Transition To Residency · Year 4 · from Transition To Residency
Case 1: Responding to an Urgent Page
Clinical Image
Source: Wikipedia - Vital signs - CC BY-SA 4.0
Case Presentation
A 29-year-old male internal medicine intern is paged at 2 AM for a 68-year-old male patient with new-onset hypotension (BP 82/54 mmHg). The patient was admitted for community-acquired pneumonia and had been stable. Using a systematic approach, the intern triages this as an emergent page requiring immediate bedside evaluation. Upon arrival, he assesses airway (patent), breathing (tachypneic at 24/min, SpO2 89% on room air), and circulation (tachycardic at 112 bpm, cool extremities, delayed capillary refill). He immediately applies supplemental oxygen, establishes IV access, and initiates a 500 mL normal saline bolus. While stabilizing, he gathers information: the patient spiked a fever (39.2C) one hour prior. He orders stat labs including CBC, BMP, lactate, and blood cultures. Lactate returns at 4.2 mmol/L. Recognizing this as septic shock, he escalates to his senior resident, who activates the sepsis protocol. The intern documents the event thoroughly, including timeline, interventions, and rationale for escalation. The patient is transferred to the ICU and recovers with appropriate antibiotic therapy and resuscitation.
Key Learning Points
- Page triage requires rapid assessment of urgency: emergent pages (patient instability) require immediate bedside response within minutes
- Systematic approach to patient deterioration follows ABC assessment, stabilization interventions, diagnostic evaluation, and appropriate escalation
- Recognizing when to escalate to senior residents or attendings is a critical skill that protects patients and demonstrates appropriate self-awareness of limitations