Columns, Patient Care

Santa’s Experiment with Prehospital Thermometers Shows They’re Reliable

Issue 12 and Volume 41.

Santa convened a special Santa Summit at the North Pole two years ago, inviting his elves and reindeer handlers as well as the JEMS editorial staff and medical experts from several countries.

The reason: His concern over insidious sepsis and deadly septic shock—conditions he felt EMS agencies should be aware of and, more importantly, do something about.

After serving milk and cookies for breakfast, Santa started the summit by defining sepsis as “generalized body poisoning by the products of bacteria,” and noted that it’s affecting and killing more people than it should.1

He became emotional and said he was tired of removing 258,000 nice people from his holiday list each year because their sepsis was allowed to progress to septic shock.2

He couldn’t believe the numbers provided by his elves, but after checking the list twice, he realized that severe cases of sepsis can advance to septic shock when systemic inflammation causes blood clots to develop and block oxygen from vital organs.3

He shocked the attendees when he told them that patients who do survive can experience severe medical consequences when their sepsis is missed, frequently having to have their fingers, hands, toes and feet amputated.4

Why? Vasopressers are used to maintain a septic patient’s blood pressure sufficiently to keep them alive while the antibiotics kill the infection, but they often cause gangrene, which leads to the amputation of their precious limbs.4

He lamented that 50,000 of the beautiful, innocent children on his Christmas list suffer from severe sepsis every year, with 4,400 of them dying unnecessarily. He added that, even if the children survived their bout of sepsis, 50% of them ended up back in the hospital. The normally jolly old guy said he wanted it to stop.5

Santa asked the assembled experts to further examine the sepsis problem and prepare articles on sepsis that outlined its causes, detection and treatment.

He gave them assignments, and the experts dashed away to address Santa’s concerns. A year later, his hard-working elves delivered a massive report to JEMS that published in September. It featured 131 footnoted references, and detailed the problem of sepsis and how it could be addressed and impacted by EMS providers.

But, in addition to their great research and articles, they presented information to Santa that both shocked and angered him. They reported that:

  • Sepsis survivors often require readmission to the hospital, with more than 62% of them being readmitted within 30 days after discharge.6–7
  • Only a small percentage of EMS agencies had a sepsis alert protocol to impact sepsis as early as possible.
  • Hospitals often failed to acknowledge that they routinely misdiagnose infections that can lead to sepsis or septic shock, often discharged patients with what they thought was a simple infection, or ordered tests too late to save the patient from septic shock.4
  • Many hospitals didn’t have a process in place to initiate a sepsis alert when EMS crews called from the field and reported their patient had a fever and two or more of the easily detected systemic inflammation response syndrome (SIRS) criteria.
  • Not only did EMS crews (BLS and ALS) not take patient temperatures, many of them don’t even carry thermometers, so they’re unable to determine if Rudolph’s red nose is an anomaly or the result of sepsis!
  • Ambulances service managers, providers, medical directors and some educators try to minimize the importance of taking a patient’s temperature, claiming that thermometers aren’t accurate.

Santa’s normally red face got beet red when he heard the information and he retorted that it was preposterous hospitals weren’t listening to EMS crews—who could easily pick up on the first stage of the sepsis continuum by detecting two or more of the major indicators of SIRS: temperature higher than 100.4 degrees F; heart rate > 90; respiratory rate > 20; or systolic blood pressure < 32 mmHg.8

He then ordered his chief elf to put thousands of hospitals on his naughty list and make sure they lost millions of dollars in federal reimbursement whenever patients, particularly children, returned to their hospitals in less than 30 days with a repeat fever, SIRS, sepsis or septic shock.

Santa also challenged the notions that temperature assessment isn’t important or that thermometers aren’t reliable, calling those claims “reindeer poop.” He said that Mrs. Claus, herself an EMT, pointed out to him that as far back as 1971, when the first American Academy of Orthopedic Surgeons textbook was released, the importance of temperature assessment was stressed along with the other diagnostic signs such as pulse, respiration, blood pressure, skin color, pupillary response, state of consciousness, ability to move and reaction to pain.9

With his own temperature rising, Santa bellowed out several retorts to the temperature naysayers that made his elves giggle:

  • How can EMS crews assess temperature variance from the 98.6 degrees F temperature norm if they don’t measure for it?
  • Without assessing a patient’s temperature, how can they tell if is a patient is hypothermic or hyperthermic and begin appropriate care?
  • How can they tell if a pediatric patient’s convulsions are the result of a fever? Do they think that the back of their cold hand can determine that, and a couple of Tylenol tablets can cure sepsis?
  • What’s next? Will they get lazy and not assess for pupil response because their patients are wearing sunglasses?

Before settling down for his usual long winter’s nap, Santa tested a group of commonly available thermometers. He used each thermometer to take his temperature in regular conditions. He wanted to prove that prehospital thermometers were reliable. (See Table 1.)

Prehospital Thermometers

Conclusion

Don’t be naughty—be nice! Don’t allow temperature to be a forgotten vital sign in your service. Don’t risk leaving a septic child at home thinking they’re only suffering from the flu, tonsillitis or an ear infection. Place thermometers in every medical kit and use them on any patient you feel could be suffering from an infection or sepsis. jems

References

1. Caroline N: Emergency care in the streets, 2nd edition. Little, Brown and Company: Boston, p. 575, 1983.

2. CDC. (Oct. 5, 2015.) Sepsis fact sheet. Retrieved Oct. 28, 2016, from www.cdc.gov/sepsis/pdfs/sepsis-fact-sheet.pdf.

3. Banerjee P, Vittone R, Criss R, et al. On the front line of sepsis: Lifesaving sepsis identification & hospital alerts in Polk County, Fla. JEMS. 2016;41(9):29–34.

4. Sepsis or septic shock. (2016.) BW&B. Retrieved Oct. 28, 2016, from www.medmalfirm.com/resources/informative-materials/sepsis-or-septic-shock-lawyer/.

5. Duckworth R. Pediatric sepsis: A killer worldwide and at home. JEMS. 2016;41(9):54–59.

6. Sutton JP, Friedman B. (September 2013.) Trends in septicemia hospitalizations and readmissions in selected HCUP states, 2005 and 2010.Statistical brief #161. Healthcare Cost and Utilization Project. Retrieved Oct. 28, 2016, from www.hcup-us.ahrq.gov/reports/statbriefs/sb161.jsp

7. Seymour CW, Rea TD, Khan JM, et al. Severe sepsis in prehospital emergency care: Analysis of incidence, care, and outcome. Am J Respir Crit Care Med. 2012;186(12):1264–1271.

8. SIRS, sepsis, and septic shock criteria. (2016.) MD Calc. Retrieved Oct. 28, 2016, from www.mdcalc.com/sirs-sepsis-and-septic-shock-criteria/.

9. Committee on Injuries, American Academy of Orthopaedic Surgeons: Emergency care and transportation of the sick and injured. George Banta Co.: Menasha, Wis., p. 44, p. 173, pp. 206–207, 1971.

10. Fever temperatures: Accuracy and comparison—topic overview. (n.d.) WebMD. Retrieved Nov. 2, 2016, from www.webmd.com/children/tcfever-temperatures-accuracy-and-comparison-topic-overview.