Schenk: This is episode 79 of the Nursing Home Abuse Podcast: How to prevent sepsis in Georgia nursing homes.
The Nursing Home Abuse Podcast is dedicated to providing news and information to families whose loved ones have been injured in a nursing home. Here are your hosts, Georgia attorneys Rob Schenk and Will Smith.
Schenk: Welcome back to the podcast. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: We got some very interesting information, important information for you today on this episode concerning sepsis, what sepsis is, how to prevent it and what to look out for with your loved one in a nursing home. Sepsis can be extremely dangerous. In our experience, a lot of our clients…
Smith: Yeah, it can be a death sentence unfortunately.
Schenk: Yeah, it can be a death sentence, but we’re not alone in discussing this important issue. Today we have a guest. I would say it’s our second medical doctor that we’ve had on since the inception of the podcast.
Smith: Yeah. July has been a month of medical doctors. We’ve had two on so far.
Schenk: Docs. Our guest today is Dr. Imrana Malik. She is the Global Sepsis Alliance advance coordinator, and Will, tell us a little about her.
Smith: I will. She is an associate professor in the department of clinical care at MD Anderson Cancer Center, which is one of the foremost institutions in the world for cancer research. Dr. Malik is primarily involved in direct patient care in medical and surgical intensive care units. Her clinical research and quality improvement interests include sepsis in cancer patients. At MD Anderson, Dr. Malik is chair of the Institutional Sepsis Advisory Committee, which seeks to improve outcomes for cancer patients with sepsis.
Dr. Malik is also the chair of the Texas Medical Center, TMC Sepsis Collaborative, which is the multi-institutional collaboration with the mission to collect, collaborate and galvanize the Texas Medical Center institutions and adult and pediatric septic care research and outcomes.
Dr. Malik also serves as a member of the Global Sepsis Alliance, GSA. Additionally, she is the coordinator for the GSA Advance program, which is a coalition of sepsis experts and supporters around the world who help advance GSA’s missions. So we are very privileged to have somebody with this pedigree on the show today to talk about the condition of sepsis.
Schenk: All right, Dr. Malik, welcome to the show.
Imrana: Thank you so much for having me.
Schenk: Great. So Dr. Malik, we have you on today to give basically a 40,000-foot view of the infection sepsis. I know that a lot of our clients that come in the door, their loved one is either battling or has succumbed to sepsis. So we know that you have a lot of experience with this, experience treating it, preventing it. Can you just walk our listener through the basics of sepsis, what it is, how is it caused?
Smith: Why it’s so dangerous?
Schenk: And why is it so dangerous?
Imrana: Absolutely. Absolutely. I think one of the first things I want to impart, and it’s probably something that’s going to be a surprise for many listeners is that sepsis is the number one cause of death from infections and is preventable. So that tells you very distinctly how significant the problem is.
In terms of how it occurs, sepsis occurs when the body response becomes an unchecked response to infection and then leads to severe damage including tissues and organs and leads to what’s called multi-organ dysfunction. It’s commonly caused by infections that may be bacterial in origin, but viruses can also cause them as well as fungi too. So we really need to be very careful and watchful when it comes to sepsis because it can come from many different sources.
Schenk: Is there a source that is more common than others?
Imrana: Well it depends on the setting in terms of the patient’s comorbidities. It depends on the age of the individual, infants versus the elderly, etc., but in general, any age, any underlining comorbidity can succumb to infection from either bacterial or viruses or fungi. It just depends on how you get infected, whether it’s from a cut or because it’s from something you ingested or just depends on whether you have a wound that becomes infected secondarily. So it just depends on what the setting is.
Smith: And can you explain to us – does every infection lead to sepsis? Or how does an infection lead to sepsis and one doesn’t lead to sepsis?
Imrana: That’s a very good question. So not all infections lead to sepsis. However, all infections have the potential to. So when you have an infection, when it is allowed to propagate and progress to the point where it can become bloodstream-born and go to different parts of the body and become so overwhelming that the body, as it’s trying to fight it, starts doing its own collateral damage, that’s what’s sepsis is, when it’s so overwhelming, when it starts involving so many organs, now the body’s in trouble because now we’ve moved onto sepsis.
