Imagine this scenario: You’re an anesthesiologist giving anesthesia care in the operating room to your second patient of the day. The Post Anesthesia Care Unit (PACU) nurse calls you regarding your first patient who is in the PACU following appendectomy. The nurse says, “Your patient Mr. Jones is still nauseated and very sleepy. I’ve medicated him with ondansetron and metoclopramide as ordered, but he’s still nauseated and sleepy.”
What one question should you ask to determine whether this patient has a serious medical problem? What one question must you ask to determine whether urgent intervention is required?
That one question would be: “What are his vital signs?”(This is a bit of a trick question, since you are asking not one question, but four or five. It’s as if you’re down to your last request from the Genie from Aladdin’s lamp, and you’re wishing for more wishes. As Robin Williams’ Genie character said in Disney’s Aladdin, “Three wishes, to be exact. And ixnay on the wishing for more wishes. That’s all. Three. Uno, dos, tres. No substitutions, exchanges or refunds.” )
The traditional four vital signs are the blood pressure, heart rate, respiratory rate, and temperature. For anesthesiologists, surgeons, emergency room physicians, and ICU doctors, the fifth vital sign is the oxygen saturation or O2 sat. Some publications tout the pain score (on a 1-10 scale) as a fifth vital sign. While I subscribe to the pain score’s importance, it’s of less value in most acute care situations than the O2 saturation.
Let’s return to the patient scenario. You ask the nurse, “What are the patient’s vital signs?”
The nurse answers, “His heart rate is 48, his blood pressure is 88/55, his O2 sat is 100, and his respiratory rate is 16.”
You answer, “His heart rate is too low and so is his blood pressure. Let’s give him 0.5 mg atropine IV now.”
Five minutes later the nurse calls back. The heart rate increased to 72 and the blood pressure is 110/77. The patient’s symptoms resolved as the vital signs normalized.
Let’s look at a second scenario. You drop off a 48-year-old hysterectomy patient in the PACU. The patient is awake, and her initial vital signs are BP 120/64, pulse 100, respirations 18, and O2 saturation 99%. You return to the operating room to initiate care for your next patient for a laparoscopy. Thirty minutes later, the PACU nurse calls you to report your first patient has increasing abdominal discomfort. Her repeat vital signs are: BP 110/80, pulse 130, respirations 26, and O2 saturation 99%. You’re concerned an intra-abdominal complication is brewing. Five minutes later, the nurse reports a third set of vitals. The patient’s heart rate continues to rise to 140. Her blood pressure is now 82/40, her respirations are 30, and her skin has become cold and moist to the touch. She’s unable to speak coherently and is losing consciousness. You can not leave the patient you are anesthetizing, but you call a fellow anesthesiologist to evaluate the patient in person, and prepare her for emergent re-operation.
The patient’s initial vital signs were stable, but the downward trend of her vital signs were a harbinger of the serious complication. Eventually the symptoms of abdominal pain and decreasing consciousness appeared, and confirmed the diagnosis of intra-abdominal hemorrhage and impending shock. The increased heart rate, decreased blood pressure, and increased respiratory rate were red flags early on.
Abnormal vital signs can indicate that a patient is acutely ill. Equally important to the value of each vital sign is the temporal trend in the vital signs. A vital sign trend increasing or decreasing from the normal range can validate that the patient is becoming acutely ill.
You may be thinking, why is Dr. Novak telling me vital signs are important? Everybody know vital signs are, well … vital.
My message to you is to seek out the vital signs, all of them, as essential clues in all patients.
As anesthesiologists, we spend our entire intraoperative clinical career staring at a patient’s vital signs on a video screen. When the blood pressure goes up, we act. When the blood pressure goes down, we act. When the heart rate goes up, we act, and when the heart rate goes down, we act. When oxygen saturation trends downward, we act. Because most intraoperative patients are unconscious, the patient’s verbal history—the traditional clues regarding acute illness—are unavailable. We can not ask our patient questions to determine whether vital sign changes are associated with symptoms of chest pain, shortness of breath, or neurologic deficits. We’re accustomed to treating patients by normalizing their vital signs.
Other healthcare providers lack this perspective. Nurses and non-acute-care physicians such as family practitioners and internists can fill a patient’s history chock full of other details so thick that the vital signs are buried. The five or six vital sign numbers are often obscured in pages of text. Most physician and nursing notes in an electronic medical record (EMR) are lengthy, and are many are copied and pasted from previous encounters. Each patient interview is a quiz bowl of medical history answers. The five or six vital sign numbers are a needle in the haystack of a modern medical history. The EMR in a clinic or a hospital can serve to worsen this plight, as vital signs are recorded by nurses and entered into nursing documents on the computer, and treating physicians may have to dig to find the correct page that lists vital signs. One possible benefit of an EMR is a proposed safety system that requires, for any abnormal vital sign entered into the computer, the nurse to document they have verbally informed a physician of that abnormal value. This system would assure that abnormal values are never ignored, and that an MD will assess whether further diagnostic or therapeutic steps need to be taken.
Ferret out the vital signs. In my career as a clinical anesthesiologist and anesthesia expert witness, I can’t recall one significant complication that wasn’t foretold by an increased or decreased heart rate, blood pressure, respiratory rate, or temperature, a decreased O2 saturation, or an increased pain score.
Keep your eye on the vitals, and keep your patients out of trouble.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: