ethereal, serene-sounding phrase, conjuring up meditative images of shimmery physician-wizards dispelling illness with a wave of a magic wand while riding on the odd airborne unicorn. (You thought of that image too, didn't you?). Reality goes probably more like this: Night float, balancing a phone on one shoulder, flipping through various stacks of "sign-out sheets" describing all the happy snoozing interns' 80 patients, trying to listen to the nurse on the other end of the line, fumbling in a dingy white coat to find the two pagers buried under the graham cracker packets that have simultaneously decided to begin insistently beeping (the pagers, not the graham crackers - although strange things happen at night), while nodding to another nurse that has just tapped you on the shoulder to talk. I think being a night float intern is kind of like how it feels to be a Walmart, if a Walmart could feel: stuffed with an assortment of random items, trying to be organized but somehow always chaotic, always struggling to produce exactly what a demanding customer wants when they need it. Not to mention, both of us could probably benefit from some disinfectant and a nice hot bath around 3 am.

But wait, say you, the astute reader. Being a doctor takes years of medical school and residency...and during the day you have three levels of care - intern, resident, and attending - triple checking work on a team of patients....and now, one lone intern is in charge of handling the workload of about 40 people. At night. How is this legal again?

Well. Lest all of you decide to start boycotting hospitals altogether, let me reassure you that the night float does have "backup" in the form of 1) a senior resident on call and 2) the night attending on call. These are the people to page if Things Are Getting Weird or Scary: i.e. a patient starts going into ventricular tachycardia every time they try to have a bowel movement, or is hurling their oxygen monitor at the window, or threatening to sue the hospital if they can't have a cigarette (true stories.) For all other items, however, the night float relies on such help as 1) Google 2) a dog-eared handbook termed the "Intern Survival Guide", 3) coffee and graham crackers. Trust me, somehow it's a system.

Importantly, this system hinges upon the vital piece(s) of paper known as the "sign-out". At first blush, the sign-out looks like any other normal piece of computer paper: 8 1/2 by 11 inches, white, 4 straight edges, that sort of thing. But don't let that fool you: the 0.5-size Arial font that it bears might as well be gilded gold ink. For the sign-out is the night float's passport, Frommer's guide, boarding pass and pocket translator all in one (if only the destination were, say, Brazil as opposed to ward 7 south. But still). Its humble pages contain such key highlights of each intern's patient as "Name", "Room number" and "Meds", along with assorted important pearls - "What to do if patient's heart starts beating at 240 bpm", "Patient's wife is very high maintenance - soy milk at bedside at all times", "Call senior if patient's blood pressure drops to 70/40 and he looks sick".

The sign-out is how an intern, paged at 0300 by a nurse on 6 Center that Patient X can't sleep and needs something now, knows that Patient X needs Ambien in lieu of Restoril (since the latter makes him sleepwalk to the kitchen and sleep-eat through all the coffee creamer packets.) Or how she knows, when paged by a nurse that Patient Y's blood pressure is 85/40, that this always happens during the night when the patient is sleeping and there's no reason to call a code.

To ensure that the night float does not spend the entire night watching the Olympics on the doctor's lounge flat screen TV (who, me?), there is also a "To Do" section, which usually entails such things as: "Make sure patient has a bowel movement tonight - very important" or, "Patient needs to finish all her colonoscopy prep solution!! Check at 8 pm and make sure she drank the entire 3 liters!!", "Follow up on chest xray and make sure patient is breathing okay and not sick", or "Check blood counts at 8 pm and transfuse blood if Hct less than 27."

As the night float learns, the hospital is a different place in the wee hours. Maybe it's the antibacterial hand gel fumes and incessantly beeping machines, or maybe it's the bad hospital food. Somehow, the conversant and lucid individuals of the day become pain-racked, fearful, sleep-deprived, blood-pressure-dropping or -raising, constipated or diarrhea-ridden, urine-retaining patients. Somehow, as the sun sets, the sweet 70-year old knitting-a-scarf-for-her-godchild-libarian-slash-grandma starts to pull out her IV and insist that the Russians are coming to kidnap her. Somehow, around 3 am, the pleasant 26-year old college student awaiting surgery for an infected gallbladder starts to break out in hives and have difficulty breathing.

And thus, night float life is filled with intimate knowledge of sleep medicines, pain pills, laxatives and stool softeners, blood transfusions, patients' nocturnal hallucinations, hearts beating too fast or too slow or funny rhythms...along with the odd adrenaline-searing experience of rushing to a code or running up the stairs to help a crashing patient.

I'll write more later - but right now, it's time to answer yet another page. Day time folks: just be glad you don't have to convince your night-time selves to drink an entire container of colonoscopy prep. It ain't pretty.

