Becky Krall hurried through the sliding-glass doors of the hospital emergency room around 8 a.m. on Sept. 25, 2015, expecting to see her feverish husband, David, sitting among the patients waiting to see a doctor. Instead Krall, who had left him for about 15 minutes while parking their car, was met by a nurse with an urgent message: Her 50-year-old husband had suddenly become unresponsive.
Krall recalls with frightening clarity the words of a critical care specialist. “She put her hand on my knee and said, ‘Your husband is very, very sick. You need to be prepared for him not to make it through the day.’ ”
How, Krall remembers wondering, did her fit and healthy husband of 10 years get so sick so fast? The night before, Krall had driven him to the same ER, sent by an urgent care center for a closer assessment of his fever and malaise. The couple had spent about five hours there but left before seeing a doctor because the ER was so swamped and David’s condition seemed unchanged. They figured they’d have better luck in the morning.
That decision, Becky Krall says, was among a cascade of serious missteps that left David, an industrial engineer, battling a catastrophic illness that kills between 60 and 80 percent of its victims. Doctors at the University of Kentucky Albert B. Chandler Hospital in Lexington managed to save David’s life, but he was left with profound, permanent hearing loss. Several of his toes had to be partially amputated.
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“I felt extremely guilty for a long time,” said Becky, an associate professor of STEM education at the university who continues to struggle with the emotional aftermath of the ordeal. “I have lots of information now. But I didn’t know any of it then.” She hopes her husband’s case, which helped spur changes in the emergency department, will serve as a cautionary tale.
“I think there were some educational deficiencies on both sides,” said Derek Forster, the infectious-disease specialist who ultimately identified the underlying cause of David’s illness. “He had all the classic signs and symptoms of another disease process.” David Krall declined to be interviewed but gave permission for doctors to discuss his case.
‘David was never sick’
Three days before he was hospitalized, David, a marathoner, had gone for a run after work, taking one of the couple’s dogs. As he returned to his suburban home, a neighbor’s dog wriggled out of its collar and made a beeline for the Kralls’ dog. While Krall was trying to separate the animals, the neighbor’s schnauzer sank his teeth into Krall’s thigh, leaving a bloody gash.
David washed the wound with soap and water and applied antibacterial cream. The following day he visited an urgent care center for follow-up treatment. He did not have a regular primary-care doctor, and other than having had a splenectomy 35 years earlier after an auto accident, he was healthy.
A clinic doctor administered a tetanus shot; the dog had been vaccinated against rabies. The doctor offered to prescribe antibiotics as a precaution, but erroneously said that only 5 percent of bites become infected. (In fact, the figure for dog bites is closer to 20 percent, and many doctors prescribe antibiotics routinely if a bite breaks the skin.) Concerned about the overuse of antibiotics, David decided to forgo them.
Around 5 p.m. the next day, he called Becky and told her he felt too ill to drive home.
“David was never sick,” Becky said. “I thought his bite had become infected or that it was a reaction to the tetanus shot.” She picked him up and took him back to the clinic.
A nurse practitioner took his temperature, which was 102.9, and noted that the area around the bite seemed warm and slightly swollen. She advised the Kralls to head for the university hospital ER and said she would call ahead.
But when the couple arrived around 7:30 p.m., there was no record of a call. (Patti Howard, director of emergency services for UK HealthCare, noted that there are two UK hospitals a mile apart. It is possible, she said, that the call went to UK Good Samaritan Hospital because such confusion is commonplace.)
After a half-hour of waiting to see a doctor, Becky grew concerned about the couple’s dogs, who had been crated for more than 13 hours. She went home to walk them, returning around 9:15 p.m.
While she was gone, a triage nurse saw David. He told her he was seeking treatment for a high fever and that he’d had a flu - not a tetanus - shot two days earlier. He did not mention the dog bite or other crucial details.
Records show that his blood pressure was low, sometimes dipping to 78/60; low blood pressure is considered to be anything below 90/60. David’s temperature hovered around 101 degrees. His responses to questions seemed slow, and he complained of dizziness. But his initial blood tests looked fairly normal, said Forster, the infectious-disease specialist. Howard said David had told the ER staff he was a runner, which they thought might explain his low blood pressure.
For the next three hours, the couple waited to see a doctor. The ER was teeming, and Becky said she did not approach the registration desk or ask any questions. David’s vital signs were being taken regularly. “I figured they knew what they were doing and we just had to wait our turn,” she said.
Shortly after midnight, Becky told the paramedic monitoring David that they planned to go home and come back in the morning.
“At that point I figured it would be another four hours before he saw a doctor,” she said. She had called another ER and was told the wait was about four hours.
“I wouldn’t leave if my girlfriend had blood pressure like this,” she said the paramedic told her. Becky said she didn’t know what David’s normal blood pressure was or what the worker meant, nor did she ask.
