The Twenty Sign

Have you noticed, most ICU drugs are managed in a range of less than 20, whether it's units, mcg, mg, g. Everything is measured in small numbers. Get out side the ICU and you have to mulitply everything by 10.  Once you hit twenty of anything in the ICU, your Twenty Sign has arrived.

Happy's Twenty Sign has a very high positive predictive value (if your units are greater than 20, you have badness). For example, take a normal 45 year old male and give him acute medical illness, severe enough to land him in the ICU. Have him start the day without an inkling of a history of diabetes and with a normal HgbA1C of 5.5%.

And then get a call from the nurse saying he's up to 22 units per hour of intravenous regular insulin. That's the Twenty Sign at work. That's badness. When you are in the ICU and the nurse calls you to tell you your patient is on twenty of of anything, that's badness. Take notice of the Twenty Sign. Use it to your advantage. Don't let time slip away from you. When the Twenty Sign is invoked, you must act immediately to find that regulatory switch gone haywire.

The twenty rule also applies to alcoholics. I have cared for many a hardcore alcoholic in the depths of withdrawal. I once had a patient on 20 mg of ativan an hour. It was nuts. That's not normal. Let me put that in perspective. A non drinker would sleep for hours with just one mg.

In fact, I believe so strongly in the Twenty Sign, I believe it should rise to the same importance of the code blue.

Code Blue in room 763

Rapid Response Team to room 457

Team Twenty to room 342, STAT.

If you're a student or a resident,check out these other great medical signs:

• Handsome Sign
• Sleeping Husband sign
• O and Q sign
• How to find a lost cell phone in the hospital:  Happy's honesty sign
  
• MFer sign
• Texting in the ER sign
• Band-Aid sign
• Intact Humor Reflex sign
• Fibromyallergia sign
• Denture Stains sign
• Square Root sign
• And while you're at it, check out these funny homeless signs.