Medical school comes and goes in a flash. The next thing you know, you are standing in an empty hospital corridor, in the middle of the night carrying a boisterous, flashing pager.
It finally hits you, “I am the doctor on call, this patient is my responsibility now”. You can’t sit back observing anymore, because it's your turn in the driver's seat. Equally thrilling and terrifying, wouldn't you agree?
If you’re anything like me, you would feel a lot of nervousness with this newfound responsibility. After all, you’re not running through a tutorial in medical school anymore. This is a real patient's life, which is yours to care and advocate for.
I was somewhat lucky having been rostered to emergency medicine as my first rotation of doctor life. I did appreciate the opportunity to grow and learn (even if it was only a few months) in my new role, before I took on any ward call shifts. Others were thrown in the deep end, and after one buddy shift, they were handed a loud little pager and sent on their merry way.
I believe there are pros and cons to being one of the first in a cohort of fresh medical graduates, to be rostered to ward call. While it is extremely daunting, and for good reason, it is a chance to rip the bandaid off and truly put your medical skills and knowledge to the test.
That being said, ward call can be considered a sink or swim exercise. If you'd rather swim, it's important to be prepared for all scenarios to the best of your ability. This way, not (too) much will blindside you, and the less thrown about you feel, the less stress you'll experience as a result.
What does the term ‘ward call’ actually mean?
This is a term that is used to describe the after-hours rostering system for patient care. As a junior doctor, you will be rostered to a handful of these shifts across each rotation. You can also pick up additional shifts if you wish.
Ward call commences after hours on weekdays (ie: 1700-2300) or are all-day shifts over the weekend. Interns are (usually) not required to do overnight ward call shifts, as they do not have enough experience with the demands of on-call shifts yet.
What does the ward call shift look like?
Every shift will be different. You will see a diverse range of patients, encounter numerous wards and departments and the workload may fluctuate dramatically. Some nights, you will feel well in control and others will be pure anarchy.
Your role as the junior doctor during ward call is to put out the spot fires. You are not presumed to work up and treat every patient you see, to the level that a treating team would hold themselves accountable. You are not there to diagnose and treat a patient's chronic hyponatremia when the page you received is about an episode of acute shortness of breath. This is the treating team's responsibility. Unless the issue is directly contributing to the deterioration of your patient after-hours, it's best to leave some things till morning.
With this, you are expected to work patients up based on the presenting complaint and keep them well overnight. You will also carry an arrest pager. When this bad boy sounds, you need to leg it to your patient's location - they have met medical emergency criteria and need immediate assistance.
How does the shift start?
Generally, you will let your day team know ahead of time that you are rostered to ward call. This gives them a chance to cover you in the morning, as you will not start work until midday in most departments. You then complete half a day 12 - 4.30 (give or take) with your day team, before commencing the ward call shift at 5 pm.
The shift starts with handover. The day team (who have been holding the arrest pagers), will meet with you and the other members of the night crew. The on-call team consists of: a medical registrar who oversees the junior doctors, two surgical ward call residents, and one medical ward call resident (however this varies by hospital and country).
You will also have an emergency registrar and nurse whose role is airway support (as they generally have the most training with advanced and surgical airways). Depending on your workplace and geographic location, other teams present overnight may include anesthetics and ICU outreach.
During handover, the medical registrar will take down all the pagers/phone extensions of the team, for quicker communication. As a team you will address any deteriorating patients that you may be called to during after-hours care - these are generally the patients who are likely to arrest or are deteriorating rapidly.
You will also hand over directly with the resident in which you are relieving. For example: if you are rostered to surgical ward call 1, you will do a handover from the previous surgical ward call 1 resident and complete any outstanding jobs that they could not complete.
Ensure that your handover is succinct. Think SBAR (situation, background, assessment, and recommendation) to keep things short and sweet. Your colleagues will appreciate this, and you will hit all the key points without the additional fluff.
Make sure you keep a list of pager numbers and extensions for your seniors so that if the time comes, you can call for advice or assistance immediately.
Although these shifts can be extremely nerve-wracking, there are some things you can do to prepare yourself. I have compiled a list of my top tips for a successful ward call shift below, I hope you find them helpful!
Bringing the essentials can make or break a night on ward call. Ensure you are dressed comfortably. I like to wear scrubs, and closed-in shoes as they are extremely comfortable and allow you to scale stairwells quickly, or perform CPR if needed. Bring a jacket, it gets quite cold at night in hospital.
Bring lots of water. I would recommend using a one or two liter bottle, leaving it at a central location where you spend the majority of your time. For me, this would be the on-call rooms.
Don’t forget snacks. These are essential. If you get hungry, you simply won’t function to the best of your ability. I find that snacks are often more satisfying than a big heavy meal, which tends to just make you want to sleep or leaves you feeling bloated. I would highly recommend trying to make homemade protein balls, which are excellent sources of carbohydrates for a long shift. Here is my favorite protein ball recipe of all time. I use all-natural peanut butter, almond milk, and honey instead of pure maple syrup. You could also try making protein muffins, egg bites, smoothies, and spiced chickpeas.