“But you guys aren’t doing anything,” she remembers telling him. Exhausted, the couple left. Soon after they departed, records show, David was called to see a doctor.
At 4 a.m. after a fitful sleep, Becky woke up and took David’s temperature. It registered 102.9. A few hours later, the couple drove back to the hospital.
David seemed sicker, but with difficulty he was able to get into the car. At the hospital, Becky and an ER aide loaded him into a wheelchair.
When Becky rushed in with the nurse who had been dispatched to find her, David was lying on a gurney, his eyes closed, “clearly out of it.” His fingernails were blue, a sign of shock.
“I remember saying it’s got to be the dog bite or the tetanus shot,” Becky recalled. She had also told the staff something they hadn’t learned the night before: David had no spleen. The lack of the abdominal organ that plays a fundamental role in the immune system made him especially vulnerable to infection. People without spleens are typically told to take special precautions, staying up-to-date on immunizations, routinely informing all health-care personnel that they lack a spleen and taking antibiotics at the first sign of possible infection.
Becky said that neither she nor David knew anything about special precautions. David didn’t have a regular doctor and had never gotten around to getting recommended immunizations, including one against meningitis.
Doctors began frantic efforts to save his life and determine what was killing him. His kidneys were failing, his breathing was labored, and he had developed disseminated intravascular coagulation, a condition that could cause him to bleed out spontaneously. A CT scan of his head showed that he probably had meningitis; doctors suspected it had invaded the bloodstream, causing septic shock.
After David was moved to the intensive care unit, Becky said, she repeatedly mentioned the dog bite as a possible cause of his infection. But she said doctors told her they didn’t think the bite was relevant. They were fairly certain that David’s meningitis infection was caused by a bacteria known as Neisseria meningitidis. How he had acquired it was a mystery.
Becky grew increasingly insistent after a physiologist friend found articles in medical journals about a rare bacterium transmitted in dog saliva, Capnocytophaga canimorsus, which causes potentially fatal infections, particularly in people without spleens.
Forster, who was called in on the sixth of David’s 51-day hospitalization, recalled that the ICU team “mentioned the dog bite as an aside. They said the wound didn’t look bad, and they weren’t focused on it.”
But Forster was. A wound may not show signs of infection such as redness or pus, even as the bacteria-infested dog saliva is wreaking havoc inside the body. “I had seen a previous case as a fellow six years earlier,” recalled Forster. Capnocytophaga “was the first thing I thought of.”
He called the microbiology lab and asked the technician whether she had noticed anything unusual about David’s blood cells. “She said they looked really small” and the bacteria were rod-shaped, not round, like neisseria cells.
The cells were also growing slowly, Forster said, another telltale feature of capnocytophaga. After the culture grew out a few days later, the lab confirmed his suspicion.
“I had the advantage of seeing that earlier case,” said Forster, adding that capnocytophaga is “fairly rare. Ninety-nine times out of 100, this is going to be neisseria.”
But, he added, “the temporal association with the dog bite was too close to ignore.”
Fortunately, the treatments for both infections are similar, Forster said, although David’s drug regimen was adjusted to specifically target capnocytophaga.
David, who was in a medically induced coma for 11 days, faced many difficult months of recovery, punctuated by setbacks. Parts of three toes ultimately had to be amputated because of a persistent infection. A cochlear implant has helped mitigate the deafness caused by his illness.
Forster said he believes there is a “reasonable chance” that the antibiotics David declined after the bite might have prevented sepsis. “I don’t think the provider … made him aware of the risk” of not taking them, Forster said.
He believes the lab would have identified the unusual infection without his involvement, once the culture grew out. But David’s case highlights the need of “having front-line providers be aware of these rare infections.”
‘Imagine my horror’
Becky Krall says she and her husband are deeply grateful that doctors saved David’s life. They hope their story underscores the importance of improving communication in emergency departments and the potential dangers facing people without spleens.
She remains upset that the severity of David’s illness wasn’t addressed more quickly during his first ER visit and that she didn’t know how sick her husband was. She didn’t learn until much later that in the throes of sepsis – when patients are often confused or delirious – David had given incorrect information to the triage nurse. Hospital officials say that had they known David had no spleen and had been bitten by a dog, his case would have triggered a sepsis alert and been given priority.
“If I could do it over again, I wouldn’t have left the hospital to feed the dogs,” Becky said. “Imagine my horror when I learned I was the only one that had the whole story.”
Last year at their request, the Kralls met with hospital officials to discuss ways to improve communication.
“We’ve looked at this case in detail,” said Roger Humphries, UK HealthCare’s director of emergency medicine. As a result of this and other cases, a physician is now part of the triage team during the busy afternoon and evening shifts. A tracking board easily visible to staff now displays patients’ vital signs. “I think we’re in a much better place than we were in the fall of 2015. We think we closed a lot of holes in the Swiss cheese.”