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Defining sepsis

  • June 1, 2014 12:10:08 PM PDT

    May I please ask for a non 'cookie cutter' definition of sepsis? Definitions are easy to come by but the value of the definition leaves a lot in question.

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    June 2, 2014 10:07:57 AM PDT

    Greetings, I would be glad to discuss this with you. I think what we can do is define Sepsis as per the current definition. Pull the original article that defines this. and then see how they chose to do that. From our prior conversations I understand that you have probably been informed of the standard definitions. 

    Please be patient, I will add more later today. UpToDate is not loading right now. They usually have links to the best references and are often a great starting point for a literature review. It will be a few hours before I can add more information about this. 

    Kindest regards. 

     

    -BrettMD


    This post was edited by DrSocial Admin at June 29, 2014 12:04:59 PM PDT
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    June 2, 2014 3:54:08 PM PDT

    Greetings,

    SurvivorsOfsepsiS

    The current defintion of Sepsis was decided at a committee meeting in 1991, and the article was published in 1992. In medicine, and in life, we have to use that which we can observe or measure to predict what is going on elsewhere. 

    What I am trying to say is, clinical criteria and definitions of disease are often defined by committees that use the best available evidence to, (as reliably as possible), predict what is actually occuring. Please let me know if you have any questions or if I can rephrase things in a different, hopefully better, and more cogent way. If what I say isn't clear, let me know and I will do my best to make it clear. Again, doctors aren't perfect, I am not a world-expert on sepsis, but I would be glad to work with you to better explore the definition of Sepsis and how it came to be.

    http://www.ncbi.nlm.nih.gov/pubmed/1597042

     

     

    Crit Care Med. 1992 Jun;20(6):864-74.

    American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.

    [No authors listed]

    Abstract

    OBJECTIVE:

    To define the terms "sepsis" and "organ failure" in a precise manner.

    DATA SOURCES:

    Review of the medical literature and the use of expert testimony at a consensus conference.

    SETTING:

    American College of Chest Physicians (ACCP) headquarters in Northbrook, IL.

    PARTICIPANTS:

    Leadership members of ACCP/Society of Critical Care Medicine (SCCM).

    RESULTS:

    An ACCP/SCCM Consensus Conference was held in August of 1991 with the goal of agreeing on a set of definitions that could be applied to patients with sepsis and its sequelae. New definitions were offered for some terms, while others were discarded. Broad definitions of sepsis and the systemic inflammatory response syndrome were proposed, along with detailed physiologic variables by which a patient could be categorized. Definitions for severe sepsis, septic shock, hypotension, and multiple organ dysfunction syndrome were also offered. The use of severity scoring methods were recommended when dealing with septic patients as an adjunctive tool to assess mortality. Appropriate methods and applications for the use and testing of new therapies were recommended.

    CONCLUSION:

    The use of these terms and techniques should assist clinicians and researchers who deal with sepsis and its sequelae.


    This post was edited by DrSocial Admin at June 29, 2014 12:05:52 PM PDT
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    June 2, 2014 3:59:13 PM PDT

    The following is from an uptodate article

    found 

    http://www.uptodate.com/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis

    Please download the text once you read it. Although it is not the full-article, I may need to redact (or remove) some of it, as it may extend beyond what is known as "fair-use." 

    Infection — Infection is the invasion of normally sterile tissue by organisms.

    Bacteremia — Bacteremia is the presence of viable bacteria in the blood.

    Sepsis — Sepsis is the clinical syndrome that results from a dysregulated inflammatory response to an infection. Sepsis is defined as the presence (probable or documented) of infection together with systemic manifestations of infection. Diagnostic criteria for sepsis include infection (documented or suspected) and some of the following [2,3]:

    General variables

     

    Temperature >38.3 or <36ºC

     

    Heart rate >90 beats/min or more than two standard deviations above the normal value for age

     

    Tachypnea, respiratory rate >20 breaths/min

     

    Altered mental status

     

    Significant edema or positive fluid balance (>20 mL/kg over 24 hours)

     

    Hyperglycemia (plasma glucose >140 mg/dL or 7.7 mmol/L) in the absence of diabetes

     

    Inflammatory variables

     

    Leukocytosis (WBC count >12,000 microL–1) or leukopenia (WBC count <4000 microL–1)

     

    Normal WBC count with greater than 10 percent immature forms

     

    Plasma C-reactive protein more than two standard deviations above the normal value

     

    Plasma procalcitonin more than two standard deviations above the normal value

     

    Hemodynamic variables

     

    Arterial hypotension (systolic blood pressure SBP <90 mmHg, MAP <70 mmHg, or an SBP decrease >40 mmHg in adults or less than two standard deviations below normal for age)

     

    Organ dysfunction variables

     

    Arterial hypoxemia (arterial oxygen tension [PaO2]/fraction of inspired oxygen [FiO2] <300)

     

    Acute oliguria (urine output <0.5 mL/kg/hr for at least two hours despite adequate fluid resuscitation)

     

    Creatinine increase >0.5 mg/dL or 44.2 micromol/L

     

