A day in the life of a medical registrar - on call
I am working as a trainee registrar ( ST3) in acute internal medicine in a District Hospital.
I am going to go through my day shifts and night shifts.
DAY SHIFTS ( 0830 to 2130)
WEEKEND
1. I wake up at 0630 AM , have breakfast and after a shower, leave by 0800 AM
2. I pick up any colleagues who are working with me on that day and arrive to work at around 0810 AM and go to the AMU doctors office where we have our handover.
3. I check my emails and get the admission e- board up on my computer ( we have an arrivals board which shows all the admissions from last night with their EWS score). I then have a general idea of what happened with the patient - in my trust, all patients are admitted via ED and usually the medical team clerks the patients in ED. The ED clerk then scans the clerking proforma onto the computer system prior to the patient being transferred to the medical ward ( and I can view them).
4. If there are any doctors from the night team, I ask them about any issues overnight. I do not ask for a lot of details as this would be discussed in the handover anyway however this allows me to go through their OBS, investigations overnight and I get an idea of what to expect.
5. I also check the list of patients on AMU and see the EWS charts ( we can see everything on the computer system and hence I do not have to go to any ward to check the notes, etc)
6. So before the actual handover I know about:
- Any sick patients admitted overnight
- Any sick patients on AMU.
7. We then do a handover led by the night registrar which starts at 0830 AM.
This is attended by :
*The night team
-2 SHOs
- 1 FY1
( 2 of whom are ward cover and one is on clerking and AMU cover )
- registrar
*The day team:
1 clerking doctor- FY1/FY2/IMT1 or non trainee/locum SHO
2 ward cover doctors
1 AMU discharge shift doctor who does the post take ward round with the post take consultant till 1700
Day registrar
Clinical outreach nurse
8. The handover starts with
Introductions
Any sick patients on the wards
Any sick patients on AMU
Any sick patients from the take overnight
Any ITU admissions from medicine
Any urgent jobs to do ( ie LPs, urgent scan requests, specialist opinions, etc)
Any other issues ( staffing, IT issues)
Then the doctors do their minor handovers to the respective doctor taking over which do not require any MDT input.
9. I write down the details handed over to me. For me, as a registrar this is what is important:https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html
Patients details ( 3 details: Name, DOB, NHS number)
Location
Escalation plan ( Full, DNAR, ward based, NIV/CPAP)
Active issues
What I need to do
10. I then thank the night team, we handover our bleeps and then I do a quick handover with the day team.
I delegate tasks and ask the clerking doctor to start clerking the stable patients ( I prefer to clerk the unwell patients myself- so we go through the arrivals board and decide which ones (s)he will be seeing. I expect a FY1 to clerk one patient in 1.5 hours and a SHO to clerk a patient in 1 hour and this gives me an idea of how many patients will be left to be seen by the time I have done my urgent jobs).
11. I make a WhatsApp group with the on call team ( after taking their consent). This way they are able to 'shout for help' early if they are getting overwhelmed with jobs.
12. I see which ones I need to see first. I usually discuss this with the critical care outreach nurse as she then knows what the main sick patients are and we make a provisional plan together ( ie, whether I need to set a ceiling of care, whether I need to involve the ITU reg early, whether we need to do an urgent ABG, etc).
13. If there are patients on AMU/ other wards I am about to see, I inform the ward junior that I will see them ( I personally do not find any point of 2 doctors going to see a patient especially when the ward cover shift is so busy for the FY1/SHO).
14. Once I have seen the sickest patients and made plans, I go to AMU and meet the consultant on call and check if there are any registrar level jobs to do ( ie LPs, to discuss any ceilings of care, etc). I introduce myself to the AMU nurses and ward clerk so that they know I am available in case they need anything.
15. I am usually done by 1000 AM and can now focus on clerking. If there are less than 3 patients on AMU who are stable, I request the clerking doctor to continue on AMU and I go to ED. I prefer to stay in ED and I am stationed there unless I have been called to see a sick patient on the ward.
16. I meet the ED consultant and nurse in charge and ask if I need to see anyone. I also ask these questions:
- Are there any sick patients they want me to see quickly?
