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.


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]


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.


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.]

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. The article is just heart-breaking. My heart goes out to those parents. I really appreciate your thoughtful response, which makes sense. My heart goes out to the doctors, too.

    I think that parents can’t help but be angry at a missed diagnosis. I look back on my pregnancy with my disabled kid. Looking back, there were a few signs that indicated something was wrong that came up. Yet they were common and mild and did not warrant follow up. I understand this and I am still angry. The radiologist really did flub things, and I am very, very angry. The anger is there even when it’s not justified and I wouldn’t have wanted anything to turn out differently than it did. I can’t even imagine what it must feel like to know that signs were ignored and that cost your beautiful, healthy child his life.

    • Just to be clear, I do not question for a single second these parents’ anger. I think they have every right to be angry, and are absolutely entitled to a clear, thorough reckoning with the hospital.

      What qualms I have are with the article, not the parents.

      • I understood that. Just thought I’d throw that in there.

  2. -Cutting through all the medical hooey —why did they not even check the blood tests they had taken but sent him home to die? I’m tired of doctors defending incompetent members of their profession

    • James, I read the article to indicate that the results were printed after he left, but that doesn’t necessarily mean they hadn’t been reviewed.

      However (and this speaks to your comment below), I completely missed the multimedia feature with the actual blood test results. Thank you for pointing them out, because they substantially alter the picture. It is much more difficult to mount even a qualified defense with a band count that high. If he had already been sent home by the time the results were available, it was a serious lapse that there was no follow-up.

      The purpose of the OP was to mount a qualified defense of the doctors involved. If they treated this child incompetently (and I agree that there is serious reason to suspect it), I don’t have any interest in defending them. I only intended to show how there may have been enough ambiguity for me to understand their mistake. There is less ambiguity than I thought, and it is thus harder for me to understand

  3. I overlooked something yesterday and I had to rerun a script and reinstall a file.

    Now, it’s probably likely that there is some huge number of folks who come into a doctor’s office who, if the doctor says “drink lots of fluids, eat some protein, get lots of rest” and gets the diagnosis wrong would still be okay.

    But I can’t imagine someone being in a life/death situation based on whether I run all five scripts correctly or whether I make a mistake on the fourth of the five.

  4. The author of the article indicates that he has read Rory’s medical records. And the parents have hired a lawyer but haven’t decided how to proceed. The lawyer in question does almost exclusively medical malpractice. The medical records are protected by patient privacy privileges, which means they ought to only have been released to the family — almost certainly through the lawyer, who is reviewing them and having his own consulting doctors conduct a liability analysis. The phrase in the article indicating that they have not decided how to proceed means that as of the NYT’s press time, the consulting doctors weren’t done forming their opinions about what the records enable the lawyer to demonstrate.

    It’s hard for me to resist getting into the nuts and bolts of the medicine and the law to see if there is malpractice here or not — but I too must resist doing so becasue what the NYT is reporting could only have come from the plaintiff’s side of the fence, meaning ultimately (although possibly indirectly), it comes from the lawyer. So it’s not surprising that the article is slanted in that direction, because the hospital and the doctors all have lawyers who, without even the shadow of a doubt, have instructed their clients to comply with Rule 1 and Rule 2. (Rule 1 was inspired by this important message from a colleague.)

    Which makes me wonder why it is that the lawyer leaked all this information to a hungry and apparently cooperative Major National Newspaper. My Rule #8 is in effect. Why? What this lawyer wants to do is make money off of the case. And he’s clearly more than smart enough to know that the defense attorneys are going to have an appealing, sympathetic case for their appealing, sympathetic, and sincerely heartbroken clients. What he ought to be banking on is a) the overwhelming factual merit of his case, which as we all agree is far from clear, and b) the desire of the defendants to resolve the lawsuit through the exchange of money, before they have to endure the public humiliation of having their competence questioned by the New York Times.


