Ready for emergencies

PUBLISHED : Saturday, 01 November, 2008, 12:00am
UPDATED : Saturday, 01 November, 2008, 12:00am

Doctors need to be well-rested before gruelling night shifts that can test patience and skills

Whenever Anthony Poon Shun-bong reports for a night shift at the Hong Kong Sanatorium and Hospital, he must be ready to deal with almost anything.

From 7pm for most of the next 14 hours, he will be the only doctor on duty to handle not just the accidents, injuries and walk-in cases seen in the outpatient department, but also any emergencies that occur in the wards, up until the patient's own physician arrives from home and can take over.

Of course, no night is typical. One hour, Dr Poon might find himself deftly removing a fishbone stuck in a patient's throat or performing minor procedures such as suturing and treating contusions. The next, he could be examining people suffering from acute chest pain, convulsions, the effects of a collapse or symptoms of severe abdominal trouble. And, at any moment, he might be buzzed to dash upstairs and take charge of a post-operative emergency or suspected cardiac arrest.

'One time, I had to perform resuscitation on the ward, which took 20 to 25 minutes,' Dr Poon recalled. 'The patient had collapsed and required incubation and electric-shock treatment. When I came back to outpatients, there were about 10 people waiting, some semi-emergencies, some needing wound dressings. It can be very stressful.'

While the cases differ and the workload varies, a certain rhythm is nevertheless often discernible. For example, the highest number of patients is usually seen between 10pm and 11pm. Convention holds that this is when people have generally had dinner and are planning to go to bed, but notice some problem or discomfort that will affect their sleep. It might be shortness of breath or digestive problems, and Dr Poon was quick to note that most people seeking late-night medical attention were not hypochondriacs, but had genuine reasons for doing so.

'I might see as many as 70 patients per night and usually around 90 per cent need treatment,' he said. 'There are few who don't really need attention.'

In the small hours, though, quite a number of the patients coming in by taxi or ambulance fall into a clearly definable category. They have cuts, bruises, sprains and perhaps broken bones, more often than not the result of fights fuelled by alcohol.

'I will try to be non-judgmental,' Dr Poon said. 'That is a very important part of being a doctor, but it takes time to learn. The most difficult thing for us, and not just on night duty, is to handle patients who are quite irritable or demanding. We need to deal with them with patience and caution, so I let the patient talk to get a better idea of their ideas and expectations. I start by taking a short history, usually before proceeding to the operating area, but if there is an actively bleeding wound, I do that at the same time as starting any procedure.'

A high level of concentration is essential at all times in order to prioritise cases correctly and work at optimum speed, he added. It is also vital to co-operate closely and communicate clearly with the nurses, who provide invaluable support and have a well-honed professional ability to anticipate the needs of both doctors and patients.

Even on busy nights, it is generally possible to break away during quieter periods - most usually between 4am and 5am - and lie down in the designated rest area. The chance, though, for anything more than a short nap is a rare luxury.

'I will try to get some rest, but it is not easy because you are likely to be called every 15 or 30 minutes,' Dr Poon said. 'It seems that just as you are about to get to sleep, the phone or pager will go.'

Therefore, in preparation for the weekly night on duty, he now sticks to a well-established routine. In line with the hospital's standard roster, he will spend the previous day from 9am to 1pm supervising patients taking ECG tests for cardiac monitoring. It is an important task, yet not too taxing, and deliberately assigned to doctors before a night shift.

On completing that, he heads straight home to Kowloon, has a quick lunch, sleeps for at least three hours and studiously avoids any attempt to dash to the shops or complete other errands.

'I don't do anything else as I want to be well rested and able to concentrate during the night,' he said.

He is back at the hospital by 7pm sharp, or earlier if he feels it is necessary to visit the wards first to check up on any patients he has been treating in his main role as a resident medical officer specialising in family medicine. Then, perhaps after phoning the pharmacy, laboratory and X-ray department to 'check in', it is simply a matter of rolling his sleeves up and dealing with things as they come.

A 14-hour stint is never easy, but Dr Poon knows from his days with the Hospital Authority that some young doctors still have to work straight through from 9am one day to 9am, noon or even 5pm the next, four or five times a month.

'I've done that and it is quite exhausting with the stress of the work and the anxiety,' he said. 'It is a harsh kind of training and you need to be young and energetic to do it.'

Nowadays, on the rare occasions when not much is happening, he will try to make productive use of the lull. For example, if there is an exam on the horizon, he will try to squeeze in a couple of hours of study or review the notes of more complex cases, track down reference material on the internet or flick through the newspaper.

For a quick change of scene and a chat, he might also wander down to the nurses' station where, if in luck, a colleague may be willing to cook a snack or order in food.

Since the basic roster is circulated a month in advance, Dr Poon has few difficulties in arranging social and other events around his work commitments. His wife, an occupational therapist, and close family members know the schedule and, therefore, when not to call, and friends somehow seem to sense the same thing.

Once off duty, Dr Poon returns home, sleeps for about six hours and then, ever mindful of his patients, usually finds himself back at the hospital by late afternoon. On balance, he has no complaints about having to work nights and regards it as both challenging and interesting.

'It makes us tougher, more independent and more mature,' he said. 'It also gives an opportunity to deal with more emergency cases, which means you get more exposure. But in the long term, the family doctor's role is to work with patients in the daytime and it becomes a disadvantage if your regular patients cannot see you then.'

This is part four in our eight-part series on people who work at night

A special diagnosis

One special case Dr Poon encountered at night involved a 40-something male patient who came in at about 3am unable to sleep and complaining of discomfort in the chest region. He never had pain during the day and had been diagnosed previously as suffering from acid regurgitation. 'The presentation was very interesting,' Dr Poon said. 'When I pressed on the tummy, there was no problem. But when we did an X-ray, I saw a big area of gas under the diaphragm pushing up under the chest. It was caused by a perforated peptic ulcer, and I would never have seen the patient in the daytime as the symptoms were not so disturbing then.'