On Call Preface and 1 General Principles

Preface
Book aims to provide a structured approach to:
Initial assessment
Resuscitation
Differential diagnosis
Short-term management
..for common on call problems

Also to provide an overall guide for hospital practice and clinical skills

logical, practical and efficient approach

Traditionally, diagnosis and management of pts problems is via a structured

approach Hx, O/E, review innvestigations and then coming up with a ddx
and management plan
In an emergency, doctors need to proceed concurrently with resuscitation,
history, examination, investigation and definitive treatment
ABCD stabilisation is needed in the first few minutes to avoid death and
disability

**A complete history and examination can take up to 60 minutes or more to

complete
However this is not possible whilst on call
Therefore need to increase efficiency and improve time management

1. General Principles
Approach to the diagnosis and management of on-call problems
When trying to manage on call problems, you dont have time to do a
completely thorough history, examination
Excessive time spent with one patient can deny adequate treatment
time to another more seriously ill patient
Therefore need a rapid, effective and efficient problem-solving
approach when on call

Systematic approach
Phone call - most problems are first communicated by telephone
Questions pertinent initial questions to help determine the urgency
of the problem
Instructions phone orders given to the nurse at the bedside to
expedite the investigation and management of the pts immeadiate
problems
 Prioritisation assessment of urgency of the problem to determine
which patients need to be seen immeadiately

Corridor thoughts
Use time spent getting to the ward by considering ddx and potential
threats to life presented by the problem at hand (ddx should focus on
most common and most serious causes which need to be considered
in hospitalised patients)
This time is also useful for organising a plan of action for the bedside

Major threats to life

In current situation, think of most likely threats to life and use them to
direct questions and physical examination

Bedside
Quick-look test well (comfortable), sick (uncomfortable, distressed)
or critical (about to die)
Airway + vitals essential in the evaluation of any potentially sick
patient

*Order of the next four steps are not uniform depends on what the
clinical situation dictates. Always need to focus initially on any life-
threatening problems and leave the less urgent problems to be
reviewed later:
Focussed history and chart review
Focused examination
Bedside and other investigations
Immeadiate management/resuscitation

Management
Immeadiate resuscitation DRS ABCDE
Supportive
Specific