Surviving on call
Intern Dr Louise Hickey provides some practical tips on preparing for on call, dealing with sick patients – and time management to maximise your sleep
Most incoming interns will regard “call” with some degree of trepidation. This is to be expected, and bar those who are exceedingly enthusiastic, or insomniac, call shifts are something to be endured, not enjoyed.
However, there are some benefits. The main upside is the chance to practise medicine, to cover unfamiliar specialties, and have increased clinical responsibility. In the junior doctor day job, you will become exceedingly competent at blood extraction and you will develop extraordinary organisation skills.
Unless you get lucky with a team who provide on-the-job teaching, "on call" shifts may be the only time you learn how to manage acute medical presentations. If you are planning on moving onto medical SHO schemes, or to sunnier pastures abroad, this experience will undoubtedly stand you in good stead.
If you are planning on moving onto medical SHO schemes, or to sunnier pastures abroad, this experience will undoubtedly stand you in good stead
Fail to prepare… prepare to fail
First things first, you need to be aware of the preparation side of things. At the beginning of the medical year, many interns slip into the habit of ordering takeaway food on every call shift.
Newly-deep pockets, along with feelings of self-pity for being in work, lead to pizza and curry being washed back with coke and cookies. It took me about six months to gain some sense, and I would advise any incoming interns to bring food with them to avoid the lure of artery-clogging fast food. Takeaways do nothing for your waistline (I learnt the hard way), or your productivity.
Once your appetite is satisfied, and the scrubs are donned, it’s time for the real work to begin. The vast majority of tasks on call are fairly routine, and with practice you will become efficient at completing them. In the initial weeks, carrying a list of common medications with their dosing is advisable.
Inserting cannulas is another thread on the fabric of an oncall shift. There is no quick tip for doing them, merely that with practice they will become easier
You will be repeatedly asked to prescribe anti-emetics, laxatives, analgesia etc, and having a list will avoid you having to continually reference the BNF. Inserting cannulas is another thread on the fabric of an oncall shift. There is no quick tip for doing them, merely that with practice they will become easier, and quicker. Patient admissions at night are commonplace and these should not cause much difficulty to junior doctors who are likely proficient in history taking and physical exam.
Most elective admissions are pre-operative patients, and hence will need a preoperative work up; bloods (very importantly include a sample for the blood bank!), ECG and chest x-ray as indicated. Doing this on call will save the admitting team’s junior doctor possibly your friend) much panic in the morning, and hopefully the favour will be returned.
MPS top tips
Before on call:
- Be organised – Pay bills etc, before starting a week of nights.
- Be healthy – A healthy and active lifestyle may reduce the negative effects of working nights.
- Be prepared – For common clinical problems that you will see on call, eg, pain and common postoperative conditions.
During a night shift:
- Eat and drink properly – Follow a similar eating pattern to the one you follow in the day.
- Double-check calculations – Your responses are not as reliable as they are during the day.
- Ask if you need help.
- Drink caffeine moderately.
- Take naps.
After a night shift:
- Limit the effects – Use earplugs, black-out curtains, and turn off your phone to help you sleep during the day.
- Be extra vigilant – Consider the risks of driving home after a night shift.
- Don’t take sleeping pills – They can cause hangover-like symptoms and addictive effects. Consult your GP if you think they are necessary; never self-prescribe.
The first key hurdle is to differentiate the truly sick patient from those with more minor ailments
Dealing with sick patients
While completing the aforementioned mundane tasks will occupy the majority of your time on call, being called to a sick patient presents the real challenges. The first key hurdle is to differentiate the truly sick patient from those with more minor ailments.
Often, you will be asked to review a patient with, for example, leg pain, or constipation. The complaint must be taken in context. For example, leg pain in a young, mobile patient may be managed with simple analgesia, whereas the same complaint in an obese, postoperative patient could trigger further investigation.
As a rule of thumb, always ask the referring nurse for the patient’s vital signs over the phone; this helps you determine how quickly the patient needs to be seen. Once assessing the patient, senior help should be enlisted if you feel their management is outside your scope of expertise. At the start of the year, this scope will be narrow, and you may need to call the medical registrar frequently. The registrar expects this, so draw on their experience, rather than make decisions you’re not comfortable with.
Most senior colleagues are friendly and helpful, but if a patient is stable they will expect relevant basics to be completed when you contact them, ie, the “intern package”.
This involves arterial blood sampling, routine bloods, ECG, blood cultures and plain films. Additionally, you should have a good grasp of the patient’s background history, current complaint, current medications and vital signs. Having all this done, or in progress, will facilitate swift management decisions to be made by the registrar, optimum outcome for the patient, and a quick return to bed for you.
Many studies of human efficiency and mental agility have shown significant dips between 10pm and 6am, and the risk of injury is 30% higher on a night shift compared to a morning one. Night work requires doctors to remain awake and alert at the time when they are physiologically programmed to be asleep.
risk of injury is 30% higher on a night shift compared to a morning one
Managing your time
Time management on call is key. Depending on your hospital you may be alone on call or with a partner. Either way, each night should begin with a sweep of the wards. This ideally should take place approximately 30 minutes after nursing handover has occurred to allow the nurses to gather all the jobs they need done for the night and compile a list for you. After completing each task from the list, I always check with the nurses on the wards that there aren’t any outstanding jobs, before moving on. This approach should minimise call-backs.
During your hospital sweep you will inevitably be interrupted by bleeps from other wards. If the issues are non-urgent, I usually ask the nurses to add them to their ward list and assure them I will complete it on my “sweep” of that ward. Giving ward staff an idea of how long you’ll be before reaching them is useful, as it allays their fears that you have forgotten them, and avoids being contacted again over the same issues.
If you are lucky enough to have a partner, usually the bleeps are split over the course of a night so as to allow for protected sleep. Classically, the shifts will be midnight until 4am and then 4am until 8am; however, in the initial weeks, getting the sweep finished by midnight would be a solid achievement!
Getting the sweep finished by midnight would be a solid achievement!
Though being on call can be hectic, the great thing is that you are essentially your own boss for the shift. There is no growling consultant on your case like during the day job, so tasks can be done at your own pace, without too much pressure. All that’s left to say is... bleep.
Dr Louise Hickey is an Intern at St. Columcille’s Hospital