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A Doctor’s Perspective – Uncovering Why Some Doctors Don’t Understand Sepsis

Posted on by CDC's Safe Healthcare Blog
Steven Q. Simpson, MD
Steven Q. Simpson, MD

Guest Author: Steven Q. Simpson, MD
University of Kansas and Sepsis Alliance

I am one of the newest members of the board of directors of Sepsis Alliance.  If you haven’t heard of Sepsis Alliance, it is a non-profit organization whose aim is to heighten awareness of severe sepsis as an emergency among the general public and among health care providers (www.sepsisalliance.org).  I joined this movement, because the need is strident.  Severe sepsis is the secret killer.  Even though its historical mortality rate is as high as 50%, it is under recognized as a cause of death.  For example, we know that cancer is a leading cause of death in the US, and we spend billions of dollars on cancer research to find preventions and cures.  Yet, what is the single largest cause of death among cancer patients?  It is listed as infection, at 48% of cancer deaths, but it is not the infection, per se, that kills.  It is the severe sepsis engendered by the infection.  And most of those deaths are logged as cancer deaths.

A large part of my own career has centered on teaching physicians, both young and old, how to recognize when they are looking at severe sepsis and how to respond quickly and aggressively.  We have substantial data from numerous trials, observational studies, and quality improvement studies that interventions can be relatively simple, consisting of antibiotics and fluids.  But only when the condition is recognized early and the treatments are given rapidly.   When there are delays, severe sepsis can rapidly become septic shock, with substantially higher risk of death.  You might think that this would be an easy sell for physicians who, after all, are there to save lives.  But you would be wrong in many cases.

After literally hundreds of lectures and workshops across the nation, I think I have worked out the root of the problem.  Nearly all doctors feel as if they know what sepsis is, having heard the word from the very beginning of their medical school careers.  Yet, many doctors have actually not been exposed to the standard definitions that critical care physicians have been using for about two decades, since they were published in 1992: infection, with SIRS and organ dysfunction.  If one stops to think about it – and I have stopped to think about it many times – the majority of physicians aged about 45 to 55, those in the primes of their careers, were not exposed to the definitions during their training.  Most often, when these docs think of sepsis they think of what we who deal with it would call septic shock, often with multiple organ dysfunction.  Often, these providers tell me that they don’t really see all that much sepsis in their practice and that when they do see it they ship it immediately to a larger center.  As a result, my job of informing and updating physicians is not going to go away any time soon.

Posted on by CDC's Safe Healthcare Blog

13 comments on “A Doctor’s Perspective – Uncovering Why Some Doctors Don’t Understand Sepsis”

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    I would like to echo what Renee Robles’ saying. Well said and I agreed. I came from a developing country and graduated from a medical school there but my major was public health. Now I am an epidemiologist working in public health agency in the US. I was a little bit surprised when I was assigned to educate our physicians how to recognize a sepsis. To me, it should be a basic training for medical students.

    The topic you have brought up is worth discussing. The safest question is why don’t they know what sepsis is. You have mentioned the effort invested into Dcs. to know sepsis. Why don’t they? Why don’t they hear you? Now how do they treat this health condition?

    I was sepsis and in intensive care for 6 days. It began with not feeling well, nausea, the chills, and I just did not feel right. I called 911, who began an IV immediately, and the brilliant ER staff , at Blodgett-Spectrum, who recognized the early signs of sepsis.
    It was not until I was in ICU, that I understood what had happened, but I had a kidney stone, that was embedded and finally blocked the flow of urine from one of my kidneys. The quick response of the urologist who did surgery for a stent, and then the Interventionist surgeons who did a percutaneous tube, within a short period of time, I am forever grateful. I so hope that all ER rooms have the same protocol as Blodgett/Spectrum. They are a great team of specialists.

    There are oral implications to systemic health; oral infections like chronic gingivitis and periodontitis (gum disease) elevate CRP/inflammatory responses in the blood; conceivably rendering a chronic “low-grade” septicemia.
    We like to tell patients “If you take all the infected gingivitis surfaces around your gums, it will equal an infected area about the size of your palm” to impress upon them if they had an infection the size of your palm any where else in the body…that’s a medical emergency.

    The first signs of sepsis are the simple ones: fever, rapid heart rate (more than 90 beats per minute), rapid respiratory rate (20 or more breaths per minute). A common sign is new onset confusion or disorientation. These are things that everyone can look for in their loved ones at home. Obviously, a cold can give one a fever and somewhat rapid breathing, and we don’t want to jump every time that happens. But persistent high fevers should get our attention and suggest that this is something more than a cold. Likewise a cold does not impair mental status, and any alterations there suggest that this is more serious, i.e. severe sepsis.

