Since I had such a bad 15hour shift tonight, I might as well relive my "nights" nightmare, and write about my 3 weeks of nights!
Nights
Week 1: Just starting out
Graveyard shifts from 10.30pm to 8.30am…. Not only am I starting internship with the “nights/relief/anesthetics” term, I’m actually starting with NIGHTS this term! On the night before people start working as interns, I had to go into hospital at 10.30pm…. a Sunday that is! And theoretically, interns are not supposed to have nights in their first term! I don’t know why RPAH is making us have it in our first term! The only good thing is that for those of us doing nights in the first week, there’s three interns on covering the whole hospital rather than the usual two interns.
As a medical student, I have never attempted to chart any fluids. The most I did was to jot down some clinical notes during ward rounds, copy medications from one medication chart to another, write up a discharge summary, and occasionally help out with taking bloods and putting in cannulas. I decided to bring my year 6 management viva notes with me on the shift!
Day 1
So, on this dark dark fateful night, I drove to the hospital unwillingly. That was the first time I have driven to RPAH and I did not even know how to get to the staff car park. After going round and round in circles, I went into a car park, which turned out to be the wrong carpark!
Anyway, I managed to make it to the 10.30pm handover on time. Walking in wide-eyed, I had no idea what is about to occur. Anyway, after the handover finished, I ended up having to cover the geriatrics, neurology and post-op wards. I went to the geriatrics ward first. This was the first time I had to take charge in a ward alone, unsupervised! And what was the first thing I had to do? Chart up fluids! I panicked! Good thing I had my management viva notes with me… it helped me remember what to chart up amidst my panic! I also had to put in some cannulas and take some bloods. Most of the actions occurred in the geriatrics ward that night:
One elderly gentleman lost 500mL of blood from his stoma from the geriatrics ward… amidst the anxiety, I did not look to see whether the blood came from the gut or the outside of the stoma. I had to take his bloods for Hb and crossmatch. The medical and surgical registrar dealt with the rest of the issue. Another elderly gentleman suddenly had an O2 saturation of 40!
Most memorable events from the week:
1) AV fistula bursted, patient poured out 1L of blood instantaneously:
The other intern could not even get a blood pressure! Everyone’s crowded around the patient trying to get bloods from crossmatch etc, while establishing IV access to get fluid resuscitation for her!
2) Spinal shock:
An elderly gentleman with spinal mets from prostate cancer! First time to see spinal shock in action! This has lead me to realize that although we know perfectly well what we’re supposed to do in this sort of situation from our 6th year management vivas, the hard bit is to actually get those tasks going! (eg. Having to find out how to call the med reg, neurosurgical reg, ordering MRI scans and actually make sure it is done etc!)
Week 2: The nightmare week
Day 1
This was the first time for me to cover half of the hospital. In the first week, there were three interns, so everything was manageable…. Tonight, it was chaos! To make it worse, I was covering the upper half of the hospital, which is said to be more chaotic than the lower half! I kept having to rush from ward to ward, getting continuous strings of pages from various different wards, many patients became unstable… It was truly an intern’s nightmare! There were several “speaking o the devil” incidences. For example, I was revising about putting in a urinary catheter before the shift and asking the other intern about where to tape the catheter after I finish. The evening registrar overheard us and told us we don’t need to worry and can just get someone to supervise us…. Then there was a urinary catheter for me to do on the wards, for the very first time in the night shifts! Furthermore, the night medical registrar was much stricter than the one I had previously; even with unstable patients, she insists on me assessing the patient fully before talking to her, and only page her immediately if the patient is actually crashing right in front of me… Earlier on, the DCT have emphasized that we should ask for help whenever the we are uncertain about anything, so I was under the impression that I should page pretty early on, and it seemed alright with the last reg I had. Anyway, I’d better get even more independent now. Anyway, after her spill from when I first called her about a patient with pulmonary oedema, I was reluctant to call her early on for the next pulmonary oedema (which I thought seriously need MI excluded), and indeed he seemed to have MI so the registrar sent him to CCU. This was the man who needed a urinary cathether, and since I’ve done a few urinary catheters in theaters before, I didn’t get her to supervise me – I got it in right anyway. And this is the first shift I got called to assist in theatres by the surgical reg! It was a laparotomy for patient with small bowel obstruction, and the reg just kept removing adhesions. It took a long time! The other poor intern had to cover for me while I was assisting in surgery so her night is also extremely hectic! The night was so busy that I couldn’t get things done fast enough and got scowled at by some nurses…. It was hard to prioritize what to do first when there’s so much to do! A night to remember….
Other very memorable events:
1) Pukes:
On one of the nights, I had to put in 2 nasogastric tubes! I did one NGT when I was in 6th year, so I decided to try the first one unsupervised…. But I made the patient gag! So I got the surgical reg to supervise me! Then I did the 2nd one unsupervised. With the 2nd patient, he already had an NGT in, but it was blocked, so I tried to flush it to make sure it was really blocked. I saw a glass of creamy colored fluid next to the bed with a syringe, so I sucked up some of that fluid and try to inject it into the NGT (yes, I was clueless about how to test NGT patency at that time), and the fluid splurted up onto my head instead! And it turned out that creamy fluid was actually the patient’s NG aspirate (another words, his puke on my head!!)
