Night shifts in medicine
Everyone hates night shifts! I was terrified of them when I started because I had "heard" and "read" that doctors are not supported. With time and experience, I realized how much I learnt on nights and then started enjoying them. Now, I actually look forward to my nights.
I am going to share some tips here which may help.
MY ROUTINE BEFORE MY FIRST NIGHT SHIFT:
Altering your natural sleep cycle is very difficult. I found these things which were helpful
- I wake up at 0730 AM - 0800 AM on the day of my night shift.
- I do not have coffee/tea.
- I go out of the house and roam about , have lunch (non caffeinated drinks)
- I come back at around 1 PM
- I go to sleep at around 1400. I have thick curtains in my bedroom so the daylight does not bother me ( You can also consider black out curtains which are even better).
- I wake up at 1800
- I have dinner and then coffee (I always have black coffee in the morning, which I skip on my nights and have after dinner).
- I take a shower and then leave the house 30 -45 min before my night shift starts.
Avoid:
- Binge watching on the day before your night shift. It will tire your eyes, stimulate your brain and prevent you from sleeping those essential 3 to 6 hours before nights.
-Any caffeinated drinks ( cola, tea, energy drinks) till you are about to start.
- Worrying about under-staffing, how you will manage without your favorite ward team whom you are used to, what will happen if no one turns up and you, as a junior doctor are made the registrar. It will not happen.
SLEEP CYCLE THEREAFTER:
I come home at around 9 AM and have taking a warm shower, go to bed at 1000 AM. I wake up at 1800 and I am completely fresh. Some people cannot sleep for 8 hours post nights like I do. However I avoid a lot of caffeine overnight even when I am on call ( unless I am very tired- which is very rare).
AFTER MY LAST NIGHT SHIFT:
I come home and sleep by 1000 AM and try to wake up at 1500. Although I am very groggy and disorientated, I try not to sleep till 11 PM and then wake up the following morning at 0730 AM and hence my sleep cycle is set this way. I avoid caffeinated drinks the whole day ( which is very difficult- I am used to my morning black coffee). This is a good day to waste your time binge watching though. I avoid driving or going out as I am a bit disorientated.
MY NIGHT SHIFTS AS A SHO ( January 2016 to July, 2019):
I was put on the on call rota 6 months into my first job in the NHS. I was, like everyone else very scared. However I realized how much support I had. These is the team on nights:
1. HCAs
2. Nurses
3. Clinical support - these are HCAs who can do bloods, cannulas, ECGs, catheters.
4. ACPs - These are nurses who are independent prescribers, can clerk patients, do A to E assessments. They are usually based in ED on nights but you may see them on the wards ( more during the day though).
5. Clinical outreach team - This includes an excellent nurse who can do all of the above plus act as a bridge between the medical team and ITU. When a patient is unwell on the ward, these nurses are called as well as the junior doctor/registrar.
6. FY1s - They are based on the ward seeing sick patients, doing urgent jobs, etc.
Their role and you, as a SHO can help them is explained here:
How to support your foundation doctors:https://omarsguidelines.blogspot.com/2018/11/how-to-support-your-foundation-doctors.html
7. SHOs - there may be one SHO for clerking and one on the ward or just 2 on clerking depending on how busy it is. There can be up to 10 SHOs if it is a busy tertiary hospital.
Their role has been explained here:
My guideline for on calls:http://omarsguidelines.blogspot.co.uk/2017/05/guideline-for-on-calls.html
8. Medical registrar - Sees sick patients not only in medicine, but also in ED resus, takes calls from GPs, other specialties and helps clerk patients.
9. ITU team - on call ITU registrar who is on site and an ITU consultant who is available for advice on the phone.
10. Medical consultant - who is available for advice on the phone.
11. Other specialties - surgery ( they have their own team of FY1s, SHOs and registrars), PAEDS ( similar to medicine)
12. Out of hours service - on call radiologist to accept urgent out of hours requests, microbiologist/hematologist/cardiologist/renal physician/neurologist( some tertiary hospital have a 24/7 service for these specialties as well ).
