Making the hospital work for you: surviving a ward on call
The third in a series of articles takes you through what to bring with you and how to hand over
- By: James Smith, Francesca Flohr, Anusha Edwards
Your first on call as a doctor is coming up, and thoughts are running through your head: “Am I ready?” “Do I know what I am doing?” and “Medical school hasn’t prepared me for this.”
As part of the series “Making the hospital work for you” the aim of this article is to reassure medical students and junior doctors that with basic preparation and simple techniques, an on call shift will fly by and hopefully be an enjoyable experience.
The thought of your first on call shift can be daunting. Try to relax the day before and avoid a late night. Being well rested and relaxed before your shift optimises rational thought and decision making.
Basics of emergency medicine
The on call doctor is often the first medic to review sick patients, and their initial assessment and management can be vital to overall prognosis. It is important that junior doctors have a basic understanding of emergency medicine before embarking on an on call shift.
Basic requirements include the prescribing and understanding of the following:
- Analgesia—understanding the World Health Organization pain ladder and the three step approach to prescribing
- Antiemetics—including indications and contraindications
- Sleeping tablets and anxiolytics
- Antibiotics—although specific to hospital policy you should know where the policy can be found
- Basic investigations, including electrocardiograms, chest radiographs, and arterial blood gases
- Blood tests—familiarise yourself with how to order them and recognise abnormal values
- Management of common acute medical diagnoses—for example: Hypoglycaemia Diabetic ketoacidosis Seizures Cardiopulmonary resuscitation (and understanding of basic and advanced life support) Peritonitis.
Although on call junior doctors are often seen struggling under the weight, they should carry the following essentials:
- Stethoscope—you will be the first doctor to clinically assess new patients, who might have chest infections or heart failure
- British National Formulary  or equivalent—carrying books can be tiring, but many wards do not have a copy of a drug formulary at hand. You should have your own copy, or get online access at www.bnf.org.uk
- A reference guide, such as the Oxford Handbook of Clinical Medicine  or Pocket Essentials of Clinical Medicine 
- Pen torch
- A pen . . . that works—don’t take your best pen as you are likely to lose it
- Notepad—this should not contain patient sensitive information or breach data protection (see Student BMJ 2011;19:d5692 Making the hospital work for you: record keeping)
- Time piece or belt watch, or both (compliant with trust infection protocol)
- A bottle of water and something to eat.
Starting the shift
Before starting an on call shift, you should familiarise yourself with the location of the wards you are covering, the canteen, the mess (junior doctors’ resting quarters), and departments that you will commonly visit, such as the emergency department, radiology, and theatres. Feeling lost in a hospital can be factual as well as metaphorical.
Make sure you have received the on call bleep/pager from the last doctor and know how to use it.
It is important to know what team you are working in and who is in the team. This should include the person to call when senior assistance is required and how to contact him or her. Make arrangements at the start of the shift if contact isn’t via a centralised switchboard.
On call team
The junior doctor plays an important part in the multidisciplinary on call team, which includes doctors, nurses, and managers:
- House officer (foundation year one)
- Senior house officer (foundation year one, core or specialty trainee year one or two)
- Specialist registrar/staff grade
- Medical/surgical director
- Site/bed manager
- Emergency crash team—during the day, this is often the medical registrar, senior house officer, nurse practitioner, and anaesthetic registrar. At night this is part of the hospital at night team.
Hospital at night
In many hospitals, at night the on call team work in a system aptly called hospital at night. This system works as one multidisciplinary team and provides support for all specialties concerned, providing cross cover when required. The hospital at night team includes doctors from medicine, surgery, and other specialties along with a nurse practitioner or site manager. In collaboration, this team often forms the crash team.
Working patterns now entail more frequent handover of patients since the European Working Time Directive. The directive restricts working time to 48 hours a week and therefore requires transfer of care of patients between different medical teams during the day. It is vital to hand over patients before, during, and at the end of every shift. A handover should include informing the next team of any acutely unwell patients causing concern, and any patients with outstanding investigations, or requiring further management (fig 1). 1 Handover should be between staff of equivalent grades and may be performed at night between all specialties.
Assessing a patient
Taking the call
- Get details of the patient’s name, age, and ward location
- Reason for admission and relevant history
- Reason for call and observations
- If possible, give treatment advice to the nurses until you can see the patient. For example, this could include giving oxygen or performing electrocardiography
Assessing the patient
- The safest approach to assessing a patient in an acute situation is to use an ABC approach—assessing airway, breathing, and circulation
- This should be followed by a thorough history and examination
Check the observation chart
- Review the observation chart, identifying the current observations and any recent changes
Check the drug chart
- Any drug allergies?
