NYT article

[Interpolfanclub]

http://www.nytimes.com/2012/07/12/nyregion/in-rory-stauntons-fight-for-his-life-signs-that-went-unheeded.html?hp

Tragic story in the NYT. The NYT also included a weblink to the ED doc's faculty website which I simply cannot believe.

People think there are lots of unneeded tests in medicine now? Keep putting articles like this on the front page of the website.

---

Members don't see this ad.

 

[coachB]

Unfortunately, this wasn't a story about unnecessary tests. Hard to send home a 12 year old with a HR of 140 that you can't explain (and a temp of 102-103 doesn't do that). And don't order a test (CBC) if you're not going to wait for the result or follow it up. To me, those are the important lessons here.

 

[Birdstrike]

.

 

[gro2001]

Unfortunately, this wasn't a story about unnecessary tests. Hard to send home a 12 year old with a HR of 140 that you can't explain (and a temp of 102-103 doesn't do that). And don't order a test (CBC) if you're not going to wait for the result or follow it up. To me, those are the important lessons here.

Do we know that that was the actual hear rate? I thought the article just mentioned it was elevated.

 

[EC3]

reading those comments, it's not very hard to understand why our costs are out of control. The lay public is absolutely clueless regarding healthcare.

With that said, don't send a 12 yo home with a resting heart rate of 130. And don't order labs if you're not going to wait for results.

 

[ensuii]

Do we know that that was the actual hear rate? I thought the article just mentioned it was elevated.

A copy of the labs/vitals are posted with the article:

http://www.nytimes.com/interactive/...l-documents-in-depsis-death.html?ref=nyregion

 

[McGillGrad]

A copy of the labs/vitals are posted with the article:

http://www.nytimes.com/interactive/...l-documents-in-depsis-death.html?ref=nyregion

Those could have been taken at any point in the process (from triage-to-discharge). For all we know, he was unstable at intake and was quite stable before discharge.

Having spent time in the pediatric ED and on the floor admitting from the pediatric ED, you see a good deal of this type of patient. I suspect that this was an adult ED since most pediatric EDs tend to be overly cautious and staffed with peds trained staff that are more attuned to pediatric patients and their tendency to crump minutes after looking stable.

 

[deleted109597]

The article notes the DC vitals as having 3 SIRS criteria. This cannot happen. Also, the cbc was likely back, but the bandemia wasn't. I know this happens to me on occasion at a couple shops.

 

[Bojack Horseman]

Those could have been taken at any point in the process (from triage-to-discharge). For all we know, he was unstable at intake and was quite stable before discharge.

Having spent time in the pediatric ED and on the floor admitting from the pediatric ED, you see a good deal of this type of patient. I suspect that this was an adult ED since most pediatric EDs tend to be overly cautious and staffed with peds trained staff that are more attuned to pediatric patients and their tendency to crump minutes after looking stable.

The ER doctor was trained in peds and did an EM fellowship according to our friend google.

 

[diphenyl]

I wonder how the wound looked or if it was even mentioned on the chart's physical exam.

I highly doubt those were his vitals on discharge. Could you imagine the nurses if you tried to discharge someone with those vital signs? They $h!t bricks if a kid has a low grade fever at discharge.

It was foolish to discharge anyone with labs pending. Even when nurses get labs going I don't think should have been ordered, I wait for them to come back if they are already running so I don't get any big surprises.

With a cbc like the one documented and his vitals signs upon initial presentation, I probably would have called them back in. The left shift is what would worry me.

 

[EC3]

A copy of the labs/vitals are posted with the article:

http://www.nytimes.com/interactive/...l-documents-in-depsis-death.html?ref=nyregion

Nice to see they corrected the SIRS criteria for a 12 yo.

If we're going to go by adult sirs criteria, every 6 yo with strep thoar needs a full sepsis w/u and icu admit.

 

[McGillGrad]

The ER doctor was trained in peds and did an EM fellowship according to our friend google.

Yup you're right, and if she signed off on him with red flag vitals (whether or not they really were that bad at discharge is unclear*) then she has some explaining to do.

*Just because the article states that it was at discharge does not make it fact. As someone mentioned a couple posts ago, nurses would cause a ruckus if those were really the vitals.

 

[gro2001]

Maybe those were not discharge vitals but triage ones and they improved before discharge...
Maybe by the time the lab resulted the diff, the patient was taken off the ER board...
Maybe he really did improve and the parents were anxious to go home already...


anyway, retrospectology is really not my specialty.

 

[deleted109597]

Retrospectoscope my ass.

53% bands? Even if they result after the patient goes home, they should get called back. That's ridiculous.
Of course, my lab calls me to tell me a critical result of a K of 3.0, or a positive tylenol in the urine, but not a lactic acid of 10 or an ammonia of 178. So without some QI, they may not have ever known.

Now granted, likely none of us were there. It is hard to say what they actually saw (see below).
But none of this chart would have any defense in any court. We can't defend poor documentation just because we like emergency docs. I don't think that the tests ordered in this patient were overdoing it or being "defensive". But, like I tell my residents, don't order a test if you don't make a decision based on the outcome.

 

[Arcan57]

My money regarding the mottling is that the patient never got undressed for the exam. It's somewhat difficult to dismiss mottling if you actually see it. Then my mind goes back to how many people I saw today that were undressed and in gowns (~3/21).

 

[b-real]

My money regarding the mottling is that the patient never got undressed for the exam. It's somewhat difficult to dismiss mottling if you actually see it. Then my mind goes back to how many people I saw today that were undressed and in gowns (~3/21).

But isn't that the responsibility of the physician to perform (and document) a thorough physical exam? And I don't mean a 2 hour internal medicine exam, but at least undress the patient and look at the skin.

 

[Arcan57]

But isn't that the responsibility of the physician to perform (and document) a thorough physical exam? And I don't mean a 2 hour internal medicine exam, but at least undress the patient and look at the skin.

For most disease processes, undressing the patient and looking at the skin has essentially no diagnostic value. So I don't think it's necessary in every patient. Of course it's the physician's responsibility to perform a focused physical exam (which I would feel includes integumentary if it's an complaint of extremity pain). However, in this case a diagnosis was missed and resulted in a tragic outcome. Most likely, the doctor that saw the kid isn't a terrible physician so we have to look at the factors that lead to the miss and see if they are amenable to fixing at the system level.

 

[xaelia]

"Negligence" as we would use in the colloquial sense is hardly the most common cause of medical errors - if you've heard Clinton Coil from H-UCLA talk about quality, or read a little bit of the literature - they usually talk about the "Swiss cheese" model for medical error. It's not just one isolated event, but, like in this story, a complex sequence of individual or system misses that, when occurring in series, results in a poor outcome. Any one of the physicians involved might have been able to pick something additional up, or the nurses might have been a little more alert to the abnormal vital signs, the parents might been able to add something that was omitted before the retrospectoscope, the WBC differential might have come back more quickly, there might have been a system in place to flag significant bandemias, et cetera. It's just a disappointing article that's so skewed it makes it seem as though everyone who touched the kid was an idiot, when it's really just the sum of many individual tiny parts.

 

[b-real]

I definitely agree the article is skewed. Did you guys catch that the journalist is a family friend of the kid?

 

[It'sElectric]

I was just about to post this article before I saw a tread had already been started. Definitely a tragic case, and the info presented does not look good. Nevertheless, there are always two sides to every story, so I'd love to see the entire chart.

What's scarier (not to dismiss the tragedy of losing an 11 year old child) is the potential ramifications of more laypeople dictating how medicine is practiced. More laws, more paperwork, more expectations while still keeping costs down, and more people thinking their child or family member with a paper cut has sepsis is not good for medicine or the public.

 

[Socrates25]

The author of this article is being ridiculous -- WTF is a journalist doing trying to tell us about SIRS criteria, when he obviously doesnt understand it himself and put up the wrong values?

Its one thing to quote another doctor, but this idiot pulls it right of his own ass!

That being said, based on the clinical presentation I think both the general pediatrician and the ER doc screwed up, with most of the blame assigned to the ER doc. Maybe the mom is lying and she never made a big deal out of the kid's initial leg injury, but if she gave the report to the doc the way she gave it to the article, I think the docs share some fault.

Recent break in skin + worsening local symptoms + fevers/vomiting = group A strep bacteremia and evolving sepsis until proven otherwise and the general pediatrician and ER doc should have been able to put the total picture together rather than just focusing on the vomiting and telling the parents its just viral gastroenteritis.

