Elevator Questions

Near the end of medical school, we had a lecture on "elevator questions." To prepare us for being interns, the lecturer discussed what to do when we got paged by a nurse in the middle of the night with a problem. At the beginning of internship, the answer is always the same: go see the patient. But we were encouraged to begin formulating questions, a differential diagnosis, and a plan while in the elevator (this was at UCSF where climbing 5 flights at 2AM was not popular). That way, we'd have a plan when we arrived at the patient's bedside. I practiced this meticulously, and through my first year in medicine, I had a mantra for chest pain, shortness of breath, hypotension, hypertension, tachycardia, bradycardia, dizziness, rash, and a half a dozen other common complaints. I knew what focused history I'd take, exam I'd perform, tests I'd order, and therapies I'd start even before I got to the patient's room.

Now in anesthesia, I have a similar habit. Usually, the information is pretty sparse, but even with a few words or phrases - "appendectomy," "craniotomy," "lots of bleeding," "compromised airway," "ICU patient," "morbidly obese," "90-year-old" - evokes enough. As I rush out of the call room (or out of my house on home call), my mind is already formulating a plan. How am I going to secure the airway? What kind of IV access do I need? Which medications and anesthetics will I choose? Do I want blood in the room? How emergent is this procedure?

Although many people (including surgeons unfortunately) think anesthesia is the same for each patient, it's absolutely not, and those five minutes of preparation and decision-making are crucial to patient safety, achieving adequate surgical conditions, and minimizing risk. Although I didn't know it at the time, the lecture on "elevator questions" taught me a lot about how to approach urgent clinical situations.