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Clinical Case 015: Septic Surprise

I have been busy learning all this week, so not much new material.  Fortunately Dr Ray Gadd out of Qld has sent me a ripper case of sepsis for you to mull and consider.    I know Ray is a keen Broome Docs reader – so let him know what your thoughts are on this case via the Comments area, we all learn from shared ideas!  I love this case because it is a true representation of the resources available to us in remote communities.  The case is definitely not “textbook” – but it is real!

Today’s case is food for thought, I will use it as a basis for some upcoming posts on Sepsis.  Over the coming weeks I hope to put together some Sepsis Resources which I reckon can make the diagnosis and management of sepsis in small / remote hospitals much easier and bring the standard of care for these super-sick patients up to a similar level they would get in any tertiary ED.

So – without further ado – Here is Ray’s case :  Septic Surprise (Apologies it is in PowerPoint – takes a bit to download)

Comments

  1. Casey Parker says:

    Hi Ray. Nice work, thanks for the case.
    My comment – on physcial exam – ïf you don’t put your finger in it, you might put your foot in it!”
    Did you do a PV? The pregnancy should have been palpable.
    My teaching to the students is that any woman between the age of 3 and 300 ispregnant until proven otherwise.
    Casey

  2. Minh Le Cong says:

    Thanks Ray for the case

    “Traumatic vasectomy”?? hahahaha..that could mean two things.

    I imagine you did not do a PV because you were about to do a pelvic USS?
    Malaria was a bit of a red herring for your differential workup.
    Nice idea about a discussion on sepsis Casey. bring it on

  3. Great case report. Kept me on the edge of my seat. It shows the importance of a wide differential, good clinical exam (?palpable suprapubic mass), and bedside ultrasound (which I increasing see as the way of the future.)

  4. Ray Gadd says:

    Casey,

    The problem with doing the PV was:

    Was very hard to get consent i dont speak pidgen or PNG. She was very hard to get a history of to start with with the language barrier and then when she got septic even harder.
    Husband was standing right Over me!

    in regards to what you tell your medical students that is exactly right. In fact I had two medical students with me and they both said she cant be pregnant because they beleived what she said! It was a great lesson for them. It was difficult to palpate the abdo was she was tense and almost rigid. Also a big girl.

    I did the US about 20 minutes into the case. Something a little controversial now is do you still do a PV if you do an ultrasound and HAPPY with what you see?

    The malaria was the big red herring but it was brillant from the fact that in central queensland where I was at the time, I had to all of sudden add all the tropical bugs into my differential. As you might have seen from the case she was very sick. I presented this at a larger hospital and as you might expect all the “not rural guys” wanted bloods cxr etc, so they could figure it out even a CT abdo was asked for! I remember discussing the case with the ID guys in Brisbane once she was stable and they were also facinated and a little excited but not very helpful basicly asked for initally meropenam(didnt stock) but settled for timentin.

    I found out a little later that she admitted to having a “backyard” abortion a few days earlier as she obviously got pregnant back in PNG. The husband had a severe bike accident several years earlier which apperently tore out the spermatic cords.

    POC of ultrasound is the way of future, espically in rural/remote setting you can diagnose a whole range of things from Casey’s retinal detachment, IUP, AAA, pneumothoracies, even fractures etc etc. Where the cost is not to prohibitive and very portable.

  5. With this patient i was lucky i was 2hours drive from my referral hospital (Rockhampton) so a short flight. So very rare that i cant get a patient out within 6 hours even to brisbane 1.5hrs flight.

    The diagnosis was a challange but what really would made this a challange was if I had this patient who had septic shock and about to go into DIC and have to sit on them for 1-2 days. What would I have done?

    What resources do I have. In terms of inotropes I only had adrenalin (from the resus trolley) and enough to last about a day, no blood products, no CVP/art line monitoring. No end tidal CO2, no ability to get bloods besides trop/and blood gases, no lactate monitoring. Have the ability to ventilate if required (oxylog 1000 at that time).

    Septic shock and sepsis was something I would have seen once a year in Blackwater (the other was among the first adult flu death in 2007 in Qld) . Yet when I went to isa and north qld it was/is a weekly event. This is something that rural remote docs see frequently and if we are remote we have to manage for days if the weather is not co-operating. Yet the protocols are often written for our ICU collegues and not for the rural/remote generalist’s with limited resources and back-up?

  6. Minh Le Cong says:

    Hey Ray

    I personally think rural doctors have to be able to initiate basic critical care resuscitation like inotropes, ventilation ( non invasive and invasive) and fluid management. We all should be able to provide advanced airway management and emergent vascular access techniques.
    Critical care should not start when someone arrives in an ICU.

    Scott Weingart is right about logistics being king. We all need to know how to make critical care resuscitation work in our rural and remote settings. The theory is not enough. The skill is even not enough. The application of the skill for your local gear, staff and environment , in an effective manner is the true goal.

    Success in varying conditions is the property of resilience and we all must strive to become resilient practitioners

    I spoke to a Norwegian Anaesthetist one day about his work for Red Cross in Bandah Aceh post tsunami. He setup and ran a makeshift ICU in a tent for over a month. He and others including the Australian army contingent successfully managed the majority of acute tetanus cases that arose after the disaster with I think only one ventilator shared!

    Yes you have to modify your approach to critical care for a low resource environment. For example, I personally think and teach that the role of Central venous lines in retrieval critical care is very limited, lacks evidence base to prove its superiority of outcomes in the critically ill/injured, and offers little more over intraosseous access for remote critical care resuscitation.

  7. Ray Gadd says:

    Minh,

    I could’nt agree more with you. Critical care should start from when we see the patient. That is what I perceive to be emergency medicine or retreival medicine should be is the ability to start meaningful interventions from first contact with the patient. The way to look at ICU in my mind it is the place to observe the critically ill patient and to fine tune management.

    I think what seperates the rural/remote generalist for lack of a better term from the tertiary trained specialist is the ability to function with limited resources at a high level. As Scott’s podcast stated logistics is key: Going over cases in your head in real time and gaining “muscle memory” of where things are or if you dont have access to this stuff how to modify your approach.

    What is the Gold standard is it a proven entity that save lives or reduces morbidity or is it a entity that proves we were right with our diagnosis and covers out butt or just makes our lives easier?

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