Although call responsibilities, expectations, and patient acuity may vary widely between practice settings, the fundamentals of orthopaedic call are constant. Residency provides the opportunity to build competence so that on graduation one is ready to confidently and safely take general orthopaedic call.
Many orthopaedic surgeons take several days of call each month. A 2010 survey of pediatric orthopaedic surgeons found an average of 7 call days/mo (range, 0 to 30 days); 93% of respondents were responsible for emergency department consultations.1 A 2015 survey of pediatric orthopaedic surgeons found that 85% of respondents took call (average, 6.6 days/mo; range, 1 to 30 days).2 These data are similar to those for orthopaedic trauma surgeons; most Orthopaedic Trauma Association (OTA) members reported 5 to 7 call nights/month.3
Taking call can be rewarding and/or a cause of physician burnout. Cunningham et al3 found positive correlation among OTA members between the number of call days per month and respondents recommending orthopaedic trauma as a career path. However, more than 2 call nights/wk has been associated with increased risk for burnout, depression, medical errors, work/home conflict, and career dissatisfaction among orthopedic traumatologists.4 Stress and anxiety may even precede the call shift. González-Cabrera et al5 found increased salivary cortisol levels in internal medicine residents on both emergency department duty days and before call shifts, suggesting a physiologic response to anticipatory stress. Call-related stress and anxiety have been widely recognized, and both the OTA and American Academy of Orthopaedic Surgeons have advocated for funded call pay, access to an operating room for trauma cases, and support from advance practice providers or residents.2
The goals of call coverage are to provide high-quality consultations and maximize learning while minimizing stress levels. Consult quality is improved by timeliness, thoroughness, high level of interest, professionalism, expertise, and decisiveness.6 Efficient routines and practices can facilitate learning and stress reduction. Our objective was to provide evidence-based recommendations for each step of taking call to assist orthopaedic surgeons in achieving those goals.
Before the Shift: Preparing to Take Call
Foundational Knowledge and Skill Development
Before starting a call shift, a baseline knowledge of clinical conditions and procedures is required to manage patients safely. This knowledge includes the ability to identify, stabilize, and treat the most common orthopaedic conditions that require consultations during a call shift. Jackson et al7 evaluated emergency department and inpatient consults performed by on-call orthopaedic surgery residents at four tertiary academic medical centers and found the distribution by subspecialty content area was highest for orthopaedic trauma (51%), pediatrics (21%), and hand (14%). Consultations for septic arthritis or osteomyelitis may occur within any subspecialty. Among inpatient orthopaedic consultations, O'Malley et al8 found the most common reasons for consultation were chronic back pain (34%), chronic hip/knee pain (29%), acute back pain (13%), acute fracture after inpatient fall (9%), chronic ankle/foot pain (6%), previous fracture history (6%), and chronic shoulder pain (3%). Surgical intervention was required in 12% of these inpatient consultations.8
Residents who are better prepared and competent with basic orthopaedic procedures are likely to have more confidence while on call, which may improve patient care and reduce call stress and anxiety.9 Lees et al9 identified internal and external factors affecting trainee confidence. Internal factors included personal perception and expectations, previous experiences, and seeing personal skill development. External factors included instructor feedback, patient outcomes, rapport with attending surgeons, and working within a supportive environment. Therefore, residency programs have the opportunity to provide the framework that builds confidence in trainees by exposing residents to an adequate breadth of patients, clinical situations, and operations. Initial learning can be facilitated by formalized training modules sometimes known as “boot camp” or an apprenticeship-style where junior trainees learn under the guidance of more senior residents. A supportive culture with direct, constructive, and specific feedback for improvement can facilitate personal and professional growth.9
Mental and Physical Preparation
Orthopaedic call shifts can be mentally and physically demanding. It is important to prepare for call by obtaining adequate rest in the days before a shift as sleep deprivation (ie, <5 hours per 24-hour period) causes a substantial effect on the cognitive and psychomotor skills of residents and attending surgeons.10 In addition, one must plan for appropriate nutrition during long call shifts. Stressors such as caring for family, pets, and other home responsibilities can negatively affect one's ability to work effectively.11 Therefore, making advanced arrangements to address these issues allows full focus on patient care once call begins.
