As a junior doctor, night shifts are inevitable. As an intern, you’ll come across ward base nights, and nights on ED. Depending on the hospital you’re at, you may be able to avoid them for the first 6 months, but they will eventually creep up on you. They normally come in your relief term, and you’ll usually get blocks of 5-7 nights in a row.

In addition to figuring out how to stay functional between 2am and 4am, while managing wards full of patients you’re not familiar with, they can be overwhelming for a variety of reasons. To help you prepare, here are some tips on surviving nights, based on my and fellow interns' experience of attempting to do the same.

Before Your Nightshift - Managing Your Sleep

Your first nights are like an awful jet lag without the holiday to enjoy on the other side. Do not underestimate the importance of prioritising your sleep in the days leading up to your first night. 

There are a lot of different approaches for how to get yourself ready for your first night shift. Ideally in the days leading up to your run of nights, you can slowly start to transition yourself into your new sleep cycle. On the day of your first shift, you should sleep in and then have a short 2-3 hour nap before heading into work. This article by Dr. Paul Harmor, a respiratory and sleep physician has some good tips on working nights and managing your sleep.  

Of course, we do not live in an ideal world. You may have to work right up until your block of nights, or life may simply get in the way of ideal preparation. In these cases, generally just trying to get a few hours of sleep in before your shift combined with some caffeine can do the trick. If you do get caught going into work without sleep, you can try and hone your skills at stealth-napping. Empty beds in the angio suite can be pretty comfy if you’re sleepy enough. But take no longer than 30-45mins or else it could make you more groggy when you wake up as well as hinder your sleep the following day. 

You also need to prepare yourself to get good sleep during the day between your nights. Make sure you have a cool, dark room (or at least a good eye mask). If you can, ask your roommates or family to keep the volume down, or try a set of noise cancelling earbuds.

Take and Give a Good Handover

When you arrive at work, pick up your pager or phone and head for handover. This is where you get the information on patients that might be challenging overnight. This will give you a sense of preparedness throughout the night. Find out what the plans are for each of the sick patients, what their baselines are and what issues might come up. 

This goes for handing over at the end of your shift, let your colleagues know what has happened overnight, any changes to the patient's condition or management.

Keep the information written down on a handover sheet that can double as a to-do list throughout the night. Add to the list as you need to throughout the night so you have it ready to go for handover in the morning.

Managing Your Worklist

Most hospitals will have some form of ‘job list’ for interns working overnight, where the nursing staff and day teams can log jobs to be completed overnight. It can be overwhelming to arrive at work when you have a list of 30+ tasks that are all flagged as urgent and you've already been paged to review patients. 

Triaging these tasks and reviews is one of the most important skills to pick up on when you start after hours. In general, reviewing patients for concerning symptoms like chest pain or shortness of breath trumps charting fluids or re-siting a day 3 cannula. There are also tasks that will come up overnight that don’t need to be addressed at 3am. I’ve been asked to check a concerning mole, review a week-old mouth ulcer, and review a patient’s long-term Parkinson's medications all in the middle of the night. 

Nurses often don’t know the workload you have on a busy night shift. If you know you’re going to be a while attending to a non-urgent job, let them know, so you can avoid being paged multiple times. 

Feeling Out of Your Depth in Clinical Scenarios

Going into my first set of nights, I was terrified at the thought of being alone handling crashing patients. In reality, when these situations come up you are very well supported.

As an intern covering nights your job is to identify these patients and escalate accordingly. Very rarely will you be required to make any decisions related to a patient's ongoing management. As a general rule, if you are in a situation where you feel out of your depth, ask for help. As you gain experience, you will get better at recognising situations that need attention from someone more senior straight away, and those that can wait.

Most people remember what it was like to start as a JMO and are happy to answer your questions, no matter how silly they are — on my first after hours shift, five days after starting internship, I asked the medical registrar if it was okay to chart paracetamol for a patient.

Seeing Patients After Hours

Reviewing patients after hours is one of the first times you get to practice being a real doctor,  which can sometimes be overwhelming, but it can also be fun and a great learning experience.

The first step to seeing any patient at night is to make sure you know where the light switch is. I've tripped and fumbled and spilt patients' cups of tea more than once, looking for light switches, and if you don’t know, just ask your friendly neighbourhood nurse.

Always keep in the front of your mind that your job overnight is not to cure someone's chronic pain, it’s to keep everyone safe until the morning. When you do see a patient for an issue, try to pre-empt the problem that might arise later in the night. If someone’s bag of fluids is going to expire in 2 hours, re-chart a second bag now. Taking steps in advance can save you multiple calls from the wards for the same issues. 

Make Friends With the Nurses

The nursing staff can make or break your night shift. If you’re covering a particular ward for a number of shifts, make an effort to go and introduce yourself at the start of the shift. When issues arise on the ward always ask what their opinion and concerns are. Always be nice, even when you’re busy. Not only is this the best approach for patient care and collegiality, but this also vastly improves your chances of the nurses sharing their Ubereats with you.

If you need to catch some zzz’s, go and let the ward know that you’re going for a nap, that you’re available for any emergencies, and would prefer if any non-urgent reviews could be kept until you’re back. 

Some Extra Hot Tips:

• In most cases when you’re asked to chart someone for ‘something to help them sleep’, giving them a therapeutic hour wait can work as well as a 5mg of diazepam. 
• When a patient's bladder scan shows 800mL and you’re asked to put in a catheter, physically walk the patient to the bathroom and give them your most inspirational spiel about not having a tube pushed directly into their urethra.  
• If someone needs a cannula, make sure if you ask if there are any nurses around that can cannulate.
  
• If you’re on the phone with someone who sounds worried and you don’t know what to say, ask for the patient’s obs while you think of what to say or do next. 
• Wear comfy shoes, you’ll have some high step counts especially if you’re covering wards on opposite sides of a hospital.  
• Drink water. Many times I’ve found myself at the end of a shift and haven’t drank anything, don’t give yourself an AKI! 

Working at night can be a difficult time for a number of reasons. You’re tired, it can be busy, and it’s difficult to do anything with friends when you wake up at 7pm. It’s a necessary evil of internship, but it’s also a great time to learn, forge friendships with the people you’re working with and most importantly, go for a big greasy post-nights breakfast, ready to do it again, in a few weeks.