A thermos will do wonders for you too. Use it to store a hot drink that you can sip on, or a soup for a warmer meal in the evening. You’d be surprised at the difference that warm food or drink can make when you are tired and cold.
If you’re breastfeeding or expressing, then you may also require breaks to do this. Slotting this in at specific times throughout the shift will be tricky, as you will generally just start leaking during the most inopportune times and you are forced to express immediately. Do your best with that; but to ensure you are prepared, take all your pumping supplies with you and have a cool fridge already in mind to store your milk till home time. A small portable breast pump will make light work of expressing when you are busy. It would be best to discuss this with your workplace in greater detail so that they can support you.
And finally, pack the right equipment. You’ll need a book/paper/clipboard, depending on your preference for note-taking. Pens, many of them, will never go astray as you’ll likely lose them sporadically throughout the night. Don’t ask me how, you just do! I also carry a small over-the-shoulder purse/bag that I keep everything in as I move around the hospital.
Triage over the phone.
I cannot express how vital this tip is. It has saved me countless hours and has expedited the diagnosis and treatment of many patients I have cared for.
How do you do this? Well, it's quite simple. It starts from the moment you receive a page about a patient. Let's say it reads, "W5D 39.1. JONES. UR123456. Patient temp 38.2, tachycardic. Please review''.
I've seen this type of page many times. We are concerned about infection as the underlying cause of the fever, but there is a lot you can do before even seeing the patient.
Start by calling the nurse looking after your patient directly. Ask them for a full set of fresh vitals (if they have not been taken), a little bit about why the patient is in hospital, what medications have been given recently and why the nurses are concerned.
This is a heap of information that you can collect in just 1 minute. I would recommend sitting at the computer during a triage if possible so that you can look over obs, recent documentation, and other relevant information depending on the nurse’s request. Two birds, one stone.
You can also request that nursing staff assist you with some baseline investigations. An ECG can be completed before your arrival, and blood work/cultures may be drawn too (depending on the skills of the staff on that particular ward). If they cannot assist you with blood collection, it could be an idea to ask for the cannulation trolley to be ready in the patient's room before your arrival.
These are small things that save a tonne of time, and you have essentially triaged the patient too. After this phone call, you should have a very good idea of how urgently you need to review the patient.
Leading straight on from triaging over the phone, is prioritising your workload. This is key, but it comes with experience. You will not know how to prioritise effectively for quite some time - be rest assured it is a skill you will learn quickly.
In my experience, patient reviews and other requests come in hot and fast via the pager, pretty much from the second you pick it up. I would recommend writing down the pertinent details on a sheet of paper or in a book, so that if the pager fills to maximum capacity, or you accidentally delete a message - you can still get on with the task.
You can write your incoming pages in column format if desired. The first column will include the ward, bed number, and last name of the patient. The second column will be the task at hand - a review, blood collection, prescribing medication or cannulation, etc. In the third column, I generally leave a blank space to add additional information or ongoing tasks once I have met the patient. It's also an excellent idea to carry a highlighter, to highlight significant information and urgent reviews.
Use the right tools for the job.
Of course, using your local hospital guidelines is a must. However, there are some incredible tools available now to assist with clinical decision-making. Here are some I use daily.
MDCalc is one of my all time favourites. It is an app that encapsulates a massive range of calculators, scoring systems, and other algorithms to assist with clinical care decisions. You can favorite the tools you utilize the most, and search tools by specialty too. This is a must-have!
iResus is another wonderful app, which can be used offline to access emergency algorithms for deteriorating or cardiac arrest patients.
Opioid Calculator is an app that was developed by the Faculty of Pain Medicine and the Australian and New Zealand College of Anaesthetists. This tool completely simplifies the calculator of equianalgesia and is expressed as total oral morphine equivalent. Gold standard if you are concerned about a patient being overdosed with analgesia.
Systematically review your patients.
Similar to how you would approach a MET call, I would recommend using the ABCDE approach with all of your ward call patients.
Collect a succinct history, and then proceed with examination.
Airway: is it patent? Speaking in full sentences?
Breathing: respiratory rate, oxygen saturations, examine the chest and trachea, auscultate the lungs
Circulation: heart rate, blood pressure, capillary refill, periphery warmth, bloods and cannula, auscultation of heart sounds, assess fluid status and JVP
Disability: AVPU or GCS, BSL, pupillary examination
Exposure: temperature, presence of rashes or skin changes, abdominal examination
Even after you complete this sequence once, you should be constantly re-assessing your patient using this approach until they show signs that they are responding to treatment or interventions. Their response will also assist you in tailoring your management.
Do not underestimate the value of an ABG or VBG.
These are like kryptonite - they pack a punch in terms of delivering vital information like hemoglobin, electrolytes and lactate within just a few minutes. Learn to obtain both quickly and efficiently, especially in cases where rapid deterioration is concerned.
