Undiagnosed Sepsis Results in Multiple Amputations

This case involves a male patient who presented to an urgent care facility complaining of abdominal pain that had been persistent for several days. The patient was seen by a nurse in the walk-in clinic, who consulted with a physician who was not located on-site but was available for consultation via telephone. At the clinic, the patient was assessed by the nurse and physician over the phone, who diagnosed him with a likely ureteral stone. At the time that this diagnosis was made, the nurse voiced concerns that the patient may be septic and conveyed this to the remote physician, but her concerns were dismissed and never investigated. The following day the patient’s condition continued to grow worse, at which point he presented to the emergency room. After being admitted to the hospital, the patient waited for more than a day before he was seen by a urologist, after which he was taken to the operating room to have a stent placed to relieve his urinary blockage. The stent was placed without incident. Shortly after the stent was placed, the patient developed disseminated intravascular coagulation, at which point he coded and was successfully revived. After this incident, the patient was noted to have vastly decreased urine output, as well as a continuation of his disseminated intravascular coagulation with a substantially lowered platelet count. Doctors noted that the patient had no detectable pulse in his extremities, and that there was evidence of early stage tissue necrosis on his hands and feet. Over the next several hours he was found to have tissue necrosis in all four limbs, which required amputations of both feet and hands. Subsequent testing revealed no signs of urinary stones, and indicated that the patient’s original symptoms were likely the result of sepsis.

Question(s) For Expert Witness

1. Do you treat patients who present with symptoms of sepsis?

2. What protocols should be followed to diagnose or rule out sepsis?

Expert Witness Response E-006911

I am a Board Certified Internist, and I have actively cared for patients in both emergency room and inpatient settings for the last 18 years. I regularly treat patients who present with symptoms of systemic inflammatory response syndrome (SIRS) or sepsis. A certain degree of suspicion needs to be held for possible SIRS or sepsis based on how the patient presents, with their heart rate, blood pressure, white blood cell count, and urinalysis measured and taken into account. In addition, aggressive intervention with IV antibiotics and possibly surgical intervention needs to be undertaken in a timely manner if called for. While I can understand how this patient's course could deteriorate in the fashion described in the case of undiagnosed sepsis, I personally have never had a patient with a similar outcome. Essentially, this patient's presentation, along with the nurse's concerns for sepsis noted when the patient first presented to the urgent care facility, should have caused a concern for sepsis and triggered the appropriate testing and treating protocols. Had the possibility of sepsis been entertained then, then it is likely that more aggressive intervention would have been pursued and implemented in a much more timely fashion than was done in this case. While it is difficult to say exactly what this patient's outcome would have been even with treatment, it is likely that it would have been far more favorable had the appropriate care been rendered.