Post nights – Risk stratification and coffee

Morning all. So as many of you know doing nights is a normal thing in medicine. The 24/7 nature of healthcare means that hospitals need cover all the time, including during ‘witching hour’ (for those fans of the BFG.) Nights are classically unpredictahle, with service provision limited to only the most necessary.  

Healthcare management, within or outside of hospital settings, is largely based on risk stratification and reasonable expectation of known history. For example, we can expect a patient having had a heart attack to follow one of a certain number of pathways. The nature of those pathways can be modified by facets of the individuals medical history, attitude, response to treatment, details of medical problem and other factors, such as complications.

Begin to add in other things like varying medications, different staff and the variant inaccuracy of measurements then you can begin to see why experience in medicine is likely the most important factor in being a good clinician. Doing a night, or indeed any ‘cover’ shift, presents new challenges to doctors, who are asked to advise on a patient that is within a established management plan but for the most part already within a only somewhat predictable pathway.

The onus of care is not limited to the doctor, with a heavy reliance placed on nurses and other team members to recognise patient deterioration via the analysis of patterns. Within most hospitals this is an ‘early warning system’, where attributes of patient physiology such as respiratory rate and blood pressure are regularly recorded and a score calculated on the level of ‘normality’

Variations from normality are seldom isolated events within one parameter measured, and usually reflect a predictable physiological response. For example, as blood pressure decreases, heart rate will tend to go up. As somebody’s temperature increases, due to infection, heart rate may go up and BP down. Recognising these patterns is the key to early identification of decline and risk stratified modification of a patients management.

Often cover medicine, in my limited experience, is about making decisions based on your best understand of what has been and what could be. The safest way to do this, and is what is generally encouraged, is to hope for the best and prepare for the worst. Night medicine, and cover in general, is a test of a teams sensibilities as well as clinical expertise.

The experience itself is exhausting, with the level of mental strain placed on doctors being much more than usual due to the need to compute and predict long term effects, and place safeguards based on changes of physiology as previously discussed. I personally found it quite a test, but also an opportunity to learn better skills and appraise not just my knowledge, but my approach.

Oh, and day sleep is useless. Coffee is god.

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