Without the escalating leg pain I would have treated it just as the docs in the story did -- but to have an abrasion or musculoskeletal injury that gets WORSE over time instead of peaking at the onset is a huge red flag that changes EVERYTHING IMHO

Strangely enough I'm studying for general peds boards and there is a review question that is almost identical to this child's presentation. 8 year old who fell down on his bike and got a scrape on his elbow that gets progressively worse over the next 4 days, then he starts having fevers and vomiting.

 

[southerndoc]

This physician may have grounds for a libel suit for naming her in the article and providing inaccurate information.

 

[StevieStud]

I definitely agree the article is skewed. Did you guys catch that the journalist is a family friend of the kid?

what, you think journalists are unbiased?

A big arse majority of these "somebody screwedup " stories has a biased journalist, senior editor or parental related unit with great marketing skills involved with encouraging the story.

 

[deleted109597]

Recent break in skin + worsening local symptoms + fevers/vomiting = group A strep bacteremia and evolving sepsis until proven otherwise and the general pediatrician and ER doc should have been able to put the total picture together rather than just focusing on the vomiting and telling the parents its just viral gastroenteritis.

Remember, it was an arm abrasion, not a leg.
So, isolated random other extremity pain in the setting of presumed gastroenteritis to me is electrolyte shift cramping or some other issue. There are plenty of small misses here, but I don't think the leg pain is one of them.

 

[EctopicFetus]

Of course the journalist is a family friend. How else do you get something like this in the NYT.

In the end the facts of the case look bad and I dont know any details of this case except for whats in the article. From my own experience just caring for famous people/major incidents I know whats reported in the news is often wrong or missing key infortmation. I take all this crap with a grain of salt.

We all miss stuff, this seems particularly bad given the biased article.

 

[beefbroccoli]

This is an inevitable lawsuit and it seems totally inappropriate and irresposible for the author to name the physicians like that. Front page of the NYT? I hope he gets his ass sued. He actually makes some good points (there should totally be a lab call back in place) but it is mixed up with biased irresponsible garbage. Why the hell is a journalist trying to explain sirs criteria to us. Terrible article and he comes off as a holier than thou when he really has no idea what he is talking about.

I like how he is trying to defend himself saying there is "not a drop of condemnation in this article" and saying he only wrote this incredibly inflammatory and incendiary piece just to raise awareness. Oh please. There are better and more appropriate ways to do that.

 

[Docuronium]

There's nothing "Retrospectoscopology" about this. At my institution, even as a 3rd year medical student if we saw this patient and as part of our management plan wanted to release them if their "vitals stabilized", we would be, at best, humiliated in public.

Granted, the article certainly doesn't paint a complete picture, but I can't see a justification for this one.

 

[Docuronium]

I like how he is trying to defend himself saying there is "not a drop of condemnation in this article" and saying he only wrote this incredibly inflammatory and incendiary piece just to raise awareness. Oh please. There are better and more appropriate ways to do that.

Are there? This certainly seems to have raised an incredible amount of awareness (perhaps more just fear) based on the number of questions I have gotten about this specific article recently.

 

[gro2001]

There's nothing "Retrospectoscopology" about this. At my institution, even as a 3rd year medical student if we saw this patient and as part of our management plan wanted to release them if their "vitals stabilized", we would be, at best, humiliated in public.

Granted, the article certainly doesn't paint a complete picture, but I can't see a justification for this one.

Why would you be humiliated for wanting to discharge someone once their vital stabilize (assuming that they are otherwise ready for discharge)? Are you saying that any abnormality in vital signs at any point warrant an admit? What about a tachycardia in the setting of a fever that resolves after tylenol and you decided the fever does not need a work up (say a kid has an URI x 1 day and nothing else concerning on history of physical)?

[sarcasm] On an unrelated note, an educational model that involves 'public humiliation' for the most junior members of a team sounds just spectacular. [/sarcasm]

 

[It'sElectric]

There's nothing "Retrospectoscopology" about this. At my institution, even as a 3rd year medical student if we saw this patient and as part of our management plan wanted to release them if their "vitals stabilized", we would be, at best, humiliated in public.

Granted, the article certainly doesn't paint a complete picture, but I can't see a justification for this one.

You sound a little out of your league. Unless of course you're being sarcastic.

