Who are the SICK?
Whenever I bring my two kids to their pediatrician, there are two entrances labeled “sick kids” and “well kids”. Self-explanatory – except that both doors lead to the same shared air… so go figure.
But in emergency medicine, the word SICK takes on a very different meaning.
By SICK, we do not mean “ill” or “not-well,” “not feeling all-right,” or just having a complaint. In EM, SICK means something is very wrong with the patient, regardless of the body system affected or injured. “This particular person is sick” is how you would start your sign out to a colleague. Translation – I am actually worried about this one.
A SICK story
I was a junior resident co-managing the Trauma Bay with my senior, when among multiple other patients a middle aged man was brought in by EMS with a chief complaint of “struck by a car”. It turned out that after finishing their mutual project, a fellow handyman was backing out from the client driveway in a van and inadvertently hit his buddy. Low speed, no head injury, stable vitals and no real complaints beyond some abrasions: no problem, right?
Within 10 minutes, the patient had developed tachycardia, dumped his pressure and then became altered. “This guy is sick!” blurted by chief with some dismay, as he was already busy with several other traumas that were much more obvious. Within a minute, we had intubated the patient and activated the surgical team response. Needless to say, the FAST was very positive.
Unfortunately, the patient never made it to the OR. He coded and died in the ED before any surgical intervention could be done from what was later determined to be a massive splenic injury. No external signs for concern on the initial physical exam. It was the unlucky height of the rear bumper and the force of the van that did it.
Searching for the SICK
Hunting for the SICK remains the cornerstone of EM. Like seeping through muddy waters, we first have to find them – before “stabilizing, treating and dispositioning”, as our mandate proclaims.
Many tools are, of course, available for this task. They range from internationally accepted nursing triage scales, abnormal vitals and “scary” labs like bandemia, sky-high CRPs and lactates to sophisticated risk stratification systems. But no lab or objective score algorithm can replace your high level of suspicion, formal training, experience and clinical gestalt.
In your EM rotations, you will hopefully encounter and be taught from all of the following: high risk chief complaints (testicular pain, sudden onset headache, tearing chest pain, etc.); susceptible populations (neonates, dialysis patients, elderly, IV drug users, returning patients and so on); ominous physical exam signs (anisocoria, tongue bed elevation, extremity pallor, Cullen’s and Grey-Turner’s, abdominal rigidity, Cushing’s triad, etc.).
The hidden SICK
Not too far from the Trauma Bay within my residency’s ED resided the Behavioral Care Unit also known as the BCU. A designated holding place for patients requiring a psychiatric evaluation, the BCU was a favorite place to go to for any resident who desired to increase her productivity numbers via rapid medical clearance of multiple psychiatric holds.
Yet for many trainees, especially seniors, BCU was also a place to hunt for the SICK amongst the crazy. Many a hypoglycemia, a hyponatremia, a sepsis or a subdural hematoma were found there on numerous occasions, often with a delay from the ideal timeline.
Here are a few more phenomena to be on the lookout for:
- The very quiet elderly – grandma is not peacefully asleep…she’s morbidly ill
- Inappropriate and unexplained vitals – especially tachycardia at intended discharge
- Lack of GCS improvement with time – the alcoholic who is not really intoxicated at all
- Worse after IV fluids – is there tamponade-type physiology, a ruptured heart valve, or internal bleeding?
- Will not walk – no one should be discharged in a wheelchair who did not come in one
- First-time migraine or psychosis at age forty – nope! thou shalt look again
- Anxiety – the real anxiety should be claiming that as your sole diagnosis
This list is yours to expand.
Finding the SICK - it’s you and your environment
Two things –
First, as a trainee, you should always be more paranoid and suspicious of hidden pathology than your supervisors and teachers, not less so. They have the mentioned training, experience and gestalt in their arsenal, you don’t. You are thus stuck with the first item. I am often responsible for teaching newly graduated physician assistants at my work – and it really rocks my boat when I hear “I think it’s just a cold” theme from a newbie.
Second, chances are your training is currently happening at the happening place: some huge university hospital. It is currently very likely and thus very easy to find the SICK. But you are not really honing your skills for working at such places. EM life in virtually any other setting will be much more like trying to find the needle in a haystack. Think about it.
