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Jim Dwyer New York Times Article – Irresponsible Journalism?

By an Anonymous Emergency Physician

The opinion piece below was written by an emergency physician regarding a New York Times article by Jim Dwyer (picture at right). The author did not want to be identified due to fears of retribution from either the NY Times or from the hospital at which the physician is employed.

In addition to the points the author raises below, I would add these additional points of information:

1. The “Stop Sepsis” campaign cited in Mr. Dwyer’s article specifically stated that it is only to be used for tracking patients with severe sepsis and that “only those patients who are hypotensive after being given 2L of fluids or that have an elevated lactate should be entered in the data portal for this Collaborative.” Rory was not hypotensive and no lactate level was included in the labs pictured in Mr. Dwyer’s article. Mr. Dwyer never mentions any of these facts. The Collaborative does not allow access to links on this page describing its screening tools or to how it believes that a determination for ordering a lactate level should be made.

I will also note that Mr. Dwyer responded to some of the more than 1600 comments to his article, including some of the issues raised below, in this follow up article.

-WC

UPDATE JULY 22, 2012
Also see an important update to this debate at this link.

——————————————

The New York Times published an incredibly sad story about a 12 year old boy named Rory who went into the NYU emergency department, was diagnosed with gastroenteritis (a viral stomach bug), and who was dead two days later from septic shock.  Those are just about the only facts that are not in dispute.  The rest of the New York Times article seems to build a mountain of evidence as to why the emergency physician screwed up.  However, as is frequently the case, the truth is much more complicated than the media would have you believe.  There are lots of comments from other doctors using the almighty retrospectoscope and so many clinical inaccuracies discussed that this sad story is turned into a piece of sensationalistic journalism.

This post is mostly for the non-medical people that read this blog to help you understand the medical issues a little better.  This is a scientific discussion of the main inaccuracies of the article followed by what possibly could have been done better.  I say “possibly” because I did not examine the patient and all of my information is through the New York Times article.  If you have already read the article and decided that the ED doctor screwed up and nothing can change your mind, then stop reading.  If you want a fair and evidence-based discussion of the article then read on.

  1. The article references the “Stop Sepsis” campaign and says that the vital signs that should have triggered an evaluation for severe sepsis.  The article says that Rory had initial vital signs of a temperature of 102, a heart rate of 140, and then points to the Stop Sepsis guidelines.  There are two problems with this: First, the Stop Sepsis guidelines are intended to be used in adults, not in children. Second, just because a patient has abnormal vital signs doesn’t mean that they have severe sepsis.  Most patients in a pediatric ED waiting room would meet these criteria and yet they don’t have severe sepsis.  The “Stop Sepsis” guidelines are a screening tool that can suggest sepsis but they have to be used in the right clinical context.  Most physicians see pediatric patients every day who meet the “Stop Sepsis” criteria and who would best be described as having “the sniffles.”
  2. The article states that Rory’s temperature at home was “104, his highest ever.”  The implication is that this high fever, in of itself, should have triggered a more thorough investigation.  This is a misconception that must be dispelled.  A temperature of 106.7 degrees and above is the only time a fever by itself is dangerous.  Significant literature shows that a fever less than 106.7 degrees is not harmful.  We see children in the ED all the time with “high fevers” but that look great and would not have been considered sick without their temperature being taken at home.
  3. After Zofran and IV fluids, Rory felt better.  His vitals before discharge were a temp of 102 and a pulse of 131.  The article continues to allege that these vital signs met sepsis criteria.  However, a heart rate of 110 is the upper limit of normal for a 12 year old and, in general, a patient’s heart rate increases by about 10 beats per minute for every 2 degree increase in body temperature.  In Rory’s case, a heart rate of 131 was appropriate or just above the upper limits of normal for his temperature.  The persistence of a fever should also not cause worry just by itself.  Physicians frequently discharge febrile children from the ED without any adverse consequences. When assessing patients for discharge, what matters most is how the patient looks. According to the documentation in this case, Rory looked better before he was discharged.
  4. The article alleges that the emergency physician didn’t see the vital signs before she wrote the discharge instructions.  While this may be true, there are several more likely explanations.  In order to be efficient, I sometimes write discharge orders on patients that I think are going home because I have a minute free to put the order in. Technically, the orders are entered before the vital signs are entered, but this is for the sake of efficiency. I still evaluate the patient prior to discharge. Another possibility is that it the nurse didn’t have the time to put Rory’s vital signs into the computer before he was discharged. It is likely that the ED physician saw Rory’s vital signs while she was in the room re-evaluating Rory and signed the discharge order before the nurse entered the vital signs.  The way the article is written, it implies that the ED physician could never have seen the vital signs, but in reality, there is no way to tell for sure without asking the physician.
  5. The article implies that the white blood cell count of 14.7 should have triggered a more aggressive workup.  There is a mountain of evidence to say that a high WBC count does not rule in or rule out an infection or severe sepsis.