    Coagulation abnormalities (international normalized ratio [INR] >1.5 or activated partial thromboplastin time [aPTT] >60 seconds)

     

    Ileus (absent bowel sounds)

     

    Thrombocytopenia (platelet count <100,000 microL–1)

     

    Hyperbilirubinemia (plasma total bilirubin >4 mg/dL or 70 micromol/L)

     

    Tissue perfusion variables

     

    Hyperlactatemia (>1 mmol/L)

     

    Decreased capillary refill or mottling

     

    Severe sepsis — Severe sepsis refers to sepsis-induced tissue hypoperfusion or organ dysfunction with any of the following thought to be due to the infection [2,3]:

    Sepsis-induced hypotension

    Lactate above upper limits of laboratory normal

    Urine output <0.5 mL/kg/hr for more than two hours despite adequate fluid resuscitation

    Acute lung injury with PaO2/FIO2 <250 in the absence of pneumonia as infection source

    Acute lung injury with PaO2/FIO2 <200 in the presence of pneumonia as infection source

    Creatinine >2 mg/dL (176.8 micromol/L)

    Bilirubin >4 mg/dL (34.2 micromol/L)

    Platelet count <100,000 microL–1

    Coagulopathy (INR >1.5)

     

    Sepsis-induced hypotension is defined as a systolic blood pressure (SBP) <90 mmHg or mean arterial pressure (MAP) <70 mmHg or a SBP decrease >40 mmHg or less than two standard deviations below normal for age in the absence of other causes of hypotension.

    Sepsis-induced tissue hypoperfusion is defined as infection-induced hypotension, elevated lactate, or oliguria.  

    Septic shock — Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation, which may be defined as infusion of 30 mL/kg of crystalloids (a portion of this may be albumin equivalent). Septic shock is a type of vasodilatory or distributive shock [2,3]. In other words, it results from a marked reduction in systemic vascular resistance, often associated with an increase in cardiac output. (See "Shock in adults: Types, presentation, and diagnostic approach".)


    This post was edited by DrSocial Admin at June 29, 2014 12:06:48 PM PDT
  • June 2, 2014 6:41:39 PM PDT

    Thanks for this information. I have access to a large number of journals, am therefore familiar w/above as quoted. Understand potential redaction.  

     

    I need a bit of time before I'm able to reply.

     

    Thanks 

     

     

     

     

    • Moderator
    • 1957 posts
    June 2, 2014 8:16:38 PM PDT

    No problem, if you have any particular question about anything feel free to ask, and I can elaborate on it. The article is itself mostly medical jargon, and I am glad to discuss any and/or all of it. A nice website I like is the free dictionary:

     

    http://medical-dictionary.thefreedictionary.com/dictionary

     

    Thanks

     

    -BrettMD

  • June 4, 2014 5:14:23 PM PDT

    Particular questions ..yes, I have several;

     

    Yes or No?

    ~sepsis is a systemic inflammatory response to an infection

    If Yes

    Yes or No?

    ~a systemic inflammatory response to an infection can occur in any number of instances including the smallest patch of swollen red skin on a hangnail, a scraped knee, a freshly peirced ear or something more serious, like a kidney infection?

     

    I'll leave it here for now.

    Thanks.

    Paige 

     

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    • 1957 posts
    June 4, 2014 5:23:39 PM PDT
    SurvivorsOfsepsiS said:

    Particular questions ..yes, I have several;

     

    Yes or No?

    ~sepsis is a systemic inflammatory response to an infection

    If Yes

     

    Yes or No?

    ~a systemic inflammatory response to an infection can occur in any number of instances including the smallest patch of swollen red skin on a hangnail, a scraped knee, a freshly peirced ear or something more serious, like a kidney infection?

     

    I'll leave it here for now.

    Thanks.

    Paige 

     

    Thank you for your questions Paige

     

    In reply to question one: the answer is "Yes," to the best of my knowledge. 

     

     

    In reply to question "two." That is an excellent question. In order for me to answer it, I will review the literature for granularity on the topic and based upon that information answer your question, and then put the answer in context.

     

    Context matters and one of the means that sham peer-review (and politics) use to malign their opponent is taking a text out of context. A few words that in a sentence have one meaning, but when used alone can mislead those who hear it. Sham peer-review and politicians often use such tactics to display their opponent in a negative manner.

     

     

     

     

    Please be patient, and I will see if I can find data that will provide me with sufficient granularity to answer that question whilst maintaining an objective, evidence-based approach. 

     

    Kind regards,

     

    BrettMD


    This post was edited by Brett Snodgrass at June 4, 2014 5:28:02 PM PDT
  • June 4, 2014 6:16:42 PM PDT

    Thanks very much. I have a large number of references that speak to this; I'll gather some links and post here.

     

    Context does matter, agreed.

     

     

     

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    June 4, 2014 6:27:12 PM PDT

    You are welcome, and Thank you, that is awesome, Please do share at your convenience. 

     

    Kind regards,

    Brett

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    June 9, 2014 8:09:28 AM PDT

    Dear Survivors of Sepsis, 

     

    I apologize for the delay in providing quantitative data in regards to your second question. 

