Missteps in a case of septic shock

ER, NBC, Thursday, May 10, 10 p.m., “Sea Change.”

The premise: A physics professor has collapsed at a conference and is brought to the ER, where she complains of abdominal pain and weakness. She has low blood pressure and a high fever. Dr. Greg Pratt (Mekhi Phifer) thinks she may be suffering from a virus, but -- while observing her for further signs -- he orders blood tests looking for bacteria as a precaution. When those tests show the presence of Gram-positive cocci bacteria, suggesting a dangerous staph or strep infection, Pratt tries to obtain the powerful antibiotic ceftriaxone from the pharmacy.

During this delay, the patient worsens, and Dr. Kevin Moretti (Stanley Tucci), director of the ICU, and his rapid response team are called. Moretti complains -- in front of the patient and her husband -- that the several-hour delay in properly triaging and treating the patient is threatening her life. He says her rapid heart rate, high fever, low blood pressure and widening pulse pressures are signs of septic shock. Pratt defends his actions, saying he thought the bacteria might be a harmless blood contaminant rather than the cause of the patient’s illness.

As Moretti gets ready to transfer the patient to the ICU, an X-ray reveals that she has “air under the diaphragm,” an indication that the bowel has perforated, leaking bacteria into the abdomen, the cause of the sepsis. The patient is rushed to the OR for surgery then moved to the ICU. She sustains a cardiac arrest, leading to brain damage.

The medical questions: Is Moretti correct that this type of patient has classic signs of sepsis, a life-threatening blood infection, and should be triaged and managed aggressively from the outset? Is a bacterial contamination of the blood a reasonable diagnostic presumption? Could the infection’s erosion through the bowel wall have been found sooner? How does brain damage occur as a result of a cardiac arrest with successful resuscitation? Was it appropriate for Moretti to voice his displeasure with the ER staff in front of the patient and her husband?

The reality: A patient with a high fever, rapid heart rate, low blood pressure and widening pulse pressure (the arithmetic difference between systolic and diastolic blood pressures) should be presumed to have a sepsis-causing bacterium, not a virus, and should be treated aggressively in an ICU-type section of the ER. Diagnostic X-rays and blood tests should also be done quickly, and antibiotics started.

Gram-positive cocci are usually pathological staph or strep bacteria. Pratt is wasting time in thinking a blood contaminant is a possibility in an unstable patient. It is also likely that a careful physical exam would have revealed a highly tender “surgical abdomen,” which, with an X-ray, would have located the infection source and expedited surgery. As for cardiac arrest, it can lead to inadequate blood and oxygen flow to the brain, a type of brain damage called “hypoxic encephalopathy.”

But no matter how shoddy the treatment, it is unprofessional for Moretti to voice his displeasure in the middle of an emergency and disparage other doctors in front of the patient and family. This can lead to a loss of confidence at a critical juncture, compounding errors and interfering with patient care.

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Dr. Marc Siegel is an associate professor of medicine at New York University’s School of Medicine. He can be reached at marc@doctorsiegel.com.