Through Every Night Shift

It is both physically and mentally demanding, and my spouse probably finds this unpleasant at times. Though I have to confess that I am secretly proud of being able to care for patients day and night.

In my affiliated clinical unit, every intensive care doctor has to work on a shift. From first-year residents to the consultant who will be retiring next year, we all do night shifts on a regular basis. Newcomers may feel surprised when the most senior physician in the unit is staying around the ICU ward at 4 am, but that is our culture and indeed the way we deliver truly intensive care.

Honestly, not everyone finds shift work enjoyable. We work fewer hours continuously at the cost of adopting a socially inconvenient work schedule. Sometimes I forget which day of the week it is until I notice the lack of traffic in the cross-harbour tunnel. (Oh, it's Sunday morning again…) One can reasonably believe that shift work is potentially harmful to health, yet I have accepted such a lifestyle as a necessity.

Night shifts are stressful. They are consistently unpredictable. Unplanned ICU admissions are more common outside office hours. From my experience, there is frequently a surge in cases requiring urgent attention and ICU interventions in the evening. It could be some sort of biased observation, but that is how we, as insiders, usually feel. Occasionally the night team has to skip dinner while juggling between critically ill patients within the ICU ward and acutely deteriorating patients in the general ward or A&E department, who may require escalation of care.

Do I feel slightly depressed before a night shift? Yes, I do, but only slightly because there is not much time for me to become upset before the adrenaline rush kicks in. Once the night shift begins (with clinical handover from the day team), one does naturally feel “high”. The high-stakes and fast-paced clinical environment will compel every conscientious clinician to fight for their (patients') survival.

Going through a night shift is a test of both strength and resilience. One must possess a wide array of knowledge and skills in order to tackle the many clinical scenarios and problems that may come up at night when there are few people who could back you up. A urinary tract infection may sound trivial, but not when the patient has been receiving novel therapeutics for an underlying haematological disease and is developing multi-organ failure as a result of sepsis. Nevertheless, frustrations or even failures are inevitable, and complications often arise when you least expect them. It would be a great trouble at night if one loses confidence over one's own competence while getting stuck at a diagnostic uncertainty or bedside procedure that did not go well.

On-the-job training is supposed to make us stronger — i.e., acquiring competencies and meeting the expected standards. It takes at least 6 years of exhausting supervised clinical practice (while taking courses and sitting examinations at the same time) to complete a specialty training programme in Hong Kong. Are we then learning to become more resilient as we get “tougher”? It requires determination and effort to build and sustain a professional environment that encourages compassion and support, forces that foster personal growth and well-being.

A few years ago, I botched a central venous catheter insertion that resulted in a large pneumothorax. I had been eager to practice the more technically challenging axillary approach at that time when my skill level was far from mastery. Fortunately, my patient suffered no further harm except that he needed insertion of a chest drain, which my supervisor and a more junior colleague in the team eventually did. I felt sorry for my patient and team members. I felt disillusioned and ashamed for myself.

When I apologised to my colleague for the extra workload I had generated towards her night shift, she actually thanked me for the opportunity to learn from this complication. She reminded me of a very important fact that it was teamwork. We cover for one another. We share both joy and tears. We bear clinical responsibilities as a team. In the end, I have learned that humility is a powerful and the necessary antidote to the inflated ego that breeds prolifically in the clinical workplace.

Recently, I have developed the habit of watching the sunset before starting my night shift. It has become a form of mindfulness practice unintentionally, and I found that useful in calming my nerves. It does not matter if the weather is gloomy. It is about staying connected to our surroundings and being grateful for every moment. Intensive care is an onerous but rewarding profession. Awareness of our own limitations and diligence in self-care as well as self-improvement keep us well-prepared for the obstacles we face as a clinician.

There is no one-size-fits-all method of coping with life challenges. How do you manage stress and fatigue? What is your way of surviving night shifts or extended working hours? Please share your tips and thoughts with us!