The on-call physician for a surgical service should feel comfortable managing wound problems. Usually, most of these problems are straightforward. However, some calls about wound problems lead to the diagnosis of a serious problem. For this reason, it is important that you examine the patient. What may appear as a benign process to the patient or the RN may appear as a more significant process to…

Changes in urine output (UO) encompass a variety of complaints, the most common being a decrease in UO in a postoperative patient because of changes in intravascular volume. Also considered in this chapter are other causes of decreased UO, increased UO, and blood in the urine. Components of these evaluations also are covered in other chapters where indicated. The function of the kidney may be divided…

The ultrasound machine has become ubiquitous in most hospitals. As ultrasound portability has improved, use of bedside sonographic assessment has expanded. Today, point-of-care ultrasound assessments aid in diagnostics and procedural technique. Ultrasound evaluation offers a rapid, low-cost adjunct to diagnostics and improves procedural safety. The on-call surgical resident should have familiarity with the basic principles behind ultrasound, general technique for use, and understanding of indications for…

Many postoperative patients will have drainage devices to facilitate their care. The types used most often fall into the following broad categories: Chest tubes Urinary drainage tubes (urinary catheters) Gastrointestinal (GI) tubes (nasogastric [NG], feeding tubes, and gastrostomy and jejunostomy tubes) Biliary drainage tubes (T-tubes, internal-external biliary drain) Wound drainage tubes (Jackson-Pratt, Penrose, and other suction drains) Problems with these tubes are frequent but generally straightforward.…

Trauma describes injuries caused by physical forces. These may be blunt, penetrating, thermal, or any combination of the three. As the leading cause of death in patients under 45 years of age, it is imperative that the on-call surgeon be able to appropriately recognize, respond to, and triage the traumatically injured patient. Phone Call 1. What is the estimated time and mechanism of arrival of the…

Syncope is a brief loss of consciousness caused by an interruption of cerebral blood flow. Causes range from benign processes such as vasovagal episodes to more serious conditions such as dysrhythmias. As the on-call physician, your job is to identify the cause of the syncopal episode, to stabilize the patient if necessary, and to identify any injuries resulting from falls secondary to the syncopal episode. Phone…

It is common to be asked to assess problems with a patient’s breathing. Shortness of breath (SOB) has many causes. Most at risk to develop respiratory distress are those who have had thoracic or upper abdominal procedures, and elderly, obese, or poorly nourished patients. Phone Call Questions 1. How long has the patient had SOB? 2. Was the onset slow or rapid? A rapid onset suggests…

Seizure activity is a synchronous discharge of electrical activity in the brain. The locus in the brain dictates what clinical symptoms are noted. Generalized tonic-clonic seizure activity is the major symptom for which you will be called. Seizure activity is frightening and disturbing to witness. Patients actively having seizures can harm themselves, and the underlying abnormalities are often serious. Some patients will have epilepsy, and will…

Bleeding in the postoperative period is a concern for the on-call physician. You must decide whether the bleeding has a surgical cause (major vessel bleeding) or a medical cause (abnormal coagulation status). Some patients will require a return to the operating room (OR) for control of bleeding. Other patients may require bedside care, reversal of coagulopathy, and/or transfusion of blood products. Guidelines for evaluation of bleeding…

One of the most unpleasant requirements of on-call responsibilities is pronouncing death. This important task represents a significant medicolegal responsibility. You may not have had much experience evaluating recently deceased persons, and there is some controversy as to what exactly constitutes the legal definition of death. This chapter provides a guide of the steps to follow when declaring a patient dead. Different states in the United…

Ideally, a patient is prepared preoperatively using a multidisciplinary strategy including primary care providers and anesthesiology preoperative assessments. Occasionally, an on-call physician will be asked to complete a workup or to check a laboratory result. Preoperative preparation encompasses those precautions that are aimed at decreasing the inherent risks of a procedure. A patient must be readied both physically and psychologically. Nutrition Extensive surgical procedures are followed…

Surgical patients have pain. Pain may be caused by a disease state or the therapies used to treat that disease state. Historically, pain has been under-recognized and undertreated, but recent emphasis by regulatory and government groups has brought into focus the need to adequately assess and treat pain. As an on-call physician, you will receive many calls requesting pain medication for patients. Many of these calls…

Nausea and vomiting are common on-call problems. There are many causes of nausea and vomiting. It is believed that the medulla contains two distinct centers that mediate vomiting, a chemoreceptor zone and a vomiting center. Toxic substances, drugs, and input from the cerebral cortex, the gastrointestinal (GI) tract, and other organs stimulate these centers to induce nausea and vomiting. Surgical patients are frequently exposed to medications…

The patient’s cognitive functioning is the most complex of all physiologic processes, and it is therefore affected by derangements in many organ systems. Appropriate assessment of mental status changes requires a knowledge of a prior mental status examination. This information may be available from the chart or from the bedside caregiver. It is useful to organize your thinking according to that baseline and how the patient…

Leg pain is common with lower extremity surgery, trauma, vascular problems, inflammatory or degenerative conditions, infection, or referred pain. Some of these conditions can be managed by telephone, whereas others require that you examine the patient. A careful discussion with the RN will help show which patients should be examined. Phone Call Questions 1. What area of the leg is painful? Pain in the region of…

Intravascular access is a means to administer fluids and medications and is a valuable tool for gathering hemodynamic information. The loss of “access” is a common reason for a phone call. This chapter provides orientation to various types of intravascular access, procedures to attain them, and common complications and problems. Some hospitals require informed consent before some of these procedures are performed; find out what the…

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Hypotension is a common and serious complication of a patient’s hospital course. In mild and early stages, there are many compensatory responses that can support tissue perfusion. If it worsens, circulatory collapse can ensue, resulting in shock. Shock is the extreme form of hypotension and refers to the condition of inadequate end-organ tissue perfusion. With a small amount of information and knowledge of a patient’s trends…

The goal on call is to treat hypertensive episodes that are symptomatic or that put the patient at risk for myocardial infarction (MI), stroke, or bleeding. As the on-call physician, it is best to leave the fine-tuning of a patient’s blood pressure (BP) to the primary team caring for the patient. Phone Call Questions What is the patient’s BP? 1. Always evaluate the magnitude of the…

While on call, you will be asked to evaluate and treat patients with headache. Postsurgical patients may develop headache as a sequela of anesthesia, stress, sleep disturbance, drug reaction, hypertension, increased intracranial pressure (ICP), and other causes. Other patients may have a history of recurrent, chronic headache. Usually, a slow-onset, chronic headache is associated with a relatively benign process. Rapid-onset headache associated with fever or a…