A night shift of a medical registrar in a teaching hospital

This is one of my night shifts as a medical registrar responsible for ED and ED resus in a teaching hospital I am currently based in. 
To protect patients identity, I have changed the ages and genders. 

This was my second night shift of four nights. 
I usually sleep well before nights 
I sleep 3 hours even if I have slept for 8 hours the night before - when I am due for my first night shift and then sleep for 8 hours consistently after my first night shifts. 

Day 2:
BEFORE MY SECOND NIGHT SHIFT
I left work at 0800 AM with just one patient to handover to the day registrar - a patient with high BMs, ketones and normal pH. Was admitted with abdominal pain. VBG on admission showed a high lactate hence the ED team kindly a CT abdomen which was normal. Hence he was started on the DKA pathway and admitted under care of medicine. I had clerked him in and he was stable enough to be transferred to the ward. 
I got home at 0820 AM and after taking a shower, I got into bed at 0900 AM 
I woke up at 1700 
Had dinner 
Played with my daughter 
Got ready 
Put my daughter to bed
Left at 1915 
I arrived at work at 1945 

HANDOVER FROM DAY REGISTRAR 
I took a handover from the day registrar - A patient had been admitted after swallowing a sharp foreign body by mistake. He was seen in ED and the ED team had discussed this with the gastroenterology consultant on call and a OGD was arranged. I was to ensure everything was in place. 
TIPS:
You can do a lot of things remotely- When the ED doctor referred another patient to me later on in the night, I asked him about that patient and he informed me that he had gone for a scope already. 


PHONE CALL WITH MEDICAL DIRECTOR 
I was asked to call the medical director on call - He informed me that there was no COVID ward registrar after 10 PM ( We have a full team from 0900 to 1700 7 days a week and then a COVID reg and SHO on the COVID wards from 1700 to 0500 AM) and I informed him that I am happy to cover the COVID wards from 2200. 
He also mentioned that ED was full of medical patients and if I was okay to clerk patients once I had managed the unwell patients. I was fine with that - I do this anyway as I prefer to sit in ED and clerk. 
TIPS:
1. Try not to be obstructive and help your colleagues. However it is important not to overwhelm yourself. In my conversation with the director, I informed him that I would let him know if things got out of hand - he was happy to be contacted at any point. 
2. The management and other consultants know all about us - they know which medical registrar has been working hard and who has been sleeping. Some registrars think they can get away with it but it always bites them later on in their supervisor meetings/ when there is a complaint against them 

ED RESUS 
I arrived in ED resus at 2030 and took a handover from the ED reg for all medical patients in ED. There were 3 medical patients and I started with the most unwell patient:

PATIENT 1 2030 TO 2100 
This middle aged lady was admitted with shortness of breath. 
I first opened her medical records, the ambulance handover sheet ( this always helps - it has critical information like BMs, BP, HR, temperature, a brief but very relevant history) and started filling the clerking sheet with the following details :
1. Ambulance sheet OBS 
2. Past medical history including previous admissions. 
3. Drug history 
4. Current OBS 
5. Investigations
I took a detailed history from her and examined her - particularly focusing on her activities of daily living : she lived independently ( did her own washing , dressing, cooking, shopped online like most people in the pandemic), had a good exercise tolerance - which had worsened in the past few days and smoked ( 30 pack year history). She had never been admitted with any respiratory conditions before. ~
She was known to have COPD and was on inhalers. 
Her bloods showed a high WCC, CRP and her ABG which showed type 2 respiratory failure.
She was wheezy on arrival but improved with nebulizers the ED team had kindly prescribed. 
I started her on antibiotics, steroids, PRN and regular nebs.
I ensured everyone knew that her target SO2 was between 88 and 92%. 
I planned to repeat an ABG in an hours time and deemed her fit for transfer to the medical ward. 
I let the SHO on the ward know to repeat her ABG whenever she arrived. Her gas slowly started to improve.

TIPS:
1. Always do an ABG in patients requiring O2 
2. If their CO2 is high, maintain target SO2 between 88 and 92% - hypercapnia secondary to over-oxygenating patients with COPD is very common. 
3. An acidotic type 2 respiratory failure patient - known COPD needs steroids, back to back nebulizers and then a repeat ABG in an hours time. If there is no improvement, then start them on NIV as per trust policy. 
4. Usually, patients just improve by ensuring the target SO2 is between 88 to 92% and after giving medical therapy. Be aware that they can deteriorate so keep an eye on such patients.  

