My date with sepsis

The Infectious Disease physician stares sepsis in the eyes.

“OK, we’re going to put your head down now.”

“So we’re waterboarding now?” No one laughed at my joke.

I have one hard and fast rule with writing and social media—I NEVER discuss my patients. I don’t want them to think our interactions are grist for writing. I have one exception—when that patient is myself.

I have written about my bout with COVID-19 in the past. Recently, I encountered a foe that I have wrestled with in the past, when taking care of other patients. This time was my turn.

The symptoms started when I noticed some frequent, and painful, urination. Due to family history and some equivocal diagnostic tests, three and a half weeks earlier, I had undergone a prostate biopsy. My main fear then, other than a possible cancer diagnosis (Negative!), was the development of a urinary tract infection. I had been given an injection of an effective, long-acting antibiotic at time of the procedure. I had a bit of pain and bleeding, that resolved in about a week.

I thought, “That’s weird. Maybe my urine is concentrated because I just didn’t drink enough. Maybe I’m anxious about upcoming knee surgery.”

I did what many people do—I ignored my symptoms and went to work.

My work that day involved rounding at a 400 bed hospital, walking all over the hospital. I had to stop more than usual to pee, but otherwise felt well. Until after lunch.

At first, I attributed my chills to the 500 mL bottle of cold water I downed at lunch.
But then the chills intensified. I checked my pulse—74 and regular. I flagged down a nurse, who was kind enough to take my temperature—97.6 degrees.

“Suck it up and go back to work,” I joked.

Still, the chills proceeded to shake my body and rattle my teeth. I knew this was rigors. I checked my heart rate again—115 beats per minute. I sent a message to my spouse and colleagues that I was headed to the Emergency Department (ED) to be evaluated.

As a physician of a certain age, we were trained to keep working no matter what. I know some younger physicians do the same, but happily, “self care” is more of a thing now than it was when I was in training. I felt bad that I had five more patients to see, but couldn’t see them. I also felt very bad that I was supposed to be on call, and now clearly could not do so.

I presented to the registration in the ED. “Do you want to sit in a wheelchair,” the kindly volunteer asked. “I’m not sure,” I said. He sat me in a chair.

I was triaged. The nurse recorded my vital signs—Heart Rate 115 beats per minute, Blood pressure 160/78 (high), temperature 97.8 degrees, respiratory rate 18.

Other than the elevated heart rate and blood pressure, nothing was amiss other than my symptoms. The elevated heart rate and blood pressure could be attributed to pain or anxiety.

As the ED was full, I was wheeled over to a waiting area for room for evaluation to open up. Astutely, the triage nurse had alerted the clinical team to my symptoms, and a phlebotomist in the waiting area drew blood tests, including blood cultures, and gave me a cup for urine testing. Unfortunately, I could not go yet.

Eventually, I was wheeled down to an open evaluation bay, and that’s when things really got interesting.

After stumbling to the bathroom to procure the vital urine sample, I collapsed onto the gurney in the evaluation bay. Soon an IV was started, maintenance fluids were started, a physician assistant, then ED physician came to see me, test results started coming back.

Urinalysis confirmed a urinary tract infection (UTI), blood tests showed my white blood cells somewhat above normal (14.8) and my heart rate continued in the 115 range. My temperature was rising to 102.3. After a CT scan to confirm the bladder and prostate were inflamed, but no abscess or kidney blockage, an antibiotic was started.

I received some narcotics for pain, was just starting to feel good, and things suddenly changed.

Another nurse was summoned to start a “large bore” IV—a bigger IV in a bigger vein, in my right antecubital fossa—the area where the elbow bends. Large bore IVs are inserted when large amounts fluids need to be quickly administered.

“Your blood pressure is 85/45.” Quickly, a “rapid response” was called, and an ICU nurse came to evaluate me. I had been placed in Trendelenburg position, with my head down and feet up. This maneuver is used when blood pressure is low, and there is concern about perfusion of blood/oxygen to the brain. That’s when I made my waterboarding joke.

At this point, the diagnosis was severe sepsis with septic shock. The source was clearly from the urinary tract; it would take another day or two to know if infection had spread to my blood stream. The severe shaking chills made me suspicious that it had.

