Sunday, July 15, 2012

Rory

In this morning's New York Times, Maureen Dowd's op-ed piece is about Rory Staunton, the 12-year old boy who recently died from an invasive group A strep infection. Rory's story was chronicled in the New York Times earlier this week in a lengthy piece by Jim Dwyer. I have thought a lot about this case over the past several days. It's a tragedy for all involved.

Ironically, over the past few weeks I've been reading the new edition of Bob Wachter's text, Understanding Patient Safety. I plan to review the book on this blog in the near future. The issues at play in Rory's case are all described in Wachter's book. There were both systems issues (e.g., laboratory data that were not acted upon because they arrived after the patient had been discharged from the emergency department) and medical decision-making issues. When the case is laid out in the well-written piece by Mr. Dwyer, it seems fairly obvious that this boy was critically ill and should never have been discharged. Yet what we can't see is what else was happening at that time that may have influenced the physicians' decision making. Many potential explanations are put forward in the 1,500 comments on the New York Times online edition.

In my conversations with Mr. Dwyer as he was writing the article, I questioned him about whether the child had a necrotizing soft tissue infection. Though no diagnosis was made (at least antemortem from what we know), this appears to be a classic story for such. Two hallmarks of necrotizing soft tissue infection were present--pain (typically in a limb) out of proportion to what you would expect from visual inspection of the area and toxicity out of proportion to what you would expect. Often these cases occur after relatively minor trauma, so minor that patients often don't think to initially tell physicians about it. In Rory's case, I suspect that the traumatic injury to his leg occurred when he dived for a ball during gym class.

In my experience, the diagnosis of necrotizing fasciitis or necrotizing myositis is not considered early in the presentation as the findings on the skin over the deeper infection are initially subtle. Often the infectious diseases physician is the first to consider the diagnosis, but the consultation may occur after critical time has passed. Importantly, severe pain in a limb with Group A strep growing in blood cultures is a necrotizing soft tissue infection until proven otherwise. However, the disease needs to be considered before the blood cultures turn positive (which often takes 12 hours or so). The natural tendency is to obtain imaging of the limb to look for the cause of pain. However, plain x-rays do not provide useful information and CT scans typically do not help either. Often, clinicians will falsely conclude that necrotizing infection is not present because imaging shows no gas in the soft tissues; however, group A strep does not produce gas. MRI can be useful but at most hospitals MRIs are difficult to obtain promptly as schedules are tight, and additional time can be lost. Diagnosis can be made quickly by having the surgeon make an incision over the suspected area, visually inspect the muscle and probe the fascia. If a necrotizing infection is found, debridement of devitalized tissue is then performed. The critical issue is that the diagnosis of group A strep necrotizing infection is often delayed and even when suspected by an astute clinician, other physicians involved in the patient's care may not act quickly to establish the diagnosis. Thus, the infectious diseases consultant may spin his wheels trying to convince other physicians of the suspected diagnosis.

My hope is that Rory's case will raise awareness of invasive group A strep infections for clinicians, and prompt hospitals to examine the systems issues at play in this case. His family has already established a website focused on raising awareness. 

Rory's story is a reminder that medicine remains a human endeavor fraught with peril and that even well-trained physicians practicing in sophisticated settings err. When I read a story like this, I get a sick feeling in the pit of my stomach as I think but for the grace of God that could have been me making similar clinical decisions that led to a terrible outcome. I continue to find the practice of medicine a humbling experience as I am reminded often of how rapidly the corpus of medical knowledge is expanding.

The two pieces about Rory in the New York Times paint a picture of a really good kid who wanted to make a difference in this world. And I suspect that in the sharing of the story of his final days, he has.


Photo: New York Times

1 comment:

  1. You're mistaken about the lack of usefulness of CT. For example, see

    McGillicuddy et al in Journal of Trauma, April, 2011
    http://www.ncbi.nlm.nih.gov/pubmed/21610394

    I agree with you regarding the likelihood of latent nec fasc in this case.

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