Common Night Calls

Hypertensive urgency and emergency

First work out why they are hypertensive. Are they vomiting up their medications? Did they simply not get them? It is acceptable for people to be somewhat hypertensive in the hospital. But if they are over 200/110, you need to bring them under 200. If they have not had their medications, give them early.

Otherwise, with IV access:

• Hydralazine 20 mg IVP. An arterial dilator that drops the pressure quickly.
• Furosemide 40 mg IVP. Takes a while to work, but they will diurese. Especially useful if they are volume overloaded.
• Metoprolol 5 mg IVP. Lowers heart rate. Not especially good at lowering blood pressure, but excellent when tachycardia is part of the picture.
• Labetalol 20 mg IVP. Lowers both blood pressure and heart rate.

If they do not have IV access:

• Clonidine 0.1 mg PO. The fastest of the oral options.
• Furosemide 40 mg PO. Slower, but they will diurese.
• Hydralazine 10 mg PO. Works fairly quickly and gives a good drop.

Hypotension

Again, work out why and fix that if you can. Are they over-diuresed? Did they just get all of their antihypertensives at once? Are they septic? Anaphylactic? Orthostatic? Did they get too much morphine? Is the tidal volume too high on the ventilator? Do they need to go to the critical care unit? Or is the nurse simply getting a bad reading?

If the cause is not obvious:

• 1 liter of normal saline, wide open
• Hold the antihypertensive medications
• Draw blood cultures if they are febrile or look septic

If that does not help you can keep bolusing fluids, but transfer them to the unit for closer monitoring.

If they remain hypotensive, transfer to the unit, get central access and start a vasopressor:

• Norepinephrine (Levophed) if you think they are septic. This is the first line pressor for most shock states.
• Dobutamine if you think this is cardiogenic shock.
• Dopamine if you do not know, since it does a bit of both. Be aware it causes more arrhythmia than norepinephrine.

Altered mental status

Altered mental status with no focal deficit is almost always one of three things: an infection, a drug, or a metabolic process.

Check a glucose first, every single time. It takes seconds and it is the one cause you can reverse at the bedside.

If you suspect infection, draw blood cultures, bolus a liter of normal saline, and if they do not improve after 3 to 4 liters, get central access and start a pressor.

If you suspect a metabolic process, get a CMP, CBC, troponin, and an ammonia level if you suspect liver involvement.

If you suspect drugs, the nurse usually already knows what happened. They got too much opiate or too much insulin. Check the glucose, ask when the last opiate dose was given, and give naloxone if it is warranted. Other psychiatric medications may be involved. Transfer to the ICU for closer monitoring if they are not protecting their airway.

Evaluate their respiratory status. Consider syncope and seizure. Get serial EKGs and troponins if you think they are having an MI. If you think they may be bleeding into their head, get a non-contrast head CT.

CVA in progress

They will have focal deficits: facial droop, arm or leg weakness on one side. Get a non-contrast head CT and transfer to the ICU.

If it is a bleed, call neurosurgery. If it is not, call neurology. Stabilize the patient and watch them closely. If the patient qualifies, ask neurology whether they want to give thrombolysis, and whether the patient is a candidate for thrombectomy.

Chest pain

Get a really good history and talk to the patient. Is it positional? Pleuritic? Reproducible with palpation? If so, it is less likely to be an MI. If it is exertional, it is more likely, and you follow the steps below.

• Get serial EKGs and troponins every 6 hours.
• If the story sounds reasonable, aspirin 325 mg PO chewed, and load with clopidogrel 600 mg PO.
• If the troponins come back positive, enoxaparin 1 mg/kg SC q12h.
• If the EKG shows ST elevation, call the cardiologist and activate the cath lab. Aspirin 325 mg chewed, clopidogrel 600 mg PO, anticoagulation per your STEMI protocol, and oxygen only if the saturation is below 90 percent.
• If they are in a lot of pain, sublingual nitroglycerin 0.4 mg.

