The Surgical On-Call Shift

Introduction

As a doctor in surgery, you will be part of the surgical on-call rota. On-calls include any out-of-hours shifts (i.e. after 5pm and before 8am, twilight or night shifts) and daytime shifts clerking and/or looking after new admissions.

Out-of-hours, there is a skeleton team of doctors in the hospital, so you will work more independently and be the initial contact (via your bleep) for issues involving any surgical patient.

Each hospital and department will work slightly differently, but in this article, we will cover general features of the surgical on-call shift to give you more confidence going on-call for the first time.

The on-call surgical team

The on-call surgical team is usually made up of:

• Foundation year 1 doctor (FY1)
• ‘Senior house officer’ (SHO): either FY2, core surgical trainee or clinical fellow/trust grade
• Registrar (SpR)
• Consultant
• Allied healthcare professionals: some departments have advanced nurse practitioners or physician associates who assist with the on-call in daytime hours (8am – 5pm)

Each department works slightly differently, but from 8am – 5pm there are usually multiple ‘surgical teams’. The on-call team sees new admissions who get added to the on-call list (NB: seeing new admissions is also to referred to as ‘clerking’ or being ‘on take’).

Patients typically stay on the on-call list until there is a changeover of on-call consultants. At this point, they move to a ward list under their admitting consultant.

Ward teams look after the patients admitted during previous on-calls or after elective surgery. This is important as between 8am-5pm you should re-direct any calls about these patients to the appropriate team. During the night, however, you are responsible for all patients.

In some hospitals, there may also be a separate CEPOD team comprising an SHO, registrar and consultant who perform emergency operations during daytime hours.

Responsibilities

The chain of escalation when on-call is:

• Foundation year 1 doctor
• Senior house officer
• Registrar
• Consultant

If a patient has a new medical problem (e.g. chest pain with ECG changes), your surgical seniors may ask you to discuss the case with the medical registrar.

If a patient is acutely unwell, critical care outreach can provide additional support on the ward.

Foundation year 1 doctor

FY1s are usually responsible for ward cover and look after patients already admitted to the ward. This includes:

• Reviewing acutely unwell patients (e.g. high NEWS score, temperature spike, confusion, falls), performing an initial assessment and arranging preliminary investigations
• Practical skills: venepuncture, cannulation, catheterisation
• Prescribing analgesia, fluids and other critical medications
• Verification of deaths

Other responsibilities include:

• Post-take ward round documentation and ‘jobs’ (tasks generated from the ward round)
• Assisting SHO/SpR with clerking, including documentation, prescribing regular medications and thromboprophylaxis
• Escalating concerns or queries (to SHO)

Senior house officer

The surgical SHO is usually responsible for:

• Referrals and clerking new admissions
• Assisting with emergency surgery
• Assisting the FY1 with post-take ward round documentation and jobs
• Providing clinical advice and support to FY1
• Escalating concerns or queries (to registrar)

Handover

Every department will typically hold a handover at the beginning and end of each day (8am and 8pm). You should find out at induction where the handover will be.

Handover involves talking through each patient on the on-call surgical list to ensure continuity of care, handing over outstanding jobs to incoming doctors and identifying any sick patients to be aware of.

As the on-call FY1, you will often receive a mini-handover at 5pm when the ward teams leave, for example, to chase the results of a scan or blood tests.

Doctors at each level (FY1/SHO/registrar) will hand over appropriate jobs to their incoming colleagues. For example:

• Jobs to be done: patients waiting to be seen or expected to come in, bloods that need to be taken (e.g. repeat electrolytes, lactate or haemoglobin) or CT scan that needs vetting
• Jobs to be chased: results of blood tests or imaging, review from another speciality
• Unwell patients to be aware of or who need overnight review

As an incoming doctor, it is useful to bring a blank piece of paper to record the jobs you are given (you can staple it to your list).

This ensures no jobs are forgotten and allows you to prioritise appropriately. Similarly, keeping your job list tidy and updated during your shift makes handing over easier. Everyone has a different system for tracking what’s been completed, and you will figure out what works best for you.

Finally, handover is a good time to find out who your senior clinicians are, how to contact them and where they will be (resident or non-resident). Write down or save the names and contact information (bleep and/or mobile number) for your FY1/SHO/SpR so they can easily be located in an emergency.

‘The list’

The surgical list summarises all new patients referred/admitted and those waiting to be seen.

It should include:

• Patient details, including NHS/hospital number and date of birth
• Location in the hospital: particularly important as patients may be spread across multiple wards/ED, and the list will be used as a roadmap for the morning ward round
• Brief history and past medical history
• Examination findings
• Important investigations: bloods, imaging
• Management plan

Example of a surgical list

Abbreviations: RUQ, right upper quadrant; T2DM, type 2 diabetes mellitus; HTN, hypertension; CRP, C-reactive protein; WCC, white cell count; U&Es, urea & electrolytes; NAD, no abnormality detected, ALT, alanine transaminase; ALP, alkaline phosphatase; Bil, bilirubin; Amy, amylase; INR, international normalised ration; USS abdo, ultrasound abdomen; IV cef + met, intravenous ceftriaxone and metronidazole; IVF, intravenous fluids; LIF, left iliac fossa; PMHx, past medical history; CTAP, CT abdomen and pelvis; IV abx, intravenous antibiotics. 

Updating the surgical list

Typically, the FY1, with help from the SHO, is responsible for keeping the list updated and printing sufficient copies in time for handover. You should find out at induction how to access and add patients to the list – depending on the hospital, it might be a Word document saved to a shared drive or another computer program.

If possible, it is a good idea to stop doing ward jobs 30-60 minutes before the end of your shift to leave time to update the list and print it. This might seem like a lot of admin, but an accurate, tidy list is invaluable, and your seniors will thank you!

