HO CALL TIPS

Please read before you follow on your first tag on HO call!

There’s nothing that can really prepare you for the onslaught of calls and stress and despair on call, but here are some
tips I wish people told me starting out.

TYPES OF CALLS
In GS / ORTHO, calls are divided into ACTIVE calls (clerking new admits) vs PASSIVE calls (dealing with existing
inpatient, CTSP, orders).

In IM, calls are not divided in this way: so you handle both ACTIVE and PASSIVE work simultaneously.

BEFORE THE CALL

- Try to go home on time, pre call blues hit hard enough, don’t need to exacerbate them by going home pre-call
at 8PM
- Sleep well, you’ll need it
- Check who else is on call with you: it makes such a huge difference to have friends on call J
- Check who is the MO on call with you
- Rehearse mental scenario of a code situation (I do this before every call)!

ON CALL DAY: GET ORGANISED

- Call sheet is very important to me; various ways of organizing, often vary with posting also
o Organize by location, some people organize by type of call (SICKIES / CTSP / Ordering stuff / Tracing)
o GS and ORTHO: good to add in check boxes for PFO bloods/imaging, consent and listing for op, DOC
vs NBM/last meal, drink to keep track of patient’s priority and readiness for surgery
- Create a call tag on your CITRIX/CPSS so you can tag patients when you’re called and for you to keep track of
them overnight .
- Contact the on call MO and create a list “NEWS 1. 66B/14/5 TAN CY, dengue fever: preclerking, not seen”
- Try to quickly finish primary team changes if not the heat really comes on when calls start coming in and you’re
still settling primary team changes
- Try to eat dinner / get coffee, or get a quick bite at least.
- Get your things to the call room early. Bathing is a luxury

ACTIVE WORK
NEW ADMISSIONS
Once new admissions hit the ward, they will be actualized in the system, or you will find out about them when nurses
call you to “clerk new case”.

1. When the nurses call you to inform you on new admission, please get the following info before they hang up
and document “doctor noted”:
- Full set of CURRENT vitals- T BP HR SpO2 + whether patient is well, alert and conversant
- If patient coming in for anything related to infection and if T (in ED or ward) > 38, please ask the SN
if cultures have been done, and whether ED gave antibiotics already (hence, even if patient is afebrile
now, please ask if they had T>38 in ED)
- The implication is that
- Patient with 2 or more abnormal vitals (eg T 39 HR 130) or are unwell appearing – they need to
be seen earlier
- If cultures have not been done, ask SN (in the same phone call, before they put down the phone),
to prepare blood culture set
- Assuming stable vitals, if patient has fever, and ED has cultured and covered with abx, then it
buys you more time, because at least whatever infection is going on, patient has already received
some antimicrobials.
- If they have not been cultured and covered, unfortunately, may need to attend a bit earlier
because you don’t want to let a patient with infection sit without antibiotics for too long. Or the
next thing you get called for may borderline BP, tachy and you’ll find yourself attending to a septic
shock patient instead.
- Generally, I will also spy on the bloods for concerning derangements: TW >16, Hb <7, K >5.5, Na
<125, Cr significantly elevated compared to baseline.
2. Inform the MO immediately
- inform the MO on new admits earlier rather than later
- update the News list in your communication to the MO: “NEWS 1. 66B/14/5 TAN CY, dengue fever:
preclerking, not seen”
- preempt the MO whether patient needs to be seen earlier based on the above; if patient is unstable,
please inform MO so they can decide to see earlier. If a patient is labelled as “early ward review” by
ED Dr, PLEASE INFORM MO of this.
3. Start preclerking the patient
- if you do not have pressing PASSIVES to deal with, if you have a desaturating patient, please inform
the MO “there’s a new, I haven’t preclerked, but I need to see a desat first”)
 - Use a clerking template
- Things in PMH to look out for when preclerking:
- DA
- Cardiac hx, EF, DM/HTN, CKD (baseline Cr), Baseline Hb, Known asthma
- Blood thinners / antiplatelets use
- Things to note:
- What has ED done / not done
- Whether patient can give hx
- Whether cultures were done, abx given
- Whether patient is COVID risk
- Last admission if any
4. Clerking the patient
- Different MOs have different preferences: some want to see together with you, some want you to see
first. Please check with MO what is their preference.
- Sometimes, MO is busy doing urgent reviews, at the same time, the new admit may need to be seen a
bit earlier because they may be unwell, please go and see and assess patient, and not wait for MO,
you’re still a doctor.
- Also please inform MO if you have to attend to urgent passive work. I do try to see the news, but I
always keep my MO informed if I have urgent passive work to do. Remember that there is only one of
you, who can only be in one place at one time. It is ideal if you can see the news, but sometimes
passive work is urgent and you just need to inform your MO what you’re doing.
5. Following up with changes
- After patient has been seen, need to do changes: adding test, doing blood cultures, ordering
antibiotics, ordering up old meds
- Remember to trace up and update MO accordingly
- “NEWS 1. 73/22/6 LIM AB, fever ?source : MO seen, cultures done, to trace ECG/CE, ketones”
- Nurses always need to know a few things:
- Diet status: allowed diet (what type and consistentcy) vs NBM vs NBM until ST review
- Monitoring – what to monitor and when to inform you
- Who will consent patient? (MO to consent)
- Old meds: antiHTN/diuretics, blood thinners/antiplt, OHGAs - to serve or withhold.

