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.