Keeping Cool When Your Patient Needs It Most: 4 Tips For Your First Rapid Response
Faculty Mentor: Will Schouten, MD, Hospital Internal Medicine, Mayo Clinic, Rochester, MN
Early in my intern year, responding to rapid response calls was among the events I feared most at the hospital. My first such call was for chest pain – I recall nervously assessing the patient who appeared visibly distressed to the point she had difficulty speaking. After ordering an ECG, which appeared benign, I asked a senior resident for assistance. Somewhat comically in retrospect, the patient had plenty of reason to be clutching her chest and visibly dyspneic. She had been gagging on a dried out mucus plug. After reflecting on this case and others, a framework for triaging, diagnosing and treating came to me later in the year. Keeping these ideas in mind during your next rapid response may help to keep your mind at ease, promote organization and focus, and even improve your effectiveness.
1) Identify the context
Approaching the room of a visibly distressed patient can be chaotic. A first instinct might be to immediately focus on the reason for the call, i.e. “the patient is short of breath”. However, even before starting there, assessing a few key points can help you quickly understand the optimal path forward. I find it valuable to know the time course of the problem at hand, and related to that, the patient’s state of health prior to whatever prompted the rapid response. Was the problem of sudden onset and perhaps unexpected? Vascular etiologies come to mind, along with arrhythmias or basic mechanical problems, even as simple as choking on a glob of mucus (to which I was called for chest pain). Was the patient ill at or even prior to arrival? Is this a progression of their initial complaint or something new? What are the patient’s wishes for their care?
By assessing these points systematically when approaching rapid response calls, one can quickly target relevant diagnoses, and determine how to best serve the patient.
2) Hone in on vital signs or similar worrisome findings
Many rapid response calls are prompted by the presence of abnormal vitals signs. After my first few rapid response calls, I came to appreciate just how aptly named vitals signs are. Vitals signs can offer valuable guidance as to where the problem lies, and how it might be addressed.
Separate from vitals signs, certain ominous symptoms are also common reasons for a rapid response. Common such symptoms include chest pain, a change in consciousness or new confusion, or bleeding, whether gastrointestinal or respiratory. Within these, work to characterize the symptom in detail, all the while working to mentally rank possible diagnoses.
3) Pause and think
This is probably the most important point of all.
After examining the patient, there is often mounting pressure to decisively call out a plan, and to do so STAT! At this point, there may be multiple staff or even family members eagerly awaiting next steps. If you feel highly confident with your assessment and what the next steps will be – perhaps you were caring for the patient earlier in the shift and already knew the situation well – feel free to state your plan and place orders. Often times, though, particularly early on, things may not be so clear.
Instead of jumping to action, I find it helpful to pause and reflect on the information I’ve gathered. I might restate to the team some of what I’ve absorbed or briefly browse the patient’s record if there’s a computer nearby. I attempt to consider what I might have missed, and how my next steps could help sort things out to diagnose and treat the patient. If needed, I might perform a specific exam maneuver that I didn’t think of initially. It may be necessary to manage the team’s expectations for immediate actions while you spend a few minutes working through these steps.
Remember, chasing the wrong diagnoses, or providing an ineffective treatment is a waste of time and money, and may negatively impact the patient’s health. Consider the scenario of a rapid response for chest pain. Listening closely for that new regurgitant murmur or feeling a radiofemoral delay could dramatically redirect the course of what initially seemed to be an acute coronary syndrome. On the other hand, one should take care to balance evaluation with any immediate needs for treatment. Performing urinalysis, chest x-ray and measuring lactate levels never saved a patient with sepsis. Fluids and antibiotics will make the difference.
The bottom line is, taking a couple minutes to collect your thoughts, which might seem like an eternity, is often a worthwhile tradeoff.
4) Solicit others’ opinions, gracefully
Early on as an intern, and even later on, there may be knowledge or experience gaps that other team members can help fill -- think nurses, respiratory therapists, or even the patient care assistant who has been one-on-one with the patient for the last five hours. Balancing the need for leadership and accountability with the recognition of one’s own relative naiveté, it can be helpful to first propose a plan to the patient and care team, and then ask if everyone agrees, or if anyone has other ideas. Proceeding in this fashion satisfies the need to make one concrete, focused plan while recognizing that we all bring different, valuable perspectives to any rapid response.
I hope you found these tips helpful. Now go out there and save some lives!