 

[WilcoWorld]

ViaB: I don't mean to talk down to you, but I do want to say that a lot of what seemed like a "slam-dunk" to me as a med student (every patient with headache and fever needs an LP!) is no longer so clear-cut (what if the "fever" was actually subjective, or if the patient has a raging case of strep and a supple neck and the headache is gone after 600mg of ibuprofen - still want to tap 'em?).

I discharge a lot of patients whose vital signs normalize after therapy. While it needs to be considered in context, it is useful information.

 

[Tiger26]

There's nothing "Retrospectoscopology" about this. At my institution, even as a 3rd year medical student if we saw this patient and as part of our management plan wanted to release them if their "vitals stabilized", we would be, at best, humiliated in public.

Granted, the article certainly doesn't paint a complete picture, but I can't see a justification for this one.

Keep in mind that every time you go to the gym (or even up a few flights of stairs) that you develop a few of the SIRS criteria . . .

 

[docB]

I think this is classic use of the retrospectoscope. Do we really require that everyone have normal vitals when they leave? Not in the private world. We d/c kids with fevers all the time. If you have a patient with GE and their pulse goes from 140 to 110 do they have to stay in the hospital? Have you ever tried to get a private pediatrician to agree to admit someone for intractable fever or elevated HR with GE or bandemia? It's a tough sell. Your other option is to hold them in the ER and keep doing stuff until everything looks perfect on paper (the hands down favorite of all admitting docs). But that's not realistic.

The fact is that this case or something like it could have happened to anyone. We discharge this all the time and rarely one was sick and missed. Double bad luck if it's the relative of a reporter or a lawyer. The reason this particular doc got burned is that they picked up the chart.

 

[jbar]

I'm not sure the vital signs need to normalize, but abnormal vital signs should be rechecked. If you don't look than someone can argue "hey, maybe their heart rate is now 180, but you didn't check."

I've found with kids rechecking temp helps me with dispo. Even though I don't really care if their temp went from 104 to 102, it seems to make the parents happy that it's moving in the right direction, and are more willing to leave.

 

[bougiecric]

There's nothing "Retrospectoscopology" about this. At my institution, even as a 3rd year medical student if we saw this patient and as part of our management plan wanted to release them if their "vitals stabilized", we would be, at best, humiliated in public.

Granted, the article certainly doesn't paint a complete picture, but I can't see a justification for this one.

Be very careful with this attitude.

You are a medical student. You do not have the slightest clue as to what it's like to carry multiple patients of varying acuity in a busy ED. You do not have experience with the nuances of presentation, and how both benign and deadly illness can overlap significantly.

If you expect to become a practicing emergency physician and go a career (or even a year) without sending someone home who has a bad outcome, you have a very inflated and possibly dangerous opinion of your abilities.

Maybe I'm reading too far into your comment, but you need to take a moment of reflection. Humble yourself. This kind of confidence is inappropriate at your level of training. If you maintain this attitude into internship, I'd personally be weary of having the responsibility of supervising you.

 

[BADMD]

Keep in mind that every time you go to the gym (or even up a few flights of stairs) that you develop a few of the SIRS criteria . . .

We were playing with a POC lactic acid device. One of our attendings had just come from the gym and had a lactate of 6.

 

[deleted109597]

Be very careful with this attitude...snip

You should see the attitude of the people in the lounge. People are starting the EM bashing ("I bet the attending didn't even see the patient" etc)

 

[Beagles]

Assuming that the facts in the article are true, two troublesome issues exist: (1) patient was discharged before the lab tests (suggesting sepsis) were back; and (2) no follow-up like a simple phone call with the patient after the lab results suggested sepsis. What's the point of ordering tests if you are going to discharge the patient before getting the results? More still, the lack of follow-up suggests that no one even looked at the results when they came back. Or worse, someone looked at the results but did nothing.

You don't have to be a seasoned physician to understand the above. I am very early in my medical training but a seasoned litigator (yes, I am a lawyer but did not practice med-mal nor do I plan on practing med-mal in the future and believe that lawyers need even thicker skin than ER docs).

Most matters in liability can be distilled into common sense ideas. Not saying that the all the facts in the article are true, but if they are, the above two items are troublesome notwithstanding the doc's volume of patients, nuances of disease detection, etc. These items will not be relevant for liability purposes.

