Wednesday, November 21, 2007
Physicians have a different conception of what the word "sick" means. It's different than the meaning an eight year old boy gives it when he tells his mommy he feels "sick". Different than what a college kid means when he relates how "sick" he got after shot-gunning six beers. For a physician, deeming someone "sick" is a declaration of war, of sorts. It means the patient isn't doing well. It means death lurks around the corner. Usually the patient is in an ICU, hooked up to a ventilator, on multiple antibiotics, vasopressors, swollen and distorted, fluids seeping out the vascular system. I was closing the fascia on a guy yesterday who had perforated his cecum. This guy's going to be sick, I kept thinking. Sick patients keep you on edge. There's no relaxing. You can't miss anything. The degree of vigilance has to be ramped up ten fold. They give me an ulcer sometimes. So how do you know if someone's really "sick"? What are the best indicators? How can you predict the ones who are likely to struggle? Here's a top five list of clinical indicators that a lot of docs use:
5. White blood cell count: I'm not a fan of this one. Sure, leukocytosis is usually associated with severe infection/inflammation but I've seen planty of patients on death's door with normal WBC counts.
4. Lactate levels: When tissues aren't being perfused, the cells undergo anaerobic metabolism. Thus, lactate will be elevated. I don't use this one very often. It always takes the lab too long to run it and lactatemia doesn't usually manifest until the patient is already starting to decompensate. So it just confirms what you already know.
3. Heartrate: An old school surgeon from my Chicago residency used to call us in the middle of the night for updates on his post op whipples. I'd ramble off streams of data; urine output, CVP, blood pressure, etc. Stop, he'd say. What's the pulse? That's all he wanted to know. Tachycardia is the first response mechanism to stress. All tachycardia ought to be investigated. Post op tachycardia should make you very very nervous. Find out why it's so fast.
2. Bandemia: I like this one. Bands are immature WBC. In the face of severe infection/iinflammation, the bone marrow will mount a massive leukocytosis. Initially, this won't show up on the CBC. Always look at the differential. Bandemia and left shifts are early indicators of something drasticly wrong.
1. Base Deficit: This is my favorite. Cells that aren't getting enough oxygen will undergo anaerobic metabolism. Lactic acid then builds up in the blood stream, lowering the pH. The body has an amazing buffering capacity, but when it gets overloaded, the pH will drop anyway. Base defict is a way of measuring one's relative buffering capacity. A high base deficit is suggestive of a body being overrun by a catastrophic event.
1a. Gestalt: How does the patient look? If they look like shit, trust your hunch. It's like that Malcolm Gladwell book Blink; sometimes your intial, subconscious perception is right on. Be very afraid of patients with a sense of impending doom, telling you they feel like they're about to die. They probably are.
On a brighter note, Happy Thanksgiving.