Surviving Nightshifts - for the House Officers
Congratulations! You have survived a gruelling 2 weeks of tagging and never seeing the sun. You should, by now, understand :
- the workflow of the ward, your bosses, your colleagues and your Most Valuable Players (MVP)
- know your strengths and weaknesses
- identify gaps in your knowledge and strive to improve them
You cannot expect to cure or treat a patient overnight. You can make sure they remain stable and comfortable until more services are available on the next day. So how do you start?
1. Create your mental workflow
Know when to arrive at work. Anticipate the number of unstable patients and the time it takes for you to review your patients. Your plan to come early may be offset by the need to attend something urgently, but for the most part, you did your best, nobody is going to hold it up against you. - To fail to plan is a plan to fail.
Ask questions when you receive Passovers. What happened to the patient, what has been done and what is/are the definitive plans for the patient? Who should you watch out for? What are the patient's expectations for today?
When you start clerking a new patient, know what the patient needs. Traced INVESTIGATIONS, endorsed MEDICATIONS, presenting complaints, all the other background history and examination we all learnt in medical school. Practice it often so that you can do it fast. Nobody likes staying up all night clerking new patients when you could have taken all the coming morning bloods and hitting the sack.
2. Teamwork and blood taking
You CANNOT WORK ALONE. Especially at night. Discuss with your colleague and delegate tasks among yourselves. Most importantly, do not be too calculative. Just because your task was straightforward and theirs was complicated doesn't mean you can sleep early. Lend a hand, so that when the time comes, you get a hand in return. You should apply teamwork for everything else here.
3. Oncall reviews and existing patients
Acute cubicles. Know which patient needs special attention. If possible, quickly walk through rows of cubicles to quickly identify problematic patients. Gasping, grimacing, unresponsive, the "very well patient", the concerned family member, etc. A stable patient will USUALLY look calm and well versed with their condition when you speak to them.
When you review a patient, (especially in the acute cubicle), TAKE NOTE of their current issue and their vitals. Your job during the nightshift is to correct the "straying" patient back to baseline, make sure everything is as physiological as possible throughout the night. Many things can happen at night, variations in blood pressure, the patient goes to sleep (hence blood sugar drops when they stop eating), daytime analgesia wears off, oxygen port unplugged (accidentally, and also the most annoying). Tweak your brain and handle everything, case by case.
Medical patients require a little understanding of their underlying conditions and their current problems of admission. Most of the acute problems you face can be rectified with simple measures. You DO NOT need to inform anyone because YOU are a DOCTOR. For example, if you encounter a sick patient, obtain VITALS and glucose first! If you suspect sepsis, apply the sepsis 6 bundle. If you think it is a cardiac problem, apply ACLS! After taking measures, THEN only you should update someone superior.
Surgical patients are USUALLY no brainer. They are USUALLY either bleeding out, grimacing in pain or their vitals are super unstable. You will need to refer to your BLS (very least) and inform. New patients will have to be OPTIMISED before their surgery. So you will need to make sure everything is in check! If there is anything MAJOR, surgical patients will require stabilisation and then a move to the operating theatre. All in all, they need to be OPTIMISED, ie, glucose, blood pressure, oxygen sats, etc.
The more you do, the more you will learn to correctly identify patients with pertinent issues you need to bring up to your senior team members.
4. Attention to the "Special patient"
The Haemodynamically unstable patient. - ACLS, ATLS
The Desaturating patient. - double-check if oxygen ports are plugged in, monitors are working!
The Dengue patient. - Underestimated. Keep all eyes on them and take your bloods on time! Refer to CPG below.
Postoperative patient. - Vitals, vitals, vitals! Review the intraoperative notes and plans. Glance over once in a while.
Ventilated patient.
There are many videos online about ventilation. Most of the time you need experience with the settings. Correlate ABG readings with the clinical status of the patient. Sometimes the tube gets blocked, often in general wards when frequent suctioning is required. Most of the time suctioning will solve the problem, the worst-case scenario you might have to change the tube, which I do not recommend if you are not familiar. If you are not familiar with anything, call the Anaesthesiology team. They are the airway experts.
Delirious patient.
Know the types of delirium. Know what drugs you CANNOT give in some conditions. Most often there IS a precipitating organic cause. (Infection, surgery, trauma or any acute stress state). Address the cause, REASSURE family members. If violence breaks out, contact the psychiatry team. Restrain yourself from restraining the patient.
5. When to sleep?
Suck it up and assume you don't. I only take a nap if you really can afford the time.
6. It's morning!
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