 

[deleted109597]

While it is sad in this case, I wonder how the nurses were able to discharge the patient with those abnormal vitals. I mean, THEIR LICENSE IS ON THE LINE. Hell, mine argue about the "low grade fever" when I d/c someone with a 99.4ºF. Thank God this kid wasn't hypertensive, he likely would have gotten some catapres before d/c.

 

[odoreater]

I am never surprised when the media/lawyers rush to judgment and demonstrate a lack of appreciation for the vagaries of probabilistic diagnostics but I am always taken aback when they find numerous physicians (who should know better) to go along with them---as evidenced by many comments in this thread.

I expect a reporter with no knowledge of Bayesian reasoning to think in binary terms in laboratory (or otherwise) diagnostics—as if there is just a yes/no answer and not degrees of probability (e.g. a change in risk based upon the interaction of 2 independent variables---a priori probability and the result of a test)---when physicians start thinking in the same terms it bodes poorly not only for the medical-legal environment but for our cohort patients in general. If you all advise your patients that there are tests that either mean you 100% have disease or 100% do not then you are just as intellectually poor as this reporter.

In terms of the specifics of this case (from what I gather from the article) SIRS criteria as defined carries a +LR of 1.05 at best (in adults---not studied in children). Posterior probability is roughly equivalent to pre-test probability regardless of starting point. Every child that walks into an ED with Strep throat meets SIRS criteria. A peripheral bandemia has a +LR for bacterial disease (versus viral) anywhere from 1 (no difference) to < 5 (clinically useless) making this a test without any validity in determining bacterial versus viral etiologies for fever. Multiple studies in children have addressed its inability to discern viral from bacterial etiologies with few finding a discriminatory zone which can either safely include or exclude bacterial disease. As better ED physicians than myself have said---a WBC is good for diagnosing 2 things&#8212;neutropenia and leukemia.

My biggest criticism would be why the CBC was ordered in the 1st place if all the physician suspected was a viral syndrome---it opens up to second guessing (such as has happened here) and adds nothing diagnostically. If the physician had a high enough pre-test probability to order the CBC then the bands should be addressed (either to the parents or in the medical decision making) but it does not make bacterial etiologies significantly more likely --or else many viral gastroenteritis/influenza/trauma patients would have to undergo blood cultures due to their bandemia.

 

[BJJVP]

I completely agree. That's one thing I find very frustrating...you can't really blame pts and laypersons for thinking what they think and feeling what they feel. But it's even worse when medical people retrospectively evaluate a case and then unfairly condemn the initial work-up/treatment.

Similar to press-ganey...I understand why administrators feel the need to get good scores. But when physicians encourage the false notion that good scores equate to good care, then our profession has lost its way.

From what I read, this couldve happened to any physician on any given shift. Kid with vomiting, WBC 14, not vomiting now & looks good equals d/c with follow-up. I doubt he presented with "my cut is painful, more red and swollen and now I am vomiting with a fever." I have never worked in an ED where the WBC diff returns in a timely fashion. Even if this bandemia were noted, if the pt is not vomiting, looks good, not sure I can blame anyone. I know, he was discharged with "abnormal vital signs." I can tell you, its a great idea to make sure fevers go down and tachcardia normalizes from a legal point of view, but I am not sure there is any medical basis in this. Kids with fever, crying, anxious will always have abnormal VS. My 2 yo probably meets SIRS half the time he goes to the pediatrician's office. That's always been my problem with this whole sepsis campaign. I could also start a "campaign" to more aggressively treat subarachnoid hemorrhages by ordering CT/LP at triage for anyone who has a HA, vomiting. Then, if anyone misses a subarachnoid, the papers can say this bad doctor missed a diagnose for which there is a whole campaign to raise awareness for the entity (not a great analogy...but you get the idea). I could also get ectopics to the OR faster by ordering preg, hcg, and US on every female at triage with abd/back/pelvic sx's. We keep this up, soon we will have 2000 different protocols at triage and 2000 certifying bodies to help our hospitals get recognized as subarachnoid hemorrhage centers, ectopic preg centers, etc.

I think we need to be a little more humble in our evaluation of these types of cases. I know the lawyers don't care how busy the ED was, what kind of pressure the doctor was under. But we, as a group need to be more cognizant of the insane work environment we are in, and how difficult it is to be spot on all the time.

Sorry about the rant. I hope this post makes sense when I re-read it later.