     

    I presently only have access to two libraries. As you can imagine, it can be an added challenge to do research in such a setting. 

     

     

    Anytime that a bacteria enters the blood stream, it is theoretically possible that it could initiate sepsis through toxin release, and replication. 

     

    The body has an impressive immune system and (inflammatory / anti-inflammatory) system which presumably prevents sepsis after cases such as a scraped knee. 

     

    However, Kidney infection is much more likely to initate sepsis... Does that answer your second question? 

     

    Thanks, 

     

    BrettMD

     

    (oh, since I am on the website, yet I know you from Twitter too, I will be formal and use "BrettMD." to sign my notes.. 

    I got the idea from KevinMD. :)


    This post was edited by Brett Snodgrass at June 9, 2014 8:10:31 AM PDT
  • June 9, 2014 11:12:05 AM PDT

    Thank you, I appreciate the feedback.

     

    Being honest; it's much what I expected so, no, it doesn't really answer the question but that does not reflect poorly on you, your efforts or the resources (or lack thereof) which you have access to.

     

    I am fairly confident saying, there isn't anyone who can answer this or many other questions with any degree of absolute knowledge.  After more than 200 years of research I believe sepsis remains a complete unknown.


    It isn't rational.  There are no answers.


    Paige  

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    • 1957 posts
    June 10, 2014 5:35:21 PM PDT
    Hi Paige,


    Thank you for your comment. What exactly isn't rational about Sepais to you.

    Some bacteria are more virulent than others, and some people are probably more susceptible to the onset of SIRS, ~ a semiquantitative situation.


    It probably isn't a complete unknown. My aim is to add more information this summer and acquire library acces to Ovid.

    Kind regards,
    -BrettMD
    This post was edited by Brett Snodgrass at June 10, 2014 5:38:02 PM PDT
  • June 11, 2014 6:27:51 PM PDT

    Hi Brett. 

    You're correct, sepsis is likely not a complete unknown.  

     

    My random choice of Twitter account names created this 'place' I now exist.  You see, a large number of accounts have Followed me over the past 18 months with the assumption that I have answers and I know, for a fact, some of them came to assume this based solely on the name I chose for my account.  The irony; it's these exact same accounts to whom I turn for the same information they seek from me.

     

    What do I find irrational about sepsis?  There is no reliable, consistent source one can turn to for answers. Surely, if this intelligence existed there would be an abundance of information; this is, afterall, the age of available information and sepsis is the flavor Du Jour ...yet no one is shouting out loud or even speaking up softly saying they have answers.  If answers do exists they're being handed out sparingly,quietly ...almost fearfully.

     

    Knowledge is acquired to learn, put into action, share proof of and teach others.  I find it irrational that no one has laid claim to stewardship of the provision of such highly sought after information. 

    • Moderator
    • 1957 posts
    June 12, 2014 7:55:01 AM PDT
    Hi Paige,

    Thank you kindly for your reply. Perhaps we view Sepsis a bit differently.

    It is already defined by a committee which is the best way to define medical conditions. I saw this long ago and asked 5,000 pathology residents if any of them might be interested in collaborating with me on the "vessels of Wearn," or other preferred term.

    During medical school I told my peers that, If I ever discover anything, I am adamant that it be named as thematically as possible to help others learn.

    There are some people who , lack insight, and take offense to the claim that they lack insight, react with rage to being asked a single question. They may be interested in naming something after themselves.

    However, most people, and especialy those who do research are seeking the common good of mankind. Reducing the suffering from disease. Thus, it is important to train future physicians, not to lie, or to let patient harm occur as at least one academic department does (verifiable by identifying case of patient harm that wasn't reported to the hospital safety network.) .. but to train future doctors as effectively as possible and put them in a position so that when they do research, they don't spend months reading through thousands of articles trying to figure out which ones are correct, which ones are incorrect, and why. Such misinformation enters the literature when people, often with egos, do not permit criticism of themselves and do not permit ethical peer review.

    For example, I noticed more than 20 errors in the publication of a pathologist about the coronary arteries. I E-mailed him and offered to let him retract the article. He was not intersted. It is shocking, but some in medicine (thankfully few, frequently pathologists, but small sample size), do not want to report accurate information, but only want the rewards that come to them from their work.

