When You’re Drowning on Call: A Triage Playbook for Interns

The night you drown on call is not about how hard you work. It is about how well you triage.

Most interns learn this the ugly way: 14 cross-cover pages in 20 minutes, a crashing patient, three families waiting, and a senior who is scrubbed in a case and cannot rescue you for another 40 minutes. I have watched excellent interns fall apart here. Not because they lacked knowledge. Because they lacked a system.

This is that system.

What follows is a concrete, step-by-step triage playbook you can run at 2 AM, post-call, half-caffeinated, with a pager that will not shut up. It will not make call easy. It will make it survivable. And it will keep your sickest patients from dying while you are refilling a bowel regimen.

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Step 1: Build Your Mental Triage Board (Before the Pager Storm)

If you wait until you are drowning to think about triage, you are already behind.

You need a default mental “sorting hat” for pages. Something you can run in seconds. Here is the hierarchy that works in real life:

1. Airway / Breathing / Circulation (ABC-level emergencies)
2. “This could go bad fast” instability
3. New severe symptoms (chest pain, SOB, neuro changes, massive pain, bleeding)
4. Orders preventing care delay (pain meds, restraints, tube feeds, insulin)
5. Logistics / non-urgent stuff (diet changes, sleep aids, constipation, home meds)

That is your backbone. But you need a way to hold it in your head.

Do this at the start of every call:

• Pull your list and mark:
  • ICU / stepdown patients
  • Fresh post-ops
  • Patients on pressors, insulin drips, heparin drips
  • High risk by diagnosis: GI bleed, sepsis, DKA, ACS, decompensated cirrhosis, advanced COPD, complicated post-op days 0–2

These are your “likely to blow up” patients. You will give their pages higher priority automatically.

Then, write your own three-word reminder at the top of your sign-out sheet:
“DEAD / CRIT / CARE”

• DEAD = anything that could kill them now (ABC)
• CRIT = could decompensate soon
• CARE = comfort/symptom/logistics

You will use this label system on every single page.

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Step 2: Use a Standard Triage Script for Every Page

You cannot reinvent the wheel every time the phone rings.

Here is a 20-second script to run on every page. Use it verbatim until it is muscle memory.

When the nurse calls:

1. Identify and orient (5 seconds):
   “This is Dr. [Name], night float intern. Who is the patient and room number?”
   Pull them up in the EMR while they talk.

2. Immediate threat check (5–10 seconds):
   “Quick check: How are vitals right now? Are they on oxygen? Any changes in mental status?”
   You are already scanning for:

   • Hypotension
   • Tachycardia
   • Hypoxia
   • Tachypnea
   • New confusion / unresponsiveness

3. Core complaint (5–10 seconds):
   “What exactly are you seeing or worried about?”
   Let the nurse talk. Do not interrupt with your plan yet.

4. Assign a triage level in your head (2 seconds):

   • DEAD (go now; drop everything else)
   • CRIT (go soon; next priority)
   • CARE (can batch with others or handle by phone/order)

Say it out loud if it helps you early on. Literally: “Ok, this sounds urgent, I am coming now,” or “This sounds stable, I will be there after I see a more urgent patient.”

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Step 3: A Hard Ranking System When You Have Multiple Pages

You will get hit with 4–6 pages at once. That is not a hypothetical. That is Tuesday.

You need a strict rule set, not vibes.

Immediate, no-debate, drop-everything cases (DEAD tier)

These get you physically to the bedside immediately:

• “Patient not breathing / gasping / very hard to wake”
• “Sats in the 70s on oxygen”
• “SBP in the 60s–70s with symptoms”
• “New facial droop / weakness / aphasia”
• “Active chest pain, crushing, new, in high-risk patient”
• “Seizure now / recent seizure and still not at baseline”
• “Massive bleeding, hematemesis, melena with hypotension, bright red blood per rectum with hypotension”
• “Anaphylaxis signs: facial swelling, wheezing, hypotension”

For these, you go. You do not finish the note you are writing. You do not place the melatonin order first.

You can give one-liner instructions while you walk:

• “I am coming now. Start a second IV, get a full set of vitals, put them on oxygen, and bring the crash cart to the room.”
• “Call a rapid response now. I am on my way.”

High-risk but not obviously crashing (CRIT tier)

These should be seen quickly (within ~15–30 minutes), but you can finish stabilizing a DEAD-tier patient first:

• Fever in a neutropenic / post-op / sick septic patient
• HR 130–150 but BP okay, especially post-op or with known infection
• New oliguria in a septic or heart failure patient
• Worsening respiratory status but sats still > 90% on known baseline oxygen
• Severe uncontrolled pain
• New moderate confusion without focal neuro deficit
• Glucose < 60 or > 400 but no obvious DKA/HHS signs (yet)

You say:

• “I will see them after I finish with a more urgent patient. Please get vitals, point-of-care glucose, and bring a recent MAR and I/O sheet to the room.”

