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Congratulations and condolences to those completing and inheriting the overnight general call responsibilities, respectively.  

As the general call torch is handed down from the outgoing, tired and downtrodden second year class to the incoming, wide-eyed and eager second year class, there are pearls of wisdom to be shared that may or may not have been picked up during your first year radiology experience while on swing shifts or weekend coverage.  

Here is a collection of sage advice from those who have survived the fun that is general call at the University Medical Center.   For an updated list of radiology call tips, check out this link.

• You won't be the only newbies starting call in July.  The hospital will be full of green interns fresh out of medical school and clueless.  Calls on "how to order" studies will be frequent, but some firm parental type teaching should limit such pages as the year progresses.
• Be polite and cordial with all the clinicians. Realize they're just as stressed and burned out as you are. Being accomodating to them early in your "call career" will go a long ways later on when they are more accomodating to you. [Dr. Nissim]
• You shouldn’t have to call in any techs personally.  The calls for this pretty much stopped by the end of the year, but in case it comes up, whoever is requesting the study should call in the MRI and ultrasound tech’s themselves via the operator.  Right now, Eva comes in at 4 am most days- so there is someone here almost all night except from 3-4am. [Dr. Carroll]
• Pages do not have to be answered immediately.  When paged, finish the study you are currently reading or risk being sidetracked while checking on some nurse's query regarding an NG tube.  It's okay to have clinicians wait several minutes while you concentrate on a study.
• When the whole surgical team comes down to go over a study, sometimes it is impractical to expect impatient individuals to wait while you finish up a study.  If you can finish your study, ask the team to have a seat while you go about your business.  If the thought of several sets of eyes peering over your shoulder and breathing down your neck troubles you, then help them out first.
• It is often distracting and stressful to go over an entire chest/abdomen/pelvis with head/c-spine/t-spine/L-spine CT while the trauma team shoots baskets and wonders aloud why they did not go into radiology.  During those instances, ask what specific question they may have and answer them accordingly.  Then make sure there is nothing grossly abnormal that does not need immediate attention (ie pneumothorax, pericardial effusion, ruptured spleen, epidural hematoma) and once the patient is cleared, ask for the team's pager number and tell them you will page them after you look at the studies a little more closely and page them should there be any additional critical findings.
• You don’t have to recommend additional imaging in your notes.  Your collegues went to medical school too and should be pretty good at figuring out what else is needed based on what you say.  You don’t want to tie their hands into additional imaging if not clinically needed.  You can say nonurgent follow up if indicated, and usually they are good about not ordering these right away. [Dr. Carroll]
• If you are busy and behind with multiple trauma studies and an intern stumbles into the reading room or calls asking for you to take a "quick peek" at an obviously non-emergent abdomen/pelvis CT for a patient post op day 3 who still hasn't passed gas, gently inform them that there is no such thing as a "quick peek" and if they want a reliable interpretation you would be happy to look over the study but you are currently busy with multiple emergent traumas.  Offer to page them with results or put in a prelim note as soon as you get to the study, within the next hour or so.  Asking them to call or page you back later can back fire if you are still behind with emergent studies when they come looking for you again.
• After-hours flouroscopic studies are not infrequently requested.  Be stern while educating your hospital colleagues that only emergent studies whose outcomes will effect management will be performed after hours.  If the study results do not alter management that very night, then it can wait till the morning.  Flouroscopic studies performed after hours include esophograms for esophageal rupture, upper GI's on babies for malrotation and midgut volvulus, and retrograde urethrograms for urethral injuries.  If there is no attending present, do what you are comfortable with and try to push everything else till the attending is present in the morning (intussusseption reductions are a different beast and will be discussed below).
• Nighttime flouro studies are fairly straight forward as the question is usually something like leak or no leak, malrotation or no malrotation, volvulus or no volvulus.  To streamline nighttime flouro studies while you are alone, follow these simple steps:
  

1. Is the study emergent and indicated?
2. Has the order been placed?
3. Call or walk over to ask the techs to send for the patient and have the materials such as gastrografin or barium ready to go.
4. Tell the tech to page you only when the patient is in the room and ready to go.
5. Go back to your workstation and continue to chip away at the ED list.

