Night Shift

A first night

On my first night on call as a surgical junior doctor I was called to a patient on the second day after major bowel surgery. He was agitated, tachycardic, and mildly hypotensive, and the nurses assured me that he had passed only 10 ml of urine in the past four hours. I ran from the opposite corner of the hospital to find a clearly sick and possibly septic patient. His ABCs (airway, breathing, circulation) were good (except for his tachycardia), and he was experiencing abdominal pain but was too agitated to tell me more than that. On examination he was guarding around his lower abdomen; it was very tense, but he still had bowel sounds. His fluid balance chart (not fully completed by the nurses) showed only one litre in over the past 24 hours, and only about 500 ml out (all day from his catheter). Culprit found: “He’s hypovolaemic,” I thought. So we gave him a 500 ml bolus of succinylated gelatin solution for intravenous infusion and followed that up with a six hour bag of Hartmann’s solution. Over the next hour his agitation worsened.

I called the surgical senior house officer, who shouted at me for having woken him, promised to come anyway, and asked if we had given the patient a bladder scan. I had to sheepishly say we hadn’t thought of that. By the time he got there we’d done a bladder scan, which showed more than 900 ml. The catheter clearly needed changing because it was completely blocked. We set up the trolley, ready for me to pass a new catheter, disconnected the catheter bag, and deflated the balloon. I was promptly soaked by the 900 ml of urine before I’d even withdrawn the catheter. The patient breathed a sigh of relief and thanked me, and the senior house officer walked in to find me covered in urine.

My tips for anyone approaching their first set of surgical nights are:

* If a patient has poor urine output flush the catheter and bladder scan them before panicking about fluid challenges
* The senior house officer may be asleep, but the trust is paying them to work, so don’t feel guilty about waking them up if you’re unsure about something
* Always have a spare change of clothes or know the code to the theatre changing room so if you get covered in blood, vomit, or urine you can get changed.

Sarah Jones, F1, Nottingham

Looking forward to my first night shift (sort of) on Friday!