    So this relates to Sepsis, we have a definition, there is research being done, a recent article was published in NEJM regarding it. There is no new "sepsis," to define, but if there were, I would try to collaborate with multiple organizations and world-leaders as I am "trying," to do with some of the coronary artery nomenclature.
    • Moderator
    • 1957 posts
    June 12, 2014 8:12:47 AM PDT
    Here is the NEJM article. There are actually several recent articles on Sepsis, but this was the one I was referring to. http://www.nejm.org/doi/full/10.1056/NEJMp1400276
    Sepsis, the syndrome of dysregulated inflammation that occurs with severe infection, affects millions of people worldwide each year. Multiple studies suggest that the incidence of sepsis is dramatically increasing. According to the Centers for Disease Control and Prevention (CDC), for example, sepsis rates doubled between 2000 and 2008.1 In 2010, sepsis was the 11th leading cause of death in the United States,2 and in 2011, it was the single most expensive condition treated in hospitals.3
    This apparent explosion in sepsis is spurring high-profile initiatives to promote earlier recognition and better treatment. Standardized screening protocols, bundled order sets, and algorithms for early, goal-directed therapy are becoming the norm in hospitals throughout the country. These algorithms typically require clinicians to measure lactate levels, deliver a minimum amount of fluids, draw blood for culture, and initiate treatment with broad-spectrum antibiotics, all within a narrow window of time. Some also require placement of a central venous catheter, admission to an intensive care unit (ICU), or both.
    Policymakers are actively encouraging these efforts. In response to the well-publicized death of a 12-year-old boy from unrecognized sepsis, New York State now requires all hospitals to adopt sepsis protocols (“Rory's Regulations”). Later this year, New York will begin requiring hospitals to report protocol-adherence rates and outcomes. Other agencies may soon follow suit. The National Quality Forum (NQF) recently ratified a metric for adherence to sepsis protocols, and the Centers for Medicare and Medicaid Services (CMS) is considering whether to adopt the NQF metric for public reporting and payment programs.
    The attention and resources being dedicated to improving sepsis care are welcome. The policy response to this apparent epidemic, however, ought to be tempered by two limitations. First, the publication of the ProCESS study in the Journal (pages 1683–1693) reminds us that we still have much to learn about how best to organize sepsis care. Second, we do not yet have reliable tools for measuring sepsis incidence. Current methods are based on analyses of insurance-claims data using sepsis-specific codes or separate codes for infection and organ dysfunction.

    --------------
    Again, I apologize about being defensive. I workded with someone who had such malicious prejudice that they would fabircate numerous evil claims and malign me with them day after day. It was horrible. For example, registering a book in my name to assess my honesty. They should be slapped by the medical board with a fine for such disrespectful conduct, that is also unethical and unprofessional. This person also accused me of having narcissitic personality disorder. Lol, it is kind of funny because personality disorders are life-long conditions, and I had been working clinically, unlike the pathologists, with USA licensed physicians for 9 years before she had the sole authority to evaluate me. My evaluations went from satisfactory-to-good to terrible. Shame on me for refusing to learn, and blaming others, despite the incompetent documentation.

    In any case there are many problems in medical regulation when patient care is put behind academic title.

    So what I am trying to say, and I apologize for, is that I am afraid someone is trying to accuse me of wanting to name things after myself. There was only one person who ever did that, but the fact that this person was listened to exclusively, in spite of incompetent documentation boggles the mind and highlights the need for accountability in medical regulation.

    There are other examples similar to this also. For example, the Medical Board, reprimanded a physician for providing excellent care to an obese patient. The FDA was on the doctor's side, and a lack of knowledge was on the Board's side.

    I think the factors that contribute to this are a
    1. lack of communication.
    2. Entitlement by board members to be better than others and a true desire to protect the public. However, this desire to protect the public is a sign of good moral character, is not matched by any responsibility for their decisions. If they could throw every other physician in prison in order to do their job they might, or do something similar.

    When we encounter problems in the medical literature, in medical regulation, it often opens a unique perspective into how to improve those.

    For example, with the peer-reviewed publications, I ultimately realized that the confusion in medical literature occuring in the 1960s & later would probably not have occurred if there was a distinct term for the "vessels of Wearn."

    Similar to the physician who was reprimanded by the medical board for preventing patient harm, I was reprimanded for preventing patient harm.
    This is affirmed by multiple emails to the DIO, and later by Dr. Zia writing an email voicing the same concern I had been voicing for months.
    Nonetheless, the medical board has written that I was not processing specimens correctly. I was processing them according to the standard guidelines. Similar to the excellent cardiologist from columbia missouri who was prosecuted for months by the medical board, because they did not take 15 minutes to read the cardiology guidelines, and to the doctor who appropriately treated their obese patient, I too have been reprimanded for providing appropriate medical care and speaking up for patients.
    Indeed, I offer people the opportunity to challenge that claim openly. Yet instead of dialogue about how to improve patient care when serious problems do exist, I was called unprofessional, disruptive, and unethical at UMKC. Pardon, but in case the medical board did not hear earlier, the majority of the attendings (two) lie repeatedly. One doctor I like, called me a misfit. I will NOT lie and say that Dr. D did not call me a misfit, but I understand that when the chair says "did you call Brett a misfit," he is probably thinking oh my gosh, I have to feed my kid... However, if you across the street to Children's Mercy Hospital, I have NEVER seen one of their pathologists lie, NEVER. This is in contrast to frequent and singificant lying by many staff members in another department. Dr. Daniel Goleman discusses such situations. However, instead of investigating this, the person in charge of the Department simply claims, that my intentions are malicious to harm her. Excuse me, but she is making a claim about my intentions in order to not discuss the validity of my claims which are supported by multiple supplementary sources, photographs, lectures, video records of time in the department and more.


