Tips for house officers
It may be scary the first few times you come across something new. The Med Reg is always available no matter where you are, and you should not be afraid to call them. You will NEVER get in trouble for calling for help. Good luck!
General tips
Prioritise your calls – Is this actually acute? Can it wait until morning?
Always ask nurse to check whether there is already a documented plan by team as to management if the presenting complaint should arise (sometimes with complicated patients or when situations can be pre-empted there is already a potential plan in place).
Get general history and ask for vitals - Are there any ‘red flag’ symptoms? Is this the first time this has happened? Is there a simple explanation for this i.e. do I need to go to the ward?
Give an ETA if you can – so the nurses know how long they will have to wait (otherwise, you run risk of being paged multiple times for the same reason).
Advise nurses of simple things that can be done before you get up to the ward.
e.g. repeat obs, ECG, analgesia, anti-emetics, IV fluids (e.g. bolus – you may choose to do a verbal order). Request nurses to have notes and meds chart ready for you to review when you arrive.
Assess each problem yourself. Requests like "Can you come prescribe some anti-emetic because the patient’s vomiting" may actually be due to an underlying acute abdomen.
Caution when giving meds to patients with chronic illnesses e.g. renal/liver/heart failure; Parkinson’s disease.
Caution when prescribing medications for the older, more frail population – e.g. avoid NSAIDs, codeine, tramadol. Also, avoid regular metoclopramide as this can cause extra-pyramidal side effects, especially in the elderly.
ALWAYS check allergy section prior to prescribing meds. If a new allergic reaction is noted, then clearly document this on med chart and in notes so that the team pharmacist is aware in the morning.
When asked to chart fluids: (1) Ask whether patient really needs fluids overnight? (2) Check recent electrolytes + creatinine in case you need to add in more K+ (3) Never prescribe sodium chloride 0.9% for a dehydrated patient with advanced liver disease (increases ascites). Consider prescribing albumin instead on consultation with the Registrar.
Have a low threshold to call a Registrar. Don’t do anything you feel uncertain about.
3 IV attempts are enough: call someone else! (Note the CNAs can do this if needed).
Manually check vital signs yourself (especially if abnormal). The trend is important.
Tips for on call
If you’re finding yourself swamped with jobs, call the CNM and ask for help. If they are not too busy they may lend a hand especially with procedural jobs or they’ll look to see which other HOs aren’t too busy and can help (there are often other services which aren’t too busy, and as colleagues we support each other and help when our workloads are lighter). If you can’t get a line in during the middle of a night shift, ask a CNM to help out.
There is an offsite on call pharmacist during out of work hours. They are really helpful and approachable so call them on long days or nights if you need.
When filling out death certification papers on call, if you’re uncertain with what you’re doing/you want to check if you’ve done it right (to avoid being called back into the hospital to make corrections), call the CNM.
Some nurses can do bloods and IVLs. You may wish to ask if anyone on the ward can assist because when on calls get busy you may need to prioritise other tasks/sick patients. Failing that there is often a roaming cannulator on from 4pm, or one of the CNMs may be able to help.
In general nurses do female catheters, HOs do male catheters
When to call the SMO
Each service has an SMO Escalation Plan (Hippo - A-Z - SMO Escalation Plan) with reasons to contact/notify the SMO after hours (e.g. in the event of an unexpected patient death or admission to ICU). In general it is the registrar’s job to make that call, but they may be otherwise occupied. Because of the large number of services and varying reasons for notifying the SMO, it is recommended that you enquire at the start of the run so you know when it is appropriate to call the consultant. If in doubt, talk with your team registrar.
Weekends
How you prepare your patients for the weekends can make a huge difference to your colleagues during busy weekend shifts.
Prior to each weekend:
Ensure patients have a weekend plan. Usually this is written on a yellow form and placed in the front of the patient’s notes, and any specific jobs handed over to the weekend house officer verbally. Ask about the usual systems on your ward. If there is a job for the HO this should be as specific and clear as possible e.g. ‘if weight has not reduced by at least 1kg, increase frusemide to 40mg BD’.
Ensure there are enough days left on the drug chart to get through to Monday, and if not, re-chart it. Weekends on call are busy enough without unnecessary re-charting.
Ensure any planned or likely weekend discharges are prepared
Phone system and finding contacts
Dial ‘0’ and follow the prompts to reach the operator.
To get through to an outside line (not a hospital extension), dial 1 first, then the number.
To search for a phone number, go to the Hippo Home Page. On the right hand side under ‘Quick Links’ you will find the banner ‘Clinical’. Click on ‘Referral and contact list’ for the most up-to-date contacts list
Nights
Meals are delivered to the RMO lounge fridge for those on nights. There are meal request forms in the café if you would like to request specific things – fill this in in the morning prior to your next night shift.
Radiology
You need to put in a request on Clinical Portal then DISCUSS it in order for it to be prioritised and booked in (unless it’s an AXR, CXR or simple USS, which do not require a discussion).
Between 4pm – 8am any requests need to be made under the Emergency/Portables option (which is radiology on level 2 next to ED). If you order via the other options they go to level 5 (the day time staff), your request probably won’t be seen and won’t get done.
You can either ring and discuss a request over the phone, or go in person to level 5 (if patient is on the ward) or level 2 (if they are in ED/CDU or it is after hours). USS generally doesn’t open until 0930.
You can usually catch the interventionalists between 0830 and 0930. Follow the signage at level 5 radiology to their workstation or ask the receptionist there for directions. If there is no one there you can write your request on their whiteboard.
Sick leave
Simply put: if you are unwell, you should take a sick day. This includes taking sick leave for your mental health and wellbeing. Make sure to call the RMO unit/leave a voicemail early in the morning so they can sort out cover for the day (or call the CNM via the operator if you’re due to work a night shift) as well as telling your registrar or consultant.
Patients out of Auckland
Ensure that you cc their usual specialist on their discharge. E.g. patient under surgeon Dr Bloggs in Nelson goes into the discharge summary- Cc: clinician name (Bloggs) - search icon - select name (Marama Bloggs) - Add. They will then be automatically included on the discharge and sent an electronic version. They often won’t have access to RCP because different computer systems are used outside of Auckland; therefore, it is essential to include them.
Te Toka Tumai email address
It is important that you access and regularly check your Te Toka Tumai email address. This is the primary way you will receive communications while working at Te Toka Tumai, and it is often overlooked by HOs. If you are unsure how to access it, please call the IT helpdesk on 27000
Resources
RMO Handbook
'On Call' book
Other useful apps/resources
NZ Formulary (medications information)
Canopy (medical translator app)
Qx Calculate or MedCalx (medical calculator apps)
DxSaurus (differentials for symptoms/signs)
NZ Blood Warfarin app
Radiology Masterclass (radiology interpretation)
ECG videos (simple video tutorials on ECG interpretation)
Life in the Fast Lane (ECGs)
Toronto Notes (specialty-specific topics, good to read up before you start a run)
Prognosis: Your Diagnosis (case learning app)
Visible Body (useful for showing patients 3D anatomy to explain an operation/procedure