At the facility where I work as an ICU provider I respond to rapid response calls. My role is to assist the team in making a diagnosis and plan of care; stabilize the patient if necessary. A common issue I encounter is getting a quick and accurate summary of what the problem is from the primary team and bedside staff. I think this stems, in part, from proximity. The closer you are to a situation the harder it can be to establish that 100 yard perspective. Compounding this is the difficulty that some people have in verbalizing and transitioning concerns into accurate diagnoses. Most are adept at pattern recognition even if they can’t verbalize what they are seeing, but few are able to synthesize the data into a problem and associated action plan. As a new provider this was a struggle for me as well. In this post I will discuss my approach to the rapid response call.

The first step is to stand at the foot of the bed and look at the patient. Like, really look. Would you describe this patient as stable or unstable, in acute distress (hemodynamic or respiratory), toxic in appearance, pale, diaphoretic, warm, cold, what is the GCS? What are the vitals and does the team already have the pt in reverse trendelenberg? Take it way back to the basics, determine your ABC’s. And while you’re looking at the patient, the second step is to listen to the story from the people in the room. At this point if there is imminent decline I initiate emergent plans for intubation or cardioversion or pressors, etc, even if I don’t know the etiology. The final step is to rapidly review the chart (labs, recent diagnostics, today’s note, meds given, vitals trend).

• Airway. This one is tricky. The question is does this person have a patent airway, but a component to this is do they have the neurological function to breathe? Start with assessing the actual airway. Are there visible food particles in the mouth? Do you hear stridor (wheezes in upper airway, not lower)? Coughing; is the nurse telling you the pt had been eating or has dysphagia? Does the pt carry a diagnosis placing them at airway risk (recent ACDF/CEA or other neck/oral surgery, epiglottitis, angioedema, allergies, etc.)? Then progress to neuro risk. Stroke or sz symptoms? Are they delirious, and why? What is the GCS? Are they alert enough to protect the airway (drooling, GCS <8, acute hemodynamic instability)? If not you need to intubate, Bipap has little benefit here, UNLESS you think this is oversedation/narcotization and you plan to give a reversal agent. A scenario where you have a clear and quickly reversible diagnosis warrants a brief trial of bipap support.

• Breathing. Are they breathing? Too much/too little? What are the sats, respiratory rate and quality of breathing? Think about how you would objectively describe this pt to another person or in your note. If breathing too little what would you want to know? Are they alert or unresponsive, what is the GCS, are they drooling, aspirating? Are they agonal, are the volumes very small, listen to the chest, can you hear air movement, do you hear wheezes or diminished air entry? Does this person need to be intubated in order to support ventilation (and/or oxygenation)? You don’t need an ABG to determine if someone needs to be intubated. If breathing too much do they exhibit air hunger (head bobbing, large tidal volumes, nasal flaring, pursed lip breathing, tripoding) or kussmauls pattern indicating metabolic acidosis or impaired ventilation (do you hear stridor, story of aspiration, visible food versus abd accessory muscle use, prolonged exhalation phase, wheezing, coughing). Accurately diagnose the type of respiratory failure and then 1 or 2 differentials for etiology. Once you have a likely cause, proceed with indicated therapy.

• Circulation. Are they hemodynamically stable? A very common call is for hypotension. Start your hypotension workup. What is the HR? If it’s high they are likely compensating although the BP can be low because you have a fast but nonperfusing rhythm so start with diagnosing the heart rhythm. (This will commonly coincide with a story like pt came in with Afib/RVR and is awaiting ablation tomorrow or has known Afib but is currently off meds, etc.) Are they hypoxic as well, is there a breathing problem? Very common issue. I’m going to start thinking about is this person in septic shock from PNA, or are they acidotic from other form of sepsis and now have kussmauls to compensate. The second step here is to determine if this is hypotension with or without shock. Think through the s/s of shock and start piecing them together. Is it warm of cold shock, what is the cap refill, does it seem like septic, cardiogenic, hypovolemic, hemorrhagic (has this person developed a GI bleed amongst other sources of bleeding), obstructive (are there signs of a PE)? Is there a wide pulse pressure? All of these scenarios are more dire than the pt with adequate end organ perfusion and no other signs of shock. My thoughts there are typically directed towards something iatrogenic. Did we give them something (sedatives, opioids, BP or HR reducing meds) vs did we withhold something (chronic midodrine or steroids) inadvertently (ask the nurse if pt has been taking meds, often people are npo or lost feeding access or are too somnolent to take meds in the hospital. Was there a recent procedure? Hypotension is really just the start here, you also get calls for tachycardia and hypertension but these aren’t in the majority so for the sake of brevity I won’t go into that here. The jist is - start thinking through your most likely differentials in real time (as you are assessing and getting information from the staff and the pt.) and formulating a plan to treat immediately.

Once you’ve made a likely diagnosis start ordering appropriate treatments and diagnostics. A chest xray, EKG, and labs are common to most RR calls. Possibly an ABG, but my caveat with this is don’t use it as a crutch to determine anything but rapid review of hemoglobin and other labs or hypercarbia. If the call was for decreased responsiveness, hypercarbia is a common cause and bipap may be your solution. Outside of that it’s useless in telling you if the pt is hypoxic (you already know this) or if the patient needs to be intubated (you already know this also).

Once stabilized, you have to decide on disposition. Is this a patient that warrants more attention than the floor nurse can handle given her workload? Can this patient move to a stepdown ICU managed by either your team or a hospitalist team? Or do you rapidly need to move this person to any open ICU and immediately begin therapies (lines, intubation). All of these scenarios involve respectful communication with the primary team and a collegial discussion about what best serves the patient.

If this is an acute situation I am 9 times out of 10 going to call the family myself to determine what GOC are. I find that I can more quickly get to the heart of the matter regarding how extensive they and the pt want resuscitative efforts to be. It starts with accurately describing to the family what diagnosis and prognosis look like. As the ICU provider I have a little more insight regarding what the likelihood is that this person has survivability and can discuss treatment options in an abbreviated manner. Having said that, the primary team usually has established report with the family and can be a wealth of knowledge regarding family dynamics in addition to more closely knowing the patient’s medical history so a team approach is often the best strategy.

Lastly, I want to highlight that this is truly a team approach. There are nuggets of wisdom and insightful ideas that stem from all the team members involved in the call. I never assume that I know more than anyone else, after all the people who called are more intimately aware of this patient and their hospital course. Brilliant ideas stem from all walks of life and all professions. I always look to the primary team and appreciate their insight while acting as a third party perspective and review all the data myself. Redundancy is necessary, especially when folks are having a hard time verbalizing the problem or offering differentials, but should never be disrespectful.