Trish M. Perl, MD, MSc; Connie Savor Price, MD
Acknowledgment: The authors thank James “Brad” Cutrell, MD, for his comments and suggestions.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-0643.
Corresponding Author: Trish M. Perl, MD, MSc, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard Y7.312, Dallas, TX 75390; e-mail, Trish.Perl@UTSouthwestern.edu.
Current Author Addresses: Dr. Perl: University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard Y7.312, Dallas, TX 75390.
Dr. Price: Denver Health and Hospital, 777 Bannock Street MC-2600, Denver, CO 80204.
Author Contributions: Conception and design: T.M. Perl, C.S. Price.
Drafting of the article: T.M. Perl, C.S. Price.
Critical revision of the article for important intellectual content: T.M. Perl, C.S. Price.
Final approval of the article: T.M. Perl, C.S. Price.
Administrative, technical, or logistic support: T.M. Perl, C.S. Price.
Collection and assembly of data: T.M. Perl, C.S. Price.
Kristi L. Koenig, MD, FACEP, FIFEM, FAEMS
University of California at Irvine, County of San Diego HHSA EMS
March 19, 2020
Travel history should be first, not fifth: The Vital Sign Zero
Kristi L. Koenig, MD, FACEP, FIFEM, FAEMS email@example.com
Professor Emerita of Emergency Medicine & Public Health, University of California at Irvine
Medical Director, EMS, County of San Diego, Health & Human Services Agency
No conflicts of interest
Travel history should be first, not fifth: The Vital Sign Zero
We appreciate the important letter by Perl and Price suggesting the need for an additional vital sign to aid in early detection of patients with a contagious emerging infectious disease that is geographically linked. This concept supports the 3I (Identify-Isolate-Inform) approach we advocate using during initial patient encounters, including for the current COVID-19 pandemic . However, our approach has been to consider this new public health vital sign to be the first parameter to assess and not a fifth, after the traditional four vital signs are measured. In fact, during the 2014 Ebola outbreak, we published the concept of a “Vital Sign Zero” to stress the importance of stopping to assess travel history prior to touching a patient to measure standard vital signs. For transmissible infectious diseases, it is critical to screen patients for an epidemiologic risk factor immediately so that they can be isolated and health care workers can don appropriate personal protective equipment prior to touching the patient to collect the four routine triage vital signs. As new viruses emerge, it will remain important to keep up to date on regions with epidemiologic disease links so that rapid screening and immediate isolation can be accomplished. This is an essential process needed to limit disease transmission to both health care workers and the public. In summary, we support the authors’ suggestion, but believe that travel history should be the first and not the fifth vital sign.
Perl TM, Price CS. Managing Emerging Infectious Diseases: Should Travel Be the Fifth Vital Sign? Ann Intern Med. Mar 3, 2020.
Koenig KL, Beÿ CK, McDonald EC. 2019-nCoV: The Identify-Isolate-Inform (3I) Tool Applied to a Novel Emerging Coronavirus. Western Journal of Emergency Medicine. 2020. https://escholarship.org/uc/item/0ch1h302, Accessed March 7, 2020.
Sisson P. How a San Diego doctor fought infectious disease with just three words. San Diego Union Tribune. https://www.sandiegouniontribune.com/news/health/story/2020-02-24/with-just-three-words-san-diego-doctor-has-helped-change-how-hospitals-handle-infectious-disease-risk, Feb 24, 2020.accessed Mar 7, 2020.
Koenig KL. Identify, Isolate, Inform: A 3-Pronged Approach to Management of Public Health Emergencies. Disaster Med Public Health Prep. 2015;9(1):86-87.
Koenig KL. COVID-19: A Call for Science-Informed Management, Evidence Aid. Mar 3, 2020. https://www.evidenceaid.org/covid-19-a-call-for-science-informed-management/, accessed Mar 7, 2020.
Koenig KL. Ebola Triage Screening and Public Health: The New “Vital Sign Zero”. Disaster Medicine and Public Health Preparedness, available on CJO2014. Available at: http://journals.cambridge.org/download.php?file=%2FDMP%2FDMP9_01%2FS1935789314001207a.pdf&code=a50034d4ef76f95114e1b68b258da7cd. Accessed Mar 7, 2020.
