I thought I’d create a real-time log of one of my nightshifts, to document the process for anyone who was ever at all curious to see what an orthopaedic night shift can entail. These shifts can be variable, however, usually a Monday night is pandemonium due to people flooding through the A&E doors with battle scars following a weekend of hedonism and debauchery. Often, whenever I’m asked, “how was the night” or “what’s an on-call shift like”, I find it difficult to expand on anything more than just “s’ok, pretty busy”. I decided to create a real-time run through the Saturday night shift during the recent May Bank Holiday weekend. This was a relatively busy night shift, due to the level of widespread activity and accident prone excitement in the local area surrounding the hospital, however it was not as busy as I had anticipated, which was a welcome relief. Nevertheless, I did my best to roughly document what was happening throughout and fleshed it out after the shift was done to try and best demonstrate how the night panned out…
I therefore decided to create a real-time run through the Saturday night shift during the recent May Bank Holiday weekend. This was a relatively busy night shift, due to the level of widespread activity and accident prone excitement in the local area surrounding the hospital, however it was not as busy as I had anticipated, which was a welcome relief. Nevertheless, I did my best to roughly document what was happening throughout and fleshed it out after the shift was done to try and best demonstrate how the night panned out…
19:52
Just arrived to get changed into scrubs, ready for shift number 2. Ran abnormally late today, as I had my deadline for uploading evidence to my portfolio ahead of the Annual Review of Competency Progression (ARCP). Last night had been persistently busy, with a number of patients needing to be optimised preoperatively, including some overspill from the day. When I arrived home, I’d logged straight onto my Intercollegiate Surgical Curriculum Programme (ISCP) portfolio to upload the remaining few forms, so had managed about 4 hours of sleep. Feeling pretty knackered tonight, eyes red and sore, but had a good drive in, sun shining, music with the volume up. Night shifts always feel like a continuous treadmill with a never-ending momentum. I find it so hard to get going initially during nights, but after the first shift, I’m usually in the flow of things, brain adapted to medicine mode. Let’s see how tonight goes…
20:03
Just dropped my bags off in the trauma office and logged into the system to have a quick glance over the handover and check the status of A&E to see how many patients may be coming our way tonight. A&E is full of patients sat in the waiting area and a large backlog because of how busy it’s been. Glancing at the triaged presenting complaints, I can already see a few arm pains/injuries waiting to be seen by a clinician. Fingers crossed they don’t all come my way. We also appear to have 1 neck of femur fracture (NOF#), which did not make it to the operating list today due to list pressures and is therefore postponed til tomorrow.
20:25
A rough handover done of patients waiting to be seen; I now hold the on-call bleep again. The Senior Fellow (SF) on-call has arrived, so we’re first going to review the patients who are waiting to be seen (or those who need an urgent review with pending jobs), and then handover afterwards. I’ll then aim to see the pre-operative (pre-op) patients on my habitual night time ward round of pre-op patients. Feeling a bit more focused now; time to face the music.
20:39
A referral has just come through from A&E for a young patient with a high energy tibial plateau fracture following a fall from 3M height. Apparently they’re neurovascularly intact and hemodynamically stable. I will go and see the patient with the on-call SF after we’re finished with the knee aspiration of the current patient, who has a swollen left knee raising suspicions of septic arthritis of the knee joint.
21:10
The knee aspiration has been completed and we’ve also just finished seeing the patient with tibial plateau fracture. Whilst in A&E, we also saw another patient who had been referred by the medical registrar on-call just before I took over the on-call bleep. The suspicion was septic arthritis of the shoulder, elbow, wrist and fingers, but transpired to just be polyarthralgia secondary to rheumatoid arthritis. Time to head back to the trauma office for a full handover with the day Senior House Officer (SHO) on call, who has finished updating the handover. They won’t be there to present the patients in the morning, which means I have to know about the all the patients in this current take and competently present them in the trauma meeting tomorrow morning.