- Are any potential discharges whom they are not sure about so that I can clerk them quickly, call the bed managers who can then ask the post take consultant to come to ED to make a decision IF I am unsure about them as well?
- Are there any patients who could go to ambulatory care?
17. I then go to ambulatory care ( which is right next to ED). If it is not covered by a medical registrar and there is a SHO there, I let them know that I am around to help and address any doubts they have. The ambulatory care unit out of hours is supported by the ED consultant however I try to help as much possible as the ED consultant can be very busy as well.
18. I start seeing the sick patients, potential discharges and I try to clerk them within 30 to 45 minutes. Some take less than that and some take more than an hour depending on how complicated they are.
19. My rule of clerking is that you should document everything as if you are going to show that documentation as evidence if you are in court- ie, detailed, your diagnosis and why the patient needs to stay in hospital.
20. I am very proactive with discussing ceilings of care so I try to have those discussions with frail patients with poor performance status actively. If they lack capacity, I call their families. I am very particular about this as I know that I will be leading the CRASH if they die in hospital and I will have to make a decision then which I could have made when I clerked them and had already developed a relationship with them.
21. I manage to see the sickest ones, the potential discharges, the potential transfers to ambulatory care by lunch time.
22. I then message on the WhatsApp group reminding everyone to have their breaks and ask if there are any issues.
23. After visiting AMU ( I always go there on a regular basis as I do not want to miss any sick patient ) and asking the nurse in charge, post take team if they need me, I go have lunch after ensuring that the clerking doctor is going for lunch as well.
24. By this time, another doctor who clerks from 1230 to 2100 has arrived ( known as the twilight shift). I delegate the patients to clerk to him/her and then head off for lunch at around 1245.
25. I come back by 1315 and quickly visit AMU, ensure the post take discharge consultant has given the post take doctor a break and then continue clerking in ED.
26. I visit ambulatory care every hour to ensure there are no issues. This way, I know if there are any empty spaces we can send patients from ED to ( cases like first trop negative chest pain which has completely resolved, frail patients with normal investigations who need OT/PT - we have a 'rapid assessment team' who are therapists working in ED and they expedite discharges from ED and avoid unnecessary admissions.
27. I continue clerking in ED. In my trust, the ED team has to fill out the medical clerking proforma and I prefer that they just fill out their ED forms and do a verbal handover to me. This has its advantages :
- I can suggest further investigations which the ED team can do
- I can suggest further treatment which the ED team can administer
- I get to decide whether they need to be admitted or can go to ambulatory care/ discharged from ED
- The ED team does not have spend extra 20 minutes filling out the clerking proforma and hence this saves their time.
- I get to teach them as well what I am looking for as a medical registrar and we discuss management of common medical emergencies.
- I can request them to involve ITU urgently/ transfer sick patients to our RESUS bay.
- It reduces my clerking time as well as I have already heard the story already ( I always ask the same questions to be double sure but this does save time regardless)
28. This way, I have now developed a very good relationship with the ED team. They know I am around and they know I am always willing to help. They also help me ( I have got unlimited access to their goodies - I am a choca-holic and the ED staff room always has some amazing chocolates) and they try to manage the medical patients as much as they can.
29. It gets exceptionally busy on the take after 6 PM so I try to be very vigilant and ensure the whole clerking team is working at full speed. I do not nag them but I also make sure that they are seeing patients at a reasonable pace ( sometimes I give them useful tips on how to speed up clerking:
https://omarsguidelines.blogspot.com/2019/08/how-to-clerk-medial-patients-safely-and.html ) but I never push anyone. Some people may be having a bad day and I do not try to judge them based on a single shift I have done with them. If I have noticed that they consistently lag, then I may sit with them and try to understand what is going on and assist them.
30. I also make sure that the consultant on call does not have to stay in till very late. We, as registrars not only have to take care of our junior colleagues but also the consultant on call. I try to get them to see any sick patients as soon as possible to avoid them staying late unnecessarily.
31.By the end of the shift, I have usually clerked 12 to 15 patients , seen 5 sick patients and ensured my colleagues and I have had a break. It has been around 6 months since I have become a registrar and there has not been a single shift in which I have missed a meal or my colleagues have not had a break.