    The problems which I have unfortunately encountered, eg. being accused of refusing to learn, and then having the medical board regurgitate the same vague, nondescript, incompetently documented claims is a red flag. Surely a medical board would recognize that impaired physicians should not be caring for patients, and when the Chair documents this repeatedly it provides the person adversely effected by the problem interest and motivation to understand how to resolve it. Since numerous physicians and a hospital multidisciplinary evaluation confirmed that I was NOT impaired at work as the claims were asserting (somewhat impaired in the gross room), (unsteady,

    Usually clinicians try to match the clinical signs to a known medical conditions, but it is unclear what the Chair was thinking on her differential diagnosis as being unsteady could be due to many conditions. What is further concerning is that she never said or did anything to investigate the unsteadiness. This was in September, 2010. Again December 3 and December 28 2010, and several times in 2011 there were multiple claims written in a resident's academic file about impairment, but the Chair made NO effort to investigate this with aim of understanding the cause.


    For example, on December 03,2010 I was reportedly impaired or befuddled in the frozen section room. Instead of investigating this potential impairment that could result in patient harm, the UMKC Pathology Chair waited 14 days to write that, and placed it in my academic file!

    A similar event occurred on 12 28 2010 when the Chair decided that I was "impaired in the gross room," Do you know how I found out about this. I found out about it around April 19, 2011 by reviewing hundreds of pages of poorly documented "tabloid-like assessments."

    What is more shocking, is that the Medical Board, did not find this to be a huge red flag, including that the Pathology Chair made no documented attempt to do anything to investigate this impairment is a *sign* that regulation of medicine is not seeking out problems and resolving them, it is letting patients go without care, awarding incompetent and bizarre documentation, whilst reprimanding the person who diligently, and politely, and repeatedly asked critical questions about that.


    The GME committee, instead of recognizing the aformentioned, they "of course," agreed with the chair, said NOTHING to me about how I felt my energy level was doing, or telepathically measured by the pathology chair.. this is during the appeal meeting in May 05, 2011..., and then decided that I "lack energy and understanding."


    My case, my life, my career, and other's careers have highlighted how problems are systematically regurgitated by "presumably very intelligent people," who make decisions at about the capacity of a ten-year old, with an IQ of 80, at best.

    Seeing multiple common sense failings in the healthcare setting at multiple levels, significant challenges in implementing appropriate care of patient's mastectomy specimens, and then seeing these claims, which any high school student would likely not believe, be recited verbatim by a medical board highlights a most significant problem within the healthcare system.

    For example, I personally do not think that the medical board is helping the public by asserting that excellent care is: Inappropriate medical care.


    Recognizing and painfully experiencing these problems, both over a period of ~three years, has permitted me to begin to try to address them. I certainly cannot do it alone, and in my effort to find collaborators, I have met many of the world's most famous physicians. For many doctors, meeting a physician who publishes 70 articles by the age of 35 in a most competitive medical speciality is like meeting a famous musician. Then, and due to the continual problems with medical regulation (many think things are just fine, but they are also completely immune regardless of their decision making)..I am able privileged to connect with the most famous physicians in medical regulation.

    Please pardon the discordant and slightly poor prose that I am writing with. One thing that many may not consider, is that the burden of correcting misinformation is approximately 10-100x times greater than writing a nice, organized piece of information that everyone understands.

    The reason that it is difficult, is not a lack of understanding...., as I was formerly accused of. Physicians don't suddenly have a lack of understanding-flaw when the attending physician refuses to explain their atypical formal letters....is because people assume that the following type of information is true: a story that someone creates by conflating, some true information that is distorted, and varying degrees of blatantly false information.

    For example, refusal to learn. The Chair tried to suggest that I had difficulty paying attention. Yet< I was never permitted to cross-examine her, she never considered a control group of residents, and she ignored numerous positive evaluations by several evaluators at Children's Mercy Hospital.
    I am fortunate that I have
    been able to connect with healthcare leaders around the country who have noble aims, but they may not see the same systematic flaws in medical regulation that I have seen, experienced, and I have seen their ultimate effect on patients who are turned away from a full-clinic due to the physician shortage. The pathologist who prefer title to performance might say "I am an ACGME board certified physician, and I am therefore competent." Nonetheless, even pre-nursing students know that a symptom is what a patient tells you, and that symptoms cannot be determined

    Thus the pathologist may claim to be an expert, but I would be highly skeptical of acceping any clinical advice form a physician who thinks she can report clinical symptoms that the patient never even mentioned. This becomes problematic when numerous other physicians assume the Chair is clinically competent enough to distinguish between the two. My guess is that she would be, as she is very intelligent, yet the malignant personality, fraudulent or incompetent claims, continued false inferences, including a sudden inability to report my clinical competency (November 2013), are evidence that some people refuse to be accurate. With the physician shortage, medical boards should not be removing physicians and claiming they don't have enough training when the physician they are removing has more training than some of them.

    Let us work together, find the high-quality sources of information on Sepsis, and I will remain honest, even when it is harmful to myself. I will not lie and say that letting potential patient harm occur is okay.