But not every infection will do that. If we are careful, if we are monitoring for those infections, if we are treating them early, if we’re taking care of potential sources for infections, it may not progress to the form of sepsis, but certainly all infections have the possibility of progressing to sepsis.
Schenk: You mentioned earlier in terms of the mechanism for the sepsis being cause as comorbidities being involved in that. Is that a reason why sepsis is more dangerous or more likely to occur in the elderly population versus just the average adult population?
Imrana: Absolutely. So as you may assume that elderly patients have a lot more comorbidities. They have many more years of prolonged comorbidities, and in general, the elderly population tends to have a lower immune system just because of their age but also because of other conditions they may have compounding all of that. So absolutely the comorbidities are definitely a component of what happens in terms of the prognosis with these patients as well as the outcomes for these patients.
Schenk: So from a health standpoint then for an average resident of a nursing home that’s of advanced age, what would be the symptoms or the signs that perhaps there is an issue with sepsis with that individual? Is it loss of consciousness? Is it the skin is infected, that kind of thing? What should the family look out for?
Imrana: Right. The common signs of sepsis are confusion, so lower mental alertness, fever, chills, rapid breathing or rapid heart rate, lower blood pressure, nausea, vomiting, and more important in the elderly, confusion and lower mental alertness is often the first sign of sepsis. And even more interestingly, when an older person becomes septic, fever is often absent for those individuals, so one has to be a lot more vigilant in the elderly than towards their average-aged patients, because they may present a little bit differently. They may be not as alert as they normally have been as their baseline and they may not present with that fever, so you really have to be very vigilant.
Schenk: What’s the reason why there’s no fever with sepsis or there may not be a fever with sepsis?
Imrana: So it really is what your immune system is able to mount. So as you’re older or if you have other reasons why your immune system isn’t very strong such as underlying cancers or cancer therapies, etc., your immune system is trying to battle an infection but it’s not able to mount enough of a fever or enough of the signs to tell you that there’s something going on in the body, hence in those patients, fever can be absent.
Smith: We hear a lot in some of our cases, and just to let you know, the vast majority of times in our cases, we get residents who get sepsis through bedsores as you can imagine. And sometimes they’ll undergo what’s known as septic shock. Can you explain to us what septic shock is?
Imrana: Absolutely. So in terms of the progressions, so there’s infection where somehow an organism such as bacteria, virus or fungi has entered into the body and has started either at the level of the skin or soft tissue or further in has started to take hold – that’s infection. Sepsis is when it has had a chance to get further into the body, into the blood stream, into other organs and started causing havoc there. Septic shock is that in those individuals where sepsis has started, they have started having lower blood pressure, and on top of that, as they’ve been resuscitated with fluids to help with their blood pressure, they become refractory to that treatment, that septic shock.
Schenk: So in your experience, Dr. Malik, how long from the general – we’ll just keep using the bedsore for example – how long from the infection to reaching septic shock? Are you talking about a matter of hours? A couple days? A week? Is there a general – what’s the window the family has to recognize the symptoms and get something done before septic shock sets in?
Imrana: Right. I think that that can vary depending on what kind of comorbidities that patient has. However, once it’s gotten into the blood stream, once it’s made its way to being sepsis, moving onto septic shock can be a matter of hours, I would say no more than days where things are going to move really quickly.
So when someone has sepsis, that is our point where we really need to get that treatment early because now we’re talking short period of time, hours, where this can actually progress to low blood pressure and then low blood pressure that does not respond to further therapy. So it’s really pertinent and important that when we identify sepsis, we are immediately thinking about getting care and appropriate treatment right away.
Schenk: Sure. So again, a lot of our clients, the mechanism for sepsis is either a bedsore or possibly UTI. Is there, basically from a health standpoint, is there a reason why those are a catalyst for sepsis versus just like a cut on the elbow or some other ailment?