Once physiologic and security needs are met, an individual can focus on higher level functions such as setting expectations and mentally preparing for the work ahead.12 This preparation includes having a general expectation of how time is likely to be spent throughout the shift. One study examining orthopaedic residents' on-call experience at a tertiary, level-I trauma center found an average of 10 consults/resident call shift.13 In another study of 12-hour call shifts, residents spent 26% of their time performing administrative duties, 23% evaluating new patients, 17% communicating with other providers, 16% in standby, 8% in transit, 4% interacting with existing patients, and 2% attending to basic human needs.14
Answering Phone Calls and Pages
Phone calls and pages should be returned as quickly as possible to maintain professional courtesy and optimize patient safety. A standardized set of information should be obtained for each consultation. Required information includes patient name, identification number, location, and clinical stability, and referring provider name, contact information, location, and the concise question the consultant should answer.6 During the initial conversation regarding a patient consultation, it is helpful to inform the provider when the patient will be seen and what additional tests or interventions should be done in the meantime (Table 1). Timing of the clinical evaluation should be dictated by the patient's overall status and hospital guidelines. Evaluation should not necessarily wait until completion of imaging studies because additional studies may be requested after the evaluation is complete.
Table 1 -
Possible Initial Recommendations When the Consultation is First Received
| Early Interventions |
Rationale |
| Make the patient nothing by mouth |
May prevent unnecessary delays if surgery is required |
| Obtain radiographs of injured region |
Define injury and detect common associated injuries |
| Provide antibiotics and tetanus toxoid booster |
Indicated for open fractures |
| Avoid providing antibiotics |
If evaluating a clinically stable patient with possible infection that may require fluid or tissue sample before treatment |
| Administer analgesia |
Ease patient evaluation or procedure |
| Gather supplies and transfer patient |
Eases access to orthopaedic supplies, including splinting materials, portable fluoroscopy machine, or equipment for a sedation team |
Phone calls may also be received from outside facilities regarding a possible patient transfer. Patient transfers are regulated by the Emergency Medical Treatment and Active Labor Act. Hospitals with emergency services that participate in Medicare are required by the Emergency Medical Treatment and Active Labor Act to provide a medical examination and stabilizing treatment for patients with emergent medical conditions.15 However, if the referring hospital does not have the facilities and resources to provide appropriate treatment of a patient, the regional referral hospital is required to accept the transfer if it has such resources.16
The appropriateness of a patient transfer is sometimes a matter of debate between referring and accepting providers, but it is unlikely that there would be grounds to deny a patient transfer to a referral center or teaching hospital. Song et al investigated pediatric orthopaedic emergency department transfers to assess the appropriateness of patient transfers and found that 78% of transfers were warranted because the patients required operative intervention, closed reduction maneuvers, or conscious sedation.17 However, it may be appropriate to complete temporizing measures, for example, placing an intravenous line for antibiotics or other medications and reducing a dislocated joint, at the referring center to improve patient comfort and outcomes.16
Phone calls may also be received from outside facilities (eg, outpatient clinics, overseas facilities, and deployed military units) regarding patients who do not require transfer. A common reason for these phone calls is to obtain advice or to assist in scheduling an outpatient follow-up appointment for an injury. These seemingly harmless calls should be interpreted with caution, especially when a reliable physical examination and imaging are not available. Failure to obtain appropriate information may result in improper treatment or disposition, for example, a Maisonneuve fracture mistaken for an ankle sprain or a slipped capital femoral epiphysis mistaken for knee pain. Providers may be liable for the advice provided despite not having personally evaluated the patient. Therefore, it is important to know the department, hospital, and state guidelines regarding such phone calls.
Patient Evaluation
Consultations for Traumatic Injuries
An appropriate history is the first step in patient evaluation unless an Advanced Trauma Life Support evaluation including a primary and secondary survey is indicated by local hospital policy or American College of Surgeons Guidelines.18 Critical information to obtain in the history for traumatic injuries includes time and general mechanism of injury to differentiate between high- and low-energy injuries. Circumstances surrounding the injury should also be investigated because a fall or motor vehicle collision may be to the result of a cardiac arrhythmia or stroke rather than a purely mechanical etiology. For upper extremity injuries, handedness should be documented. Any previous injury or surgery to the involved area should also be noted because either may alter its normal appearance or anatomy. The time of last oral intake should be recorded in case operative treatment is required. A medical/surgical history should include any relevant medical conditions, particularly those which affect planning for anesthesia and surgery (eg, coronary artery disease and sleep apnea) and any adverse reaction to anesthesia. Reviewing the medication list with attention to anticoagulants, insulin use, and allergies (including metal sensitivities which can delay surgery if appropriate implants are not ordered in a timely fashion) reduces the risk of adverse effects.19 Social history relating to tobacco use, alcohol use, and activity and work status is often helpful in making treatment recommendations.
