The lights are dimmed, rings of telephones are silent, the quietness of the hospital proves the night! The patients: some awake, some asleep. Nurses keep an eye on the charts and remain alert when the patient alarm will go off. The one person who walks in the hallway of the hospital, working against the circadian rhythm, is the nocturnist. The hawks’ eye and the prompt alertness make him an unique personality.
Sreerupa Patranobish recently had a conversation with Dr. Bharat Bhushan, who is a Lead Nocturnist associated with the Sound Physicians in Lubbock, Texas, in the southern state of the United States. Dr. Bhushan easily comes across as an individual with great poise, a steady demeanour and a great passion and enthusiasm for the tough job that he is entrusted with. He is an NRI physician, who earlier accomplished his MD in General Medicine from India and played an important role in patient triaging during the Bhopal Gas Tragedy while he was a medical student, prior to relocating to the US in his current roles. He shared his years of expertise in the field on this special role in hospital health care.
Q: Welcome Dr. Bhushan
BB: Thank you, it is a pleasure.
Q: Please elaborate the role of a nocturnist in the hospital.
BB: When night falls in the hospital, the role of a nocturnist begins. The role becomes more precise with accurate evaluation and prompt treatment plans, and to look over the patients who gets admitted for various reasons in late hours. Its unlike the residency days and you are the sole decision maker at night. So a physician in a hospital at night has definitely an added advantage in patient care. The stability of a patient may decrease and while the call to his doctor may be too late, the role of the nocturnist is vital, who can provide relief and make the situation stable. The Emergency Department has to be monitored and patient admission and initial treatment protocols are activated. At the night time, it is a great opportunity to establish a one-on-one relationship with your patients. Communication skills are key to success in this profession. Additionally, it is a great privilege to establish camaraderie with my nurses.
Q: What are the challenges of being a nocturnist?
BB: In a hospital at night, the biggest challenge is that nocturnists are the first point of call for any situation. It is to be ensured that all patients are taken care in the hospital. There are many concerns but one who can formulate the protocols in a systematic way and can manage things efficiently can rule the game, as manpower is scarce during the night. There are an array of things which requires monitoring for the current patients, like the patients’ stay in hospital, readmission risk, mortality risk, etc. These are the primary challenges that have to be meticulously addressed. The nocturnist is the “solo” conductor at the hospital at night, and I carry a sense of gratitude for the opportunity to serve in this role.
Q: What are the major tenets of care that you envisage as a nocturnist?
BB: The first thing I focus when I am on the floor is to reduce the noise level in the hospital as the night progresses. I am passionate about noise reduction in the hospital. Some of the key issues involved include, dimming the lights, for less routine checks for stable patients unless its required, talking in low voice with the staffs present for any queries and reducing the frequency for medical alarms. The ultimate aim is to increase the sleep hours for the patients, as night time is the prime time for healing. I have advocated these issues of hospital care through a web portal.
Q: As a nocturnist, what are the types of care you provide and how diversified is your role as a physician?
BB: The average shift is 10-12 hours which starts in the evening. Developing to work alone is a major criteria and the ability to make fast decisions. Intense clinical leadership with organizational skills is required in hospital care at night. My past experience in Medical Management at the Carnegie Mellon University is highly helpful and engaging in this regard. I pay attention to make sure the competency of the team to implement care for the sickest patients. Elderly patients have chance of falls in hospital. Falls in elderly can cause injury and even more complications like fractures. I make sure that preventive care is taken for the elderly and frail, like to monitor their mobility with assistance. Night time is an episode of vulnerability. Earlier, through my publications, I have raised awareness on the efficiency of management of deep vein thrombosis, especially at night, since slowing of blood flow and stasis pre-disposes to clot formation and pulmonary embolism. Other common complications spike at night for patients who are admitted to hospital with chronic diseases like hypertension, diabetes, arthritis, and dementia. I make sure their treatment plans are well taken off care in the night before the sleep, including their medications and ensuring that the notes are uptodate. So this ensures seamless transition of patients in day care.
Q: How are nocturnists key in 24/7 hospital care and patient care system?
BB: I enjoy my role as a nocturnist. The Joint Commission has emphasized the hospitals for the specialized care at night in hospitals and hence it has been a integral part of every hospital. The nocturnist not only provide the regular patients admitted at night time where they also take active part in Emergency Department care, where a serious patient who may may be suffering from a heart attack may quickly be shifted to the floor or the ICU. The nocturnist also respond to codes for critical care patients, so it’s an all-round performance that is needed in hospital care system at night.
Q: What are some of the most challenging situation you tackle as a nocturnist?
BB: Some of the challenging problems that I come across at night is hospitalization for drug overdose. Excessive consumption of alcohol and also drug overdose is common among young adults. Statistics shows that these rates are rapidly increasing. The toxic effects of excess consumption can be life threatening. Overdose of prescription drugs like opioids pain medication, sedatives, and tranquilizers can cause deaths. Often these people face communication problem due to language barrier. I have collaborative developed and utilized a digital innovation of an android mobile application Talk2All, which can translate numerous languages in real time and makes things easier for treatment. This app can help establish communication with the family members as well as the acutely confused patients, who are often inebriated. Rapid action is needed as drug poisoning can be deadly. By bringing in efficient communication, we have the ability to convert a potential law enforcement situation to one of a appropriate medical admission.
Q: We are informed on your innovation of voice iteration software in appropriate identification of an emergent health condition. Could you please elaborate on this and how it is useful to patient care in the hospital
BB: There is gender based disparity in how health emergency calls are placed to the first responders through 9-1-1. For example, a female subject would not be explicit in mentioning that she has frank chest pain arising out of an emergent acute MI. Using principles of deep learning and by feeding thousands of recorded calls to a system, the first responder would be alerted that the semantic content of the call likely resulted from a challenging health situation like heart attack. I took this step forward by incorporating a kind of unsupervised learning in a zero sum game framework, which has recently been used to generate novel pictures from pre-existing data. However, this iterative methodology, also called generative adversarial networks (GAN), finds utility in predicting the breathing patterns that is resulting from an impending heart attack. It is definitely a strong step forward in our current tools. From a nocturnist perspective, we can assess the incoming patient load right in the hospital by having a transcript of the voice and running it through the software.
Q: Thank you for this enlightening discussion.
BB: Thank you for having me.