Rapid response:
the first five minutes

Why this session

Deterioration on the wards is where three bootcamp threads converge: recognizing sick, escalating early, and communicating under pressure. Incoming interns themselves rank urgent and emergent care among the areas they feel least ready for (the evidence), and unlike most of medicine, the first five minutes of a rapid response are almost entirely proceduralizable. There is a sequence. It can be rehearsed on a Tuesday in a conference room, and it holds up at 11:20 on a Thursday when it is real.

What interns leave able to do

1. Run the first sixty seconds: arrive, announce, ABCDE with hands and voice, assign roles.
2. Climb the oxygen ladder promptly while the workup proceeds in parallel.
3. Execute the sepsis reflexes — cultures, lactate, antibiotics, fluids with reassessment — without being prompted.¹
4. Use closed-loop communication with the response team.
5. Handle the aftermath: the family, the documentation, and their own adrenaline.

The case

Disclosed one part at a time. If an empty patient room or simulation space is available, walk there for Part 1 — physical rehearsal beats armchair rehearsal.

Running the room

Part 1 — the first sixty seconds

1. Arrive and announce: “I’m the primary team’s doctor — what happened?” The nurse’s summary is your first data: onset, trajectory, what changed. The rapid was called for a reason; that gestalt started the clock.
2. ABCDE, out loud, hands on: Airway — he’s talking, patent for now. Breathing — RR 34, accessory muscles, 88% on 4 L: escalate the oxygen now; listen; watch the work of breathing. You do not need a diagnosis to treat hypoxemia. Circulation — HR 132, BP 96/58: second IV, fluids ordered within the sepsis frame, perfusion check — mental status, cap refill, urine. Disability — arousal trajectory; “harder to arouse between sentences” is a deteriorating trend, said out loud. Exposure — a quick full look: rash, bleeding, the focused exam.
3. Assign and delegate: “You — vitals every five minutes. You — point-of-care lactate, glucose, blood gas. You — ECG. Someone — his medication list and code status from the chart.” People stand in doorways until they are given jobs.
4. Call for help early: the response team is coming — and your senior and attending hear about it now, not after resolution. Help early beats help late is the whole session in five words.
5. Position and tone: stand where you can see the patient and the room; speak in a level voice. The room calibrates to your tone.

Part 2 — the ladder, the reflexes, the voice

• The oxygen ladder: nasal cannula → non-rebreather → high-flow nasal cannula → noninvasive ventilation where the physiology fits → intubation. The intern does not own the top rungs — that is why the ICU is coming — but must climb promptly: 91% on a non-rebreather in a tiring patient is not “improved,” it is bought time.
• The sepsis reflexes, spoken as a checklist¹: cultures before antibiotics without delaying them; the lactate (done: 3.8, and it will need a recheck); the antibiotic question asked out loud — he is on day 2 of pneumonia therapy, so is this progression or a new process, and does coverage broaden with the senior and ICU; fluids for hypotension with reassessment after each bolus — his lungs have crackles, so fluid and pneumonia are a dance: give, reassess, give again if he is responding; urine output; and vasopressors as an ICU conversation if the pressure will not move.
• Closed-loop communication: “Sarah — a liter of lactated Ringer’s now, tell me when it’s in.” → “Liter’s in, 11:42.” → reassess out loud. Orders into the void are how nothing happens, loudly.
• The CT question: “Not yet — he’s not stable enough to travel. ICU sees him first, then we decide.” A sick patient does not leave the floor for diagnostics before a clinician with critical-care skills has eyes on him.
• Narrate for the room: “Here’s where we are: likely pneumonia progressing to sepsis, lactate 3.8, holding 91% on the non-rebreather, second liter going, ICU en route.” Narration organizes the room — and the narrator.
• Know the code status before the intubation question arrives. Minute one, from the chart or the nurse — not minute nine, when the fellow asks.

