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A Student felt a sharp pain in her side. This is how her organs shut down J.C. is a 21 year old woman Presenting to the emergency room with appendicitis The inflammation of her appendix her boyfriend Jake tells the admitting nurse that they were together at a fraternity house on their college campus participating in Thirsty Thursday They were having a great time amongst friends when suddenly J.C. felt a piercing pain in her sight she collapses Begins crying and curls up in pain as the pain grips the lower right part of her abdomen His poor college students Jake drives her to the emergency room Confirmed by CT scan JC’s appendix is about to burst she can live without it But the inflammation and complications arising from it can be life-threatening J.C. goes to the operating room to get an appendectomy the removal of her appendix the operation is successful And she goes into post-operative care with no immediate complications Being young at 21 years old and not pregnant means recovery for her shouldn’t be a problem She’s conscious again But she feels some discomfort from her peripheral IV line and once the site changed the nurse Rhonda notices that J.C. has an unsightly rash on her left arm J.C. Tells her that last week a cat scratched her and she’s been having an allergic reaction ever since it’s already noted in her medical chart Down the hallway another patient was in his room He was supposed to be admitted to a different ward because he was suffering a MRSA infection at his surgical site That’s a deadly bacteria and a common cause of nosocomial Infections his daughter Katie didn’t realize that her father’s bacteria was living on the surface of her gloves And she wasn’t educated on the topic of changing them in washing her hands every time she left her father’s room The nurses were unaware that Katie had contaminated the surfaces at their station as she went around looking for help for her father as nurse Rhonda goes into the storage cabinet to get materials to replace JC’s IV site she comes into contact with the contaminated service with lowered guard uneducated patient family involved, Rhonda Changes the IV site to J.C’s right arm opposite the rash without washing her hands. She thought the use of new gloves would have recovered It’s been eight hours Rhonda’s about to finish her shift and J.C. complains that she feels cold and requests extra blankets the fourth-year medical student Starts his night shift. He’s the one that gets to monitor J.C. before nightfall He observes that she now has a fever of 101 degrees and a blood pressure of 140 over 90 He reports this to the attending physician the temperature of 101 is not atypical for appendicitis. In fact, J.C. was already on prophylactic or preventative antibiotics. For her surgery and even requesting extra blankets was not out of the ordinary for a low-grade fever that one could have after appendectomy But J.C. was getting worse in the morning She presents to the medical team at rounds with confusion the student mentions that J.C. IV site is now swollen and red The attending chastises the student as J.C’s medical history has a rash on her arm due to cat scratch the student put on the spot Backs down and doesn’t say any more He knows that the injection site is on a different arm, but he’s unsure if there’s really a problem Or if it’s really just some bruising or something else, and he doesn’t speak up. He’s about to graduate He just wants to finish without any problems the attending physician finds nothing wrong with J.C. and tells a student to monitor for peritonitis the inflammation of the peritoneum a Membrane that lines the abdomen over the next 24 hours J.C. Continuously gets worse as the student keeps watching her blood pressure is now 90 over 60 Shockingly low her breathing is now 25 breaths per minute. It’s very high indicating that there’s probably something wrong Temperatures at 102 degrees still high and even worse her eyes only respond to pain when she’s pinched She’s incoherent confused and hasn’t produced urine for eight hours J.C’s worsening conditions prompts her move to the intensive care unit the ICU Upon arriving in the ICU. J.C’s intubated meaning that a tube is placed down her throat and a machine provides Oxygen to her. This is to protect her Airways to place the tube she needs to be sedated if she’s sedated She can eat food, so she’s fed intravenously Since she’s sedated She’s not moving and in this case we have to watch for deep vein thrombosis or DVT a blood clot that typically forms in the legs of people who haven’t moved for some time it can happen to people sitting too long in an airplane and It can also happen to ICU patients if a DVT breaks off it can lodge into the lungs causing a pulmonary embolism Which causes sudden death with this unfortunate sequence of events she’s confirmed to have septicemia Septic is an old word meaning putrid but more commonly meaning bacteria and emia meaning presence in blood bacterial presence in blood This didn’t have to happen The patient down the hall with a MRSA infection should have been in another ward his daughter should have been educated on Changing gloves and washing hands after coming in contact with her father the nurse who changed J.C’s IV line should have washed her hands the medical student should have spoken up and the attending physician should have Taken a closer look once the low pressure appears persistently J.C’s chances of survival immediately decreased to just 80% and decreases another 7% For every hour she does not receive antibiotics that infection in her blood it’s from a bacteria named MRSA standing for methicillin-resistant Staphylococcus aureus. It’s a strain of bacteria that is abundant locally in the hospital biome It’s living and crawling around in every single hospital Methicillin is an antibiotic. That’s supposed to be able to kill staph aureus, but not this resistant strain MRSA has descended from mutated ancestors that have survived months even years of antibiotic activity in the hospital it has infected J.C. through her IV site, and is now spilling into her blood and Reproducing throughout her body in our current medical paradigm today. We look at this from two points of view First the bacteria is a foreign pathogen which is infected J.C’s body and second is that her body is a host That’s carrying the pathogen if we infected two different people with the same bacteria We could have to varying severity zuv response so we look at what she has through the lens of the host What J.C. has is a life-threatening organ dysfunction caused by dysregulated host response to infection She also has profound circulatory and metabolic abnormalities, which substantially increase mortality. We call this septic shock. J.C’s body is the host. Her organs are shutting down But why is this happening? Isn’t the body supposed to be able to fight infection? Well yes But J.C’s immune system is trying to differentiate