13.Bed managers - who help with admissions and patient flow. In some hospitals, they act as a "hospital at night in-charge" whereby all wards bleep them and then they prioritize jobs for the on call team making everyone's life very easy
As you can see, this is a huge team. This team is there to support you. When I realized this, I was more relaxed.
MY TIPS FOR FY1s and SHOs ON NIGHTS:
- Sleep well as mentioned above
HANDOVER
- Come a few minutes early ( 10 minutes is fine). Grab 2 sheets of paper to jot down the details of the patients you are handed over.
- Listen carefully when the patients are handed over. Remember, you will either be covering wards or clerking and hence you DO NOT need to know about both.
- This is what I usually write down:
Name, bed number, ward
Admitted with
Current active issues
Escalation status
Any outstanding jobs I need to chase ( make boxes which you can fill as you go along as this way, you will remember what is left).
PRIORITIZE!
This is very important. You are on call. Ideally, you should have a 'hospital at night system' whereby bleeps are filtered. If this is not the case, then request the bleeping ward to make a list of jobs for you so that when you go, you can sort everything out and they do not have to bleep you again unless a patient is unwell..
See the sick patients first. That IV fluid which still has 3 hours to go can wait but a patient EWSing at 8 needs your attention first.
ASSESSING SICK PATIENTS
Know your limits. If you are bleeped to review a patient scoring at 12 and was previously fine, ask the nurse to bleep the medical registrar and critical care team. Go to assess the patient immediately - always follow an A to E assessment and do the basics ( ABG, CXR, IV access, bloods, sepsis screen, catheter, ECG). You will realize how easy managing acutely unwell patients is - but always ESCALATE! You have got a team with you for this very reason. But also, please do not shy away from assessing sick patients either. You will soon become confident enough to manage them ( under supervision) soon.
BREAK
Remember, if you do not take care of yourself, then no one will. Be kind to yourself and give yourself regular breaks. Have food no matter how busy it is. I have seen doctors faint because of hypoglycaemia. It is not a pleasant sight.
Bring food and put it in the fridge in the doctors room. If you do not feel like cooking, you can easily get ready to heat meals from your local grocery store.
If possible, take a nap for 30 minutes ( some people cannot do this as they feel more sleepy). Washing your face with cold water often helps after you have taken a short nap.
SUPPORT YOUR JUNIOR COLLEAGUES
This is an excellent opportunity for you, as a SHO to develop your leadership skills by supporting your FY1. I have mentioned some tips here:https://omarsguidelines.blogspot.com/2018/11/how-to-support-your-foundation-doctors.html
SOCIALIZE
When you are relatively free, the clerking board is clear and the ward is stable, go sit with the nurses. They are very friendly. I remember getting food delivered and then chatting with them on a regular basis when I was free on nights ( which was quite rare to be honest). I am still close friends with them and they supported me throughout my placements.
ASSESSMENTS
Ask your registrars to do assessments for CBDs, DOPs, MSFs, TABs, mini- CEXs, etc. You discuss cases with them all the time ( that is a CBD), if they have observed you do a procedure ( ABG, NGT, LP, drain) then send them a ticket for DOPS and so on. I have explained these assessments in detail here:
Maintaining your e-portfoliohttp://omarsguidelines.blogspot.co.uk/2017/03/maintaining-your-e-portfolio.html
BE SAFE
That lumbar puncture to rule out subarachanoid hemorrhage can wait till the morning. Do not do such procedures unless the consultant/registrar has clearly said that it needs to be done overnight ( if you are suspecting meningitis, then a LP ASAP is preferred).
The same goes for ascitic drains and chest drains ( for pleural effusions).
AS A REGISTRAR
All of the above apply.
LEADERSHIP AND CARING FOR YOUR TEAM
However I feel that it is very important to be a good leader and ensure that your team is fed, watered and has rested.
Personally, I have been in this for 3 years ( 18 months as a non trainee SHO, 2 years as a core trainee and now as a registrar since August, 2019) and I can recognize when I need a break and will find an opportunity to re-energize myself. However, my junior colleagues may not be this experienced and may not recognize when they are tired, hypoglycemic and are overwhelmed.
HOW CAN YOU, AS A REGISTRAR MAKE THINGS BETTER FOR THE NIGHT TEAM.
