Good night and good luck

WHEN considering nightshifts your first thoughts may be tinged with apprehension - that is only to be expected. If your consequent thoughts are vats of coffee, Pro Plus, matchsticks for eyelids and thumb tacks in your shoes, then you are setting off on the wrong foot (and a soon to be bleeding one at that).

Know your enemy

It’s not that scary consultant in A&E, it’s fatigue. Let’s not get physiological about this but your body is fighting to tell you to sleep. Outside it’s dark, your hormones are in flux and a baseball programme is on Channel 5; you should be hugging teddy. If, however, you equip yourself properly for battle, nightshifts can become some of the most fruitful times of your early career.

Preparation

Trying to sleep before the first nightshift is hard and there are a multitude of techniques that each individual will advocate as the most successful. Tempting as it may be, a night of drink and dance until the sun glints on the rooftops will not best prepare you for the ensuing nights of work and concentration. A lie-in followed by an afternoon nap is probably a suitable way to ease into a new sleep pattern.

Your bedroom needs to be just that: a room with a bed for sleeping. I find black-out material which I Velcro over the blinds helps plunge me into foetal darkness. You may prefer an eye-mask or the addition of earplugs for those times when your neighbours all decide to Hoover at once.

You must remember to eat, and getting your shopping done to cover the period of your nightshifts will save an exhausting traipse round the supermarket post-shift, or an infuriating early rise in the evening to shop pre-shift. Caffeine-laden comestibles are, in the main, best avoided. A brief period of heart-pounding alertness will signal an even deeper tiredness and the inability to sleep in the morning. Water and fruit juices to combat dehydration and “slow release” foods like nuts and dried fruit are good. Cereal bars are always handy to carry in a pocket and munch on between wards. Ideally you’d have a veritable banquet laid on by the HDU staff each night as I happily experienced once, but I can’t guarantee it.

Make sure you have all the usual tools of your trade: stethoscope, pens and the rest. You’ll see lots of the usual night's calls, such as dropping BP, decreased urine output, chest pain, falling Sats and requests for night sedation. Read up on these beforehand if you need to and revise your resuscitation guidelines. Carry a helpful book you trust such as an Oxford handbook or good on-call book (pocket-sized preferably). If your hospital/NHS Board has a prescribing guide then take that too.

First night nerves

Be on time and write everything down. Make sure you know who else is on with you and who to contact if you have a problem. I worked with a Registrar who, on the first night, would head off saying: “Call me if you need me”. He would then lope down the corridor before coming back and asking: “What’s my page number?” Invariably the junior wouldn’t know it and hadn’t thought to ask. Make sure you do.

Get a good handover from the evening shift. It’s tempting to be magnanimous and graciously say: “I’ve got it, you head off”. Resist this admirable temptation and find out what is left over from the previous shift – problem patients, tasks to be completed at certain times overnight or results that must be available for morning rounds.

Tiredness breeds laziness. Strongly resist the urge to cut corners and ensure you write fully in the notes. Three in the morning is rarely a good time to drastically change a patient management plan unless your seniors have approved it.

Don’t let nightshift be lonely; there are plenty of other people in the same boat, wandering the hospital. Help those around you and they, in turn, will help you. Teamwork is especially important at night.

Napping may be of benefit for short periods of 20-45 minutes. Longer may lead to deep sleep and grogginess upon waking. Times are changing and on-call rooms disappearing but you are entitled to breaks and these may be utilised for naps if you so wish. Remember to eat, drink and use the “facilities” as mother might say.

Although there is often a pleasurable sense of autonomy in working at night, you should be well-supported by an experienced team including more senior medical personnel on-site. Remember the maxim: get help sooner rather than later.

The morning after

Keep in mind the tired and emotional state that you may occupy come morning. A particular diagnosis or event may elicit a hyped-up mood or a sad event may hit you harder than you feel it might on a day shift. Taking time to talk these over at handover in the morning or with a colleague coming off shift will help to clear your head.

Driving home after a nightshift puts you at an increased risk of being in an accident. Ideally take public transport home or rest before driving. However you make your way home be aware your alertness is not functioning at peak capacity.

For all kinds of good reasons don’t stay up watching daytime TV. This is also not the time to make that trip to the bank, return those books to the library or meet that friend for lunch.

Have a light meal, turn your mobile to silent, set an alarm and head to your wellprepared, dark and peaceful, bedroom.

And in the end

Getting back into daytime mode can be difficult and you’ll feel discombobulated for a day or two. Try having a brief sleep in the morning, a nap late afternoon and a good attempt at a proper night’s sleep that evening. Although daunting, nightshifts can provide excellent opportunities to improve clinical and diagnostic abilities. So grab your stethoscope and a banana, and get stuck in.

Dr Tom Berry is an FY2 in Glasgow and a BMA Scottish Junior Doctors’ Committee representative

More information

• Horrocks N, Pounder R on behalf of an RCP Working Group. Working the night shift — preparation, survival and recovery: a guide for junior doctors. RCP, 2006.

• Robinson G, Bernau S, Aldington S, Beasley R. From medical student to junior doctor: the night shift. sBMJ 2006(Nov); 14: 397-440