One of My Most Memorable Medical Mysteries as a medic was a call from a man for his 50ish-year-old wife. On arrival I asked, What’s going on? “She’s just not herself,” he said. Has she been ill? “She had been talking to her doctor who thought she either had a kidney stone, or a bladder infection. She has an office appointment tomorrow.”
Other than that, he said, she had no medical problems, and took no medications. Not a lot to go on, but I went in to see the wife, who was in bed.
Her husband was right: she wasn’t herself. She was awake, looking at us, even talking, but nothing she said made any sense — as medics sometimes put it, “The lights were on, but no one was home.” She was a bit concerned about all the strangers in her bedroom, but was otherwise cooperative — and confused.
My usual first touch with a patient is to take their pulse: they expect it, it’s non-threatening, and it tells us a lot. But I couldn’t feel it. Sometimes that “just happens,” and sometimes it means problems. Meanwhile, what I did feel was that she was warm; hot, even. It made me worry about something specific, so I grabbed my blood pressure cuff and stethoscope. Her blood pressure was 54 over 38 — she was in shock.
“Shock” Isn’t a Psychological Condition
The more medical name for shock is hypoperfusion: her blood pressure was too low (hypo) to get sufficient oxygenated blood to her brain and other vital organs (perfusion), so no wonder she couldn’t think clearly. Meanwhile, her body had shunted her blood supply away from her periphery to try to get more to her brain, which is why I couldn’t feel a pulse in her wrist.
I told her husband she needed to go to the hospital. “You really think so?” he asked, clearly unsure. Yes: right now.
One of the causes of shock is an infection that’s out of control, and causing systemic breakdown leading to “multiple organ failure” — and she was well on her way.
Getting to the Diagnosis
The husband had given me a hint: possible bladder infection. The result of such an out-of-control infection is called sepsis, which leads to septic shock.
It was a common cause of death before antibiotics. Even now, there are about 20 million cases a year worldwide, and around half the people who progress to septic shock die from it, since the mortality rate rises at about 10 percent per hour once they’re into shock. It’s a darned good thing he called 911 when he noticed his wife was acting strangely.
The only thing we could really do for our patient was to start an I.V. and dump fluids into her to get her blood pressure up a little, as well as simply make her blood less toxic. The medic saying is “Dilution is the solution to pollution.” That, and “apply diesel” — quickly get her to the hospital so they could try to save her with antibiotics and other supportive care in the Intensive Care Unit.
In the News This Week
She lived, in large part because she was otherwise quite healthy. Muhammad Ali, being much older and in declining health, didn’t live through his septic shock: that was his cause of death on Friday. He had bouts with pneumonia and other infections in the past couple of years. He died in a hospital after being admitted for respiratory issues: that apparent infection, even in a hospital setting, got out of control and killed him.
“More antibiotics!” some say. But the rash overuse of antibiotics is part of the problem: bacteria evolve in response to their environment, and medicine can’t keep up with that. That’s why there’s talk of antibiotic resistance, “superbugs” and even “the end of antibiotics” — we’re losing the war due to antibiotic overuse for things like colds and flu, where they don’t work, and feeding low-dose antibiotics to livestock to make them (and their profitability) fatter.
It’s going to get worse before it gets better, so maybe it’s nice to learn about septic shock before someone close to you is diagnosed. Ali’s death is what brought this all to my mind again this week.
All that sounds pretty gloomy, but hey: we saved our patient. May you and yours also be as lucky until the antibiotics problem is solved! Meanwhile, it’s one of the things that attracts me to EMS: I love figuring out the medical mysteries we sometimes need to unravel, which is the first step to getting them healthy again.
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