Oncall
Day oncall shift (08:00-20:30)
Referrals
Oncalls are often feared, but shouldn’t be as senior help is ALWAYS available. All referrals (A&E / GP etc) should come via the SHO, however, people often bleep the SpR directly. You should ideally see referred patients & arrange necessary first-line investigations before discussing with your SpR. The VFC protocol has useful information on how to manage and assess the most commonly referred T&O conditions. If you are not sure, ask your SpR. (We understand that T&O is a very specialist field and don't expect you to know everything! We are here to help.)
Referrals can range from phone calls asking for simple advice or asking for patient asses. Do the basics and gain as much history as you can during the phone call. Often because of work pressure and demands, you might not be able to see the patient immediately. So a smart way to be efficient and lessen your work is to gain all the relevant history before you even see the patient, and ask the referrer to complete some investigations where possible (e.g. blood tests, bladder scans, x-rays, getting equipment ready etc).
You must attend all trauma calls. A trauma call will go out over the bleep & you should attend A&E resus as a matter of urgency. The SpR on-call should also attend. Trauma calls are lead by the A&E SpR / consultant. An understanding of the ATLS basics can be extremely useful. If you never had any experience of attending trauma calls, ask your SpR to teach you some basics.
Admitting patients
During the day on-call shift, the on-call SpR will make the decisions to admit or discharge patients. In general, there are 3 types of patients that need admission. 1) needing trauma surgery, 2) needing investigation. 3) need observation / IV treatment. - you will gradually get an idea of what conditions we admit or discharge over time in your placement).
All admitted patients require a drug chart with consideration of analgesia and DVT prophylaxis. In some cases, it is important to hold or reverse anticoagulants like warfarin. NBM patients may need IV fluids, sliding scales etc (prescribe these in advance so the ward nurse won't have to keep bleeping you later on!) Make sure all investigations are reviewed (especially all blood results - all patients undergoing major surgery should have valid Group & Saves ready for electronic cross-matching by time of surgery) Patients are unfortunately easily forgotten once they leave A&E so make sure they’re stable ASAP.
Patients admitted for surgery should be marked and consented. The consent process is done by the oncall SpR (but to make their life easier, you can ensure the consent form is ready!)
TCI patients
Some patients who require surgery but are ambulatory can wait at home rather than being admitted (NB this is decided by the SpR). These TCI (To-come-in) patients still need all the necessary bloods & MRSA swabs done before going home. (obtain the patient's contact phone number and ideally, they should have signed a consent form). A copy of the notes should then go to the trauma coordinators & they should be added to the Trauma Board (in addition to the Take List). There is specific information for patients waiting for surgery. They will be contacted by the trauma coordinators (ideally 24 hours in advance).
Record keeping
Make sure you keep an accurate list of all the patients you’ve seen (regardless of whether they’ve been admitted to hospital or not). In addition to documenting clinical assessments and plans on Sunrise (hospital electronic patient records). All patients referred should ALSO be added to TrakTrauma (the T&O Take list). Patient requiring surgery needs to be added to the "trauma board" within TrakTrauma. It is good practice to update the Take list whenever possible (so patients don't get missed). Update the handover list early so you’re already to present at 8AM / 8PM.
Some tips to being an excellent oncall SHO
work as a team with your SpR (be available, communicate)
be proactive (don't stand there just watching your SpR assessing the patient, be on the ball and start documenting, clerking, writing drug charts, adding patient to the Take list etc)
be enthusiastic (there are tons of learning opportunities during your oncall shift - e.g. interrupting x-rays, joint aspirations, fracture reduction, plastering etc etc)
send CBDs / CEXs! (we are always more than happy to complete these)
take initiative (if the information is online (e.g in VFC protocol) use it first! As your placement progresses, avoid being over-reliant on your SpR for everything)
#NOF – these are probably the most common referrals in orthopaedics so you’ll get lots of experience managing them. There is a specific proforma used in clerking these patients. All patients need bloods (inc x2G&S), catheter, urine dip, CXR & ECG. These should all be ordered by A&E, but it is your responsibility to chase the results. Both the Pre & Post Operative AMTs MUST be completed.
Night Oncall shift (20:00-08:30)
These are tough, no doubt about it. You are the point of call for all T&O referrals AND ward issues. (thankfully the workload is less at night). The key is to stay calm and be organised. If something needs doing, GET ON & DO IT! Get to know what is urgent and what can be done during working hours.
You may be required to make decisions on admitting patients (in general, admit patients who need urgent surgery, IV treatment, investigation or observation) Life or limb-threatening injuries (e.g. NV compromise, compartment syndrome, necrotising fascitis) should be discussed with the oncall SpR. (however, make sure these referrals have been reviewed by A&E registrar or consultant, you are likely going to need their help too)
SpRs are always available for advice but remember they are non-resident and have been working all day so make sure you’ve done as much as you can (SAFELY) before you call them. (e.g. bloods, x ray etc, the VFC guideline has lots of information.) YOU ARE NOT EXPECTED TO MANAGE PATIENTS ALONE. It’s good practice to discuss all patients with your SpR (at least initially).
There are a few specific jobs that need to be done overnight:
Ensure the handover list is updated.
Chase any outstanding investigations (e.g. some bloods may be pending from the day)
make sure patient location is as accurate as possible on the Take List.
Print off copies (five should do) of the handover list & trauma list (do this around 7:30am)
Prepare the theatre list - write patient names on the theatre whiteboard, do booking forms (list orders are done by the Consultant on-take at evening handover, but admissions overnight may change the list order, these can be discussed with the on-call SpR before hand-over)
Make sure all patients on the trauma list are ready for theatre (NBM, medically stable, necessary bloods done, anticoagulants held etc). This is especially important for the first patient (the "golden patient" to prevent any unnecessary delays to the list.