32. I then go to the doctors handover room at 2030 and then tidy up any last minute jobs. The night team start arriving and we start our handover at 2100.
33. I then enter the NHS numbers of all the patients I have seen on a word document in my work computers drive so that I can reflect upon the cases I saw and managed later on, when they have been discharged.
34. I ask if any doctor needs a lift back ( I live in a small city and it is very convenient to drop people as long as they live in the same city- which most of them do)
On a good day, I do not handover any patients. There are a few waiting for ED cubicles in the corridors who have already been put on the clerking list but they are yet to be seen by the ED team first and they are usually stable are are managed by the ED team till they are shifted to the acute medical unit.
WEEKDAY LONG DAYS
Weekday long days are a bit different because:
1. There is a full team on AMU ( 3 consultants, 2 to 3 junior doctors)
2. The wards have a full team from 0900 to 1700
3. Ambulatory care unit usually has a consultant/ registrar
Hence, as a medical registrar on call during weekdays I just need to focus on clerking and seeing any urgent medical referrals from other specialties ( ie gynae OBS, surgery, etc)
Overall, my day is pretty much the same as when on weekends and I follow the same routine.
NIGHT SHIFTS
Please read this post:
https://omarsguidelines.blogspot.com/2019/09/how-to-work-on-nights-medicine.html1. I arrive in the medical handover room at 2020 and after putting my food in the fridge ( I get microwavable meals from my local grocery store, a can of coke and a packet of crisps), I sit in front of a computer and open the arrivals board, scan the acute medical unit and ED department to get an idea of
- How many patients are to be clerked
- How busy ED is
- If there are any sick patients.
2. I socialize with the day doctors and help tidy up any last minute jobs with them ( prescribing medications with them if they are clerking and have a few jobs to do- ideally they should STOP clerking at 2000 and then tidy up their jobs)
3.I then have a few minutes to check my emails.
4. The night handover starts at 2100 and is attended by
-The day team ( Medical registrar on call, 2 juniors covering the wards, 2 juniors on clerking)
-Critical care outreach nurse
-Bed manager
-Sometimes, a consultant ( if it is exceptionally busy and they had to stay in till late)
5. After doing the usual handover ( see point 8), I delegate tasks, make an on call WhatsApp group and start seeing the unwell patients on the wards first.
6. By 2200, I start clerking. Like a weekend shift, I request the clerking junior to continue on the acute medical unit and I station myself in ED ( I visit AMU every 2 hours to ensure the nurse in charge is happy).
7. The ward doctors bleep me if there are any concerns.
8. In my trust, we have an amazing bleep filtering system overnight ( from 2200 to 0600) whereby the bed managers take all bleeps from medical wards and then make a list of jobs for the junior doctor covering that ward. If it is urgent, they bleep them immediately and bleep me as well if they want a more senior decision making. This way, the junior doctors are not overwhelmed with jobs which may at times be unnecessary. The bed mangers are actually band 7 nurses, are ALS trained and hence have an excellent idea of how to prioritize jobs for junior doctors.
9. We also have clinical support who is a trained nurse who can do bloods, cannulas, catheters and ECGs. Most wards in this trust also have a HCA/student nurse who can do bloods so this helps the junior doctors as well.
10. I ensure the team has a break every 3 hours so I send them a reminder text at midnight.
11. At 0200 AM, we all meet up in the doctors office ( ie all medical doctors on call, the clinical outreach nurse and bed manager) and we have our meals there. We discuss any issues and if we need to redistribute the workforce ( ie if one of the wards is exceptionally busy, maybe the clerking doctor can help support the ward doctor if it is not very busy on the clerking shift).
12. I then ask the juniors to take a nap. I cannot sleep when I am on call and we have a nice room with a bed and fresh bed linen ( which is changed everyday) in the doctors mess ( which is actually a whole floor with lots of rooms - some are single bedded rooms and some have sofas , there is a shower room and a kitchen as well). I inform the bed managers to redirect bleeps to them to me if it is not too busy on the clerking shift.