Respiratory distress

Work out why, and what their history is.

If this is heart failure

They sound wet, they have pitting edema and distended neck veins:

• Furosemide 80 to 120 mg IVP now
• Nitroglycerin, which vasodilates and venodilates and redistributes the fluid away from the lungs quickly
• Put them on BiPAP, roughly 12/4, at whatever FiO2 they need, to help them breathe and buy time for the drugs to work

If this is asthma or COPD

They are wheezing and tight:

• Methylprednisolone 125 mg IVP. This takes 6 to 8 hours to work, so give it early.
• Albuterol and ipratropium (Duoneb) nebulized continuously for an hour
• Oxygen by nasal cannula or non-rebreather after the nebs, targeting 88 to 92 percent in a COPD patient

If they still look bad:

• Transfer to the ICU
• Epinephrine 1:1000, 0.3 to 0.5 mg intramuscularly
• Magnesium 2 g IV over 20 minutes, which may help relax bronchial smooth muscle
• Have the intubation kit at the bedside and ready

Constipation

• For quick relief: polyethylene glycol, 6 capfuls in 24 oz of a sports drink, taken at once.
• For maintenance: 1 capful per day in 12 oz of fluid, which produces softer stools over a few days.

You can use both: the larger dose for relief now, the daily dose to keep it from happening again. Also look at the medication list, because the opiate they are on is usually the reason you are being called.

Diarrhea and GI bleeding

First, rehydrate with IV normal saline. You can work out the cause afterwards.

Send stool for C. difficile toxin. Guaiac the stool for blood. Then look at it yourself:

• Bright red. This may be a brisk upper GI bleed or a lower GI source. Get a CBC to see whether they are dropping their hemoglobin quickly, and call GI for an urgent scope if they are.
• Black and melenic. A slower upper GI bleed. It can usually wait until morning. Check a CBC to be sure they are not anemic.

Either way, type and screen them before you need the blood rather than after.

Fever

If it is post-surgery, post-procedure, post-trauma, post-intubation or post-anesthesia, and it is under 102 degrees Fahrenheit, it is usually nothing to chase. If it is over 102, or the patient looks unwell at any temperature:

• Acetaminophen 1 g PO once
• Urine and sputum cultures
• Blood cultures x 2, from two peripheral sites, 20 minutes apart
• Vancomycin 1 g IV once now
• Piperacillin-tazobactam 3.375 g IV q6h, first dose now

That covers most of what you will meet on a medical floor. Narrow it as soon as the cultures speak, and check your local antibiogram, because resistance patterns differ between hospitals.

Hypercalcemia

Calcium is tightly regulated. Nobody should be running much over 10. If it is high, hydrate them with normal saline. This is usually dehydration, malignancy, or both. Do not give IV furosemide or a thiazide. Just saline. The body will correct with hydration alone in most cases.

If it is severe, or it is clearly malignancy related, that is when you add a bisphosphonate or calcitonin, and you go looking for the cause with a PTH level.

Hypocalcemia

Make sure it is real. Check an ionized calcium, and correct for albumin, because a low albumin will drop the total calcium without dropping the physiologically active fraction.

You do not have to wait for the result to act. Calcium gluconate 1000 mg IV is very safe. Check the magnesium too, since you will not correct the calcium while the magnesium is low.

Hyperkalemia

How acute the change is matters more than the number itself. A chronic dialysis patient tolerates a higher potassium with far fewer problems than someone whose level moved two points overnight.

Between 5.4 and 5.8: a potassium binder and time is often enough. Get an EKG anyway.

Anything higher, or any EKG change:

• EKG immediately
• 1 amp of calcium gluconate IV, to stabilize the myocardium. This does nothing to the potassium level, it just buys you time.
• 10 units of regular insulin IVP with 1 amp of D50
• A potassium binder PO. Sodium polystyrene (Kayexalate) is the traditional answer, but patiromer and sodium zirconium cyclosilicate are faster, better tolerated and preferred where available.
• Accuchecks every 15 minutes for 4 to 6 hours, because the insulin will outlast the dextrose

Over 6.8 with an acute change: place a temporary dialysis catheter and start dialysis in addition to all of the above.