PASSIVE WORK
There is a myriad of passive work. It can be very stressful juggling between all the passive work. Prioritising and triaging
is very important.

When you’re called, please get the NRIC + BED + CTSP for _____ + current VITALS accurately.
• It is a disaster to get the wrong bed number and cannot trace back which patient you were informed re:
massive PR bleeding or desaturation.

CTSP
1. Prepare CTSP templates, esp for your first few calls.
- The CTSP templates you prepare in peacetime will guide your thought process on call and keep you from
forgetting important things to rule out or important things to do/monitor
- Common CTSP to prep: fever, hyper/hypotension, tachycardia, desaturation, hypoglycaemia, chest pain /
breathless, AMS/drowsy patient
- Always show you’ve noted important CTSP related background
o EF, recent culture, current antibiotics
- Always show that you’ve excluded emergencies
o Cardiac/respi emergencies, HTN emergency/stroke, I/O
2. Always as for more details! Nurses will call and tell you “ABC has XYZ” then they will say and document “Dr noted”.
If anything happens, DOCTOR ALREADY NOTED. SO ALWAYS ASK FOR MORE!!
Ø It is imperative and very important to ask for more to help in your triaging and prioritizing. You can have 4
fevers to see on hae onco call, not to mention many other CTSPs. You need a better idea of the patient so that
you can prioritise who to see first. It is not common that nurses automatically volunteer more background and
information, and they may be in a hurry to hang up after informing you “ABC has XYZ”.
o When they call you for fever (officially T > 38, but they’ll call for T > 37.5), please ask
§ When was T taken? What are the other vitals, please give me a CURRENT set of FULL vitals?
Is patient alert and talking to you?
§ What did patient come in for? What infection is primary team treating for?
§ When was last T spike, what was the T?
§ When was last blood cultures done?
§ What antibiotics is patient on?
§ Any paracet on- then inform them to cold compress?
o When they call you for H/C high or low, please ask
§ When was h/c taken? Is the patient alert and talking to you?
§ Is it pre meal? Did patient have a snack?
 § When was last insulin/ OHGA served?
§ What has the h/c trend been like? Specifically looking for hypogly eps
Ø Always ask WHEN, WHAT TIME. It is unfortunately not uncommon that you only get informed retrospectively,
especially during change of shift handover period. It can be very misleading, and this can be quite dangerous. I
have been informed of desat to 84% 2h after desat, fever 4h after fever spike and patient already afebrile, h/c
18 (made to sound like it is now, but actually taken 3h ago). And the worst part is that it can be documented in
the flowsheets/nursing report to sound like you were informed there and then. And it’ll appear to the primary
team next day as though you didn’t attend to patient promptly when they called you. You definitely don’t want
to be acting on non contemporary information, it can even be dangerous. Imagine giving actrapid to a patient
whose h/c was 18 3h ago. HOs have been informed of a Fall 6h after the fall.
Ø Every CTSP you get, please request for CURRENT STAT vitals and whether patient is WELL ALERT + TALKING
