April 22, 2008
Not quite able to sleep, neither am I meant to be sleeping at this time. I thought ‘Ah this would be the best time to finally write what I intended to’ so here I am.
I’ve changed over from doing Psychiatry and was thrown head first into the Surgery unit, doing mainly night shifts. I usually start my shift in the late evening; to be on my feet for the next 14 hours before I handover to the morning doctors (while trying not to yawn) and then heading home for some much needed sleep.
I’m already 3-4 weeks into my surgical nights rotation. Still fairly new to it, but there’s already plenty to muse about *grins*.
There wasn’t much of an orientation to night shift. The only formal instruction which I have received was to “Turn up and do what it is needed”. Needless to say, I was quite anxious prior to commencing this rotation as I was already imagining all the worst-case scenarios that could take place in the night.
I was browsing through my rostered shifts from the timetable that was given; half-rejoicing that I am getting more days off since I’m putting in more hours at a time…until I read the fine print below it.
Surgical interns are expected to cover ALL surgical beds in the hospital, including those in the Emergency Department.
It then promptly dawned upon me that I’d be the only intern skulking the corridors at night. This is matched by the equally scarce number of senior doctors on-call at the same time – solely because it’s night time and most patient’s are stable (or so we’d like to think!).
Given that most of the active planning and execution of the patients’ treatment plan are done during the day, there is a common belief that there’s nothing much to be done at night as patients should be sleeping and things should be quiet.
Honestly, no. Not from what I experienced at least.
There is no written rule for the patients sounding anything like ‘Thou shalt not fall sick after the sun goes down’. Aha – well yes, they are unwell to begin with but some of them could suddenly deteriorate through the night which makes me wanna pee in my pants sometimes.
As mentioned there’s only one intern from the surgical unit whom is around at any given night, and we would pick up our pager prior to starting each shift. I still remember my very first page happened right just within 10 seconds of me picking it up. It was the surgical registrar (whom was the only one on-call from his ranks too) and the instructions were swift.
“I have an emergency appendix now and I NEED help”.
Okie. So I ran and get myself changed into a spanking blue pair of scrubs. Walked hurriedly looking for the registrar; palpitations with every step that I took. Found him scrubbing by the sink and promptly joined him. We had a very brief self-introduction and I shelved all my plan for small talk seeing how sombre and serious he looked.
In my weird and overactive lil’ head, I imagined what would it be like if he’s as new as me (which thankfully he isn’t, of course).
*Fictitious conversation which in no way should ever take place prior to any surgery*
Newbie registrar : I’m new. What about you?
Newbie intern : I’m new too. Gawd, so nervous! Think I feel like crapping in my pants now.
Newbie registrar : Now that makes the two of us.
*End of imaginary revelation by the surgical sink*
Anyway…to business. The patient was sedated and anaesthetised; draped and the procedure was ready to go. I saw the registrar making a quick incision near the hip and started to probe around to locate the appendix. He was gently pulling up some of the bowels, rocking them a lil to free them up and to reveal the appendix which would normally be attached to it at the illeocaecal junction (where the small bowel kinda joins with the beginning of your large bowel – the appendix normally hangs around there).
He was holding a portion of some pink bowel.
Me : What’s that?
Him : The caecum.
Me : Ah.
Unable to locate the appendix yet (this was done with a minimal sized incision so there’s actually very little view of the inner abdo) he then gently reintroduced that portion back in (although stuffing would be a more precise word) and started again with another portion of the bowel. He eases the new loop into view.
Me : What’s that?
Him : The caecum.
Me : Ah?
Well it did looked a lil bit different to me, but then again I hardly spend much time looking into people’s guts so can’t be too sure on how it looks like from all angles. I just realised that we each have about a good 4-6m length of intestines in total, and I had the good fortune of pointing to the exact same area twice. What are the chances of that? Hmm.
I realised that when it comes to removing the appendix, it pretty much comes down to how soon we can find it. It can get pretty tiring with the registrar stuffing his fingers into the patient’s abdo, grunting as he tries to get a feel of that elusive tiny appendage of the intestine – and the intern who’s job is mainly to hold the retractors to keep the incision site opened as much as possible for better visibility. Trust me, it gets pretty tiring. I can’t bend my elbows to hold the retractors back (ala prying open 2 sliding foors) as by doing that my head would get into the way and block the surgeon’s view, so i kinda had to hold the retractors at a 90 degree angle (imagined trying to force open 2 sliding doors with your elbows locked straight) and keeping it there till the entire deal finishes. Phew.
Once done, I’m usually walking around (I’m covering 4-5 wards) checking the to do list on each of the ward’s white boards. Most of them are to refresh orders for medications or fluids, but you do also tend to get the scary stuff like patient has sudden chest pain or patient is having problem breathing or patient’s temperature is near 40 degrees Celsius. Trouble is, sometimes all of these happen at around the same time and you’d really have to prioritise which one to attend to (given they’re all quite nasty sounding) as well as making allowances for the time which you’d spend reviewing them.