COMMUNICATION
Make a WhatsApp on call group. The on call team can communicate with each other, you can keep asking them if they are doing okay, if they need any help. Keep reminding them to take breaks.
When you meet them face to face during your shift, keep asking them if they are okay.
They have my mobile number and hence call me directly to discuss cases rather than waiting for me to answer my bleep.
HANDOVER
Ensure you take a detailed handover of any unwell patient from the day team. Usually the handover which starts at night is led by the day registrar.
Quickly skim through the electronic EWS charts of patients on AMU, ED, CCU, Oncology ward, gastro wards when you are about to start your shift and ask if the day registrar knows about these patients ( if he/she does not, then you should see them ASAP).
Ask the day juniors if they know of any sick ones.
Ensure that clinical outreach and the bed managers do not have any concerns.
DELEGATING TASKS TO THE NIGHT TEAM
Usually, they already have designated roles on the rota. But sometimes, there are 2 SHOs and 1 FY1 and it is up to the registrar to decide what he/she wants them to do. I usually ask the FY1 in private first . I ask them what they would be comfortable with and if the clerking board is not too busy, if they are keen I ask them to clerk patients. However I prefer that a SHO clerks and the FY1 and other SHO cover the wards.
SEEING SICK PATIENTS
Once you have written down the details of sick patients, prioritize.
I usually see the sick ones on the wards first. The sick ones in ED would continue to be managed by the ED team and hence, they can wait UNLESS they are waiting for the medical registrar to make a decision.
CLERKING
Help If you are on the clerking shift, clerk patients. It will be busy on the wards but when you have seen all the sick patients, help the clerking team.
Sit in ED. This is where patients are admitted to medicine. You can discuss cases with them directly and hence decide for them what the initial management should be and whether the patients need to come in - remember, sometimes at night the ED team does not have a consultant or may have locum senior doctors who may not know the system well.
I personally just stay in ED if the wards are stable, clerk patients directly, see the sick ones in ED resus immediately. I also try to get regular handovers from the ED nurse in charge about any "potential medical admissions" so that I can pick them early.
I am now on excellent terms with the whole ED team and given that I am a new registrar, they assist me in managing unwell patients.
I understand that a lot of registrars do not like doing this as "ED then refers everyone to medicine" but actually it is the other way around - you can make a decision there and then and prevent inappropriate admissions.
BED MANAGEMENT
You may have heard registrars complain about this. But personally, I really enjoy doing this ( I really enjoy the management part of the NHS). I always ask the bed managers how many empty beds there are when we do our handovers to get an idea of ITU, CCU, HDU, AMU bed capacity.
They bleep me at 0200 AM to identify patients in AMU who are safe to be moved to the other ward and I ask them to request the nurse in charge to identify them rather than me going through the notes of 30 patients. The AMU nurse in charge knows the patients well anyway. It takes a few seconds for her/him to identify such patients and then I go through the EWS score, notes and then decide whether it is appropriate or not.
BE SMART
You, as a registrar need to take care of yourself as well. You cannot do everything but you can delegate and prioritize. This comes with experience and my experience as a SHO helped me a lot. I still have a long way to go but I have learnt how "not to get involved in everything"
For example, the FY1 calls me to see a patient EWSing at 9, which is new.
I will ask him/her to start doing the necessary investigations ( ABG, bloods, portable CXR, ECG), I will ask him to request the nurse to bleep the other SHO and critical care outreach nurse ( if the patient is for full escalation) and go to see the patient. By the time I get there, some of these tasks have already been done and I help with the rest ( some FY1s may struggle with cannulas, ABGs so I do them if that is the case).
I then go through the notes and do a S-B-A-R and A-B-C-D-E assessment. I have explained these terms here:
https://omarsguidelines.blogspot.com/2019/08/my-first-week-as-medical-registrar-ward.html
I then make a full proper plan.
An unwell patient has 3 options:
1. Treat on the ward for now - monitor OBS every hour.
2. Transfer to ITU
3. Discuss escalation with the patient/family/NOK and put a DNAR, decide about ceiling of care ( ward based vs NIV/CPAP as ceiling vs ITU for inotropic support vs palliation).
This decision comes with experience and with assistance of the ITU team.