13. Some doctors just relax for an hour or 2 in the doctors mess and some manage to sleep as well. I rotate my doctors like this so that by 0600 AM, all 3 junior doctors on my team have been able to have at least an hours break/nap.
14. I continue clerking in ED and by 0800, we do not have any patients to be seen.
15. I come back to the AMU handover room and tidy up my jobs. I also update my logbook at that time.
16. I handover any unwell patients to the on call team.
17. I offer to drop any doctors who live locally and then head off home.
REVIEWING UNWELL PATIENTS ON THE WARD
I do a full A to E assessment, go through the notes, make a SBAR ( explained here: http://omarsguidelines.blogspot.com/2017/05/guideline-for-junior-doctors-working-in.html ) , a list of active issues and then make a clear plan.
I also try to actively put ceilings of care for sick patients on the ward. In my simpleton mind, they are either going to go 2 ways:
1. ITU
2. Ward based care - NIV/CPAP or no NIV/CPAP. If not for NIV/CPAP, they do not need a repeat ABG
If they are for ITU, I get the ITU registrar/consultant to see them ASAP. I get my medical consultant on call immediately as well to ensure that (s)he is in agreement.
If they are not for ITU, I discuss DNAR with the patient (Next of Kin if they lack capacity - I do not shy away from calling the family in either: their loved one is ill and we need a decision ASAP. I do not want them to suffer by doing something which is not appropriate).
It is very easy to manage acutely unwell patients. They are either in pulmonary oedema or have a hospital acquired pnuemonia. Occasionally, I do see some interesting cases ( an acute ischemic stroke on the ward, an acute MI on the ward, etc)
It does not take long to make a decision about ceilings of care. I have got the nurse in charge, critical care outreach nurse and if I am still not sure, the ITU registrar/consultant and my medical consultant on call to help me make a decision.
TIPS FOR HANDING OVERhttps://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.htmlI try to make an escalation plan for all unwell patients I have seen. Hence it makes it for the team taking over from me to make a decision.
Overall, I really enjoy my on calls. I have learnt these tips by other registrars and I have also learnt that you are appreciated if you work with your team ( and do not overpower them with jobs while you chill out in the doctors mess).
.
I am going to go through my day shifts and night shifts.
DAY SHIFTS ( 0830 to 2130)
WEEKEND
1. I wake up at 0630 AM , have breakfast and after a shower, leave by 0800 AM
2. I pick up any colleagues who are working with me on that day and arrive to work at around 0810 AM and go to the AMU doctors office where we have our handover.
3. I check my emails and get the admission e- board up on my computer ( we have an arrivals board which shows all the admissions from last night with their EWS score). I then have a general idea of what happened with the patient - in my trust, all patients are admitted via ED and usually the medical team clerks the patients in ED. The ED clerk then scans the clerking proforma onto the computer system prior to the patient being transferred to the medical ward ( and I can view them).
4. If there are any doctors from the night team, I ask them about any issues overnight. I do not ask for a lot of details as this would be discussed in the handover anyway however this allows me to go through their OBS, investigations overnight and I get an idea of what to expect.
5. I also check the list of patients on AMU and see the EWS charts ( we can see everything on the computer system and hence I do not have to go to any ward to check the notes, etc)
6. So before the actual handover I know about:
- Any sick patients admitted overnight
- Any sick patients on AMU.
7. We then do a handover led by the night registrar which starts at 0830 AM.
This is attended by :
*The night team
-2 SHOs
- 1 FY1
( 2 of whom are ward cover and one is on clerking and AMU cover )
- registrar
*The day team:
1 clerking doctor- FY1/FY2/IMT1 or non trainee/locum SHO
2 ward cover doctors
1 AMU discharge shift doctor who does the post take ward round with the post take consultant till 1700
Day registrar
Clinical outreach nurse
8. The handover starts with
Introductions
Any sick patients on the wards
Any sick patients on AMU
Any sick patients from the take overnight
Any ITU admissions from medicine
Any urgent jobs to do ( ie LPs, urgent scan requests, specialist opinions, etc)
Any other issues ( staffing, IT issues)
Then the doctors do their minor handovers to the respective doctor taking over which do not require any MDT input.