I am never surprised when the media/lawyers rush to judgment and demonstrate a lack of appreciation for the vagaries of probabilistic diagnostics but I am always taken aback when they find numerous physicians (who should know better) to go along with them---as evidenced by many comments in this thread.

I expect a reporter with no knowledge of Bayesian reasoning to think in binary terms in laboratory (or otherwise) diagnostics—as if there is just a yes/no answer and not degrees of probability (e.g. a change in risk based upon the interaction of 2 independent variables---a priori probability and the result of a test)---when physicians start thinking in the same terms it bodes poorly not only for the medical-legal environment but for our cohort patients in general. If you all advise your patients that there are tests that either mean you 100% have disease or 100% do not then you are just as intellectually poor as this reporter.

In terms of the specifics of this case (from what I gather from the article) SIRS criteria as defined carries a +LR of 1.05 at best (in adults---not studied in children). Posterior probability is roughly equivalent to pre-test probability regardless of starting point. Every child that walks into an ED with Strep throat meets SIRS criteria. A peripheral bandemia has a +LR for bacterial disease (versus viral) anywhere from 1 (no difference) to < 5 (clinically useless) making this a test without any validity in determining bacterial versus viral etiologies for fever. Multiple studies in children have addressed its inability to discern viral from bacterial etiologies with few finding a discriminatory zone which can either safely include or exclude bacterial disease. As better ED physicians than myself have said---a WBC is good for diagnosing 2 things—neutropenia and leukemia.

My biggest criticism would be why the CBC was ordered in the 1st place if all the physician suspected was a viral syndrome---it opens up to second guessing (such as has happened here) and adds nothing diagnostically. If the physician had a high enough pre-test probability to order the CBC then the bands should be addressed (either to the parents or in the medical decision making) but it does not make bacterial etiologies significantly more likely --or else many viral gastroenteritis/influenza/trauma patients would have to undergo blood cultures due to their bandemia.

 

[Hamhock]

That's always been my problem with this whole sepsis campaign. I could also start a "campaign" to more aggressively treat subarachnoid hemorrhages by ordering CT/LP at triage for anyone who has a HA, vomiting. Then, if anyone misses a subarachnoid, the papers can say this bad doctor missed a diagnose for which there is a whole campaign to raise awareness for the entity (not a great analogy...but you get the idea). I could also get ectopics to the OR faster by ordering preg, hcg, and US on every female at triage with abd/back/pelvic sx's. We keep this up, soon we will have 2000 different protocols at triage and 2000 certifying bodies to help our hospitals get recognized as subarachnoid hemorrhage centers, ectopic preg centers, etc..

I agree with most of your post and nearly all of odoreater's post. However, the comments regarding sepsis are off base. The surviving sepsis campaign and properly run sepsis programs at individual hospitals are not looking for sepsis and are not treating sepsis any differently. 2 SIRS criteria gets nothing. 2 SIRS criteria and suspected infection gets just a bit more testing (often just a lactate).

However, severe sepsis and septic shock get all kinds of attention. This is the point of the surviving sepsis campaign. Without a doubt, severe sepsis and septic shock carry much higher levels of mortality and this increased mortality can be decreased with early, aggressive resuscitation (although exactly what makes up this early resus has yet to be determined).

It seems to me that you shouldn't have a problem with the sepsis campaign. It seems you should try to understand the campaign and learn to fully separate SIRS and sepsis from severe sepsis and septic shock.

HH

 

[southerndoc]

Assuming that the facts in the article are true, two troublesome issues exist: (1) patient was discharged before the lab tests (suggesting sepsis) were back; and (2) no follow-up like a simple phone call with the patient after the lab results suggested sepsis. What's the point of ordering tests if you are going to discharge the patient before getting the results? More still, the lack of follow-up suggests that no one even looked at the results when they came back. Or worse, someone looked at the results but did nothing

Not all diffs are available immediately. The 50% bandemia may not have been available until the following morning because lab protocol might require a pathologist to look at it before being released.

 

[Apollyon]

Not all diffs are available immediately. The 50% bandemia may not have been available until the following morning because lab protocol might require a pathologist to look at it before being released.

The solution, though, is a grass-roots approach, because not even all people working in the same lab will hew to the same level - the night crew might be the opposite of the day or evening.

