Midnight Medicine: A Psychiatric Mental Health Nurse Practitioner (PMHNP) in Consultation-Liaison Psychiatry After Dark

By Dr. Starr Montalvo, DNP, PMHNP-BC

Introduction

Night Shift Notes: Consultation-Liaison Psychiatry doesn’t sleep, and neither do the psychiatric complexities of medically ill patients. As the PMHNP nocturnist on overnight duty, I’m the bridge between psychiatry and the rest of the hospital, covering everything from delirium, capacity to suicidal ideation.

5:45 PM – The Calm Before the ChaosI clock in as the sun sets. Most of the hospital is winding down, but for the night shift, we’re just getting started. My pagers are clipped, phones by my side, and my tea is strong. I’m reviewing the consult list and the day team's handoff: ICU delirium, two new psych-oncology consults, and a behavioral crisis brewing in the ED and a new PMHNP student to precept. 

As we walk the units, I explain what makes CL-Psychiatry different from other psychiatric roles:

“In CL-Psychiatry, we’re not just treating mental illness, we’re treating the psychiatric consequences of medical complexity. We sit at the bedside of uncertainty.”

CL-Psychiatry is psychiatry without borders-we respond to mental health crises across every unit, from the ICU to the surgical floors. But here, in a cancer hospital, our CL work is deeply tied to psycho-oncology-caring for patients navigating the psychological toll of cancer diagnoses and treatment. The pager is quiet for now, but that never lasts.

6:30 PM – A Familiar Page

The pager breaks the silence: Room 522, “agitation, hallucinations, pulling lines.” I head to the ICU. The patient is tachycardic, sweating, flailing at unseen objects, trying to get out of bed, disoriented and combative. —classic delirium tremens, in a man admitted for pneumonia. I initiate haloperidol and lorazepam, collaborate with the primary team, and educate the nurse on the symptom-triggered withdrawal protocol.

C-L Psychiatry isn’t just psychiatric care, it’s rapid risk assessment, medical-psychiatric coordination, and clinical teaching, all at once.

7:20PM  " PACU (Post-Anesthesia Care Unit)- The History Hidden in the Handoff”

The page comes in-“PACU” consult – 42 year old female with breast Cancer and this recent surgery was part of an aggressive treatment protocol. History of Bipolar disorder, well-controlled on Lamotrigine 200 mg daily for over a year, but has recently missed multiple doses. Agitated post-op, trying to leave AMA. Please evaluate.”

This one’s a great teaching case,” I say, grabbing my coat. “Lamictal isn’t just a mood stabilizer—it’s a medication you never restart casually.”

We head down to the PACU. She was on Lamictal, but we don’t have it listed as given since she’s been NPO since surgery.” This isn't just post-op confusion. This is a convergence of psychiatric vulnerability, pharmacologic disruption, and oncologic trauma.

Last documented Lamictal dose: three days ago.“Why does that matter?” my student whispers, eyes on the screen. “Because Lamictal withdrawal doesn’t always mean seizures, it can also mean psychiatric destabilization. And if you go more than 3-4 days without it” I pause for effect. "-you can’t just restart it full dose. There’s a risk of Stevens-Johnson syndrome.”  We’ll need to re-titrate from 25 mg, slowly building back up. But we can support her now, maybe with a temporary antipsychotic to help settle agitation while her Lamictal ramps back up.

She nods, and I can see the gears turning.

This wasn’t just about psych symptoms—it was about safe medication reconciliation and comprehensive oncologic support. So we show up. We catch it. We teach. And when we teach students to notice what others overlook, we protect future patients too.

8:15 PM – Psycho-Oncology Call

The med-surg floor pages. A 32-year-old woman with a new AML diagnosis has stopped eating, refusing her medications and won’t speak to staff. When I arrive, she’s staring at the ceiling, hollow-eyed. I sit gently at her bedside. “I’m part of the psychiatry team,” I say. “We help people cope with what no one should have to go through alone.”

She is despondent and begins to open up slowly. She started speaking only after I stopped filling the space. Silence is a clinical tool. It’s not active suicidality, it’s paralyzing despair. We talk about fear, control, what it means when your body betrays you, the shock of being young and facing mortality. She’s not suicidal. She’s overwhelmed. I offer medication, but mostly I offer space, something even an oncology unit can overlook.

This is psycho-oncology at night. It’s not always about intervention. Sometimes it’s presence in a place where everything else feels uncertain.

10:30 PM – ED Consult: Passive Suicidal Ideation

Down in the emergency department, a man with end-stage liver disease tells his nurse, “I don’t care if I live anymore.” He’s tired of dialysis. The ED needs to know: is he suicidal? Or simply speaking the truth? His ammonia is elevated. Part of this is organic; part of it isn’t.

