Surviving a night in Medicine.

It snowed on Friday – in any sane country six inches of snow would merely be an aside to life. But obviously in the UK it all went to pot. Five mile drives to work were taking hours, nurses/midwives on the late shift couldn’t get home, the night shift couldn’t get in.

And the Doctor doing the night shift in medicine called in sick – so I get a call from medical staffing wondering if I could do the night shift. I agree because it looks like I’m going to be stranded at work anyway so I might as well be paid for it.

I finished on Labour Ward at 5.30pm and started as the Medical House Officer (or F1 as they’re now called), scrounged some food from an HCA’s leaving buffet.

I’ve realised I’m now quite good at surviving night shifts: here are my handy hints..

 Step one be prepared:

Usually you’ll get the day off before the night – unless you were on nights the night before it will be difficult to actually sleep but try and do as little as possible and have as long a lie in as you can.

This is my list of ‘night shift survival items’

• Food – plenty of snacks and a couple of sandwiches. A night shift is 13 hours – you wouldn’t do a 13 hour day shift without a break but how many doctors do a 13 hour night shift without any food or drink at all.
• Drink. I take several cans of Redbull and some bottles of other drinks. I try to take small re-seal-able bottles.
• Oxford Handbook of Clinical Medicine

I dump my food and drink under the computer I use to check blood results on – that way when I’m checking a patients blood results I can have a snack.

Step 2. Surviving the night.

In my hospital the medical admissions are referred by A and E or GPs and then sent to the medical admissions ward whilst they are waiting to be seen. At night the Doctors also cover the wards.

Avoiding stress.

Getting stressed is pointless, the more stressed you are the worse you will be at the job, keep your head when all about you are loosing there’s. All the sources of stress can be summarised as ‘lots to do and not enough time’.

Prioritise your emergency admissions.

There are two sorts of emergency admissions those that need your attention instantly and those that can wait. Patients from A and E have been seen by a doctor already so hopefully they don’t need instant attention – the A and E doctor will have given an idea of how quickly they need to be seen whilst you are admitting them. A GP patient has already been seen by an experienced doctor who has decided they need urgent medical treatment – so they may be more unstable.

The nurses will usually have assessed a patient and are often very experienced and will tell you if they’re worried about patient.  Sometimes you will get the hint that a particular Nurse or A and E doctor is an utter muppet so don’t always trust their assessment.

Every so often eyeball the ‘patients waiting list’ if you have a feeling one particularly nurse is not so experienced you should keep a closer eye on his or her patients.

Can you do a ‘quick fix – go back later’?

Not advisable but often possible – for instance in a patient who has taken a paracetamol overdose you can prescribe the N-Acetylcystine and then go back and talk about ‘how the feel’ later.

‘Ward problems’

Please prescribe some analgesia – if a ward is concerned that a patient is in pain then you can give a verbal prescription for analgesia and go and assess the pain later. Take a quick history from the ward and find out exactly what the pain is. Chest pain in a patient admitted with ‘angina’ needs you attention instantly’

‘Needs a venflon’

Find out what it’s for and can it wait. If it can’t it needs doing now. If it’s urgent it’s often a quick job. If you are very busy offer the ward a choice – find a nurse who can do it or the patient will have to wait.

‘Write up fluids’

If you don’t have time to go instantly then give an oral instruction and go when you are passing. Check there is  no history of heart disease and how much fluid they’ve had in the previous 24 hours. Then reassess the patient.

‘Angry relatives’

The longer you leave them the angrier they will get. Not a nice job and no one wants to do it, but often if you defuse the situation then you can prevent everyone spending hours over a formal complaint.

‘Patient wants to self discharge’

Really only a 10 minute job – are they competent,  explain the risks and give them a self discharge form.

If you are covering several wards then you might find it useful to do a ‘non-urgent round’ eg. ring up to tell them you are coming to do all the non-urgent jobs around midnight, give them a reminder 10 minutes before.

‘Sick Patient’

Obviously you are going to go – ask nursing staff to do ‘bloods, ECG, start fluids’ (all if appropriate) whilst you are going there.  Stay calm.

Cardiac Arrest.

Run, attempt to resuscitate, release it’s futile, fail, give up. Occasionally you might get one back.  If you get spontaneous output back then argue with ITU for a bed. No reason to panic at all.

Step 3 Stay awake.

Being awake makes you do your job better than being tired. You may not get time to sit down for 15 minutes and do nothing else but there are plenty of other ways to take a break.

‘Checking blood results’ Keep your supply of food and drink by the computer you most often use for blood results – and snack whilst checking them.

Walking to the ward’ You can eat or drink something on the way.

Writing in notes Most nurses stations will have some chocolates as gifts from patients around. Very useful food.

Know your ‘patients per RedBull’ rate. I need one can of Red Bull per 5 or so patients on a night shift. Incidently the adrenaline from running for a crash call is equal to 1 Redbull.

Join in a ‘takeaway order’ Often nurses will order a take away together – get something for yourself as well. It may be cold by the time you eat it.

Always have a Redbull before the post-take ward round so you can stay alert and cheerful in the face of consultants.

If all else fails you may have to resort to ‘taking a break’. This is an unusal practice in Medicine but it’s sometimes needed. Once you have decided to take a short break (about 15 minutes) remember there are only two things that can interupt you.

1. Patient about to arrest
2. Patient who has arrested

And finally…

Stay for the post take ward round – so you can learn. So what if you don’t get paid for it- it’s for your own good.