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MICU survival GUIDE

As an intern, you will typically have about 2 weeks of Nightfloat, (NF)

typically divided eually between !offitt (during your "#$$ %onth) and &F$'
(during your () %onth)* (+cept for very, very rare circu%stances in which you %ight be
asked to help ad%it a patient with the resident NF, your pri%ary ,ob as -ntern NF is to
handle the cross.cover for all of the %edicine patients (e+cept the patients cared for by
the tea%(s)*) /his allows the interns to focus on ad%itting* 0ou will
typically be given a nu%ber of patient care.related tasks (e*g* checking vitals1eyeballing
pts, checking labs, etc) to do* 0ou will also be the pri%ary physician to assess and
proble%.solve when any of the patients you2re covering has a change in clinical status*
/his can be a scary thing (particularly if you2re doing NF early in the year), but
re%e%ber that you always have a resident NF there to back you up, as well as -#"1##"
residents* 0ou should never feel alone3
4e%e%ber that the night (and the week15 days1whatever), no %atter how
harrowing, 6-77 co%e to an end* 0ou will %ove on to so%ething else, and you will greet
the nightfloat with tre%endous relief and happiness when 08" are the one on call trying
to ad%it and cross.cover at the sa%e ti%e*
Intern NF, Typical Night
Arrive 9 :;<=.5p%
Figure out who the interns on-call are (at Moffitt, 2 teams are on call M-F, 1 team
on weekeds at !F"#, 1 team is on call e$ery night%
Figure out who the &esident NF is (on 'mion under (shift)%* The resident NF
will arri$e at +,*
$et signout, pick up cross.cover pager(s)
/ontact the on-call interns (usually pager0o1 works 0est% to ask for signout* 's a
courtesy, offer to meet them where they are to get signout*
2ick up the cross-co$er pager(s%
o 't Moffitt, this is the Intern NF pager (33--&4FF%, which stays in the
resident room in a small wicker 0asket when you5re not there
o 't !F"#, these are the Intern (') and (6) pagers, carried 0y the on-call
interns until you arri$e* 7ist your na%e and pager as -ntern NF on the
white board in the resident roo%*
!ee (!ignout) section under ("eneral Tips and 'd$ice,) 0elow
!ake your /o )o 7ist
6efore the on-call interns arri$e to sign out, get ready to organi7e the To 8os (see
(Making a To 8o 9ist) under ("eneral Tips and 'd$ice,) 0elow%
>atient #are 9 5;?@p%.:;?@a% (or 5a% on weekends)
/ompleting (To 8o) Tasks, triaging and managing patient pro0lems
&ignout in A! 9 A;?@.:;?@a% (or 5a% on weekends)
&eporting 0ack to the primary teams on the e$ents of the night
Attend 4esident 4eport (optional but encouraged, :;?@.5;?@a% !.F e+cept /hurs)
"eneral Tips and 'd$ice
:ating and sleeping
o 't Moffitt,
(ating; you are gi$en an allowance for eating on NF (;+<night%* The
caf= (2
floor% is open until 11pm* >n-call teams will often meet for ice
cream around 1.,-. or 1.,3? @ Aoining up with them, if you ha$e time, is
always nice @ makes you feel less lonely in the sometimes lonely world
of NF* For late night hunger pangs, there are $ending machines on the
floor as well (to your 9:FT, away from cafeteria, from the ele$ators%*
&leeping; you are assigned a call-room, listed on one of the 0ulletin
0oards in the resident room, along with the door code which you5ll need
to get in
o 't !F"#
(ating; The caf= closes 0y Bpm, 0ut the resident lounge (on the 2
0y the chapel% gets stocked with food at +pm* Food items usually
include 0asic stuff like fruit, crackers<granola 0ars, cookies, chips, water*
!ometimes there are microwa$ea0le foods like Cuiches and peanut 0utter
and Aelly*
&leeping; you are assigned a call-room in the 0asement, which you
access $ia the sensor attached to one of the cross-co$er pagers
4nderstand and anticipate the $ariety of nights that you will e1perience on NF,
o Most often, there5s a solid 0ackground of calls for stupid scut stuff (filling out
'>!es, restraint orders, diet orders, etc etc%, mi1ed in with a smaller num0er of
potentially real medical stuff (0leeding, dropping #ct, !>6%, and not unusually
one patient who is acti$e and potentially sick or decompensating* 8> N>T
#:!IT'T: T> /'99 D>4& &:!I8:NT >N NF E#:N !>M:>N: ":T!
