Reproduced with permission from General Surgery News, published in the September 2017.
Protocols and pathways are supposed to make patient care more efficient and cost-effective. Protocols promote uniformity in patient management and hopefully promote safety. However, protocols and pathways can cause doctors to stop thinking.
As an example, my patient had an extended right hepatic lobectomy and bile duct resection for cholangiocarcinoma. He was older and also had a slightly enlarged prostate. His operation went well and his postoperative course was smooth except for a low-grade fever due to atelectasis. On postoperative day 4, his epidural pain and urinary catheters were removed. He developed urinary retention, and the resident and the nurse warned him about an impending “straight cath” if he did not void his bladder soon. No doubt this stressed him out. And I am relatively sure that the recently discontinued epidural pain medication allowed for the return of his pain, with worsening urinary retention.
As a result of pain from the full bladder and the incision, as well as the threat of the insertion of a Foley catheter, the patient’s heart rate jumped to 110. The increased pain also made it a little more painful to breathe and that right subcostal scar is no picnic either. Yes, you guessed it: atelectasis, and now a fever to 100.4.
Then, DING!
A little light went off in our hospital computers and the sepsis protocol lights started flashing. The rapid-response team was mobilized; nurses made sure he had oxygen; IV access was established; and arterial blood gas and lactate level tests were done. A fluid bolus of 30 cc/kg by IV was ordered, which amounted to about 2 L of fluid, which the nursing staff planned to slam in with a blink of an eye.
Thankfully, the response team decided to call me after only about 200 cc of fluid had been infused, and I calmly said, “Hmm, do you think you can just put that Foley in first?” They did, and 800 cc of urine passed. The patient’s heart rate returned to normal; he became a lot more calm; and his fever came down.
Now, did this patient really need that sepsis protocol adventure, or would a dose of common sense have avoided all of the drama?
This is not unique to the surgical service. Last July, one of my relatives went to the emergency department. He was elderly, had some bad dim sum earlier that evening and had a bout of loose stools. He had fallen while trying to get to the bathroom and had difficulty getting up. With that history and a heart rate of 112, the emergency physician did a quick evaluation.
Again, DING!
The sepsis protocol light went off in his head and the computer. Oxygen was administered and a lactate level and arterial blood gas were obtained. They immediately slammed 1,000 cc of normal saline into him. His heart rate increased to 120.
The emergency department team then recruited an admitting team, and they prepared to infuse another liter of fluid in what surely must be refractory sepsis (at least in their view). My relative mentioned that he felt a little “winded” after the first liter of fluid and so the ICU team was summoned. There was discussion about severe gastroenteritis, systemic inflammatory response syndrome, intubation, stool cultures, broad-spectrum antibiotics and a surgery consult.
Because it was July 1, and it was my relative, I decided to stop by the emergency department. I arrived to this little situation. I pointed out that his blood pressure was in the 180s and had never been under 160. He could not possibly have been that dehydrated with just one bout of loose stool two hours ago, and he was walking and talking like a normal person before that. He also had a history of congestive heart failure and tachycardia with fluid overload. He took multiple antihypertensive, diuretic and cardiac medications.
At this point, I asked them to please check his last echocardiogram. Irritated by the bossy physician relative, they looked this up and found that his last ejection fraction was 30%. I pleaded, “Please, can you give him some Lasix and stop all this fluid.” There was almost audible eye rolling. By morning, my relative was sitting in a chair complaining about the runny eggs for breakfast and wanted to go home.
Was that sepsis protocol adventure really necessary?
Protocols can be helpful in managing patients. In the past, original thinking was called for with each clinical problem. But the new “thinking point” for physicians is deciding when protocols are appropriate and when they are not. Protocols were developed based on evidence-based medicine, performed in a very controlled fashion on consenting adults. Many patients were, and are, excluded from protocols. Conclusions cannot necessarily be extrapolated to everyone on the planet. It certainly did not account for the fear of the Foley catheter re-placement or the consequences of bad dim sum in a cardiac patient.
We cannot stop thinking. We struggled hard to get into medical school, studied hard, passed all those FLEX tests, went through a grueling residency, took some demoralizing oral board exams and paid $250,000 tuition for the privilege of all this torture. We cannot suddenly turn off that highly trained brain and put the whole world on a protocol. We cannot let all of the ancillary staff, health extenders, paraprofessionals and the hospital computers run the show just because they are armed with protocols and policies. Medicine is just not that simple, and physicians cannot be replaced by computers.
Despite what all of the high-tech artificial intelligence people say, physicians are still needed to make important management decisions based on the totality of the patient and the human condition. Never forget that. Never be afraid to do what you believe is right for a patient based on your skills, training, experience, expertise, and knowledge of the literature and the patient. You work hard, and you need to think hard. The protocol is a standardization of things that cannot always be standardized. You are smarter than that.
Dr. Wong is professor of surgery, University of Hawaii, in Honolulu.