In the beginning, it was pretty overwhelming. I was pretty much alone in the middle of the night, and clueless. Not a good combination to have, neither would it be a good one to be in. These kinda situations are often a true ‘sink or swim’ rule where there is no way to go around it but to bite the bullet and throw yourself in. I must admit, it is a tremendously steep learning curve where it matters. We’d often feel quite horrible dealing with it for the first time, but coming away from it knowing that there were so much learnt. In terms of training, it can be viewed as a form of a necessary stress exposure where one couldn’t have been better without.
The main things I came across with night shift.
1. You do random stuffs.
The Good. This is pretty good form of training. Surgical patients have medical problems as well which I’d have to learn to manage – so I get a bit of both (medical and surgical) exposure, really. You’d hardly ever get bored I must say. There’s some bit of thrill crawling under the bed looking for the patient’s lost urine container. Expect everything, I’d think.
The Bad. Being so random means often I’d be running around the entire hospital doing a variety of things. It could get pretty dizzying at times as I can get about up to 30 pages within a shift and suddenly you’re wanted/needed all over the place. I often spend a good few minutes standing in the corridors just working out a list in order of attendance.
The Ugly. On my first night, I remembered receiving a call to pronounce a patient dead. That was really an eye-opener as I’ve never done it before, neither have I been familiar with the process. I know I have to deal with this sooner or later, just that I didn’t expect it to be this soon and at such an unsuspecting time. The patient was new to me and the nurse left me in the room with the patient to do my stuffs. Let’s just say that was the first time I entered a patient’s room without attempting to introduce myself.
I proceeded with examining the patient for signs of life (heart sounds, breath sounds, pulse, etc) and whipped out a pen-torch to check her pupils for a light response. She was still a bit warm when I examined her, and I just learnt that night that often a newly deceased’s eyes would remain open (previously closed as she passed away in her sleep) after I’ve done checking for a light reflex. I documented my findings and pronounced her dead – thought that was it.
Little did I know (or was I prepared for) that it was a reportable death which would mean I’d have to make a coroner’s report. This was all news to me and I remembered sitting in the dimly lit work area sifting through her file, looking for information to fill in the report form. This process of course would be less time-consuming if I were her regular treating doctor (the day team) but since I’m doing random night shifts (and my first night then too) – I was hopelessly clueless. It was a bit nerve-wrecking knowing that whatever you wrote in the report would be made viewable to the department of justice and there was much anxiety in trying to keep it as accurate as possible with such little knowledge that I have of the patient.
I filed the report. Had to contact the coroner’s office to inform them of her death and their impending case. I thought that should be about it but I was wrong.
Coroner’s office : Thank you for the information, Dr. Now I’ll just send over the police to take a statement from you.
Me : Oh…okie.
So there was I, giving a police statement for the first time in my life. Prior to this, I thought my first personal encounter with the police (if ever) would most likely be me trying to talk my way out of a speeding ticket. Apparently not.
2. You encounter all sorts of people.
The Good. After some mixing around and some chance encounters, you’d really get to know whom are the ones who look out for you, which is particularly reassuring for a newbie. People tend to be more understanding and patient when they know you’re a newbie; some are really keen to teach and night time is surprisingly not a bad time to do so as we’re not as caught up with the morning paperwork.
My rotation so far has familiarised me with the night nursing staff. Given that this would occur regardless of which shift I am on, somehow I find that we’re more at ease and laid-back with each other – this is most likely due to each of us having a general understanding that there’s less people staffed at night, so we’d all better get along as we’d be seeing/needing a lot more of each other. It’s also a lot easier to really get to know your colleagues when we’re within a relatively smaller group.
The Bad. Some people are, uh, difficult. I received this strange request from the ward one night to ‘talk to the patient’. I went upstairs to see this really disgruntled middle-aged guy whom was giving the nursing staff a hard time. He refused to be treated citing that he demanded to know the exact plan of his treatment, questioning every single detail he could pick out (from why are there 2 bags of drips instead of 1, why did they change the dose of his medications, etc). I could understand the rationale for some of his issues although I thought it looked a bit odd for him to bring all this up at midnight when none of his regular doctors are around.
Soon he started questioning the point of monitoring him (why did we took his blood pressure, why his pulse, etc) and suddenly he asked if he can use the phone to obtain legal advice. I told him he has all the right to obtain external advice and aid, just that I’m not too sure if there’s somebody on the other end of the line in the middle of the night. I gradually explained every single thing that I could with regards to why there is a need to monitor him etc (I find it ironic that he questioned the reason to keep him under observation when he was claiming that we’re delivering a subpar level of care apparently) and gone through a long-winded process of placating him to wait till morning comes for his regular treating team. I repeatedly explained to him that I would not be the best person to advise him of his long-term course of treatment as this would be best done by his regular consultant whom would be more knowledgable of his condition.
Fortunately, he became more reasonable. He waved as if going ‘I’ll have mercy on you, newbie” and settled back in his bed twiddling his fingers. This guy looks pretty determined to get what he wants (or hear what he wants to hear), or he just had the best episode of sleep-talking I have ever seen.
