It's Just a Virus

Many of the journalism stories of deaths involve sepsis. But often these accounts do not give the full picture. That is, had an initial illness been recognized and treated appropriately, the deaths could probably have been avoided. To begin, sepsis is not a primary illness. In other words, it is a consequence or a result of a preceding illness. So when you hear "It's just a virus," that's an excuse not to fully investigate what's going on with an illness. The point is that every person and their illness must be considered individually. This is why playbooks often miss subtle problems.

The first way is to avoid sepsis is to not have it at all. So, in the case of the eight-year old girl who died as a result of a neglected sore throat (bacterial strep), early diagnosis and early and effective treatment with PenVee, ampicillin, or erythromycin would have most likely effectively treated the strep throat and completely avoided the sepsis and the death. The cost of treatment to avoid this death—ten dollars or less.

Early treatment saves lives and prevents injury, which should be enough reason to look carefully at conditions the medical playbooks consider not worth treating. Especially when early treatment saves money, lots of money. Compare the cost of PenVee with the cost of amputating limbs as a result of sepsis.

The second method of managing sepsis is to diagnose and treat the sepsis associated with a disease early. A week or so of IV antibiotics and hospitalization is far superior to dying from sepsis.

The third way of treating sepsis is what these news stories are all about, completely missing the primary illness and having a disastrous result with late diagnosis and late or inadequate treatment of the sepsis. Incidentally, of all the maternal deaths I’ve read about in Texas attributed to Dobbs, misdiagnosing the primary illness and failing to treat sepsis effectively is the only cause of these deaths I’ve seen so far.

So, the third way of treating sepsis has the worst physical, mental, emotional and spiritual result, and costs the most. The old adage, “A stitch in time saves nine,” has never been truer. Given the fact that early and effective treatment has the least costly and best outcomes, what’s the problem?

If there is a good definition of patient-centered care this would be it. Take the time and make the effort to appropriately diagnose and treat the patient accurately and effectively the first time. But let’s face it, “patient-centered care” is a much over-used PR term used by public and private enterprises to make themselves look good for Medicare, Medicaid, insurance, and the entire healthcare system.

In genuine patient-centered care, a physician takes the time to make a hard diagnosis, Especially if the playbook says everything is O.K. and there's nothing wrong with the patient. A doctor must always ask the most crucial question: "What is the worst health problem this condition could be or turn into?" Then all questions during the interview, exams, and labs must revolve around that question: “What’s the worst thing this could be?” This involves thinking, something that has nothing to do with electronic medical records (EMRs). Answering that question saves misery, money, and lives.

For example, one of my patients, a 26 -year-old female presented to the emergency room with right-sided back pain. In treating her, I had to ask myself what was the worst thing this could be? My thoughts? A pulmonary embolus (PE). She was on birth control pills. I asked her about shortness of breath, but she said she had no shortness of breath. But I was still trying to rule out the worst thing this could be, the PE. So, I asked a different question: “Are you short of breath when you walk up the steps?” Without having to think about it, she said yes. For a young woman on birth control pills with a backache on her right side and shortness of breath, the worst diagnosis is still the PE, so, I ordered a CAT scan of her chest. The scan showed so many pulmonary emboli (blood clots to her lungs) that the radiologist said any more clots would have resulted in her death. She responded well to treatment. This what patient-centered care really is.

Thousands of doctors who think about strep throat, (or whatever) treat it correctly, avoiding the cost of poorly treated sepsis followed by death of the patient. More power to them! But we see too many news stories of lack of treatment resulting in sepsis.

Sepsis is hard to diagnose, especially with children. We say, “It’s only a virus.” So, how do we feel when we have a virus? We have a fever, chills, headache, ache all over, fatigue, nausea, and sleepiness. We just want to stay in bed and not move. And the reason we feel that way is that we have what is called, viremia, caused by viral particles floating around in our blood streams.

The reason we are willing to tolerate a viral illness is that most often we recover, although we can get a viral encephalitis, (brain infection) myocarditis, or a secondary bacterial infection, such as pneumonia.

