Surviving Sepsis – A Word to the Wise…

I just read a really awful heart-wrenching story in the New York Times today. It’s the story of Rory Staunton, a 12 year old boy in New York City who presented to his pediatrician’s office on a Thursday ill with fever, vomiting, and leg pain; was sent to the emergency room at NYU Langone where he was diagnosed with viral gastroenteritis with dehydration and sent home only to return to the emergency room for admission to the intensive care unit where he died on the Sunday from group A Streptococcus sepsis with shock and multi-organ failure. Three days of an unchecked rampant inflammatory process.

A terrible story, not because the presentation is so rare (it isn’t sadly) but because hindsight as provided by the article showed a number of system errors that really could have saved his life if they had been recognized in time. A terrible story because even though I, as a doctor “upstairs” who routinely lambasts the emergency room physicians for their inadequacies, realize that the physician who sent Master Staunton home must have really felt gutted in this case as s/he probably sent countless other people home that day who presented the same way and who did not return 3 days later to die.  The flip-side of this story could have been that the patient did indeed have viral gastroenteritis but was prescribed unnecessary antibiotics because of the abnormal vital signs and blood work results or “just to be sure” or because the parents insisted they wouldn’t leave the ER without antibiotics.  Only to then develop a fatal adverse reaction to the antibiotic such as Steven-Johnsons syndrome/toxic epidermal necrolysis or a fatal C.difficile infection. Yes, medicine is truly an art.

It’s a terrible story because it highlights how damaged the healthcare system is in the United States. It truly is. I see evidence of that every day and all we are doing is patching up cracks in the dam with flimsy Band-Aids, patches destined to fail in one big way. The system errors are a daily affair, sorry to say.   

Difficulty getting in to see your primary care physician because s/he is busy. I routinely get patients calling my office for a rather routine infectious disease issue because they couldn’t get in with their PCP. Or perhaps their PCP had suggested that a specialist, or the emergency room, or the urgent care center address this rather “simple urinary tract infection” instead.

Miscommunication or lack of communication between healthcare providers. How many times have I, a physician, have to go through countless messaging options only to be put on hold or given the roundabout trying to reach another physician about a mutual patient? It’s maddening and therefore no surprise when physicians decide to “just forget about it”. Our days are not limitless after all. In another scenario, I routinely send my office follow-up consultative notes to the surgeon who requested the consult in the first place. Ask me how many times s/he returns the courtesy? Instead, I am left to frustrate our mutual patient by asking them what it is the surgeon said or has planned for them. And as the patient shuttles back and forth between myself and the surgeon, who gets lost in the loop? The primary care physician who really should be in control of everything or at the very least, in the know. That is not the way it should be. Yes, I am part of the problem.

Not following up on bloodwork. One of my earliest pearls I received in my training was “if you are going to check a lab, you need to check the result” and “don’t get a lab test if you don’t know what to do with the result”. I think each pearl speaks for itself but I can offer an example of how “the system” works against us. When I send a patient out of the hospital on a long course of antibiotics I routinely ask for bloodwork to be done to monitor for adverse effects of antibiotic therapy or to monitor response to therapy. It is without fail that the rehab center or nursing home the patient goes to will claim that they never got my orders to do the bloodwork, or they might have obtained the labs but neglected to or decided not to send them on to me. In either case, the onus is on me to remember to call Nursing Home X and ask for the bloodwork I have ordered. A total waste of time (duplicative work), but very necessary least the patient falls through the cracks. There is no efficiency in healthcare delivery, I swear. Zero! This is bloodwork where I am the ordering physician. So imagine the hurdles the primary care physician has to go through if they aren’t the ones ordering the tests but who are expected to follow-up on them. They probably don’t even know that there are tests “out there” to be reviewed. Scary? Yes!

Triaging or treating a patient by phone. I know it’s 2012 and maybe it’s just me or maybe I haven’t fully developed the necessary telephone diagnostic skills. I don’t like speaking on the phone in general even with friends and family. I miss out on physical cues, facial expressions and the like. So when a patient tries to talk to me about an issue on the phone more than once, I insist on an office visit. I can hear them think “great, she wants me to come into her office so she can get my money”. But that’s not the case at all. Why should I keep talking to you about your red, hot, swollen leg day after day? Let me see it! Touch it! Listen to it! Smell it! I probably could never get away with this were I to be a primary care provider due to large patient load which is part of the reason I am not a primary care physician.