Physical examination should initially be dictated by patient stability. Stable patients should undergo a focused orthopaedic physical examination. Assessing the patient's general appearance and vital signs will provide helpful baseline information. Examination of the heart, lungs, and abdomen may reveal life-threatening conditions that require treatment before additional orthopaedic evaluation and intervention. A thorough, sequential musculoskeletal examination of the entire involved area can then be performed: inspection, palpation, range of motion, motor, sensation, vascular status, and special tests. This systematic sequence provides a consistent framework for performing the examination and communicating its findings. A tertiary survey may be necessary for higher energy mechanisms or for injuries with known common associated injuries that may be missed during the primary and secondary surveys.
Radiographic imaging is indicated in nearly every orthopaedic consult. Orthogonal imaging should be obtained for each area of interest. In patients with traumatic injuries, radiographs of the region immediately above and below the zone of injury should also be obtained. When evaluating radiographs, the provider should rule out diagnoses that have a higher risk of being missed on radiographic analysis or have a higher morbidity if diagnosis is delayed. These commonly missed and “can't-miss” diagnoses include posterior shoulder dislocation, perilunate dislocation, lunate dislocation, Monteggia and Galeazzi fractures, Maisonneuve fracture, Lisfranc fracture, and nonaccidental trauma. Confirmation of findings and discussion with radiologists can improve accurate radiographic interpretation.20-24
Laboratory analysis has a more limited role in the evaluation of most orthopaedic trauma patients; however, unstable patients and those injured by high-energy mechanisms may need laboratory analysis to evaluate their physiologic status. Laboratory tests including pH and base deficit can help determine whether an unstable patient requires treatment along a damage-control orthopaedics pathway or whether a more stable patient can undergo initial definitive treatment.25
Consultations for Infection
Evaluating for musculoskeletal infections involves different critical elements of the history, physical examination, and diagnostic workup. History components include date and time of symptom onset, presence of systemic symptoms (eg, fevers, chills, or sweats), and the time course of erythema or drainage. Previous injury or surgery to the affected region is also important because symptoms may be secondary to a postoperative infection.26 Previous treatments, including antibiotics, are noted because they may mask an underlying infection. Environmental exposures or mechanisms of injury such as cat bites, puncture wounds, or high-pressure injection injuries should be noted. As with the trauma evaluation, noting the time of last oral intake and various aspects of medical history offers similar baseline information for clinical decision-making. The physical examination should include outlining areas of erythema and labeling them with the time to allow monitoring of any advancement, especially any rapid changes. Any open wound near a joint should raise suspicion for septic arthritis.
Laboratory studies provide additional information for diagnosing and monitoring treatment for orthopaedic infections. Commonly obtained studies include a complete blood count with a focus on leukocyte count, mature polymorphonuclear neutrophil percentage, C-reactive protein, and erythrocyte sedimentation rate.
Radiographs are routinely obtained to identify foreign bodies or evidence of osteomyelitis. Ultrasonography can identify soft-tissue abscesses or guide diagnostic aspirations; however, ultrasonography is limited by provider skill and depth of visualization. Advanced imaging can be used to evaluate for abscess, myositis, pyomyositis, and osteomyelitis27. Magnetic resonance imaging is the most sensitive modality for evaluating soft-tissue infections, although availability may be limited.27 CT is more widely available but has the downside of radiation exposure and less soft-tissue resolution than magnetic resonance imaging.27
Procedures
Orthopaedic consults may require minor procedures as definitive or initial treatment. These procedures include closed reduction, joint aspiration, and wound exploration and débridement. Developing a standard approach during residency for planning and executing these procedures will translate to success with major surgeries as an attending.
Informed consent is required before performing minor procedures. The provider must explain, in nonmedical terminology: the diagnosis or differential diagnosis; the planned intervention's indications, procedure, goal, and associated risks; and any alternative courses of action. It is also helpful to set expectations for timing of events, pain, recovery, and other issues that may arise.
The planning and setup for minor procedures, including determining the proper location, having a clear primary and backup plan, and obtaining the required equipment, can greatly affect the experience for the provider and the patient. Proceeding without such a plan or proper equipment can result in confusion, adverse outcomes, and distress to the patient. It may be advantageous to transfer a patient from an emergency department bay to a procedure room to provide additional space, special supplies, and access to equipment such as portable fluoroscopy or improved lighting. Planning should also include analgesia and access to the appropriate medications. Supplies for completing the primary plan and the backup plan should be gathered, including splinting material for two splints in case the initial attempt is not satisfactory and a complete laceration kit in case a small wound débridement requires more supplies than those on an initial small tray.