In order to keep this balanced, here are some things that I believe could possibly have been done better in Rory’s case.

  1. Discharging the patient before labs were back.  While this is sometimes done in cases of cultures or other “send out” tests, it is generally not a good idea to discharge patients before labs results are reported.  The most concerning lab in Rory’s case was the elevated number of bands or immature white blood cells at 53%.  High band count can be a red flag in the right clinical situation, but may also be a sign of a vigorous immune system response to a viral infection.  In addition, Rory’s carbon dioxide was normal.  In severe sepsis one would expect Rory to have acidosis and a low carbon dioxide level. A normal carbon dioxide level suggests that Rory may not have had severe sepsis at the time of his first ED visit.  Instead, he was probably in the early stages of sepsis which can be very difficult to distinguish from a simple viral illness.  A more thorough review of the labs may have prompted an admission for observation, but without having examined the patient no one can make that call.
  2. Rory’s vital signs at discharge were at the upper limits of what could be considered normal given his fever.  While the vital signs did improve, when I read the article the first time I admit that the discharge vitals raised an eyebrow.  However, as I previously noted, a child’s appearance is probably the most important indicator of severe illness and the ED physician is the only person who examined Rory.

I would like to end this article with a plea to the public to not crucify this ED doctor.  The New York Times should not have published the doctor’s name.  She is not a public figure and she has not been named in a lawsuit.  It is egregious that the New York Times published her name and thus unleashed the public venom on a private citizen.  I can guarantee that the ED doctor feels terrible about this case.  We don’t need the rest of the world coming down on her as well.  Even worse, due to federal patient privacy laws, the physician is prohibited from speaking about this case.  In any other profession, if a newspaper published something condemning your professional abilities you would be able to give your side of the story.

This case is every ED doctor’s worst nightmare and it can happen to the best of us.  As Greg Henry says, cases like this make you say to yourself “only by the grace of God go I.”  Cases like this keep physicians up at night.  The New York Times didn’t see it that way and wrote a sensational article condemning the ED doctor involved.  The reality is that very rarely, kids get sick and die.  Sepsis is a cruel disease and it can take a child that is otherwise healthy and looks great and kill them within hours to days.  It is no one’s fault – it is just bad luck.  Sometimes we catch that needle in the haystack and no one hears about it.  Sometimes we don’t and then it becomes front page news.  Let’s not make this situation worse by placing all the blame on this ED doctor.  This is a terrible case and while we should always try to learn and be better for the next patient, sometimes bad things just happen.

11 Responses to “Jim Dwyer New York Times Article – Irresponsible Journalism?”

  1. ThorMD says:

    The article in the NYTimes is quite inflammatory. It’s hard to comment on it without having access to non-biased information. However, one thing I do want to point out is that every single patient I see has vital signs checked after I print out their discharge instructions. Why? Our nurses are required to do discharge vitals – and they do them in the room while reviewing the instructions with the patients/family. I’m not sure why the reporter made such a big deal about that. But then again, he wasn’t trying to be fair or balanced.

  2. Birdstrike says:

    Amen, Anonymous Emergency Physician. We will add your editorial to the very long list of supporting documents for the argument that Physicians should be judged by juries of “their peers” rather than juries of people who know nothing of the infinite complexity of medicine with all of its uncertainties and gray areas. We all know that tragic outcomes can occur despite competent doctors doing “everything right”; however, lay people often assume, “Well look what happened, he MUST have screwed up!” A nation in which physicians feel chronically persecuted and embittered, is one in which none of us should want to live. Let’s band together to fix this.

