Night shifts as a registrar is a different kind of scary to nights as an intern or a resident. An unaccredited surgical registrar takes us through how to not only survive, but also how to get the most out of your nights.

“He’s a 58-year-old male presenting with lower abdominal pain on and off for three days, associated with diarrhoea and loss of appetite. His bloods are fairly unremarkable aside from a mildly elevated white cell count. I’ve scanned him and I don’t think there’s anything to explain his symptoms. I think it’s viral and I want to discharge him home…but I just wanted to make sure it’s safe to do so and have you look over the scan and clear him for discharge.” I confidently tell the emergency department (ED) doctor that I’ll look through the patient’s file and see them. Inside, I am a ball of nerves as it is night one of a month of night shifts, and the very first time I’m the night general surgery registrar.

There is a typical hierarchy of junior doctors rostered to staff a hospital on night shifts from around 8pm to 8am.  Speciality units will have an intern or resident who is in the hospital overnight and is the first point of contact for patient care.  These doctors will cover multiple units and are supervised by a medical registrar and a surgical registrar who are also in the hospital overnight.  In turn, these registrars are supervised by fellows and consultants who are on call from home.  Overnight, the registrars are the most senior doctors covering the hospital, and calling for help means waking up a doctor who is asleep in a warm comfortable bed and has been working all day.  The key is knowing when to call for help, and it is almost never in response to the question, “I want to discharge them home but wanted to double check!”

This is why my heart is racing after the phone call from ED.  I’ve been looking at CT scans throughout my first year as an unaccredited registrar, but there was always a senior surgical registrar or fellow to also look through them with me. On night shift, if I want to run a scan past someone, I need to wake them up knowing they have worked all day and will be working the next day too.  When someone is critically unwell, this is an easy decision to make.  However, the subtlety of identifying patients who require surgical admission versus those that are safe to discharge home can be a tricky decision to make — and it is also one of the key lessons for junior registrars to learn.  This is the major difference between being the day surgical registrar on call versus the night surgical registrar — the responsibility for patient decision making relies on you, while your senior supervisors get some well deserved rest at home. 

Does this patient require an admission? Does this patient require urgent surgery tonight? Is this patient safe enough to be discharged home from ED with or without outpatient follow up? Have I just admitted a patient to hospital who doesn’t require an admission and the fellow will be unhappy with my decision tomorrow morning? Have I missed something and discharged a patient home who should have been admitted? These questions swirl through my head as I start to read through the patient history, look over the bloods and then the CT scan. Liver, gallbladder, pancreas, stomach, small intestine, large intestine, kidneys …check check check. No free gas, no free fluid, no red flags. I assess the patient, decide there are no acute surgical concerns and agree with the ED doctor that they do not require an admission.  Finally, I provide a safety net for the patient by educating them about concerning symptoms and to re-present to the ED if they feel more unwell.  For the next hour my mind races over each of the decisions I have made with this patient, re-tracing the patient’s history and blood results, worrying if I made the right decision.  That is until another referral comes through from ED, a new patient with a new set of problems to assess and come up with a management plan for.  Did I mention it is 1am and the night is still young?! 

How to develop your clinical acumen and decision making is outside the scope of this article, but I thought I would share some of my insights and tips for junior registrars tackling their first shifts as a surgical registrar, now that I have a few under my belt.

1. Fear

The first few nights I was constantly worried I would make a mistake, make the wrong decision about patient management, miss a diagnosis, not escalate to the fellow early enough, wake the fellow up for a minor question, give the intern the wrong advice.  The constant worry was exhausting.   What I learnt very quickly was to remember that ultimately as a junior surgical registrar I just need to deliver safe care to my patients.  The fellow is paid to be on call and yes, they are at home and likely asleep, but they are also there to help you manage sick deteriorating patients.  If you need help to manage patients in the safest way possible then you ask for it.  No one expects you to perform major operations at night alone.  No one expects you to make life and death decisions on your own.  And everyone has been in your position before and remembers their first nights as a junior registrar.

2. Teaching

The other huge learning curve that makes nights as a surgical registrar different to nights as an intern or resident is that you are the final point of call for junior doctors.  The interns and the residents call you to clarify their clinical assessments and ask for management advice. They call you for support and guidance when they feel out of their depth, and they call you to make sure they are being safe.  Unlike during daylight hours you cannot turn to your senior registrar to make sure you are giving them the right advice — suddenly you’re the more senior surgical doctor in the hospital! It can feel overwhelming at times as it is a steep learning curve, but it’s likely that by the time you are a surgical registrar you’ve developed lots of skills along the way. Luckily, there are also lots of other registrars in the hospital to help you manage patients and collectively we share lots of experience and knowledge.  You can always call your radiology registrar to help assess the CT scan; your medical registrar colleague to help manage acute perioperative complications in your patients; your anaesthetic and intensive care colleagues to manage difficult IV access or critically unwell patients; and your senior nurses for help managing the delirious patients or for a debrief after a challenging clinical situation — just like they call on you for advice and help.  Health care is a multidisciplinary team effort to manage complex patients, this is never truer than the 3am medical emergency team call for the acutely deteriorating patient who has been in hospital for months. There is a finite number of medical staff on night shifts, so don’t hesitate to work together and help one another out where you can!

3. Leadership

As a registrar on night shift, it is your responsibility to attend urgent codes and clinical reviews for patients, and unlike when you were a resident or intern working nights, suddenly you will be leading the codes with the medical and intensive care registrars.  The junior doctors you are supervising will be looking to you to run the codes, make management decisions, and instruct other team members to escalate where appropriate e.g, you may ask a very nervous junior doctor to wake up a speciality medical or surgical consultant about their patient.  Deteriorating patients are stressful for doctors and nurses, even more so overnight where resources are limited.  Remember to remain calm and approach each patient systematically so as to overcome any mental errors from fatigue.  Don’t forget you are not alone.  I’ve said this before, and I will say it again, work together as a team on night shift regardless of your training speciality background. Teamwork makes the dream work! 

4. Operative Skills

What all surgical registrars secretly dream of each day, operating!  Night shifts present the opportunity to assist the fellow with operations for acutely unwell patients.  We always try to minimise after hours operating – as studies consistently show increased risk of complications and errors with fatigued surgical, anaesthetic and nursing staff – however sometimes patient surgical care is so time sensitive it cannot wait.  Whilst there is a long line of doctors wanting to jump in and operate, at night there is at most your consultant, fellow and then you. Make the most of any opportunities to develop your skills as first assist and ride the adrenaline high of the three-hour emergency laparotomy case that starts at 4am — you’ll never feel more awake! 

5. Preparing for Night Shift

Finally, the practical logistics of preparing for night shift must be emphasised.  Fill the car up with petrol or top up your public transport card; stock the fridge with easy to prepare meal ingredients (or even better order some pre-made meals for nights); buy an eye mask to block out the daylight; do your washing pile and clean your home; minimise your other commitments; and tell your family or roommates when you are working nights so they will hopefully keep the noise to a minimum. Nights play havoc on your body clock and circadian rhythm even if you’re a ‘good sleeper’.  Do everything you can to make it a little bit easier on yourself, the physical toll and jet lag feeling is very real. 

Don’t forget, you are still a junior trainee, there is always someone to ask for help …and the day light comes quickly because surgical ward rounds start early! Good luck!