Nocturnist Issues

[sylvanthus]

Any fellow nocturnists want to toss me some thoughts/advice? Dealing with some issues that have realllllyyy started to grind my gears and my morale is in the ****ter.

Im currently solo coverage at night for a 24 bed icu, no midlevels, avg census prob 16-17 ish. Day shift has two docs. Lately, im getting night-shift-guyed hard. Patients dumped off from OR with no report/signout from anesthesia or the surgeon on what happened. No information on the bed situation so often the transfer center will be more updated than me (ill be blindsided by outside hospital transfers when at start of shift we only had one admit bed available). Patients coding in house, resuscitated, brought to ICU with, again, no signout. Patients im primary on will have my plan changed during the day when rounding (dont mind if its a change in abx, but sometimes its a complete opposite plan). Consultants putting in orders on my patients at night without telling me. Consultants telling nurses to tell me to do procedures (CTS telling them to tell me to do an aline or intubate their patient) and giving me attitude when I tell them if they need something they need to discuss it with me directly. Etc etc etc.

Ive brought up these issues time and again and nothing is improving. So, do I accept my fate, lower my standards, and just be the guy that puts out fires and just deals? Cuz im getting night-shift-guyed hard OR completely disrespected in which case, fuk it, ill put in the bare minimum and just deal.

Thoughts? Rants? Flames?

---

Members don't see this ad.

 

[tartesos]

I cover a week of nights a few times a year and you are describing typical issues. Just ride the elephant and do the best for your patients.
If it makes you feel any better wake up a consultant from time to time on a recorded line if they pull that “consult x” to the nurse after you give them time to fall back asleep 😬.

 

[chessknt]

It isn't culture in that place to hand off that it appears--if it really bothers you then yea, the only choice you have is to leave because you can't change culture. You can always call the surgeon or whoever else I suppose to get hand off if that would make you feel better.

When you say primary do you mean you night round only on specific patients you have admitted and think the day team shouldn't be adjusting your plan? I have to say I have never seen that and nights being firefighters is definitely the norm. I'll admit someone and plan would have the day team consult xyz, sometimes they don't but whatever, they are the ones in charge.

 

[CCM-MD]

Do you only do nights? I’ve noticed some of what you are describing to be more of an issue for folks who only do nights and have less interaction with physicians/surgeons during the daytime. Less familiarity = less communication. Night shift is clean up duty, you can’t be upset at the plan changing during the daytime.

 

[bigdan]

OP -

It sounds like you work where I work.

First, protect yourself. I write “HPI gleaned from EMR review and information shared with bedside RN” in my note - that’s bigdan-speak for “no one from surgery or anesthesia spoke with me” - and that’s what I’ve said in M&M, and what I plan to tell the hospital/attorneys if (when) the situation presents itself. There’s ONE ICU guy - they can find you or at least call you.

Second, I admire and appreciate your concern. Have you spoken to/written to the Anes and Surgery leadership? I have done this by email, because it leaves a time-stamped paper trail.

Third: If you have ANY quarter with the powers that be, it’s worth asking for candid, off-the-record commentary on your concerns. We have a few bad actors that I’d reported to patient safety and to peer review; both went nowhere. So I asked the Chief Medical Officer “is there any universe in which my concerns are addressed?”, and she told me “We talked about it, and, no…that guy is an institution here”. Deflating answer to my attempt to make things better, but at least I knew where to focus my energies.

Don’t fall for “…it’s the culture here”. Kudos for seeking the right thing for you and your patients.

 

[SurfingDoctor]

Overnight sucks no matter where you are…

 

[sylvanthus]

It isn't culture in that place to hand off that it appears--if it really bothers you then yea, the only choice you have is to leave because you can't change culture. You can always call the surgeon or whoever else I suppose to get hand off if that would make you feel better.

