Category: Commentary

What are the earliest signs of infection after surgery? This question was posed to me for the Malpractice Monitor series at MDLinx. My response became the sentence that anchors their article. The boring, early warning signs, the ones easily rationalized and dismissed by medical providers, are the most critical ones to catch.

Here I expand slightly on that quote. The sentence is easily understood and difficult to practice, and its simplicity belies its gravity.

I do not know the facts of the malpractice case or the individuals involved. What I do know is a pattern, one that plays out in hospitals around the country, even at leading institutions.

Every Sign You Can Name Is a Late One

Ask a room full of seasoned clinicians to name the recognizable signs of sepsis and the list is exhaustive. Low blood pressure. Narrowing pulse pressure. Cold, clammy skin. Elevated lactate. An abnormal white cell count. High creatinine.

These are all legitimate. They are also all indicative of a patient who is already ill.

By that point, the window for the easiest intervention has slammed shut. A simple recheck, a phone call, one perfectly timed consultation will not turn the clock back. You are playing catch-up against a destabilizing physiology that moves faster than a hurried clinician.

The early warning signs are subtler. A pulse that sat at 78 yesterday reads 96 in the morning and 108 by evening. A temperature that rises slightly above the patient’s average but is not officially a fever. Urine output that declines inexplicably. Breathing that picks up a little. A patient who is slightly disoriented, a little sluggish, just not himself. After abdominal surgery, pain that increases without resolving, plus new bloating, nausea, or no passage of gas.

Individually, none of these would raise much of an alarm. Taken together and moving consistently in the same direction, they are the whole warning.

Sepsis Lives in the Trends

That is what I gave MDLinx, and it is what I would emblazon on the ward board of every surgical unit in the country.

The most egregious failure is dismissing a vital sign as a single isolated value rather than reading it as one point on a moving line. Heart rate of 104? Just a number. Heart rate of 82 turning to 91, then 98, then 104 across four sets of vitals? That is a story, and it tells a clear direction.

Our focus narrows to the current number because the current number is the only thing the chart makes easy. The chart is great at providing a value and terrible at providing trajectory. The nurse sees the elevated heart rate. A resident looks. A covering physician looks. One at a time, each person reasonably concludes that 104 is acceptable.

Each of them, individually, is not technically wrong. All of them together are demonstrably wrong.

Fragmented Care Kills the Curve

The problem is not intent or a lack of caring. It is a broken process.

Care is fragmented. At the next shift rotation, the nurse who saw the patient looking sickly at midnight is replaced by the nurse present for rounds at eight in the morning. The surgeon who operated is not always the one rounding afterward. The handoff, which is the critical moment to transfer a patient’s trajectory, often degenerates into a list of tasks.

Handoffs are where the trend dies. “Vitals stable overnight” can be factually accurate and clinically ruinous. Stable from what level? Stable compared with when?

There is no complicated or flashy fix for this. Call the direction out loud. Say instead: “Her heart rate has climbed thirty points since yesterday evening and her urine output is down.” That handoff communicates the trend. The extra five seconds are the price of knowing a patient instead of a chart.

Why I Take This Personally

I completed my general surgery residency at Texas Tech University Health Sciences Center and my plastic surgery fellowship at the Mayo Clinic, and I am board certified in both general surgery and plastic surgery. I trained and worked on wards where perforation, peritonitis, and postoperative sepsis are not abstractions.

The drama of sepsis arrives abruptly in some patients and subtly in others.

It is the subtle ones I still think about.

People assume aesthetic surgeons exist in a pleasant vacuum, far removed from all this. Not true. Infection after an elective operation is rare, and rarity, if anything, makes people less vigilant rather than more. When you expect a clean result every time, your mind subconsciously learns to rationalize the one odd finding. She is tachycardic because she is nervous. He feels warm because the room is too hot. Her pain is up because she missed a dose.

Each of those explanations is usually right. That is exactly what makes them dangerous.

What I Do In My Own Practice

I follow my patients closely and early, and I do not hand them to autopilot. A form gives me a value. A patient standing in front of me gives me a trajectory, and the trajectory is what I need.

My patients can call the office directly and they can text. Send me ten messages that turn out to be nothing so that I do not miss the one that was something. That is not customer service. It is clinical care. The patient is the only person present for every single data point, which makes their trend line the most complete one in the building.

So do not ask “is the pain bad.” Ask “is the pain worse than yesterday.” Do not ask “do you have a fever.” Ask “is your temperature climbing.” I care very little about the number on any given day. I care where it is going.

What a Patient or Family Member Should Escalate On

If someone you love is recovering from surgery, at home or in a hospital bed, be loud about these:

• Pain that is steadily worsening, or spreading instead of staying focal
• A heart rate that keeps climbing, even when any single reading looks acceptable
• A fever, or a temperature whose trend line is heading the wrong way
• Confusion, abnormal drowsiness, or simply not acting like themselves
• Passing far less urine than they should
• Breathing faster or more labored than expected
• After abdominal surgery, bloating, nausea, vomiting, or an inability to pass gas

You are not trying to be right. Your burden is to be loud.

Use the word trend. Ask what the numbers were last night. Put the direction in front of the team, not just the value. A spouse who says “she has gotten worse every day for three days” has handed over the one piece of information nobody in the institution managed to preserve.

That is not impolite. In the right moment, it is the only actionable thing anyone says all day.

The Point

No one misses sepsis because nobody knows what sepsis looks like. It gets missed because each of the early signs looks uneventful on first pass, each one can be explained away, and the points land on the shoulders of four different people who will only ever know their own piece.

Read the curve. #StayBeautiful.

For the patient-facing version of this post, see the companion on agulloplasticsurgery.com. For the way we follow up with postoperative patients in the practice, see the version on swplasticsurgery.com.

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