What started out as a simple cut took an unfortunate turn for the worse, and 12 year old Rory Staunton lost his life.
Source: NY Times https://www.nytimes.com/2012/07/12/nyregion/in-rory-stauntons-fight-for-his-life-signs-that-went-unheeded.html
For a moment, an emergency room doctor stepped away from the scrum of people working on Rory Staunton, 12, and spoke to his parents. "Your son is seriously ill," the doctor said.
"How seriously?" Rory's mother, Orlaith Staunton, asked.
The doctor paused. "Gravely ill," he said. How could that be?
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.
For three long days, the Staunton's went back and forth between Rory's pediatrician, and they would ultimately return to the emergency room, but nothing could prepare them for what this emergency room physician was going to tell them. Their child was gravely ill. What started as a simple cut in school was treated as a stomach bug in the emergency room, and the pediatrician's office turned out to be sepsis. A deadly, fast-moving infection very commonly infecting patients in the hospital.
When Rory was initially discharged his parents followed all of the doctors' directions and discharge papers, but Rory was not getting better at all; in fact, he was getting worse by the hour.
The Staunton's found out that his vitals in the original ER visit were not within normal limits, and he was also tachycardic.
His labs were never discussed prior to being discharged or followed up on either from the faclilty or his pediatrician. They showed the Rory had high levels of neutraphils suggesting that his body was creating white blood cells to fight off an infection.
Shortly after midnight on March 29, Ms. Staunton heard Rory retching in the bathroom. "There wasn't a huge amount of vomit, but he kept saying, 'My leg, my leg, Mom,'" she recalled. Back in bed, he moaned. His mother rubbed his thigh. In the morning, he was weak, his leg still hurt, and his temperature was 104 degrees, his highest ever.
The parents began calling Dr. Susan Levitzky, who had been the family pediatrician for about five years. She saw Rory that evening. He was lethargic, and in a lot of pain. He was also very nauseous and threw up on the pediatrician when she attempted to do a swab strep test. Although Rory and his mom told the pediatrician that they did not believe the issue was his stomach, she sent him back to the Emergency Room to be "rehydrated."
The weak vitals from the previous emergency room visit and labs were not discussed or followed up by either the ER or the pediatrician, if they were Rory may still be alive because three hours after the original discharge his CBC showed his body was in crisis
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.
Yet nowhere along Rory's journey, from boy with a bellyache on Thursday to gravely ill boy on Friday night, did anyone act on strong indications that he might be fighting for his life. Critical information gathered by his family doctor and during his first visit to NYU Langone was not used, was not at hand or was not viewed as necessary when decisions were made about his care, records show.
This is a horrible and tragic breakdown in the system. Just because the patient was discharged, the labs should have still been reviewed by the ordering doctor and sent to his primary care provider. This should be easier today than when healthcare teams relied on paper in an era of electronic records.
"The Stauntons knew nothing of his weak vital signs or abnormal lab results.
"Nobody said anything that night," Ms. Staunton said. "None of you followed up the next day on that kid, and he's at home, dying on the couch?"
A screening tool in the Stop Sepsis program, used when a patient first arrives in the emergency room, calls special attention to a person with three symptoms of a possible eight. At the hospital, Rory showed two: he was breathing 20 times per minute, and his pulse was 143.
As the next two days passed, doctors tried anything that might halt the shutdown of Rory's organs. "I can't say enough about the ICU," Ms. Staunton said.
Relatives and a priest gathered bedside, talking of Irish football and tomfoolery and politics. Perhaps, one doctor whispered in a fleeting, hopeful aside, Rory might get away with losing his toes and nose. His skin blackened. He passed no urine. His blood would not clot. His heart had to be restarted twice. Three specialists who chronicled Rory's decline on his intensive care chart each noted that he had a fever and significant signs of infection in his blood on Thursday night when he was sent home from the emergency room.
On Sunday night, Dr. Mayer Sagy, who had not seen Rory on his first visit to the hospital but spent the weekend struggling to keep him alive, told the Stauntons that the team had been unable to resuscitate him a third time.
“I said to him, ‘I brought him here to you the other night and you sent him home,’ ” Ms. Staunton said.
“He said, ‘You have every right to be angry.’ ”
More than anything, the Stauntons said, NYU Langone owes an honest accounting of what happened. Racked with loss, they and others remembered Rory as a steadfast champion of schoolyard underdogs.
"Above all," Ms. Staunton said, "we know that Rory would want no other child to go through what he went through."
Rory suffered and died in 72 hours because both the hospital staff and pediatrician dropped the ball. I have been septic. It hurts to have a sheet on your skin. His death was avoidable with better communication and follow-up.