Imrana: I think there’s a couple of reasons for that. One is that unlike a cut on your arm where you can see it and be aware of it, bedsores may not be getting the right kind of attention, so they’re not being evaluated. It’s hard to notice when they’ve progressed – sometimes it’s a little too late. Similarly for UTI – you can’t really tell that someone is having a very obvious UTI unless they’re telling you about their signs, and sometimes nursing home residents may not be able to explain the signs that they’re having in terms of urinary pain, but they also may not show fevers. So those are things that are harder to find, harder to diagnose, and so that leads into delay in identification. And a delay in identification leads into delays in treatment. So those are the reasons why those tend to be common, but they’re also commonly found in older individuals who are in nursing homes.
Schenk: I see. Can you walk us through what happens to the body when it goes from sepsis to severe sepsis into septic shock? What’s literally going on with the organs and the blood stream, that kind of thing?
Imrana: Sure. Sure. So when you’re progressing into septic shock, that means that the body’s organs have now been overwhelmed and the functions are not able to maintain appropriate care for that patient. So for instance, we may have blood pressure that is so low and so refractory to resuscitation that it’s not pushing through to the brain, so the patient is less responsive. It’s pushing to the kidney so the kidneys are not making urine, they’re not clearing toxins out of the body, those toxins – the acid levels in your body, more signs of blood pressure become the cyclical cycle. There’s less blood pressure and flow to the heart, so you may actually have not only demand-related heart symptoms or what we call demand ischemia or basically similar to a heart attack but because of the low blood pressure. You can also have low heart function related to the profound sepsis and septic shock that’s going on.
You can also have the liver that’s overwhelmed and is not able to clear the toxins that the liver normally clears, and those toxins such as ammonia build up in the system. That leads to less responsiveness and sometimes even to being comatose because of all the toxins that are being in the body. So all the major organs are shutting down.
Now as we increase the number of organs that are shutting down, the likelihood of improvement drops dramatically. The mortality increases dramatically. So with sepsis and septic shock, the mortality for an average person is upwards of 40 percent. With respect to the elderly, two-thirds of the elderly have incurred sepsis, and that’s for the individuals over the age of 65. Their mortality rates are much higher. They can be upwards of 60 percent, especially if they’re developing septic shock. So the mortality rates for elderly patients are up to 1.5 times higher than in younger individuals, and that relates to all this organ failure that is going on that cannot sustain normal function.
And then you start having to put the patient on dialysis, put them on a ventilator with a tube in their throat so we can help them with the breathing because they’re not breathing well for themselves, especially if they have pneumonia on top of everything else, so we’re doing a lot to support those organs and try to get them through this process.
One thing that’s very key in that treatment is early antibiotics. So as soon as we know that we’re suspecting sepsis, we need to get antibiotics on board because we know that for every hour of delay in treatment of sepsis, the risk of death increases by 8 percent. So all of these things are trying to not only buy time, but keep those organs functioning so they don’t completely fail.
And that’s kind of an overview picture of what happens as a person progresses from sepsis to septic shock.
Schenk: So of the treatments that you’ve stated, the dialysis, the respirator, that kind of thing, is antibiotics the principal treatment that’s probably going to be the same for everybody you’re going to get on massive amounts of antibiotics to treat it?
Imrana: Absolutely. And what we do is we try to put on what’s called broad spectrum antibiotics at the beginning until we know what kind of organism we’re dealing with and then we can narrow the antibiotics down. But in everything that we use to treat sepsis, the number one thing that can actually reduce their possibility of death or their death rate in patients with sepsis are timely antibiotics. So those are very key, very important, but it requires someone recognize what’s going on, and that is the crux of the problem. Individuals, the patients themselves, the families, the caregivers, they need to be on a high alert for diagnosing this. Everybody needs to be able to understand what they’re looking at and put the picture together and have concerns for sepsis because that’s when people start with getting the treatment and getting the antibiotics on board.
