bleep.guide · FY1: The Missing Manual
Thursday, 23 July 2026
Common out-of-hours calls, safe first steps, and when to escalate. How to optimise your life for being nocturnal and get through each run.
# Nights & On-Calls — session notes
FY1: The Missing Manual · Session 2 of 4 Thursday 23 July 2026 · led by Dr Oliver Devine
Nights feel frightening because you picture being the only person awake when something goes wrong. You won't be. A night shift is staffed as a team — other ward-cover F1s, an SHO, one or two medical registrars, a site manager, a resus/outreach team, a consultant on call, and a crash team. You are never the only person responsible for a patient, and you are never the only person who can respond to an emergency.
Your job when someone is sick is the first few minutes — recognise it, start safe A–E management, and call for help. You should never be left single-handedly running a critically unwell patient; there should always be someone you can escalate to, and 2222 exists precisely for the moments you feel out of your depth. If that help is routinely slow to arrive, that's a staffing problem worth raising with your educational supervisor — not a failing on your part.
The second reassuring thing: the night has a shape. Once you know it, it stops being a wall of unpredictable dread and becomes a shift you can plan around. Most of this talk is that shape, and how to set yourself up to get through it well.
People muddle these, so plainly:
Long day / evening ward cover. You do your normal ward job in the morning, then from ~5–6pm you cover your ward plus a few others for the evening — usually your specialty or a block of specialties (e.g. as the cardiology F1 you might cover cardiology, respiratory and infectious diseases out of hours, ~100 patients). Evenings are intense — a lot gets handed over from the day — but you're not as tired, so in some ways they're busier than nights.
Night ward cover. The same job, overnight, for a block of wards or a whole segment of the hospital. As an F1 I covered medicine and surgery for the whole tower with one other F1 and a medical registrar — somewhere between 400 and 600 patients. That sounds impossible; it's manageable, because only a handful are ever actually unwell at once, and there are strategies for the rest (below).
"On call" (what registrars mean). For a registrar, "on call" often means clerking their specialty's referrals in A&E on top of ward duties. Worth knowing, because the medical registrar you call at night may be busy in A&E rather than sitting waiting for your bleep — so know who your senior is and where they are.
Same disclaimer as last week: you already have the knowledge; what you lack is clinical experience. You'll be responsible for the initial management of sick patients (the first few minutes while help is on the way), and for the whole assessment of simple things with remote senior input — if someone needs fluids, you're expected to assess fluid status and make a call yourself (bearing in mind fluids can do harm in heart failure or renal impairment, so it's an assessment, not a reflex). That doesn't mean you shouldn't phone your senior to discuss, but your senior may not need to physically re-assess the patient themselves.
On an evening shift you'll spend the first half hour or more taking handover from the day doctors who want to go home — scribbling down the jobs and pending results being passed to the evening and night (that second troponin still cooking at 6pm, say). On the evening you're the go-between linking the day team to the night team.
The one rule: don't feel bad about handing over, and do leave on time. The entire point of handover is that you shouldn't be working unpaid past your shift; if you routinely are, submit an Exception Report. Across my whole F1 year I left late maybe six or seven times, always for a genuinely unwell patient who benefited from continuity — where it made no sense to hand a patient I'd watched all shift to someone who'd never met them. That's one of the few good reasons to stay.
This is where you have the most control over how bad or bearable a set of nights feels. Plan it.
Sleep before the shift — nap. Ignore anyone who tells you to stay up all night beforehand: forcing an extra sleepless night just to be tired for your first shift is a terrible idea, and it's physiologically shocking. Equally, don't wake at 9am, run your whole normal day, and roll into a night — by 9am the next morning you'll have been awake 24 hours, which is not a state you'd want your own relative's doctor to be in. The balance most people who cope well settle on: live your day roughly as normal, then have a couple of hours' sleep in the late afternoon (around 3–5pm) before you go in. You may not manage the nap for your very first few nights because you're too wired — that's normal; it gets easier as the medicine gets more familiar.
A word on the fear itself: a "sense of impending doom" before a night is almost universal, and it fades. Tellingly, after five years of clinical training the biggest anxiety about nights is no longer do I know what to do — it's will I be too tired to perform, and will I struggle to sleep afterwards. Early on you'll worry about the medicine; with time the worry shifts to the sleep. Both are manageable.
Sort the rest of your life so it isn't a decision at 3am. Plan your meals — what you'll eat at the start of the shift, what you'll eat around 3–4am, and what you'll eat when you get home. Meal-prep or buy decent pre-made meals (Chefly again, still unsponsored — freezes and travels well). The circadian evidence says eating in the night isn't ideal metabolically, but realistically most people can't get through a night without something around 3–4am; the goal is to have eaten before you get home, so you're going to bed neither starving nor on a full stomach.
