Explained: On Call

This is something that, as a Medical student you become used to, and as a physician, you have to do ever so often. * The first rule of on call: We never say have a good/quiet on call! The second rule of on call: We never say have a good/quiet on call!*

Jokes and superstition aside, being on call refers to your team/unit receiving for a 24hr period (we work either after midnight or until midnight). Which means you're responsible for all the currently warded patients, as well as the admissions to hospital and any requisite emergencies. Fun.

So, lets talk about some cases you may encounter, and how to stratify said scenarios.

Case #1 A 20 year-old girl with a pre-existing spinal cord injury (C5 ASIA A) from an MVA at the age of 2, returns to ICU post-op following drainage of a large epidural abscess. She had presented with systemic sepsis 4 days previously and an MRI had demonstrated the epidural abscess.  She has a long and complex medical history, including a sub-rectus sheath intrathecal baclofen pump inserted 2 years ago, several spinal fixation operations for spinal stability (the last 5 years ago), and chronic excoriation of both flanks from scratching.

The operation had gone smoothly, with the surgeons satisfied they had drained the collection. The anaesthetic had also been unremarkable and the patient had been awake and lucid in recovery.

After she had been in ICU for 15 minutes, you are called to see her, as her level of consciousness has suddenly decreased and her right pupil is much larger than the left...

Should you be worried? Yes!

The currently held belief is that as the epidural abscess was drained, canal compression was released and CSF flow was altered. A bolus of intrathecal baclofen (from the pump, which had always been running) then reached the brain in high concentration, and caused coma.

The anisocoria was also attributed to the baclofen overdose, although this usually causes bilateral pupillary dilation. It is difficult to explain why only one pupil was affected  — perhaps there was a degree of  post-operative Horner’s syndrome affecting the side of the ‘small’ pupil?

With supportive treatment complete neurological recovery occurred over the next 48 hours.

Case #2 Consider a 49 year-old female with a history of smoking and two weeks of increasing shortness of breath. She is being treated for pneumonia on the ward for three days but getting worse. An ICU review is performed on the ward and the following ECG is obtained.

Should you be worried?

Yes!

The ecg shows electrical alternans Electrical alternans is usually associated with tamponade and there are many reasons why pulsus paradoxus may be absent in the presence of cardiac tamponade including:

Pericardial adhesions(particularly over the right heart), which impede volume changes

Severe left ventricular failure or marked left ventricular hypertrophy- in circumstances the pericardial pressure effectively equilibrates only with the right heart pressures with the much less compliant left ventricle resisting phasically changing pericardial pressure

Right ventricular hypertrophy without pulmonary hypertension- causes esistance to the effects of breathing

Atrial septal defects- venous return balanced by shunting to the left atrium

Severe aortic regurgitation- sufficient regurgitant flow to damp down respiratory fluctuations

Case #3 A 50 year-old man presented to the ED with sharp abdominal pain localised to his left lower quadrant.

The pain came on rapidly the day before, when he took his dog for a walk after dinner. The pain is non-radiating and worse on movement, but he has no other symptoms. Past medical history is unremarkable. His vitals were within normal limits, his abdomen was soft with no herniae or scrotal abnormalities, but he was distinctly tender in the left lower quadrant.

FBC, UEC and urinalysis were within normal limits. Following a surgical review, a CRP was ordered and the following CT abdomen was obtained:

Should you be worried? Yes!

Rule out insidious causes, then determine it's Epiploic Appendagitis. Epiploic appendages are the 50–100 fatty blobs that originate in two rows (anterior and posterior) either side of the taenia coli.