It’s More a Guideline Than a Code

photo: JParadisi 2009

  “But what about the Pirate’s Code?” Elizabeth, (Keira Knightley), asks Captain Barbossa, played by actor Geoffrey Rush, as he reneges on a bargain she’d negotiated with him, in a scene from the movie The Pirates of the Caribbean: The Curse of the Black Pearl.  “Well,” Barbossa replies, “…the code is more what you’d call ‘guidelines’ than actual rules,” and he sails off, keeping her captive. 

      I’m reminded of this scene while reading the post by Anahad O’Connor,  What’s Your Temperature? Rethinking 98.6   in the New York Time’s Well Blog (December 28, 2009). Many commenters posted  annoyance with nurses and doctors who seem to ignore them when they explain that their temperature is usually lower than 98.6°Farenheit ( which is 37° Celsius, used in most other countries than the United States ).  As a Registered Nurse, almost every patient I see in a shift tells me their temperature normally runs below 98.6. I know. So does mine. Most of my patients run a little below 98.6, in the 97’s.  However, 98.6°F has become a cherished rule in our society, by which patients decide if they are sick.  If they are higher than 98.6°F, they reason they are sick.      

     98.6°F is an average body temperature. This means there is a range of some degrees below and above that are considered a normal body temperature. It’s a guideline, and only one factor in the assessment of whether or not a patient has an infection (viral or bacterial). Many adult patients present with an infection without reaching a temperature of the textbook rule 101°F.  There are a few more guidelines I want to consider: What is the patient’s blood pressure, and how does it compare to the patient’s blood pressures in the past? When I suspect infection, I’m often more concerned with a drop in the patient’s blood pressure, than an increase.  Is the pulse (heart rate) higher or lower than usual? Is the patient complaining of pain or achy? Is she dizzy? Is there a rash or swelling anywhere? Finally, what is my overall impression of the patient? Does she look sick to me? If vital signs are borderline normal, but my gut tells me the patient is ill, I’ll call her doctor to discuss the findings. I’ll actually tell the physician, “The numbers are normal, but she is symptomatic (has symptoms) and she looks sick to me.” You’d be surprised how many doctors order blood cultures, a chemistry panel, CBC, a urine analysis, and prophylactic antibiotics based on a phone call like that from a nurse, especially in oncology. 

     My point is  to illustrate why, when you tell your doctor or nurse that 98.6°F is high for you, it seems we aren’t listening to you. What we are doing is looking and listening to you, to decide what the best plan of care might for you.  98.6°F is only a guideline, not a code. 

Disclaimer: It is not the intent of this blog to dispense medical advice. If you have concerns about fever, infection or other personal health issues, please consult a licensed medical practitioner.