  3. In one of the responses to comments to his article, Mr. Dwyer noted:
    “For more than 20 years, my mother worked as a nurse in the Emergency Department at Bellevue, which is closely affiliated with NYU. That gave me over two decades of exposure, through her, to the front line work done in emergency rooms, the demands on the people who work there, the absolute necessity of their service to society, and the devotion to the commonweal of so many of them.” I wonder what Mr. Dwyer’s mother would have thought about the following comment from a reader:
    “Publishing links to the doctor’s names and faces pending a fair investigation seems irresponsible and inflammatory.” Mr. Dwyer never responded directly to this accusation, because there is no excuse for this kind of journalism.

  4. CJL says:

    Universal caveat: I certainly do not know all the facts of this case.

    I think that the point about discharging the patient before the labs came back is a very important one. One of the hottest topics in medicine right now is cost saving – you talk about it on this blog all the time – so why order a CBC and BMP, and not use them in the clinical decision making? 53% bands is not insignificant, and in my experience would usually warrant more investigation.

    That being said, I definitely would not want all of my clinical decisions critiqued under a microscope, so I will give this doctor the benefit of the doubt.

  5. Lisa K. says:

    I’ve been wondering if you were going to weigh in on this case. Thank you.
    From a patient/parent’s perspective on the situation what advice would you give parents on trying to find the right line between demanding a reasonable re-evaluation while avoiding excessive concern over the sniffles?

    • Birdstrike says:

      I don’t know which poster you directed this question at, but I’ll answer it. As a parent myself, I can tell you, just listen to your instincts. If you are concerned, you are concerned. When a mother says, “I know my child. Something just isn’t right”, usually they’re picking up on something I haven’t sensed yet. I don’t blow that off. I use it to my advantage. Sometimes it means just sitting in the ED for a longer observation period, or rechecking the vitals once or twice more. A sick child will let you know it, if you watch them long enough. Once they’re out that door, you can never be sure. When a mom says, “Can we go, we’re tired of sitting around, Johnny wants to go ride his scooter?”, that tells me one thing. On the other hand, “Johnny just doesn’t seem to be perking up, in fact, he seems worse”, tells me something entirely different. Sometimes “observation” is the best test you can run.

      I don’t care if a mother brings a kid in for the sniffles 10 times. Sometimes we’re all surprised and what seems like the “sniffles”, can be the early presentation of something bad.

      Listen to your instincts, and demand that the doctor does, too. I say that as a parent, not a physician. You’d never forgive yourself, if you let someone convince you to ignore that “little voice”. Reassurance, after a proper evaluation is one thing. Dismissal is another.

      The art of Medicine is the hardest thing to learn.

  6. Jim Dwyer says:

    Dear Editor,

    It’s hard to know who was writing what in your post and introductory remarks about my “irresponsible journalism.” This is a reference to an article I wrote in The New York Times that reported on the death of a febrile, tachycardic child who went into a septic crisis after he was sent home from the NYU emergency room without benefit of his revealing labs.

    I am contacting you now to clarify a couple of things that were raised in the introductory blog note, signed by “WC,” and also in the unsigned post that took me to task for writing about this.

    1. You say that the stop sepsis campaign is for tracking severe sepsis. That misstates both the nature of the campaign and my citation of it in the article. The campaign’s goal is to aggressively identify sepsis and begin treatment within an hour. (The tracking of cases you cite is secondary.) To begin the process of identification, the initiative created a triage screening tool which gives a list of 8 signs and calls for additional investigation if a patient has three of them. As I wrote, Rory Staunton had two when he came into the ER. He had three when he was leaving. (BTW — his heart rate over a period of two hours ranged from 131 to 143. That’s in the article, too.) In the distribution literature with the screening tool, there is no distinction between pediatric and adult patients. Whether or not you think the values are relevant to a 12 year old, 5’9″, 169 lb boy, Rory was assessed for possible sepsis in triage.
    2. He didn’t have lactate levels done when he came in because, apparently, he only had two signs on the triage screening tool. Of course, it didn’t matter, since even the labs that were done were not used in the assessment of him.
    3. Blood differentials showed the 53% bands noted in the blog post and the article. They were not part of his assessment, even if your anonymous author believes they could appropriately be folded into the belly-ache diagnosis, without any indication that the treating doctor actually saw them.
    3. Your anonymous doctor cites literature stating that a temperature up to 106.7 is not harmful, and takes me to task for reporting that the boy’s temperature at home, 104, was his highest. I gather this should not have been mentioned because it would unnecessarily alarm people, in the view of Anonymous. In this case, the parents were correct that his fever was a sign of something dangerous happening. (Later on, after his temperature had dropped, it rose two degrees following his receiving fluids and tylenol in the ER.)
    4. Your blogger writes, “The article implies that the white blood cell count of 14.7 should have triggered a more aggressive workup. There is a mountain of evidence to say that a high WBC count does not rule in or rule out an infection or severe sepsis.”
    I wrote no such thing about the WBC, nor did I imply it. Many experts I consulted told me about the non-specific nature of an elevated WBC. In actual fact, I wrote that the lab found highly abnormal levels of bands and neutrophils.
    Here is what I wrote concerning his labs:
    “About three hours later, Rory’s lab results were printed. He was producing neutrophils and bands, white blood cells, at rates that were ‘very abnormal and would suggest a serious bacterial infection,’ Dr. Edmond said.”

