Of Sepsis

This blog requires a little bit of pre information to bear in mind whilst reading.

Sepsis is a life-threatening condition that arises when the body’s response to infection injures its own tissues and organs.

Medically it is defined as Systemic (whole body) Inflammatory Response Syndrome (SIRS) plus evidence of suspected infection.

SIRS criteria:

-Respiratory Rate greater than 20 breaths per minute

-Heart Rate (pulse) greater than 90 beats per minute

-Temperature greater than 38 or less than 36 degrees Celsius

-White Cell Count (these fight infection) greater than 12 or less than 4

Other points to consider:
-Sepsis has a 16 percent mortality.

-A temperature of 41.1 is a medical emergency.

A chaotic two days, in late May.

I eluded to this in a previous blog but Georgie and I wanted to publish this when things were more clear. In late May I went with Georgie to a hospital appointment of her own. She’d had an abnormal cervical smear during routine screening and needed further assessment with a colposcopy and potentially a biopsy. Now this is no mean feet, if there’s one thing Georgie despises in life, it’s personal gynaecological assessment. Nothing quite fills her with more dread and loathing than a gynaecology examination. Fortunately she was first on the list, the Nurse Practitioner doing the test was fast albeit formal, this was despite Georgie informing them at the beginning how anxious she was. So Georgie was at unease throughout but at least it was over, and unfortunately they did take a biopsy. We sat down for a long time afterwards and then left. I reassuringly and unhelpfully said “well this will be the longest time until the next one”, how wrong I was.

Later that day we headed to London, this was due to me needing blood tests at the Marsden and we had arranged to go to a pub quiz in Putney. Everything seemed completely fine and we took the boat down the river to Putney and met with friends. We all danced to the music round the table and then went home again. Apart from Georgie feeling sore in her abdomen and on a background of feeling a bit rubbish for the last few weeks or so nothing seemed overly amiss.

The next day, I woke up at my normal 4am and was typically lying there restless and awake for a few hours. I took some Zopiclone (a sleeping tablet) and slept until half 8. The problem with Zopiclone is that it has the hangover effect and I was feeling a bit disorientated. Georgie had been writhing around in pain, and was suffering. Ironically she’d been trying not to wake me up. Georgie was very agitated but I felt it was due to abdominal pain and was trying to calm her down and then went and made porridge thinking food would help. I came back to “Examine me” “examine me”. I found my thermometer and blood pressure cuff (I carry them everywhere), it read 38.9 degrees. I sprung into action. The blood pressure was fine on the cuff but the heart rate was a very worrying 122. SIRS. What is happening? Georgie needs an ambulance. I rang an ambulance they were dubious initially about coming immediately, I was a little incensed as she hit the SIRS criteria implying something nasty was going on. But what!? He said a paramedic would call me back, I then told him I was a doctor. During this time the paramedic had called, but I was on the still on the phone to the operator. Before I got around to ringing them back the sirens were blasting down the road. They had to be for Georgie. I buzzed in two very nice paramedics. The source of the infection was difficult to ascertain: headache, neck pain, inflamed tonsils, a productive cough for weeks, the cervical biopsy yesterday and abdominal pain. Georgie was not being a simple case. We got into the ambulance. Other than a 12 hour stint during my ambulance day, at medical school, this was the first time I can actually remember the journey. How did this happen? We had been planning for a quick blood test then off to the Natural History Museum. Then it got worse, despite Georgie having had paracetamol and ibuprofen, which both lower temperature, the ambulance windows wide open, her temperature had risen to 40.9C. Life is wacky and so fragile. Georgie had not only just become a patient, but a very sick one at that. She needed antibiotics and fast. Due to the high temperature, the blue lights came on and minutes later she was straight into a resus bed at Chelsea and Westminster hospital. She was pounced on by the awaiting staff. Her blood pressure was lowering and she was peripherally shutting down (to try and keep blood in the vital organs) so they had difficulty gaining access with the cannulas (tubes into veins to give fluids and antibiotics) into her arms. Her oxygen saturations were lower than usual. They were very fast, very friendly and very efficient. She was started on IV Morphine, fluids going in fast and a large cocktail of antibiotics (Ceftriaxone, Gentamicin and Metronidazole), the decision slightly impeded by Georgie’s penicillin allergy, at least all these other doctors had no idea where the infection was either.

After seeing Georgie again on resus and seeing that she was just about ok/high on morphine she told me to go to the Marsden to get my bloods done. Both of us patients for once. Her mum was very near by then.

