It’s been a while hasn’t it. It’s tough finding the energy and the want to write on this blog these days but I’ve also had the issue that I can’t document like I did as a med student as I would be breaking a lot of patient confidentialty!
So I have thought about this long and hard and I thought I would share my experiences and hacks as a doctor in the 21st century NHS and in a time of turmoil for my profession.
So, first article. Nights.
These are shifts that you will not get out of as a junior doctor (obv barring occy health needs) and everyone handles them differently. It vastly depends what you are doing for nights as to how you will find them. I find that ward cover is depressingly slow, AMU cover is variable but does make you a better independant doctor and A&E nights were the best shifts for just flying away.
I think I prefer the hospital at night. Theres less chaos, less refferals needing to be done (two years in I still hate referring) and everything is more informal. It’s just better. I also like having the independance to build my own management plans without standing by a bedside on a ward round bored out of my mind.
AMU Nights
AMU nights where I work are basically looking after an AMU unit overnight. We have 5 units in the LRI (plus an HDU area). Night shifts are rather like day shifts but there is generally less to do. You clerk any patient that arrives and then just problem solve any issues over night. I tend to use these shifts to catch up on portfolio work, make sure my training is up to date and any other admin work. These shifts really depend on bed flow in the hospital as to how busy you are. Weekends tend to be slower as there are no ward rounds so there are fewer discharges. Not zero discharges, but fewer. Weekdays tend to be busier as you have the discharges from the ward which can happen at any point as although we try to get discharges done early, sometimes you only sit down to write letters at 5pm (yes I have had this before). So you can get admits at any time of the night.
Ward Cover
As it says on the tin really. You are assigned a number of wards to look after overnight. Your tasks are mainly what the nurses send (fluids, painkillers, warfarin dosing) and tasks set by the day team to do such as chasing bloods/scans/ clinically reviewing patients. As in AMU how busy you are depends on the wards you are covering. However, every ward cover night I have worked I tend to see a quiet period between 2am – 6am. This is because patients are asleep and all medication rounds are done. 6am tends to get busy as this is when the first obs are done in the morning so any poorly patients are picked up here. I will say beware the “this patient is drowsy” bleep. Despite needing sleep to heal, hospitals are poor for getting good quality sleep so give that poor patient time to wake up before you whisk them off to a scanner.
I love Leicester for their out of hours system. Gone are the bleeps and we have mobiles in which nurses can send tasks to so we can see them all and are not disturbed when doing tasks like blood taking or talking to patients. We can also prescribe from these phones which is so helpful for “patient wants paracetamol”and you are not near a computer or the ward.
The only bad thing about nights is making sure you aren’t dragged into jobs that are day team jobs. Nights are for fire fighting any issues that come up. It is not for writing discharge letters or non-urgent referrals. The reg’s holding the bleep taking referrals will not thank you for a ?toe fracture on a non weight baring patient at 3am. If you are not busy and dont mind it, then it doesn’t mean you cant do discharge letters but they should not be done before any night tasks. No matter how much the ward chase you ( ok fast track discharge patients please do but even these should have been done by the day team).
A&E
The same as the day.
…..
Well, slightly tricker as elderly patients tend to not have anyone with them to help with history taking and you can’t call relatives up so you rely mostly on the ambo crew history. It can also be slightly trickier to manage patient flow as some specialties are non-resident on calls so you have to awkwardly wake up someone and do a handover on the phone ( I hate doing phone referrals as it is, do you think I really want to wake someone up and THEN also do one?!?). Otherwise the job is literally the same.
So night life hacks:
The day before…
I used to stay up the entire night before and sleep the entire day — only to wake up at 1pm anyway. This was exhausting and I am now convinced this actually proved detrimental to me recovering. I now go to sleep the night before and sleep in. I then will get up and have lunch about 1ish before going back to bed. The key to sleeping when everyone else is awake is blackouts. I have tempoary blackout blinds I can suction to my widow which work amazingly for stopping any sunlight getting through.
I also have a sleep mask with speakers in. This again blocks out light but since I listen to background noise going to bed anyway, I can play it straight into my ears blocking other sounds that might wake me up like cars or people talking outside.
I would also like to add about the place where you live. You are not going to have the energy / motivation to clean your place of living over nights. I try and make my flat as clean as I can. At minimum I make sure my sink is empty and my dishwasher is ready to take on more dishes. This means that I don’t have piles of mugs/bowls growing over nights leaving me a lovely pile of washing to do on the last morning which inevitably never happens anyway.