Hypokalemia

If it is under 3.6:

• 40 mEq KCl rider IV over 4 hours
• 80 mEq KCl PO once now
• 2 g magnesium rider IV
• Repeat a BMP an hour after the rider is finished

Sometimes patients are depleted at the whole body level, and you will be doing this for days. Every 0.1 of measured potassium takes roughly 40 to 80 mEq to replace, so going up a full point can take 400 mEq or more.

If they are not responding to replacement, replace the magnesium. You cannot fix the potassium while the magnesium is low, so check a level and treat it.

The fall

The call is "your patient is on the floor." Before you hang up, ask three things: was it witnessed, did they hit their head, and are they on anticoagulation. Get a set of vitals and ask whether they are back to their mental baseline. If there is neck pain or an obviously deformed limb, tell the nurse to leave them where they are until you arrive.

On the way, pull up the chart. Medication list first: warfarin, a DOAC, therapeutic heparin, dual antiplatelet therapy. Check the last INR and platelet count, and remind yourself why they were admitted, because sometimes the fall is the disease talking. The GI bleeder who stood up and syncopized is not a "mechanical fall."

At the bedside, examine the whole patient, not just the part they landed on. Palpate the scalp for hematoma, press on the cervical spine, run the clavicles, wrists, ribs and hips. A shortened, externally rotated leg is a fractured hip until proven otherwise. Then do a neurologic exam you would be willing to defend, because it is the baseline for every neuro check that follows. Check a glucose. Then answer the only interesting question: why did they fall? Tripping over the IV pole is one story. Syncope, new weakness, or the sedative given two hours earlier is another, and each has its own workup.

Image the head for anticoagulation as above, for any new neurologic finding, vomiting, worsening headache, or a patient too confused to give you a reliable exam. X-ray whatever hurts or will not bear weight.

The post-fall note: time, witnessed or not, head strike or not, anticoagulation status, vitals, the exam including the neuro exam, glucose, what you imaged and why or why not, your best explanation for the fall, and the plan: neuro check frequency, a PT evaluation, any medication you stopped. "Patient found on floor, no apparent injury" is not a note, it is an invitation to a deposition.

Low urine output

The call is a number: 15 mL over the last two hours. Real oliguria is under about 0.5 mL/kg per hour for more than a couple of hours. On the phone, ask whether there is a Foley, when it was last flushed, what the vitals are, and whether the belly looks distended or the patient is uncomfortable.

The flush-first rule. A large share of overnight oliguria is a bad Foley, not a bad kidney. Have the catheter flushed with 30 to 60 mL of sterile saline before you order a single lab. If it will not flush and return freely, replace it. If there is no Foley, get a bladder scan. Several hundred milliliters sitting in the bladder is retention, not oliguria: place a catheter, then ask why. Opiates, anticholinergics and the prostate are the usual suspects. An empty bladder on the scan means the kidneys are genuinely not making urine, and now you have a real call.

Real oliguria at night is usually prerenal. Look at the intake and output for the day, the diuretic doses, and the medication list for NSAIDs, ACE inhibitors and recent contrast. Examine their volume. If they are dry, give 500 mL of normal saline and recheck the output in an hour or two. Send a BMP.

When it is the pump, not the tank. If this is a heart failure patient with edema, distended neck veins and crackles, low urine output is a forward flow problem. Boluses make it worse. These patients may need diuresis, not fluid, and if the pressure is soft too, they may need inotropy and a monitored bed, not a rider. When you cannot tell tank from pump at the bedside, that uncertainty is itself a reason to escalate.

Escalate for anuria with a patent catheter, for hyperkalemia or a significant acidosis on the BMP, or for oliguria plus hypotension, which is evolving AKI in front of you. Document the hourly rate, the flush, the scan result, your volume exam, what you gave and when you will recheck.