Back at Chelsea and Westminster Georgie was admitted on to the Acute Assessment Unit for further IV antibiotics, gynaecology review (including another speculum exam), abdominal US scan and a chest X-Ray. After the initial treatment she had started to feel much better and I optimistically thought she’d get out that evening. However by the evening and just prior to seeing the consultant she had deteriorated and was rigoring again. They then sent an FY2 doctor to take further blood cultures to try and find the causative bacteria. A few stabs later she eventually got some blood. Georgie’s heart rate was still high and her blood pressure was still low despite the antibiotics and the litres of fluids put into her.

A lot of dithering happened over the next two days and Georgie was still breathless. The chest X-Ray was discussed with the radiologists, the radiologist felt there were signs of a pneumonia or pulmonary embolism (PE). Also Georgie’s tonsils were inflamed. Each doctor seemed to have a different opinion on what the final diagnosis was and whether an abdominal ultrasound was really necessary. But once a diagnosis of pulmonary embolus is even considered, it has to be ruled out and that’s difficult. A D-Dimer test (the blood test to rule it out) came back raised, this leaving us none the wiser. After measuring Georgie’s oxygen level directly via an arterial blood gas (needle into the artery of the wrist) which came back at 14kPa (which is normal, in PE it can be low), the radiation risk to a young woman was deemed too much for a CTPA (computed tomography pulmonary angiography – the definitive test for pulmonary embolism) due to a PE diagnosis now being very unlikely indeed. She was given 8mg Dexamethasone to open up her throat. My personal opinion is she had sepsis either from the tonsils and a pneumonia. After ten days of clarithromycin Georgie’s cough has cleared up and she’s feeling much better, just a bit run down. However health can be more complicated than that, the lack of real clarity with chest X-RAY Georgie is having another one in a couple of weeks time to see if everything has resolved.

The whole experience was very emotional it showed me how vulnerable anyone is and how fragile life is for everyone. Having seen these situations now as a doctor, patient and a fiancé. I can confirm the latter is the worst. I was too unwell as a patient to know really what was going on. Georgie was critically unwell until the antibiotics got in and I was frightened and scared of the outcome. You feel so much more helpless and the situation is so out of your control. A temperature of 40.9 for a period would be fatal. As I doctor you get into a professional mode where you’re almost automatic, you don’t give yourself time to reflect on the personal grief of every case because if you did you’d have to quit. As a fiancé the fear of losing Georgie was overwhelming and that’s a feeling I’ve given her too many times. Georgie could have easily died that day particularly if she had been alone. How would she have called an ambulance or when it came been able to open the door? But as I keep alluding to, the saga didn’t end there.

The bad news continued, the result from the colposcopy and biopsy came back as CIN type 3 (Cervical intraepithelial neoplasia (CIN) – disease confined to the epithelium). In other words, this means there were high grade dyskaryotic cells (cells which have the ability to spread) which are potentially cancerous in Georgie’s cervix, which could spread to other parts of the body if they breach the basement membrane, it’s cancer in a pre-invasive state. The type refers to the depth of the cells within the epithelium and type 3 is the worst as there’s dyskaryotic cells across the full thickness of it. The exact risk (although we were told it’s very high risk) of CIN 3 turning into cancer is unknown but it is felt safest to remove the affected tissue.*

The biopsy result meant another colposcopy, this time with a particularly nice consultant that Georgie liked, and an excision of Georgie’s cervix. Ironically Georgie has just started her gynaecology placement and spoke about how she will probably be sitting in the consultants clinics next week. Georgie and I joked at least she’s in the right place! The problem is Georgie now requires a 6 month and then yearly follow ups for the next ten years and the results of the excision biopsy takes four weeks.

Georgie and I discussed whether to include the gynaecological story in the blog at all. We realise as medics we’re quite open about bodily functions, which can be surprising to non health professionals. At first Georgie felt not to include it into the sepsis story, but when the results came back as serious we both strongly felt it was very important to highlight how important smear testing is. Georgie said that if this makes just one person not ignore their smear test or go to the doctors if they are getting any abnormal symptoms then it has been worth it. During my gynaecology placement at medical school the consultant described our screening programme as a modern day miracle and the best in the world. The mortality rate of cervical cancer in developing countries is ten times higher than it is here. The discrepancy is partly to do with our cervical cancer screening which prevents 41% of cancers in 25-39 year olds and 63% of cancers in 49-54 year olds.

The process of going through a smear, colposcopy with or without biopsy is a bad one and seeing Georgie go through two colposcopies and a smear reminded me why around 25% of women don’t go for smears. It’s embarrassing and you’re in a vulnerable position with two complete strangers. It’s uncomfortable. Georgie was stopped from fainting after both biopsies. This being said the result shows why she needed to go through with it. The CIN tissue has hopefully all been taken away and we can go back to me being the sick one.

*https://www.bsccp.org.uk/women/frequently-asked-questions/