PERS PE C T IV E
Lactates and Local Knowledge
Lactates and Local Knowledge — A Parable of Teamwork
Aaron L. Schwartz, M.D., Ph.D., Matthew F. Basilico, M.A., and Jennifer L. Friedman, R.N.​​
O ur patient looked bad, and his
labs looked worse. We had
never seen a lactate level as high
as 10 mmol per liter; soon, it
would be even higher. What was
going on?
Mr. P., a 68-year-old Hispanic
man, had been admitted to our
general medicine service 2 days
earlier with a diabetic foot infec-
tion. His stoicism might have kept
him at home if it hadn’t been for
his daughter. Worried about his
chronic foot wound, she urged
him to come to the emergency
department. He reluctantly com-
plied, arriving febrile and tachy-
cardic. The foot was hot, red, and
quite swollen, with a malodorous
toe ulcer that was a necrotic nidus
of infection. Over the next 2 days,
his foot only worsened. Ultimately,
the vascular surgeons rushed him
to the operating room for a toe
amputation.
At the time his lactate level was
checked, 5 hours after surgery, we
were worried: despite having re-
ceived antibiotics, fluids, and sur-
gery, he had another high fever,
103°F. He was also tachycardic and
breathing fast, though his blood
pressure was robust for the mo-
ment. In a case such as this, a lac-
tate level so high was equal parts
worrisome and mysterious. We be-
gan a comprehensive workup.
The diagnosis would soon
emerge, along with a lesson. The
different perspectives and types
of expertise within our team
would prove crucial to solving the
mystery.
A.L.S., M.F.B.: Here is how
events unfolded from the physi-
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Lactates and Local Knowledge
cian perspective. The laboratory
paged the junior resident and
fourth-year medical student caring
for Mr. P. to inform us of the el-
evated lactate. We rushed to his
room along with two interns to
seek the source of this new and
apparently catastrophic lack of
tissue perfusion. Our leading sus-
picion was sepsis caused by his
foot infection. But perhaps there
was another infected site.
Surrounded by white coats,
Mr. P. appeared anxious and dia-
phoretic. The only new symptoms
he noted were mild shortness of
breath and back pain. A check of
his vital signs confirmed that he
was still febrile and tachycardic,
with normal blood pressure. Al-
though he was breathing a bit
quickly, he was comfortable on the
little supplemental oxygen that had
been initiated in the postanes-
thesia care unit. Aside from the
clean surgical wound where his toe
once was, his swollen foot looked
unchanged from the morning. The
discordance between his dire lab-
oratory value and stable appear-
ance was puzzling. We gave him a
bolus of additional fluids, ensured
that he was receiving his IV anti-
biotics, and gathered more data;
routine labs, an arterial blood gas,
a chest x-ray, and a repeat lactate
level were on the way.
Given Mr. P.’s rapid decline, we
wanted more than data: we want-
ed advice. “Never worry alone” is
a maxim we learned early in train-
ing. So we sought counsel widely,
thankful for the many seasoned
physicians available at our aca-
demic hospital. Concerned that we
might be missing a rare cause of
n engl j med 380;15 nejm.org April 11, 2019
The New England Journal of Medicine
lactic acidosis, we reviewed online
clinical resources. We particular-
ly wondered about perioperative
causes of isolated lactic acidosis.
Do amputations themselves cause
artifactual lactate elevations? No,
said the surgical fellow. Could
propofol from the OR, a rare pre-
cipitant of lactic acidosis, have
been the culprit? Unlikely, said the
anesthesiologist. Our internal
medicine attending agreed with
the specialists that the lactate el-
evation was due to sepsis; we con-
tinued to provide generous quan-
tities of IV fluids. Fortunately,
Mr. P.’s blood pressure was steady.
Unfortunately, his lactate level was
now 14.
Two senior medicine residents,
on call to help with unstable pa-
tients, pored over the data with us.
The laboratory results were per-
plexing. Although Mr. P.’s meta-
bolic profile suggested severe aci-
demia, the arterial blood gas pH
was normal. Also odd was his com-
plete blood count, which suggested
that his leukocytosis had resolved
and been replaced with a new
anemia. We would have to repeat
that CBC. With a normal chest
x-ray, his mild oxygen requirement
seemed like a red herring. The
senior residents suggested that the
lactate elevation and back pain
could be an atypical presentation
of an abdominal catastrophe. It
seemed unlikely, but none of our
hypotheses fit the presentation
cleanly. So we ordered a CT scan
of his abdomen.