    In 2011, after having my second total knee replacement, I suddenly awoke one day, unable to walk due to sever pain in the operative knee. I went to the surgeon for a 6 week checkup and was told that my red, hot swollen knee which was draining gooey brown drainage was NOT infected, just inflamed. All I can say is thank God I’m a nurse and didn’t listen to him. I saw my PCP who told me that it was definitely infected & put me on Doxy. I thought about it overnight the next day called her and asked for a referral to another orthopedic surgeon for a second opinion. I called for an appointment & was seen the next day. He was horrified and admitted me the next day for a wash out surgery. The culture showed what I dreaded: MRSA. I knew the risks of a post op infection with this bug: loss of function of the joint, loss of the leg (AK amp), and death. Well, I survived that but 2 weeks later, back in rehab for the second time, I suddenly felt freezing cold and asked my husband to get me a nurse with a thermometer and a blanket. My temp was 103. By the time I got to the hospital where I had my second surgery, it went up to 104.7. I remember the ambulance attendants arriving & putting me on the stretcher & that’s it. I woke up 1 1/2 days later in the ICU with a dx of sepsis due to an infected PICC line and pyelonephritis. Had the staff not been on the ball and recognized it, that may have been my last hospitalization. How my poor immune system stood the insults to my body in such a short time, I’ll never know! But I thank God every day for the wonderful people who saved my life.

    Hand in hand with a greater understanding of sepsis must also come a greater understanding by primary care physicians AND intensivists of the delirium which so often accompanies sepsis in the ICU. Most patients are told either during or after their hospitalization that sepsis played a key role in their need for treatment in the ICU. So when they find themselves survivors of sepsis and feel physically well again they are terrified by the idea that they still feel so non-functional in their everyday lives.
    Sepsis survivors end up blaming sepsis when in fact more often than not it is the after-effects of ICU delirium which have caused their ongoing cognitive functioning to be impaired.

    Great point, Dr. Simpson. As a clinical pharmacist having received excellent training in part from you at KUMED, sepsis recognition is a key education point for me to nurses and other pharmacists. Nursing recognition early on can really help raise the alert level for the physician about to see the patient, and get the ball rolling. One thing I have noticed, is physicians using “severe sepsis” and “septic shock” interchangably. I’m not sure if it is just mis-speak, or if the differences between the two really need to be reiterated.

    My two and a half-year old recently went into septic shock related to an intussception which went too long undiagnosed and caused necrotic bowel. Despite my constant baggering of the hospital inpatient team and the nurses he laid in his hospital bed for almost 36 hours before they finally agreed to a CT scan that showed the necrosis. They kept telling me they fixed the intussception and he must have a viral infection coincidentally, not related. He had a high white cell count and very high fever despite Tylenol and Torodol. He was not on fluid replacement or antibiotics during this time. He was admitted for observation only because I refused to take him home because he was so obviously sick. He quickly progressed from awake and upset to lethargic and not aware of his surroundings. He then began swelling and had no urine output at all. I was completely freaking out during this because no one was doing anything and it seem so obvious to me how sick he was, and this was a children’s hospital. I have since read his medical files and his labs show a clear indication that he was heading toward septic shock, coupled with his altered mental status and fever it seemed so obvious that he was in big trouble. Once his CT scan was complete he was rushed to surgery hemodynamically unstable for a bowel resection. He then went to PICU and did not wake for 2 days because his little body had been through so much. I am so upset that his condition was not recognized for so long. I hope that all medical facilities and hospitals develop a sepsis protocol. I feel beyond lucky that our little guy survived this and came out okay. We are about a month out from surgery and he is doing great! Thank you for educating on this important topic!

    I am a Sepsis MRSA survivor. When I first went to hospital they diagnosed me with a viral infection. When I came back again they did a blood test and determined the cause of my sickness. During my time in hospital I was in renal failure and cardiac failure as well as pneumonia. I coded several times and was brought back. Through the introduction of an experimental drug, I survived. However, if I had died, what would have been the cause of my death? Either pneumonia, renal failure or cardiac failure. The fact that sepsis MRSA was the culprit would never have been known. We, in this country need to define the cause of death by the “initiating disease,” not the one that the patient died from.

    Dr. Simpson, I think, identified the key issue — student physicians should learn and understand the history of medicine, not just its current practice. Once upon a time, sepsis was an everyday, common occurrence. A prick on a rose thorn could turn septic and kill an amateur home gardener. “Child-bed fever” (postpartum infection) used to be the number one killer of young, child-bearing women. Septic infection was the chief challenge facing battlefield physicians.

    Today, these situations are rare, thanks to clean water, public education, and widely available, inexpensive antibiotics. However, as physicians, we cannot take these things for granted. It would be prudent for medical students to at least know how doctors 150 years ago dealt with these things, and how to recognize and manage them today when situations might not be ideal.

    For example, witness the Ebola epidemic in Africa. The public health landscape there is far from ideal. Knowing how to practice medicine in less than ideal circumstances, with less than optimal resources, could potentially save many, many lives.

    As a person who has experienced septic shock, I can add that it is the most terrifying thing this side of Alzheimer’s, and were it not for the quick-thinking medical professionals in my local ER, I would certainly have died. Anything this serious needs to be better understood not only at the physician level, but at the layman level as well.

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