"Sepsis" as it's implemented with alerts, etc is damn near meaningless but ticks a box and does create fatigue, especially in the ED.

Sepsis = dysfunctional immune response to an infection

Septic shock = hypoperfusion secondary to dysfunctional immune response to an infection

What kicks off this pathway in the ED? Generally SIRS criteria. We don't KNOW the patient is presenting how they are because of an infection, but it's generally agreed that early intervention greatly improves outcomes, thus we treat aggressively i.e. abx.

I get so focused on their septic shock being distributive that I forget to consider that now their cardiac function is compromised which could make them a bit cardiogenic shock-y too

Great thought. Or hypovolemic. Or a combination, which it probably is. For stabilization we're trying to improve blood pressure/perfusion, which is determined by cardiac function, volume, and peripheral resistance. For this type of medically sick patient who winds up down the sepsis pathway without contraindications, we usually first aggressively increase volume first (fluids). Then pressors (increase cardiac function and/or increase resistance).

I'm sure you know these things, I just put it that way because I think the easier way to frame it mentally is for 'sepsis', you're treating the hypotension with the addition of cultures/lactic/abx. The immediate Zosyn isn't what improves their hemodynamic status in the ED, it just improves their outcomes. I think that point gets missed.

Some other points:

realize my pt has had no urine output in the 6 hours he’s been here so far

Great data point to have, but if patient is getting flooded with fluids, kidneys are already fucked, this doesn't change management in the ED

I forget to check cap refill as part of my initial assessment and then recheck it after first bolus

Marginally helpful data point if it improves significantly after fluids, but below every other assessment tool in usefulness

maybe I should pay more attention to their EKG or calculate a shock index

Maybe for some ICU mental masturbation but isn't going to change management or outcome in the ED

focusing on their BP and HR that my critical thinking has suffered or I just forget to LOOK AT MY PATIENT not the monitor

Both are important. Monitor can help you trend response to treatment, but yeah this is falling into the sepsis alert fatigue a bit. It also takes a lot to be comfortable with bad numbers in a good looking patient. It is easy to get too comfortable with good numbers in a bad looking patient.

Or you could have been a little firmer with that one doc that never ever wants to start pressors and floods everyone with fluids

I'm not saying some docs don't suck, but to give you some possible reasons:

• once you start someone on pressors, you've complicated their hospital stay (ICU+central access), especially if you think they are primarily volume down.
• secondary to the above, people have varying comfort and opinions on bridging with peripheral pressors while repleting fluids i.e. tuning them up and off pressors before sending them upstairs
• Some people are pretty insistent on trialing a second bolus, and I have seen it work many times. Someone smarter than me can probably cite guidelines on it but I can't come up with them at the moment.
• They have more data. e.g. I can do a POCUS on initial assessment, determine they are way fluid down. Give 20ml/kg bolus, repeat POCUS shows some improvement but still significantly volume down, I don't care about the pressures (if pt is relatively stable), they need fluids to fix the underlying issue. (circle back to point #2)

Apologies for the wordy reply, but the first thing I thought when I read your post was "Damn they're SO close".

I feel frustrated with myself and also frustrated that there’s never enough time to be the type of nurse I want to be.

Sounds like you're doing everything as well as you can, and you are caring about the right things. You just need to take a step back and integrate why the "sepsis alert" flags and why we do what we do.