ESCALATE
You always have the medical consultant to escalate to. I have rang the medical consultant at 0300 AM at least thrice in my first one month as a registrar. You, even as a registrar sometimes need help from your immediate senior ( who is the medical consultant on call).
In some situations, the ITU team wants me to let the medical consultant know about a ward patient they are taking to ITU.
OTHER SPECIALTIES
You will always get a bleep from ortho about an unwell patient on the ward. And unfortunately, there is sometimes just a FY1 dealing with the patient while the registrar/SHO are in theatre. You must assess these patients ASAP. The FY1 cannot deal on their own. I usually give them a list of things to do, request them to call the critical care outreach nurse as well so that they have extra support and see the patient. Usually, it is an elderly patient with a NOF who has now developed a HAP/PE. If the FY1 is on their own, I help them make a decision about escalation where appropriate however I always bleep the registrar of that specialty and ask them to come and assist me since the patient is under their care.
OUT OF HOURS CALLS
You, as a registrar will get a call from an out of hours GP for a patient they would like to discuss. They have assessed the patient and you are relying on their information. If you are unsure, ask them to send the patient to hospital. Do not risk your GMC license by being bold and saying that there is no need to send a patient whom you have not assessed yourself. Because the GP will just document " Discussed with medical registrar on call at .... , name... GMC number.... , Hx, Ix noted. Advised not for admission" If the patient becomes acutely unwell or worse case scenario, dies it will all come down on you.
LOG BOOK
Try to maintain your logbook of patients you have seen. I keep a word document in my hospitals computer on my personal drive with these patients details so that I can go through them later on just to see if my management was appropriate.
Do not forget to update your e-portfolio!
AT THE END OF YOUR SHIFT
Thank your team, especially the FY1 who runs around the whole hospital the whole night and ask them to send any assessments ( CBDs, MSFs, DOPs, TABs for whatever they discussed with you/you observed them do)
Overall, night shifts are tiring but they are fun. As a SHO, you get to see sick patients and can build your leadership skills by assisting your FY1 and as a registrar, you make decisions which help you become a good consultant.
I have written this blog after 1 month of working as a registrar and I am sure I have loads to learn and add to this. If you have any suggestions, please comment below.
I am going to share some tips here which may help.
MY ROUTINE BEFORE MY FIRST NIGHT SHIFT:
Altering your natural sleep cycle is very difficult. I found these things which were helpful
- I wake up at 0730 AM - 0800 AM on the day of my night shift.
- I do not have coffee/tea.
- I go out of the house and roam about , have lunch (non caffeinated drinks)
- I come back at around 1 PM
- I go to sleep at around 1400. I have thick curtains in my bedroom so the daylight does not bother me ( You can also consider black out curtains which are even better).
- I wake up at 1800
- I have dinner and then coffee (I always have black coffee in the morning, which I skip on my nights and have after dinner).
- I take a shower and then leave the house 30 -45 min before my night shift starts.
Avoid:
- Binge watching on the day before your night shift. It will tire your eyes, stimulate your brain and prevent you from sleeping those essential 3 to 6 hours before nights.
-Any caffeinated drinks ( cola, tea, energy drinks) till you are about to start.
- Worrying about under-staffing, how you will manage without your favorite ward team whom you are used to, what will happen if no one turns up and you, as a junior doctor are made the registrar. It will not happen.
SLEEP CYCLE THEREAFTER:
I come home at around 9 AM and have taking a warm shower, go to bed at 1000 AM. I wake up at 1800 and I am completely fresh. Some people cannot sleep for 8 hours post nights like I do. However I avoid a lot of caffeine overnight even when I am on call ( unless I am very tired- which is very rare).
AFTER MY LAST NIGHT SHIFT:
I come home and sleep by 1000 AM and try to wake up at 1500. Although I am very groggy and disorientated, I try not to sleep till 11 PM and then wake up the following morning at 0730 AM and hence my sleep cycle is set this way. I avoid caffeinated drinks the whole day ( which is very difficult- I am used to my morning black coffee). This is a good day to waste your time binge watching though. I avoid driving or going out as I am a bit disorientated.