Make the room cold, dark and quiet — that's the whole formula for daytime sleep.
(Links to the specific earplugs and blinds are below.)
Sleep aids — handle with care. This is not medical advice. People try various over-the-counter things to help them sleep after nights, but the evidence for most is thin to non-existent and a fair bit of it is placebo. If daytime sleep is a real, ongoing problem, the safe route is your GP or occupational health rather than self-medicating — melatonin, for instance, is something to use only if it's actually prescribed to you. Don't build a nightly pharmacological habit around what is usually a fixable environment-and-routine problem; get the room and the schedule right first.
Driving — the genuinely dangerous bit. Driving home exhausted after a night is one of the real mortality risks of this job; several doctors have died doing it. Live as close to work as you reasonably can. Until you're over the acute early phase — when you're not sleeping well, not yet in autopilot, and carrying extra stress about the medicine — try hard to avoid driving home; even a short cycle can feel unsafe when your reaction times are shot. Under the BMA rest charter your trust should provide somewhere to sleep on site if you're too tired to travel, but scope out the quality of that accommodation in advance, because discovering it's grim (or unavailable) at 8am is miserable.
Caffeine — small and early. A single coffee (~40mg) early in the shift is fine. Much beyond midnight and it starts to eat into your recovery sleep and can leave you jittery.
After the shift: go home on time, decompress, and don't panic at the dreams. Especially after nights — nobody wants you to stay, there are no prizes for it, and there is definitely someone better than you at the job at 8:30am. Hand over and get out. It takes an hour or two to come down mentally, so don't get straight into bed and force it — wait until you're actually sleepy. And it's completely normal, especially after intense early shifts, to half-dream you're still on shift, checking a list. Don't be alarmed by it.
A run-through from clock-in to clock-out.
~20:30 — Handover. You'll gather (a lecture theatre, a boardroom, or the AMU office) for the "hospital at night" handover: day team handing to night team, ward-cover doctors, take doctors, the medical registrar(s), often the on-call consultant, the site manager (a senior nurse), and the resus/outreach team. There's usually a roll-call so everyone knows who's on. Surgical handover often happens separately and is a lighter affair. Once the day team has handed over, they go home and you head to your ward or area.
Know the four kinds of handed-over patient. As you take handover, sort each patient into:
Never accept a handover blindly — get the "if X, then Y". The most useful handovers tell you the threshold for action: if the potassium is above X, contact renal; if the creatinine is above Y, consider for dialysis; how far does the troponin need to rise before I start ACS treatment? The outgoing team should already know what they'd do with the result they're handing you. Probing this is how you protect yourself from needing to phone anyone later. Good follow-ups on a handed-over scan: has it been protocolled and approved by radiology? (it's improper to hand over a scan that hasn't been) and is there actually a porter slot for it tonight, or can it wait for the morning?
Getting settled. You pick up the bleep from your day counterpart (or a dedicated night bleep from an office), and everyone spreads out. Where the ward-cover doctors go varies — sometimes everyone sits together in the mess round a bank of computers, sharing jobs and hive-minding problems; sometimes each person retreats to their area's office to work (and maybe sleep) alone. Both are fine. Set up a night group on WhatsApp or your trust's secure messaging with all the F1s, the SHO, and the most senior medical (and surgical) decision-maker on it, so help is one message away even when the reg is down in A&E.
~20:30–21:30 — Prioritise. Sit with your list — sick patients, reviews, investigations to chase, and your "be aware"s — and order the night. If anyone sick has not been made known to the registrars, tell them: they will want to know a patient was unwell during the day. Then think about timing — when were the investigations ordered, when will they realistically be back? You'll quickly learn how long a CTPA takes in your trust.
~21:00–01:00 — The busy stretch. This is when the bleeps come thick and fast, often while you're already with a patient. The approach: answer or read each, note it down, and unless it's more urgent than the patient in front of you, it waits. You cannot be everywhere at once, there are only ever a finite number of genuinely unwell patients, and the jobs don't pile up into something unmanageable. It feels overwhelming now; it feels far less so in a year.
~01:00–06:00 — The quiet stretch. Patients are asleep, no med rounds, no routine obs — the nurses are in overnight autopilot and won't be finding much to bleep you about unless it's serious. This is your window to work back through the jobs you noted, as the evening's handed-over results and imaging start landing on your computer. Chase what's outstanding; decide whether results genuinely need action/calls overnight or can wait for the morning.
~03:00–04:00 — The window of circadian low. Aviation and other safety-critical industries recognise this as the period of highest error risk. You may not consciously feel it (for me it shows up as feeling cold). So: don't see new patients at this time unless they're unwell, run things past a senior if you're in any doubt, and — most importantly — take your break. On a night you're typically entitled to 90 minutes (see last week); this is the time to use it, and a good time to eat, since it's long after dinner and not right before you go to bed.