The solution is, if a confirmatory test or pathologist review is indicated, to note the interim result - it is marked plainly as interim/not confirmed, and that a confirmatory test will be performed, or that pathologist confirmation is needed.

The breakdown arises when the tech in the lab notices that, but releases a result as final without letting the recipient know, or takes an unduly amount of time because the confirmatory test is running. It is things such as the HCG, or a really high troponin, or a K+ - if the HCG is still diluting out, so it is over 200K, then I know it - I don't have to wait for a hard result. Likewise, if the preliminary K+ is 7, and there is no apparent hemolysis, then I, on the end with the patient, have more data with which I can tailor my management. The lab gives me the number, and tells me that it is unconfirmed. OK, I can work with that. Likewise, for the sickler with a smear that has to be reviewed, or a crazy bandemia, let me know that there is unspecified badness. If I tell you a passenger train has crashed, would you feel you were in the wrong to mobilize 10 ambulances, a two-alarm response, and a police task force headed by a lieutenant to start, before you have a clear indication as to what you have?

To go back to the golf analogy, if you can point me towards the fairway, at least to where I can see the green, it's a lot better than just hacking away out of bounds, because the dog leg doesn't let me see what is down range. Even though I can't yet see the precision of the green, I'm moving in the right direction.

 

[Beagles]

I think we need to be a little more humble in our evaluation of these types of cases. I know the lawyers don't care how busy the ED was, what kind of pressure the doctor was under. But we, as a group need to be more cognizant of the insane work environment we are in, and how difficult it is to be spot on all the time.

My assessment of the troublesome issues has nothing to do with humility. Assuming all the facts stated in the article are true (the veracity of which a jury or judge will determine if it goes to court), I find these issues troublesome. The article stated that a lab report came back three hours after discharge that indicated sepsis. This isn't about nuances of diagnosis - the results indicated sepsis. Moreover, follow-up never occurred. If someone reviewed the results, the reasonable course of action (as suggested in the article) would have been to monitor for sepsis - this is where expert testimony would come into play (medical professionals in the article suggests that the standard of care was not met).

I get the difficulty of second guessing things, the variables involved, and the working conditions for docs. But a kid died. Not saying that all the facts in the article are true (again for a fact finder to determine). But assuming that they are, a mistake occurred in my opinion, the absence of which may have prevented a death.

I also get that mistakes happen. Lawyers are held accountable for mistakes they make (as they should). It would be a mistake if a lawyer received notice from the court but did nothing or missed a deadline. Similarly, injured patients should have recourse if a medical mistake is made like discharging a patient before relevant lab results come back and worse, not doing anything about it when they do.

I feel flames coming..

signed: lawyer but soon-to-be lawyer/doctor that may have likely but unintentionally ticked off a significant portion of future colleagues.

 

[la gringa]

a kid died.

SOMEONE must have done SOMETHING wrong... (heavy sarcasm)

lord almighty may this never happen to me.

 

[Nest]

^^

Get back to us in 8 years (Beagle). This is a one in 1/1000000 case- bad luck for the family and physicians involved.

 

[gettheleadout]

I just love how the comments section is a long string of specific criticisms from doctors and the author telling them they're all wrong.


Sent from my iPhone using SDN Mobile

 

[Docuronium]

Be very careful with this attitude.

You are a medical student. You do not have the slightest clue as to what it's like to carry multiple patients of varying acuity in a busy ED. You do not have experience with the nuances of presentation, and how both benign and deadly illness can overlap significantly.

If you expect to become a practicing emergency physician and go a career (or even a year) without sending someone home who has a bad outcome, you have a very inflated and possibly dangerous opinion of your abilities.

Maybe I'm reading too far into your comment, but you need to take a moment of reflection. Humble yourself. This kind of confidence is inappropriate at your level of training. If you maintain this attitude into internship, I'd personally be weary of having the responsibility of supervising you.

Keep in mind that every time you go to the gym (or even up a few flights of stairs) that you develop a few of the SIRS criteria . . .

You sound a little out of your league. Unless of course you're being sarcastic.

Why would you be humiliated for wanting to discharge someone once their vital stabilize (assuming that they are otherwise ready for discharge)? Are you saying that any abnormality in vital signs at any point warrant an admit? What about a tachycardia in the setting of a fever that resolves after tylenol and you decided the fever does not need a work up (say a kid has an URI x 1 day and nothing else concerning on history of physical)?