9. I write down the details handed over to me. For me, as a registrar this is what is important:https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html
Patients details ( 3 details: Name, DOB, NHS number)
Location
Escalation plan ( Full, DNAR, ward based, NIV/CPAP)
Active issues
What I need to do
10. I then thank the night team, we handover our bleeps and then I do a quick handover with the day team.
I delegate tasks and ask the clerking doctor to start clerking the stable patients ( I prefer to clerk the unwell patients myself- so we go through the arrivals board and decide which ones (s)he will be seeing. I expect a FY1 to clerk one patient in 1.5 hours and a SHO to clerk a patient in 1 hour and this gives me an idea of how many patients will be left to be seen by the time I have done my urgent jobs).
11. I make a WhatsApp group with the on call team ( after taking their consent). This way they are able to 'shout for help' early if they are getting overwhelmed with jobs.
12. I see which ones I need to see first. I usually discuss this with the critical care outreach nurse as she then knows what the main sick patients are and we make a provisional plan together ( ie, whether I need to set a ceiling of care, whether I need to involve the ITU reg early, whether we need to do an urgent ABG, etc).
13. If there are patients on AMU/ other wards I am about to see, I inform the ward junior that I will see them ( I personally do not find any point of 2 doctors going to see a patient especially when the ward cover shift is so busy for the FY1/SHO).
14. Once I have seen the sickest patients and made plans, I go to AMU and meet the consultant on call and check if there are any registrar level jobs to do ( ie LPs, to discuss any ceilings of care, etc). I introduce myself to the AMU nurses and ward clerk so that they know I am available in case they need anything.
15. I am usually done by 1000 AM and can now focus on clerking. If there are less than 3 patients on AMU who are stable, I request the clerking doctor to continue on AMU and I go to ED. I prefer to stay in ED and I am stationed there unless I have been called to see a sick patient on the ward.
16. I meet the ED consultant and nurse in charge and ask if I need to see anyone. I also ask these questions:
- Are there any sick patients they want me to see quickly?
- Are any potential discharges whom they are not sure about so that I can clerk them quickly, call the bed managers who can then ask the post take consultant to come to ED to make a decision IF I am unsure about them as well?
- Are there any patients who could go to ambulatory care?
17. I then go to ambulatory care ( which is right next to ED). If it is not covered by a medical registrar and there is a SHO there, I let them know that I am around to help and address any doubts they have. The ambulatory care unit out of hours is supported by the ED consultant however I try to help as much possible as the ED consultant can be very busy as well.
18. I start seeing the sick patients, potential discharges and I try to clerk them within 30 to 45 minutes. Some take less than that and some take more than an hour depending on how complicated they are.
19. My rule of clerking is that you should document everything as if you are going to show that documentation as evidence if you are in court- ie, detailed, your diagnosis and why the patient needs to stay in hospital.
20. I am very proactive with discussing ceilings of care so I try to have those discussions with frail patients with poor performance status actively. If they lack capacity, I call their families. I am very particular about this as I know that I will be leading the CRASH if they die in hospital and I will have to make a decision then which I could have made when I clerked them and had already developed a relationship with them.
21. I manage to see the sickest ones, the potential discharges, the potential transfers to ambulatory care by lunch time.
22. I then message on the WhatsApp group reminding everyone to have their breaks and ask if there are any issues.
23. After visiting AMU ( I always go there on a regular basis as I do not want to miss any sick patient ) and asking the nurse in charge, post take team if they need me, I go have lunch after ensuring that the clerking doctor is going for lunch as well.
24. By this time, another doctor who clerks from 1230 to 2100 has arrived ( known as the twilight shift). I delegate the patients to clerk to him/her and then head off for lunch at around 1245.
25. I come back by 1315 and quickly visit AMU, ensure the post take discharge consultant has given the post take doctor a break and then continue clerking in ED.
26. I visit ambulatory care every hour to ensure there are no issues. This way, I know if there are any empty spaces we can send patients from ED to ( cases like first trop negative chest pain which has completely resolved, frail patients with normal investigations who need OT/PT - we have a 'rapid assessment team' who are therapists working in ED and they expedite discharges from ED and avoid unnecessary admissions.