!I/F >& D>4 8>N5T FN>E IF !>M:T#IN" I! !:&I>4!, >& 8>N)T
FN>E E#'T T> 8>* The >N9D way that you can screw up as an intern is 0y
N>T calling for help when you should ha$e* Dour residents will e1pect to hear
from you ' 9>T, 0oth on NF and on the wards in the first few months*
o &arely, you will ha$e a night when multiple patients are crashing* &est in the
knowledge that these nights are truly rare, and when they happen, you and your
resident may well end up working as a team with one of you at the 0edside of
each patient, since, after all, you can only 0e in one place at one time*
o &arely, you will ha$e a "9>&I>4! night when the calls, e$en for scut, will 0e
few* :nAoy them as much as possi0leG
o 8o N>T, under any circumstances, try to 9:'&N all of the patients as they are
signed out to you* The key things to listen for are these few things,
2eople who the primary team identified as sick, who may crash
o$ernight* If time permits, talk 0riefly or round on these folks with your
resident NF when he<she arri$es, so that you know what to anticipate*
2eople who ha$e had any cross-co$er issues (this is good 0oth 0ecause
people who ha$e 0een acti$e during the day<e$ening often will continue
to 0e so and, if nothing else, you5ll 0e the one communicating what
happened to the primary team in the morning%* Dou should make sure
you understand any notes that ha$e 0een Aotted down 0y the cross-co$er
To 8o tasks for you (often +pm<MN<CHh la0 checks, f<u on consultant
recs, etc%* These should 0e written on the signout sheet anyway, so if you
don5t go through these with the on-call intern signing out, no 0ig deal*
o Ask the people signing out to you to filter their signout for the above details 9
Bust tell %e about the people who are sick or who have been active 9 so that
you don2t get overwhel%ed*
Making your To 8o 9ist
o 6efore the on-call interns arri$e to sign out, get ready to organi7e the signout*
"et a fresh sheet of paper and make a few categories,
9ist of the floors where medicine patients usually are
't Moffitt, 13M, 139, 1.!, I-I/4, Misc floors
't !F"#, ?', ?/, ?8, 36
o 's the on-call interns are signing out (or after they lea$e, when you look 0ack
through the signout sheets%, write down the name and team of the patients that
you ha$e To 8os for*
For e1ample, if the on-call team tells you to check I<> on Ms* !mith on
team 6 in 13M at MN, put down (Team 6, !mith, I<> at MN under your
(13M) list*
If it5s a la0 check, try to figure out when the la0 is due (typically la0s
take an hour or so to get results once they5re drawn, so check for +pm
la0s around Ipm%, then write down the pt5s name, team, and time to
check la0 under your 9a0s category*
o /aking =.C@ %inutes %ake this list at the beginning of the night will save you
/8N& of ti%e during the night, since you2ll get your /o )os done in the fewest
a%ount of tripsD also, you2ll be less likely to forget to do one of your /o )os,
which are all buried in a huge stack of papers*
o 's you get calls to fill out forms or e$aluate patients during the night, you can
easily add the pt5s name (and team% to your To 8o 9ist
2atient care
o 'nticipate a lot of pages early on in the e$ening and lots of To 8os early on in
the e$ening* !tupid cross-co$er scut stuff usually dies down after 12-1 'M*
o Try to make sure 0y I,-. that +pm la0s you5re supposed to check ha$e actually
0een drawn, if they5re not pending in the computer* 2hle0otomy draws are only
C2h, on the e$en hours*
o ' word on $er0al orders,
Jer0al orders are accepted at Moffitt in emergency situations (the nurse
will ask for your name, then will lea$e a sticker in the order section of
the chart for you or the primary team to sign later%
Jer0al orders are not accepted on any floor at !F"#
o Ehen paged 0y the nurses, the first Cuestion to ask if which team the patient is
on* This will help you find the patient in a 0ig stack of sign-outs*
!uggestion, (/arry a copy of the roster of the current medicine teams, so