Part 3 — the aftermath

The daughter, sixty seconds, in the hallway: honest, plain, no false reassurance and no prognosis you cannot give: “His pneumonia has gotten worse, and his breathing and blood pressure were struggling. He’s going to the intensive care unit right now — that’s the safest place for him, with constant monitoring. I don’t know yet how tonight will go. Can I walk you up — and what’s your name?” Then hand her to the ICU team explicitly. The team that may intubate him at midnight should not meet her for the first time over a consent form.

The documentation: an event note while it is fresh — the timeline, the vitals trend, interventions and responses, who was called and when, disposition. It is the clinical and medico-legal record of a dangerous hour, and the note is how 7 a.m. reconstructs it.

The replay: the 2 a.m. loop about the soft morning pressure is the small sibling of the second-victim experience — the error session goes deep. Two moves tonight: ask your senior or the ICU fellow, tomorrow, “what should I have done differently at 8 a.m.?” — not to self-flagellate but to calibrate the trigger you will use next time. And tell someone. The intern who says at sign-out “my patient got rapided yesterday and I keep thinking about it” gets the room’s best stories back. Everyone has one.

And normalize the physiology out loud: hands shake, and the adrenaline bill arrives at 9 p.m. Plan the easy evening.

Common pitfalls to surface

• Doorway paralysis — waiting for someone senior to start the ABCs. An intern is allowed, and expected, to start oxygen, IVs, and monitoring before anyone else arrives.
• Fixation: the CT-scanner fantasy, the troponin reflex. Treat first.
• Silent doctoring — thinking in your head while the room guesses. Narrate.
• Not knowing code status until it matters.
• “He held 91%, so I relaxed.” Trends and tiring matter more than snapshots.

Key teaching points

1. ABCDE with your hands, out loud, in the first sixty seconds. Oxygen does not need a diagnosis.
2. Help early beats help late — senior, attending, ICU. Calling the ICU is a success.
3. Sepsis reflexes: cultures, lactate, antibiotics, fluids with reassessment, urine output.
4. Closed loop: name a person, name the task, hear it back.
5. No diagnostics off the floor before critical-care eyes.
6. Afterward: the note, the family handoff, the debrief, and telling someone.

Pocket card

Variations

• Swap the physiology: anaphylaxis to a newly hung antibiotic (the epinephrine conversation), acute coronary syndrome with pulmonary edema (noninvasive ventilation and preload instead of fluids), or opioid oversedation on the floor (naloxone) — same structure, different levers.
• The full-simulation version: run Parts 1–2 in the simulation lab with the facilitator as the nurse, then debrief. Adds thirty minutes; changes people.
• The code version: for a stronger group, let Part 2 deteriorate to a pulseless moment and rehearse the intern’s actual code role — compressions or the recorder’s clipboard, almost never the airway — and the discipline of a crowded room with one voice running it.

Notes

The clinical teaching reflects the current Surviving Sepsis Campaign guidance¹; the case is a fictional composite, and no patient in it is real. The evidence for why first-response skills anchor an intern bootcamp is in the bootcamp introduction.

Sources

1. Prescott, H. C., Antonelli, M., Alhazzani, W., Møller, M. H., Alshamsi, F., Azevedo, L. C. P., Belley-Cote, E., De Waele, J., Derde, L., Dionne, J. C., Evans, L., Gershengorn, H. B., Hodgson, C. L., Honarmand, K., … (2026). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2026. Critical Care Medicine, 54(4), 725–812. https://pubmed.ncbi.nlm.nih.gov/41869847/ Supersedes the 2021 edition; the Campaign revises periodically, so confirm the current edition before teaching. ↩₁ ↩₂ ↩₃

This page is a teaching scenario for facilitated small-group education. Every patient in it is fictional. It is not clinical guidance for the care of any actual patient; doses, thresholds, and escalation pathways belong to your hospital’s protocols and your rapid-response system — localize before teaching. Last reviewed July 2026.