TO YOU. A lot of times, unfortunately, when you ask for vitals, you get informed on vitals taken 1-2h ago. But
does it make sense to operate on vitals taken 2h ago when patient is having chest pain or fresh melena RIGHT
NOW?
o If patient has 2 or more vitals deranged, please see early.
o If patient is well alert talking to you, vitals stable, can buy you more time.
3. ALWAYS VERIFY. Regardless of everything you’ve been told in point 2, please review the case notes personally and
verify everything you’ve been told.
- Unfortunately, the first rule as a HO is to TRUST NO ONE.
- Please personally verify everything. If you’re going to be one making decisions, ordering inx, ordering
meds, then you need to take responsibility in the end.
- Personally review patient’s antibiotics, culture results, T trend, H/C trend, BP trend, team’s impression,
team’s plans.
4. TREND is very important: CTSP HR 109 is different in patient whose baseline HR is 50-60 vs baseline 90-110s. CTSP
SBP 95 is different in patient whose baseline BP is 90s-100s vs 160s-170s. Compare everything: CXR today vs
previous CXR, Hb today vs previous Hb, Cr today vs previous Cr.
5. Please physically see patients and document your review of patients you’ve seen
- Always document truthfully and accurately
- If patient is unwell, please don’t write “non toxic, comfortable”. Don’t just H S1S2 L clear A SNT. Examine
properly and make a note, “nil creps heard, bowel sounds present”
- It is very useful to paint a picture of the patient at the time of your review, “watching video on
handphone”, “making jokes”, “comfortable and not in distress”.
- Remember that you may be the last person to see the patient well.
6. Some cases you may review case notes but not physically see patient eg T 37.8 and stable vitals
- If I did review the notes, but didn’t see patient, I also document as “casenotes reviewed” to show that I did
screen the case
- Don’t portray as though you saw patient when you didn’t.
7. ESCALATE!
- If a patient is unwell and worries you, always escalate. Discuss with your MO, get some plans and direction.
- If you get a CTSP you’ve never encountered before, and are unsure about, always escalate
- Leaking vac?? CVP dislodged?? Bleeding perm cath?? Transfusion reaction??

SICKIES
- ALWAYS CHECK THE CODE STATUS.
- As per CTSP (refer above)
- Sickies come FIRST.
- Please inform MO of sickies early
- Please keep track of your sickies, trace up work up promptly eg ABG because these inx may indicate a rapidly
deteriorating patient, can affect management, and can change dispo (may need to go ICU)
- Make sure things you called for is actually done- stat portable CXR
- When you’re called for other things when you’re dealing with sickie, I always inform the nurse: “I am dealing
with a sick patient now, is this urgent? I cannot note this right now, please call me in 15min.”

PTRV / PORV
- Post transfer / post op review is there to make sure post transfer/op patient is well
- When reviewing post ICU transfers and post op/procedure patients, please note and document the
op/procedure instructions or the last ICU handover instructions; “PLAN (as per POT)”.
- As appropriate: check for drains/bleeding/dressings/pulses.