MY NIGHT SHIFTS AS A SHO ( January 2016 to July, 2019):
I was put on the on call rota 6 months into my first job in the NHS. I was, like everyone else very scared. However I realized how much support I had. These is the team on nights:
1. HCAs
2. Nurses
3. Clinical support - these are HCAs who can do bloods, cannulas, ECGs, catheters.
4. ACPs - These are nurses who are independent prescribers, can clerk patients, do A to E assessments. They are usually based in ED on nights but you may see them on the wards ( more during the day though).
5. Clinical outreach team - This includes an excellent nurse who can do all of the above plus act as a bridge between the medical team and ITU. When a patient is unwell on the ward, these nurses are called as well as the junior doctor/registrar.
6. FY1s - They are based on the ward seeing sick patients, doing urgent jobs, etc.
Their role and you, as a SHO can help them is explained here:
How to support your foundation doctors:https://omarsguidelines.blogspot.com/2018/11/how-to-support-your-foundation-doctors.html
7. SHOs - there may be one SHO for clerking and one on the ward or just 2 on clerking depending on how busy it is. There can be up to 10 SHOs if it is a busy tertiary hospital.
Their role has been explained here:
My guideline for on calls:http://omarsguidelines.blogspot.co.uk/2017/05/guideline-for-on-calls.html
8. Medical registrar - Sees sick patients not only in medicine, but also in ED resus, takes calls from GPs, other specialties and helps clerk patients.
9. ITU team - on call ITU registrar who is on site and an ITU consultant who is available for advice on the phone.
10. Medical consultant - who is available for advice on the phone.
11. Other specialties - surgery ( they have their own team of FY1s, SHOs and registrars), PAEDS ( similar to medicine)
12. Out of hours service - on call radiologist to accept urgent out of hours requests, microbiologist/hematologist/cardiologist/renal physician/neurologist( some tertiary hospital have a 24/7 service for these specialties as well ).
13.Bed managers - who help with admissions and patient flow. In some hospitals, they act as a "hospital at night in-charge" whereby all wards bleep them and then they prioritize jobs for the on call team making everyone's life very easy
As you can see, this is a huge team. This team is there to support you. When I realized this, I was more relaxed.
MY TIPS FOR FY1s and SHOs ON NIGHTS:
- Sleep well as mentioned above
HANDOVER
- Come a few minutes early ( 10 minutes is fine). Grab 2 sheets of paper to jot down the details of the patients you are handed over.
- Listen carefully when the patients are handed over. Remember, you will either be covering wards or clerking and hence you DO NOT need to know about both.
- This is what I usually write down:
Name, bed number, ward
Admitted with
Current active issues
Escalation status
Any outstanding jobs I need to chase ( make boxes which you can fill as you go along as this way, you will remember what is left).
PRIORITIZE!
This is very important. You are on call. Ideally, you should have a 'hospital at night system' whereby bleeps are filtered. If this is not the case, then request the bleeping ward to make a list of jobs for you so that when you go, you can sort everything out and they do not have to bleep you again unless a patient is unwell..
See the sick patients first. That IV fluid which still has 3 hours to go can wait but a patient EWSing at 8 needs your attention first.
ASSESSING SICK PATIENTS
Know your limits. If you are bleeped to review a patient scoring at 12 and was previously fine, ask the nurse to bleep the medical registrar and critical care team. Go to assess the patient immediately - always follow an A to E assessment and do the basics ( ABG, CXR, IV access, bloods, sepsis screen, catheter, ECG). You will realize how easy managing acutely unwell patients is - but always ESCALATE! You have got a team with you for this very reason. But also, please do not shy away from assessing sick patients either. You will soon become confident enough to manage them ( under supervision) soon.
BREAK
Remember, if you do not take care of yourself, then no one will. Be kind to yourself and give yourself regular breaks. Have food no matter how busy it is. I have seen doctors faint because of hypoglycaemia. It is not a pleasant sight.
Bring food and put it in the fridge in the doctors room. If you do not feel like cooking, you can easily get ready to heat meals from your local grocery store.
If possible, take a nap for 30 minutes ( some people cannot do this as they feel more sleepy). Washing your face with cold water often helps after you have taken a short nap.