Hypoglycemia and hyperglycemia

Hypoglycemia first, because it can kill before morning. Below 70 with symptoms, or below 55 regardless, treat now. Awake and able to swallow: 15 to 20 g of fast carbohydrate, juice or glucose tablets. Altered, NPO or unsafe to swallow: 1 amp of D50 IV. Then the part people skip: recheck in 15 minutes, and again after that. The D50 wears off long before the cause does. Long-acting insulin, sulfonylureas, renal failure and liver failure all keep pulling the glucose down for hours. Sulfonylurea hypoglycemia in particular recurs, so those patients get a D10 infusion and frequent checks, and some protocols add octreotide. Then fix the orders, because the usual story is a full insulin dose given to a patient who stopped eating.

Hyperglycemia at 3 AM is a different animal. A single glucose of 280 in a type 2 diabetic who feels fine is not an emergency, and the reflex to correct it hard is how you get called back at 6 AM for the hypoglycemia you caused. Overnight correction stacks on top of whatever basal insulin is already on board, and nobody eats breakfast for hours. Give a modest dose per the existing correction scale, or nothing, and let the day team fix the regimen properly, as laid out in inpatient insulin management.

The exceptions: a type 1 diabetic, a glucose over 400, or anyone with nausea, abdominal pain or deep rapid breathing gets a BMP and an anion gap, because DKA and HHS are not sliding scale problems.

Insulin drip patients are different. The protocol owns the glucose. Follow its titration table and do not freelance corrections on top of it. If the drip patient is low, the protocol tells you the new rate and the D50 dose. Your job is to ask what changed: usually the tube feeds were stopped and the drip was not turned down.

Document the value, what you gave, the recheck values, and the order you changed so it does not happen again tomorrow night.

Pain control requests

The lazy answer is to phone in one more dose. Reassess before you redose. New pain, worse pain, or pain in a new location is a symptom, not a nuisance. The "pain control" call is how chest pain, an acute abdomen and compartment syndrome sneak past you at night. The post-op patient whose pain keeps escalating through appropriate doses is not becoming tolerant in six hours, they are telling you about ischemia, a bleed or a leak.

On the phone: is this the same pain as before or something new, where is it, what are the vitals, how sedated are they, when was the last dose and did it do anything at all. If any of those answers is off, go see the patient before you order anything.

Opioid-naive versus tolerant. An opioid-naive 80 year old gets a small starting dose, oxycodone 2.5 to 5 mg PO or hydromorphone 0.2 mg IV, with a planned reassessment. A patient on chronic high-dose opioids will get nothing from that, and underdosing them is not caution, it is undertreatment. Pull up their home regimen and use the opioid conversion calculator to dose in their actual range.

The patient you do not snow: obstructive sleep apnea, anyone already hypoxic or hypercarbic, anyone already sedated or altered. Stacking opioids on those patients converts a pain call into a naloxone call. Look at the sedation level yourself before redosing, and remember that a sleeping patient who is "still complaining of pain" per the flowsheet deserves a second look at who is actually asking for the dose.

Use the rest of the toolbox: scheduled acetaminophen, an NSAID if the kidneys and gut allow, repositioning, ice, and treating the constipation or urinary retention that is masquerading as pain. Document what you examined, what you gave and why, or why you deliberately did not.

Agitation, sundowning and the sleep request

Two calls, one trap. "He is agitated, can I have something," and "she wants a sleeping pill." Agitation is delirium wearing a costume until you prove otherwise. Before you sedate anyone, check a glucose and an oxygen saturation, bladder scan for retention, ask about pain, and read the medication list for what was started or stopped: benzodiazepines, alcohol at home nobody asked about, anticholinergics, steroids. New agitation in a previously clear 80 year old is a medical finding, and the workup is the same one described in ICU delirium, which applies on the floor too.

