One of the biggest myths in medicine is:

“Good doctors handle everything themselves.”

In reality:

Good doctors escalate early.

On-call is not about being heroic.
It’s about keeping patients safe.

If you’re unsure or the patient looks unstable, calling for help is not weakness.

It’s good clinical judgement.

First mindset shift

Stop thinking:

❌ “Can I manage this alone?”

Start thinking:

✅ “Is this safe to manage alone?”

Very different question.

Your job overnight is not to prove independence.

Your job is:
👉 prevent deterioration and harm

Escalation is part of that.

The golden rule

If you’re asking yourself:

“Should I escalate?”

You probably should.

Trust that instinct.

Hesitation is usually your brain recognising risk.

Situations where you should escalate immediately

No debate. No delay.

Call registrar/outreach/ICU early.

🔴 Airway or breathing problems

airway compromise
low GCS with poor airway protection
persistent sats < 90% despite oxygen
increasing oxygen requirement
respiratory distress
type 2 respiratory failure
NIV/CPAP concerns

These patients can crash quickly.

Don’t manage alone.

🔴 Circulatory instability

systolic BP < 90
persistent hypotension
shock
active bleeding
tachycardia not settling
poor perfusion
lactate rising
not responding to fluids

If BP isn’t improving → escalate early.

Not after “one more bag”.

🔴 Reduced consciousness

new low GCS
seizures
prolonged post-ictal
unexplained drowsiness
confused + unstable

Neurology + airway risk = senior input early.

🔴 Sepsis not improving

persistent hypotension after fluids
worsening lactate
increasing oxygen needs
organ failure
you’re worried

Sepsis can deteriorate very fast overnight.

Never sit on worsening sepsis.

🔴 Major GI bleed

Especially your area.

haematemesis
melaena + unstable obs
dropping Hb
cirrhosis/varices
ongoing bleeding

These need early senior + endoscopy planning.

Never manage alone.

🔴 DKA / HHS / endocrine emergencies

severe acidosis
very high ketones
altered mental state
potassium issues
not responding to protocol

These often need senior oversight.

🔴 “Looks really unwell”

This sounds vague but is very real.

If your gut says:

“Something isn’t right”

Escalate.

Clinical intuition is powerful.

Many arrests are preceded by this exact feeling.

Trust it.

Situations where escalation is still appropriate (but not crashing)

Not emergencies, but don’t struggle alone.

🟠 Uncertain diagnosis in sick patient

You’ve assessed but still unsure.

🟠 Not improving after initial treatment

You tried fluids/antibiotics/oxygen — no response.

🟠 Complex decision-making

ceilings of care
DNACPR discussions
discharge risk
anticoagulation decisions
tricky ethical issues

🟠 You’re overloaded

Too many sick patients at once.

It’s okay to say:

“I need help prioritising”

That’s safe practice.

What stops juniors from escalating (and why it’s wrong)

Let’s be honest.

Common fears:

❌ “I’ll look incompetent”
❌ “They’ll think I can’t cope”
❌ “I should know this”
❌ “Don’t want to wake them”

Reality:

Registrars prefer:
✔ early call
❌ late disaster

No senior has ever complained about:
“Thanks for calling early”

But many complain about:
“Why wasn’t I told sooner?”

How to escalate properly (SBAR makes life easier)

Don’t ramble.

Be clear and structured.

Use:

SBAR

Situation

“Hi, I’m the SHO on Ward 5. I’m worried about a septic patient with hypotension.”

Background

“Admitted with pneumonia, NEWS 7.”

Assessment

“BP 85 systolic despite fluids, lactate 4.2, oxygen increasing.”

Recommendation

“I think they need senior review/IC escalation.”

Clear. Focused. Fast.

Seniors appreciate this massively.

Escalation is not failure

It’s part of the system.

Hospitals are designed like this:

juniors assess early
seniors support decisions
outreach/ICU manage instability

No one expects you to do everything alone.

Medicine is team sport.

Not solo performance.

Common junior mistakes

❌ waiting too long
❌ trying multiple treatments alone
❌ hoping things improve
❌ not trusting gut feeling
❌ calling too late when patient already crashing

Late escalation creates stress for everyone.

Early escalation prevents it.

Senior mindset

Good doctors escalate sooner than you think.

They don’t wait for collapse.

They escalate when they see trajectory worsening.

Trend > single observation.

If things are drifting the wrong way, call early.

Simple escalation checklist

Escalate if:

✅ unstable obs
✅ not responding to treatment
✅ you feel out of depth
✅ unsure what to do
✅ multiple sick patients
✅ gut feeling says “unsafe”

That’s enough reason.

You don’t need permission.

Take-home concept

Escalation is not incompetence.

It’s safe medicine.

Patients deteriorate faster than juniors expect.

Calling early prevents disasters and makes your shift easier, not harder.

When in doubt:

Call.

Always.