Sepsis: The Deadly Threat You Don’t Know
It was supposed to be a simple outpatient procedure.
Erin Flatley, then 23 and a recent graduate of the University of Georgia, had painful hemorrhoids, so doctors recommended they be removed.
It would be a minor surgery, they told her — so minor that Erin’s father, Carl Flatley, went out and bought his daughter a personal watercraft before the operation so she’d have something to look forward to after her two-week recovery period. Erin loved the water, he says. Always had.
On that Wednesday, April 24, 2002, Erin’s mother drove her to the hospital to have the procedure. Six hours later, they returned home with a prescription for Vicodin and the number of the on-call physician, because Erin’s doctor would be out of town that weekend. He warned the Flatleys that their daughter would be in some pain for awhile.
“Some pain” was an understatement. By Friday, Erin was in so much agony that her mother decided to take her to the emergency room. Doctors there ran tests, which revealed that Erin’s white blood cell count was elevated, but after consulting with the on-call surgeon, they sent her home with a topical cream.
Over the next two days, Erin’s condition continued to worsen. On Monday, she returned to the ER, where records show she was classified as “non-urgent” and had to wait several hours to be treated. Antibiotics were prescribed but not administered, and by the time the attending physician finally saw her, her white blood cell count was nearly 10 times the normal range. She was in septic shock, a severe form of sepsis, which occurs when the immune system overreacts to an infection and starts attacking the rest of the body.
The next morning, she died.
A Father’s Grief Becomes His Life’s Work
Carl Flatley, a retired dentist, hasn’t been the same since. After Erin’s death, he learned everything he could about sepsis. He even teamed up with a drug company and several nonprofits to found the Sepsis Alliance, an organization to raise public and medical professional awareness about the condition. And then he took her doctors to court.
“The system failed us. It was a lot like the Staunton case,” he says, referring to 12-year-old Rory Staunton of New York, who died of toxic shock, a form of severe sepsis, last April. “It never should have happened.”
Flatley spent years tied up in litigation with the physicians who treated his daughter. In 2005, he and his family won a considerable settlement for Erin’s death — enough money to sustain the Sepsis Alliance for several more years. Today, he is the founder and chairman on a board that includes multiple doctors and the former U.S. ambassador to Denmark, among other advisers. Their mission, he says, is to educate people about the signs of sepsis so more may survive.
“It’s all about early recognition,” Flatley says. “If we raise awareness and treat sepsis promptly, we can save thousands of lives.”
That may not be as easy as it sounds. According to a recent survey by the Sepsis Alliance, fewer than half of Americans have even heard the word “sepsis,” and many of those who have can’t define it. This, despite the fact that it kills more than 200,000 people in the United States every year, making it the Centers for Disease Control and Prevention’s 11th leading cause of death.
Flatley admits that he, too, was ignorant about the condition before it took his daughter’s life in 2002. “I didn’t know anything about sepsis — and I was a dentist,” he says. “I think a lot of physicians are the same way. Maybe they’ve heard of it, but no one is taking ownership of it. And everyone has to take ownership.”
The Facts About Sepsis
Sepsis can occur when the body has a severe inflammatory response to an infection, usually bacterial or fungal, explains Martin Doerfler, MD. Doerfler is vice president of Evidence-Based Clinical Practice at the North Shore-Long Island Jewish Health System, which launched a program in 2009 to improve sepsis protocol. Anyone can become septic, he says, but those most at risk are very young children (younger than 1), the elderly, and people with suppressed immune systems, like cancer patients.
“Basically what happens is that your immune system starts attacking everything,” Dr. Doerfler says. “And when you attack an infection too aggressively, you begin to damage your body to an even greater degree than you are harming the infection.” It’s like the immune response equivalent to using a fire hose to douse the flames in your fireplace.
“We don’t know what causes this overreaction,” he adds. “Investigators are studying it, but we haven’t figured out why the switch flips. We don’t truly understand that at any level that we need to yet.”
There’s a lot we don’t understand about sepsis. Doerfler notes that sepsis can be very tough to identify, even for veteran doctors, because it often presents with nonspecific symptoms at first: fever, high heart rate, low blood pressure, confusion, pain, etc.
One of the most effective ways to diagnose the condition, Dr. Doerfler says, is using the criteria for systemic inflammatory response syndrome, or SIRS. SIRS criteria include a body temperature below 96 or above 100, a heart rate above 90, a respiratory rate above 20, or a white blood cell count of less than 4,000 or more than 12,000. If a patient comes in with an active infection and meets two of these screening criteria, he or she should be evaluated in more depth. That means testing for lactate, a potential indicator of shock; getting a complete blood count; and using blood cultures to identify the source of the infection.