Asking for Help
Some on-call situations will be beyond one's capabilities, such as a diagnosis that has not been managed previously, a patient with an unclear diagnosis, a procedure that has not been attempted under supervision previously, or an attempted procedure that is unsuccessful (eg, a closed reduction or joint aspiration). There is educational value in being uncomfortable and stretching the zone of capability, but this potential benefit cannot extend into providing unsafe care. It is advantageous for residency programs to have systems such as telephone support or taking call alongside a more senior resident to allow adequate oversight while trainees are learning new tasks. New junior residents should review consultations with a senior resident or attending before discharging patients in case immediate correction is required. These systems also reduce the stress and anxiety of residents first learning to take call.28
However, asking for help can be easier said than done. One strategy is to apply the “call-save-threat” framework described by Novick et al29 for intraoperative situations. The first step is to recognize when a situation is out-of-hand, at which point the provider calls a colleague for decision-making and/or technical assistance. This active assistance to complete the challenging situation is the “save.” The “threat” is the potential downside of calling for help because it may involve giving up autonomy or decision-making control, confusion as to who is in charge, concerns about one's professional image, and losing an opportunity to advance by pushing one's skill boundaries.29 Nevertheless, seeking help from colleagues is often viewed positively for promoting patient safety, producing learning opportunities, and providing support for tough cases.29
Completing the Consult
After the initial evaluation and treatment, the provider must complete the appropriate disposition to urgent/emergent treatment, observation, or outpatient follow-up.29 For patients who require emergent or urgent surgery, the medical and administrative tasks required before surgery must be completed as expeditiously as possible. For persons who are going to be managed as outpatients, the provider must supply clear discharge and follow-up instructions so that care can be safely and efficiently transitioned to clinic.
Scheduling after-hours or add-on operative cases can be cumbersome. To provide appropriate care, one must fully understand and execute the hospital's preoperative processes in a timely manner, including appropriate documentation, review of laboratory and imaging studies, and communicating with the operating room (Table 2).
Table 2 -
Common Preoperative Tasks
| Category |
Task |
| Administrative |
Complete required documentation |
| History and physical note |
| Medication reconciliation |
| Surgical consent |
| Document resuscitation status |
| Diagnostic |
Indicated imaging studies have been obtained |
| Required laboratory results obtained (eg, pregnancy test) |
| System-based practice |
Communicate plan with |
| Operating room scheduler |
| Anesthesia providers |
| Referring provider |
| Implant representatives |
| Patient |
Transport to preoperative holding area and ensure patient is appropriately monitored |
| Review plan and answer questions |
If the patient is going to be managed as an outpatient with subsequent nonsurgical treatment, it is critical to ensure a smooth continuity of care, including components of accountability, communication, timely interchange of information, and involvement of the patient and family. A transition of care consensus policy statement endorsed by multiple societies recommended that “at every point in the transition, the patient and/or the family or caregivers need to know who is responsible for the patient's care.”30 This goal can be optimized by having standard processes in place between surgeon practices and emergency departments. Instructions should be given to the patient and reviewed with them before discharge. At a minimum, discharge instructions should include the patient's diagnosis, test results, treatment plan, the future provider's practice name and phone number, return precautions, and an emergency plan and phone number.30
Patient education is a critical component of transitioning from the consultation to outpatient management. Hashim31 reviewed the basic skills of patient-centered communication and highlighted proven techniques for improving communication between physicians and patients. Physicians should first evaluate the patient's understanding of his/her current condition by exploring in an empathetic manner the concerns, expectations, and anticipated effect on daily life.31 When discussing treatment options, physicians can use the “ask-tell-ask” technique to provide information without overwhelming the patient. In this model, the physician asks a patient about his/her current knowledge of an illness or injury, provides small amounts of information, follows up with a question to check understanding, and then repeats the process as needed.31 Successful patient education results in “increased patient satisfaction and improved outcomes and adherence.”32 In addition to verbal counseling, patient education can be augmented with written and audiovisual aids (at appropriate reading levels), group counseling, videotapes, and computer-based teaching modules.32
Patient Turnover and Hand-Offs
Every patient needs to be reviewed with the responsible attending surgeon at the appropriate time during or at the end of the call shift. Proper resident presentations provide an opportunity to describe the clinical findings, provide rationale for decision-making, show content knowledge and prudent judgement, and demonstrate efficacy with procedures such as fracture reductions. Concise presentations allow the team to review each patient efficiently while ensuring appropriate care. Poor resident presentations may signal clinical knowledge gaps or areas for improvement in technical skills.