Nonpharmacologic first, and actually mean it: lights that match the time of day, glasses and hearing aids on, reorientation, family at the bedside or a sitter, and remove every tether you can. The telemetry nobody is reading, the Foley, the IV running at 10 mL an hour: each one is something to pull at and climb over. Half of sundowning is an old brain in a strange dark room full of alarms.

The sleeping pill request in an elderly patient deserves thought, not reflex zolpidem. Benzodiazepines, zolpidem and diphenhydramine in elders buy you falls and the 3 AM delirium call later this week. Melatonin is the safest yes. Better still, ask why they cannot sleep: pain, urinary frequency, or the vitals check you could safely space out.

If the patient is a danger to themselves or staff and the above has failed, a low dose antipsychotic per local practice, commonly haloperidol 0.5 to 1 mg or quetiapine 12.5 to 25 mg, with a glance at the QT first. Avoid benzodiazepines for delirium, with one exception: alcohol or benzodiazepine withdrawal, where they are the treatment, not the problem.

Document what you ruled out, what you tried before medicating, and the behavior that justified the drug. "Agitated, gave Haldol" is not an assessment.

Nausea and vomiting

It is easy to phone in ondansetron and go back to sleep. The job is to not miss the obstruction. On the phone: how many episodes, what the emesis looks like, bilious, bloody or feculent, whether there is abdominal pain or distension, whether they are passing gas or stool, and whether they have had abdominal surgery. Feculent emesis, distension and obstipation in a patient with prior laparotomies is a bowel obstruction until proven otherwise.

At the bedside, look at the abdomen, listen, and press. If it is distended and tympanitic and nothing is moving through: NPO, IV fluids, a KUB or CT abdomen, and drop an NG tube to suction. The NG in an obstructed, vomiting patient is therapy, not punishment. It decompresses the bowel and it protects the airway from aspiration. Call surgery for anything that looks like a complete obstruction.

Antiemetic choices, with QT awareness. Ondansetron 4 mg IV is the usual first move, but it prolongs the QT, so glance at the EKG and the medication list for methadone, fluoroquinolones and antipsychotics before you stack it. Metoclopramide 10 mg IV adds prokinesis and suits gastroparesis, but never give it in obstruction, and avoid it in Parkinson disease. Prochlorperazine works well for many patients and carries the same QT and dystonia cautions.

Then ask what the nausea actually is. The inferior MI presents as nausea, especially in diabetics and women, so new nausea plus any chest symptom in a vasculopath earns an EKG. Think about DKA, uremia, raised intracranial pressure with headache, and simply the opiate or the antibiotic started yesterday.

Document the episodes, the abdominal exam, what you gave and why, and the NG output if you placed one.

Tachycardia and bradycardia

Ask the nurse to run a 12 lead EKG before you arrive, and look at the actual tracing, not the monitor's interpretation of it.

Sinus tachycardia is a sign, not a diagnosis. It is fever, pain, hypovolemia, bleeding, hypoxia, withdrawal or pulmonary embolism until you have looked. Giving metoprolol so the monitor stops alarming masks the disease and can strip away the compensation keeping the patient perfused. Find the cause and treat that.

The afib with RVR call. First question: stable or not. Hypotension, ischemic chest pain, pulmonary edema or altered mental status means synchronized cardioversion now, following the approach in ACLS and running a code. If they are stable, rate control: metoprolol 5 mg IV, repeatable, or diltiazem as a bolus then a drip, avoiding diltiazem in decompensated heart failure with a reduced ejection fraction. Then hunt the driver, because RVR at 3 AM usually has one: sepsis, volume depletion, PE, the home beta blocker that got held on admission. If the afib is new, note the time of onset and score them with the CHA2DS2-VASc calculator. The anticoagulation decision usually belongs to the day team once the rate is controlled, but it goes in your note tonight.

