Sepsis: A stealthy, sudden killer
Dying is effortless. That became clear to me as I lay on a gurney in an emergency department bay at Penn Presbyterian Medical Center. It was 10 p.m., almost five hours since my primary-care physician Michael Cirigliano (better known as Dr. Mike from Fox29) diagnosed me as septic, bundled me into his car, and rushed me to the hospital.
Dying is effortless.
That became clear to me as I lay on a gurney in an emergency department bay at Penn Presbyterian Medical Center. It was 10 p.m., almost five hours since my primary-care physician Michael Cirigliano (better known as Dr. Mike from Fox29) diagnosed me as septic, bundled me into his car, and rushed me to the hospital.
After several hours of intravenous antibiotics and four liters of fluid, my blood pressure was crashing, a hallmark of sepsis, a potentially fatal condition caused by an exaggerated immune response to injury or infection.
My daughter, Lindsey, a surgical-trauma nurse at Children's Hospital of Philadelphia, heard a group of doctors discuss my case in the hall. Without a word to her two aunts and uncle, who were keeping vigil with her, she came to the side of my gurney.
"Dad," she said in a voice that was both determined and terrified, "don't you die on me."
Nearly 800,000 cases of sepsis are reported in the United States every year, accounting for almost $16 billion in medical costs. A quarter of a million people, roughly 30 percent of septic patients, die. That's more than the combined deaths from breast and lung cancers. Sepsis killed Muppets creator Jim Henson in 1990. And now it was shoving me at age 61 uncomfortably close to eternity.
"Severe sepsis or septic shock can kill you in a big hurry," said Clifford Deutschman, a critical care specialist at the University of Pennsylvania, who has studied sepsis for 25 years.
Mortality has recently begun to fall, he said, thanks in part to an international campaign by doctors to share better guidelines.
"The key things we know are that you have to get the fluid in fast and a lot of it," Deutschman said. "And you have to get the antibiotics started early. Every half hour you wait, from the time when the diagnosis was suspected until the time when antibiotics start, the mortality rate increases."
Current thinking says sepsis occurs when an infection enters the blood stream or severe tissue damage stimulates a disproportionate response from the body's immune system. That response begins damaging and shutting down organs.
"If you don't get it under control relatively quickly and stop the process, it will get out of hand," Deutschman said.
Sepsis isn't an easy diagnosis. Outside of hospital intensive care units, physicians rarely see cases of sepsis. They often mistake the fever, chills, and general malaise for the flu.
In April, Rory Staunton, 12, of Queens, N.Y., died from septic shock three days after ER doctors at New York University Langone Medical Center treated him for vomiting, fever, confusion, muscle pain, and dehydration and sent him home. The Manhattan hospital was named to the U.S. News "Best Hospitals" honor roll for 2012-13.
In January, in his State of the State address, New York Gov. Andrew Cuomo, citing the Staunton case, said every hospital must adopt best practices for early identification and treatment of sepsis.
Wednesday, Dec. 12, started like most others at my Wyndmoor home. I walked the dog and fed him, ate breakfast, scrubbed the kitchen floor, and went to work as a freelance writer. OK, I usually don't scrub the floor.
The chills and 101.2-degree fever started around 10 a.m. Thinking I had the flu, I gulped down two Advil and climbed into bed. A constant urge to urinate soon developed. By noon, my temperature was 101.8 degrees. At 3:30, it was a toasty 102.8 degrees. I decided to call Mike.
After hearing my symptoms, he told me to come in to his office. I begged him to just call in a prescription. He refused, saying I likely had a urinary tract infection, which men rarely get, but when they do, it's serious and can quickly turn grave.
"You have three choices," he said. "You can go to the emergency department at a local hospital, come in to my office, or lie back in bed and die."
I was shivering convulsively in Mike's office. It was just after 5 p.m. He took my vitals: heart rate of 120 (normal is 90 or below), a fever, and blood pressure of 80 over 60 (a first number lower than 90 is a marker for sepsis). He called Laurence Gavin, an ER physician at Penn Presbyterian. I listened as Mike said he suspected I was septic and was driving me to the hospital.
At 5:34 p.m., I was on a gurney in a bay. Two nurses descended on me like a NASCAR pit crew. In no time, they had me in a gown, took my blood pressure and temperature, drew blood, took a urine sample, started intravenous lines for fluid (chilled and under pressure with two antibiotics), and gave me 975 milligrams of acetaminophen orally. My temperature, a roaring 104.3 degrees, earned ice bags under my arms and between my legs.
"We started the protocol" for patients deemed to have serious infections, Gavin told me later. "So we take out a big hammer and try to hit as many different things as we can."
The big hammer included intravenous infusions of the antibiotics cefepime and vancomycin. At 6:30 p.m., my blood pressure was 113/57, not great but out of the danger zone. By 7:15 p.m., my temperature had fallen to 99.9 degrees, and while my heart rate said that I was still running a race, things seemed under control. Gavin asked a medical floor team to come down and assess me for admission.
Just before 10 p.m., two doctors arrived to do a history and physical. My blood pressure had slipped into the low 90s, but I was fully aware. The medical floor emissaries stepped into the hall with Gavin to discuss my case. That's when my blood pressure tanked to 80/60. Ross Kessler, Gavin's resident, fetched his boss. Literally in a heartbeat I went from sick to critical.
"People can circle the drain right in front of you and jump down the hole, and there is nothing you can do," Gavin said. "You were one of those people. I was worried."
The bay was cleared as things quickly ramped up. Ever calm and poker-faced, Gavin explained that they were inserting a central line into the internal jugular vein on the right side of my neck to deliver blood pressure drugs almost directly to my heart. It would give him a truer read on my fluid status and the pressure in my heart, important because the less fluid, the harder the heart works. The harder it works, well, you get the idea.
After I signed consent forms, Kessler, gowned as if entering a toxic dump, gingerly inserted a huge needle into my neck and snaked the central line down next to my heart. He used a smaller needle on the back side of my left wrist to place the arterial line. He threw a few stitches around each line to hold them in place.
Drugs to support my blood pressure were pumped into the central line. By 11:02 p.m., the top number of my blood pressure had rebounded to 102.
Within the hour, I was transferred to the medical ICU. The attending physician greeted me with two questions: If my heart stopped, did I want them to restart it? And if I stopped breathing, did I want them to put me on a ventilator? Why was he asking such disturbing questions, I asked.
"You're in critical condition," he said.
I spent two days in the ICU, where I received fabulous care. I was moved to a medical floor and discharged on Sunday. My official diagnosis was septic shock, the most acute level of sepsis. The culprit, E. coli bacteria, had somehow wormed its way into my blood stream.
Several doctors asked about my stress level. When I said 2012 was the most stressful year of my life, they said that likely compromised my immune system.
As it turns out, I am one of the rare septic shock survivors who escape lasting damage to their heart, kidneys, lungs, or brain.
"You're one of the lucky guys," Deutschman told me. "The fact that Mike forced you to go to the emergency room saved your life. If it had gotten any further along, it might not have been reversible."
Bob Calandra can be reached at 215-836-0101 or email@example.com.