Following successful completion of your Initial Assessment of Competence, you will be able to join the on-call rota for anaesthesia. This may seem like a daunting prospect, but presents the opportunity to develop your skills, experience and confidence, that will lead to a greater degree of autonomy.
Some anaesthetists in training may feel more anxious about being on call and providing anaesthesia for urgent or emergency cases with only indirect supervision. However, the experience can be very rewarding and even enjoyable! Whilst you have the opportunity to further expand your newly acquired skills in a less supervised context, it is important to remember that you must never feel pressured to work beyond your own skill level.
Please ensure you have read the Help, Guidance and Support section of this disk.
Who is on call?
Hospitals vary considerably with regard to staffing of the on-call team.
There will be at least one on-call Consultant for the hospital. In smaller hospitals, the consultant on call may be responsible for more than one department such as theatres, ICU and Obstetrics. However, in larger hospitals it is likely that there will be a separate consultant on call for each department. It is important to identify who this is and how to contact them at the start of each shift.
It is possible that you will have a supervising Registrar (ST3 or above) or SAS grade on call with you, but remember that this person may also be covering a separate department simultaneously, such as Obstetrics or ICU.
Where and what do you cover on call?
When you first start on call, it is likely that you will be covering the emergency theatre as part of the general on-call rota. During your first 3 months of training you should have been exposed to non-elective surgery and be aware of how and where this is organised in your hospital.
Either the on-call anaesthetic theatre team or ICU team can cover emergencies on the wards and in the emergency department; find out what your local protocols are. You should also check which team is responsible for cardiac arrests, trauma calls and inter-hospital transfers.
As an acute specialty, an anaesthetic team is on call 24/7, but hospital's emergency work changes during evenings, nights and weekends. Check your local protocols for guidance as to what kind of operations are or should be done out of hours. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) advises that only life/limb threatening conditions should be operated on after midnight. If in doubt, discuss with a senior member of the on-call team for anaesthesia BEFORE starting a case.
- pre-op assessment of patients requiring surgery
- requests for pre-op assessment of patients scheduled for surgery at another time
- recovery and post-op problems (pain, post operative nausea & vomiting etc)
- arrests & peri-arrests
- transfers (intra- and inter-hospital)
- venous access.
Tips and guidance
Preparation, preparation, preparation...
Being organised will save you a lot of time and energy during your time on call:
- find out what the on-call responsibilities will be before your first shift
- this will not only allay some anxieties, but also ease the transition from novice to on call
- learn how the system (e.g. CEPOD list) works – this will vary greatly between hospitals in terms of who takes the referrals and who has responsibility for booking and prioritising cases
- consider shadowing the on-call team for a shift during your novice training to better understand how the system works in your hospital & identify common pitfalls. Many novice training programmes already do this
- find out what kind of expertise you have on site (e.g. ENT, vascular etc.).
It is important to always know where your help is going to be in case you need it before starting any case. It is good practice to discuss cases that you are undertaking with indirect supervision for the first time with your senior supervising colleague, as they will often have insight into unforeseen difficulties, as well as knowing what else is going on in the hospital that may affect the running of your case.
If you have any specific concerns, discuss these with them openly and ask for help early; you may well be happy with maintenance of a case but would like assistance for induction or emergence. Good communication is the key; asking for help shows insight not weakness.
Being prepared for both anticipated and unanticipated difficulties is very important.
Before embarking on any case you should always ensure that you have prepared your theatre, have the correct equipment to hand and have drawn up emergency drugs in advance. You should also be aware of how to manage common anaesthetic emergencies and where to find additional equipment such as the cardiac arrest/difficult intubation trolley and drugs used in specific emergencies such as anaphylaxis, LA toxicity and Malignant Hyperthermia.
Further guidance can be found in Other resources/AAGBI Guidelines/Emergencies
Don’t get or feel pushed into working independently until you’re happy to do so; have a low threshold to ask for help. In all circumstances it is important to recognise your own limitations and call for help early.
It is easy to get tired, lonely, and thirsty when on call, so get to know your team and support each other.
And most importantly, enjoy it!