PA CME: Surgical Abdomen and Sepsis
With a surgical abdomen, my first thought is always sepsis. If you have someone who you think is septic, if, in your mind, you look at someone and say, “I really think they are sick. I think they have a potential life-threatening infection, whether it is a two-month-old, three-month-old, five-year-old, 85-year-old, you pull the trigger on a septic work-up.
First pearl is you have to get a valid temperature. I have had three full-time jobs in my career. I do a lot of per diem and local tandem work, and when I go into a new facility and they do not know me and let’s say I have a kid who is sick with an ear infection or some kid who comes in with an infectious disease. If the nurses bring him back with a tympanic temperature and try to give me that patient with a tympanic temperature, that just means they are testing me. They are just saying, “Is this a good PA? Is this someone who practices good medicine?”[one_second]
If you think someone is sick from an infectious disease, you have to own the temperature. You have to get a valid temperature. I am not saying I get rectal temperatures on everybody, but you have to own the temperature and with children, I want a rectal temperature. I will give you a pearl here. Do not be fooled by the 85-year-old demented person. It is classic. An 85-year-old demented person is not acting right. They come in with an O2 stat of 85%. The nurse gives you an oral temperature of 97. Now what happens classically with breathers, they are trying to keep the thermometer under their tongue, and this person is not following instructions, so that has to be pseudo-hypothermic, where I have gone down in the past thinking this was CHF just to do a rectal temperature and find a temperature of 103 and see that now it is a pneumonia and not CHF. Do not be fooled there. Get a valid temperature. Own the temperature. It is a way that if I was a head PA, someone was working under me and a kid came in and was sick, it is wimpy to accept tympanic temperatures.[/one_second]
If you are a new grad PA, it is a good time to say, “Do you mind if I get a rectal temperature?” I am not asking you to do that. I will do it because I would feel more comfortable. You will get a CBC. No big deal. With a basic white count, you are looking for neutrophils and a left shift, your band count, and always get blood cultures. Let me give you the official rule or the best that I can give you on blood cultures. As a hospitalist, it was almost a knee-jerk response when someone was febrile to do two sets of blood cultures, and very rarely did that ever really save the day, did it ever really make the case. I can tell you, the government has said if you have someone with pneumonia, you need two sets of blood cultures. You have to do it. It is a quality indicator. For medical reasons, for good medicine as mid-level providers, if you do not do two blood cultures, a supervising doctor down the road is going to slap your hand saying, “You didn’t get cultures?”
So, if you are going to work someone up for infectious disease, do two sets of blood cultures. Remember the rule, if you are going to do it, you have to get either two sets, two different venipuncture sites, which the nurses are not crazy about or 30 minutes apart. If I really think someone is sick like meningitis or a curved belly, I will actually get three sets. I am not waiting a half an hour to do the same site. I will do it right away. Here is a question for you: Based on the Critical Care Society, you see someone who you think has meningitis, so you go high fever, they look like crud, they have a rigid neck and you go, I think they have meningitis. As soon as you think that, how long do you have to put antibiotics on board? Think about it. Do not say it, but just think about it and I know what you are thinking because we all think that we want to get an LP first or we are when you get yelled that down the road. That is the best thing to do. If you can get an LP great, but what is the timeframe to put antibiotics on board and someone you think has meningitis? It is an hour. You have one hour from the time you say they have meningitis to put it on board.