ORDERS
- Don’t just order as told, review the casenotes and verify.
- When in doubt call on call pharmacist
- Please check EF and renal status before ordering drip
- Please check allergies, renal function, last analgesia given- time and dose, existing analgesia ordered before
ordering analgesia. Don’t tramadol 50mg a renal patient. Don’t NSAID an asthmatic.
 - Sleeping meds sound benign, but please ensure not QT prolongation before you happily order
antihistamines/sedatives. And think twice before ordering antihistamines for elderly – if not the next thing you
get called for will be ARU. When in doubt, melatonin (it won’t work overnight but it’s safer than antihistamines).
- Laxatives are never urgent.
- AM bloods that primary team neglected to order are also not urgent.

TRACING
- Please remember to trace up inx you’ve ordered
- Act on urgent things: hyperK, ketones, Hb drop, sky high whites
- Act on other things: trace and replace Mg / PO4.

PROCEDURES
- Male IDC: please remember to reposition the foreskin, IDC procedure must be documented
- Bloods: please remember to remove the tourniquet and clear ALL your sharps
- PICC bloods: please remember to do under aseptic technique + lock with heparin saline.

IN CODE BLUE
- ALWAYS CHECK THE CODE STATUS! If not documented, it is presumed full active. Please do not resuscitate a
DNR patient L
- CALL MO AND CODE BLUE TEAM. THE RULE IS TO FILL THE BOAT!
- PPE FIRST!! PROTECT YOURSELF.
- Please get people in: call the nurses to get the crash cart and e-drugs pushed in, the defib ECG monitoring on,
airway kit/ambu bag
- Stay with the patient at all times! You are the doctor.
- Assess ABC. If no pulse no breathing, please start CPR (ask someone) + bag and mask patient (usually you at
the head of bed, can use oral airway to help).
- Always assess the patient first. Have an eye out for where the IVs are.
- Hopefully your MO is here by now and speed reading through patient’s background and issues. (sometimes
when your MO comes, your MO may take over the code and ask you to read up instead)
- Set 2 large bore IV + obtaining bloods (ABG + all 4 tubes) are mainstay HO jobs in resus / code / near code.
- Hopefully your Reg / code blue Reg is also here by now
- In SGH, take 2 patient stickers + ABG on ice and run to MICU (W45). If MICU ABG machine down (no joke,
true story), run to CCU (W44), or SICU/CTICU (Blk 2).
- Snap a photo of the ABG when it comes out and send to MO/REG
- The rest should be settled by your seniors, i.e. intubation, calling ICU, sending patient to ICU
- But always run back to the code site to help out. Extra pair of hands is always good.
- Sometimes you may be asked to do the Code Log; a record of what drugs given what time, what rhythm etc.
Pay attention in a code!
- Follow seniors instructions until you get sent off to do other things.

