How to Prioritise Patients
Dear Friend,
It seems like summer has finally arrived. This past week was one of my toughest as a junior doctor, with four night shifts each lasting 12.5 hours. By the time I completed my shifts on Friday morning, I didn’t realize how burnt out I was. It has taken the entire weekend to recover.
Medical night shifts generally fall into two categories. The first is medical take, which involves working in A&E and admitting new patients to the hospital. This includes taking a history, prescribing medication, ordering investigations, and developing plans, which are then reviewed by a consultant in the morning. This shift can be very busy since you see patients back-to-back, and some may be very unwell. However, it allows you to compartmentalise patients and see them one at a time (usually).
The second type of shift is ward cover, where you are the on-call doctor covering multiple wards and all the patients in them. If a patient becomes sick on these wards, the nurses will page you to review. Additionally, it involves chasing blood results and investigations that the day team might not have seen, updating families, handling self-discharge requests, prescribing medication, and more.
This week, I was on medical ward cover. Usually, a team of three doctors handles this in my hospital: a registrar, an SHO (myself), and an FY1. However, the registrar called in sick, leaving just the FY1 and myself, with the A&E medical registrar available for help if needed.
In such situations, prioritising patients and tasks becomes crucial. A good doctor isn’t one who completes the most tasks, especially at night, but one who recognises and addresses the most critical tasks based on patient acuity. As an FY1, I used to try to do everything, often skipping breaks, but sustaining this for four consecutive shifts is impossible. This week, I want to share the lessons I learned about prioritising patients and managing the workload as a junior doctor on night shifts to feel less overwhelmed.
A-E Approach
The A-E approach is an essential method for assessing patients and determining which ones require immediate attention. When a nurse asks you to review a patient, check their notes, review their observations, and evaluate their condition.
- Airway: Ensure the airway is patent. If it is not, this constitutes an emergency.
- Breathing: Check the respiratory rate and oxygen saturation. Low values indicate a critical situation.
- Circulation: Assess heart rate (HR) and blood pressure (BP). Extremely high or low readings are dangerous.
- Disability: Monitor temperature and consciousness. Unresponsiveness is urgent.
- Exposure: Address any other issues. Problems in this category are generally less urgent.
The A-E approach helps prioritize patients effectively. For instance, a patient with a fever of 38.1 degrees and normal HR and BP is less critical than one with the same fever but an HR of 150 and BP of 90/60. When managing multiple patients, use this framework to prioritize care. Not all patients with a fever require immediate review, especially with limited staffing. If they are stable, it is acceptable to wait until morning.
Delegate the Jobs
As an FY1, delegation may be less critical, but it becomes increasingly important as you advance. During night shifts, senior staff should handle the more severe cases while assigning stable patients to junior staff. This approach allows junior doctors to take histories and perform examinations, then discuss with a senior to create a care plan. This method fosters trust and efficient teamwork.
Learn to Say No to Nurses
Nurses are invaluable, but they may have a narrow focus, caring for only a few patients at a time. As a doctor responsible for many patients, you must prioritize tasks. Feel confident in politely but firmly declining non-urgent requests from nurses when necessary.
You Don’t Have to Do Everything
Night shifts can be overwhelming, with tasks continuously appearing on electronic systems. It’s crucial to recognize that you cannot complete every task. Prioritize the most important jobs and avoid attempting to be a hero, which is unsustainable.
Know Your Limits
The hardest time during a night shift is around 7 AM, when sleep deprivation can impair judgment. Evaluate the necessity of any new requests carefully. If the patient is stable, it’s often better for them to be seen by the day team. Urgent cases should still be addressed promptly, but consider bringing a colleague to minimize errors.
Conclusion
Night shifts are challenging and can create pressure to handle everything. However, these shifts are primarily about managing emergencies and maintaining patient stability. When faced with staff shortages, prioritize ruthlessly. Your efforts will be remembered for keeping patients safe and addressing urgent needs, not for the sheer volume of tasks completed.
I hope you have a great week and enjoy the wonderful weather. See you next week
Drug of the week
Lepirudin
Lepirudin is an anticoagulant used to prevent and treat blood clots, particularly in patients with heparin-induced thrombocytopenia (HIT).
It is a recombinant form of hirudin, a natural inhibitor of thrombin.
Lepirudin works by directly binding to thrombin, blocking its ability to convert fibrinogen into fibrin, which is essential for blood clot formation.
This direct thrombin inhibition helps to reduce the risk of clot-related complications in affected patients.
A Brain Teaser
A 43-year-old man is reviewed on the mental health ward following a deterioration of his psychiatric condition. The patient was originally admitted with a major depressive disorder associated with psychiatric hallucinations.
Recently the patient has been consistently reporting that he believes he is dead. As a result, the patient has stopped eating and has clear evidence of self-neglect. The patient is not known to have any other medical conditions other than his mental health issues.
What syndrome is this patient suffering from?
A: Capgras syndrome
B: Charles Bonnet syndrome
C: Cotard syndrome
D: De Clerambault syndrome
E: Impostor syndrome
Answers
The answer is C – Cotard syndrome.
This patient has presented with the rare psychiatric disorder Cotard syndrome where an affected patient holds the delusion that they (or part of their body) are dead or non-existent. The condition is associated with severe depression/psychotic disorders and can have significant detrimental effects on patients suffering self-neglect and withdrawal from others. Management ranges from pharmacological treatments as well as electroconvulsive therapy.
Capgras syndrome is an irrational delusion of misidentification where patients believe that a relative or friend has been replaced by an identical impostor. The diagnosis is normally associated with schizophrenia although cases have been reported in patients suffering significant brain trauma or dementia.
Charles Bonnet syndrome is a psychophysical visual disorder where patients with significant vision loss have vivid, often recurrent visual hallucinations. These hallucinations can be simple (i.e. shapes, patterns) or complex (i.e. detailed objects, people) but patients almost always have insight into the fact that they are not real and do not suffer from any other forms of hallucinations (e.g. auditory) or delusions.
De Clerambault syndrome, also known as erotomania, is a rare delusion disorder where patients believe another individual is infatuated with them, often despite the individual being imaginary, deceased or someone the patient has never met. A common symptom of the syndrome is patients perceiving that they are being sent messages from the false secret admirer via innocuous events (e.g. messages via number plate or the television).
Impostor syndrome is a pattern of negative psychological behaviour where an individual doubts their own ability or achievements and hold a chronic fear that they will be exposed. These beliefs are held often despite clear external evidence they are false and patients often report feeling they are ‘frauds’.
