It is 3am, and all I can do is sit here holding my breathe, hoping my pager doesn’t go off again and I can catch a break for a few minutes to grab a bite to eat. At this point, I’ve been on shift since 5pm and have only been able to eat the almonds in my white coat pocket and a pack of saltine crackers that I grabbed from the pantry on my way to see another patient. The energy I had at the beginning of my night is winding down, and fatigue is setting in my body. My brain is exhausted from triaging which patient I need to examine first on the list of calls I just received from nurses, and from making quick decisions on the patient with a true medical emergency during the middle of the night. The busiest time of the night is between the hours of 9pm and 2am. Why those hours? Well, the nurses change shift at 7pm and come 9 they have gotten sign-out and are ready to begin their night. The majority of the calls the Night Float gets are for little things that the day nurses just didn’t get around to doing. Potassium repletion, fluid order renewals and the 1am call that the patient is constipated and they need an order right away for senekot and colace. Then 10pm comes and the pager doesn’t stop for Ambien. An hour later comes the calls for IV Morphine or Dilaudid from the drug seeking patients that were unsuccessful at getting the day team to prescribe them. These patients are particularly smart. But, no it is not going to happen. I examine every patient with pain that the nurse calls about. I’ve had to learn the hard way, but if a patient is complaining to the nurse about pain, I am going to go do an assessment. No Morphine unless I assess. And unless the day team gave specific instructions ‘No Morphine’, the patient is getting 1mg if that’s what will get them through the night. Covering 80 patients at night is not easy, but there are times when we need to make our best judgements in emergency situations, no to change the plan of action of the patient’s stay in the hospital. One wise upper year resident told me at the start of the dreaded night float rotation, it is not the night doc’s job to change the way the day shift is managing the patient’s care. It is your job to keep my patients alive. The last thing that the day team wants to hear is that you changed the patient’s blood pressure medication from a calcium channel blocker to a beta blocker because there was more evidence on the resource ‘up-to-date’ that it would benefit the patient given his condition. This is not the job of the night float. Our job is to keep patients alive. Keep them afloat. A call came around 2am to assess a patient on the 15th floor, the Oncology Unit. As an aspiring oncologist, I particularly like this floor. It has some of the best nurses that I have worked with. They are especially attentive to their patients, which is a necessity if you are going to be an Oncology nurse. But, as much as I like being in the Oncology unit, the Cancer patients are some of the most fragile in the hospital. And day or night, anything can happen at any time. The call was from a nurse stating that a patient on the Yellow Team 4 was complaining of pain, 10 out of 10 on the severity scale. At this point I have only slept 3 hrs in the past 36, and now here I am again, in the middle of another 14 hr night shift in the hospital having to go assess another patient’s pain. But I know the calls from the Cancer Center nurses are not an over exaggeration. They are serious calls. So I ran up 5 flights of stairs as quick as I could to assess. When I arrived, I did not even have to look at my patient list for the room number, as I could hear the cries for help from the stairwell. My patient was Mr. J.C., 54 year old African American male with Leukemia. Mr J.C. was admitted one month ago for an Allogenic Bone Marrow Transplant, a procedure that takes Stem Cells from the bone marrow of a donor and injects them into a recipient in the hope that the stem cells will form new healthy bone marrow. Mr J.C. had previously failed 2 other transplants, both anonymous, and the transplant he received one month ago was his last chance. The stem cells came from his sister, his best match in the family. But even with cells from a matching donor, there is still the risk of serious complications. And that was the case with Mr. J.C. Mr. J.C. was suffering from something called ‘Graft versus Host Disease’. It is a complication of a new stem cell transplant, and it occurs because the donor stem cells see the patient’s body as ‘foreign’ and attacks it. My patient was undergoing Graft versus Host disease, and the inner lining of his GI tract was being attacked by the donor’s cells. His gut wall was sloughing off as the cells died. It all happened so suddenly, causing Mr J.C. to be in extreme amounts of pain that the highest doses of narcotics could not take away. I felt for him and his suffering. I wished there was something more that I could have done. He was screaming for help, and the situation was far beyond under my control. The only thing in my power was to have him transferred to a higher level of observation that only the Intensive Care Unit could provide. He needed sedation to help him at this point. As we rushed Mr. J.C. to the Intensive Care Unit, I had wondered if he would ever get better from this horrible disease. But what happens during the dark hours of the night dissipates by morning, and the day starts all over again. More often than not, we never know what happens to the patients. If their name does not appear on the list the next night, one can only imagine the worst. But that is the job of the night float, to keep the patient alive until morning. And now here I am. It is 3am. Awake. Alert. Waiting for my pager to go off… How to Survive the Night Shift at the Hospital Slowly transition: Any changes to your circadian rhythm should be made gradually. When I need to adjust to a major shift in schedule, I like to take 2 days, as long as my schedule allows. The human body does not adapt well going from day to night, so take it slow, and you will get there in no time. Set up a proper sleep environment: The right environment can help you sleep longer and sounder. I make my bedroom as comfortable as possible by blocking out sunlight with blackout curtains. You can also use an eye mask to shade your eyes. Mute street noise with ear plugs or get a fan. Resist Caffeine: As much as I try, It’s hard to do! The quick boost caffeine gives me instant gratification, but I often pay for it later when I want to crash around 4am, and then get a second wind only to go home and not be able to fall asleep at 9am. It’s a known fact that Shift workers who rely on caffeine have more trouble getting to sleep after work. Avoid energy drinks: I never have them and never will! Downing energy drinks to stay awake will only make you crash harder later, plus they’re filled with extreme levels other ingredients that can negatively affect your health. Drink tea and coffee for a more natural caffeine kick, and drink plenty of water. Keep a consistent eating schedule. This is a HUGE problem for everyone I know. It’s easy to order Take-out when you are working nights with your friends, and it is also easy to make bad choices in what you will eat for dinner at midnight. Not to mention – Sleep deprivation disturbs your appetite, which leads to increased feelings of hunger and weight gain. What I do is to eat dinner before starting my shift, and snack every two to three hours during it to stay focused and energized. This way I’m never tempted to eat a heavy meal at the end of my shift. Decompression: Sources have said that it is ideal to have some decompressing time after work instead of heading home and going straight to bed. Just like someone working the day shift, it’s important to take time to relax and unwind, especially after a particularly stressful night. Do some yoga, watch your favorite TV show or spend some time with family. I like to take at least 90 minutes to unwind at the end of a shift before going to sleep. Source