If sepsis is suspected, Doerfler says, antibiotics should be administered — not just prescribed — within 180 minutes of presentation.
“Early antibiotics correlate with improved survival at all forms of sepsis,” he explains. “Subsequent to that, the second major element of treating sepsis is fluid administration. When the body attacks itself, your blood vessels dilate, so we have to compensate for the increased volume with extra fluids.”
Timing is everything, Doerfler stresses, noting that his team at North Shore-LIJ is trying to get their treatment time down to within one hour of presentation for patients with severe sepsis. “Timely aggressive antibiotics are a huge factor in reducing mortality,” he explains.
And that’s the goal, after all. Reducing mortality. Saving lives.
“It’s a devastating disease,” Flatley says. “If it doesn’t kill you, it leaves you so disabled. And then there’s the collateral damage — family members and friends who are devastated for the rest of their lives, too. This is truly a blanket of death. It’s awful, and it’s not even talked about.”
Raising Sepsis Awareness
Both Flatley and Dr. Doerfler are working to change that.
“The big thing here is really awareness,” Doerfler says. “Sepsis is an uncommon disease outside of the elderly, neonates, and patients with compromised immune systems. So when people come into the emergency department with a fever and nonspecific complaints like abdominal pain or headache, they often get sent home. And the overwhelming majority of the time, these are not serious issues. But we need to at least be thinking about the possibility of sepsis under circumstances when it’s not likely.”
The first step in doing that, he adds, “is making parents and individuals aware that sepsis exists, so they can simply ask the question: Could this be sepsis? The majority of the time, the answer is going to be no, but just put it in the mind of the physicians. Trigger them to expand their differential. That alone is probably the biggest thing that families and individuals can do around their own care.”
Flatley can attest to this. In 2006, four years after his daughter’s death, he went to the hospital with a urinary tract infection. The doctor tried to send him home, but Flatley refused. By that time, he knew all the signs and symptoms of sepsis, and he was concerned he had it. He was right. He spent the next 11 days in that hospital, underwent two surgeries, and was on antibiotics for nearly six weeks.
“That guy said I had nothing to worry about,” he says. “That’s why we try to educate patients. We don’t expect to make nurses and physicians out of them — we just want them to be able to put their healthcare providers on alert.
“I’ve been at this for 10 years,” he adds. “We’re making progress, but we still have a lot to do.”
What is sepsis?
Sepsis is a medical emergency caused by the body’s response to an infection and can be life-threatening. Sepsis is the consequence of widespread inflammation (swelling) in the body. Inflammation and blood clotting during sepsis causes reduced blood flow to limbs and vital organs, and can lead to organ failure and even death. Over 1.5 million people in the United States are diagnosed with sepsis yearly, and approximately 30% of patients do not survive.
Who is at risk for sepsis?
Sepsis can affect anyone, but those at particular risk include:
- The very old (older than 65 years old) or very young or pregnant women
- People with pre-existing infections or medical conditions such as diabetes, lung disease, cancer and kidney disease
- People with weakened immune systems
- Patients who are in the hospital
- People with severe injuries, such as large burns or wounds
- Patients with catheters (IVs, urinary catheters) or a breathing tube
What causes sepsis?
Bacterial infections are the most common cause of sepsis. Sepsis can also be caused by fungal, parasitic, or viral infections. The source of the infection can be any of a number of places throughout the body. Common sites and types of infection that can lead to sepsis include:
- The abdomen: An infection of the appendix (appendicitis), bowel problems, infection of the abdominal cavity (peritonitis), and gallbladder or liver infections.
- The central nervous system: Infections of the brain or the spinal cord.
- The lungs: Infections such as pneumonia.
- The skin: Bacteria can enter skin through wounds or skin inflammation, or through the openings made with intravenous (IV) catheters (tubes inserted into the body to give or drain fluids). Conditions such as cellulitis (inflammation of the skin’s connective tissue) can also cause sepsis.
- The urinary tract (kidneys or bladder): Urinary tract infections are especially likely if the patient has a urinary catheter to drain urine.
What are the symptoms of sepsis?
Because of the many sites on the body from which sepsis can originate, there are a number of symptoms. The most prominent are:
- Fast heart rate
- Fever or hypothermia (very low body temperature)
- Shaking or chills
- Warm or clammy/sweaty skin
- Confusion or disorientation
- Hyperventilation (rapid breathing) or shortness of breath
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