PATIENT 2: 2100 to 2120
I was called to AMU by the nurse in charge to see a patient who was keen to go home. He was admitted with blurred vision, dizziness and high bloods pressure. His bloods were normal, urine dip did not show any protein, fundoscopy and MRI head were normal. The plan as per the consultant ward round was to discharge this patient on anti-hypertensives (which were already prescribed). As everything was normal, I documented this in his notes and discharged him. 

TIPS:
1. Listen to the nurse in charge. They need to maintain patient flow and no matter how busy you are, you can easily take time out to do quick reviews. It took me 20 minutes to sort everything out. 
2. Always ensure all the investigations are normal and the patient is fit to go - look at the scan reports, OBS, bloods even if the consultant has mentioned they are normal. Sometimes, things can be missed even by experienced consultants. 

PATIENT 3: 2120 to 2200 
This middle aged gentleman was admitted with chest pain - worsening through the day but got extremely bad later on in the day , radiating to his back, jaw, arm with shortness of breath. 
The ED team were concerned about possible dissection hence requested a CT aorta which was reported as normal. His troponin came back to be high and he had a normal ECG. He was chest pain free and I called the cardiology registrar to see if they could take him to their cardiology unit directly. Unfortunately due to lack of beds, he was to be admitted in AMU for a cardiology review. 
I prescribed ACS treatment and deemed him fit for transfer 

TIPS: 
1. Always talk to the specialists - especially in a teaching hospital. This patient needed a cardiology bed - had there been beds on the cardiology unit, he could have been transferred and we could have a spare bed in AMU for other patients. 
2. History is important when it comes to MI - with time you will know what to ask and it does not take long. 

PATIENT 4: 2200 to 2240 
This elderly gentleman with multiple co-morbidities and a valid RESPECT form was admitted with confusion and pyrexia. 
He had recently had a catheter change and he became unwell after that. His bloods showed high WCC, CRP and his CXR was normal. His bladder scan did not show any retention. He was requiring oxygen.  I started him on broad spectrum antibiotics for chest and urine and deemed him fit for transfer to the ward. 
TIPS:
1. Always check the RESPECT /DNACPR form to ensure it is valid, not a photocopy ( in which case it will need re-writing) and what the exact escalation plan is ( RESPECT forms can still mention that the patient is for full escalation) 
2. If a patient with a long term catheter has been admitted with UTI, it needs to be changed under antibiotic cover ( usually gentamicin but this can vary from trust to trust) 

PATIENT 5 2240 to 2330 
This middle aged patient was admitted with what seemed to be an anaphylactic reaction. He had itchy hands and a rash which then spread to his whole body, he then became breathless and wheezy. The paramedics gave him IM adrenaline and when he came to ED, he was still breathless but improved after a nebulizer. He was known to have COPD. 
TIPS:
1. Always remember to keep such patients in for monitoring for a few hours. 
2. Prescribe steroids to prevent delayed reactions 
3. Prescribe antihistamines and PRN epipen. 

SENIOR REVIEWS FROM 2330 TO 0100 AM
I, as a medical registrar have to do senior reviews of patients clerked by ACPs, FY1s and SHOs. It is to decide if they are safe to outlie to other wards if their COVID swabs are negative so that they can be post taked by the consultant responsible for that ward. 
As COVID swabs can sometimes be falsely negative, a registrar usually makes this decision overnight.  
HOW I MAKE DECISIONS:
1. I check their symptoms - whether they have a new cough/fever/loss of taste/smell. The teams clerking such patients almost always document these. 
2. Check their CXR to features of COVID ( please note that CXR may be normal) 
3. Check their bloods - low lymphocyte count, high CRP ( however this may not always be the case) 
Some patients still come out to be positive when transferred to the ward but luckily, currently as the cases are dropping it is less frequent. 
If I am suspicious but the swab is negative, I either advise to keep the patient in the screening ward or to move them to a side room on any medical ward. This is the current trust policy and may differ from trust to trust. 
Apart from doing this, I also quickly go through the clerking and add in things which my colleagues may miss- they are very good though and it is very rare that I have to add anything. I always see patients in detail who are unwell and make escalation plans for patients who are frail. 
TIPS:
1. Always try to do senior reviews whenever asked to. This prevents bed blocking. Our COVID screening ward is not big and the team need to get patients to other outlier wards as soon as their swab results come back 
2. This is not ONLY about deciding whether they are fit for transfer to outlier wards - you should also see if there is anything missing in the management plan. 
2. It does not take long long to do senior reviews. But do not rush this either. Or be too slow. Otherwise you will be on the ward the whole night. 
I did reviews for around 10 patients 