SUPPORT YOUR JUNIOR COLLEAGUES
This is an excellent opportunity for you, as a SHO to develop your leadership skills by supporting your FY1. I have mentioned some tips here:https://omarsguidelines.blogspot.com/2018/11/how-to-support-your-foundation-doctors.html
SOCIALIZE
When you are relatively free, the clerking board is clear and the ward is stable, go sit with the nurses. They are very friendly. I remember getting food delivered and then chatting with them on a regular basis when I was free on nights ( which was quite rare to be honest). I am still close friends with them and they supported me throughout my placements.
ASSESSMENTS
Ask your registrars to do assessments for CBDs, DOPs, MSFs, TABs, mini- CEXs, etc. You discuss cases with them all the time ( that is a CBD), if they have observed you do a procedure ( ABG, NGT, LP, drain) then send them a ticket for DOPS and so on. I have explained these assessments in detail here:
Maintaining your e-portfoliohttp://omarsguidelines.blogspot.co.uk/2017/03/maintaining-your-e-portfolio.html
BE SAFE
That lumbar puncture to rule out subarachanoid hemorrhage can wait till the morning. Do not do such procedures unless the consultant/registrar has clearly said that it needs to be done overnight ( if you are suspecting meningitis, then a LP ASAP is preferred).
The same goes for ascitic drains and chest drains ( for pleural effusions).
AS A REGISTRAR
All of the above apply.
LEADERSHIP AND CARING FOR YOUR TEAM
However I feel that it is very important to be a good leader and ensure that your team is fed, watered and has rested.
Personally, I have been in this for 3 years ( 18 months as a non trainee SHO, 2 years as a core trainee and now as a registrar since August, 2019) and I can recognize when I need a break and will find an opportunity to re-energize myself. However, my junior colleagues may not be this experienced and may not recognize when they are tired, hypoglycemic and are overwhelmed.
HOW CAN YOU, AS A REGISTRAR MAKE THINGS BETTER FOR THE NIGHT TEAM.
COMMUNICATION
Make a WhatsApp on call group. The on call team can communicate with each other, you can keep asking them if they are doing okay, if they need any help. Keep reminding them to take breaks.
When you meet them face to face during your shift, keep asking them if they are okay.
They have my mobile number and hence call me directly to discuss cases rather than waiting for me to answer my bleep.
HANDOVER
Ensure you take a detailed handover of any unwell patient from the day team. Usually the handover which starts at night is led by the day registrar.
Quickly skim through the electronic EWS charts of patients on AMU, ED, CCU, Oncology ward, gastro wards when you are about to start your shift and ask if the day registrar knows about these patients ( if he/she does not, then you should see them ASAP).
Ask the day juniors if they know of any sick ones.
Ensure that clinical outreach and the bed managers do not have any concerns.
DELEGATING TASKS TO THE NIGHT TEAM
Usually, they already have designated roles on the rota. But sometimes, there are 2 SHOs and 1 FY1 and it is up to the registrar to decide what he/she wants them to do. I usually ask the FY1 in private first . I ask them what they would be comfortable with and if the clerking board is not too busy, if they are keen I ask them to clerk patients. However I prefer that a SHO clerks and the FY1 and other SHO cover the wards.
SEEING SICK PATIENTS
Once you have written down the details of sick patients, prioritize.
I usually see the sick ones on the wards first. The sick ones in ED would continue to be managed by the ED team and hence, they can wait UNLESS they are waiting for the medical registrar to make a decision.
CLERKING
Help If you are on the clerking shift, clerk patients. It will be busy on the wards but when you have seen all the sick patients, help the clerking team.
Sit in ED. This is where patients are admitted to medicine. You can discuss cases with them directly and hence decide for them what the initial management should be and whether the patients need to come in - remember, sometimes at night the ED team does not have a consultant or may have locum senior doctors who may not know the system well.
I personally just stay in ED if the wards are stable, clerk patients directly, see the sick ones in ED resus immediately. I also try to get regular handovers from the ED nurse in charge about any "potential medical admissions" so that I can pick them early.
I am now on excellent terms with the whole ED team and given that I am a new registrar, they assist me in managing unwell patients.
