Intensive care is medicine without margins. Every night, I walked into a unit where every patient had already crossed a threshold — past the ward, past the ER, into the territory where physiology is managed hour by hour and the difference between stability and catastrophe is measured in minutes. Two years of nights in that space shaped the way I think about clinical decisions, risk, and the weight of being the doctor in the room.
Admissions, Triage & Initial Stabilisation
Every shift began with receiving critically ill patients from the emergency department, referring units, or direct transfers from other hospitals. I conducted rapid primary and secondary assessments, established working diagnoses, and initiated time-sensitive resuscitation protocols before specialist review. For patients arriving in extremis — septic shock, acute pulmonary oedema, hypertensive emergencies, or multi-organ dysfunction — the night RMO is the first stabilising force. I ordered and interpreted urgent investigations, arranged bedside imaging, and co-ordinated with lab, pharmacy, and nursing staff to compress the time from arrival to definitive intervention.
What the Nights Actually Looked Like
Ventilator Management
Initiating and titrating mechanical ventilation; adjusting modes (AC, SIMV, PSV), PEEP, FiO₂, and tidal volumes; interpreting ventilator waveforms; managing ventilator alarms and patient-ventilator dyssynchrony through the night.
Vasopressor & Inotrope Titration
Running and adjusting norepinephrine, dopamine, dobutamine, and vasopressin infusions in real time; monitoring haemodynamic response; escalating or weaning support based on MAP, lactate, and urine output trends.
Fluid & Electrolyte Management
Correcting critical electrolyte disturbances — dysnatraemia, hypokalaemia, hypomagnesaemia, hypophosphataemia — and managing fluid balance in oliguric or fluid-overloaded patients, including in the context of AKI and hepatic disease.
Cardiac Monitoring & Arrhythmia Management
Continuous ECG interpretation; recognition and management of life-threatening arrhythmias including VT, VF, complete heart block, and AF with rapid ventricular response; co-ordinating cardioversion and initiating anti-arrhythmic therapy.
Altered Consciousness & Neuro Emergencies
Assessment of GCS, pupillary reflexes, and focal deficits; managing hepatic encephalopathy, hypoglycaemic coma, hypertensive encephalopathy, and post-ictal states; liaising with neurology for stroke and raised ICP scenarios.
Sepsis Protocols & Antimicrobial Stewardship
Implementing sepsis bundles within the first hour — blood cultures, broad-spectrum antibiotics, IV fluids, lactate measurement; reviewing culture results, de-escalating antibiotics, and liaising with microbiology on resistant organisms.
Cardiopulmonary Resuscitation
Leading ACLS-based resuscitation teams during cardiac arrests; managing airways, defibrillation, adrenaline dosing, and post-ROSC care; debriefing teams and communicating with families after critical events.
Overnight Documentation & Handover
Maintaining accurate ICU charts, drug infusion records, fluid balances, ventilator logs, and procedure notes throughout each shift; delivering structured clinical handovers to the morning team with a clear picture of every patient's overnight trajectory.
Bedside Procedures Performed in the Unit
In a resource-constrained ICU environment where specialist response at 2 a.m. is not always immediate, the night RMO is expected to be technically capable. Over two years of night shifts, I performed and assisted in the following procedures:
- Endotracheal intubation (RSI)
- Bag-mask ventilation
- Central venous catheter insertion
- Arterial line placement
- Nasogastric tube insertion
- Urinary catheterisation
- IV access (peripheral & emergency)
- ABG sampling & interpretation
- Chest drain assistance
- 12-lead ECG acquisition & reading
- Defibrillation & cardioversion
- Transcutaneous pacing (emergency)
- Intraosseous access (emergency)
- Point-of-care glucose & ketone testing
- Wound care & dressing in ICU context
- Lumbar puncture assistance
Serving Through the COVID-19 Pandemic
My tenure at Jamal Noor spanned the entire first wave, the surge months, and the vaccine-era transition of the COVID-19 pandemic in Karachi. In an ICU during that period, every clinical challenge was amplified: critically hypoxic patients requiring prone positioning and high-flow oxygen, cytokine storm management with corticosteroids and anticoagulation, cohorting infected patients, working under full PPE for entire night shifts, and making difficult triage decisions when beds were scarce. I witnessed and participated in the full spectrum of critical COVID-19 care — from initial stabilisation to end-of-life conversations with families who could not be present at the bedside. It was the hardest clinical experience of my career, and the most defining.
Clinical & Professional Skills
Two years of uninterrupted night ICU work built a clinical profile that no classroom or short posting can replicate:
"The ICU teaches you that medicine is not about what you know — it is about what you can do with what you know, at 3 in the morning, when you are the only doctor in the room."— Dr. Hamid Fazal, reflecting on two years of night ICU duty