Intern Bootcamp: Managing Scary Clinical Pages

General Approach to Urgent Pages

• 🧘 Breathe before responding to urgent pages; panic is unhelpful, and you usually have time to assess.
• 🚶 See the patient in person rather than relying solely on chart reviews or phone calls for accurate information.
• 🛠️ Know your toolbox by understanding the utility of basic labs, imaging studies, and available hospital resources.
• 🤝 Load the boat by looping in senior residents early, especially when concerned about a patient's condition.

Hypotension Management

• 📉 Identify shock as a critical cause of hypotension, differentiating from measurement errors or baseline low blood pressure.
• 📞 On the phone: Confirm vitals, I/Os, and gather information on recent notes, history, and prior studies.
• 🚶 On the way: Review PMH/PSH, recent notes, vitals, and labs to understand the patient's status.
• 🩺 In the room: Assess ABCDs, perform a focused exam, and consider labs, imaging, and specific workups for shock etiologies.
• 🏥 Initial management depends on the cause, potentially including fluid resuscitation, access, Foley catheterization, and considering ICU transfer.

Hypoxemia Management

• 🫁 Differential diagnoses include atelectasis, COPD, pneumonia, PE, hemothorax, pneumothorax, and volume overload.
• 📞 On the phone: Ascertain oxygen requirements, delivery device, and rate of escalation.
• 🚶 On the way: Review pulmonary/cardiac history, PE risk factors, and evidence of infection or volume status.
• 🩺 In the room: Assess ABCDs, perform pulmonary and cardiac exams, and evaluate volume status.
• 🔬 Get more info: Order basic labs, ABG/VBG, CXR, and consider CTA chest for PE suspicion.
• 💊 Initial management involves supplemental oxygen, potentially higher level of care, intubation, or other adjuncts based on etiology.

Altered Mental Status Management

• 🧠 Differential diagnoses include stroke, medication effects, hypoxemia, metabolic issues, infections, and delirium.
• 📞 On the way: Review PMH/PSH, recent notes for agitation, and baseline mental status.
• 🩺 In the room: Assess ABCDs, check for focal neurological deficits, and assess orientation.
• 📊 Get more info: Order basic labs, blood gas, and CT head if stroke is suspected.
• 😴 Initial management focuses on ruling out acute causes and optimizing sleep/wake cycles, pain control, and medication review, avoiding sedation unless necessary.

Oliguria Management

• 💧 Differential diagnoses include prerenal causes (hypovolemia), intrinsic renal disease, and post-renal obstruction.
• 📞 On the phone: Clarify Foley catheter status, bladder scan results, and obtain full vitals.
• 🚶 On the way: Review renal history, I/O trends, and fluid status.
• 🩺 In the room: Confirm ABCDs and Foley catheter function.
• 🧪 Get more info: Order basic labs, urine electrolytes, consider a fluid challenge, and renal ultrasound.
• 💊 Initial management often starts with IVF bolus, but avoid overload if not responsive; investigate other etiologies.

Tachycardia Management

• ❤️ Differential diagnoses include sinus tachycardia (pain, hypovolemia, infection), arrhythmias, MI, and PE.
• 📞 On the phone: Confirm vitals, assess acuity of heart rate change, and review I/Os.
• 🚶 On the way: Review cardiac history, PE risk factors, and signs of infection or volume status.
• 🩺 In the room: Assess ABCDs, perform cardiac/pulmonary exams, and evaluate for infection.
• ⚡ Get more info: Order basic labs, EKG, CXR, and troponins; consider cardiology consult for arrhythmias.
• 💊 Initial management depends on etiology, with options including rate control medications, addressing underlying causes, or cardioversion for unstable patients.