Smith: You mentioned that there are different ways that somebody can become septic – bacterial, fungi, I guess maybe even viruses or parasites, I assume. What is the most common?
Imrana: You know, it actually depends on the season, so if it’s flu season, that’s what we’re going to see more commonly, but we are exposed to bacterial elements day in and day out, and if our immune systems are not able to combat them in their most easiest formats, it’s going to be overwhelming for the body. So bacteria, we are in contact with them constantly. Viruses, they can kind of come and go depending on how the season is, and maybe what you’re kind of exposure is. So if you’re an elderly patient and you’re visiting your grandchildren, children tend to have more viral illnesses as they’re growing older, and so it depends on what type of season you’re in, what your exposure is and what your immune system is like. And for certain individuals, that means they’ll have a higher likelihood of bacterial infections. For others it would mean because of their contacts and things like that that they may actually have more of a likelihood of viral infections.
So we can actually expect that when a patient has sepsis, we’re going to investigate for all of them because it certainly could be any one of those.
Schenk: That’s actually a great segue, Dr. Malik. So what are the top tips to prevent sepsis that you would give to the average family member who has a loved one in a nursing home that’s a senior citizen?
Imrana: Sure. So one of the things that older individuals may actually be resistant to getting urgent medical care, but it’s really imperative to get timely medical treatment in those patients in order to increase survival. As I mentioned, for every hour delay in appropriate antibiotic treatment, the risk of death increases by 8 percent, so it really bears repeating over and over is the best way to combat sepsis is to prevent it.
And so families and caregivers definitely can play an extremely important role in prevention. Both the elderly and their caregivers should get appropriate vaccinations. They should pay very close attention to handwashing as well as wound care. And they should know the signs of sepsis, especially the signs that are common in the elderly, such as lowered mental status being one of the first signs.
And finally, as I said previously, they should seek care and treatment as early as possible when there’s a concern for sepsis. And I also think that families and caregivers should be empowered to say the words, “I think I may have sepsis,” because it really puts a red flag up, it really gets the medical teams on high alert when someone is using that terminology. In the UK, the UK Sepsis Trust, they have been advertising on ambulance doors and things like that, and those advertisements say, “Think sepsis, say sepsis,” so that we’re having this conversation about something that’s beyond, “I think I have a cut. I think I may have an infection.” We’re talking about sepsis because there are signs that show us that things have progressed and we need to be able to say those words.
Schenk: So Dr. Malik, can you walk us through the Global Sepsis Alliance? When did they form? What do they do? How can people get in touch to get information about sepsis?
Imrana: Absolutely. So the Global Sepsis Alliance started in 2012 as an organization that was very interested in bringing awareness to the healthcare workers but also to the general public about sepsis and improving everyone’s knowledge about it, but then also the outcomes. The Global Sepsis Alliance website has excellent resources and tools to help identify sepsis and for bringing awareness to the general public. So I would absolutely recommend that if the listeners are interested in finding more about sepsis, that would be an excellent source for information.
Now that’s an international organization of experts throughout the world. We also have nationally the Sepsis Alliance – sepsis.org – and they have a tremendous amount of resources online as well. So my institution at MD Anderson, we have posted and published articles on our online Cancer Wise blog posts. There are several videos on YouTube and MD Anderson, my organization, has put together one called “What is Sepsis?” which goes through a lot of this education and basic education about sepsis but also shares patient stories along the way as well.
And finally related to what we’re talking about, there’s also the Alliance for Aging Research. They have a wonderful pocket film called “Sepsis in Older Americans: Saving lives through early detection,” and I think it really hones in on a lot of the points that we were talking about today. I was very honored to be able to work with them helping to create that pocket film. I think it’s very relevant for the older American nursing home patients as well.
Schenk: Well great. Well Dr. Malik, this has been extremely informative. I think we’ve learned a lot. I think our audience has learned a lot. If anybody has any questions, is there a way they can reach out to you specifically? Reaching out to your organization, is that good? How do they get involved?