between J.C.’s own cells and the bacteria in her blood it recognizes a mass influx of foreign entities Things that aren’t supposed to be there and it releases chemicals to signal for more immune cells to spill into the blood You ever get a cut on your arm, and 30 minutes later. It’s warm. Well. That’s inflammation bacteria lives on your skin it’s always going to be like that in fact when you shower you shed six million units of staph aureus But when you get cut some of that bacteria gets into the wound and your immune system responds by sending white blood cells and platelets to that site Once those cells are there they stimulate the release of a chemical called nitric oxide to make the blood vessels larger. We call that vasodilation This is so even more immune cells can come to the site to fight the infection But Casey doesn’t have an injury on her arm instead She has bacteria Flowing freely in her blood her entire body is vaso dilating meaning her blood pressure’s dropping dramatically There’s a lot more intravascular space for fluid to flow But there isn’t more fluid in her body the blood isn’t reaching her organs and her heart isn’t strong enough to compensate for that loss Take for example this sink when I turn on the water it flows at a certain rate through the Diameter of the faucet if I press my hand on the faucet the diameter through, which the flow passes is decreased It’s going through a smaller hole This increases the pressure of float and when I let my hand go it increases the diameter again and the pressure decreases So not only is there less blood reaching J.C’s organs because nitric oxide has Vaser dilated her But small blood clots are being lodged into various parts of her organs Further preventing blood flow without that blood reaching her organs the tissue doesn’t receive oxygen and when it doesn’t receive oxygen Those organs are slowly dying Inside of her she hasn’t produced urine because her kidneys are now malfunctioning her liver isn’t functioning properly So it’s spilling a chemical called bilirubin the thing that’s responsible for making your poop brown Into her blood her lungs aren’t effectively exchanging oxygen to her blood She’s confused because there’s less blood getting to her brain all of this was a preventable tragedy Most immediately if Katie and Rhonda had washed their hands the chances of this happening to J.C. would be closer to zero the washing of hands would have eliminated a majority of Bacteria on their hands and most importantly clear the MRSA that ended up in J.C’s blood There was a time when you were more likely to die from infection than from heart attack cancer Or stroke unlike today in fact Surgeries 150 years ago were done out in the open with multiple people watching before we understood what bacteria was Today our hospital and operating room procedures are largely the legacy of this early 20th century movement towards aseptic processing But despite knowing the problem better today than we did 150 years ago our antibiotics While a cure for current infections may not stand the test of time with J.C.’s infection in the other 1.5 million cases of sepsis per year in the United States were effectively creating stronger bacteria every year in the form of drug-resistant strains Inevitably some bacteria are going to survive those multiple doses of antibiotics that they’re exposed to and some of those will feature mutations that make them harder to eliminate the next time in some doomsday scenarios humans are running out of Antibiotics to use as the bacteria are adapting and evolving to their and it’s a matter of time before another pandemic Thins out the world’s population through super infections If we look at J.C’s septic shock from the pathogen perspective There’s one immediate thing that we have to do we have to discontinue the prophylactic Antibiotic for her peritonitis it was mainly to cover the bacterias ecoli in Klebsiella One is a bacteria known to cause food poisoning, and the other is commonly found in your mouth These are not the bacteria causing J.C. Septic shock upon her admission to the intensive care unit this is promptly discontinued in favor of a broad-spectrum Antibiotic agents that will eliminate a wide variety of bacteria this antibiotic is appropriate to treat mersa infections At least it is for now now if we look at J.C. septic shock from the hosts perspective There’s two immediate things that we can do to treat her the first is to address the severe Vasodilation there is more space in her blood vessels to hold fluid so one way to combat This is to give her more fluid the more fluid is present the higher the pressure will be so We infuse her with this normal saline at least 2 liters for J.C. all the way up to maybe 5 liters second I mentioned that her heart isn’t strong enough to compensate for vasodilation meaning it can’t be harder to maintain normal blood pressure But we can make it beat harder you may be familiar with something called epinephrine also called adrenaline It’s what flows in your blood when you get scared and sets off that fight-or-flight response We could use that in J.C. But at low doses it mainly increases her heart rate and at high doses in mainly vaso constricts It does one or the other depending on how much you give that’s okay, but we want both to happen So there’s something called norepinephrine It’s similar to epinephrine and it’s also made in your body naturally, but it’s mainly a chemical. That’s in your brain a neurotransmitter No matter the dose it both constricts the blood vessels and increases the contractility of the heart the story of Jacy Isn’t unfamiliar to most people who have worked in a hospital a quarter of a million people die from sepsis every year in the United There’s always a huge push in hospitals and even in the general public to wash your hands because really it doesn’t matter what? Technologies humans have at any point in time Weren’t dirty creatures and we can be taken down to death by microorganisms that we cannot see with our eyes No tsukkomi. Oh infections are a huge challenge for hospitals as the institution typically eats the cost of treating every case aside from the human cost of death Which is the most important each case of sepsis can typically range from 100 to 500 thousand dollars per patient? By those two drivers it’s less common that you would suffer anything close to J.C. The next time that you go into a hospital with fluid resuscitation and restoration antibiotics and much monitoring while in ICU along with an attending physician that has been taught a lesson to take a closer look a student who has learned to speak up when he’s unsure and a nurse who has learned to wash her hands and never make assumptions when Patients are under her care J.C. was able to clear her infection with her organs fully functioning again Thank you so much to all my colleagues in the Illinois medical district And thank you so much for watching take care of yourself Wash your hands and be well