Medical expert defends doctor’s assessment before Heather Winterstein’s death at St. Catharines Hospital

Heather Winterstein did not show signs of potentially life-threatening sepsis during a triage screening the day before she died at a hospital in St. Catharines, Ontario, an emergency medicine specialist told the coroner’s inquest of the 24-year-old.

Early detection of the extreme response to the bacterial infection that took Winterstein’s life on Dec. 10, 2021, is important, but Dr. Ron McMillan said there is no magic pill when it comes to diagnosing the condition.

McMillan, an expert at McMaster University, reviewed hospital records and a post-mortem examination report on Winterstein. On Tuesday, he appeared to support several clinical decisions made by Dr. Imad Noor, the emergency physician who treated Winterstein on Dec. 9, 2021, the day before the Indigenous woman died.

Winterstein complained of body pain, especially in his right leg. Although they checked her for possible symptoms of infection, Noor ultimately determined that she had no symptoms.

Noor testified last week, several days after the inquiry began on March 30, and is expected to continue his testimony later this week.

The inquiry, which was announced to take place in 2024, is being conducted virtually. Twenty-two witnesses are expected to testify over 13 days. Those who have already testified include members of Winterstein’s family, a police officer and a paramedic, a triage nurse and a senior executive from Niagara Health, which runs the hospital now known as Marotta Family Hospital.

Inquiries are held to inform the public about the circumstances of the death, but do not assign blame or conclude guilt or innocence. A coroner’s jury reviews evidence to determine the facts surrounding a death and may make recommendations to prevent similar deaths.

Winterstein’s mother previously said she hoped the jury would make recommendations. Since her daughter’s death, family members and community organizations have also expressed concerns that addiction discrimination and anti-Indigenous racism may have played a role in Winterstein’s treatment.

‘You can’t get sepsis without infection’

On Tuesday, McMillan said triage screening showed that Winterstein’s temperature was almost normal, blood pressure was below normal and respirations were normal. While her pulse was slightly elevated at 115 beats per minute, they said it could be caused by factors other than sepsis.

Noor chose not to retrieve Winterstein’s vital organs and also decided not to send him for blood tests, the inquest previously heard.

Instead, she was given Tylenol, sent home and instructed to return to the emergency department if her symptoms worsened.

In her report, Noor said that “social issues” were behind her visit to the hospital.

The next morning, Winterstein’s family called an ambulance and she returned to the hospital. After spending hours in the emergency department waiting room, Winterstein collapsed on the floor. The medical staff’s efforts to revive him failed.

McMillan defended many of Noor’s clinical decisions on Tuesday when questioned by Jan Liles, the lawyer representing Noor and three other doctors.

McMillan said Noor did not find any signs of infection in Winterstein.

“Sepsis is a life-threatening condition,” he said. “(But) you can’t have sepsis without infection.”

McMillan said the post-mortem report also said no source of infection had been identified.

“This is important because the post-mortem is factual and objective. If no source of infection has been identified, it supports the clinical examination conducted by Dr Noor on December 9.”

Similarly, a widespread infection like sepsis would require confirmation of a fever, as opposed to a localized infection, McMillan said. The temperature recorded by the triage nurse does not show this, he said.

When questioned whether he thought Noor should have ordered blood tests, McMillan said: “No, in my opinion there was no need for any laboratory testing based on the clinical assessment conducted on 9 December.”

Experts defend not prescribing antibiotics if there is no infection

When asked by a lawyer representing Winterstein’s family, McMillan also defended the decision not to start Noor on antibiotics.

McMillan said prescribing antibiotics when no infection is present can increase the risk of antibiotic resistance, and doctors should not do so without first determining whether an infection is present.

“It’s important to treat the infection promptly, but it’s most important, in fact, it’s essential and it’s essential, that you actually identify the infection early,” he said. You cannot treat an infection (if) you do not have clinical evidence of its existence.

“Antimicrobial resistance is truly a global health risk.”

MacMillan also supported Noor’s decision not to retake Winterstein’s vital signs.

People who have sepsis can develop septic shock or toxic shock with specific types of bacterial infections, in which blood pressure can drop to dangerously low levels with multi-organ failure, he said.

“That form of shock can come on very quickly, within a matter of hours.”

McMillan said the hospital has screening tools for sepsis including the inflammatory response syndrome (SIRS) test. But he said Winterstein’s vital signs and apparent lack of infection do not meet that threshold.

“There is no single test that can diagnose sepsis,” he said.

Those screening tools can help with early identification of sepsis, but are not perfect, McMillan said.

“They do not and were not meant to replace clinical judgment when evaluating a patient.”

Expert opinion on doctor’s diagnosis of ‘social issues’

He also said that, in his view, Winterstein’s diagnosis reflected Noor’s controversial “social issues” in his doctor’s notes – Noor mentioned his history of substance abuse and housing instability. — The emergency department diagnosis was not out of line.

“‘Social issues’…usually used when there is no definite diagnosis that is apparent on clinical evaluation.

“It’s certainly not a definitive diagnosis, but it is a diagnosis that is used by emergency physicians in emergency departments.”

McMillan said psychosocial issues, mental health issues and housing issues can cause physical symptoms in patients who come to hospital emergency departments.