27. I continue clerking in ED. In my trust, the ED team has to fill out the medical clerking proforma and I prefer that they just fill out their ED forms and do a verbal handover to me. This has its advantages :
- I can suggest further investigations which the ED team can do
- I can suggest further treatment which the ED team can administer
- I get to decide whether they need to be admitted or can go to ambulatory care/ discharged from ED
- The ED team does not have spend extra 20 minutes filling out the clerking proforma and hence this saves their time.
- I get to teach them as well what I am looking for as a medical registrar and we discuss management of common medical emergencies.
- I can request them to involve ITU urgently/ transfer sick patients to our RESUS bay.
- It reduces my clerking time as well as I have already heard the story already ( I always ask the same questions to be double sure but this does save time regardless)
28. This way, I have now developed a very good relationship with the ED team. They know I am around and they know I am always willing to help. They also help me ( I have got unlimited access to their goodies - I am a choca-holic and the ED staff room always has some amazing chocolates) and they try to manage the medical patients as much as they can.
29. It gets exceptionally busy on the take after 6 PM so I try to be very vigilant and ensure the whole clerking team is working at full speed. I do not nag them but I also make sure that they are seeing patients at a reasonable pace ( sometimes I give them useful tips on how to speed up clerking:
https://omarsguidelines.blogspot.com/2019/08/how-to-clerk-medial-patients-safely-and.html ) but I never push anyone. Some people may be having a bad day and I do not try to judge them based on a single shift I have done with them. If I have noticed that they consistently lag, then I may sit with them and try to understand what is going on and assist them.
30. I also make sure that the consultant on call does not have to stay in till very late. We, as registrars not only have to take care of our junior colleagues but also the consultant on call. I try to get them to see any sick patients as soon as possible to avoid them staying late unnecessarily.
31.By the end of the shift, I have usually clerked 12 to 15 patients , seen 5 sick patients and ensured my colleagues and I have had a break. It has been around 6 months since I have become a registrar and there has not been a single shift in which I have missed a meal or my colleagues have not had a break.
32. I then go to the doctors handover room at 2030 and then tidy up any last minute jobs. The night team start arriving and we start our handover at 2100.
33. I then enter the NHS numbers of all the patients I have seen on a word document in my work computers drive so that I can reflect upon the cases I saw and managed later on, when they have been discharged.
34. I ask if any doctor needs a lift back ( I live in a small city and it is very convenient to drop people as long as they live in the same city- which most of them do)
On a good day, I do not handover any patients. There are a few waiting for ED cubicles in the corridors who have already been put on the clerking list but they are yet to be seen by the ED team first and they are usually stable are are managed by the ED team till they are shifted to the acute medical unit.
WEEKDAY LONG DAYS
Weekday long days are a bit different because:
1. There is a full team on AMU ( 3 consultants, 2 to 3 junior doctors)
2. The wards have a full team from 0900 to 1700
3. Ambulatory care unit usually has a consultant/ registrar
Hence, as a medical registrar on call during weekdays I just need to focus on clerking and seeing any urgent medical referrals from other specialties ( ie gynae OBS, surgery, etc)
Overall, my day is pretty much the same as when on weekends and I follow the same routine.
NIGHT SHIFTS
Please read this post:
https://omarsguidelines.blogspot.com/2019/09/how-to-work-on-nights-medicine.html1. I arrive in the medical handover room at 2020 and after putting my food in the fridge ( I get microwavable meals from my local grocery store, a can of coke and a packet of crisps), I sit in front of a computer and open the arrivals board, scan the acute medical unit and ED department to get an idea of
- How many patients are to be clerked
- How busy ED is
- If there are any sick patients.
2. I socialize with the day doctors and help tidy up any last minute jobs with them ( prescribing medications with them if they are clerking and have a few jobs to do- ideally they should STOP clerking at 2000 and then tidy up their jobs)
3.I then have a few minutes to check my emails.