• Intuscusseption reductions require an attending to be present.  Dr. Gilbertson's phone number can be found in the resident's lounge wall above the television.  Follow the steps found here for how to prepare for the intuscusseption reductions.
• Look for a parafalcine subdural and subtle temporal bone fracture on every head CT.  Learn what arterial dissection, cord injury, and spinal ligamentous injury look like on MRI. Look at old studies, clinical info and call ER docs when needed.  It can save you. We all miss stuff.  Learn from it. [Dr. Rademacher]
• Be general, conservative and brief in your notes. (i.e. enlarged cardiac silhouette vs. cardiomegaly, as etiology may be pericardial effusion). [Dr. Rademacher]
• Mentally prepare yourself for the possibility of handling an anaphylactic or IgE mediated IV contrast reaction (inpatient studies overnight are not done in the ER, and you may be closest MD). [Dr. Rademacher]
• Do you know how to get to the ED in case they need you to consent a pregnant patient?  Do you even know how to consent a pregnant patient for a CT?  Here's a good read on irradiating pregnant ladies.
• The cafeteria closes at midnight and opens at 6:30am.  Plan your munches accordingly. [Drs. Horsley and Carroll]
• Even the worst nights slow down eventually, and it's natural to feel stressed but resist the urge to disturb your senior except for critical questions.  And if things don't slow down, your shift will eventually end at 7 am. [Dr. Horsley]
• Use your seniors if needed, but at least try and look at the study and formulate your own impression before asking others to look at it. [Dr. Carroll]
• When the first year residents start dictating ED body and U/S studies from overnight, keep a list written down for them so they know which studies to dictate.
• Unless you miss something big, no one is going to seek you out to go over your previous cross sectional imaging.  Learning from your mistakes is key part of your mini ED radiology fellowship but you can't learn when you don' t know what you've missed.  When things slow down, check to see how the day people interpreted your studies and compare it to your overnight notes.  Some people keep a written log of all their cases while others adjust the filter settings on Synapse to review prior studies.
• Know the common blind spots you've picked up at M&M and from your day to day experience and try to include them in your search pattern, ie RCC on T&L spine CT, sternum fractures on trauma chest CT, tentorial or parafalcine SDH and ossicular chain disruption on head CT.
• Use Keats' Atlas of Normal Roentgen Variants, especially for skeletally immature patients.  (Those are the ischiopubic synchondroses... not healing fractures) [Dr. Rademacher]
• Start crying if you see [insert certain ED attending or resident's name here] name on any order.  You will know what I mean. [Dr. Rademacher]
• Brush your teeth at the end of your shift.  After a night of dictating for 12 hours, it will make you feel human again.  Others will appreciate it as well.
  
• Outside CD’s:  if no one is in main CT area, have them go over to ED CT to have the images loaded. [Dr. Carroll]
• Try and keep up with the inpatient body list when possible to keep an eye out for PE studies, which should get prelim reports also.
• Contrast infiltration:  if it happens in the ED, theCT techs have been calling the ED residents to deal with it.  If it happens in the main CT suite- go evaluate the arm, the techs can put ice on it, and then call the primary team so they can consult plastics if needs be.  I have tried to get plastics involved myself and that gets messy- just have the team do it. [Dr. Carroll]
• Play movies or music in the background all night, it helps with the sanity. [Dr. Carroll]
• Learn to triage cases by order of severity.  Cross sectional imaging should take precedence over plain films. A trauma should take precidence over a renal stone CT.
• Use the note count function on your list- it helps keep track of what you have seen already, but be aware- the ed will occasionally drop notes also which can screw you up if you aren’t paying attention. [Dr. Carroll]
• Learning the nuances of each of the attendings will help make edits to your dictations smoother, ie for Haber:  pelvic ultrasound- if no IUP and the study is for a pregnant pelvis- say ectopic cannot be excluded based on this examination. For Friedman: don't ever use "perihilar peribronchial thickening." For other attendings, there is no such thing as a normal pediatric chest.
• Use the white board to call the residents on their direct “bat phone”.
  

Thanks to all who contributed.  Compiled by James Chang, if there are any edits or additional tips, please leave them in the comments or email me.

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