Wow. I go away for a couple days and find out I really made some people upset.

First off, let me apologize for coming across a bit as a know it all (in retrospect, reading my original post I sound a little like a brat).

I've actually gone and done some research following my mistake, reread the article (a poor source to judge from but the only one we have unfortunately), and consulted with a couple other doctors. Also, while I'm still a med student, I am a bit older, and have worked in emergency medicine departments/related fields for a long time now (>10 years without giving anything away. Finally I am the farthest thing from an expert, but have seen a lot of patients).

I am hoping there is something to be learned from this tragedy, and I am wondering what in the patient's history makes a lot of posters on here feel so comfortable releasing him (again, it's a fairly biased article, so probably at the time there was more information indicating he could be discharged--but we don't know)

Looking at the story again though, I can't imagine this child being released so quickly from any medical center I have ever worked in. Is there something huge that I am missing?

First off, he was 12 years old, 5'9" tall, and weighed nearly 170 pounds (almost my size). It's true kids aren't just little adults, but in light of this, at the places I've worked, adult criteria are given at least some acknowledgment.

He came in from a community pediatrician (I've always been told when someone sends you a sick patient, your index of suspicion should rise considerably) with a pulse of 140, a temp of 102, and a respiration rate of 36. It sounds like he had considerable leg pain, was vomiting a lot, and his skin was mottled (a kid who is apparently non-stop vomiting and his chief concern is leg pain just seems odd). That sounds like a pretty sick kid to me, at least sick enough to spend a little more time on.

When he was discharged his pulse was still in the 130s and a temp of 102. While at the EDs I have worked in have sent home kids with abnormal vitals, I haven't seen someone with vitals like that following a presentation such as this one sent away without some kind of better explanation and pending lab results. It's also surprising to me that he was apparently in and out of there in 2 hours.

[sarcasm] On an unrelated note, an educational model that involves 'public humiliation' for the most junior members of a team sounds just spectacular. [/sarcasm]

And yeah, some times it can be tough being a med student where I am. It feels like they expect a lot of us, and I have been chewed out a lot of times (by public humiliation I mean getting sternly lectured in front of the team, not in the town square) but it's clear that the attendings are trying to make sure something sticks rather than belittle us. I suppose I would rather be publicly humiliated than not learn something they consider to be an important lesson.

 

[BJJVP]

However, severe sepsis and septic shock get all kinds of attention. This is the point of the surviving sepsis campaign. Without a doubt, severe sepsis and septic shock carry much higher levels of mortality and this increased mortality can be decreased with early, aggressive resuscitation (although exactly what makes up this early resus has yet to be determined).

It seems to me that you shouldn't have a problem with the sepsis campaign. It seems you should try to understand the campaign and learn to fully separate SIRS and sepsis from severe sepsis and septic shock.

HH

My analogies were poor and I chose my words carelessly. Let me clarify: I have no problem with the current efforts to reduce mortality from sepsis. And I realize that not everyone with SIRS gets the full court press with a central line, antibiotics, etc. My point, however, is that the initial screening tools for sepsis are very sensitive, and not specific. And to hang this doctor out to dry based on these results alone is not fair.

From my reading of the article, this patient was ill from a wound infection that was missed. Maybe the doctor was careless and didn't do a full examination. Maybe the ED was busy and he was rushed. Maybe the patient/family were difficult historians or the physician himself did not have the social skills to obtain an adequate history. Maybe there was a significant anchoring bias. Or possibly, the symptoms were initially vague and non-specific and sounded like gastroenteritis. The end result was that a severe infection was missed and misdiagnosed as a viral gastrointestinal illness. My thought is that the situation is more complex than the way the article presents the case. Suggesting that the bandemia or fever and tachcardia should've led to the diagnosis and automatically changed management/disposition is too simplistic. Using isolated, very sensitive, yet non-specific, clinical data points and lab values to retrospectively criticize the physician is premature and unfair.

I really feel for the family but I am not sure that this death could've been prevented without a significant increase in utilization of resources in identifying this pt out of the thousands of other febrile, vomiting, 12 year olds. I will have to admit that I may be a little biased here. I do believe that we are one of the worst victims of Monday morning quarterbacking and so I do tend to get a little defensive.