When you say primary do you mean you night round only on specific patients you have admitted and think the day team shouldn't be adjusting your plan? I have to say I have never seen that and nights being firefighters is definitely the norm. I'll admit someone and plan would have the day team consult xyz, sometimes they don't but whatever, they are the ones in

Ya, patients I have admittd I continue to write notes and supposedly am primary on until they downgrade

charge.

 

[sylvanthus]

Do you only do nights? I’ve noticed some of what you are describing to be more of an issue for folks who only do nights and have less interaction with physicians/surgeons during the daytime. Less familiarity = less communication. Night shift is clean up duty, you can’t be upset at the plan changing during the daytime.

Yup, only nights, so I have none of the collegiality and familiarity that goes with dayshift. Im the night bitch.

 

[sylvanthus]

OP -

It sounds like you work where I work.

First, protect yourself. I write “HPI gleaned from EMR review and information shared with bedside RN” in my note - that’s bigdan-speak for “no one from surgery or anesthesia spoke with me” - and that’s what I’ve said in M&M, and what I plan to tell the hospital/attorneys if (when) the situation presents itself. There’s ONE ICU guy - they can find you or at least call you.

Second, I admire and appreciate your concern. Have you spoken to/written to the Anes and Surgery leadership? I have done this by email, because it leaves a time-stamped paper trail.

Third: If you have ANY quarter with the powers that be, it’s worth asking for candid, off-the-record commentary on your concerns. We have a few bad actors that I’d reported to patient safety and to peer review; both went nowhere. So I asked the Chief Medical Officer “is there any universe in which my concerns are addressed?”, and she told me “We talked about it, and, no…that guy is an institution here”. Deflating answer to my attempt to make things better, but at least I knew where to focus my energies.

Don’t fall for “…it’s the culture here”. Kudos for seeking the right thing for you and your patients.

Good thoughts ty.

 

[chessknt]

Honestly tell the group you need to switch to days at least half time it will help a lot. Also stop being primary at night.

 

[SurfingDoctor]

OP -

It sounds like you work where I work.

First, protect yourself. I write “HPI gleaned from EMR review and information shared with bedside RN” in my note - that’s bigdan-speak for “no one from surgery or anesthesia spoke with me” - and that’s what I’ve said in M&M, and what I plan to tell the hospital/attorneys if (when) the situation presents itself. There’s ONE ICU guy - they can find you or at least call you.

Second, I admire and appreciate your concern. Have you spoken to/written to the Anes and Surgery leadership? I have done this by email, because it leaves a time-stamped paper trail.

Third: If you have ANY quarter with the powers that be, it’s worth asking for candid, off-the-record commentary on your concerns. We have a few bad actors that I’d reported to patient safety and to peer review; both went nowhere. So I asked the Chief Medical Officer “is there any universe in which my concerns are addressed?”, and she told me “We talked about it, and, no…that guy is an institution here”. Deflating answer to my attempt to make things better, but at least I knew where to focus my energies.

Don’t fall for “…it’s the culture here”. Kudos for seeking the right thing for you and your patients.

I literally had a consultant service transfer a patient to our unit with no signout and I wrote as the HPI “Patient admitted for no apparent reason. Transport EMS has no idea what is happening but they transported the patient anyway. Reportedly a consultant accepted this patient but they aren’t here. There is no other history obtainable… Signed SurfingDoc”

 

[Radetzky]

Work in a closed unit

 

[The kitchen sink]

Any fellow nocturnists want to toss me some thoughts/advice? Dealing with some issues that have realllllyyy started to grind my gears and my morale is in the ****ter.

Im currently solo coverage at night for a 24 bed icu, no midlevels, avg census prob 16-17 ish. Day shift has two docs. Lately, im getting night-shift-guyed hard. Patients dumped off from OR with no report/signout from anesthesia or the surgeon on what happened. No information on the bed situation so often the transfer center will be more updated than me (ill be blindsided by outside hospital transfers when at start of shift we only had one admit bed available). Patients coding in house, resuscitated, brought to ICU with, again, no signout. Patients im primary on will have my plan changed during the day when rounding (dont mind if its a change in abx, but sometimes its a complete opposite plan). Consultants putting in orders on my patients at night without telling me. Consultants telling nurses to tell me to do procedures (CTS telling them to tell me to do an aline or intubate their patient) and giving me attitude when I tell them if they need something they need to discuss it with me directly. Etc etc etc.