    My thoughts is that there may be many more cases, including one about a cardiologist ,who was prosecuted for months by the ignorant medical board. I say ignorant because they did NOT even read the guidelines. The judge said their conduct was shocking for a state agency. Due to the intimidating nature of medicine, the Mayo clinic administration NOT being everywhere to seek excellent care, implementing improvements with the ultimate aim of improving society, patient care, including the number of patients receiving care, and then medical boards that feel justified in spending months prosecuting good care and/or gossip... is a very large challenge. Thankfully I have met some amazing physicians and patient advocates on Twitter, and I have been telling the exact same true story for three years. I was called a liar by the medical board, but they were unable to say what about a website was not true.



    I will try to review the medical literature on Sepsis and provide more granularity to the information posted. As for now, we can say when it is appropriate to diagnose sepsis. When physician make a diagnosis, they then usually pursue a treatment. Pathologists used to receive an intern year where they would learn to communicate and obtain critical information in a timely and pleasant fashion. Unfortunately, a lack of this, and leadership then given to the subsequently trained persons, has created a cycle of harm, misinformation, and numerous physicians trained to alter their (the patient's) results, lie and simply stay below the radar.

    Again, I can state when a person should make the diagnosis of sepsis, what sepsis is, what can cause it, but I cannot answer the question which you have alluded to, but haven't asked directly.

    What I mean is, could you please elaborate on your statement that: there is no reliable, consistent source one can turn to. Why do you feel that way, and if you can let me know two sources you have, and what your question is about any discrepancy, then I would be glad and probably more than able to help you.

    Also feel free to share ideas on how we as a society can improve transparency, equity, and the quality of patient care through prudent medical regulation.

    Kindest regards,
    This post was edited by Brett Snodgrass at June 12, 2014 9:07:27 AM PDT
  • June 12, 2014 11:55:18 AM PDT

    I am VERY impressed with your reply and appreciate a deeper sense of why you do what do, with such passion.  I, in fact, have been in this similar situation, not once ...but twice in the past 5 years and although not a risk to me professionally, very much has been at stake, personally.  So, just understand at least one person is totally ok with 'you being you' regardless of past judgments made by others.

     

    My brain is in meltdown at the moment and I don't have as many good hours in a day as I'd like to but I will respond to the above posts within a day or two and I am very sincere when I say Thank you, you really are the best.

     

    Paige Ward 

    • Moderator
    • 1957 posts
    June 13, 2014 5:03:02 PM PDT

    Paige,

     

    You are far too kind. Dealing with negative reviews feels negative, but my aim is to 1. be accurate, 2. be equitable, 3. admit wrongdoing when I have done it. 4. Advocate for change. 

     

    It used to be illegal for physicians to advertise. Seriously, they could not post that they have a business here, or there, and do this type of surgery. 

     

    I am sorry to hear that you have had similar experiences twice. It can be very frustrating when people assume that one person is correct and then do not permit cross-examination (well, outside of court). 

     

    Regardless of the judge's decision, I am going to start working with State Representative to try and help improve medical care for the poor. for example. People shoudn't be turned away from clinic, and that they can't be seen, because the medical board thinks blaming someone isn't good. If I harmed a patient or something, it may be understandable, but they set the bar of professionalism near perfection, but they accept unlawful activities that are more common. For example, I have never received a speeding ticket, or anything other than disturbing the peace, once, in 2012 in an effort to get the Pathology Chair to do her job and reply to me with feedback. 

     

    It had absolutely nothing to do with patient care, and had she performed her job or conducted her evaluations in a manner that is ethical per the American Medical Associaton, I would never have considered such a foolish decision. 

     

    The issue is that the medical board never thinks that the person with a higher academic title might be wrong. 

     

    After providing appropriate, yes I said appropriate medical care, by diagnosing a blast cell on a peripheral blood smear, the patient received a bone marrow biopsy. The pathology chair filed a patient safety report AGAINST me for GOOD care. She said that there was plasma cells in the bone marrow and that the cell in the peripheral blood was therefore a plasma cell. As I detailed, and the medical board repeatedly ignored ( I have contacted them several times from 2011-2014), there is often distortion of information. What I mean is that the argument is specious, and leaves out critical information. People read what is written and see, oh plasma cells, and they don't usually backtrack to bone marrow, peripheral blood etc. 

    Yet, I digress. It takes a great deal of reporting to make all of the connections when false inferences are subtle but frequent. 

     

    Also medical regulation needs to change, and doctors won't be the one's to advocate for poor patients. For example, there is a shortage of physicians. The real-world impact is that people will not receive care and maybe even die when a medical board chooses to decide that a physician "blamed someone," and therefore cannot practice. The FBI is investigating the VA, and what they find is no different than what they will find in the UMKC Pathology Department, or the Missouri Medical Board. There is fear and intimidation, and physicians cannot speak up for their patients. Now, this doesn't happen at most places, and so there are those physicians who think medical boards shoud be immune. Why would physicians on medical boards need immunity if they judged their peers equitably. 

