One of the scariest things about starting work as a junior doctor is covering the wards out of hours i.e. being ‘on call.’ But this is also the best time to grow as a doctor. This 5-min read offers some tips, tricks and things to think about before that dreaded day, alongside a a list of resources which you might find helpful.
1. Things to know before your On-Call:
Who is your senior and how do you contact them; make a note of their bleep number and make sure you know how to bleep!
What wards will you be covering? All the medical wards? Including medical patients on surgical wards?
How to request imaging, where to send blood samples, how to check bloods, how to view x-rays, etc. On-call is not the best time to learn these things!
Get a piece of paper and have a structure of how you will triage calls. e.g. based on urgency Some people divide their piece of paper into the wards they will cover. Do what works best for you. It is also a good idea to draw a small square next to jobs and fill them in when they are done so you can keep track of things.
2. What to do when you’ve been bleeped:
Write it down. No matter how simple the task, you will forget.
Take the patient’s name and NHS number. You will need this when viewing bloods and imaging.
Assess the urgency of the situation; can this wait? Does this even need to be done overnight? Or perhaps they should be putting out a peri-arrest call instead of contacting you!
Get as much information as you can over the phone. So the patient has chest pain... Have they had this before? Any cardiac history?
Get a baseline. The patient has a systolic of 95... Is that normal for them? Asking the caller if they are worried is often a good indicator.
Check how much the caller can do. If a patient has chest pain then ask for an ECG while you make your way there. Ask if the nurse can do bloods on the patient.
Safety net. You do not need to run to every call. If there is nothing worrying but you are hesitant (completely normal!) suggest that the nurse repeats the observations in 15 minutes “…if the systolic drops let me know” or “if they need more oxygen call me back.” This is a good way of managing multiple tasks when there are more urgent things to do whilst protecting yourself and making the caller feel listened to.
3. Managing the acutely unwell patient:
Try to get as much background information over the phone and initiate simple tasks. e.g. “Can you do some bloods/ECG/titrate their oxygen and I’ll be there in fifteen minutes.”
Once you get to the patient have a quick glance at them: Do they look really unwell? Are they struggling to breathe, on 15 Litres of oxygen, and drowsy? Or do you have time to gather some more information before you assess them - are they sat up, chatting away, not in distress?
If you have time, read their notes first. Some patients may be on the ward for a long time and will have pages and pages of notes. You don’t have time to look through all of them. The most important information you need to elicit is: - The reason they came into hospital in the first place - Co-morbidities e.g. shortness of breath in someone with Asthma will be very relevant! - Ceiling of care Are they for ITU? Do they have a DNAR? - Most recent Ward Round entry What are their current problems? Are they just awaiting discharge? Did the team anticipate a deterioration and clearly document what should be done? What was the team’s most recent plan? For example, worsening cellulitis in someone who just started Antibiotics today is not necessarily worrying - the antibiotics just haven’t had time to take effect yet.
Take a brief, focused history from the patient based around the problem. e.g. Chest pain: When did it start? What was its nature? Remember, you want to rule out concerning things e.g. a Myocardial Infarction!
A-E assessment. If you are unsure always, always do an A-E assessment. Your priority is to keep the patient safe.
Fix the things you can fix: Give oxygen, give IV fluids, take bloods, request a chest x-ray if warranted, request an ECG.
Escalate. If you have no idea what is going on, unsure about what to do next or feel the patient is very unwell, speak to your senior. Tell them at the very start what the problem is e.g. ‘I’m with an unwell patient and am not sure what to do next/I need help.’
There will be times when you will have more than one unwell patient on the wards. This is where your triage skills come in; which is more urgent? And how much can the nursing staff do on the wards before you can assess the patient? If you find yourself in the middle of two very unwell patients who are both time-critical, speak to your senior. Do not suffer alone.
4. If it all gets too much…
Take a coffee break. Things can wait. It may not feel like it at the time with your bleep going off incessantly, but there will be time for a break. Go somewhere quiet with a hot drink and a phone by your side. Continue to answer your bleep as needed and make a note of the jobs based on severity. Make it clear to the caller that it will take you time to get there. Just sit there for five or ten minutes and breathe. It will get easier.
Lists. Poor organisation of your jobs list will make things unnecessarily stressful. Write down every job you are given and have a system of assessing its urgency e.g writing the number 1, 2 etc next to jobs as per their urgency, or an asterisk next to jobs that are time-critical. If you have too much going on, take a break and go through your list; what can wait and what needs to be done soon? Do not expect yourself to do everything and never be scared to hand things over to the next doctor. Remember, you can always hand things over.
Speak to your senior. If you are really struggling, speak to the person senior to you. Tell them how you’re feeling and that you’re struggling with the pace or amount of jobs. They will have been through the same struggles and will be able to sit down with you, go through the list of jobs and advise on what can wait. They can also be a source of comfort and tips of their own. Seniors will also want to know if you’re struggling early. They will want to know about an acute patient early - not when they can no longer do anything about them. Remember, they are responsible for the wards as well.
5. Useful Resources
Things to read before your first On-Call:
Oxford Handbook of Clinical Medicine Covers common presentations including emergencies in a concise manner, including symptoms to look out for, investigations and initial management which you can start yourself on the ward. This is also available as an app.
"Asked to See Patient" Website An excellent overview of common things you will be bleeped about and how to handle these scenarios.
List of common medications and their side effects including anti-emetics and analgesia (you will be asked to prescribe these a lot).
How to manage electrolyte abnormalities. Common things you may be called about include high and low sodium, potassium, calcium and magnesium levels. Your trust may have their own guidelines. If not, there are some helpful flowcharts and guidelines from other trusts you can use (some people like to take a photo and save them on their phone for quick use): 1. Resus Council Guidelines for Hyperkalaemia 2. Society of Endocrinology Guidelines for Hypocalcaemia
List of Drugs not to prescribe in Penicillin allergies (more common than you think)
Helpful Apps:
British National Formulary (BNF) To quickly look up doses and contraindications.
Rx Guidelines Antibiotic guidelines for common infections including local guidelines.
PocketDr Covers common on-call queries including a list of analgesia and anti-emetics to use (and when not to use).
iResus Helpful for the tachycardia & bradycardia algorithms.
By Dr Gunjan Sharma