- GET A WARM OUTERLAYER
Seriously, you think hospitals are cold during the day? Try removing all the body heat of day staff and the general hustle and bustle. There technically is no uniform requirement but I go for a blue fleece/zip up to make myself look smarter and looks more professional when you see patients (after rolling up yoursleves of course). You can get personalised ones on Etsy or just buy a plain blue/black layer and customise it yourself or leave it blank. Its your clothing 😀
2.Bring snackage
Im lucky that my hospital has a 24 hour canteen. Ok there isn’t the best food avaliable but its warm and there is access to sandwhiches etc. Most hospitals don’t have this and the best you are going to get is anything from a vending machine which is going to cost a lot. If you are in a big enough city you can take advantage of food delivery apps but just be mindful that you will have to go to the entrance to get this. Bring food – and then bring some extra. Your body is not used to being awake at 3:40am. It will fight back (seriously there are actual papers documenting this phenomenon at 3-5isham). I try to bring healthyish things like apples, rice cakes and yoghurt and of course some treats like crisps and chocolate because being on nights is bad enough without comfort food. I would also bring some drinks/ things to make drinks because again, vending machines are not the answer all the time. Which brings me onto my next point…
3. Careful with Caffeine
Especially if you are working your first night shift ever or just the first of the block, be careful with how much you are intaking. I tend to have a rule – no coffee after 3am and only decaf tea after. You may be struggling but what you don’t want is to get home wide awake and then not sleep and then have another rough night.
I tend to opt for softer caffeine intake like diet coke and tea during night shifts with a cup of coffee if I am struggling. I have an aeropress and portable coffee pod maker which are my lifelines. It’s worth the investment even just to keep you from buying expensive (and often vile) canteen coffee.
If I am struggling I will go for a walk outside the hospital and get some cold fresh air into my lungs and go up and down a couple of flights of stairs to help get the old heart pumping. I try my best to avoid sleeping on nights (partly because there is nowhere to sleep) and partly because I wont then sleep when I get home.
4. Don’t get stranded
Make sure you know who you need to escalate to and that you have their contact details. You do not want to be stuck on a far flung ward with a sick patient and no idea who to ask for help and not know how to get hold of them. Don’t be shy about making people stop at the end of handover for this. It’s patient safety, double check you have the right number and that all devices are working and charged.
5. Have you tried a warm glass of milk?
Patients ask for sleeping tablets all the time and I do feel for them. Hospitals are not quiet places and standing trying to print something out with what felt like the worlds loudest printer mere meters from a patients bed felt awful. However, these tablets just make things worse in the long run. They completely screw up the cycle and the patient ends up not sleeping at all. Stand your ground and say no (it’s helpful to explain how they muck their cycle up). You could offer antihistamines which have a sedating side effect as a push but I really would avoid prescribing sleeping tablets. Plus, give it some time before you go and review the patient asking for the tablets and 9/10 you’ll find they have drifted off by themselves! This leads me onto my next point ….
6. Don’t sedate grandma
The Care of the older person consultant will be after you if you do this. Delerium is a delightful illness where patients tend to sleep cycle reverse and will be sleeping statues during the day and then recite the entirety of the hamilton musical at night (ok not really but you get my jist). You may be asked to prescribe lorazepam for them and I urge you to not to. This like the sleeping tablets will make the situation worse. Any patients who are struggling with these behaviours should have a 1:1 with them to try and settle them or look after them should they start to wander. It’s awful, but really try to avoid it. Often when the antibiotics kick in they will begin to settle anyway. If you really are stuck a TINY (0.5mg) dose can help but prescribe it as a STAT one off rather than a PRN.
7.Handover on time
Sometimes you wont get to do this (we are NHS staff after all) but make sure you are ready to go for handover. This means stopping clerking an hour before changeover, stopping any non-urgent ward jobs half an hour before and your ED department will have their own rules (ours was do not pick up any new patients an hour before end of shift and just finish on the ones you have). Stop and write down anything that needs to be said in handover. In AMU I tend to have my own A4 document on the go over the night which has details I need so I can update as we go and then print it off. Your brain will be 10000% done by handover so make life easier on yourself.
8.Check you are safe.
It is now policy for hospitals to have beds for staff who are drowsy. Too many staff members have died/ seriously injuried from crashing on their way home from work because of how tired they are. Do not become a statistic. The rooms are often known as “too tired to drive” and are avaliable to book. Make sure you know how to book these and DO NOT DRIVE if you are unsafe. Booking into a local hotel is better than trying to avoid crashing. People find that blasting cold air, having the radio on max and singing along helps to avoid drifting off.
9. The day after
It may feel like you want to race off home and collapse in bed but remember you only have 48 hours to get back on a normal people schedule. People go about this different ways but what I tend to do (because I have the self control of a puppy) is stay up all day and go to bed about 8ish. I don’t sleep when I get home as I wont wake up at 1pm so I’ll just have sofa day and catch up on mindless TV. I then go to bed at 8-9pm and then wake up at 9ish the next day and force myself to get up and do things.
It’s so so hard and its so unfair that we are seen has having three days off but we have worked minimum 9 hours of one of those days which is the same as a 9-5. If you find youare really struggling with this then reach out to your ES / GP / Occy health to see if there is anything they can offer. I really struggled in F1 but I am used to it now in F2 so maybe I just needed time to get used to it.
10. Enjoy them. Nights are hard, but for us juniors, it’s one of the only times we get to use our clinical brains. I used to look forward to the independence and using my brain on nights instead of being someones secretary. One of my favourite parts of nights is watching the hospital come to life at around 5:30am. One of my least favourite parts is the hour when the fresh faced day nurses start and then bombard you with everything they have found is unanswered. Sometimes, the answer is wait until the day team arrive (if its not urgent), after all, they will be the fresh faced doctors who can deal with it.
MedBeeMedic 
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