Steven Yale MD, Halil Tekiner PhD, Eileen S. Yale MD, Joseph J Mazza MD
University of Central Florida, Department of the History of Medicine and Ethics Erciyes University School of Medicine, University of Florida, Marshfield Clinic Research Institute
March 23, 2020
Travel is Not a Vital Sign
TO THE EDITOR: We concur with the comments made by Perl and Price1 regarding the importance that an accurate travel history be obtained given recent international emerging infectious disease outbreaks. Taking a detailed travel like a sexual, family, past, social, and occupational, history is essential in order to identify key findings that may assist in appropriate triage and diagnosis. These are not however, vital signs. The term “vital signs” had been used long before the idea of its application in the clinical decision making process gained importance in the 19th century. One of the earliest papers appeared in the literature was in 1866 as reported by Edward Seguin, "The cases are accompanied by a diagram, fac simile of the tables of “Vital Signs,” used at the bedside to make the daily record of temperature, pulse-beats and respiration. This one only differs from ours in that on it are represented the curves for three cases, whereas usually but one case is put upon a table (2, p. 193)."Harvey Cushing in 1903 called for including blood pressure in the medical record, "At the present time, largely owing to the convenience of our timepieces, pulse-rate is commonly recorded alongside of the temperature and perhaps of the respiration on our clinical charts, to the utter neglect of a numerical record of that vascular quality which in many condition is incomparably of greater clinical consequence, namely, arterial tension (3, p 252)."The term “vital signs” was appropriately named as it represents a finding found on physical examination through observation (respiratory rate), palpation (pulse), and device (blood pressure and temperature) or signs that are vital or essential for life. Thus, in order to call something a vital sign it must meet the criteria as being 1) objective and quantifiable, 2) required for life. We contend that medical terminology be accurate and precise so that it can be easily communicated and understood. Thus, such terms as pain, physical activity, functional status, delirium, and travel are not vital signs since they do not meet the medical definition. In fact, the only other function that merits this definition, and that is sometimes included as a vital sign, is the oxygen level as measured by pulse oximetry.4 What these emerging infections should remind physicians is that despite technological advancements, the core information obtained from the history and physical examination remains paramount to appropriate diagnosis and delivery of meaningful cost-effective medical care. References1. Perl TM, Price CS. Managing emerging infectious diseases: should travel be the fifth vital sign? [published online ahead of print, 2020 Mar 3]. Ann Intern Med. 2020;10.7326/M20-0643. doi:10.7326/M20-0643.2. Seguin E. The use of the thermometer in clinical medicine Chicago Med J. 1866;23:193-201. 3. Cushing H. On routine determinations of arterial tension in operating room and clinic. Boston Med Surg J 1903;148:250-256. doi: 10.156/NEJM190303050481002/.4. Neff T. Routine oximetry. a fifth vital sign? Chest. 1988;94:227. doi: 10.1378/chest.94.2.227°.
Chia-Yen Dai, M.D., Ph.D., Ming-Lung Yu, M.D., Ph.D., Yuh‐Jyh Jong MD, DM Sci
Kaohsiung Medical University Hospital, and College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
March 28, 2020
Importance of the travel history: evolve with time
We read with interest the paper by Perl et al. mentioned that travel history, a key epidemiologic information to integrate into risk assessments of the health care team, could serve as a warning sign that prompts protective measures for the novel SARS coronavirus 2 (SARS-CoV-2) infection (1). Habibi et al. recently described many of the travel restrictions by some countries during the 2019-nCoV outbreak are not supported by science or WHO that was advised by the International Health Regulations (2005) (2). Nevertheless, the first patient of coronavirus disease 2019 (COVID-19) in many countries, as the United States in January 2020 (3), actually has the common travel history to the Wuhan, China. In response to the outbreak of COVID-19, the Taiwan Centers for Disease Control (CDC) has call on the staff in the medical community to be vigilant and implement the "TOCC (travel history, occupation, contact history and cluster)" consultation and related infection control measures on January 2, 2020 (4). Taiwan’s experience by far provides an exemplary model in earlier fighting COVID-19, with the quick response including travel restriction for persons from Wuhan city since January 23, 2020 and then from other cities and even whole China described in Taiwan by Wang et al. (5). As of March 28, 2020, total 283 laboratory-confirmed patients, significantly less than other countries were reported in Taiwan with two deaths after tests for 29,389 individuals (4). It is noteworthy that 241 (85.2%) of the 283 patients were imported cases with travel history to other countries (4) which indicates that traveling is still currently the major causes of COVID-19 in Taiwan. Of course, after declaring the outbreak of the new coronavirus is a pandemic on Mar 11, 2020 and currently 509,164 confirmed cases and 23,335 deaths globally by the World Health Organization on March 27, 2020, the travel history may become less important in the countries with a rapidly increased number of patients. Hence we believed that travel history plays a crucial and very important role on the spreading of the COVID-19 before the community infection or transmission developed. On the other hand, it has to be greatly noted that after the isolation or lockdown measures are eased, the possibility of the second waves of COVID-19 outbreak may occur again with the communication of people particularly by travelling. We consider that the importance of travel history indeed changes as the epidemic of COVID-19 evolves.References1. Perl TM, Price CS. Managing Emerging Infectious Diseases: Should Travel Be the Fifth Vital Sign? Ann Intern Med. 2020 (Published online March 3, 2020) doi: 10.7326/M20-0643.2. Habibi R, Burci GL, de Campos TC, Chirwa D, Cinà M, Dagron S, et al. Do not violate the International Health Regulations during the COVID-19 outbreak. Lancet. 2020;395:664-6. 3. Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020;382:929-36. 4. Taiwan Center for Disease Control. https://www.cdc.gov.tw/En5. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan. Big data analytics, new technology, and proactive testing. JAMA. (Published online March 3, 2020.) doi:10.1001/jama.2020.3151
Richard M Fleming, PhD, MD, JD (FHHI-OI-Camelot); Matthew R Fleming, BS, NRP (FHHI-OI-Camelot); William C Dooley, MD (Oklahoma University Health Science Center); Tapan K Chaudhuri, MD (Eastern Virginia Medical School)
FHHI-OI-Camelot; Oklahoma University Health Science Center; Eastern Virginia Medical School
March 30, 2020
Conflict of Interest:
FMTVDM issued to first author.
