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We talk a lot about recognizing “sick vs not sick.” We say it’s what you learn intern year, etc.
This phrase has made me increasingly uneasy over time.. I want to explore why:
#MedThread
This phrase has made me increasingly uneasy over time.. I want to explore why:
#MedThread
First, must say: Of course it’s critical to recognize the sick patient. If someone looks unwell, has very abnormal vitals etc, you have to notice it. That gestalt is *specific* enough. Take action.
It’s the “or not sick” that can be problematic...
It’s the “or not sick” that can be problematic...
There are patients who are sick (in this context, have acutely life-threatening illness), but don’t look it.
Lady walking around smiling, bacteremic.
Friend with saddle PE and normal vitals.
Guy who just dissolved an LAD clot, or clotted an aortic bleed - for now..
Lady walking around smiling, bacteremic.
Friend with saddle PE and normal vitals.
Guy who just dissolved an LAD clot, or clotted an aortic bleed - for now..
We often learn this the hard way. So I worry about overemphasizing the “not sick” gestalt because it’s not *sensitive* enough, and has too many false negatives.
But our phrasing and tone often suggest that it’s a reliable judgment. Does he look sick? No? Then he’s not sick.
But our phrasing and tone often suggest that it’s a reliable judgment. Does he look sick? No? Then he’s not sick.
That brings us to the next point:
What exactly are these criteria for “looking sick?” Hopeful to get a lot of comments here.
But my sense is that they’re much more often alluded to than defined/explicitly taught. And likely different among clinicians.
What exactly are these criteria for “looking sick?” Hopeful to get a lot of comments here.
But my sense is that they’re much more often alluded to than defined/explicitly taught. And likely different among clinicians.
Finally, there’s a problem with the false dichotomy.. either sick or not sick.
Everything is on a spectrum. I think we can do better than binary assessments.
Everything is on a spectrum. I think we can do better than binary assessments.
It may feel like a subtle difference, but I am much more comfortable with the Unstable 
Watcher 
Stable system often used in IPASS handoffs these days.
Watcher Stable system often used in IPASS handoffs these days.
Recap:
- be more explicit/specific when teaching/learning when to conclude that someone is “sick” (please comment!)
- recognize that “not sick” is often an insensitive and hazardous judgment, and consider avoiding the phrase
- acknowledge the spectrum
- be more explicit/specific when teaching/learning when to conclude that someone is “sick” (please comment!)
- recognize that “not sick” is often an insensitive and hazardous judgment, and consider avoiding the phrase
- acknowledge the spectrum