My Infectious Disease brain was not shut off. I mentioned to the nurse that with my change in status, maybe the doctor should be called about adding a second antibiotic, called vancomycin, which is used to treat MRSA, a drug resistant Staphylococcus aureus infection. I’ve never had MRSA, and my only antibiotic exposure was three weeks earlier at the prostate biopsy, but I am around it every day at the hospital. I had been around enough patients to know that about a third of S. aureus blood infections, MRSA or otherwise, are “spontaneous”—no preceding risk event.

After more fluids were administered, and my blood pressure started to stabilize—not normal, just not life threatening—I was deemed stable enough to transfer to a regular hospital bed, outside of the ED.

By 11 pm, I was in a room with a more “normal” bed—although hospital beds are built for utility, not comfort—and a room with a bathroom. I shooed my wife home, knowing that she would not be able to sleep in my room. Thankfully, my wife is a retired nurse and strong advocate for her husband. When the night shift nurse said, “We only check vitals once a shift,” my wife admonished her that the ED was checking them every 30 minutes, and this should continue.

She was right, as around 2 am, my blood pressure again went down to 80/40, another “rapid response” was called, and another ICU nurse was summoned to evaluate me. He performed a non-invasive cardiac output monitoring (NICOM) test, and determined that more fluids would not raise my blood pressure. Fortunately, for whatever reason, my blood pressure did start to slowly improve, and further medication called pressors, specifically Levophed (norepinephrine) would not need to be started.

As I was supposed to be working that day, I’m appreciative that my colleagues stepped up to cover for me. Nevertheless, the answering service sent me a message to see a consult—on myself!

It took another day or so for my fevers to stop, my blood pressure to return to a more normal range. After the urine culture returned with E. coli, the most common cause of UTIs, with a fairly normal antibiotic resistance pattern, I was sent home on some oral antibiotics.

I’ve known that being a patient in the hospital is not a comfortable experience, despite the best intentions of staff and administrators. The beds are built for utility, not comfort. While hospitals try to reduce noise and light disturbances, there were alarms and staff activity that prevent deep sleep. The lights from the parking garage across from my room shone all night, as did the anteroom light for my room. Too much light, noise, pain, meds and sleep deprivation can cause delirium.

When I returned home, some 60 hours after leaving home, my weight was up about 12 pounds. This is about an extra 5 liters of fluid, from intravenous antibiotics and other fluids, that had been administered to save my life. Weak from sepsis, I was forced to carry extra weight as well.

It was sweet relief to curl up in my own bed, exhausted from the events of the last few days, and grateful for the expert care I had received from all the nurses, aides, and physicians.

Now I am recovered, but still taking antibiotics. I needed about a week at home to fully recover. My wonderful spouse and family took great care of me in the hospital and at home.

Sepsis is a wily foe. Diagnosis is based primarily on signs (physical findings on exam, including vital signs) and symptoms. There is no single diagnostic test that can confirm the presence. My white blood cell count was elevated. My lactic acid level was normal. My initial procalcitonin was normal, but later became quite elevated. It can take some time to find the source. Sometimes, no definite source is found. It is the third leading cause of death in the United States, primarily in people older or sicker than I am at this time.

Even when appropriate antibiotics are started, sepsis can get off and running, with organ injury begetting organ injury. The kidneys and lungs and heart and liver can all get damaged at the same time. It is a scenario I have seen many times. I’m grateful it didn’t happen to me this time.

My mistake was ignoring early symptoms of a UTI—and going to work instead of going to urgent care. Had I started antibiotics earlier, I might have avoided hospitalization.

The lesson for me is: when sick, don’t suck it up—go get help.

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Addendum: After I wrote this post, my wife, who was at my side through almost the entire ordeal, pointed out numerous inaccuracies in my recollection.

“I told you to go to the Emergency Room.”

“You were in Trendelenburg three times.”

“They called three rapid responses on you.”

“They were checking your vital signs every ten minutes in the Emergency Room.”

I blame septic shock brain and sleep deprivation for my hazy recall. And a reminder as a clinician that sick patients can’t always be trusted to get their story straight!