Not picking up on vital signs or not being aware of nuances in a patient presentation. In my second month as a medical intern (my first was an elective rotation) I was assigned to the medical wards. That early in my training, I was just collecting vital signs and lab data and neatly recording these series of numbers in my progress note to be filled out with meaningful analysis later after discussion with the senior resident and/or attending. Humbling moments. I will never forget nonchalantly presenting a patient’s blood pressure as 90/60 or something of the sort on rounds one day. That’s low. That is what it had been an hour earlier when I pre-rounded. My resident stopped me in mid-sentence with panic in her eyes and I still didn’t get it. The patient was sick yes, the blood pressure is low yes, but he looked the same as he looked the day before, and the nurses who we rely on that early in our training to guide us as to the acuity of a patient’s status didn’t alert me to anything different with him. Well, I was not offered the opportunity to finish presenting him. We rushed to his bedside where his blood pressure was still low and he was just beginning to have difficulty breathing. The patient was becoming septic and I didn’t even realize it. NUANCES OF MEDICINE for real!

It is for this reason that I continue to refuse to see children. It really is a point of contention between administration and myself at my current place of employment. Yes, I’m an infectious disease specialist but I got to this point by training as an internist, a doctor of adults. The most important lesson I learned in my two month rotation in pediatrics as a third year medical student was “children are not little adults”.

Woe is unto me if I go the bedside of a sick child and present myself to the parent as “the infectious disease specialist”. I have actually done this in the past and even clarified that I’m not a doctor of children but will do the best that I can. I doubt the parent truly hears me or understands what that means. In those few children I have consulted on in the past I did well by them, thank the Lord. But what if one had nuances that I couldn’t pick up on because I am ignorant of them by virtue of not being trained in pediatrics. What then? Would administration continue to provide me a livelihood were my medical license be stripped for what a pediatric medical expert would call “a gross misconduct” or “a gross negligence” when I’m brought to malpractice trial? Obviously the answer is no and therefore my answer is also no to presenting myself as an expert to sick children and their parents. In my opinion, I shouldn’t even be asked to do so. First, do no harm.

What is Sepsis?

Speaking of nuances and getting back to the story of Master Staunton it is said, in hindsight of course, that he had signs suggestive of sepsis when he was discharged from the emergency room 3 days before his death. Sepsis. Sepsis. Sepsis. The bane of my existence over the past year. Sepsis, in short, is the state in which the body goes into overdrive with an inflammatory response trying to control an infection, any kind of infection. It is akin to the body trying to kill a fly with a cannon ball instead of a fly swatter only to have that cannon ball wreak havoc on the body instead. It can also be described as the body sending out a SWAT with miltary-grade weapons to confront an intruder instead of the local neighbourhood watch and then suffering the havoc caused by the SWAT.

Havoc such as lung failure (requiring mechanical ventilation), kidney failure (requiring hemodialysis), liver failure, heart failure (manifesting as volume overload or low blood pressure), brain failure (confusion, lethargy, seizures), undsoweiter.

Management of sepsis includes diagnosing and treating the underlying infection but more importantly controlling this over-active inflammatory response and providing supportive care. Sepsis is no joke. Tens of thousands of people become severely septic in the United States every year. Mortality rates range anywhere from ~30% to ~50% depending on which studies you read.

There is a surviving sepsis campaign designed to help healthcare providers identify patients at risk for sepsis faster so that treatment can begin sooner. Time is precious, as Master Staunton’s case highlights. Sepsis has become the bane of my existence because in the past year, we have initiated a sepsis screening tool in the emergency room and on the nursing floors, similar to that described in the article. We have tried to enforce the use of a sepsis orderset that guides physicians in ordering appropriate labs, antibiotics, and fluid resuscitation. We, the infectious disease physicians, have been accused of being self-serving when after we review the results of all blood cultures obtained within the hospital we suggest infectious disease consultations when we think the patient may benefit from our input and guidance. You wouldn’t believe the resistance from physicians who perceive that their autonomy is being challenged or that from the nurses who complain that they have yet another silly form to waste their time with. It feels as if we are flowing against a tide when in fact all we want, all we all want is better care of our patients. But it seems the unspoken question is at whose expense since everyone is already over-burdened with the current state of health care provision.

It is for all these reasons and more that I’m grateful to Rory Staunton’s parents for sharing his story. Dying from sepsis is an all too common event that should not have happened to him and I’m deeply sorry that he had to fall victim to the system.