PCR or FMTVDM: The question over who should be tested, depends upon the test being used and what you are trying to accomplish with the test – screening, or diagnosis and determination of treatment results.
PCR swabs are touted as being important for our understanding of CoVid-19. While they do provide limited information about the prevalence of disease, taking into account sensitivity and specificity errors, they do not provide diagnostic information – and that is the information physicians and the general public are looking for – noting particularly that a PCR test will not tell you who is contagious, who is going to become critically ill, or the outcome of those individuals.As of yesterday, 29 March 2020, it appears we have accepted the loss of 100K to 200K Americans – or more – using the current approach of trying to flatten the curve and limit the spread of CoVid-19. Understanding that viruses are never eradicated and they will continue to recur year-after-year means we are willing to accept a yearly loss of people from CoVid-19. Even the potential future development of a vaccine does not – as we have seen with all vaccines – eliminate the yearly cycle of disease and death.More important than a PCR screening test, is the need for a diagnostic test . One that can quantitatively measure the resulting inflammatory process and pneumonia [2-5] caused by CoVid-19 (CVP) as well as determine the effectiveness of treatment in each individual. The use of FMTVDM will allow us to direct patient treatment - determining which of the proposed treatments save lives, and which do not. References:1. The Fleming Method for Tissue and Vascular Differentiation and Metabolism (FMTVDM) using same state single or sequential quantification comparisons. Patent Number 9566037. Issued 02/14/2017. 2. Fleming RM. Chapter 64. The Pathogenesis of Vascular Disease. Textbook of Angiology. John C. Chang Editor, Springer-Verlag New York, NY. 1999, pp. 787-798. doi:10.1007/978-1-4612-1190-7_64. 3. Fleming RM. The Fleming Unified Theory of Vascular Disease: A Link Between Atherosclerosis, Inflammation, and Bacterially Aggravated Atherosclerosis (BAA). Angiol 2000; 51: 87-89. 4. Fleming RM, Boyd L, Forster M. Reversing Heart Disease in the New Millennium - The Fleming Unified Theory, Angiology 2000;51(10):617-629. 5. Fleming RM, Fleming MR, Dooley WC, Chaudhuri TK. Invited Editorial. The Importance of Differentiating Between Qualitative, Semi-Quantitative and Quantitative Imaging – Close Only Counts in Horseshoes. Eur J Nucl Med Mol Imaging. 2020;47(4):753-755. DOI:10.1007/s00259-019-04668-y. Published online 17 January 2020 https://link.springer.com/article/10.1007/s00259-019- 04668-y https://rdcu.be/b22Dd
Thomas w. Filardo, M.D.
Chief Lexicographer and New Terms Editor, Stedman's Medical Dictionary
April 1, 2020
Travel is not a vital sign
While no one doubts – or ought doubt – the importance of travel history in any complete patient history, such information does not comprise a sign at all, despite the critical nature of such information in the current COVID-19 pandemic: signs are measured physical variables, as others here have commented. Over the past decades there have been attempts to attach “the fifth vital sign” to a number of historical issues, some more properly fitting into the symptom category, others belonging within aspects of social or other sub-categories of the personal history: smoking status, health literacy, pain, sleep habits, contraceptive use; and likely others which have escaped my attention.Clarity in recording history and physical exam findings remains highly important; confusing the nature of signs, symptoms, and historical aspects cannot improve the quality of this essential information.
Perl TM, Price CS. Managing Emerging Infectious Diseases: Should Travel Be the Fifth Vital Sign?. Ann Intern Med. 2020;:. [Epub ahead of print 3 March 2020]. doi: https://doi.org/10.7326/M20-0643
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