    5. This is a narrative about important information that was not used — whether due to oversight, unavailability, or lack of understanding — when it might have made a difference in the life of the patient. I don’t blame any one or any place for this, because I don’t know how things went wrong — just that they did, somewhere along the line as Rory Staunton moved from pediatrician to emergency room to emergency room doctor to discharge. The names of the doctors and the institution, as well as the name of the patient, are germane to the narrative of his treatment for viral gastroenteritis, when he actually had a Group A strep infection in his blood.
    6. NYU has announced changes to address the issue of vital signs being reviewed before the patient leaves the ER, as well as clinically relevant lab results. In the event a patient is gone when they come back, they are creating a procedure to contact the patient or the referring doctor. These things clearly went wrong in the Staunton case. That’s what the article is about. It’s journalism. I’ll sign my name to it.

  7. Allison says:

    That “Stop Sepsis” tool, as you mentioned, does seem inappropriate for the pediatric population. A lot of children’s hospitals have started using the Pediatric Early Warning Score (the tool is on Page 9 of the following link, with a pretty cool flow chart that Denver’s children’s hospital is using to guide nurse interventions based on the score):

    http://www.ucdenver.edu/academics/colleges/nursing/Documents/PDF/SIM_PEWS_TCH.pdf

    Kids are very unpredictable patients; they can look great right up until the moment they code. Where I work, we’re starting to use the PEWS and I know there have been chart audits on children who ended up having bad outcomes and on review, their PEWS scores were in the yellow or red zone prior to the bad outcome.

    I’m curious as to whether or not non-children’s hospitals use PEWS.

    • Allison says:

      I should’ve mentioned in my first comment that the PEWS tool is used to predict deterioration in any pediatric patient, not just septic ones. Studies done on it have been pretty impressive.

  8. Ryan says:

    When are we going to start having a discussion about appropriate journalism?

    I understand your upset, and this is no doubt a tragedy. However, you publicly named and judged a physician who is forbidden by laws governing patient information to stand up for themselves. Furthermore, even if she did, she doesn’t have the platform or the resources to respond in kind to your public degradation. Say whatever you want, Mr. Dwyer. You’re article was dripping with condemnation, and you can’t take those words back. You’ll never have to live and sleep at night with the decisions we have to make. It’s hard for me to believe you can’t see that publicly naming a physician like that is even a somewhat questionable call.

    Do me a favor, either try to perform your job with the 100% accuracy and perfection that you demand of us or stop pretending that your job is anywhere near as important and lose the self-righteous attitude. You may think you’re the next Sidney Zion, but you’re just an angry bully. You ran roughshod over the personal well being and professional reputation of a physician who’s already sacrificed decades of their life to care for them.

    It’s at best an angry, knee-jerk response to a tragedy and at worst, libel. Shame on you.

    I regret having to consume the NYT’s drivel and grant you some fraction of a cent from your advertisers just to rant about it on some online forum, but it needs to be said you should hold yourself to the same high standard you hold us. And if nothing else, the irony of having someone who has no part of your industry telling you how to do your job shouldn’t be lost on you, either.

  9. The Captain says:

    I had a 41 YO, healthy male, no co-morbidity factors who was mowing his lawn. Some object ricocheted from the blade and made a 3 cm cut on his leg. Common, routine laceration in any ED on any given day, right? Treated like we normally treat any “simple” cut: cleaned, no FB, sutured, dressed, normal after care instructions. The patient was dead 2 days later from necrotizing fasciitis from some weird bug, not MRSA or strep. Do I now send patients home with antibiotics for routine lacerations? Yup! Will this practice change cause resistant bugs? Possibly. But it will certainly lessen my changes of being excoriated by a plaintiff’s attorney.

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