So, it’s easy to say, “It’s just a virus,” but what we really mean is “It’s just viral sepsis.” And guess what? Because viral sepsis and bacterial sepsis feel and look the same, the stage is set for patients and providers to mistake bacterial sepsis for viral sepsis.

In 2013, New York Governor Cuomo passed a law called “Rory’s Regulations” requiring all hospitals to adopt best practices for early identification and treatment of sepsis. The triggering protocol actually made some sense. It included a white blood count of less than 4000 or greater than 12,000, a temperature of less than 36 degrees centigrade of more than 38 degrees centigrade, and a heart rate of higher than 90, plus a known or suspected infection.

The problem with these so-called triggers is that they are low enough that they could be seen without sepsis and therefore a lot of doctors will simply ignore them or find them to be meaningless. Even if these values would be significantly out of range, a physician would still have to look at them or find them in order to act on them.

So, who was Rory, and what happened to him? Rory Staunton born May 13, 1999 and died April 1, 2012, was a young boy from Queens New York, whose death from sepsis created a nationwide movement to address the issue of early recognition of sepsis and its treatment. Rory got a scratch in the locker room. He was not sent to the school nurse to address his wounds. Most often an infection from a scratch would be plain old strep group A, the organism responsible for strep throat. His pediatrician drew labs, but didn’t look at them. When Rory went to the emergency room, they didn’t know he had had labs done so they didn’t look for the labs. It turns out his labs were abnormal, but no one looked at them. He was sent home where his condition worsened, and he became seriously ill before returning to the hospital the next evening, but by then it was too late and he died of sepsis at NYU Langone on April 1, 2012.

With sepsis, the body's coagulation system is falsely activated by the infection. Clots form in the most distant blood vessels first, and then travel slowly to the heart. Subsequent to this disordered clotting, all of the clotting mechanisms are used up, and if no treatment is rendered, the final cause of death is due to blood loss from hemorrhage because the blood has no remaining clotting ability.

Most likely staff at the hospital where Rory died came from three groups: private physicians, resident physicians, and teaching physicians. The same hospital fired Dr. Daniel because of the death of a mother and two weeks later in a separate event the death of a fetus in labor. This is most likely a systems problem which was erroneously addressed by firing Dr. Daniel. Such an action is scapegoating. This is a false solution that avoids the real systems problem, which means that the real problem continues to go on without a real solution.

Airplanes, for example, hardly ever crash for only one reason. Years ago a pilot was pushed out of the airplane when the airplane’s wind shield, under pressure, popped out He lived and so did everyone else on the plane. The investigators looked for the source of the problem, which was the wrong sized bolts holding in the window.

Rather than blame only the mechanic who placed the wrong bolts, investigators identified systems problems in the entire maintenance department. Since there are so many problems over so many years with the hospital where Rory died, there are most likely layers of problems in multiple systems. Firing one doctor has the appearance of problem solving, but still leaves the remainder of the systems problems unsolved. In short, hospital systems could learn from the airline industry about sincere pathways to improvement.

Today our dysfunctional healthcare system is overloaded with systems problems. Anything that distracts us from our primary goal of patient care is a potential systems problem. The EMR is so user hostile and intrusive that often a physician has a choice of taking care of the chart or taking care of the patient.

Taking care of the EMR chart has become so important because somebody from the Centers for Medicare and Medicaid Services (CMS) or another payer can come and look over a physician's charts several years later and decide they think the a chart note from five years ago is poor. Perhaps the note didn’t meet their required standards and therefore wasn’t considered a note at all. In the minds of these reviewers, a physician can be accused of fraud for collecting money for a service which the patient's chart doesn’t properly reflect, even something as insignificant as a poor chart note. Years later.

So, there are many systems difficulties or even systems errors that take us away from patient-centered care. If payers and government intrusions into the practice of medicine would just stop making matters worse and instead address real systems errors, I believe healthcare “errors” would begin to drop significantly.

Ninety-eight percent of providers want to do well.

So let us.