     

    Furthermore, they have no accountability to provide care for patients. Physicans are imperfect, eg, (I sent too many emails from the FDA to some jerk who lied about me for two yers). Instead of saying, "oh, we might kill a few people because they cannot receive medical care due to a lack of providers, they say, "this doctor does not have good moral character." 

     

    Some of the doctors they prosecute are very bad people, and I think that they label every person who they receive a complaint about as the doctor who covered up patient harm and told no one. 

     

    The AMA Code of Medical Ethics would provide a good reason that peer reviews could be immune for their decisions, but if closely analyzed, many places conduct sham peer review. The doctors don't say, "I really need to remove any bias I might have and consider both sides of this scenario." Instead physicians say, 

     

    I have seen a resident contemplating changing the patient's results because the numbers were similar and someone might accuse her of making them up. 

     

    An atmosphere where the person who provided appropriate patient care is often reprimanded. 

     

    Dear Paige, 

    ---

    We can get back to sepsis soon :)

     

    Thank you again for your kind words, they are refereshing as gatoraide after a soccer game. 

     

    ---

     

    Take care, 

     

    -BrettMD

  • June 13, 2014 7:47:35 PM PDT

    I will never understand malicious behaviour.  

     

    Truth.  So rational, so simple.  

     

    When truth is called into question we count on justice to right what is wrong.  We trust justice, blindly until breached, believing an offender will be punished and a truth presented.  

     

    The process of filing complaints is required regardless of who's actions are questionable. Doctors, Law Enforcement Officers and Employees at Burger Shops must all be held accountable for the responsibilities bestowed upon them. 

     

    It appears we have both come to know life can be brutally unfair.

     

    I don't get into this on Twitter, not because it doesn't deserve time or visibility, it's just ...I'm confident in my situation in this regard and would rather not muddy the sepsis message. 

     

    Just so you know I  really do understand: 

    http://www.size1andahalf.blogspot.ca/

     

    If you'd ever like to 'talk' via Skype or FT or FB Vid etc ..let me know? survivorsofsepsis@gmail.com

     

    'Gatoraide after a soccer game'! That's a hell of a compliment :) Thanks! Oh, btw, you're welcome.

     

    Be well (be in touch)

    Paige

    • Moderator
    • 1957 posts
    June 16, 2014 7:10:53 AM PDT

    Dear Paige,

     

    Thank you kindly for your comments. 

    You are very kind. I wish you the best. 

     

     

    Please feel free to share sepsis article or links, and I will do so also, as they become available.

     

     

    Kind regards.

  • June 16, 2014 11:43:00 PM PDT

    Hello Brett

     

    Is there an email address you would like me to send links to rather than posting directly here?  I have many ..perhaps in excess of 100 (going light with that estimate).  You may want to pick and choose which you find of interest.  I have them 'relatively' organized by topic (well, I began doing so and have become a bit overloaded).

     

    Also, I would like to share an image with you privately, how can I do this?

     

    Thanks and Be Well

  • June 26, 2014 6:58:45 PM PDT

     

    Hello to you!

     

    I'll continue in this thread(?) Let me know if you'd like it reposted, or feel free to move, of course!

     

    Would you agree there is no current (or past) 'screening' process for sepsis under the guidelines of WHO Principles of screening which include:

    1. The condition should be an important health problem.
    2. There should be a treatment for the condition.
    3. Facilities for diagnosis and treatment should be available.
    4. There should be a latent stage of the disease.
    5. There should be a test or examination for the condition.
    6. The test should be acceptable to the population.
    7. The natural history of the disease should be adequately understood.
    8. There should be an agreed policy on whom to treat.
    9. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
    10. Case-finding should be a continuous process, not just a "once and for all" project.

    If you agree there is no screening process for the detection of sepsis, do you find the following statement irresponsible/misleading?

     

    "A full septic screen, lumbar puncture and MRI of the spine were all inconclusive. After 3 days, the patient deteriorated and repeated blood tests—initially unremarkable—revealed neutropaenia and acutely deranged liver function. Connective tissue disorder was considered due to a negative septic screen and lack of response to antibiotics."


    I have not been able to locate anything on the WHO site, which indicates screening exists for sepsis but I don't know that I'm looking in all the right places so would appreciate your input.

     

    Thanks for all you do. 

     

    Paige 

    • Moderator
    • 1957 posts
    June 26, 2014 10:30:33 PM PDT

    Hi Paige, 

     

    Thank you kindly for your questions. For the first question,

     

    1. The condition should be an important health problem
    2. There should be a treatment for the condition.
    3. Facilities for diagnosis and treatment should be available.
    4. There should be a latent stage of the disease.
    5. There should be a test or examination for the condition.
    6. The test should be acceptable to the population.
    7. The natural history of the disease should be adequately understood.
    8. There should be an agreed policy on whom to treat.
    9. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
    10. Case-finding should be a continuous process, not just a "once and for all" project.

    1. Sepsis is an important health problem

       I agree that it is important.

     

    2. There should be a treatment for the condition.

      I agree and there is. The treatments are far from perfect.