Ive brought up these issues time and again and nothing is improving. So, do I accept my fate, lower my standards, and just be the guy that puts out fires and just deals? Cuz im getting night-shift-guyed hard OR completely disrespected in which case, fuk it, ill put in the bare minimum and just deal.

Thoughts? Rants? Flames?

Yea sounds like the typical bs

Is it an open / closed icu?

This sort of set up typically leads to bad outcomes and quickly burnt out CC docs due to lack of communication, basic respect and support from ancillary and physician colleagues…

If the administration does not assist in improving your workflows, then it will never change and you already know your biggest bargaining chip is your feet

I personally left the world of in house nights in 20+ bed icu’s for these particular reasons….. and i am infinitely happier

I personally think ICU’s should be open with intensivist consultation services… with the teams as the primary… this way there is some shared liability and you get to focus on the patient, without being overly involved in all the beauracracy and polictics (accept/reject, bedboard, transfer calls, family meetings on trach/peg rocks, social work, endless idiotic consults from ER floor OR all of which just boil down ‘uhhh we don’t know what’s happening but the patient can’t stay here’ …. That statement itself equals moral injury. If we are going to be the only ones taking care of ‘sick’ patients, no one else by nature is going to care for anything that gets a little ‘sick’. ICU’s should have never ‘closed’ , intensivists should have only take the responsibility they were trained for…

Just my 2 cents

 

[The kitchen sink]

Work in a closed unit

Does not work unless you have a strong leadership and workflows between divisions, in my opinion …..

Unfortunately most hospitals I work at will let their sick patients deteriorate and call repeated rapids until you ‘accept’ the patient and now all of it is entirely your responsibility

Sure we signed up for this, but it gets tiring and contributes to burn out if it is happening at high volumes with zero sign out, zero collegiality between other services and the CC service especially with zero administrative support or short staffing

Competitive salaries keep ppl on board but only to a certain extent

There are so many different set ups for critical care and you do have the ability to find places that have significantly better workflows in my honest opinion

 

[Siggy]

Patients dumped off from OR with no report/signout from anesthesia or the surgeon on what happened.

Unless they're actively dying, I just refuse to see them. I tell the nurse that, "I haven't had report on this patient... I'm unaware of what happened in the OR or any complications. It would be unsafe for me to put orders in for the patient without knowing... and that they should page the surgeon or anesthesiologist for orders or to call me."

This normally gets me an angry call from the surgeon pretty quickly... where I reiterate the lack of signout, the need to have an idea of what happened, including why the patient remains intubated (was there a difficult airway, was there clinical instability, hypoxia, etc? Is there plans to return to the OR? From the surgeon position, is there any pressing needs to keep the patient intubated, or can I start working towards extubation now?), and the patient safety aspect. Keep repeating the patient safety aspect. At every hospital I've been at, the intensivist has a Spectralink... we're probably the easiest physician to get a hold of in the entire hospital. Literally one phone number that should be posted in the OR work room.

Once I get report I thank him and agree to put in orders.

Of course if the patient is actively crashing, that's a different story. Unhappy, undersedated patient that the RT can't document on because there's no vent order? ¯\_(ツ)_/¯

 

[sluggs]

1. When you have signout with your partners at shift change (both day and night) discuss the care plan and work through differences
2. Ask the ICU medical director to require handoff from the primary/surgeon/previous attending when transferring a patient to the ICU
3. Have a closed or "modified closed" unit where consultants must discuss orders with the intensivist, or call the intensivist with suggested orders rather than writing them without telling you

The system you are describing is way too out-dated and harms patients (and harms you)

 

[sylvanthus]

Thanks for the advice guys. Sorta glad to see alot of the issues is just being the night bitch and not just cuz I suck.