The Night Float Panic...

Cut to the Chase: General Surgery Survival Series — Post 23

The day team leaves all at once.

Sign-out ends, chairs scrape, somebody says good luck without looking up, and thirty seconds later the workroom is quieter than it's been since five in the morning.

You're holding a printed list of nineteen patients. You operated on none of them. You've met four.

Then the phone rings. It's a nurse on a floor you couldn't find without reading the elevator sign, asking what you want to do about a blood pressure.

You've spent two years being asked what it is. Nobody is going to ask you what it is tonight. They're going to ask you what happens next.

And you think the problem is that you don't know enough medicine to cover nineteen patients you didn't operate on. Nobody does. Not your chief, not the attending, not me on a Saturday with somebody else's list.

Cross-cover has never been a knowledge test. It's a triage problem with a phone attached. Your job isn't to name what's wrong. It's to decide whether the patient is sick or not sick and get that to somebody who can act on it.

The panic comes from believing the whole thing terminates in you. It doesn't. You're the first person awake, not the last line of defense.

Every page is one of three things: something you settle from the workroom, something you walk for, or something that needs a more senior person awake. Melatonin and a new oxygen requirement arrive with the same sound.

Sort the three pages in front of you before you answer any of them. The one you answer first should be the one you'd walk for, not the one that came in first.

Anything with a vital sign attached to it, you walk. Anything with the word changed in it, you walk. When three pages land at once, write down the two you deferred with the time beside them. The one you slid to the bottom at 3:15 is the rapid response at 5:40.

Before you hang up, get the full set of vitals, and the last several sets with them. A heart rate of 112 in someone who's run 105 since the recovery room is a different animal from 112 in someone who was 68 at dinner.

Ask for the last three sets, not the current one. It costs the nurse forty seconds and it's the difference between a number and a direction.

Then ask her how he looks. That question is the most underused instrument in the hospital. Doesn't look right, from somebody who has watched hundreds of post-op patients get better and a few get worse, beats most of what you're about to order.

So go look. Fatigue doesn't take your knowledge at three in the morning. It takes your working memory. Tired brains are bad at charts and still remarkably good at faces.

Stand in the doorway for thirty seconds before you touch anything. Work of breathing. Color. Full sentences or three-word bursts.

You already know how to read a belly from the doorway. Same skill, worse lighting. Then put your hands on him, warm and dry or cool and damp.

Only then go to the record, and watch for the real trap in cross-cover. It isn't ignorance. It's borrowed confidence.

Somebody who knew this patient better than you wrote that note, so you assume it still holds. Expected post-op tachycardia doesn't stay expected forever, and monitor the abdominal exam isn't permission to watch tenderness get worse.

Check when the sign-out line you're relying on was written, and by whom. Expected tachycardia was expected at four o'clock yesterday, by somebody who is asleep now.

Then call, and call before you're comfortable. Interns wait because they want a diagnosis first, and calling without one feels like walking upstairs to announce you couldn't figure it out.

And don't narrate. Who the patient is, what operation, what changed and when, what you found, what you've already done, and then, out loud, what you want. “I need you to come look at him” is a complete request. What makes a senior short with you at three in the morning is never the phone call. It's four minutes of story with no ask at the end of it.

Second year, I had a man on post-op day two after a colectomy whose heart rate went 90, then 104, then 118 across three checks. Pressure fine, no fever, belly unimpressive. His only complaint was that he couldn't get comfortable in the bed. I didn't have a diagnosis, so I didn't call. I ordered a bolus and a repeat set for five.

At ten past six he was a rapid response. He was leaking, and he went back to the OR with a pressure in the seventies. I had three numbers at 3:40, and I was waiting for a fourth.

The call I should have made would have been six sentences. “I don't have a diagnosis. Post-op day two colectomy, heart rate 90 to 118 across three checks, pressure fine, no fever, belly unimpressive, and he can't get comfortable. I'd rather you heard it now than at six.” That's a trend and an ask, and it's what a good three a.m. call is made of.

Everybody who has stood outside a room with a hand on the door has made that other deal. Maybe it's nothing. Maybe the next set looks better. It's always a bad trade.

Nobody has been written up for waking a senior at two. People do get asked why they waited until six.

Some night a few months from now the phone will ring at three, and you'll notice your handwriting is steady while you write down the room number. You still won't know what's wrong with him.

You'll just know what to do first. And you'll already be walking.

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What to Read Next: Post 24, “Terrified I'll Miss Something.” Getting good at the pages you receive is half of night float. The other half is the patient who never pages anybody at all.