Check your Data

During this past week, I read a series of articles about the unfortunate death of Rory Staunton, a 12-year old boy in NYC.  He scraped his arm in school, went to his primary care doctor who sent him to the emergency room.  The doctors there hydrated him and sent him home thinking he had the "stomach bug" that was going around.  After he was discharged, lab values came back showing he was fighting a serious infection.

However those values were not reviewed and not provided to his primary care doctor.  A few days later Rory was admitted into the ICU where he died of septic shock.

A follow-up article in the NY Times talks about the procedures the NYC hospital has put in place to make sure this doesn't happen again.  These procedures include a checklist for the nurse and doctor to make sure all imporant lab tests are received and reviewed and vital signs are checked and verified before discharge.  How simple is this?  It took the death of a child to put something as simple as this in place?

I found these paragraphs from that article interesting:

Joshua Needleman, a specialist in pediatric pulmonology at Weill Cornell Medical Center in New York, said the implications of the Staunton case went beyond ferreting out a specific disease and showed how important it was for doctors to keep open minds.

“The big questions are about how to integrate new information that doesn’t fit with the perception you have formed,” he wrote in an e-mail. “How to listen to the patient when they are telling you something that doesn’t fit with your internal narrative of the case. These are the hardest things to do in medicine and yet the most important.” Dr. Needleman said he planned to use details of the Staunton case to teach those points to medical students and was grateful that the boy’s parents had disclosed the painful details.

I put in red what I think is the most important part of this - ACTUALLY listening to the patient (or the patient's parents) and not being driven by the quickest, easiest diagnosis.

Here are the links to the news articles:

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

http://www.nytimes.com/2012/07/19/nyregion/after-rory-stauntons-death-hospital-alters-discharge-procedures.html?nl=todaysheadlines&emc=edit_th_20120719