- Any recent drugs started?
- Any regular drugs omitted?
- Any drugs absent from the chart—for example, venous thromboprophylaxis or antibiotics
Read the medical notes (emergency department records and current entries in the medical records)
- Admitting condition
- Premorbid status
- Any recent medical entries?
Blood tests and investigations
- Check the recent and serial measurements
Make a management plan
- Decide whether any drugs need to be prescribed urgently
- Order appropriate investigations
- Inform nurses of the frequency of observations—for example, hourly observations (blood pressure, pulse rate, respiratory rate, saturations)
- Review after implementation of plan or seek senior review
The ability to prioritise jobs is one of the fundamental skills to learn during your time as a doctor. It is a skill that evolves during training and relies on being able to recognise sick patients, understand appropriate management plans, and realise that some jobs on the ward can safely wait in favour of more urgent jobs.
In your first on call shift, be organised and write down the jobs that are required. If two or more patients seem to have similar and urgent priorities do not be afraid to contact a senior doctor for assistance.
As the on call doctor you may be called to two unwell or peri-arrest situations at the same time. It is important to realise that one doctor cannot see two patients; in this situation we recommend seeking senior assistance early.
Making a referral
Making a referral to another specialty can be an intimidating prospect. Being direct, structured, and organised can help. Plan what you are going to say before you pick up the phone (fig 2). 2 If you don’t agree with the decision that is made by a member of the other team, don’t be afraid to go to the next level in that team. The second article in this series, “Making the hospital work for you: requesting specialty reviews,” will help you to become familiarised with the SBAR approach to making a referral. The acronym stands for Situation, Background, Assessment, and Recommendation, and should be outlined in your referral:
- Patient details—name, date of birth, hospital identifier, location
- Urgency—how soon does the patient need to be seen?
- Summary of presenting complaint and events since admission, including test results, observations, and current treatment (Situation)
- Relevant medical and drug history (Background)
- Any important social or psychological factors
- Differential diagnosis (Assessment)
- Your question to the reviewer—that is, reason for referral (Recommendation)
- Your contact details
- Referral date, time, and your team’s lead consultant
- Documentation—in the notes, and as per your hospital guideline
- Be friendly and approachable throughout your shift to all employees. The nurses provide practical and emotional support and their experience should be respected
- Avoid arrogance. A medical degree does not entitle you to over confidence—all employees have a vital role in the hospital
- Although time-consuming, accurate, structured, and contemporaneous documentation is crucial
- Look out for each other, work together, and try to divide jobs between you and your team. Other on call doctors, even in different specialties, will always appreciate your help
- Respect your seniors and their experience. Seek assistance early, as it is better to ask for help sooner rather than later
Reflection is vital for ongoing education and plays an important part in appraisal. At the end of your first on call, sit down and think about how the shift went. Ask yourself some simple questions: “What did I do well?” “What could I have done better?” “What have I learnt?” and “How would I change my practice for my next shift?”
Documenting your reflection in your paper based or e-portfolio can provide evidence at your appraisal of formal self assessment and may be required for application for future employment.
The first on call is always a difficult shift but should be enjoyable. No one in the hospital expects an on call doctor to look after every patient’s medical problems. Remember that the best doctors aren’t the ones who think they know exactly what they are doing; they are the ones who admit early on that they don’t.
Smith J, Flohr F, Edwards A. Making the hospital work for you: record keeping. Student BMJ 2011;19:d5692
Roughley CI, Anwar A, Roberts P, Salter T. Making the hospital work for you: requesting specialty reviews. Student BMJ 2011;19:d6704
1 Department of Plastic Surgery, Frenchay Hospital, Bristol, 2 Brighton and Sussex Medical School, Brighton, Sussex, UK, 3Department of Transplant Surgery, Southmead Hospital, Bristol, UK
Correspondence to: email@example.com
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- World Health Organization. WHO’s pain ladder. www.who.int/cancer/palliative/painladder/en/.
- British National Formulary 62. BMJ Group and Pharmaceutical Press, 2011. http://bnf.org/bnf/index.htm.
- Lungmore M, Wilkinson I, Davidson E, Foulkes A, Mafi A. Oxford handbook of clinical medicine. 8th ed. Oxford University Press, 2010.
- Ballinger A, Patchett S. Pocket essentials of clinical medicine. 4th ed. Saunders Elsevier. 2003.
- Roughley CI, Anwar A, Roberts P, Salter T. Making the hospital work for you: requesting specialty reviews. Student BMJ 2011;19:32-3s.
Cite this as: Student BMJ 2011;19:d7248
- Published: 09 December 2011
- DOI: 10.1136/sbmj.d7248