    Now the defendants have a lot less to lose by pushing the case to trial, since they’ve already been publicly humiliated. Now they have an incentive to be publicly vindicated. It’s harder to settle this case and more likely it will go to a high-profile jury trial. And the plaintiff’s lawyer can only take his best guess about what the doctors are going to say and what the jurors are going to think about it.

    In poker terms, going to the press before even filing a lawsuit is an all-in on the blind. At best, a reckless, incautious gamble. I am skeptical of the wisdom of this move.

    I will leave it to others to question the wisdom of publishing such a piece from the journalism perspective. Those concerns are obvious, though: you only have information from one side, and you know that side has a financial stake in what you do. Where you go from there ethically is a matter that I will leave to professional journalists to discuss.

    • Thanks for this, Burt. It seemed a shaky idea to me to go to the press directly, but I chalked that up to my biases (as noted). I appreciate your perspective a lot.

      For the doctors’ sakes, I hope they’re really, really good at documenting. The blood pressure seems to have been initially reassuring, but the escalating symptoms and that band count are really hard to explain away. And there seems to have been pretty lousy communication between the primary care provider and the ED.

    • I read the doc’s update above. Let’s assume that the case is a sure-fire winner on the merits. Rule #8 is still in effect, for the reasons I stated above in my (admittedly quite lengthy) comment. That fact raises the stakes but does not (IMO) significantly alter the probability of ultimate success.

      If the merits are such that the case is indefensible on liability, the case is still at least partly defensible on the issue of damages and there is always the tactic of apealing to the ever-fickle jury’s sympathy. No matter how sympathetic the plaintiff might be, juries want to like doctors. Thus, settlement value increases with discretion, not with publicity.

    • Perhaps (and this is mere conjecture), the parents are more interested in getting the story out to try to prevent this from happening to other kids than they are of winning a lawsuit, thus putting the lawyer in a tough position.

  5. Is it par for the course to order lab work and release a patient before the results are in?

    • For a test like this, quite the contrary. I can think of only two defensible answers:

      1) The doctor really did have the results, but the only thing documented is when they were printed, not when she saw them. Unfortunately, the medicolegal truism is “if it isn’t documented, it didn’t happen.” But she could at least try to argue that she knew about the results, and didn’t think they were of significant concern.

      2) The patient looked so well clinically that the doctor thought he was stable to go home, regardless of the results. Of course, the argument in response is that clearly the patient looked ill enough to warrant the tests in the first place. She would have to document a pretty significant improvement to stand on that argument. And if it were me, even then I would at least tell the parents that results were still pending and why I had decided to discharge the patient anyway. It sounds like the parents had no clue about any of this.

      • Can this be handoff error?

        I mean, I can imagine being tired enough that I order a test and then forget that I did so. But I can also imagine ordering a test and then moving on to something else, and having the person who actually takes over the patient miss that there are test results pending, or something of that nature.

        This is the sort of thing that a stringent medical informatics system should catch; if tests of type blah have been ordered, discharging the patient without the doctor reviewing the results inside the system would be impossible without some sort of escalation procedure.

        • This is the sort of thing that a stringent medical informatics system should catch; if tests of type blah have been ordered, discharging the patient without the doctor reviewing the results inside the system would be impossible without some sort of escalation procedure.

          I think a mechanism such as that would be a great idea.

  6. Four of four SIRS criteria, plus a significant bandemia in a child and they sent him home? The boy was septic at the first glance at his vital signs. NYU just might be the Staunton medical center before this is over. Failure to diagnose is a real bummer. Vital signs are supposed to improve before sending someone home.

    • I can construct a notion of how they might possibly have explained the vital signs. But that bandemia is nigh unto impossible to explain away. I really wouldn’t want to defend the decision to discharge in light of those lab values, presuming they even reviewed them.

  7. In this case and every other medical malpractice case you really have to take all the information into account. Sometimes it is really difficult to see if it was really the doctor’s negligence alone that lead to the unfortunate death of the child.

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