Routine / comfort / logistics (CARE tier)

These you batch and do in chunks every 30–60 minutes:

• Sleep medications
• Bowel regimens
• Diet changes
• Home medication reconciliations
• Re-ordering routine labs
• Non-urgent nursing requests (“Can you dc the Foley if okay?” when vitals are stable and patient is fine)

You say:

• “That sounds non-urgent; I will enter the order in the next 15–20 minutes.”
• Or: “I will come see them when I am caught up with some urgent issues, likely in about an hour.”

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Step 4: Use a Real-Time “Triage Queue” Instead of Mental Chaos

Do not keep all this in your head. You will drop something.

Make a quick triage queue that lives on your sign-out sheet or a sticky note. Something like:

Rank	Patient / Room	Reason for Page	Tier	Status
1	Mr. L – 724	BP 70/40, septic	DEAD	Going now
2	Ms. K – 731	New O2 requirement	CRIT	Next
3	Mr. S – 716	Worsening pain	CRIT	After #2
4	Ms. W – 703	Bowel regimen	CARE	Orders later
5	Mr. J – 709	Melatonin request	CARE	Batch with #4

Every time you get a new page, you quickly:

1. Run your triage script
2. Assign tier
3. Drop it into your queue in order

Then you tell people honestly where they are in line:

• “You are number 2 in my queue right now. I am with an unstable patient. I will be there as soon as I am done.”

Nurses respect this a lot more than vague promises. And you protect the truly sick.

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Step 5: What To Do When You Walk in the Door (Rapid Bedside Assessment)

Standing at a sick patient’s bedside without a plan is how interns freeze.

You need a 60–90 second default assessment you can run on any patient you are called to see.

Use this every time:

1. Look first (5–10 seconds):

   • Are they talking? Full sentences or 1–2 words?
   • Work of breathing? Use of accessory muscles? Tripoding?
   • Skin: pale, sweaty, cyanotic?
   • Monitors: HR, BP, RR, O2 saturation, rhythm

2. Touch (5–10 seconds):

   • Feel radial pulse: fast? thready? strong?
   • Feel extremities: warm or cool? clammy?
   • Check capillary refill

3. Talk and orient (15–30 seconds):

   • “Hi, I am Dr. [Name]. What is going on right now?”
   • Are they oriented? Name, place, time?

4. Immediate stabilization moves (30–60 seconds):

   • Oxygen: If hypoxic or increased work of breathing, put on nasal cannula / non-rebreather while you think.
   • Positioning: Sit them up if SOB; supine with legs elevated if hypotensive and no obvious CHF.
   • Access: Ask for a second IV if they look shocky.
   • Monitor: Make sure they are on full monitoring if not already.

5. Call backup early if your gut says yes.

   • Say the words: “This patient is very unstable; I need my senior here now and we should call a rapid.”

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Step 6: Standard Mini-Protocols for Common High-Stress Pages

You do not have time to “rethink” chest pain or hypoxia from scratch at 2 AM. Use simple templates.

A. Chest pain

1. At bedside: ABCs, vitals, O2, quick focused history:

   • Where is the pain? Radiation? Quality?
   • Started when? At rest or exertion?
   • Associated: SOB, diaphoresis, nausea, syncope?

2. Immediate orders:

   • STAT EKG
   • Troponin
   • Vitals q15–30 min
   • SL nitroglycerin if SBP > 100 and no contraindications
   • ASA 325 mg chew if not given and no allergy / contraindication

3. Call senior / rapid if:

   • EKG looks ischemic
   • Persistent severe pain
   • Hypotension, arrhythmia, or pulmonary edema

B. Acute respiratory change

1. Quickly check:

   • Is the hypoxia real? Check waveform, probe.
   • Sats, RR, work of breathing, speech

2. On the spot:

   • Sit them upright.
   • Start O2 (nasal cannula to NRB as needed).
   • Listen: wheezing vs crackles vs almost nothing (bad).

3. Orders:

   • Stat ABG or VBG with lactate
   • CXR
   • Consider nebs if wheezing
   • Lasix if clear CHF and volume overloaded (after discussing with senior initially as an intern)

4. Escalate:

   • If sats < 90% despite NRB or rapidly worsening → call rapid, senior now.

C. Hypotension

You will get paged for “BP 88/50” that is not a crisis and “BP 70/40” that is.

1. Re-check:

   • Manual blood pressure.
   • Compare to baseline.

2. Evaluate rapidly:

   • Mental status, urine output, skin perfusion.
   • Look for bleeding, sepsis (fever, source), cardiogenic (JVD, crackles, chest pain).