4. The night handover starts at 2100 and is attended by
-The day team ( Medical registrar on call, 2 juniors covering the wards, 2 juniors on clerking)
-Critical care outreach nurse
-Bed manager
-Sometimes, a consultant ( if it is exceptionally busy and they had to stay in till late)
5. After doing the usual handover ( see point 8), I delegate tasks, make an on call WhatsApp group and start seeing the unwell patients on the wards first.
6. By 2200, I start clerking. Like a weekend shift, I request the clerking junior to continue on the acute medical unit and I station myself in ED ( I visit AMU every 2 hours to ensure the nurse in charge is happy).
7. The ward doctors bleep me if there are any concerns.
8. In my trust, we have an amazing bleep filtering system overnight ( from 2200 to 0600) whereby the bed managers take all bleeps from medical wards and then make a list of jobs for the junior doctor covering that ward. If it is urgent, they bleep them immediately and bleep me as well if they want a more senior decision making. This way, the junior doctors are not overwhelmed with jobs which may at times be unnecessary. The bed mangers are actually band 7 nurses, are ALS trained and hence have an excellent idea of how to prioritize jobs for junior doctors.
9. We also have clinical support who is a trained nurse who can do bloods, cannulas, catheters and ECGs. Most wards in this trust also have a HCA/student nurse who can do bloods so this helps the junior doctors as well.
10. I ensure the team has a break every 3 hours so I send them a reminder text at midnight.
11. At 0200 AM, we all meet up in the doctors office ( ie all medical doctors on call, the clinical outreach nurse and bed manager) and we have our meals there. We discuss any issues and if we need to redistribute the workforce ( ie if one of the wards is exceptionally busy, maybe the clerking doctor can help support the ward doctor if it is not very busy on the clerking shift).
12. I then ask the juniors to take a nap. I cannot sleep when I am on call and we have a nice room with a bed and fresh bed linen ( which is changed everyday) in the doctors mess ( which is actually a whole floor with lots of rooms - some are single bedded rooms and some have sofas , there is a shower room and a kitchen as well). I inform the bed managers to redirect bleeps to them to me if it is not too busy on the clerking shift.
13. Some doctors just relax for an hour or 2 in the doctors mess and some manage to sleep as well. I rotate my doctors like this so that by 0600 AM, all 3 junior doctors on my team have been able to have at least an hours break/nap.
14. I continue clerking in ED and by 0800, we do not have any patients to be seen.
15. I come back to the AMU handover room and tidy up my jobs. I also update my logbook at that time.
16. I handover any unwell patients to the on call team.
17. I offer to drop any doctors who live locally and then head off home.
REVIEWING UNWELL PATIENTS ON THE WARD
I do a full A to E assessment, go through the notes, make a SBAR ( explained here: http://omarsguidelines.blogspot.com/2017/05/guideline-for-junior-doctors-working-in.html ) , a list of active issues and then make a clear plan.
I also try to actively put ceilings of care for sick patients on the ward. In my simpleton mind, they are either going to go 2 ways:
1. ITU
2. Ward based care - NIV/CPAP or no NIV/CPAP. If not for NIV/CPAP, they do not need a repeat ABG
If they are for ITU, I get the ITU registrar/consultant to see them ASAP. I get my medical consultant on call immediately as well to ensure that (s)he is in agreement.
If they are not for ITU, I discuss DNAR with the patient (Next of Kin if they lack capacity - I do not shy away from calling the family in either: their loved one is ill and we need a decision ASAP. I do not want them to suffer by doing something which is not appropriate).
It is very easy to manage acutely unwell patients. They are either in pulmonary oedema or have a hospital acquired pnuemonia. Occasionally, I do see some interesting cases ( an acute ischemic stroke on the ward, an acute MI on the ward, etc)
It does not take long to make a decision about ceilings of care. I have got the nurse in charge, critical care outreach nurse and if I am still not sure, the ITU registrar/consultant and my medical consultant on call to help me make a decision.
TIPS FOR HANDING OVERhttps://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.htmlI try to make an escalation plan for all unwell patients I have seen. Hence it makes it for the team taking over from me to make a decision.
Overall, I really enjoy my on calls. I have learnt these tips by other registrars and I have also learnt that you are appreciated if you work with your team ( and do not overpower them with jobs while you chill out in the doctors mess).
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