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.


rlbates said...

You've had a tough run of some truly sick folks. Hope things get better for all of you.

make mine trauma said...

That is the most disgusting pumpkin I have ever seen!

Sid Schwab said...

Good post! you're right about the word "sick." Never really considered it before but you are right on about its meaning to a doc. And I agree with your signs, too. And there's nothing like feeling a pulse, and putting a hand on the knees (cool knees = not so good.)

Enrico said...

Forgive the student-level question(s) here, but wouldn't #1 simply be acidosis? And speaking of the beans, post-op azotemia and/or oliguria (when not present pre-op) would be an ominous sign, no?

I always thought some degree of tachycardia was expected after surgery...certainly not anything extreme, but I know the couple of times I've had surgery (nothing serious), my HR was always >100 w/in the first 24-36h post-op/post-recovery with no ill effect. But I agree it needs to be investigated, not only because of the stress response but for compensatory response to blood loss (which would show up in other ways, obviously). Also never heard of 'bandemia' (left shift, yes) -- I like it!

Again, I'm just trying to stimulate discussion; I don't doubt anything you said. :) Thanks!

Jeffrey Parks MD FACS said...

A lot of things can alter the pH. Respiratory and non-anion gap metabolic acidoses don't concern me as much. Review your acid/base physiology books if you still have them. Good questions though. The bads are seen on the CBC with Differential, it won't show up if you just order a CBC.

Anonymous said...

I don't know if anyone will see this as your posts are from last year. I have a 25 year old patient who is 3 days post op and we are still having persistent sinus tachycardia. We have treated pain, fever, volume, etc and still cannot seem to get the HR <125. None of the treating physicians have any ideas, so I am looking for some of my own. Thanks, concerned nurse.

Jeffrey Parks MD FACS said...

What was the operation? Is he acidotic? Anemic? I always worry about PE in cases of unexplained tachycardia.

Alex Wade said...

First let me say I often quote Dr. Doolas, too. On his last day operating, I steppex on the headlight cord he was dragging behind him, wrenching his head back. He said, "Are you trying to kill me?" in the deepest baritone voice. As an intern, killing Dr. Doolas would have killed me.
Second, the suggestion of PE in a post-op tachy patient isn't "cute" it's potentially life-saving advice.
Third, thanks for the interesting post.
from - a fellow non-academic (rural) general surgeon.

DHS said...

This is a long time past, but I like lactate - many modern gas machines will run a lactate alongside the basic biochem panel on the machine, so it is often one of the first labs to come back.