CAUTION!
General reminders and advice; super important.
1. Always check drug allergies!!! Patients can be allergic to anything, even paracetamol.
2. Always as for more details! Nurses will call and tell you “ABC has XYZ” then they will say and document “Dr
noted”. If anything happens, DOCTOR ALREADY NOTED. SO ALWAYS ASK FOR MORE!!
3. ALWAYS VERIFY. Regardless of everything you’ve been told in point 2, please review the case notes personally
and verify everything you’ve been told.
4. Always give clear, unambiguous instructions.
- Please give the dextrose drink and recheck h/c in 1h AND INFORM ME.
- Please prepare blood c/s set and IDC set, I am coming to do now
- Please recheck PVRU and insert IDC (female) if PVRU > 250ml
- Please monitor the GCS, if GCS drop >2 or patient drowsy, please inform me ASAP
- Please advance the NGT by 5cm and call for repeat CXR (I will order) – DO NOT FEED until I clear the CXR.
5. Always keep your MO updated on important things you’re doing. Escalate things early.
- Better to over-call and over-escalate than under-escalate. On call is not about your ego, it is about
patient safety first. But of course, please use common sense when you escalate.
- Please look up impt info on the patient eg. EF, cardiac/respi hx, fluid status, resus staus, because
these are things you need to tell your MO on top of just “desat to 80%”.
- Escalate a sick patient early, but make sure you are on the way / reviewing patient there and then
also. Escalating doesn’t mean “dumping” the patient on the MO and letting them deal with it. You
need to be doing something about it also.
- If you’re in doubt, please consult someone, clear with someone, ask someone. Don’t proceed with NG
feeding if you are unsure about the NG position on the post NG CXR. Don’t dextrose drip an ESRF
patient who has DM but is NBM, without checking with someone. (even though the two separate rules
are: no drip for ESRF patient, and all DM patients kept NBM need a dextrose containing drip)
6. Always ask for help from fellow HOs, or MO if needed. ASK EARLY.
 - Remember that there is only one of you. Call for help early and promptly, and not when things have
gone south and they are circling the drain.
- You cannot attend to 2 sickies simultaneously. If you have multiple dangerous CTSPs that need urgent
attending to, please alert the MO. You cannot be doing that ABG for this desat, and pushing D50 for
that drowsy hypogly, and seeing this central crushing chest pain all at once.
- You have many things to do overnight. Please don’t be stuck trying to set plug for same patient for the
5th time. It is not fair to the patient also.
- Sometimes you can get stressed when MO asking you to do many things, and you’re getting passive
calls also. Prioritise, and inform your MO that you’re seeing this desat first, will clerk take cultures for
that new admit after.
- If you’ve never done something before, please inform MO. PICC cultures, CVP cultures have a specific
technique that you need to be brought through.
7. Know what you can and cannot do (this is sometimes hospital dependent).
- HO cannot sign up a death – please ask them to call MO
- HOs cannot consent procedures – please ask them to call MO
- In TTSH, HO cannot take blood consent, whereas in SGH, HO can take blood consent.
- In TTSH, you need to be trained and licensed to take PICC bloods, whereas in SGH you can take (if
you’ve been taught). But if you’re unsure, please get MO to show you. DO NOT take from a TPN line.
- Porta-cath bloods is OUT OF BOUNDS. No matter how much SN pressure you, please tell them to call
onco resident nurse. The last thing you want to do is to mess up a chemo line.
- Respi swab and COVID swabs cannot be done in GW (aerosol generating, need full set of PPE).
8. Know what other people can and cannot do
- In TTSH, phlebo can take bloods + cultures up to 9pm, but not GXM. Nurses can take bloods, but not
cultures or GXM. GXM must be taken by doctor only. Cultures to be taken by doctor after 9PM when
phlebo goes home. PICC bloods to be taken by doctors only.
- In SGH, nurses can take bloods + GXM, but not cultures. No phlebo to take bloods. Cultures and PICC
bloods to be taken by doctors only.

DOCUMENTATION
Documentation is paramount in HO year. It is a often a burden, but you don’t know how important it is until something
happens and people review your documentation to find out what was amiss.

As a HO, when things go smoothly, you don’t get credit. When things go badly, you’ll be the first one everyone (from
nurses to regs) look at – “the HO didn’t do this or that”, “I informed the HO”. Sometimes you do everything right, and
shit still happens, and you will still get the blame. As a conscientious HO, you’ll realise that good documentation is very
important and has saved me many times.