I understand that a lot of registrars do not like doing this as "ED then refers everyone to medicine" but actually it is the other way around - you can make a decision there and then and prevent inappropriate admissions.
BED MANAGEMENT
You may have heard registrars complain about this. But personally, I really enjoy doing this ( I really enjoy the management part of the NHS). I always ask the bed managers how many empty beds there are when we do our handovers to get an idea of ITU, CCU, HDU, AMU bed capacity.
They bleep me at 0200 AM to identify patients in AMU who are safe to be moved to the other ward and I ask them to request the nurse in charge to identify them rather than me going through the notes of 30 patients. The AMU nurse in charge knows the patients well anyway. It takes a few seconds for her/him to identify such patients and then I go through the EWS score, notes and then decide whether it is appropriate or not.
BE SMART
You, as a registrar need to take care of yourself as well. You cannot do everything but you can delegate and prioritize. This comes with experience and my experience as a SHO helped me a lot. I still have a long way to go but I have learnt how "not to get involved in everything"
For example, the FY1 calls me to see a patient EWSing at 9, which is new.
I will ask him/her to start doing the necessary investigations ( ABG, bloods, portable CXR, ECG), I will ask him to request the nurse to bleep the other SHO and critical care outreach nurse ( if the patient is for full escalation) and go to see the patient. By the time I get there, some of these tasks have already been done and I help with the rest ( some FY1s may struggle with cannulas, ABGs so I do them if that is the case).
I then go through the notes and do a S-B-A-R and A-B-C-D-E assessment. I have explained these terms here:
https://omarsguidelines.blogspot.com/2019/08/my-first-week-as-medical-registrar-ward.html
I then make a full proper plan.
An unwell patient has 3 options:
1. Treat on the ward for now - monitor OBS every hour.
2. Transfer to ITU
3. Discuss escalation with the patient/family/NOK and put a DNAR, decide about ceiling of care ( ward based vs NIV/CPAP as ceiling vs ITU for inotropic support vs palliation).
This decision comes with experience and with assistance of the ITU team.
ESCALATE
You always have the medical consultant to escalate to. I have rang the medical consultant at 0300 AM at least thrice in my first one month as a registrar. You, even as a registrar sometimes need help from your immediate senior ( who is the medical consultant on call).
In some situations, the ITU team wants me to let the medical consultant know about a ward patient they are taking to ITU.
OTHER SPECIALTIES
You will always get a bleep from ortho about an unwell patient on the ward. And unfortunately, there is sometimes just a FY1 dealing with the patient while the registrar/SHO are in theatre. You must assess these patients ASAP. The FY1 cannot deal on their own. I usually give them a list of things to do, request them to call the critical care outreach nurse as well so that they have extra support and see the patient. Usually, it is an elderly patient with a NOF who has now developed a HAP/PE. If the FY1 is on their own, I help them make a decision about escalation where appropriate however I always bleep the registrar of that specialty and ask them to come and assist me since the patient is under their care.
OUT OF HOURS CALLS
You, as a registrar will get a call from an out of hours GP for a patient they would like to discuss. They have assessed the patient and you are relying on their information. If you are unsure, ask them to send the patient to hospital. Do not risk your GMC license by being bold and saying that there is no need to send a patient whom you have not assessed yourself. Because the GP will just document " Discussed with medical registrar on call at .... , name... GMC number.... , Hx, Ix noted. Advised not for admission" If the patient becomes acutely unwell or worse case scenario, dies it will all come down on you.
LOG BOOK
Try to maintain your logbook of patients you have seen. I keep a word document in my hospitals computer on my personal drive with these patients details so that I can go through them later on just to see if my management was appropriate.
Do not forget to update your e-portfolio!
AT THE END OF YOUR SHIFT
Thank your team, especially the FY1 who runs around the whole hospital the whole night and ask them to send any assessments ( CBDs, MSFs, DOPs, TABs for whatever they discussed with you/you observed them do)
Overall, night shifts are tiring but they are fun. As a SHO, you get to see sick patients and can build your leadership skills by assisting your FY1 and as a registrar, you make decisions which help you become a good consultant.
I have written this blog after 1 month of working as a registrar and I am sure I have loads to learn and add to this. If you have any suggestions, please comment below.
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