0100 TO 0200 - BREAK 
I then had my ready to heat meal ( Chicken tikka masala and pilao rice from Morrison's is currently my favorite - I have it with a packet of crisps and a can of coke) 

0200 TO 0210 - CALL FROM COVID WARD 
As I was covering the COVID ward, I got a call from the SHO for a patient he had seen and I suggested things to do. I did not need to see the patient as he was confident in managing everything. 
TIP:
1. You do not need to see every patient. In this case, I knew the SHO well and knew he was confident enough 
2. If your colleagues say they are worried, then that patient is a priority- get up and see that patient ASAP. Do NOT be that sort of registrar who takes a 30 minute long history on the phone and then gives a long list of things to the already overworked and overwhelmed doctor. 

SENIOR REVIEWS FROM 0210 TO 0245 
I was called back to the COVID screening ward for more senior reviews for patients whose swabs were back. I did 5 reviews and made plans for them 

0245 TO 0330 - BREAK
I went to ED resus and it was not busy so I had a nice break again.  

CALL FROM ED NURSE IN CHARGE
I was asked to see 3 patients in ED who had negative swabs but were waiting for beds on medical wards. 2 of them were elderly and if I clerked them and deemed them fit, they could be transferred to the elderly assessment unit ( which does not take direct admissions after 10 PM unless clerked by the medical team)
TIP:
When the nurse in charge asks you for help, go help them. I have had extremely busy shifts in the past 2 years ( 1 in a district hospital and now in a busy teaching hospital) and almost always get time to review patients - sometimes not immediately but usually in 30 minutes or so. 

PATIENT 6 0310 TO 0330 
A frail gentleman with cellulitis 
This was a pretty forward case. She could got be discharged because of frailty needs. 

PATIENT 7 0330 TO 0355
A frail lady with dehydration 
This was a pretty forward case. She could got be discharged because of frailty needs. 

TIPS:
Make escalation plans upon admission- I have seen elderly patients CRASH and CPR was completely inappropriate. I do not wait for frail patients to become unwell to make a decision - I make a decision when I know that if they become critically unwell and their heart stops beating/they stop breathing, CPR/intubation will be inappropriate and I make a decision even if they are currently stable. 
https://omarsguidelines.blogspot.com/2020/02/teaching-session-ceiling-of-care-in-nhs.html

PATIENT 8 0355 to 0455
I was asked to see this middle aged gentleman who was admitted with shortness of breath and chest pain. His chest x ray showed pulmonary oedema and his troponin was high. 
My diagnosis was NSTEMI causing CCF. 
He was in type 2 respiratory failure and the ED team had already started him on NIV, IV furosemide and catheterized him. They had called the cardiology reg who advised to admit on AMU and their team would review him in the morning. 
When I went to see him, I had to wear full PPE 3 as he had NIV and was awaiting his COVID swab. I asked the nurse if she wanted anything doing as I was going in and she gave me his oral medications to give to him. 
So I went in, took a history, examined him and then gave him his medications by removing his NIV mask and putting it back on. 
I then did an ABG and he was no longer in type 2 failure. So I stopped the NIV and started him on a furosemide infusion. 
I called the cardiology team again to see if they would consider taking him over now that he was no longer on his NIV but they still suggested to keep him on AMU. So I deemed him fit for transfer. 
TIPS:
1. Always talk to the specialists- even if they are not on site, every hospital has a major trust for referrals. It is useful to get advice when you are not sure. 
2. If NIV is started, it does not mean it needs to stay on forever. Repeat an ABG within an hour and if things are improving ( especially in such a situation- ie, not COPD ) , you can remove the NIV. 
3. Try to help the nurses when it comes to PPE3 - there is no point of you going in wearing full PPE 3 and then a nursing colleague going in soon after you to give tablets. Of course, if it is intravenous medications, then you cannot do much. 
4. Catheterization is very important in CCF exacerbations- these patients urinate like anything when started on furosemide. 

I then went to AMU and there were no more patients for reviews. ED was stable as well so I took a break 

0520 to 0730 
I sat in an office for a good 2 hours! I kept an eye on the ED board, chased the results of the patients I had seen and did a bit of portfolio work. 

I did another round of ED, ED resus and AMU from 0730 to 0755 and everything was fine. I handed over the bleep to the day registrar with no outstanding jobs and went home. 

As you can see, 
I had plenty of time to enjoy my meal 
I had plenty of breaks 
I was able to help on AMU to do senior reviews and in ED
Life is not difficult as a medical registrar - just be proactive and help your colleagues.