I’m currently working on a tragic wrongful death case where a man in his early 50s after a car wreck. The tragedy is that he didn’t die from the injuries he had in the accident. Instead, he got a hospital-acquired infection that the nurses and doctors missed. That infection, and not the car wreck itself, led to sepsis and his death a short time later.
One of the difficult things about any blunt-trauma injury, including a car wreck, is that patients have injuries all over their bodies. During the initial treatment in the emergency room (ER), doctors have to figure out what they’re dealing with before deciding what care and treatments are most urgently needed.
In this man’s case, the medical team didn’t identify any life-threatening injuries from the car accident. The ER doctor admitted him to the intensive care unit (ICU), where two trauma surgeon intensive care physicians managed his care.
As we carefully reviewed the case with the help of a board certified critical care medical expert, the focus came down to one lab value, lactate level.
Doctors treating ICU frequently order lactate levels because they’re a quick, inexpensive, and easy way to assess how a patient is responding to medical therapy and care. A normal range is 2.0-2.5 mmol/L. Most laboratories consider any lactate level over 3 mmol/L to be an abnormally-high critical value.
While critically-high lactate levels can certainly be caused by the shock of a traumatic injury, when there are other symptoms doctors need to consider the whole picture. That’s what didn’t happen in my case.
Two days into this man’s hospitalization, he had two critical lactate levels. They were so high that lab personnel realized that there was a problem. Both times, a lab tech picked up the phone and called the ICU nurses to make sure that they were aware of the critical lactates. On top of the critical lactate values, the patient had a documented fever of over 101 degrees.
The nurses and doctors allowed a bias to guide their care, rather than thinking critically to rule in and rule out all possible causes for critically-high lactate levels associated with a fever of 101 degrees, starting with the most dangerous one. In this patient’s case, it wasn’t the trauma from the accident that was causing his problem.
On autopsy, they discovered that this patient had an infection of a hospital-acquired bacteria called Serratia marcescens. Our critical care expert concluded that the combination of this infection, plus two critically-high lactate levels, and the fever make it clear that this man went into sepsis and septic shock.
But even when the physicians and nurses were in the dark about the specific bug causing the infection, having the critical lactate levels in a patient with a fever was enough to require further workup that would’ve led to the true cause and appropriate treatment.
The medical literature reflects that sepsis and septic shock are one of the most common causes of a critically-high lactate level. Unfortunately, the doctors and nurses treating this patient allowed a bias to cloud their care and decision-making. I don’t mean racial or gender bias, though.
I mean that they couldn’t overcome their biased thinking that everything wrong with this patient was related to the initial injury. As a result, they didn’t consider or explore other highly possible causes, like sepsis. I think that this type of sloppy care is more dangerous than a lot of car wrecks!