COMMENTARY:
Dr Wong’s thoughtful commentary highlights the potential harm of the Surviving Sepsis Campaign Guidelines, the consequences of blindly following these guidelines and the impact of codifying these guidelines as standard of care (by CMS and others); this has resulted in the universal adoption of a management strategy that is devoid of supporting scientific data, is frequently applied inappropriately (as highlighted by Dr Wong) and has likely harmed thousands of patients.
Paul Marik
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There is virtually zero evidence that atelectasis causes fever. Why are you still subscribing to this outdated thinking? It’s hard to take the rest of the article serious after that sentence.
Referring to a protocol as “moronic” requires some knowledge of the protocol. I can only comment on local protocols, which do in fact refer to guidelines and associated definitions. Let’s take a moment and look at the guideline, available from survivingsepsis.org. : “2. We recommend that, in the resuscitation from sepsis-induced hypoperfusion, at least 30?mL/kg of IV crystalloid fluid be given within the first 3 hours (strong recommendation, low quality of evidence).” This suggests that there are at least two pre-conditions for the fluid bolus: some evidence that there is sepsis and further that the sepsis accounts for evidence of hypoperfusion. Sepsis is currently defined as suspicion of infection AND evidence of organ dysfunction. Regardless of the screening tool and alerting system used, it’s not sepsis until someone is sufficient suspicious of infection to get cultures and give antibiotics AND someone has looked to determine by SOFA score that there is temporal association with organ dysfunction. Evidence of hypoperfusion might be based on clinical exam (cool, delayed capillary refill, etc.) or it might be based on a vital evidence such as significant hypotension or loss of urine ouput or a lab test showing lactic acidosis. Anyone here feel that, in… Read more »
Hi,
I think you hit the nail on the head when you ask whether a couple bags of RL is, “on average,” a bad idea. On average, it isn’t, But in some cases, it can and is.
I don’t want to provide care that is good on average. I want to provide the right care for the ONE patient in front of me, so if my assessment of the IVC, the portal vein, the lungs, cardiac function, abdominal compliance and the general physical examination tell me that i am dealing with a patient that is either volume intolerant or unlikely to be fluid responsive, they get no fluid. Unless it contains levophed or even lasix.
Cheers
Philippe
Excellent perspective.. Treat the patient, not the protocol.
I remember reading new sepsis protocols a few years ago and thought that a healthy 18 year old with pharyngitis and a temp of 103 and a tachycardia at 110 would be classified as”septic” and thrown into all of the protocol measures. All he or she would need would be tylenol and maybe a little fluid.
2liters of fluid IV stat is a serious intervention for anyone, esp an elderly patient with heart failure. Giving it unthinkingly (is that a word?) is dangerous. Our guideline recommends 500ml and reassess, an intervention that would probably be safe in both of the above be cases.
I agree with you completely. The idea of giving large fluid boluses to patent’s with sepsis is illogical, reflects a poor understanding of human physiology and is likely harmful. “The gold standard for testing fluid responsiveness is a fluid challenge. The technique consists of infusing a SMALL quantity of fluid in a short period of time, enough to increase the preload and test the response of the ventricle according to the Frank–Starling principle.”[1-3] (this is a direct quote from a paper authored by Dr Rhodes, first author of the SSC). In the FINECE study which analyzed the use of fluid boluses (FB) in 2213 patients from 311 centers across 46 countries the median FB was 500 ml [IQR 500-999].[4] Almost all beside clinicians agree that the most effective approach to fluid resuscitation is to give a 500ml bolus of crystalloid and then for the clinician (at the bedside) to monitor the response. If the patient demonstrates no hemodynamic benefit; then it makes no sense to give more fluids- STOP. If the patient demonstrates a hemodynamic benefit, then the clinician may decide to cautiously give a second bolus. Giving a 2L bolus is reckless behavior and likely to result in severe… Read more »
Policy and protocols can become more like brain-washing. I work in a unit where a few senior staff actively discourage critical thinking. Replaced with, “why didn’t you do X” (per policy/protocol) despite protocol being inappropriate in circumstances.
Nursing staff are harassed about getting pts on sepsis pathways, regardless of the bigger picture.
Why didn’t you tell Dr. pt should be on sepsis pathway? Make sure you document, “Asked Dr why not on sepsis pathway” etc.
Personal favourite is an audit of transfers out due severity of illness. In retrospect, “Why didn’t you phone for escalation?” “Umm, the Consultant and Registrar were standing next to me at the time?”
I was told that ‘technically’ I should call a code for apnoea and bradycardia in a premature baby (which can be normal). Fair enough if other clinical concerns, but without? Being Ex-NICU, this was one of the more stupid applications of protocol I’d ever heard. Especially given that adult ED and adult ICU teams would attend the call, NOT Paeds.
Unfortunately I have to agree with the author. Protocols, especially the sepsis ones are really risky when applied by juniors doctors without supervision by a senior. I think all major decisions should be reviewed by an attending before applying them indiscriminately. thank you for sharing your thoughts
In general terms , I feels protocols might elevate the floor while lowering the ceiling of clinical care So many of these protocols are embedded in the EMR and encourage the “one size fits all” model and generate a knee jerk reaction to over- simplified “pattern recognition” Two illustrative cases:
Last month I have had a patient with borderline hypotension, confusion and high lactate given a fluid bolus when the correct diagnosis was thiamine deficiency and who now has irreversible short term memory loss. Last week a patient with undiagnosed AIDS and Class I pulmonary HTN(PAP 100mmHg) , with mild hypotension (90/60) died of acute R heart failure after 3l on ringers lactate. Both of these adverse outcomes could potentially have been prevented by a more thoughtful physician spending more time with the patient and not “bundling” up.