Bradycardia. Symptomatic or not is the whole question. An asymptomatic rate of 45 in a beta-blocked or athletic patient gets held medications and observation. Hypotension, syncope, altered mental status, or a high grade block on the EKG, meaning Mobitz II or complete heart block, gets atropine 1 mg IV, pacing pads on the chest now, transcutaneous pacing if the atropine fails, a monitored bed and a call to cardiology. Check the potassium, the digoxin level if they are on it, and what rate-slowing doses went in over the last 12 hours. The bradycardia that needs pads is not a patient you leave to go chart.

Document the rhythm strips themselves in the chart, the rate and pressure with each intervention, and the trigger you found or excluded.

Bleeding calls

The oozing line site. Firm pressure for ten minutes by the clock, not ten minutes of nurse-guessing while doing other tasks. Most ooze stops. While pressure is held, check the platelet count and INR and ask what anticoagulant is running. Recurrent ooze gets labs, a pressure dressing and a hold on the anticoagulant until you have thought about it. Pulsatile bleeding from an arterial site is a different call entirely: pressure and help.

Melena discovered at 2 AM. Two large bore IVs, CBC and BMP, type and screen, hold the anticoagulants and the antihypertensives, start a PPI. Trend the vitals, not just the hemoglobin, because the first hemoglobin lags behind the blood loss. Tachycardia with a narrowing pulse pressure means you call GI tonight and think about the unit. Stable melena can often wait for a morning scope, but never without access, labs and blood set up first.

When one unit is the wrong answer, in both directions. The stable patient with a hemoglobin of 7.5 and no ischemia does not automatically need blood at all: restrictive practice, as covered in transfusion thresholds. And the briskly bleeding patient does not need one polite unit trailing the hemorrhage, they need the massive transfusion protocol, balanced products and a plan for source control. One unit is the dose for neither of them.

Epistaxis on anticoagulation. Sit them up, lean them forward, pinch the soft part of the nose for 15 uninterrupted minutes, oxymetazoline spray. If that fails, anterior packing. Blood running down the throat despite an anterior pack suggests a posterior source: ENT and a monitored bed. Reversal is a separate decision made on severity, not reflex. Major bleeding on warfarin gets vitamin K and four factor PCC per protocol, as laid out in warfarin and reversal. Nuisance bleeding usually gets a hold and pressure, because reversal carries thrombotic cost.

Document the source, the estimated loss, the labs, what you held and what you gave.

The seizure call

Give instructions on the phone: turn the patient on their side, nothing in the mouth, pad the rails, suction at the bedside, and note the time it started. The clock is the most important data point you will collect, and most seizures stop on their own inside two minutes.

If they are still seizing when you arrive, protect and time. At five minutes of continuous seizing, lorazepam 4 mg IV, or midazolam 10 mg IM if there is no access, repeatable once per your protocol. Check a glucose immediately, because hypoglycemic seizures are common and completely reversible, and you look foolish loading an antiepileptic into a patient whose problem was 40 mg/dL.

When it is status. Five minutes of continuous seizure, or repeated seizures without return to baseline in between, is status epilepticus. Second benzodiazepine, load an antiepileptic, commonly levetiracetam, plan for the airway, move toward the ICU and call neurology now. Doses here are illustrative, your institution's status protocol governs.

What to send: glucose, BMP, magnesium, calcium, antiepileptic levels if they are on one, a tox screen if the story suggests it. A first seizure, head trauma, or anticoagulation earns a non-contrast head CT. A known epileptic who missed two doses mostly needs a level and their medication.

Afterward, postictal confusion is expected and should clear steadily. A focal deficit after a seizure can be Todd paralysis, but it can also be the stroke that caused the seizure, so a deficit that persists or does not fit gets imaged. The exam and workup are covered further in the neurology rotation guide.

Document start and stop times and who witnessed them, what it looked like, focal onset, head turn, incontinence, tongue trauma, every drug with its time, and the postictal exam. "Seizure, gave Ativan" helps nobody at 7 AM.

