General surgeons are trained in performing a wide range of routine and emergency surgical procedures. They are called upon to consult and testify as experts in routine outpatient surgical cases as well as issues arising from acute surgical emergencies such as appendicitis, cholecystitis, pancreatitis, intestinal obstruction, etc. Sepsis, an inflammatory response to infection, is a serious complication for the surgical patient. It appears to be a contributor to or major cause of as many as half of in-hospital deaths. Research scientist Vincent Liu, MD, Kaiser Permanente in Santa Clara, CA, reports that most sepsis is present at the time of hospital admission.
The Society of Critical Care Medicine called upon a task force to redefine criteria for sepsis and septic shock diagnosis. The committee found that the SOFA score worked at predicting mortality, but was not always a rapid identifier. Per SCCM.org:
To facilitate diagnosis of sepsis, the task force has identified new clinical criteria that physicians can use in their offices, emergency departments, and hospital wards to quickly evaluate and assess patients for sepsis.
The new diagnostic tool is named quickSOFA, or qSOFA. It consists of three simple tests that clinicians can conduct at the bedside to identify patients at risk for sepsis. The qSOFA assessment directs physicians to look for these warning signs in patients:
- An alteration in mental status
- A decrease in systolic blood pressure of less than 100 mm Hg
- A respiration rate greater than 22 breaths/min
Data indicate that patients with two or more of these conditions are at a significantly greater risk of having a prolonged ICU stay (3 or more days) or to die in the hospital. For these patients, the task force recommends that clinicians investigate further for organ dysfunction, initiate or escalate therapy as appropriate, and to consider referral to critical care or increase the frequency of monitoring.
Sepsis is just one of many medical conditions that a general surgeon must be able to diagnose effectively. As the leading cause of death from infection in the US, the seriousness of this inflammatory response cannot be ignored. In litigation involving standard of care in routine and emergency surgical procedures, as well as related complications such as sepsis, the highly trained general surgery expert witness is essential.