1. As a GS Reg told me early on in HO year, if you didn’t document, you didn’t do it.
- HOs do so much leg work to make sure “simple things” happen. It takes so much effort, and you
spent so much time on it, please document so that you don’t get accused of not doing it. Don’t let
your effort go to waste or not recognized.
- Eg. You listed for op, called OT to make sure they received the chit, please document. You called BTS
MO to get this special precious blood approved, please document. You informed the nurse to do
ANYTHING – from keeping patient NBM, repeat h/c 1h, get the blood from blood bank, advance / flush
the NGT – please document. You updated the CVM reg, please document. CVM reg gave you
instructions, please document. You updated family, please document. You spent 1h placating family,
please document. You informed patient re: COVID discharge advisory, please document. You traced
up the positive blood cultures or the high K, please document. You did the IDC, removed that drain,
please document. You called to expedite the scan but duty radio say cannot expedite, please
document. You called the GS reg x4 times, no pick up, please document.
2. When you review a patient, please document because you never know when a patient you saw well last night
deteriorates the next day and gets sent to ICU, and everyone will be reviewing the notes to see the HO review
last night to see if anything is amiss.
- The last thing you want is to be called up by Reg next day, asking you why you didn’t see this sick
patient, when you had in fact seen the patient who was well at the time of your review.
- I always get anxious when a patient I reviewed the night before gets sent to ICU the next day.
Conscientiously reviewing patient, appropriately escalating, and accurately documenting when I CTSP
a patient reassures me that I have done my due diligence.
- For sick patient especially, document timing: desat @ ____, informed @ ____, patient seen @ ____.
- Always document accurately. If you had assessed it, document. If you didn’t do it, don’t document as
having done it.
3. Documenting it informs others that you noted something and you didn’t miss out something important.
- You noted that patient’s ANC < 1.0, hence decision to escalate to abx as per neutropenic sepsis abx
guidance
- You noted that K went up to 6, and noted ECG showed Tall T, hence decision to give hyper K kit
4. If you discussed with a senior, or a senior gave a particular instruction, please document
 - You’re a P license, so someone always has to be informed / supervising you. And don’t take everything
on yourself. If things go south, they’ll see who was the senior you escalated to, and who made the
decision to do this or that.
o d/w MO Dr ______, plan as follows
o as per REG Dr______, plan as follows
5. Counter-documentation
- Documentation is medical-legal. And when anything happens, documentation testifies.
- Unfortunately, it is not uncommon that nursing notes and flow sheets may be erroneous or
misleading. And many times, HOs may be at the losing end of it, especially if you neglect to document
properly.
- HOs have been called up by Reg next day, why you didn’t see this patient who had T >38 or
tachycardia HR 130, it was documented that you were informed — when in reality, the HO was not
informed.
- Counter documentation is necessary to set the events straight from your perspective and for your
defense. For credibility sake, always make sure you are objective and not at all biased/accusatory in
your counter documentation.
o “Patient desat @ ____, informed @ ____, patient seen @ ____. MO informed immediately.”
o “Was not informed re: _______. When I found out, I attended to patient immediately. MO
informed.”
6. Documentation reflects you
- Conscientious documentation reflects a conscientious HO
- Careful documentation reflects a careful and safe HO
- Credible documentation gives you more credibility
- Sloppy documentation drops your credibility and belies a sloppy HO.

LAST WORDS
1. DO NO HARM
2. Safety first, ego later.
3. Expect the worst (eg no sleep) and everything will be a pleasant surprise.
4. Do your best but remember there’s only 1 of you – it’s about prioritising, not perfection.
5. Escalate early, fill the boat!
6. You are not alone – reach out to MO, other HOs on call for help
7. What if you’re the last one to see the patient well?
8. Always carry snacks / sweets with you.
9. Be kind, say please and thank you.
10. The sun will rise.

It’s normal to be stressed, overwhelmed, depressed, or even cry on call. But take 5 mins, collect yourself, get
help/support from other people on call, and reboot by focusing and prioritizing the tasks at hand. You’re still the doctor
on call, and there are still things to be done and patients to be seen. When it feels like they are all weighing on you,
your phone won’t stop ringing, and you can’t even make it through the blood culture without your phone going off,
breathe and break it down into one task at a time.

There’s no medal for the traumatic calls you survive, I’m not even sure if they are “character building” as they say, but
when I remember what I’ve experienced before, it always makes me more confident to face the next call.

P.S. It’s useful to follow up on patients you’ve seen post call. That way you can learn what happened to them after,
what primary team did, how you can improve your practice, what you must consider next time.