22:30
Just sorted out the jobs for the patient with the tibial plateau fracture and placed them in an above knee backslab to immobilise the fracture and provide some analgesia through structural support. Still have some jobs pending from the day team to go and sort out, e.g. taking blood cultures for a patient with a septic joint and then checking up on the pre-op patients.
00:11
Bloods all collected from the patient with the septic joint. Took a full set of pre-op bloods at the same time as taking the blood cultures, as there was a query about whether the patient will require a washout on the trauma list. I’ve marked, consented and provisionally fasted them ready for theatre, should the decision be taken. It’s been a real pain tonight as the label printing machines are currently down, which means that every tiny blood bottle and form have to be filled out by hand. Not necessarily taxing, but just annoyingly time consuming!
01:39
Just seen two patients who were referred over the last hour. One was a request to review a patient under the medical team to check for the presence of a septic joint, as the patient had been admitted feeling general unwell with total body pain. The other was a patient under General Surgery with back pain, who had a CT proven mild compression fracture of the 4th lumbar vertebrae (L4). Both reviewed and documenting in their notes now. The patient with the septic joint transpired to be generalised arthralgia with no focal septic joint in the end. However, the patient with back pain was more interesting and may need further investigations, including a bone scan. Plan is to MRI the lumbar spine in the meantime and discuss with the local tertiary spinal centre.
02:21
Spinal patient referred to the tertiary spinal centre, will keep a look out for what they say. Starting to flag now, also feeling hungry so may try and grab some food in a bit while I can.
02:58
All documentation up to date and new patients added to the handover. Let’s go and get some food.
03:33
Got bleeped back to the ward due to a patient with leg pain. No evidence of DVT, full pain free mobilisation on the affected leg. No acute orthopaedic intervention required.
03:45
Just had a quick browse through the A&E list to see what was coming in. I spy a possible fractured neck of femur… No x-rays yet.
04:43
The suspected fractured neck of femur patient did indeed come to me in the end. Displaced intracapsular neck of femur fracture. A&E are thankfully doing a fascioiliaca block to provide some crucial analgesia for the patient.
06:11
Seen the patient with the NOF# and optimised them preoperatively. Kept NBM, IV fluids prescribed, analgesia prescribed, ECG and chest X-ray done, marked and consented for a hip total or hemiarthroplasty. Functionally, I feel they could be suitable for a total hemiarthroplasty, but I’ve advised them that their comorbidities may preclude them from this, and so a hemiarthroplasty may be a safer operative option. Documented and added to handover, ready to go.
06:33
The trauma coordinator has arrived and I’ve updated her. Also updated the SF on-call with regards to what’s come through the door. The SF or Specialty Registrar (SpR) usually phone in the morning to check how urgently they need to come in, e.g. do they need to review any of the patients before trauma meeting, or am I happy that I’ve seen and stabilised everyone, as well as marked and consented them, ensuring they are ready to go as soon as the meeting is finished in the morning.
07:07
Just popped up again to do a final check of the pre-op patients and ensure everything is in place for them prior to the trauma meeting. As luck would have it, one of them was pyrexial; I’ve taken and sent blood cultures and repeat bloods, just laboriously handwriting the labels now as the label printing server is still down…
07:19
Drawing ever closer to the trauma meeting. Time to head back down to the trauma office and check the final few bits of the most recent admissions to ensure everything is in place ready for the day. Still need to print the trauma handover and ensure I know all the patients including day team, as I have to present them all this morning in the absence of the day SHO on-call from yesterday.
07:38
Trauma handover printed and ready to go.
07:50
Inputting all the hospital numbers into PACS ready to bring up the x-rays during the trauma meeting whilst we discuss patients. Everything ready to go, handovers all printed including information about previously admitted patients who are on today’s trauma list.
08:38
And that’s a wrap. I feel like all the patients were presented well, with a few educational discussions to keep the brain cells stimulated after a long shift. Feels like a good night’s work, very ready to sleep now.
Vasudev Zaver 