Imrana: Oh, absolutely. Please feel free to email me. It’s firstname.lastname@example.org or find me through the MD Anderson website – “Imrana Malik.”
Schenk: Excellent. I encourage everyone in the audience to go to YouTube to check those videos out that she was talking about because they’re really good, concise…
Schenk: …Informative places to get this stuff.
Smith: Because this is a bigger issue than people realize.
Smith: It’s like you said, the number one cause of death from infection, and I don’t think people understand that. In our research for this, we discovered that it was a big deal I guess in World War II and there’s even some interesting propaganda posters that America made in trying to combat sepsis or “blood poisoning” as they called it back then. But yeah, people need to learn a lot more about this.
Imrana: Absolutely. And I think when we say that it’s the number one cause of death from infections, that’s a worldwide number. That’s number one worldwide.
Smith: That’s insane. That’s amazing.
Schenk: Well Dr. Malik, again, thank you so much for being on the program. I think we’d love to have you on a future program to go a little more in-depth into sepsis and your organization.
Smith: And thank you for what you do.
Schenk: Absolutely. Absolutely.
Imrana: Thank you very much and I am very happy to join you all and I think this is such a wonderful way to get the message out and get the information out and I look forward to working with you guys in the future.
Smith: Absolutely, thanks so much.
Schenk: Thank you, Doc.
Imrana: Thank you.
Schenk: Okay, bye-bye.
Schenk: Yeah, I don’t think sepsis is – I’m not trying to do a Donald Trump, but I don’t think sepsis is something that’s very well-known, like a lot of people are not talking about sepsis.
Smith: What I wanted to show and maybe Gene can do this is this poster from World War II. It’s an American poster or it could possibly be English, and it’s about Hitler’s greatest ally, and it says he uses blitz methods, and it’s blood poisoning. So basically the purpose of this poster, and you should be able to see it right now if Gene’s doing the right thing, is that if you get a cut or if you’re in the field and you get a cut, if you’re in combat, you get a cut, you need to attend to it immediately, because if you don’t do that, there’s always a chance you could get an infection and that infection becomes septic, and I suppose you’ve got to think about it, if sepsis is the number one killer of people with infections, it’s a big deal if you have a large contingent of troops and they’re getting cuts, they’re getting infections, maybe they’re tired and their bodies are run down, but blood poisoning, that’s what they used to call it, that’s the old term for it, blood poisoning, septicemia, sepsis, it’s really a serious issue and more so than I think people think, so it was good to have somebody like Dr. Malik on today.
Schenk: Yeah, you can definitely say that sepsis is no one’s friend.
Smith: You could say that. That’s definitely a good way to put it.
Schenk: And I say that only because today, July 30th, is International Day of Friendship. I don’t know why we bring these up but I think it’s funny. I don’t know.
Smith: I forgot to look at the paper and what the issue was.
Schenk: What the special holiday is – but it is International Day of Friendship, and again, I don’t know what that means but I’m sure it’s nice. At any rate, again, thanks to the team for putting this podcast together and thank you dear audience for watching or listening or reading.
Smith: Or reading.
Schenk: Or reading the transcript. So there are lots of ways to listen every week. You can watch us, NursingHomeAbusePodcast.com or the Youtube channel, you can download the audio on Stitcher, iTunes, Spotify or Podcast Puppy, wherever you get your podcast from, or you can read the transcript.
Smith: You can read.
Schenk: You can read the transcript. You can go to the website.
Smith: And read it.
Schenk: And read it. Anyways with that, we will see you next time.
Smith: See you next time.
Thanks for tuning into the Nursing Home Abuse Podcast. Nothing said on this podcast either by the hosts or the guests should be construed as legal advice, nor is intended to create an attorney-client relation between the host or their guest and the listener. New episodes are available every Monday on Spotify, iTunes, Stitcher or your favorite podcast app, as well as on YouTube and our website, NursingHomeAbusePodcast.com. See you next time.