Referrals

Typically, the surgical SHO is responsible for receiving new surgical referrals, which may come from:

1. Emergency department (patients in the ED)
2. General practice (patients in the community)
3. Another speciality: depending on local policy, new referrals from the ward, i.e. patients that are already admitted under another speciality, may be referred to the registrar rather than the SHO

Taking a surgical referral

Clarify role

Clarify who you are at the start of the conversation: “Hi this is X, the surgical SHO”.

• It is not uncommon for referrers to be put through to the wrong person, and this will save you listening to a referral only to realise they were looking for the orthopaedic SHO!

Record the referral

Record referrals clearly and logically so patients don’t get lost or forgotten (e.g. in a grid on the back of your list rather than on scraps of paper or in margins). Include:

• Complete patient details: full name, NHS/hospital number, date of birth, age, gender, location
• Salient details about the history and investigations to jog your memory when handing over the patient or discussing with your registrar

Ask about observations and treatment

Ask about current observations and treatment the patient has received so far.

• Observations will help you to prioritise patients and determine who needs to be seen most urgently. If a patient sounds particularly unwell, you may also want to inform your registrar sooner.
• Don’t be afraid to politely ask the referring clinician to do appropriate jobs if you are seeing other patients, e.g. prescribing antibiotics and fluids, inserting an NG tube and catheter in a patient with bowel obstruction or vetting a CT scan.

Be wary of incomplete referrals:

• The differential diagnoses for abdominal pain are broad and can include serious medical pathology. Be wary of accepting referrals where basic investigations are incomplete (e.g. epigastric pain without an ECG/troponin).
• A pregnancy test in women of childbearing age is essential.
• A rectal (PR) exam should have been performed in patients presenting with PR bleeding. Differentiating fresh bleeding (likely lower GI) from malaena (likely upper GI) determines whether the patient should be referred to the surgical or medical teams respectively.

Consider local management and admission policies

Be aware of local admission policies. Depending on local policy, certain diagnoses or patient cohorts will have different management pathways. Clarify pathways at induction or find out where local guidelines are located on the trust intranet.

Examples of different management pathways may include:

• Acute pancreatitis: typically, chronic alcoholic pancreatitis is admitted under medicine, and all other cases of pancreatitis are admitted under surgery
• Pyelonephritis: may be admitted under medicine or urology
• Paediatric patients: district general hospitals (DGHs) typically accept children over a certain age and with either simple abscesses or suspected appendicitis; all other cases are referred to the local paediatric surgery centre
• Breast pathology: patients requiring admission will be referred to general surgery and then reviewed or followed up by breast services depending on local pathways
• Rib fractures: isolated rib fractures after trauma are usually admitted under surgery
• Limb pathology, including an abscess or haematoma, should be referred to orthopaedics
• Face/anterior neck triangle pathology shoulder be referred to ENT or maxillofacial (maxfax)

Surgical specialities like neurosurgery, vascular and hepato-pancreato-biliary (HPB) do not exist in every hospital. If required, the referring clinician should typically discuss with the specialist team and then refer locally to general surgery if that is the advice. 

Example of referral documentation (grid format)

Abbreviations: 3/7, three days, D+V, diarrhoea and vomiting; NAD, no abnormality detected; hCG neg, pregnancy test negative; TCI, to come in; GP, general practice.

Other tips

If a patient has been referred from the community, you will usually be informed when they arrive in ED/triage. A nurse or healthcare assistant is usually responsible for performing venepuncture and urinalysis for patients in the waiting room. Ask for these initial investigations to be done when the patient arrives to improve efficiency.

Don’t accept the referral if you are unsure whether a patient should be admitted under the surgical team. Politely explain that you are unsure and offer to call the referrer back after you have discussed the case with your registrar. Referrals from ED are a one-way system and cannot be ‘handed back’, so inappropriate referrals become your problem to sort out or refer on!

Before going to clerk a patient, always check their location. Referred patients may be transferred to a surgical ward before being clerked to help with patient flow in the emergency department. 

CEPOD

CEPOD is the name for the 24-hour emergency theatre. Usually, it is a single operating theatre shared between all surgical specialities. The case order is determined by clinical urgency, and surgical registrars or consultants will negotiate this amongst themselves.

If it is decided that a patient needs emergency surgery, as the SHO, you may be asked to ‘book the patient for theatre’ or ‘add them to the CEPOD list’. Often, your registrar will help with part or all of this process, but if they are busy or travelling from home, you may be required to do it.

1. Add patient to the emergency/CEPOD theatre list: depending on the hospital, this might be via an electronic system or by contacting the theatre coordinator.
2. Inform the on-call anaesthetist: have patient details, including location, to hand and be prepared to give a short handover about suspected diagnosis, planned operation, medications and social history.
3. Ensure group & save has been collected and thromboprophylaxis documentation is complete.
4. If the patient is having a laparotomy, complete the NELA risk assessment and record the results in the medical notes.

It is also useful to locate and keep a consent form with you or at the bedside. As you get more experienced, you may be able to fill out the consent form and progress to consenting for procedures.

Final tips

It is normal for your first surgical on-call shifts to be daunting. You will be busy with many patients to look after, some of whom may be acutely unwell. However, you will find that you learn the ropes quickly and the team around you will support you.

The same basic principles always apply:

• Ask for help: don’t be afraid to escalate concerns or queries to your senior, especially if you are dealing with an unwell patient
• Be organised with your documentation and list-keeping
• Learn to prioritise jobs: reviewing a patient with low saturations takes priority over writing a discharge summary
• Be polite to your colleagues and ask the ward staff and nurses for advice; they are an excellent source of advice and an extra pair of hands when you are busy
• Remember to take a break and refuel when you can