Abstract
The case of Rory Staunton, deceased at age 12 years in New York City at a major academic medical center, received much media attention [1]. Your humble correspondent has no direct knowledge of the events as they transpired, expresses no opinion as to the propriety of actions taken or not, and casts no aspersions. Recounted here in encapsulated form are the events as reported by The New York Times [1].
Two days prior to admission, Rory cut his arm while playing basketball at school. His pediatrician evaluated him in the office the next day for complaints of fever, vomiting, and pain in his leg. According to the media report, in the pediatrician's office Rory's temperature was 102oF, his heart rate was 140 beats/min; his respiratory rate was 36 breaths/min, and his skin was mottled, whereupon he was sent to the emergency department of the academic medical center. The diagnosis: An upset stomach and dehydration! Fluid and odansetron was given, acetaminophen was recommended, and Rory was sent home. Seen and sent out…there is hardly another colloquialism in clinical medicine so laden with connotation or fraught with peril.
Seemingly just ordinary childhood woes, Rory's condition was already dire. He was likely bacteremic at the time. Crucial information gathered by his pediatrician and during his first visit to the emergency department (marked leukocytosis with bandemia) may have been discounted or not considered when decisions were made about his disposition. His parents may not have been advised of, or may not have understood, the early signs to watch for at home that would have indicated he was deteriorating. There may have not been any proactive follow-up to determine how the child was faring at home. When his deterioration became profound (he turned “blue,” according to his parents as recounted by the media report) his family was instructed by the pediatrician to return to the academic medical center. He was diagnosed with and treated for Streptococcus pyogenes bacteremia and septic shock, but succumbed to multiple organ dysfunction syndrome three days later in the intensive care unit.
By all accounts Rory was a good kid. Big for his age, and mature beyond his years, he was involved in student politics, knowledgable of world affairs, and already enrolled in flight school, determined to become a licensed commercial pilot. Legal counsel has been retained.
To those of us who treat sepsis every day, it may be difficult to imagine that sepsis can go undiagnosed, or be diagnosed (too) late, but the experienced do recognize that sepsis has protean manifestations, some of which may be subtle at first, and not all of which may be present in an individual case. Sepsis can be a difficult diagnosis to make, and time is certainly of the essence. Several organizations have developed educational programs and clinical tools to assist clinicians with the early diagnosis and expeditious treatment of sepsis, including the Surviving Sepsis Campaign [2,3]. Indeed, the mortality of severe sepsis and septic shock may be decreasing overall, confounding our ability to advance the field by clinical investigation [4,5]. Nonetheless, stories such as this remind us all to strive every day to do the best we can for our patients with sepsis in the realms of diagnosis, treatment, education, and quality.
By way of example, the Greater New York Hospital Association and the United Hospital Fund have partnered to create the STOP (Strengthening Treatment and Outcomes for Patients) Sepsis Collaborative [6,7]. A consortium of 56 hospitals participates in the New York region, including the center that treated young Staunton. The goals are focused on clinician performance: To reduce mortality in patients with severe sepsis and septic shock by developing a protocol-based approach to case identification and rapid treatment; and to enhance communication and patient flow between the emergency department and other areas of the hospital, in particular, the intensive care units [6,7].
The Global Sepsis Alliance (GSA) [8,9], of which the Surgical Infection Society is a Committed Member, is working to heighten sepsis awareness not only among practitioners, but also among policy makers and the public, crucial stakeholders both. The founding members of the GSA, the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM), the World Federation of Pediatric and Intensive and Critical Care Societies (WFPICCS), the World Federation of Critical Care Nurses (WFCCN), the International Sepsis Forum (ISF), and the Sepsis Alliance (SA) prepared the World Sepsis Declaration [10] (Tables 1 and 2) to set targets to change the global burden of sepsis by 2020. Professional associations from 69 countries, representing more than 600,000 individual members, support the World Sepsis Day. Your editorial correspondent asks you, the reader to make your own personal commitment.
From reference [9].
From reference [9].
Every time you are confronted with a seriously ill patient, or by a clinical picture that confounds, ask yourself the question: Could this be sepsis? An answer in the affirmative, or even equivocal, should lead to rapid diagnostic and therapeutic action that could save a life. Had Rory's parents (or any loved one in a circumstance analogous) asked the question, would the outcome have been different? That is a big part of what World Sepsis Day is about.