On another night, there was one patient who became so sick that she started having feculent vomiting! So the surgical resident asked me to take bloods while she was trying to put in a NGT at the same time – the patient’s arms was all in spasm, but luckily I managed to get some bloods!
2) 1 intern covering whole hospital for 4 hours
I had no sleep during the previous 3 or 4 nights! So this time, it was one of those rare nights when I finished all my tasks at 4am. I thought to myself, “Wow, I could finally get some sleep”, when I suddenly got called by the switch board that the intern covering the lower half of the hospital is called into the operating theater to assist in an appendectomy, so I will be covering the whole hospital for half an hour. If only it was really half an hour. It turned out to be a four-hour operation because they couldn’t find the appendix and even had to call the consultant in (=attending)!!! So I ended up covering the whole hospital for 4 hours, and obviously, the pager started ringing continuously and it was impossible for me to finish everything I was called about!
3) My first seizure patient
There was a patient in hospital with traumatic subdural hematoma with a background history of epilepsy. I was suddenly called to see the patient because the patient suddenly could not open his eyes and was not responsive to his wife! I asked the wife if that’s how his epileptic seizures are like, and she said he’s never been like this in his attacks! Anyway I got really worried and started thinking of things like brain herniation ad stuff! I called the med registrar. It took a long time before the she came! By then, the patient was half recovered and the reg winked at me and told me not to be so nervous!
Week 3: Very sick patients that kept me very busy for the first half of the week
This is the week where I learnt the most. Why? Because for some strange reason, there were a lot of very sick hematological patients in the usually not so busy hematology ward! Yes, a busy week despite covering the “less busy lower half of the hospital”! Therefore, I had a lot of interaction with the med registrar, who had to routinely review these very sick patients every night.
Lots of patients spiked fever every night! There were also quite a lot of patients with deranged K – hypers and hypos! In fact, with the first hyperkalemia I encountered that week, where I immediately charted insulin/dextrose and resonium and ordered an ECG, it turned out the task was already done in the morning but they just forgot to rub it off the board! What a waste of my time!
However, I got a lot of sleep during the last 2 or 3 nights of this week…. As unfortunately and inevitably, the sickest patients eventually died towards the end of the week!
Nights
Week 1: Just starting out
Graveyard shifts from 10.30pm to 8.30am…. Not only am I starting internship with the “nights/relief/anesthetics” term, I’m actually starting with NIGHTS this term! On the night before people start working as interns, I had to go into hospital at 10.30pm…. a Sunday that is! And theoretically, interns are not supposed to have nights in their first term! I don’t know why RPAH is making us have it in our first term! The only good thing is that for those of us doing nights in the first week, there’s three interns on covering the whole hospital rather than the usual two interns.
As a medical student, I have never attempted to chart any fluids. The most I did was to jot down some clinical notes during ward rounds, copy medications from one medication chart to another, write up a discharge summary, and occasionally help out with taking bloods and putting in cannulas. I decided to bring my year 6 management viva notes with me on the shift!
Day 1
So, on this dark dark fateful night, I drove to the hospital unwillingly. That was the first time I have driven to RPAH and I did not even know how to get to the staff car park. After going round and round in circles, I went into a car park, which turned out to be the wrong carpark!
Anyway, I managed to make it to the 10.30pm handover on time. Walking in wide-eyed, I had no idea what is about to occur. Anyway, after the handover finished, I ended up having to cover the geriatrics, neurology and post-op wards. I went to the geriatrics ward first. This was the first time I had to take charge in a ward alone, unsupervised! And what was the first thing I had to do? Chart up fluids! I panicked! Good thing I had my management viva notes with me… it helped me remember what to chart up amidst my panic! I also had to put in some cannulas and take some bloods. Most of the actions occurred in the geriatrics ward that night:
One elderly gentleman lost 500mL of blood from his stoma from the geriatrics ward… amidst the anxiety, I did not look to see whether the blood came from the gut or the outside of the stoma. I had to take his bloods for Hb and crossmatch. The medical and surgical registrar dealt with the rest of the issue. Another elderly gentleman suddenly had an O2 saturation of 40!
Most memorable events from the week:
1) AV fistula bursted, patient poured out 1L of blood instantaneously:
The other intern could not even get a blood pressure! Everyone’s crowded around the patient trying to get bloods from crossmatch etc, while establishing IV access to get fluid resuscitation for her!
2) Spinal shock:
An elderly gentleman with spinal mets from prostate cancer! First time to see spinal shock in action! This has lead me to realize that although we know perfectly well what we’re supposed to do in this sort of situation from our 6th year management vivas, the hard bit is to actually get those tasks going! (eg. Having to find out how to call the med reg, neurosurgical reg, ordering MRI scans and actually make sure it is done etc!)