It is wise to ask a staff member who is assisting you, to run the sample to ED or ICU (depending on the location of the machines) so that you can continue to monitor your patient.
Take regular breaks.
Pretty self-explanatory, but you would be surprised how many doctors simply neglect their personal needs while on-call. You are no good to anyone else, if you’re not okay yourself. Take the time to eat a snack, visit the bathroom, have some water and just breathe. You have to remember that you are a human with needs too.
Involve your shadowing medical student.
We were all medical students once. Half the time it felt as though we didn’t exist, and the other half we prayed for invisibility if the consultant decided it was time for a bedside pop-quiz. Include your MD student as much as possible; they can be a massive help when you are feeling stretched to your limits and they will thank you for the learning opportunities.
Minimise mindless walking.
During the shift, you will receive countless pages to locations all over the hospital. It can be quite the workout. To minimize your time spent walking and overall fatigue, attempt to complete all jobs in a certain area before you move on.
For example, if you know that you need to see three people on a certain ward - do it all before moving to another ward. Of course, this will highly depend on the nature of the reviews and how urgent they are. Urgency will always take precedence over trying to minimize additional walking.
Always confer with your seniors and escalate early.
There are two key reasons you should consult a senior - firstly, you simply don't know something, and secondly, you are worried.
For example, if you have been asked to chase an APTT for a patient and then alter the infusion rate of heparin, but you’ve never done this before, it is always best to ask. Making a mistake could result in the patient bleeding out.
Your seniors will never get annoyed with you for asking if you are unsure. Before you do, ensure you have exhausted all your options including, searching for the information yourself, reading a guideline, asking someone nearby, etc.
And no matter the issue, if you are concerned about a patient, you need to raise this with a senior immediately. They would prefer you call them early than wait for the patient to code.
You may also call a senior if you would like to run a plan by them. Discussing a patient plan is an excellent opportunity for you to show off your knowledge. Ask if there are any changes your senior would like to make before you proceed.
You’ll see a wide range of patients and complaints across the ward call shift. Some of the most common scenarios you may encounter are listed below.
The febrile patient.
Temperature spikes are a common reason for the request for review. The main things you’ll want to know are:
(1) Why is the patient in the hospital? You’re looking to see if this patient has an infection already, such as an infective exacerbation of COPD, or if they have developed a potential infection in the hospital (ie: in surgical cases).
(2) Do they have a known infection already? If so, you need to know what treatment has already been used and whether it was effective last time. If you can see clear documentation that the previous infection was responsive, this might guide your treatment this time too.
(3) If they don’t have a diagnosed infection already, what is the source of the fever? This is where you need to start digging through all potential source sites and working the patient up.
Screen your patient for rigor, cough, sputum production, dyspnea, abdominal pain or distention, dysuria or urinary frequency, new-onset confusion or decreased GCS, recent surgeries or obvious external infections, painful swollen joints, and signs of meningism.
These signs may indicate that your patient is septic, and a septic screen is urgent. Septic screens usually involve collecting blood (FBC, chem20, CRP), two sets of blood cultures, a urine M/C/S, and chest x-ray.
Reasons you might need to insert a cannula include: inserting a fresh cannula for a new patient or re-siting a cannula that may have tissued or stopped flushing. Cannulating a difficult patient after hours can be extremely challenging, especially if your access to ultrasound and vascular medicine is limited.
It's best to decide how urgently this patient requires a cannula and prioritise it accordingly. A cannula required for IV antibiotics in a septic patient is much more important than a cannula for maintenance fluids in a hemodynamically stable patient who is euvolemic.
You’ll also be paged to prescribe medications and fluids, which may range from simple analgesia to anticoagulation and insulin. Ensure you know enough about the patient and their presentation by reading their chart before you prescribe anything. It's helpful to read the treating team's last entry, as they may discuss medications that can be used or avoided for their patient.
Be careful prescribing strong analgesia without first assessing the patient, especially in patients who may be drug-seeking. If you are asked to chart fluids, ensure your patient does not have heart failure.
These are also known as “code blues” where a patient has met code criteria, is unwell, and deteriorating quickly. This sound will alarm when a staff member has activated the medical emergency call button.
A large team will attend MET calls; including the after-hours registrar, various residents, ICU outreach, nursing and ward staff, and the emergency team for airway support. Your role will be allocated on a needs basis by the senior doctor overseeing the patient's care.
If you arrive first, start with the ABCDE approach and gather information about the patient. You may be asked to scribe and search for investigations, arrange ECGs or medications, establish IV access and collect blood or assist with CPR. Remember, communicate clearly in your role.
I hope that this blog has enlightened you, and in some way made you feel that much more prepared for your ward call shifts. Logically prioritise your to-do list. Be systematic and thorough. Think about whether something can be done tomorrow, or does it require urgent attention? And finally remember that if you are unsure or worried, escalate with a senior sooner rather than later.
Good luck on the wards!