The Ugly. Ah, the meanies. Every now and then (hopefully not too often) you’d bump into people whom appears unstoppable at making your life difficult. I can understand that it’s at night, we’re all tired and hungry and sleepy but some are just bloody grumpy to no end. I’ve had a senior nurse who had shrieked at almost every single thing I was about to do with the reasoning that I looked like I’m about to do it wrongly. With an unbelievably ‘huge’ amount of faith and confidence that she had in me, she could very well be my best friend for life. Pfft.
What really irks me is that she’d morph into a very sweet and charming personality the moment the senior doctor makes an appearance. Suddenly she becomes very chummy and friendly with me, teasing and sharing jokes amongst us as if nothing has happened. Look, I’d really appreciate it if she’s being all warm and friendly towards me but that doesn’t mean that she should have a spade shoved up her arse each time the senior doctor isn’t around. Sheesh.
There are also patients who demonstrated a tremendous amount of confidence in your ability, mainly exhibited by heart-warming and encouraging questions/statements such as Are you sure you know what you’re doing or Can I have someone else more senior or even You haven’t done this before haven’t you?.
I can totally understand their concern, besides it is their health we’re talking about after all. But then again many of them do not realise that this is how we all learn in the first place – the highly regarded seniors and consultants all pretty much started out as newbies once upon a time as well, and they got to where they are now because of their level of experience and expertise. Having said that, I for one agree that some procedures and decisions should only be carried out by the seniors as it requires that level of experience for good decision-making…but um, all I was trying to do was to take some blood/put a drip into their arm. It is a simple basic procedure, but I think most of you out there (especially those in the medical field) would understand that it’s not fool-proof and it only gets better with practice.
So unknown to them (not consciously at least), they’re actually not helping us newbies to learn by denying the opportunity. Can’t level up as we tend to say in video-game talk.
3. Things are done differently at night.
The Good. Not much formalities. We all pretty much turn up in comfy casual clothes, which is good news for me as I wouldn’t have to bother much with the ironing (cause I am a lazy bum). It’s a nice change to be able to walk into work in shirt, jeans, and sneakers. No formal ward rounds, which would mean much less paperwork for me.
There is a relatively more relaxed atmosphere at work. I usually would bring a bucket-load of sweets and chocs to keep my energy up throughout the long night; passing them around to the much-delighted staff as we pored over our patients while nibbling away. No hustle-bustle like during the day when various teams of doctors scuttling around reviewing their patients and no waiting around for your unit to congregate to start a round. Just pop in and do whatever that needs to be done.
The Bad. As it is night time, you could become relatively busier as suddenly you find yourself needing to do everything (as opposed to sharing the responsibilities with the other intern from your team during the day). It’s a one-newbie show most of the time. It makes things more difficult when you have to cover the wide variety of surgical patients regardless of what unit they’re from (anything from the usual gastro to plastic surgery) and that could be quite a huge patient list to deal with.
The emergency department is also particularly busy at night as patients are directed/shunted to turn up at the ED as most clinics are closed after hours. I’m usually paged to the ED for any surgical admissions to finalise the paperwork for them to be transferred to the wards. Due to high patient intake, I find myself often facing pressure from the ED nurses to do the admissions as soon as possible (given that I’m stuck in the wards most of the time sorting out stuffs there) as there is a pressing need to empty the ED beds for new patients. Usually during the day, this could be discussed and negotiated with the other junior doctors on your team on whom would best available to go down to the ED to admit the patient. During after hours however, it would only have to be the one surg intern on duty (me!) as there isn’t anyone else. So needless to say, it can get immensely busy.
The Funny. There was a time when I had to prepare the patient for a surgery. This would include doing a cross match for blood in the event of heavy blood loss during surgery, as well as the insertion of a urinary catheter. Usually it’s fairly straightforward when it comes to putting in one, except that there is less light to work with at night. It would be ideal to actually just turn on the entire room’s lights but that would mean having to wake every patient in the room up – which would be inconvenient. So we normally just turn on a small bedside light located at the head of the bed, which would suffice most of the time. Most of the time, I say.
The lady whom I was supposed to insert a bladder catheter into was very pleasant and cooperative. I had the trolley and all the equipment set up and ready to go. Trouble was, it wasn’t very easy to locate the urethra under suboptimal lighting and I was straining my eyes trying to find it (trust me, it’s not as easy to find as we all thought it would be). I didn’t want to spend too much time fiddling around, and for a moment I had this grand idea of asking the patient to pee a bit so I could see where it’s coming from BUT there is a risk of getting my face sprayed with it so never mind. I still think it’s a brilliant idea though.
I asked the nurse to assist me in locating the urethra and she resourcefully turned up clutching some huge torchlight (when I say huge, I meant those heavy duty ones which people use when going camping or caving). I had to stop myself from grinning when the nurse proceeded to shine the beam centred between the patient’s legs so I could carry on with the task. The patient must have felt awfully weird to be in such a vulnerable position with legs splayed out wide and to have a personal ‘spotlight’ on while 2-3 people doing a mini treasure hunt. She took it all in good humour, commenting that “I would normally enjoy all the attention except that it’s all down there”.
The powertorch helped, and we got the job done. Hehe.
Now that was a fairly long post. That’s all for now, folks! Stay tuned *grins*.