~06:00–07:00 — It ramps up again. Patients wake and start to fall; med rounds resume; nurses spot prescription problems; the bleeps climb again as the ward comes off autopilot. Remember: the day team are only a couple of hours away. Does this job genuinely need doing by you overnight, or can you advise whoever's bleeping you that it can wait for the day team?
~07:00 — The crash-call dread. Around now you start dreading a crash call when you've been up nearly 24 hours. Remember who else carries a crash bleep: the resus team and probably at least two medical registrars. As a ward-cover F1 your bleep is often also a crash bleep, but even if you're first there, your job is narrow — get the crash trolley, get the pads on, put a cannula in if there isn't one, do a gas. Within a few minutes others arrive. In a whole F1 year I was never first on scene at a crash, and when I was there I was asked for a limited, doable set of things: bloods, a cannula, a gas, scribing, or pulling up the record to work out who the patient is and why they're unwell.
~08:00–08:30 — Handover out, and home. Over a typical night you'll have dealt with ~20 calls and put ~20 note entries in. You do not need to walk round every ward giving verbal handovers — if you've documented well and the day team will round between 9 and 12, they'll pick it up from the notes. Only go and find a team in person for something genuinely urgent or time-critical before their round (but remember some patients — and therefore your notes — might not be seen until the end of that round). Then hand over your bleep and go home.
From the app's usage data (which tracks how often each scenario is viewed), the realistic frequencies — useful because it tells you what to be ready for:
Emergencies. You'll be asked to exclude sepsis on essentially every shift. Hypoglycaemia comes up often. COPD exacerbations are very common; acute asthma turns up too. Upper GI bleeds and hyperkalaemia feature. Reduced GCS, SVT and anaphylaxis are rarer — but you still need to know what to do. Fast AF and peri-arrest tachycardia are the ones people find scariest (flagged last week), so they get looked up a lot.
Ward-cover scenarios. Delirium — every shift, often several times. Falls — several per shift. Non-pathological low readings and hypotension because the patient is simply asleep — very common, and worth knowing how to tell safe from not (there's a section on exactly that). Blocked catheters, constipation at all hours, new oxygen requirements. Talking to families — at some point, yes. Verifying a death — maybe every couple of shifts; actively dying patients tend to be the registrar's call, so you'll know about them but usually won't be the one changing the end-of-life plan.
The point isn't to memorise all of the management steps now. It's that none of it will be unfamiliar knowledge — you've done six years of this. It'll be an unfamiliar piecing-together of knowledge you already have, under time pressure, which is exactly what having a resource or checklist is for. Keeping reference material available isn't cheating; it's standard practice in every safety-critical job.
How should I prepare for a set of nights — do I change meal times? Yes — expect to. Your circadian rhythm is going to be disrupted anyway, and you'll get hungry in the night however hard you resist it, so eat when your body needs it (many people settle on something around 3–4am). Beyond that, everything in the prep section above.
Tips for swapping from day to night the day before starting? People differ. The two sensible options are a late-afternoon nap before the first night (recommended) or powering through the day and into the night (doable, but you'll be wrecked the next day). Staying up all night beforehand is the one to avoid.
I'm starting on nights with no clinical experience — how do I navigate my first night? Correction to what was said in the session: it is apparently NOT against policy (despite lobbying) for F1s to start on nights, though many trusts disallow it. If you have concerns, I'd recommend asking your trust what extra support will be in place. I know F1s starting on nights at my own trust get extra support — additional registrars whose only job that night is to support the F1s.
Straight after shadowing I start on two nights — should I flag this? Yes. Flag it and ask specifically what additional support is in place. (Some hospitals do start F1s on nights with a companion/buddy senior — that's the mitigation to ask for.)
How do I tell what's within my competence — e.g. prescribing paracetamol — versus needing to escalate? You define your competence, and if you're not sure, ask — nobody senior worth their salt will think less of you. No one will bat an eyelid at an F1 asking about paracetamol prescribing; everyone senior was an F1 once (even the ones who've blocked it out). Look it up in the BNF, and if you're still unsure, ask.
I'm starting on nights but haven't passed the PSA — how do I prescribe? Unclear, and worth checking directly with your trust, as it may be a medicolegal/indemnity matter for them. The safe default: if you're unsure whether you're allowed to prescribe, don't — ask first.
What shouldn't you hand over to the night team? Anything that fails the test "could this wait until morning?" The classic is being asked to hand over a routine PR exam that "should have been done today" — if it won't change overnight management, don't hand it over (and don't accept it if someone hands it to you — why wouldn't there have been time to do this during the day?). Flip the question: what would I say if this were handed to me? If the honest answer is "this won't change what I do overnight," it doesn't need handing over — it's fine to keep a job on the list for the next day.
