Sick vs. Sick-sick

So, on the third day of my rotation with the hospitalist group, my preceptor told me that I needed to learn how to tell sick from sick-sick.  This is a variation on the idea of sick vs. not-sick that we discussed earlier.  Those of you who are in medicine know that it takes time to be able to tell the difference very quickly from sick or not-sick.  It takes a lot of experience and a keen eye, as well as (in some cases) a medical "sixth sense" that we students admire and hold in awe.  "You mean, you can tell from the way the patient smells just how sick he is...?"  - or some variation of this amazing set of skills.

Thus you might understand my reaction when my preceptor said (on a Wednesday), "I want you to learn the difference between sick and sick-sick and we'll review it on Friday."  I knew what she was looking for so all I could do was blubber a, "Sounds goo-ood???"  She passed on some hints to focus my research: Rapid Response Teams (RRTs).  And thus I got the picture a little more fully.

RRTs are a group of providers in the hospital setting who are dedicated to being at the patient's bedside within five minutes of activation no matter what time of day.  RRTs are made up of physician(s) (sometimes specialists, sometimes just ER or Intensive Care doctors), PAs (sometimes), Nurses (the backbone), CNAs, Respiratory Therapists, etc. who all have trained together and come together at any time to manage a patient who is, essentially, rapidly getting worse and on the verge of dying in the hospital.  It makes sense to have such a team.  So when should we call them?

This is the question - when do we activate the RRT and get this medical juggernaut rolling along to save a life?  How do we know when they need to be called?  The short answer is this: how does the patient look?  But this isn't a well enough guided answer.  To a noob like myself, a patient might look "Bad, but not really bad," when in fact they are two steps shy of meeting their maker.  Thus, many great minds have gotten together and created some criteria for the activation of RRTs.  One sample is as follows:

Respiratory signs:
Resp rate less than 8 or greater than 28
SpO2 of 86-90% for greater than 5 minutes
Increasing amounts of supplemental oxygen to maintain SpO2
PEDS - child (18-30), infant (30-60)
* Any significant change in respiratory status*

CV signs:
Rate 40-160 or
Rate greater than 140 with Sx
PEDS - child/adolescent (60-140), infant (85-190)
*Any significant change in pulse with Sx*

BP signs:
Systolic 80-180
Diastolic > 100
PEDS - age x 2 systolic

Neuro signs:
ALOC
Acute mental status changes
Unexplained lethargy/agitation
Seizure
Stroke Sx
- loss/change of speach
- sudden loss of movement/weakness of face/arms/legs
- numbness and tingling

Chest Pain:
No response to NTG
Acute or new onset

Other changes:
Pain
Fluid Status
Skin color (pale, dusky, blue)

Uncontrolled bleeding

Behavioral Emergency

This is the most comprehensive list of activation criteria that I could find.  It comes from the Institute for Clinical Systems Improvement protocol that you can go do by clicking here.  The utility of this set of guidelines is that it helps us to have some hard and fast references for activation.  As one nurse that I interviewed about this topic said, it gives you something to know early on...  After you get these numbers down and understand what they might indicate, then you can put it all into the context of the patient and the clinical picture and it will help you know sick from sick-sick (this is paraphrased).

A medical intern's perspective on this topic can be found here.  This intern's perspective is what led to my interview of the nurse that I referenced above.  Thus, another note to all of us who are fledglings out on the wards: ask your nurses...  They'll be the first to know if something is going wrong - if you find out what they know, you'll have a much better chance of doing the job well.