Green Tea and Beyond: The Wisdom of Medicine.

How do you really learn medicine?

As I complete lap #2 in the 12 month intern year cycle, this question often rears its niggling, bemused head (okay, maybe that's my bemused head. But the question is still niggling. And I still got to use both those words!). And it especially niggles every time I meet a patient who grips my hand gratefully when my white coat enters, in their eyes an implicit trust that I will not only Tell Them What's Wrong, but I will Help Them Feel Better. For those patients, I'm a magical computer that can instill diagnostic meaning and context to myterious symptoms and physical findings, such as "My pinky toe, Doc, it's been twitching southward at exactly 5:03 pm for the past month. What's that mean?" or "Why does the corner of my right eyelash itch when I'm trying to sleep?"

In essence, for many patients I'm regarded as an auror, or a tea-leaf reader, or maybe a slightly better-dressed $1.99/min telephone psychic, taking in the facts and symptoms calmly with just the right gravitas inflecting my "Mm-hmm", "Uh-huh" and "I see", cooking them in the white-coat-aura machine and emerging triumphantly with a Diagnosis and Treatment Plan. It's kind of like in high school, when you learned about the concept of a function in algebra, there was that annoying picture in your textbook showing a picture of a computer taking in x and spitting out f(x) . (That one's for all my fellow high school Mathletes and Math Club alumni! Long live the differential!) I don't think I ever really understood that function computer thing until now - when, presumably, after 4 years and a $150,000 education, I'm supposed to be that computer, able to spit out f(symptom) at a patient's whim. Where symptom could be anything: that vague scratch in their throat, that faint pink rash on their upper arm, the strange rumbling in their stomach after eating that street-corner hot dog (come on, patient - I think we both know what caused that one.)

Of course, not all patients adopt the pleasant world view that Doctor Knows Best. Some patients are a little more, shall we say, jaded. Or maybe skeptical is the right word. No, how about questioning? Challenging? Domineering? I-Googled-This-Yesterday-And-I'm-Not-Leaving-Until-I-Get-A-Biopsy? (Ooops, not an adjective).

The anti-climactic reality is that doctor-ing lies in between those two extremes. If you've followed my posts, you probably have already happened upon the rather non-concealed truth that I'm hardly an auror, or a tea-leaf reader, and hopefully I look at least a little more shapely than a computer spitting out parabolas (and those weird asymptote graphs - didn't you hate those?) when handed a patient's symptom questionnaire chart. But I would also, at this juncture, clear my throat rather pointedly and turn the reader to Exhibit A, which is Myself upon the eve of our medical school White Coat Ceremony, a day where my knowledge of medicine consisted of little more than how to wear a white coat. Compared to that happy-go-lucky rapscallion, my current self possesses some symptom-processing knowledge to match those impressive undereye circles, no? Even if, ironically, I seem to have lost the ability to wear a white coat without instantly attracting some sort of stain. (I need that irritating Cheer Detergent lady who always seems to be bleaching some unkempt bachelor's socks to accost me on the street and whiten my coat. That would be a miracle.)

As residents, we like to think we're more dynamic and critically appraising, more contemplative and (hopefully) more alive and alert than an isolated Google I'm Feeling Lucky search, But the uncomfortable part of the doctoring reality is that, even after all those tests and classes and presentations and memorizing, even though we Know Stuff and Treat Things, we residents are still doctors-in-training. The "in-training" part means that every patient encounter is still practice. And that a lot of times, we have to act a lot more confident and authoritative than we feel.

There's an infamous motto of medical training that runs like this: "See one, do one, teach one." This is not the learning style that medical schools stress in their glossy brochures, which feature the requisite multi-ethnic group of pleasantly dorky students gazing intently at a microscope or textbook (and yes, that does happen to be me looking at that slide of squamous tissue on page 2. The lone pair of 3-inch heels in the bunch!) These happy booklets are geared at convincing the pre-med student, whose often nearsighted obsession with getting into medical school can obscure thinking about what lies beyond, that Medical School X will give you the knowledge and tools to doctor away like a pro. What you find out, only after completing medical school, is that even if you memorize every fact and ace every test, there is still nothing that teaches you...like practicing on the real thing. Even if, for example, you were one of those annoying people who could recite the precursors to oxaloacetate and identify the exact defect of the hypoxanthine phosphoribosyltransferase pathway in Lesch-Nyhan syndrome...you still might not know that you never give Fleet Enemas to patients with renal disease. So there. Nyah.