3. Always:

   • Ensure IV access.
   • Consider small fluid bolus (250–500 cc) if not in florid CHF and no contraindications, but call senior early.

4. Call rapid / senior for:

   • SBP < 80, especially with symptoms.
   • Hypotension with altered mental status, chest pain, or respiratory distress.

D. “Patient looks different / not right”

Nurses are usually right about this.

1. Go see them. Do not manage by phone.
2. Run your full rapid assessment.
3. Assume something is wrong until proven otherwise:
   • Check vitals.
   • Check glucose.
   • Quick neuro exam.
4. Get basic labs if you cannot explain the change:
   • CBC, BMP, LFTs, lactate, blood cultures if infection suspected.

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Step 7: Use Your Senior and Rapid Team Properly (Not as a Last Resort)

Interns get into trouble by trying to be heroes. That gets patients killed.

Here is the rule: If you are worried enough to think “should I call my senior?” the answer is yes.

You are not bothering them. Their job that night is exactly this.

Clear thresholds to call your senior immediately:

• Any time you call a rapid or code
• New oxygen requirement above 4 L, or any need for NRB / BiPAP
• New MAP < 60 or SBP < 90 with symptoms
• New neuro deficit
• Any patient you think might need ICU transfer
• Repeated pages on the same patient for worsening vitals or symptoms

Say it simply:

• “Hey, I am in 724. Mr. L is hypotensive with suspected sepsis. I have started fluids and called a rapid. I need you here.”

Do not hide the ball. State your level of concern plainly.

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Step 8: When Everything Is On Fire: A Crisis Flow

There will be a night where you have:

• A rapid in room 724
• A chest pain page in 731
• A confused patient trying to climb out of bed in 716
• Ten more pages queued up blinking on your pager

This is when you run a strict crisis algorithm.

Intern On-Call Crisis Triage Flow

Step	Description
Step 1	Multiple urgent pages
Step 2	Go to sickest room now
Step 3	Rank CRIT pages
Step 4	Call rapid and senior early
Step 5	Stabilize ABCs
Step 6	Assign tasks to nurses
Step 7	Step out for 1 min
Step 8	Update queue and re-rank
Step 9	Address CRIT pages in order
Step 10	Batch CARE tasks last
Step 11	Any DEAD tier?

Use this literally:

1. Drop everything and go to the absolute sickest patient (DEAD tier).

2. Call rapid / senior early at bedside.

3. Stabilize ABCs, assign concrete tasks to nursing:

   • “You: call RT.”
   • “You: get another IV.”
   • “You: 1 L NS hanging now.”

4. When the room is full of people and things are momentarily stable, step just outside the door for 60 seconds.

   • Re-open your triage queue.
   • Re-rank your next CRIT patients.

5. Tell the rapid team or senior:

   • “I have to go see a chest pain in 731 next. Please page me with any updates on 724.”

Then go. Do not hover in a room where you are now the fifth-most-useful person while others deteriorate elsewhere.

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Step 9: Batch the Non-Urgent Stuff Like a Pro

You can cut your perceived workload in half by batching CARE-tier tasks.

Instead of:

• Running to floor 7 for melatonin
• Then to floor 9 for bowel regimen
• Then back to floor 7 for a diet change

You do this:

1. Every 45–60 minutes (when no active emergencies), stop and:

   • Open your list of CARE-tier pages.
   • Write down:
     • Orders you can place without bedside evaluation.
     • Patients that actually need a quick check.

2. Place all “no bedside needed” orders in one EMR session.

3. Walk the floor in a loop:

   • See all patients that need a quick in-person look.
   • Handle as many low-level orders as possible while you are already in that geographic area.

This is how you keep your sanity. And get out of the hospital before lunch post-call.

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Step 10: Communication Phrases That Actually Work

How you talk on call either buys you time or gets you buried.

Use crisp, honest phrases:

• When overwhelmed but handling it:

  • “I am with an unstable patient right now. You are next in line. Realistically I will be there in about 20 minutes. If anything changes before that—BP drops, chest pain, new SOB—page me STAT.”

• When something is not safe to manage by phone:

  • “That does not sound like something to fix with an order. I am coming to examine the patient.”

• When someone wants you to drop a higher-acuity patient:

  • “I understand the concern. Right now I have a potentially life-threatening situation in another room. Once I stabilize them, I will come straight here.”

• With your senior:

  • “Quick heads up: I am getting hit with multiple high-risk pages. Here is my current queue and who I am most worried about.”

You are not just triaging patients. You are triaging expectations.

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Step 11: Protect Yourself from Mistakes You Will Regret

Most disastrous intern stories share the same three errors:

1. Managing a sick patient by phone.
   Do not. If you are called about:

   • New SOB
   • Hypotension
   • Neuro change
   • Serious bleeding
     You must see the patient. Period.

