Every doctor’s nightmare [updated]

This story is heart-breaking:

For a moment, an emergency room doctor stepped away from the scrum of people working on Rory Staunton, 12, and spoke to his parents.

[snip]

Two days earlier, diving for a basketball at his school gym, Rory had cut his arm. He arrived at his pediatrician’s office the next day, Thursday, March 29, vomiting, feverish and with pain in his leg. He was sent to the emergency room at NYU Langone Medical Center. The doctors agreed: He was suffering from an upset stomach and dehydration. He was given fluids, told to take Tylenol, and sent home.

Partially camouflaged by ordinary childhood woes, Rory’s condition was, in fact, already dire. Bacteria had gotten into his blood, probably through the cut on his arm. He was sliding into a septic crisis, an avalanche of immune responses to infection from which he would not escape. On April 1, three nights after he was sent home from the emergency room, he died in the intensive care unit. The cause was severe septic shock brought on by the infection, hospital records say.

The article goes on to describe in some detail Rory’s initial symptoms and the progression of events that led to his tragic and almost certainly preventable death.  It paints a pretty damning picture of the physicians who were involved in this child’s care, at least at the early stages.

I went back and forth in my mind a bit when I read this story about whether or not it would be wise to write about it.  I’ve obviously decided to do so, but there are a few things I must stipulate right up front.

First and foremost, while I’m going to write a tentatively sympathetic, qualified defense of the doctors, nothing they are going through can begin to compare to what these parents are suffering.  Though I think it would be more illuminating to spend my time presenting one pediatrician’s reading of the story than to focus on the more obvious facts of the parents’ grief, that does not in any way mean I am not incredibly sorry for their loss or that I think their complaints are invalid.  Any critiques I might have are about the story as presented, not about their entirely understandable desire to know why their son died.

In the interest of full disclosure, I also must mention that I had an institutional affiliation with NYU Medical Center for several years.  I have no particular affection for the place, nor do I feel a special loyalty to it.  Of course this story resonates more with me because I know the intensive care unit where they tried to save Rory (and which is spared any criticism in the article), but I don’t think my reading of the story is otherwise affected much by my connection to NYU.  Further, I have never met any of the doctors in the report, and I know nothing of this case other than what is included in this story.

With all that said, I’ll dive into my reaction to this article.  To me, it describes one version of every doctor’s nightmare.  All of us dread missing the signs that led to a patient’s death or disability.  And as brilliant as any of us may believe ourselves to be, all of us miss diagnoses at one point or another.  I like to think that had Rory been my patient, I would have caught what was missed.  Certainly there are places where I can see myself acting differently.  But I can understand all too well how an otherwise competent medical provider could miss important clues, because I consider myself to be a pretty decent physician and I’ve missed things, too.  (I learned from them, and hope I’ll never miss those particular clues ever again.)

This article is necessarily quite lopsided.  None of the doctors involved offered any meaningful commentary, because doubtless they have been advised by counsel in no uncertain terms to keep their mouths shut.  It would be monumentally stupid for them to say anything to a reporter.  Part of me feels it is unfair to essentially pre-litigate a malpractice case in the press.  On the other hand, if a person died because his elevator dropped down the shaft I’d expect it to be reported, so it’s probably my professional bias that balks at seeing this piece in the paper.

I’m going to parse a few bits of the article, though, because I think they admit more nuance than the writer presents.  In particular, this:

Moments after an emergency room doctor ordered Rory’s discharge believing fluids had made him better, his vital signs, recorded while still at the hospital, suggested that he could be seriously ill. Even more pointed signals emerged three hours later, when the Stauntons were at home: the hospital’s laboratory reported that Rory was producing vast quantities of cells that combat bacterial infection, a warning that sepsis could be on the horizon.

And, later on, this:

The challenge for physicians is recognizing an invasive infection, whether from Group A strep or other pathogens, before the cascading damage of sepsis has picked up too much speed. The consortium of New York hospitals has a goal of starting antibiotics within an hour of spotting sepsis in the emergency room, according to officials with the Greater New York Hospital Association’s Stop Sepsis program.

For every hour’s delay in giving antibiotics after very low blood pressure had set in, a study found, the survival rate decreased by 7.6 percent. [emphasis added]

This:

The parents also remarked that Rory’s skin became blotchy when they pressed a finger on it. Those concerns were well-founded, said Dr. Edmond, the infectious disease specialist, who was not involved in Rory’s care: The mottling, which Dr. Levitzky made note of, could mean that vessels in his skin were constricting from low blood pressure; the leg pain could mean an invasive infection. Rory’s temperature was 102 and his pulse was 140; he was taking 36 breaths a minute. These, too, were “worrisome” observations, Dr. Edmond said.