For attending surgeons, such presentations are an excellent opportunity for clinical education. Attendings should be mindful of a quote from John Paul Jones that leaders and teachers “should not be blind to a single fault in any subordinate, though at the same time, he should be quick and unfailing to distinguish error from malice, thoughtlessness from incompetency, and well-meant shortcomings from heedless or stupid blunder.”33 Attendings should also remember that it takes years to learn to construct a complete and concise oral presentation.34 Oral presentations improve over time as knowledge is gained, more repetitions are completed, and clinical connections are made.34
For patients admitted to the hospital, end of shift hand-offs to oncoming teams must be conducted safely and efficiently. Clinical tools, such as the I-PASS mnemonic, have been developed to standardize communication for patient hand-offs. Elements of I-PASS include illness severity, patient summary, action task list, situational awareness and contingency planning, and synthesis by the oncoming provider to ensure that information delivered has been successfully received.35 Implementation of an I-PASS-supported handoff process has been shown to improve patient safety, practice efficiency, and provider satisfaction.36
Learning and Teaching
Residents and attending surgeons are required to advance their knowledge during their career. Taking orthopaedic call provides many opportunities for practical learning. For technical skills, rapid cycle learning and feedback loops in real time can provide accelerated skill development and correction of poor technique.9 For each condition treated on call, the provider is expected to understand the presentation, workup, diagnostic features, and clinical decision-making.
The amount of reading necessary will vary based on the condition and experience. A provider may already have a strong knowledge base for common conditions. For other conditions, it is helpful to read before seeing the patient. At the conclusion of the consult, reading about the final diagnosis can facilitate learning by anchoring the clinical knowledge around a memory of a particular patient or emotional environment.37 This improvement in learning and transfer of clinical skills and knowledge occurs because emotional experiences tend to be well remembered.37
After the initial consultation, some patients are followed by other residents or attendings. These transitions can result in the loss of the opportunity for feedback based on mid-term and long-term outcomes. For example, a fracture that was deemed stable may have required repeat reduction or surgery. Other events that serve as learning experiences happen later, such as a patient treated operatively for a hip fracture who subsequently sustains a distal radius fracture after a fall at home.38 Therefore, doing routine follow-up chart reviews on previous consults can increase learning and experience.
Attending orthopaedic surgeons learned from their teachers and are expected to pass on knowledge and expertise to their students. Teaching can occur at any time—between patient interactions, during conversations at the scrub sink, or over coffee. Often these short interactions involve back-of-the-napkin drawings or clinical pearls that improve the learner's knowledge base by making connections between domains of knowledge or clarifying points of confusion. Surgeons who function independent of a formalized residency training program also have opportunities to train and teach. Reviewing clinical signs and symptoms with other providers, demonstrating skills to cast technicians to better assist with reductions, and coaching scrub technicians or surgical first assistants on more advanced operative techniques are all appreciated. These efforts may slow the surgeon down in the near-term or may fall on an uninterested audience but have the potential over time to improve the quality and efficiency of future patient care. Lessons learned on call can also be taken to more formal educational settings and included in grand rounds, teaching cases, or a published article.
Summary
Orthopaedic call is a requirement of residency and most orthopaedic jobs. Successful call shifts require thoughtful preparation, thorough and efficient patient evaluation, appropriate treatment, and careful follow-up or transitions of care. Call provides an excellent learning experience as a chance to further expand or solidify knowledge and improve technical skills. With the proper outlook and preparation, orthopaedic call can transform from a burden to an opportunity.
References
References printed in bold type are those published within the past 5 years.
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2. Lind A, Latz K, Sinclair MR, Williams DD: Pediatric orthopaedic surgeons dissatisfied in on-call practices despite improving call conditions. The 2015 POSNA membership survey regarding trauma care. J Pediatr Orthop 2018;38:e33-e37.
3. Cunningham BP, Swanson DC, Basmajian H, McLemore R, Ortega G: Professional demands and job satisfaction in orthopaedic trauma: An OTA member survey. J Orthop Trauma 2015;29:e499-e503.
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5. González-Cabrera JM, Fernández-Prada M, Iribar C, Molina-Ruano R, Salinero-Bachiller M, Peinado JM. Acute stress and anxiety in medical residents on the emergency department duty. Int J Environ Res Public Health 2018;15:506.
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28. Trout AT, Wang PI, Cohan RH, et al.: Apprenticeships ease the transition to independent call: An evaluation of anxiety and confidence among junior radiology residents. Acad Radiol 2011;18:1186-1194.
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