First independent on-call as a house officer
The first nights when you are the first doctor the nurses call. Practical preparation, the common calls, when to escalate and how to recover.
On this page
What “first independent on-call” actually means
You are the first doctor the nurses call. The registrar is available, but the initial assessment, the decision to call, and the documentation are yours. Most people feel the weight of that for the first few nights.
In many Pakistani hospitals that responsibility is bigger than the title suggests. You may cover several wards, admit from emergency, answer calls about patients you have never met, and work with limited night-time investigations. The aim of this page is to give you a plan before you walk in, so that your first nights are safe for patients and survivable for you.
Preparation that reduces panic
- Know the sickest patients on the list before the night starts.
- Have the registrar’s number and the crash-team process clear.
- Review the common first-step approaches for fever, hypoxia, low urine output, chest pain and new confusion.
- Eat and drink before the shift. Decision-making is worse when you are depleted.
Your pre-call checklist
| Check | Why it matters |
|---|---|
| Who your senior is tonight and how to reach them | You will need them at the worst moment; do not waste time finding a number |
| Where the crash trolley, defibrillator, oxygen and suction are on each ward | Seconds matter in an arrest |
| Which labs and scans work at night and how to request them | Saves hours of wasted samples and arguments |
| Where emergency drugs are kept and who holds the keys | Many wards lock stock at night |
| The sickest patients and any "do not resuscitate" or treatment-limit decisions | Prevents confusion during an emergency |
| Pending results to chase from the day team | Handover jobs are easy to forget |
Write a one-line list of your sickest patients on a card or your phone notes: bed, problem, what to watch for. Review them early in the night before the calls start.
During the call
See the patient, take a focused history and examination, document what you find, and decide whether this needs senior review now or can wait. When you are unsure, call early rather than late. A timely call is safer than waiting until the patient is worse.
Write the time, your findings, the plan, and who you spoke to. Memory is unreliable at 3 a.m.
Use ABCDE for any unwell patient
When a nurse says "the patient doesn't look right", go through the same order every time:
- Airway: is the patient talking? Any noisy breathing, vomit or obstruction?
- Breathing: respiratory rate, oxygen saturation, chest movement and auscultation. Give oxygen if hypoxic.
- Circulation: pulse, blood pressure, capillary refill, urine output; cannula and bloods if needed.
- Disability: level of consciousness, pupils, and always a blood glucose.
- Exposure: temperature, rash, bleeding, drains, wounds, calves.
Fix problems as you find them, then reassess. Our deteriorating patient guide walks through this in more detail.
The calls you will get, and where to start
| Call | First things to do | Guide |
|---|---|---|
| Fever or temperature spike | ABCDE, look for a source, blood cultures before antibiotics, think sepsis | Temperature spike |
| Low oxygen saturation | Sit up, oxygen, chest exam, check the probe, ABG if available | Low oxygen sats |
| Low blood pressure | Repeat it manually, look for bleeding, sepsis or drug causes, fluid status | Low blood pressure |
| Low urine output | Check the catheter, fluid balance, renal function and potassium | Low urine output |
| Chest pain | ECG within minutes, observations, compare with old ECGs | Chest pain on the ward |
| New confusion | Glucose, oxygen, infection, drugs, retention, pain | Confused patient |
| Low blood sugar | Treat first, then find the cause; check insulin and feeding | Low blood sugar |
| High blood sugar | Check ketones and fluids; think DKA if unwell | High blood sugar |
| Patient has fallen | Injuries, head injury, anticoagulants, why they fell | Patient has fallen |
| Seizure | Protect, airway, oxygen, glucose, time it | Patient is fitting |
Always check a blood glucose in any drowsy, confused, fitting or sweaty patient. A low glucose (below 4 mmol/L, 72 mg/dL) is quick to treat and easy to miss.
When to call your senior straight away
- A patient who is getting worse despite your first steps.
- Any threat to airway, a falling conscious level, or a seizure that does not stop.
- Systolic blood pressure persistently low, or signs of shock.
- New chest pain with ECG changes.
- Suspected surgical emergency (acute abdomen, bleeding, compromised limb).
- Any time you feel out of your depth. That is a valid reason on its own.
How to call so you get help fast
Seniors respond faster to a clear, structured call. Have the notes, observations and drug chart in front of you, then say:
- Who and where: "I'm the house officer on Ward 5, calling about bed 12."
- The problem: "He's hypotensive, 80/50, and more drowsy."
- Background: "Day two after a laparotomy, on IV antibiotics."
- Your assessment: "Saturations 94% on air, pulse 118, abdomen more distended. I think he may be bleeding or septic."
- What you need: "Can you come and see him now?"
Then write down the advice you were given and the time.
Prioritising when everything comes at once
Calls rarely arrive one at a time. Sort them quickly:
- Now: unwell patients, abnormal observations, chest pain, falls with head injury.
- Soon: pain relief, fluids running out, drug chart rewrites for due medicines.
- Later or morning: routine cannula re-sites in well patients, non-urgent forms, discharge letters.
Tell the nurse honestly when you will come. "I have a sick patient on the next ward; I will be with you in 30 minutes, call me again if anything changes" is better than silence.
Safe prescribing at night
Night-time errors cluster around a few drugs. Double-check potassium (dose, route and rate), insulin (write "units" in full), opioids, anticoagulants and any drug you have not prescribed before. Use the drug guide if you are unsure, and ask the nurse or your senior rather than guessing.
After the night
Hand over clearly in the morning. Then protect sleep. The first independent on-calls are tiring because of the responsibility as much as the workload. Recovery matters.
A good handover lists the patients you were called to, what you found, what you did, and what still needs doing. See proper handover and notes. For more on staying functional across a run of nights, read surviving night duty.
Read next: House job survival guide · Surviving night duty · Studying for FCPS Part 1 during house job · Clinical guides for the ward: medicine on call and surgery on call.
Frequently asked questions
What if I make a wrong decision?
Document your reasoning and the senior advice you received. Everyone makes imperfect calls early on. Learning from them is the point.
How soon does it start feeling normal?
Usually after a handful of nights. The anxiety drops once you have a few real experiences behind you.
Will my senior be annoyed if I call too often?
Some may sound irritated, but a clear, structured call about a genuinely worrying patient is never wrong. It is far worse to call late. Batch non-urgent questions so you are not calling every few minutes.
What should I carry on my first on-call?
A pen, a small notebook or card for your task list, a charged phone, your stethoscope, a torch, and something to eat and drink. Know where the key equipment is before you need it.
What is the first thing to do when called to an unwell patient?
Go and see them, and assess with ABCDE. Check observations and blood glucose, start oxygen if needed, and call your senior early if the patient is seriously unwell.