David Krall was in a medically induced coma for 11 days after being bitten by a dog.
David’s wife, Becky, took her husband to the emergency room on September 25, 2015, and after parking the car and expecting to join her husband in the waiting room, Becky was met by a nurse with an urgent message: 50-year-old David had suddenly become unresponsive.
But how could that be? She had only left him for 15 minutes to park the car! Becky was terrified as a critical care nurse specialist put her hand on Becky’s knee and told her that her husband of ten years was “very, very sick.”
“You need to be prepared for him not to make it through the day.”
How could her fit and healthy husband become so ill so fast?
The Washington Post reported that David and Becky had attended the same emergency room the previous night because David had a fever and needed to be assessed; however, after five hours and still unable to see a doctor, they left, with a the goal of returning in the morning.
According to Becky, that was their first bad decision: a decision that left David battling a catastrophic illness that kills between 60 and 80 percent of its victims. David’s life was saved by doctors at the University of Kentucky Albert B. Chandler Hospital in Lexington, but several of his toes had to be partially amputated, and he now suffers with profound permanent hearing loss.
His wife, Becky, an Associate Professor of STEM education at the University, said she felt extremely guilty for a long time and continues to struggle with the aftermath of the traumatic ordeal.
Her wish is that her husband’s case will not only create changes in the emergency department, but also serve as a cautionary tale
“I have lots of information now. But I didn’t know any of it then.”
Derek Forster, the infectious-disease specialist who identified the underlying cause of David’s illness, spoke of “educational deficiencies” from all parties.
“[David] had all the classic signs and symptoms of another disease process.”
David Krall was a marathoner, and three days before being hospitalized he had gone for a run after work and taken one of the family dogs. As he was returning home, one of his neighbor’s dogs attacked his dog, and while trying to separate the animals the neighbor’s schnauzer bit David on his thigh.
David cleaned the wound and applied anti-bacterial cream, and the following day he sought treatment at an urgent care center where he was administered a tetanus shot. While the doctor offered to prescribe antibiotics as a precautionary measure, he also mentioned that only five percent of bites become infected. As it turns out, this information was incorrect because the figure for dog bites is closer to 20 percent. David knew about the overuse of antibiotics, and decided not to take them.
The next day David was too ill to drive home and called Becky, who picked him up and took him back to the clinic.
“David was never sick. I thought his bite had become infected or that it was a reaction to the tetanus shot.”
His temperature was 102.9, and the area around the bite was warm and swollen, so the nurse practitioner advised the couple to go to the University Hospital E.R., saying she would call ahead. When David and Becky arrived at the hospital there was no record of any call and, after waiting half an hour to see a doctor, Becky became concerned that their dogs had been crated for more than 13 hours, so she went home to walk them.
A triage nurse saw David while she was gone, and David told the nurse he needed treatment for a high fever, and that he’d had a flu shot (not a tetanus shot) two days earlier. He failed to mention anything about the dog bite.
For the next three hours they waited to see a doctor, but because the E.R. was so busy Becky did not approach the registration desk or ask any questions. All the while, David’s vital signs were being taken regularly so they assumed there was no urgency.
“I figured they knew what they were doing and we just had to wait our turn.”
Just before midnight Becky spoke to the paramedic who was monitoring David and advised that they planned to go home and return in the morning.
“At that point I figured it would be another four hours before he saw a doctor.”
She said the paramedic told her, “I wouldn’t leave if my girlfriend had blood pressure like this,” but she didn’t know what David’s normal blood pressure was or what the paramedic actually meant.
Becky remembers telling him, “But you guys aren’t doing anything,” and exhausted, the couple left.
The following morning the couple drove back to the hospital. David seemed worse, but he was able to get into the car. At the hospital he was loaded into a wheelchair by Becky and an E.R. aide.
When Becky rushed back into the hospital, David was lying on a gurney with his eyes closed: he was clearly out of it – his fingernails blue, a sign of shock.
“I remember saying it’s got to be the dog bite or the tetanus shot.”
She also told hospital staff that David had no spleen, which meant he was especially vulnerable to infection. People without spleens are usually told to take special precautions, including informing all health-care personnel that they lack a spleen, staying up-to-date on immunizations, and taking antibiotics at the first sign of possible infection.
Neither Becky nor David knew anything about these special precautions, and because David didn’t have a regular doctor he’d never had the recommended immunizations.
Doctors began frantically trying to save David’s life. His breathing was labored, his kidneys were failing, and he had developed disseminated intravascular coagulation. A head scan showed that he probably had meningitis, which had invaded his bloodstream and caused septic shock.
While David was being moved to the intensive care unit Becky repeatedly mentioned the dog bite as a possible cause of infection, but the doctors weren’t concerned because they believed his meningitis infection was caused by bacteria called Neisseria Meningitidis, even though they had no idea as to how he acquired it.
Becky still wasn’t convinced, especially after a friend found articles in medical journals about Capnocytophaga canimorsus, a rare bacterium transmitted in dog saliva which causes potentially fatal infections, especially in people who have no spleen.
Derek Forster, the specialist who eventually identified the cause of David’s illness, was called in on the sixth of David’s 51-day hospitalization. He said the ICU team mentioned the dog bite, but said the wound didn’t look bad and they were not focusing on that. But Forster was concerned, because wounds don’t necessarily show signs of infection when all the while the bacteria infested dog saliva can wreak havoc inside the body.
“I had seen a previous case as a fellow six years earlier. Capnocytophaga was the first thing I thought of.”
Tests on David’s blood cells confirmed his suspicion.
“I had the advantage of seeing that earlier case. Capnocytophaga is fairly rare. Ninety-nine times out of 100, this is going to be neisseria.”
However, the specialist noted that “the temporal association with the dog bite was too close to ignore.”
Fortunately, the treatment for both infections are similar, said Forster.
David Krall was in a medically induced coma for 11 days and faced many months of recovery, punctuated by setbacks. Due to a persistent infection he lost part of three toes and required a cochlear implant to mitigate the deafness caused by his illness.
According to Forster, the antibiotics declined by David following the dog bite could well have prevented sepsis.
“I don’t think the provider made him aware of the risk of not taking them.”
He also believes that David’s case highlights the need of having front-line providers being aware of rare infections.
While Becky and David Krall are deeply grateful to the doctors who saved David’s life, they hope their story reinforces the importance of improving communication in emergency departments. And Becky is still upset that David’s illness was not addressed during his first E.R. visit, and that she was not made aware just how sick her husband was.
She certainly wasn’t aware that when patients are in the throes of sepsis, are confused, or are delirious, that they can provide incorrect information to hospital staff.
“If I could do it over again, I wouldn’t have left the hospital to feed the dogs. Imagine my horror when I learned I was the only one that had the whole story.”
Last year David and Becky Krall met with hospital officials to discuss ways to improve communication.
Roger Humphries, U.K. HealthCare’s Director of Emergency Medicine, said they’ve looked at David Krall’s case in detail, and, as a result, a physician is now part of the triage team during the busy afternoon and evening shifts. In addition, a tracking board 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.”
[Featured Image by Tyler Olson/Shutterstock]