The Neurosurgery registrar’s on-call survival guide
Generally speaking, being on-call is one of the most stressful parts of a clinician’s job. However, this is where the bulk of training and essential experience is gained. What we like to think we learn from being on-call in neurosurgery is how to operate. Although this may be true to an extent, what we learn much more about is high-stakes decision-making processes. In this respect the on-call can also be thought of as an administrative exercise. An organised on-call helps to keep patients safe and allows you to turn it into a positive learning experience.
Here are three general tips before you start. If you can apply some of these broad principles, you’re well on your way to being able to manage the drama of a neurosurgical on-call:
1. It's a marathon not a sprint, so pace yourself, especially if you're doing a 24 hour shift.
2. Document referrals and to do lists either on paper, digitally or in your head. (If you work in a hospital that uses Referapatient.org then use it to your advantage)
3. Have a system. There are various different systems you can use and I’ve described three below. You can use one, all, a mix or none. You should find what works for you. The aim of this article is to provide you with the tools and mindset necessary to own your on-call and not be owned by it.
· Patients for theatre
· Sick patients
· ED patients
· External patients/referrals
· Ward patients
· Things to do
· Things in progress
· Things that you've sorted
· Things to discuss with Consultant now
· Things to discuss with Consultant when convenient.
Now that your mind-set is focused on owning the next 24 hours, here are the things that you should get out of the way as soon as possible, provided there are no emergencies that you have to deal with.
Eat – a hungry, dehydrated surgeon is not a happy surgeon. Being dehydrated will slow down your processing power.
Go to the toilet – do not take referrals whilst thinking about how much longer your bladder is likely to hold out. This will inevitably lead to mistakes or not gathering enough information to make an appropriate decision.
Make sure your bleep or phone is charged – it will run out of battery and you don’t want this to happen whilst discussing the logistics of bringing a dying patient over to your hospital as an emergency.
Secure an on-call computer with access to referapatient (or whatever method you have for documenting referrals) and PACS. Log in to a computer and leave a polite notice so that colleagues avoid using it. Make sure you don't need to make anymore decisions at work than you have to
Despite all of this, if it gets busy and all of your plans go pear shaped, you'll find yourself in fire-fighting mode. The phone won’t stop ringing. The emergency patient is ready to go but not consented. You’ve just been told that there is a patient with an acute subdural with a dilated pupil in resus and ITU have called to say that your patient with the head injury has an ICP of 70. Their family also want to talk to you. Right now.
When this happens, it is essential to avoid "paralysis by analysis". This happens when you overthink because there is no immediately obvious way to prioritise. You end up in a never ending mental Möbius strip and become more and more anxious and incapacitated with every minute.
If you are able to clearly prioritise, well and good. But if you find that you are unable to prioritise, start with anything you can. The only way the jobs will disappear is if you start doing them.
You'll find that it will become easier and easier the more you act and the less you think about planning to act. You can avoid this in the first instance by creating a time map, breaking down your shift into segments. If you know what you have lined up for the next 24 hours, great, but don't keep looking at your 24 hour view. Look at the 20 minute, 30 minute or even 60 minute view.
Breaking things down into chunks makes handling things easier.
This article was written by Mr. Amin Elyas, Locum Consultant Neurosurgeon at the Royal London Hospital.