On my first evening as a night-float intern at Memorial, the world-famous cancer hospital in Manhattan, an intern handed me a list of her patients with their major medical problems, allergies, and a short summary of their hospital course. "There is one patient I have to tell you about," she said almost parenthetically. A patient with colon cancer had been hallucinating all afternoon. "He's quiet now, so he shouldn't give you any trouble," she quickly added. "But if he does, just snow him with more Haldol and Ativan." Then she left.
Night float was the scene of my worst moments as an intern. Your shift began at 5 p.m., when the other interns departed for the day, and ended at 7 a.m., when they returned. Meanwhile, you had to make critical decisions for other doctors' patients, about whom you knew next to nothing. You're an inexperienced intern, tackling potentially serious problems with not enough information.
That first night at Memorial, within minutes, my beeper went off. The patient whose care I had just assumed responsibility for was delirious, and his blood-oxygen saturation was dropping. When I went to his room, he was sprawled in bed, his arms and legs tied to the rails. He apparently did not speak English—apart from obscenities—because a German translator was there, grinning nervously. "He says that things are coming down at him," the translator said. "He feels that things are crawling on his skin."
A nurse asked me what I wanted to do. I had no clue. About the only thing my colleague had said to me before leaving was that this patient wasn't going to give me any trouble. I asked about his base-line mental state. The nurse shrugged. "I'm just a float," she said, meaning that she worked only per diem shifts. "I'm meeting him for the first time, too."
When I finally called the delirious patient's family, hoping for a clue, his daughter informed me that he had undergone a brain scan that afternoon. His intern had forgotten to mention it. What were the results? I did not know. So I gave the patient more Haldol and hoped for the best. (Later, I learned the scan showed a vaguely abnormal speck in the brain—a possible metastasis—which could have explained the delirium.)
Night float is the product of reforms in medical education that limit the number of hours that residents and interns—doctors in training—can work. Because they can no longer rely on the same doctor caring for a group of patients day and night, teaching hospitals have had to arrange more cross-coverage when the primary resident is not on duty. Most have created the position of a resident who works the night shift, usually for a few weeks. The upside is that other residents can sleep. The downside is frequent patient handoffs, which can result in the transfer of faulty or inadequate information. The nightmare of night float raises a central question about work limits for interns: Is it better to be cared for by a tired resident who knows your case or a rested resident who does not?
The push to limit interns' and residents' work hours gained momentum with the death of a woman named Libby Zion at the emergency room of New York Hospital, after the intern and resident treating her were slow to respond when she reacted adversely to a drug they gave her. If the young doctors had been more rested, soul-searching medical educators asked themselves, would they have been able to save her? In 1987, a special commission proposed a number of changes in residency training in New York state. Residents were prohibited from working more than 24 hours at a stretch or more than 80 hours per week, averaged over four weeks. They also got one day off a week. After intense debate, in 2003 similar changes were instituted at residency programs throughout the country.