Night Float

I am back in the Cardiac Care Unit this rotation. If you recall my earlier tribulations from my previous CCU block, this means I am once again forced to Constantly Replete Potassium. I have never really forgotten how much I hated the CCU – all other rotations are judged in relative fractions of CCU terribleness – but I had, at least, airbrushed out the violent rage induced by being interrupted every eleven seconds about electrolytes.

(This post is, in fact, not about electrolyte repletion, although there will be frequent references. You may all breathe a sigh of relief.)

But before I forget:

Speed+of+potassium+repletion

It is a testament to my juvenile sense of humor and abject nihilism instilled by intern year that I still laugh every single time I see this slide. I am going to go waterboard myself now.

You may be asking why I am forced to complete not one but two rotations in my own personal seventh circle of hell. In my program, we do two weeks of “ICU night float” divided between a week of the CCU and a week of the medical ICU. I show up at 7pm every night to one of these two places and have two jobs:

  • Prevent people from dying
  • Admit new patients

It goes without saying that in the CCU, “prevent people from dying” and “replete potassium” are synonymous.

Okay, I’m sorry. No more potassium jokes for a little while.

Aside from the fact that you’re asleep during the day, when the road workers have elected this exact financial quarter to jackhammer the road in front of your apartment, it’s a pretty great job. For the first, and probably only time, my job is – and ONLY is – to practice medicine. It’s great.

In between electrolyte repletion orders, I wondered why it was that night shifts are so much more tolerable and borderline enjoyable compared to day shifts. A big reason why is the absence of the functional unit of medicine: the Daily Progress Note.

Every day a patient is in the hospital – whether in an observation unit, a low-acuity “floor” team, or the ICU – the primary team is required to write a progress note. Not so bad, right? There should be some kind of record of how the patient is doing and what changes to the plan of care were made that day, so that other teams can track what’s been going on. Reasonable.

It makes total se-HAHAHAHAHA joke’s on you! The Daily Progress Note, in fact, contains zero useful information. I am not exaggerating. When ,earning about a patient that I’m either taking over, admitting, seeing in the ER, or whatever, I never, ever read the progress notes. They contain absolutely nothing of value.

You non-medical readers may be indignant. You may be asking, “what the hell are you millennial doctors doing all day? Why can’t you take the time to genuinely and honestly keep records of what’s happening with your patients?”

The answer is, as usual, money.

Every note we write is carefully scrutinized by a “coder.” Most hospitals, including mine, employ a massive, shadow staff of coders whose job is to scour the notes for billable details. The note tells the coder how much money the hospital can bill for that patient that day, based on an indecipherable and thoroughly byzantine system that I will not even begin to attempt to explain.

I have never met one of these people. I harbor suspicions that the army of coders is actually just one coder – the depressed robot AI, Marvin, from Hitchhiker’s Guide to the Galaxy. I fear the hospital gives Marvin different names to prevent us from catching on.

orig_693518

“Coding” is a process that only makes even a smidgen of sense in the grotesquely obese, self-immolating, and terminally diseased American healthcare system, which is largely fee-for-service: you get paid for what you do, not how the patients do. It also is a process that sustains the biggest piece of the monstrous, inefficient overhead that drives up the cost of healthcare, but that’s a subject for a different and more boring rant.

If you can’t tell, I have some criticisms of the system.

The practical effect of this billing riptide: progress notes are largely copied and pasted from the previous day, because the amount of information unimportant to clinical medicine – but crucial to billing – has to get documented somehow.

For example, a patient with a relatively uncomplicated heart failure exacerbation – where the mainstay of inpatient care is “make the person pee off their extra fluid” – a good note should contain how much they peed the last 24 hours and any electrolyte derangements that occurred and were fixed. Probably not much else, if we are being truthful. Instead, this simple note contains:

  • A twelve-point “review of systems,” which implies that we asked the patient comically irrelevant things such as whether they get cold easily, or if they have any changes in their vision;
  • A full 12-system physical exam, which in reality consists of at most four parts (heart, lung, abdomen, legs);
  • An enormous amount of “objective” information – vital signs, lab work, imaging – all of which is more easily accessed elsewhere in the chart, and never read by anyone within the body of the note;
  • A bloated “assessment and plan,” which is supposed to be a brief overview of the changes for the day, but in reality is a copied-forward atrocity of outdated and irrelevant information. For instance, there will almost always be a series of issues listed in the plan that are useless, such as “High cholesterol: continue home Lipitor.” How this is of use to anyone but a coder is totally beyond me.

Also: if I write, say, merely “heart failure” in the note, I get a blizzard of questions from the coders. Is this acute decompensated heart failure, or chronic compensated heart failure? Is there systolic or diastolic dysfunction? Would you like to add the patient also has hypercapnic respiratory failure? Please document your answers in the note.

It is worth (ha!) adding that in nearly every case, this level of precision bears exactly zero impact on the patient’s actual care – but can make a big difference in reimbursement.

Anyway. The note is a waste of time, and yet it occupies the majority of a medicine day. For that reason, nights are better.

The other reason nights are fun is that you’re covering the entire service pretty much by yourself. Truly knowing much of anything about a patient is difficult, so you get basically a “one-liner” – age, primary reason for admission, major complications – and a list of things to do.

This array of Tasks That Need Doing is ripe for a hyper-organized, OCD-tendency-pleasing system of check boxes.

I. Love. Check boxes.

By this point of intern year I have developed a sophisticated, multi-layered, and totally opaque system for accomplishing tasks. Nowhere is this as well-utilized as in the CCU, where there is always a Potassium in Need of Repletion, or almost as good, a Urine Output Goal. I can document, on my list of checkboxes, exactly when, on whom, and how much K was Repleted, or How Much Urine Was Peed. The coders would be pleased, except I am not writing notes about this.

At the end of a long night spent ordering electrolyte repletion I triumphantly present my list of fully bubbled-in checkboxes to the day team, who arrive to take signout in the morning. They roll their eyes, but I know they are just envious of my completed boxes.

These fellow interns, prisoners to another day of illegitimate note-writing, are also quite likely low in potassium.

I will be receiving a page about them soon.

2 thoughts on “Night Float

  1. Great SciFi concept: Coders lurking in the shadows, rewriting history as it happens.

    This reminds me of your original warning: Never ever go into a hospital. Ever!

    PS You were like this when you were three.

  2. your ruminations remind me of a song
    MONEY MAKES THE WORLD GO ‘ROUND
    THE WORLD GO ‘ROUND
    MONE MAKES THE WORLD GO ‘ROUND
    wait have to google the last line. guess who

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