Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Approach to On-Call Surgical Problems
Why write a book on surgical on-call problems? All surgical training programs require time spent “on call.” This is the time, usually overnight or on weekends, during which a physician is responsible for the care of hospitalized patients. It is also the time when new clinical problems arise. These times have extraordinary educational value, but are also the source of great stress. While on call, the physician is typically among the first to encounter significant changes in the condition of a patient and variances in recovery patterns. Hence, it is a unique time to hone clinical skills. However, under current training practices, a significant amount of the time spent “on call” occurs early in the educational process and the individual may not have encountered a wide range of clinical situations. Being on call often requires late hours and prioritizing numerous tasks. Additionally, being on call usually involves “cross coverage,” or responsibility for patients whom the on-call physician may have little familiarity or information. Often life-threatening changes in a patient’s condition may be hidden under seemingly innocuous symptoms. Knowledge and anticipation of these problems may make a great difference in the patient’s outcome. It is useful, therefore, to have a plan for evaluating and administering care to patients in a rapid but thorough and organized fashion.
This book provides an outline for the organization and implementation of care plans in response to many on-call surgical situations. It is written for the intern and junior resident, but we hope that the information will be useful for individuals at all levels of training. Obviously, not all on-call situations can be covered, but emphasis has been placed on the more common and more life-threatening problems.
The structure of this book follows closely the flow of information as it reaches the individual on call. Most chapters are divided into six major headings, as follows:
-
Phone Call
-
Elevator Thoughts
-
Major Threat to Life
-
Surgical Chart Biopsy
-
Bedside
-
Management
-
Special Surgical Considerations
Phone Call 
The first notification of a change in the status of a patient is often a phone call from the bedside caregiver. During that phone call the status of the patient and the urgency of the response must be assessed immediately. It is important to determine whether the patient is pre- or postoperative. If necessary, orders for immediate action are given and initial laboratory studies are ordered. The bedside care provider should be given an estimate of when to expect the physician’s arrival at the bedside. Rarely, the problem may be handled entirely over the phone, but usually, a bedside evaluation is required to fully assess the situation. If there is any question, always err toward a bedside evaluation. You will never be faulted for a bedside examination; the same cannot be said for only a phone call with a potentially sick patient.
Elevator Thoughts 
The travel time to the bedside is wisely spent in consideration of the differential diagnosis of the presenting symptom. These are called elevator thoughts . This term was coined by Shane A. Marshall, MD, and John Ruedy, MD, in the first edition of On Call: Principles and Protocols , and it refers to the long distances through the hospital that often have to be covered while on call. Elevator thoughts also may be used to organize a plan of action once at the bedside. The differential diagnoses given in this text are not meant to be complete; attention is given to those that are most common and to those that could be life threatening. Always bear in mind that there are many uncommon causes of symptoms that can be diagnosed or treated with simple measures, and these must also be entertained. Know what the preliminary plan of action will be before arriving at the bedside.
Major Threat to Life 
In many clinical situations there is a potential of serious injury or risk to life, although these outcomes are, thankfully, uncommon. Many patients are initially hospitalized to anticipate or treat these potential complications. This section will focus on those observations and tests that will best ensure the safety of the patient. The major threat to life is rarely the most common item on the differential diagnosis list.
In clinical practice, it is a wise educational tool to imagine what the major threat is to each patient each day, pre- and postoperatively, and to outline a plan of action. Although these threats may not become a reality, the anticipation of a bad outcome leads to appropriate vigilance and avoidance tactics and to suitable preparation in the face of an unfortunate event.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here