Tonight, I am completing my first two week stint as the Neurology night shift resident at my hospital. For better or worse, I did not have any night float experience as a Medicine intern (plenty of long and painful on-call shifts, but no long consecutive stretches of nights), so these two weeks have been an interesting, exploratory experience for me. I have a total of two months of the night float rotation during my residency, so I have plenty more time to perfect my strategies for both maintaining the best possible patient care and making the best use of the time. I have picked up a few pearls that might help other residents who also will be filling this role:
 The Plan and Pickup
As detailed in my last post, signout is an extremely important process and is the initial and primary means of high-yield information gathering for the night shift resident. Day residents are often tired and worn out by signout time, making it difficult to execute an effective delivery of all of the important details that a night shift resident covering all of the patients requires. Accordingly, it is the night shift resident’s job to ask the important questions when important information is left unsaid.
Of the many details that are valuable, I find that there is special significance in the day team’s plan of action for the patient. The night shift resident’s job is sometimes viewed as a “float” position where one simply tides the patients over until the next morning when active patient care can continue; the job in that case is very passive and only activated in reaction to new developments. Sometimes the team’s plan for the patient is glossed over during a signout process or even omitted. However, the night shift resident covers half of the twenty-four hour day, and much can be done during that time (albeit in smaller, discrete measures, given that the night shift resident is covering a much larger patient census). Sometimes medication titrations started during the day (e.g. for blood pressure control or diuresis) can be continued during the night. Sometimes a new therapy or plan started during the day shift might result in a less desirable outcome, requiring that it be reverted back to the original regimen during the night shift.
Inevitably, small details of care are omitted from signouts, whether intentionally or unintentionally. Nonetheless, the night shift resident can assess the team’s plan and pick up where they left off by following up on ordered studies, touching base with collaborating services or nurses, etc.
 The Preemptive Measures
Anticipation is a valuable skill. Being able to predict needs and requests can save valuable time. For example, at my current hospital, the order set for cardiac telemetry does not include a system to indicate whether or not the patient can leave the hospital floor without telemetry when being transferred to another part of the hospital for testing (e.g. Radiology). Residents have to manually type in a text order to give the nurses permission to release patients to the transport team. Accordingly, whenever I start my night shift, I look to see which patients are scheduled for overnight tests, determine whether it is reasonable for them to be off cardiac telemetry monitoring for a period of time, and then indicate such in the ordering system. Placing a few orders and touching base with nurses early in the shift helps prevent the potential slowing down of care delivery when one is dealing with multiple consults, admissions, codes and triggers, and other unpredictable developments.
 The PM Rounds
For me, there is great value in laying eyes on each patient. Unfortunately, the 8PM start time for my night shift is past the bedtime for many patients, so they are hidden behind curtains in dark rooms. Nonetheless, I make a concerted effort to locate all patients and mentally store an image of where patients are and what they look like (if I can see them). That way if something happens later requiring me to rush to the bedside, I know exactly where to find each patient. I try to lay eyes on the patients whose clinical statuses are more likely to change, and I examine the patients who are quite sick and are already changing in stability. With regards to examinations, I find that it is important to think about the patient’s pathology, their baseline examination, and the likely changes that one might see with the most likely complications. For example, a patient with a large cerebellar hemorrhage might develop brainstem abnormalities or depressed level of consciousness on examination, so that’s what I would look for as an indicator of worsening clinical status and a trigger for intervention.
 The Face Time
The geography of my night is unfortunately split between three locations: three floors in three different buildings, separated by a series of bridges and elevators. Furthermore, the Neurology floor is on the top floor of one building and the Emergency Department is on the bottom floor of another. Accordingly, I find it useful to split up my night into segments where I can minimize my migration from one section to another. Generally, I spend the first four to five hours of my twelve hour shift on the floor where most of my department’s patients are located. This is the start of the nursing shift as well, so there is more activity, more requests, and fresh pairs of eyes reviewing the orders and the patients themselves. The night shift is the best time to get to know the nurses in a hospital with regional admissions: there’s only one doctor on the floor, and that’s me! During those first few hours, I can be a useful resource to the nurses, both by providing some insight conveyed by the physician teams and by helping to facilitate the care ideas generated by the night nurses. Putting in this face time early in the rotation is quite valuable, too, because one develops relationships of trust with the nurses and can better triage requests and nurse assessments when brought to one’s attention later. After the floor patients quiet down, I usually migrate down to the call room which is closer to the Emergency Department where I can more easily set up camp, eat and drink, write notes, and run to either the floor or the ED as needed.
 The Quiet Place
Although the hospital is quieter at night (literally), there is still a cacophony of telemetry beeps, yelling and moaning patients, and chatter. A large part of a physician’s job is documentation, and writing well requires mental focus. For me, I can generate clinical documents much faster if I can find a quiet place, be this the call room, a quiet hallway, or an empty conference room. Finding a quiet space and making it a frequent stop during the night shift can help improve efficiency when the admission and consult notes start piling up. Some people prefer to work to music, so finding a room with a computer where one can play Pandora or an iPhone/Android on speaker can help facilitate the written work that needs to be done.
 The Energy Food
Shifting to the night schedule can screw up one’s gastrointestinal clock. I eat breakfast and dinner at the usual times, but I have switched lunch to a post-midnight meal so that I don’t have to wake up in the middle of my daytime nap to maintain my calorie intake. However, despite changing over to the night schedule with my meals, my stomach continues to growl constantly and loudly between 4AM and 7AM, or until whenever I can next eat.
The most important thing with regards to food and drink is to keep up one’s energy levels and hydration. As an on-call intern, I spent my on-call budget on a cache of Life Waters; I would keep four or five bottles in one of the physician conference rooms, and then I would down one bottle at a time to stay hydrated throughout the night. Now, as a night shift Neurology resident wandering between different floors and buildings, I keep close tabs on the water machines and on my supply of food (whether in my bag, locker, or the conference room fridge) so that I can snack throughout the night and stave off hunger and dehydration. Everyone has different preferences for on-call food: make it tasty and energizing!
 The Rally
Inevitably, fatigue ensues. With fatigue comes a loss of willpower and the onset of complacency. When the hours wear on and one is nearing the end of the shift (particularly in the 4-8 AM hours), it is important to buckle down and push through. Stretch, snack, or take a quick power nap to reenergize and refocus. The end is near: race to the finish!
Hopefully, these tips will be useful to those who will be doing the night shift, which is to say, virtually all residents now that the 16 hour work day restrictions have come into effect for interns. However, don’t be a night float and just muddle through through the night. Be a night rider!
Do you have other tips or strategies for surviving and adapting to the night shift? Please post your comments and suggestions below.