I assess him carefully. I assess capacity, suicide risk, and whether his wishes are rooted in hopelessness or distorted cognition. No plan, no intent, just a deep weariness. We talk about palliative options. I make recommendations for safety, supportive care, and psych follow-up in the morning. I page palliative care to discuss goals of care. I coordinate with the primary team and social work to ensure his voice doesn’t get lost in medical noise.

This is the ethical tightrope of CL-Psychiatry—honoring patient autonomy while ensuring safety.

12:30 AM – A Quiet Lull (Almost)

For about 45 minutes, the pager stays quiet. I chart. I breathe. I drink water. I check in with the nurse about our mutual psych patient on the surgical floor. Then the pager buzzes-its Room 812, Neurology ICU: "Patient screaming and trying to leave AMA."

1:00 AM – Behavioral Rapid Response

I walk into an emotionally charged scene—nurses trying to de-escalate. Agitation, confusion." We head up to find a cachectic man thrashing under the blankets, drenched in sweat and now bloody because hes pulled out IV access from both arms. His bladder is distended, but he’s refusing all care except from me. I glance at my student. “Sometimes in CL-Psych, we roll up our sleeves.” I steady him, then place an IV and ask the nurse to push the Ativan-“We cant give Haldol, he has Parkinson’s- I’ll explain later”. I glove up, grab the bladder scanner, and perform a quick check. Nearly a liter retained. A consult is placed for Urology. “Psychiatry doesn’t end at the chart,” I whisper. “Sometimes it starts at the bedside.”

2:00AM A Pause for Teaching

We find a moment of stillness in. I pull out a whiteboard and sketch the overlap between delirium, catatonia, and primary psychiatric illness.

We discuss Parkinson’s disease—how delirium in Parkinson’s often mimics psychosis, yet antipsychotics can worsen motor symptoms.

“In Parkinson’s,” I say, “we use quetiapine cautiously, and always check for infection, dehydration, or medication triggers before labeling it psychosis.”

She asks thoughtful questions about neurotransmitters. I show her a study on cholinergic deficits in delirium. We talk about what it means to be both a clinician and an educator.

2:30AM   Steroid Mania: Meds and Medicine Collide

The telemetry unit pages me about a young breast cancer patient who’s pacing and hyperverbal, convinced her IV is poisoned. Her chart indicates high-dose steroids post-chemo, a known risk factor for steroid-induced mania. “What do you think is going on here?” I ask my student. “Steroid-induced psychosis?” she suggests. I nod. We adjust her meds, holding the next dose of dexamethasone, and administer low-dose olanzapine to calm her. “Psychiatry helps with medication,” I say, “but we always have to remember that psychosis in medically complex patients can be part of a broader medical issue.”

3:00 AM – The Weirdest Hour-Charting, Reflections, and Resilience

This is when everything feels surreal. The hallways are dark. Machines beep rhythmically. I re-check my consult list, review imaging, labs and write notes. In between consults, I let my student write a draft of a progress note. We go over documentation—objective, focused, and legally sound, especially with capacity and risk cases.

Being a night shift PMHNP requires autonomy. You’re it. You make the decisions. You explain psychiatry to medicine, and medicine to psychiatry.

4:30AM – Teaching by Rounding/ Follow-Up on Catatonia Consult

I check in on a leukemia patient who is unresponsive, post-steroid therapy, with waxy flexibility and mutism following a prolonged post-op stay. The nurses suspect “psychosis,” but I suspect catatonia. I talk my student through the Bush-Francis Catatonia Rating Scale, and why early recognition matters. She watches closely as I perform a lorazepam challenge, 1 mg IV. Ten minutes later, the patient starts to speak in whispers.

“Catatonia isn’t just a psychiatric condition,” I explain. “It can occur in severe medical illness, and if missed, it can be fatal. My student nods, scribbling notes. “I’ll never forget that lorazepam test.”

6:00 AM – Shift ChangeThe pager is off. The sun is rising. I sign out to the day NP and head to my car, physically tired but emotionally alert. I’ve held space for grief, managed psychosis, prevented harm, and built bridges across disciplines.

Reflections from the Night

People often imagine psychiatric nurse practitioners working in quiet outpatient settings. But in Consultation-Liaison Psychiatry, especially overnight, our work is raw, urgent, and deeply human. We are responders, listeners, advocates, and educators. We bring the mind back into focus when the body is all anyone else sees. And in the darkest hours of night, we carry light, not always fixing, but always showing up.

CL-Psychiatry and psycho-oncology are specialties of nuance, grit, and empathy. As a Psychiatric-Mental Health Nurse Practitioner, I don’t just treat patients, I mentor the next generation of clinicians who will hold the line in hospitals long after my shift ends.

And the best way to protect that work? Teach it.