J.L.F.: Meanwhile, the case
looked somewhat different from
the nursing perspective. As Mr. P.’s
PE R S PE C T IV E
nurse, I took care of him when he
returned to the floor after surgery.
Despite the fever, he remained his
pleasant self. With my basic Span-
ish and his few words of English,
we could communicate fairly ef-
fectively. Throughout his time with
me, he reported no symptoms at
all, physical or otherwise. Did his
high lactate level indicate that he
was becoming septic, even though
he said he had no symptoms? I let
my charge nurse know that he was
a patient to watch, with the po-
tential for rapidly becoming much
sicker. I made sure my other pa-
tients were settled, in case Mr. P.
suddenly required more intensive
care. As we conducted more tests,
I kept a close eye on him.
I was concerned, but I didn’t
have the sinking feeling in my
chest that I sometimes get when
a patient is very sick. Mr. P. was
laughing with family members.
Was he underreporting his symp-
toms so his family wouldn’t worry?
Was the language barrier causing
miscommunication?
Then Mr. P.’s niece, who is a
phlebotomist, made an odd re-
quest. She asked whether she
could draw any further labs he
might require. She had concerns
about the technique that the oth-
er phlebotomist had used to draw
the sample for his CBC. This in-
teraction made me think more
about the mismatch between the
severity of his labs and his mild
symptoms.
I was still considering this
question as I gave report to the
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nurse on the incoming shift. As I
described what we had done for
Mr. P. up to that point, which in-
cluded giving several liters of LR
and drawing frequent labs, it hit
me. I knew that if labs were drawn
using improper technique, IV flu-
ids could cause inaccurate results
— I had seen it happen many
times with normal saline. I stopped
in the middle of my report and
approached the doctor and medi-
cal student. “Could it be the LR?”
I asked.
“Lactated Ringer’s,” the student
slowly enunciated. “Lactated.” The
doctors were floored. Contamina-
tion of the multiple blood sam-
ples was the only hypothesis that
seemed to fit the data. Lo and be-
hold, a new blood sample, drawn
from the arm that was not being
used for infusion, revealed a nor-
mal lactate level. The other lab
anomalies also vanished. Because
LR contains 28 meq of lactate,
arithmetic suggests that roughly
half the prior lab samples were
blood and half were the LR infus-
ing just upstream from the veni-
puncture site. We canceled Mr. P.’s
CT scan moments before the con-
trast was to be administered. His
infection soon resolved.
The concept of “local knowl-
edge,” popularized by anthropol-
ogist Clifford Geertz and applied
to biomedicine by psychiatrist Ar-
thur Kleinman, emphasizes that
critical information can often be
ascertained only at close social
distance from a problem.1,2 This
April 11, 2019
Lactates and Local Knowledge
view is at odds with bureaucracies
that assign authority in a vertical-
ly ascending manner, which can
cause misguided pursuits led by
titled experts. Medical teams are
accustomed to hierarchies, in
which people at higher organiza-
tional levels are thought to have
a diagnostic advantage over those
on lower rungs. Our case suggests
a more nuanced model of a sub-
specialized team with complemen-
tary areas of expertise.
Nurses witness many thou-
sands of lab draws and spend
countless hours observing patients
and family members. By noting
the concerns of a patient’s niece
(who was an expert in phleboto-
my) and synthesizing that obser-
vation with knowledge of IV flu-
ids, a nurse (and not eight M.D.s
at a prestigious hospital) formu-
lated the pivotal hypothesis in a
confusing situation. Rather than
looking up and out for expertise,
this time we needed to look with-
in, and to harness the deep local
knowledge in our interprofession-
al team.
Disclosure forms provided by the au-
thors are available at NEJM.org.
From the Departments of Medicine (A.L.S)
and Nursing (J.L.F), Brigham and Women’s
Hospital, and Harvard Medical School
(A.L.S., M.F.B.) — both in Boston.
1. Geertz C. Local knowledge:​further es-
says in interpretive anthropology. 3rd ed.
New York:​Basic Books, 2000.
2. Kleinman A. Four social theories for
global health. Lancet 2010;​375:​1518-9.
DOI: 10.1056/NEJMp1815228
Copyright © 2019 Massachusetts Medical Society.
Lactates and Local Knowledge
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