What's appropriate to leave for the day team? Anything that won't change management further overnight. You usually won't know the ward-cover patients beyond this one encounter, so beyond the immediate management of an urgent issue, leave things for the parent/day team who know the patient. In particular: don't write discharge letters overnight for patients you don't know — if a discharge letter is missing, flag it to the nurses and to the day team in the morning that the parent team didn't do it; it isn't safe for you to write one for a patient you've never met.
Do you keep your jobs list for the next day? The real jobs list is the plan written at the end of the ward round — your personal list is just your working copy of it. In principle you can shred your note at the end of the day and whoever's on next picks the jobs up from the documented plan. If you're back the next day and have outstanding jobs, keep the list somewhere secure (a locked office or drawer, not off-site). It is also possible your ward has a central digital jobs list, which really is the best way of maintaining jobs continuity.
Long day on-call — just bleeps, or ward round and jobs too? Both. In most specialties a long day is your normal base ward and its jobs by day, then from ~6pm you also cover several other wards (your colleagues bring their handovers to you) — roughly 100 patients for the evening.
How do I manage continuous bleeps? First ask whether they're all from the same nurse or team — if so, it's reasonable to pick up the phone and say, firmly and politely, "please stop bleeping me; I know, and I'll come back to you." If they're all unique bleepers, write down each number and call back when you have a moment. Anything truly critical goes out as a 2222, not a bleep — so a bleep could be someone who may be heading that way, not someone already crashing. If you're with a sick patient, your responsibility is to them, not to the theoretical patients on the bleep. In most places you're looking at maybe one 'real' bleep every half hour (averaged over a shift), not a wall of them.
Two deteriorating patients and I can't prioritise — what do I do? Call for help — and don't hesitate to put out a 2222. The hospital is designed for simultaneous emergencies: the crash team receives the call and splits. (As an F1 with two hypoxic patients in eyeshot and my colleague already at an arrest, I put out a crash call because I physically couldn't be in two places — which is exactly what it's for.)
If a bleep is more pressing than the patient in front of me, should I make a plan for the nurses first? In practice a crash call is about the only thing more urgent than the sick patient you're already with (or someone collapsing nearby with no one attending). It's unlikely to be a real dilemma.
Who gets the bleep when I go on break? Someone else — anyone else: your reg, your SHO, or another F1. There's always someone to hold it.
Is the 1.5-hour break protected — can I sleep and hand the bleep over? It should be; if it isn't, raise it with your local BMA rep, or submit an Exception Report. Hand the bleep over, and if you can find somewhere to sleep, sleep — most trusts have signed the BMA rest charter and provide on-site rest facilities, and any reasonable colleague will take the bleep so you can rest (you return the favour later).
What are the expectations of an F1 in an emergency? Identify that someone's sick, start initial A–E management (airway; oxygenate if needed; check BP and heart rate; ECG? fluids? a VBG/ABG?; if there's an arrhythmia, crash trolley and pads on), and call for help. You're really only going to find yourself responsible for the first few minutes. You already know how to do A–E — you passed finals — you just lack the confidence, which comes with experience.
When do I escalate urgently versus assess first? Usually: do the initial management, then escalate — but escalate urgently the moment you feel out of your depth, and you're the best judge of that. Escalate more rather than less, especially early on. A useful signal: how scary a situation feels is a fairly direct reflection of whether you've met it before, and nobody expects an F1 to handle something they've never seen, alone, for the first time — so let that fear cue the call.
General surgery on-call — any tips? Surgeons are territorial about their patients, and few genuinely surgical problems land on the F1 overnight, so most of what you'll do is medical basics: fluids, patients spiking fevers, pain management. You will always have someone surgical to escalate to. Genuinely surgical issues — a drain putting out too much blood, peritonitis — go straight to the surgical senior.
Starting on A&E — will people be lenient doing gen-med on-calls for the first time in rotation 2? Yes. People are almost always lenient with F1s and even F2s. Expectations are a little higher in rotation 2, but honestly not by much.
I feel I've forgotten a lot of medicine — how do I keep on top of it? Everyone forgets a lot. The important things come back and stick as you're exposed to them clinically; the daunting feeling passes relatively quickly once you're in the job.
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Monday 27 July, 19:00 — Clerking for FY1s: what to do before the senior review. The one that felt strangest to me starting out — seeing new patients, making a safe first plan, and presenting for senior review. Most useful if you're starting on a medical, ED or general-surgical job where you'll be clerking; less essential if you won't clerk for a while. Then the final questions-answered session two weeks in (Wed 19 Aug).