Let me say up front that I do not object to protocols in principle. I have been responsible for the development of several protocols, both for trauma and for critical care. At their best, protocols serve as guidelines and memory aides prompting us to do the right thing to help and protect our patients. They can be powerful reminders and guides for those who don’t often deal with a particular problem, or conversely, may keep those of us for whom certain critical interventions are routine from becoming complacent.
I do object to protocols that take the place of critical thinking, especially when that is coupled with an electronic medical record that forces the physician to follow a checklist. Recently, this was brought home during an episode at my primary hospital.
My patient was a 59-year-old man who had under gone a laparoscopic assisted right colectomy. He was a two pack a day smoker and had some modest high blood pressure. He did well with surgery and the initial postop period. On day 3 however, he became hypoxic (low oxygen saturation in the blood), had some tachycardia (rapid heart rate) and had a little confusion. This was enough to trigger a “sepsis alert.”
Severe sepsis is an inflammatory response to severe infection. It is an exaggerated expression of the fever and normal inflammation that accompany an infection. It can cause a cascade of low blood pressure, fever, poor tissue perfusion and acidosis leading to organ failure and death.
The sepsis initiative is designed to improve outcomes by identifying patients with early sepsis and providing physicians with a standard set of orders to treat it. So far so good.
So when the sepsis alert triggered on my patient, I first looked at his blood pressure and temperature. Both were normal. Then I checked the trend of his oxygen saturations. They had been declining slowly for several hours before they reached a ‘critical’ level. Finally, I remembered the old surgical adage, ‘When all else fails, examine the patient.’ He was sitting up in bed, awake and alert with very little pain. He was breathing rapidly, but his breath was not labored. He was not wheezing and although the breath sounds were diminished in the lower part of his chest, they improved with a cough. All signs of an early pneumonia, a common postoperative risk for a smoker. It explained his hypoxia, his rapid pulse, and his brief confusion. He needed antibiotics and aggressive pulmonary toilet (coughing, deep breathing, and maybe nebulizer treatments), but he was not septic.
I tried to order the appropriate treatments, but the sepsis order set kept popping up, and I couldn’t do anything until I had checked off the boxes on the list. I didn’t need blood cultures, I didn’t need a serum lactate, and I didn’t need blood tests or a transfer to a monitored bed. I ended up ordering a bunch of things I didn’t need and then canceling the orders once the sepsis alert was satisfied.
I have been doing trauma and critical care for 30 years. I’m very familiar with the presentation and treatment of sepsis. I also understand that many physicians do not have my level of experience and training. The sepsis order set is a useful guide, but it does not replace critical thinking. The way that the electronic record has set it up, however, a physician who has actually evaluated the patient and decided that sepsis is not present can’t over ride the order set. I can’t help but wonder how many unnecessary tests and transfers to higher-level care are happening as a result of physicians not taking the time to do that evaluation, or not being comfortable with deviating from the order set.
I finished the orders and spoke to the patient’s nurse about his status. I thought that resolved the matter. Two hours later, the nursing supervisor paged me. She asked me if I was aware that a sepsis alert had been triggered on my patient. “Yes,” I said, “and it’s been taken care of.”
“Well, I noticed that you hadn’t ordered blood cultures or a lactic acid level. Would you like me to put those orders in for you?”
I struggled to keep my temper, or at least remain civil. “No,” I said. “I saw the patient and ordered the appropriate measures to deal with his problem.”
“But the sepsis protocol is incomplete,” she said, as if that was more important than my evaluation.
“He has pneumonia, not systemic sepsis.”
“Patients can be septic from pneumonia,” she said in a condescending tone.
“Yes, they can,” I agreed. “How will a lactic acid level help me take care of his pneumonia? And how will blood cultures tell me what bacteria are in his sputum?”
Dead silence. She clearly had no clue what the tests on the protocol were designed to look for, or even what the real issue with systemic sepsis was. (Hint: it’s all about blood pressure and tissue perfusion)
“So you don’t want these orders entered?” she finally asked.
“No, thank you,” I managed to say in a marginally civil tone and hung up before she could say anything else.
Bruce Davis, MD, is a Mesa AZ based general and trauma surgeon. He finished medical school at the University of Illinois College of Medicine in Chicago way back in the 1970’s and did his surgical residency at Bethesda Naval Hospital. After 14 years on active duty that included overseas duty with the Seabees, time on large grey boats and a tour with the Marines during the First Gulf War, he went into private practice near Phoenix. He is part of that dying breed of dinosaurs, the solo general surgeon. He also is a writer of science fiction novels. His works include the YA novel Queen Mab Courtesy, published by CWG press (and recently reissued by AKW Books as the e-book Blanktown). Also published through AKW Books are his military science fiction novel That Which Is Human and the Profit Logbook series, including Glowgems For Profit and Thieves Profit.