Medicine globally is becoming more personalized , protocols are antithetic to this
Hi Paul always a pleasure. first guys, watch your adverbs. (Aaron: “seriously”), and Tim: “sufficiently” suspicious. second, Tim, i’m not sure thats the best use of the word “disingenuous”. (definition: “not candid or sincere, typically by pretending that one knows less about something than one really does.”) Paul Marik, if he is nothing else, is so very sincere. and quite candid. (perhaps to a fault). and he certainly doesn’t pretend to know less about something…. and one must admit, using the term moronic does grab one’s attention (as per Tillerson). And i think we all agree that Paul has more than some knowledge of the protocol. I see what you are saying Timothy. But there is a growing concern that there are “forces” about that more than encourage the use of 30cc/kg of crystalloid for one episode of hypotension or a lactic greater than four (correct me please if i’m wrong , Paul or Tim). for my patient who weighs 110 kg, (not uncommon) thats 3300 cc. in my shop, we are often very busy, the nurses very busy, and when i put the 30 ml/kg or into Cerner , its not the easiest thing for the nurses , or… Read more »
Bravo Dr Wong for recognizing the emperor is naked. The “forces” at work as Tom mentions above are those of fear- maybe fear of not being reimbursed, fear of having to face disciplinary action from administration if you don’t complete the bundle, or just plain fear of having to think critically. Innumerable sick folks meet criteria for being “septic” when the clinical issue is completely something else. From a nursing standpoint, the rubber hits the road here when your census is high and the pressure is on to get the order set finished; or “It’s too hard to keep up with all this studying and research” (a commonly heard lame complaint) -this is our job- not sitting around on social media while you monitors alarm. (is that why it’s hard to keep up with reassessment, nurses?…..) A cookie cutter approach doesn’t work at all; and often hurts the patient. Some have become so governed by the SSC guidelines that when they hear hoofbeats, they assume it’s a horse and let it run completely over them. That’s conditioned response. Too bad that many health care professionals are blindly following a government mandate because they are afraid of consequences to THEMSELVES and… Read more »
First off, I agree with the authors. I would like to point out, though, the danger of lumping “ancillary staff, health extenders, and paraprofessionals” together as blind followers of protocol. In the first place, these are all antiquated terms and do not do the professions justice. In the second, physicians are not necessarily the last defenders of medical reasoning. Don’t get me wrong – I do not have the skills, experience, or knowledge to do a physician’s job. But I can do a nurse’s job pretty well, and that includes some modicum of critical thinking. If you want to talk about ways to individualize care and utilize practitioners’ skills to the fullest extent, think about leveraging the nurses, APRNs, pharmacists, etc. and using their knowledge and skills to counter reckless implementation of protocol. After all, none of us is really captain of the healthcare ship.
And of course this is a call to physicians, and as such it is very true and worthwhile. But I question a perspective that groups health extenders together with hospital computers.
I think the author somewhat misses the point. The protocols exist because we, as a group, are crap at spotting sepsis.
Yes, the red lines that trigger the “sepsis call” catch a lot of non sepsis pathologies. But those red lines would not be there if we didn’t keep ignoring patients who have a resp rate of 30.
Always, senior decision making and clinical experience need to be used. But I’m a fan of the sepsis alarm being triggered, and I’m more than happy to be the physician who diagnoses a non sepsis pathology, sticks in the foley, and tells everyone else they’re being idiots.
[…] Wong uses the Surviving Sepsis Campaign Guidelines to explain why it isn’t about sticking to protocols but, rather, about critical thinking. […]
Practicing Intensive Care Medicine requires knowledge of (patho-) physiology and a very close observation of the effects of our interventions as physicians and nurses. The French proverb “Le mieux est l’ennemi du bien” (better is the enemy of good) should be the professional hymne for intensivists. So which blood pressure is required: enough. How much fluids must be given? Just enough. That means not too much and not too little. You do not need to be Einstein to acknowledge that patients are very different, unlike Boeing 737-800 airplanes. You need an individual approach. One can look in different ways at protocols for complicated diseases in patients. Protocols can be useful in situations where little knowledge and training is available and one does not know what to do. Then protocols can be of help. But on the other had: protocols can be like fire arms, or 500 HP cars and 18 wheelers: they are powerful and can be useful. But without proper professional training and indiscriminate use they can become deadly tools. Prof. Buchman has a point when he defends the use of protocols but probably unintentionally he also points at the dangers. At many points thoughtful decisions have to be… Read more »
Great points Armand Girbes.
I have heard it said and I don’t know who to attribute it to, “Learn the rules like a pro so you may break them like an artist”, or conversely, “you cannot break the rules like an artist until you learn them like a pro.”