Transfusion reaction mid-unit

Stop the unit first. Before you reason, before you examine, before you decide it is probably nothing. Keep the line open with normal saline through new tubing, and recheck the unit against the patient's armband at the bedside, because a clerical error is the classic cause of the worst reaction there is.

Then sort what you are looking at:

• Fever alone. Usually febrile nonhemolytic, the most common reaction. The problem is that early acute hemolysis looks identical at the bedside, so the unit stays stopped and the workup goes anyway. Acetaminophen for comfort.
• Hives alone, with normal vitals and no other symptoms. A mild allergic reaction, and the one situation where many protocols allow an antihistamine and a cautious restart of the same unit. Your blood bank's rules govern, not your confidence.
• The bad ones. Fever with flank pain, dark urine or hypotension is acute hemolysis. New hypoxia during or within six hours of the unit is TRALI. Wheeze, swelling and hypotension is anaphylaxis. Rigors, high fever and shock is a contaminated unit. All of these get aggressive support and a unit-level-of-care conversation, and epinephrine if it is anaphylaxis.

The workup: send the bag and tubing back to the blood bank, repeat type and screen, direct antiglobulin test, CBC, haptoglobin, LDH, bilirubin, and a urinalysis for hemoglobinuria. The blood bank's reaction paperwork will walk you through it, fill it out completely.

Whether they still need blood afterward is a separate question, answered the same way it was before the reaction: by transfusion thresholds, not by the fact that a unit is now sitting there half used.

Document when the unit started, when you stopped it, the volume infused, vitals before and during, the symptoms, and that the blood bank was notified.

Critical lab callbacks

The lab calls you at 0300 with a critical value and a read-back. The rule is verify, then treat, but verify in parallel, not in series. Repeat the specimen while you act on the parts that cannot wait.

The potassium of 6.8. First question: is it hemolyzed? Ask the lab, and send a redraw without a tourniquet-and-fist-pump collection. But do not sit idle waiting for it. Get an EKG now. Peaked T waves or a widening QRS means the value is real enough, treat immediately per the hyperkalemia section above and the doses in electrolyte replacement. A normal EKG in a stable dialysis patient at their usual baseline buys you the time for the repeat. Context decides, the EKG referees.

The INR of 9. One question: bleeding or not bleeding? Not bleeding: hold the warfarin and give oral vitamin K per your protocol, then recheck. Bleeding: this is now a bleeding call, see the section above, and reversal gets decided on severity. Do not reflexively give plasma to a number.

The troponin nobody ordered. It came on a panel, or a colleague ordered it and left. It is yours now. Go see the patient, get an EKG, ask about chest symptoms, and compare to prior values. A modest troponin in sepsis or renal failure is often demand, but that is a conclusion you reach after the EKG and the exam, not instead of them. If there is any doubt, serial troponins and EKGs, exactly as in the chest pain section above.

Never leave a critical value unacknowledged. If you decide it is spurious, the chart should say why, with the repeat value that proved it. Document the time you were called, the value, what you did, and the recheck. The critical call that was received and ignored reads very badly later.

Lost IV access at night

"We lost the IV and nobody can get another one" is a triage question, not a procedure request. Who actually needs a line before morning? Yes, tonight: anyone on a vasoactive drip, insulin drip or heparin drip, IV antibiotics for sepsis, active bleeding, instability, or electrolyte replacement that cannot go by mouth. Can wait: the stable patient on maintenance fluids and medications with PO equivalents. Convert what converts, many IV drugs have oral forms with perfectly good bioavailability, and let the day team or the vascular access team place a line in daylight with better resources.

Before anyone escalates, look for the access everyone forgot: a port, a PICC, a midline documented on admission and never used. Then ultrasound guided peripheral IV, if you or an ICU nurse has the skill. Then call for help. Two failed attempts by your best sticker means anesthesia, the ICU, or the access team, not attempt number six on a patient who is now bruised and furious.