As scary as the connecting between "practice" and "patients" sounds (and I'm not even thinking about the patient yet!), the system of medical education rests on this implicit nudging forward of residents beyond their comfort zones, of learning by apprenticeship. Of course, you always have backup - your senior resident, the attending, etc. But funadmentally, our education is based on the notion that the only way for residents to be comfortable inserting catheters and arterial lines, of performing lumbar punctures and placing chest tubes, of using a defibrillator to convert a dangerous cardiac arrythmia....is to practice. On, incidentally, real live people.

For mortals like me, who incidentally really, really warmed to that "doing no harm" theme mentioned in the Hippocratic Oath, the notion of Just You, Some Book Knowledge, and the Patient can be terrifying. Which might explain why my heart was racing as, standing in a patient's room at 2 am, with a nurse, heart monitor and crash cart to keep me company, I slowly injected a potent anti-arrythmic medication in the IV line of an 86-year old patient whose heart stubbornly beat away at 190 beats/min. Or why, despite my sustaining a chronic sleep debt rivaling the U.S.-China trade deficit, I suddenly felt every cell in my body poised on hyper-alert as I prepared to insert a 10-cm needle into the spinal column of a patient with possible meningitis.

You learn in biology about the "fight or flight" response - the biochemical changes of the body's "sympathetic response" that happen when you face the odd grizzly bear, hungry man-eating monster, someone rushing ahead of you to grab the last pair of 75%-off cognac Frye boots. Nothing, I submit, nothing captures "fight or flight" - well, the "flight" part, anyhow - quite like Intern Year. 2008 may be the Chinese Year of the Rat, but to interns it is the Year of Eternal Adrenalin.

The funny thing is that you start glimpsing a logic to the system, the veracity to the "see one, do one, teach one" principle. A procedure, done even once, takes on the aura of charted territory: despite - or perhaps because of - that initial terror gripping you before the first attempt, the imprint of the experience and its lessons are indelibly marked in your brain. And thus, another piece of the impenetrable, mysterious black box of medicine becomes visible. Terror and adrenaline is ultimately replaced by calmness, confidence, that serene feeling of This is familiar, and I know what needs to be done here.

It's this demeanor of calmness, I have found, that instantly identifies the knowledgeable, good doctor. (And I'm not talking about that strained "I'm calm! I'm really calm! I'm so calm! Where's my inhaler?" expression that we interns tend to wear on our face.) Case in point: A month ago, I remember being called on a patient complaining of chest pain; arriving at bedside I found a patient who looked pale, clutching her chest and wheezing for air. I was handed an EKG that showed an abnormal, very fast heart rhythm and tell-tale signs of cardiac ischemia. The nurse then informed me, "Her blood pressure's dropping - and she's going down on her oxygen." Despite having attended three cardiology luncheon talks that week, at that moment the only thought that ran through my head was Help! I need a doctor!

Much like a mirage, only except real, my senior resident appeared in my peripheral vision, walking to the nurse's station to file a chart. I pounced, breathless, shoving the EKG in his face: "Mrs.-Bates-chest-pain-she's-tachycardic-EKG-bad-she-looks-terrible-blood-pressure-dropping-think-she's-having-an-MI-help!" And he calmly surveyed the EKG, calmly reviewed the vitals, calmly entered the room,calmly examined the patient and patted her on the shoulder as he calmly, effectively reassured her, "Mrs. Bates, we're here - we're going to help you,", calmly instructed the nurse to bring the crash cart inside along with 2 1-Liter bags of normal saline, camly drew up a syringe of metoprolol, while calmly instructing me on the key clinical pearls of the differential diagnosis and treatment of tachyarrythmias. This was the James Bond of doctoring: so calm, cool and in control he made Buddha look tense.


In the end, the good news about learning to be a doctor is that If You Seek, It Shall Come. As you go through the experiences...watch your super-human senior residents achieve the impossible (ie. convince the patients to eat the low-salt renal diet tray? That's pretty much the litmus test of "impossible". I bow down.)...and, yes, practice...you begin to find out that more of the mysterious black box is becoming your readable tea leaf.

Which is maybe why, when I got called a couple of days ago on a patient with chest pain and a heart rate of 180, and another wheezing patient with oxygen saturations of 82%, I found myself actually striding directly to their rooms, my feet avoiding their usual detour to the resident-on-call. Instead of the usual stream-of-consciousness panicked chorus of "oh no oh no what do i do oh no oh no where's the resident help!", rational and logical thoughts of differential diagnoses and treatment plans were carefully building like Lego block towers in my head. (Okay, maybe more like a Lego hut, or a hill. But still. Progress.) "Let's get an EKG now - we'll draw a Chem 7, and please also have crash cart in the room," I found myself saying. In what, I suddenly realized, was an oddly calm voice.

Who knew?