     

    3. Facilities for diagnosis and treatment should be available.

         There are, they are usually - emergency rooms, and in patients in a hospital.

          Also medical clinics. 

     

    4. There should be a latent stage for the disease

         The latent phase is not necessarily present. What I am trying to say is that sepsis is comparable to walking along a cliff, and then falling off or being pushed off. 

        The inflammatory response in the body often becomes exponential. This is comparable to falling 40 feet off a cliff, 

       - Fall off a chair, and often people are okay. Yet the difference between sepsis and not sepsis is due to this exponential amplification of the inflammatory response aka - the SIRS.

       - There may be an early phase of the disease, but it may go unrecognized at this stage as not all of the criteria of SIRS are present. What I am trying to say is, the term "Sepsis," is only applied after the underlying process, infection, has progressed to a certain point. Then, we apply the term "Sepsis,"  

     

    p1

    5. There should be a test or examination for the condition.


       The condition can only be diagnosed with multiple tests used together.

    Tests needed include 

    1. Temperature check

    2. Heart Rate

    3. Measure Blood pressure

    4. Examine mental status, eg,   Glasgow coma Scale: Eye opening, verbal response, motor

    5. Blood glucose

    6. Blood gas

    7. Pulse oximetry 

    8. Visual inspection of skin for petechiae 

    9. Complete Blood Count test with differential of cell types  into standard categories. 

    10. Blood lactate   > 3.5 mol (in peds)

    11. Urine output

    12. serum Na, K, Cl, Bicarbonate, Phosphate, creatinine (Basic metabolic Profile, Serum Aspartate Amino Transferase (enzyme present in liver); serum alanine aminotransferase (ALT); 

    13. International normalized ratio  (

       1. Temperature is test 1:      (X <36) OR (X > 38.5) Celsius; (x >38.3 in adults)

    14. More, 

     

     

    6 .The test should be acceptable to the population

        As you can see there many tests, including some I'm sure I left out that are used in the evaluation of sepsis. I agree that a single test should be available for the population, it would most likely be blood, urine, or other cultures, and collecting those has a small risk of harm, getting poked with a needle, collecting urine. For example, if the blood culture returns incorrect culture results, which may happen rarely, then the patient will get the wrong drug. 

     

    Thus, it would be great if we could test people that are doing well for the risk of sepsis, but it would almost definitvely do more harm than good. 

     

     

    7. The natural history of the disease should be adequately understood

        We are always learning more in medicine, but the pathogenesis of the disease is discussed in an uptodate article which I can send you.

     

    8. There should be an agreed on policy of who to treat

               All patients with sepsis usually receive treatment... 

     

    9 & 10 I feel are closely related.

              I would love an economical test to predict sepsis, but it may occur after a traumatic event, such as motor vehicle crash, or being thrown from a motorcycle. In those events, testing the people before hand would not be useful. The latent time from infection to sepsis, probably varies significantly by type of infection, location of infection, and whether the immune response neutralizes the infecting organisms. Neutralization includes the phagocytoses & digests, destroys the bacteria with antibodies and exposure to toxic metabolites from the neutrophils. the infecting organisms. 

     

     

    Feel free to correct me on any of this, add additional helpful information, or ask additional questions. 

     

    Thanks again for asking, these are great questions. 

     

    -BrettMD


    This post was edited by Brett Snodgrass at June 26, 2014 11:23:23 PM PDT
  • June 27, 2014 9:42:22 AM PDT

    Thanks very much.

     

    I appreciate you for what you do and who you are.

     

    Paige :)

  • June 27, 2014 8:08:03 PM PDT

    'Full sepsis screening' s likely to mislead the public into believing that sepsis is, in fact, something that can be diagnosed.  This condition lacks a clear standard definition and the current 'generally acceptable' definition contains many subjective elements such as 'suspected infection' requiring nuanced judgments for diagnosis.  

     

    Several of the principles for 'screening' are not met following the guidelines of the WHO, imo.

     

    3. Facilities for diagnosis and treatment should be available.

    Being there is no repeatable reliable method of diagnosis, it stands to reason there can not exist a facility that offers diagnostic treatment.

     

    5. There should be a test or examination for the condition.

    'Test or Examination' infers there is some'thing' being tested for ..an end result of an examination that would lead to a factual diagnosis.  This is not the case with sepsis.   

     

    6 .The test should be acceptable to the population

    There is no test.

     

    7The natural history of the disease should be adequately understood

    I have great difficulty believing there exists an 'adequate understanding' of sepsis.  I can't even estimate how many different questions I have asked countless researchers and clinicians only to receive very different, sometimes contradictory answers. 

     

    8There should be an agreed on policy of who to treat

    An agreed on policy of who to treat would require an understanding of the condition along with a way to diagnose it! It's painfully obvious, these things do not exist.  There is so little policy many patients who present with sepsis are vulnerable to not receiving treatment.  In addition, proposed mandates and protocols create a potential risk for over treatment in patients who do not have sepsis.

     

    This is hard for me to wrap my head around.