Subinternship Medicine · Year 4 · from Subinternship Medicine
Case 2: Recognizing and Escalating Deterioration
Clinical Image
Source: Wikimedia Commons - Emergency Medicine - CC BY-SA 3.0
Case Presentation
At 11 PM, the sub-intern is paged about a patient with chest pain. Mrs. Garcia is a 65-year-old woman admitted 2 days ago for cellulitis, now reporting substernal pressure that started 30 minutes ago. The sub-intern immediately goes to the bedside and finds her diaphoretic and clutching her chest. Vital signs: HR 110, BP 95/60 (previously 130/80), RR 22, O2 sat 94% on room air. She recognizes this as a potential cardiac emergency. She applies high-flow oxygen, obtains IV access, and orders a STAT ECG while simultaneously paging the senior resident. The ECG shows ST elevations in leads V2-V5, consistent with anterior STEMI. The senior arrives within minutes, confirms the findings, and activates the STEMI protocol. The patient receives aspirin 324 mg chewed, heparin bolus, and is taken emergently to the cath lab. She is found to have a 100% LAD occlusion requiring PCI. The sub-intern later reflects on the case: her immediate bedside response, recognition of instability, parallel processing (treating while calling for help), and appropriate escalation prevented delay in definitive treatment. The patient does well and thanks her upon discharge.
Key Learning Points
- Rapid response triggers that warrant immediate escalation: respiratory rate greater than 30, oxygen saturation less than 90%, heart rate greater than 130 or less than 40, systolic BP less than 90, acute mental status change, or staff concern
- For chest pain, get an ECG within 10 minutes; treat first, diagnose second when a patient is unstable
- Parallel processing: perform initial interventions (oxygen, IV, monitoring) while simultaneously calling for help; don't wait
- When in doubt, escalate early; it is always better to call for help that turns out to be unnecessary than to delay calling when it was needed