When it is an IO. A crashing or peri-arrest patient who needs drugs now gets an intraosseous line, not a 20 minute vein hunt. If you are reaching for an IO outside of an arrest, you should simultaneously be asking why this patient is still on the floor.

A central line at 3 AM is for the patient who needs central access, pressors or no other option, not for convenience. If it comes to that, consent, full sterile technique and the checklist in ICU bedside procedures apply at 3 AM exactly as they do at 3 PM.

Document the attempts, who made them, what access the patient ended up with, and the plan for definitive access in the morning.

The AMA request at 2 AM

Go to the bedside. This is not a phone order and it is not a form. Most 2 AM AMA requests are about something fixable: uncontrolled pain, nicotine withdrawal, a nightmare roommate, nobody having explained the plan, or a real obligation at home, kids, a dog, a shift they cannot lose. Ask why they want to leave before you explain why they should stay, then fix what you can: the pain, a nicotine patch, a room change, a plain-language plan with an endpoint. "One more troponin at 6 AM, and if it is negative, cardiology sees you at 8" changes more minds than any lecture about risk.

Capacity, assessed on the spot. Capacity is decision-specific and you assess it at the bedside: do they understand their condition and the risks of leaving, do they appreciate that those risks apply to them personally, can they reason about the options, and can they communicate a stable choice. The intoxicated, the delirious and the floridly psychotic cannot leave AMA, because they cannot consent to the risk, and that becomes a different problem involving a sitter, security and your attending. The same capacity framework runs through goals of care and code status conversations, and it is worth being fluent in it.

If they have capacity and they are leaving, do not punish them. Leaving AMA does not void their insurance coverage, a myth that refuses to die, and it does not end your obligations. Give them the best discharge you can: prescriptions, follow-up, wound care instructions, and an explicit invitation to come back at any hour. Slamming the door only raises the cost of returning when they get worse, and some of them will get worse.

The documentation protects everyone: the capacity assessment in specific terms, including what they said back to you, the risks explained bluntly, naming death when death is on the table, what you offered and what they declined, that the attending was notified, and call them, it is not optional, and that they were told they may return anytime. The signed AMA form is neither necessary nor sufficient. The note is what stands, and medical legal charting covers how to write it.

The new rash or allergic reaction

Two triage questions before anything else: is there any airway, breathing or circulation involvement, and is there any mucosal involvement or skin pain. Those two questions separate the nuisance from the two emergencies.

Anaphylaxis. Hives plus any of wheeze, throat tightness, lip or tongue swelling, vomiting or hypotension is anaphylaxis, and the treatment is epinephrine 0.3 to 0.5 mg IM in the anterolateral thigh, now. Not diphenhydramine first, not a steroid first, epinephrine first. Antihistamines and steroids are adjuncts. Stop the running culprit: the antibiotic infusion, the contrast, the unit of blood. Then a monitored bed, because biphasic reactions happen after everyone has relaxed.

The ordinary drug rash. Itchy, morbilliform, trunk-predominant, appearing days into a new medication. Antibiotics, allopurinol and antiepileptics are the classic culprits. Stop or substitute the likely drug, give an antihistamine for the itch, and update the allergy list with a description of the reaction, not just the drug name. "Rash" versus "anaphylaxis" in that field changes what this patient can safely receive for the rest of their life, so write which one it was.

SJS territory. Mucosal involvement, mouth, eyes or genitals, skin pain out of proportion to what you see, dusky or targetoid lesions, blistering or sloughing, fever with the rash. Any of these and you stop every nonessential medication, call dermatology tonight, start fluids and involve ophthalmology if the eyes are in. This is a burn-level illness that declares itself gradually and then moves fast. It is not a morning consult.

Whatever it is, describe it properly: distribution, morphology, mucosal status, and the timeline mapped against the medication list, because the timeline is usually what convicts the drug. The vocabulary for describing lesions is in the dermatology rotation guide. Document the suspected drug, the reaction, what you stopped, and the allergy entry you added.