Week 2: The nightmare week
Day 1
This was the first time for me to cover half of the hospital. In the first week, there were three interns, so everything was manageable…. Tonight, it was chaos! To make it worse, I was covering the upper half of the hospital, which is said to be more chaotic than the lower half! I kept having to rush from ward to ward, getting continuous strings of pages from various different wards, many patients became unstable… It was truly an intern’s nightmare! There were several “speaking o the devil” incidences. For example, I was revising about putting in a urinary catheter before the shift and asking the other intern about where to tape the catheter after I finish. The evening registrar overheard us and told us we don’t need to worry and can just get someone to supervise us…. Then there was a urinary catheter for me to do on the wards, for the very first time in the night shifts! Furthermore, the night medical registrar was much stricter than the one I had previously; even with unstable patients, she insists on me assessing the patient fully before talking to her, and only page her immediately if the patient is actually crashing right in front of me… Earlier on, the DCT have emphasized that we should ask for help whenever the we are uncertain about anything, so I was under the impression that I should page pretty early on, and it seemed alright with the last reg I had. Anyway, I’d better get even more independent now. Anyway, after her spill from when I first called her about a patient with pulmonary oedema, I was reluctant to call her early on for the next pulmonary oedema (which I thought seriously need MI excluded), and indeed he seemed to have MI so the registrar sent him to CCU. This was the man who needed a urinary cathether, and since I’ve done a few urinary catheters in theaters before, I didn’t get her to supervise me – I got it in right anyway. And this is the first shift I got called to assist in theatres by the surgical reg! It was a laparotomy for patient with small bowel obstruction, and the reg just kept removing adhesions. It took a long time! The other poor intern had to cover for me while I was assisting in surgery so her night is also extremely hectic! The night was so busy that I couldn’t get things done fast enough and got scowled at by some nurses…. It was hard to prioritize what to do first when there’s so much to do! A night to remember….
Other very memorable events:
1) Pukes:
On one of the nights, I had to put in 2 nasogastric tubes! I did one NGT when I was in 6th year, so I decided to try the first one unsupervised…. But I made the patient gag! So I got the surgical reg to supervise me! Then I did the 2nd one unsupervised. With the 2nd patient, he already had an NGT in, but it was blocked, so I tried to flush it to make sure it was really blocked. I saw a glass of creamy colored fluid next to the bed with a syringe, so I sucked up some of that fluid and try to inject it into the NGT (yes, I was clueless about how to test NGT patency at that time), and the fluid splurted up onto my head instead! And it turned out that creamy fluid was actually the patient’s NG aspirate (another words, his puke on my head!!)
On another night, there was one patient who became so sick that she started having feculent vomiting! So the surgical resident asked me to take bloods while she was trying to put in a NGT at the same time – the patient’s arms was all in spasm, but luckily I managed to get some bloods!
2) 1 intern covering whole hospital for 4 hours
I had no sleep during the previous 3 or 4 nights! So this time, it was one of those rare nights when I finished all my tasks at 4am. I thought to myself, “Wow, I could finally get some sleep”, when I suddenly got called by the switch board that the intern covering the lower half of the hospital is called into the operating theater to assist in an appendectomy, so I will be covering the whole hospital for half an hour. If only it was really half an hour. It turned out to be a four-hour operation because they couldn’t find the appendix and even had to call the consultant in (=attending)!!! So I ended up covering the whole hospital for 4 hours, and obviously, the pager started ringing continuously and it was impossible for me to finish everything I was called about!
3) My first seizure patient
There was a patient in hospital with traumatic subdural hematoma with a background history of epilepsy. I was suddenly called to see the patient because the patient suddenly could not open his eyes and was not responsive to his wife! I asked the wife if that’s how his epileptic seizures are like, and she said he’s never been like this in his attacks! Anyway I got really worried and started thinking of things like brain herniation ad stuff! I called the med registrar. It took a long time before the she came! By then, the patient was half recovered and the reg winked at me and told me not to be so nervous!
Week 3: Very sick patients that kept me very busy for the first half of the week
This is the week where I learnt the most. Why? Because for some strange reason, there were a lot of very sick hematological patients in the usually not so busy hematology ward! Yes, a busy week despite covering the “less busy lower half of the hospital”! Therefore, I had a lot of interaction with the med registrar, who had to routinely review these very sick patients every night.
Lots of patients spiked fever every night! There were also quite a lot of patients with deranged K – hypers and hypos! In fact, with the first hyperkalemia I encountered that week, where I immediately charted insulin/dextrose and resonium and ordered an ECG, it turned out the task was already done in the morning but they just forgot to rub it off the board! What a waste of my time!
However, I got a lot of sleep during the last 2 or 3 nights of this week…. As unfortunately and inevitably, the sickest patients eventually died towards the end of the week!
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