The T&O SHO on call is a busy job. This is what we think you need to know before you start. Most of this is common sense stuff!
Make sure you know:
- The on-call registrar’s name and phone number
- The on-call consultant’s name and phone number. There could be more than one (e.g. a general consultant and a spines consultant)
Most hospitals have a morning trauma meeting to decide on cases admitted to the take. You will probably be expected to present at this (see below) and it is vital that you know where and when this takes place. It may be different midweek and weekends.
Make sure you know where and when the various handovers take place. There may be different handovers for registrars and SHOs. Check which you are expected to attend.
Make sure you know whether your night time registrar is ‘resident’ or ‘non-resident’.
‘Resident’ means that they will be in the hospital and should be available at fairly short notice. They may well be up all night seeing even relatively routine admissions, because they will get the next day off to sleep!
‘Non-resident’ means that they will not necessarily be on site (but they will be able to attend within about 30min). They are expected to sleep for part of the night, as they will be in work the next day. Do not hesitate to call them for advice, or if you have an emergency, however.
Major trauma & trauma calls
The UK operates a “major trauma network”, meaning that a few large hospitals (Major Trauma Centres, or MTCs) accept the most seriously injured patients. Other centres are referred to as Trauma Units, or TUs.
If you are in an MTC, you are likely to see seriously injured patients: those with isolated major injuries (e.g. open fractures and pelvic trauma) and those with multiple injuries (‘polytrauma’). Although this seems scary, you will have a resident registrar to help you. You may be responsible for taking referrals from TUs with cases in these peripheral hospitals.
If you are in a TU, then you must know what your local MTC is – this may be different for adults and children. You are less likely to receive the sorts of injuries seen in MTCs, but do not assume this! If a patient is very unwell indeed, they might be brought to a TU for stabilisation before transfer to an MTC. Not all major trauma patients are initially recognised as such, either, so be prepared to see these patients in a TU, discuss with your senior and the MTC, and arrange urgent transfer.
Regardless of where you are working, make sure you know what injuries require immediate transfer to an MTC. This varies region-to region, and your registrar is a good resource to ask. If you’re not sure, seek senior help early.
Examples of cases that may be transferred directly to an MTC from a TU ED (not exhaustive, and by no means all these injuries get transferred):
- Open fractures (especially lower limb)
- Spinal injuries with abnormal neurology
- Pelvic trauma
- Intracranial injuries
A trauma call is a team-based approach to the management of a seriously injured or potentially seriously injured patient. It may be instigated before patient arrival (if the paramedics are concerned), on arrival, or at any time after arrival (if a clinician realises the patient is or may be seriously injured). Do not be afraid to put out a trauma call if you think a patient requires one.
You will have an assigned role. This may be the same for all trauma calls, or may be assigned on a case-by-case basis by the trauma team leader (TTL).
The most important advice is not to panic, find out what your job is, and to do that job well. If you feel that senior orthopaedic input is required, then call your senior.
Some registrars want to be informed of all trauma calls. If your registrar is resident, they may be required at all trauma calls. Check with them at handover.
The following are injuries/patients who may or may not be admitted under T&O, and the possible alternative admitting teams. Every hospital is different, but there should be policies in place to guide the patient to the correct team. It’s worth checking with your registrar who admits what injuries at the start of your first shift.
- Head injuries (neurosurgery, neurology, medics)
- Spine injuries (neurosurgery)
- Back pain without injury (neurosurgery, medics)
- Cauda equina syndrome (neurosurgery)
- Metastatic spinal cord compression (neurosurgery, medics)
- Social admissions with a fracture (medics)
- Possible #NOF with normal X-rays (medics)
- Soft tissue injuries and infections (plastics, general surgeons, medics)
- Chest wall injuries (respiratory, medics, general surgeons)
- Hand injuries (plastics)
- Diabetic foot infections (vascular, endocrinology)
- Flexor tendon and digital nerve injuries (plastics)
To reiterate, these injuries may be admitted by T&O in your hospital, but it is worth checking before you start. Ultimately, if you encounter resistance from another specialty, you should act in the patient’s best interests and admit them. If it is daytime hours, or you are particularly concerned that admitting incorrectly will lead to patient harm, then discuss with a senior.
Before you start your shift, make sure you know the following:
- Consultant(s) on call
- Registrar on call (name and number)
- Time and location of handover and trauma meeting
- Whether you are an MTC; if not, which is your local MTC
- Your role in a trauma call, and your registrar’s role
- What patients to admit, and which to direct to another specialty
- When your registrar wishes to be contacted
The trauma meeting
This is when all cases from the previous 24hrs are discussed, as well as any operative cases for the day (and sometimes other outstanding cases and cases from previous days). There will usually be a number of consultants, registrars and SHOs as well as other staff (e.g. anaesthetists, theatre staff, plaster technicians) present. It is a vital opportunity for MDT discussion of cases, handover of jobs and teaching.
If you have been on call in the previous 24hrs, you will probably be expected to present your cases, although in some centres the registrar will do the majority of the presenting. Before the meeting, make sure you know the following for all your patients:
- Presenting complaint, history and examination findings
- Results of imaging and other relevant tests
- Current treatment
- Results of discussions with other clinicians
- Outstanding jobs/tests
- Patient location
- Whether they are NBM
- If at home, whether they are expecting a phone call, letter or similar contact
The trauma meeting is also an excellent opportunity for teaching. Expect to be asked questions and pay attention to what other people are saying. You are not expected to know everything, but you are expected to pay attention, have a basic (medical school) level of orthopaedic knowledge and to remember what you have been taught before. If in doubt, the following phrases will get you out of trouble:
- “This is a high energy injury, which I would assess as per ATLS protocols”
- “I would want to make sure this is an isolated, closed, neurovascularly intact injury with no signs of compartment syndrome”
- “This is an AP/lateral radiograph of XYZ showing…”
- “The relevant principles are to reduce the fracture, hold the reduction until union, rehabilitate the patient and respect the soft tissues throughout”
Author: Hamish Macdonald
Last updated: 29/03/2020