2. Ignoring your gut.
   If you “just do not like how they look,” assume they are sicker than the labs show.

3. Delaying escalation.
   Near-misses always include, “I thought about calling the senior but wanted to see the labs first.” Do not wait.

Create three hard personal rules:

• I will see every patient with a new vital sign abnormality that worries me.
• I will never be annoyed that a nurse called for “patient looks different.”
• I will page my senior early on any patient I think might deteriorate.

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Step 12: Use Simple Cognitive Offloading Tools

Your working memory at 3 AM is useless. Outsource it.

Here is a small, practical “intern on-call card” you can recreate on an index card and keep in your pocket:

Front side:

• DEAD: airway, breathing, circulation, acute neuro, active severe bleed, sepsis with hypotension
• CRIT: chest pain, rising O2 needs, fever in high-risk, HR > 130, acute confusion
• CALL SENIOR: rapid/codes, MAP < 60, new O2 > 4 L, new neuro deficit, any gut worry

Back side:

• Chest pain = EKG + troponin + O2 + ASA
• SOB = sit up + O2 + CXR + gas + RT
• Hypotension = recheck + fluids if safe + sepsis workup if suspected
• “Not right” = vitals + glucose + neuro + consider labs

You check this instead of trying to recall algorithms from your last rotation.

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Step 13: Debrief After The Storm (So Next Time Is Less Bad)

You will have awful nights. The question is whether you learn from them.

After any terrible call shift, do a 10-minute solo debrief before you go home or after you nap:

1. List the 3 scariest patients you managed.

2. For each, ask:

   • Did I see them soon enough?
   • Did I call for help early enough?
   • What would I do differently next time?

3. Write down one concrete practice change for next time:

   • “Next time any patient needs NRB, I will call my senior right away.”
   • “I will keep a running triage queue instead of just answering pages in order.”

You do not need a full reflective essay. Just ruthless, honest self-review. That is how you stop repeating the same painful shift for an entire year.

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Step 14: Remember the Real Goal of Call

Your goal on call is simple:

• Keep people alive and reasonably safe
• Do not miss the truly sick
• Do not drown yourself in tasks that can wait

You are not there to make everyone comfortable, fix every chronic issue, or write beautiful notes. You are there to triage and stabilize.

You will still feel behind. You will still feel stressed. That part is baked in. But you will not feel lost.

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A Simple Visual to Keep in Your Head

If you like visual structure, think of your time on call as a stacked bar:

Intern Time Allocation on a Busy Call Night

Category	Emergencies	Urgent but Stable	Routine/Administrative
Early Night	20	30	50
Peak Pages	40	35	25
Late Night	15	30	55

Early in the night you can clear routine stuff. At the peak, you should be heavily weighted toward emergencies and “could crash soon.” Late night, as things quiet a bit, you mop up the remaining routine tasks.

If your “Peak Pages” period is 70% routine work, you are triaging wrong.

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One More Thing: Your Emotional Bandwidth

You will feel guilty leaving one patient to deal with another. You will feel pulled by nurses, families, consultants. That is normal.

Anchor yourself with this question:

“Where am I most needed in the next 10 minutes to prevent the most harm?”

Not where people are yelling the loudest. Where the physiology is most at risk.

You are allowed to say “no,” or “not yet,” or “I will be there after I stabilize someone who is much sicker.” That is not neglect. That is good medicine.

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A Quick Process Map You Can Screenshot

Here is a compact flow you can mentally run every time your pager goes off:

On-Call Page Triage Mini-Algorithm

Step	Description
Step 1	Pager Goes Off
Step 2	Call Back with Script
Step 3	Check Vitals and Core Complaint
Step 4	Go to Bedside Now
Step 5	Add to High Priority Queue
Step 6	Add to Low Priority Batch
Step 7	Stabilize ABCs
Step 8	Call Senior or Rapid if Concerned
Step 9	Update Queue
Step 10	Repeat for Next Page
Step 11	DEAD, CRIT, or CARE?

This is the game. Slot each page into DEAD / CRIT / CARE. Act accordingly.

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Your Next Step (Do This Today)

Do not wait for the nightmare call to “figure it out.” Build your system now.

Today, before your next shift:

1. Take an index card or small sheet of paper.
2. Write at the top: DEAD / CRIT / CARE.
3. Under each, list 3–5 examples from this article you know you will see on your service.
4. On the back, write your personal “Call Senior When…” triggers.

Put that card in your pocket on your next call. When your pager starts screaming, pull it out and force yourself to classify every page before you react.

Then, after that shift, look at the card again. Add one thing you wish you had written there.

Open your sign-out template or personal notebook right now and add a section labeled “Triage Queue.” Because the night you feel like you are drowning is coming. Better to have a playbook in your pocket before the water rises.