that you can identify a pt5s team num0er<letter 0y intern or su0-i*)
!uggestion, (>nly when I ha$e located the patient do I ask them whatKs
going on*) /his ensures that you2ll actually hear what they2re saying*
Make a note with the time L issue on the signout each time you5re paged
!uggestion, (Ehen lea$ing notes on the sign-outs, try to use a non-0lack
pen* ItKs easier to pick out what youK$e written, it distinguishes 0etween
you and the on-call intern when youKre e1plaining in the morning what
o Ehen the nurse is calling regarding a change in the patient5s clinical status, your
ne1t Cuestion should 0e, (Ehat are the $italsM) Ask for a F"77 set of E&*
o /heck the signout section ('nticipate 2ro0lems) to see if the team has any d1 or
r1 ad$ice for you*
o /onsider what additional information or inter$ention might 0e helpful to ha$e the
nurse get started while you5re on your way to see the patient (e*g* get an :F",
call for a /N&, put the pt in Trendelen0erg if hypotensi$e and altered, call &T%
o !tart thinking through your differentials, get additional information or help as
necessary, while you5re on your way @ re%e%ber that it2s A76A0& best to err on
the side of calling your resident earlier rather than later3
o !uggestion, (Ehile itKs always 0est to see the patient for most issues, I do gi$e
$er0al orders for things that are $ery straightforward (e*g* last night a nurse
called 0ecause a sta0le, 2--year old patient had recei$ed am0ien ? mg and still
couldnKt sleep, so I ga$e a $er0al order for additional 'm0ien ? mg without
seeing the patient%*
o For any maAor management decision, inter$ention, or change in pt5s clinical
status, you should lea$e a 0rief note (e*g* (:$ent Note)% in the chart
o !uggestion, (Ehen nurses or pharmacists ask me to change management<meds
that are not urgent or wonKt change anything o$ernight, I defer to the primary
team and tell them that IKll pass their concern<suggestion on to the primary team*)
&esident 0ack-up
o Though it may not feel like a glamorous Ao0, you will learn a tremendous amount
on NF, particularly in terms of how to triage and manage patients who are getting
sick* Ehile you should certainly do your 0est to assess the patient and come up
with your plan for what to do ne1t, when in doubt, call your resident3
o The resident NF is your primary 0ackup howe$er, don5t forget that there are
always multiple senior residents who can help you, on-call medicine or
cardiology residents, I/4 residents
!igning out to the primary teams in the 'M
o Try to 0e 0ack in the resident room 0y H,-. or Bam (especially in the 0eginning
of the academic year% to gi$e signout to the primary teams*
o Feel free to let people know if there was so%ething unclear, %issing, or wrong in
their signout* Bust as %uch as you2re learning how to cross.cover, they need to
learn how and what is appropriate to sign out to NF* -f you do it in a
constructive, diplo%atic way, they will thank you for it*
!uggestion, Make sure to pro$ide feed0ack in the morning* If there
were notes that were really helpful, acknowledge that* If you felt that
they signed out something without making it clear what was to 0e done
with that information, also let them know that, so that they can impro$e
in the future* >ne thing that I ga$e feed0ack on was when people asked
me to check results (especially of radiology studies% without letting me
know what I was looking for or how the plans would change*)
o If interns ha$en5t arri$ed 0y B, on weekdays (e1cept Thurs% or +am on
Thurs<weekends, you should lea$e their signout in a marked spot in the resident
room (usually on or near the white 0oard%* 9ea$e your name and pager O in case
they want to contact you with details
Morning &eport
o Dou5re e1pected to go to (&esidents5% Morning &eport, which happens at B,-.-
+,-. on e$ery weekday e1cept Thurs* :nAoy the opportunity to hear some cool
cases and how the residents are approaching them* (Dou may also end up cross
co$ering on one of the pts presented later on in the weekG%