This:

Two hours later, though, he had three: his temperature had risen to 102, his pulse was 131 and his respiration rate was 22. But by the time those vital signs were recorded, at 9:26 p.m., they had no bearing on his treatment. In fact, the doctor had already decided that Rory was going home. Rory’s “ExitCare” instructions, signed by his father, were printed 12 minutes before those readings.

And finally this:

About three hours later, Rory’s lab results were printed. He was producing neutrophils and bands, white blood cells, at rates that were “very abnormal and would suggest a serious bacterial infection,” Dr. Edmond said.

I recognize that’s a lot of information.  Much of it does appear very worrisome.  But there is a lot of information missing, too.

The reason I put the one sentence in bold is that it describes a particular risk factor for mortality.  But then the rest of the article elides what Rory’s blood pressure was.  It discusses vital signs as a category and presents the ones that look worst, but does not give the one vital sign that has already been reported as being predictive.  This strikes me as unfair.  If his blood pressure was normal during his stay in the ED, the reporter owes it to the people treating him at that time to say so.  While his pulse and respiratory rate are notably elevated, fever can raise both heart rate and respiratory rate.  A respiratory rate of 36 is quite high, but 22 is not so elevated that I cannot understand how it might have been attributed to the fever alone, and the fever understandably attributed to a viral gastroenteritis.  Similarly, I can understand how the elevated heart rate could have been erroneously attributed to a combination of fever, pain and dehydration.

We also simply don’t know what the physical exam revealed.  I don’t know what “blotchy” means, or whether I would have found it significant.  Even when giving follow-up care to my own patients when they’ve gone to an ED I don’t generally prefer and gotten treated in ways I don’t endorse, it is rare that I will be too critical because, simply put, I wasn’t there.  For all his expertise. Dr. Edmond wasn’t there.  And we all know the old saw about hindsight.

Finally, there are those lab results.  An elevated band count, also called a “left shift,” happens when the bone marrow is churning out white blood cells at an increased rate, sufficient that it starts shooting them out when they’re immature.  (Bands are an immature form of certain white blood cells.)  An increased ratio of immature cells to total cells is indeed a sign of sepsis.  But once again the exact numbers aren’t reported, only Dr. Edmond’s interpretation of them.  “Vast quantities” and “very abnormal” are subjective readings of unreported objective findings, and as both doctor and reader I have no way of knowing if I would use the same terms to describe the same numbers.  While I wouldn’t call the omission misleading, I will at least make note that it is an important omission that confounds my ability to form a sound opinion.  [Please note update below.]

Are there red flags?  Certainly.  For my part, any time I get a sense that there is some outlying symptom (in this case, the leg pain) that cannot be accounted for by the prevailing diagnosis I feel compelled to revisit it.  And I certainly get the sense that the family kept calling the primary pediatrician with mounting concerns.  This particularly:

“‘I told her, ‘I’m not sure you’re getting the picture, Dr. Levitzky,’ ” Mr. Staunton said. “‘I can’t even get him to sit up. I don’t know how you expect me to get food into him.’ ” [emphasis added]

Again, it’s so easy for me to second-guess someone else’s decisions after the fact.  But if I hear from a parent something along the lines of “I’m really worried, and I don’t think you get it,” that’s pretty much an automatic trigger for me to have the patient seen again as promptly as possible.  It’s part of my spiel whenever I see a sick kid to tell the parents before they leave that they should always let me know if anything makes them worried.  It is never, ever a good idea to leave a parent feeling like their concerns weren’t taken seriously, even if it ends up being nothing.  At best you end up with a pissed-off parent, and at worst you get a story like this one.

But oh, how easy would it be to see a kid with the same symptoms as all the other kids you’ve been seeing lately and call it the same thing?  Lots of visits for fever and stomach pain that’s just a virus going around?  That sick child with the fever and stomach pain looks like just one more.  I don’t think anyone can plausibly dispute that mistakes were made.  I can just understand how even a good doctor might make them.

Missing a kid with an invasive streptococcal infection is the kind of thing that would make a medical provider break out in a cold sweat.  I know nothing can compare to the parents’ pain right now, but I’m willing to bet those doctors are in a pretty wretched place, too.  If the information missing from this report contributes to the conclusion that they were truly negligent, then of course they must be held responsible.  But there is more to the story than what is included in this article, and I’m not ready to cast these physicians as incompetents based upon what I read here.

After all, I would want to be treated with the same judiciousness if I were ever to find myself in the same situation.  I pray to high heaven I never do.

[Update:  I see from comments that I missed a very important part of the story, which is included as a multimedia feature that accompanies the article.  It does include both the BP (which was normal) and the actual numbers of the band count.  The band count of 53 is indeed very elevated, and in light of the additional information it is much harder for me to defend the initial decision to send the patient home with that information.  If the results weren’t available before discharge, it raises the question of why they were drawn in the first place.  In any case, far more communication and follow-up should have been done, and my ability to understand the decisions made initially by the providers in the ED is now quite limited.]