WhiteCoat

Jim Dwyer New York Times Pediatric Fever Article Debate

This is probably a record length post for me, but I thought it was important to respond to Mr. Dwyer’s comments to a post written on this blog regarding the article he wrote that appears in the NY Times.

I had planned to leave my comments after his, but they became too long and involved and I also wanted to paste a couple of pictures from Mr. Dwyer’s article, so I instead decided to answer his criticisms in a post.

If any of you were wondering, I was not the anonymous physician who authored the previous post on Mr. Dwyer’s article. I spent most of my afternoon creating this response because Mr. Dwyer’s original article was somewhat frustrating to me, but I found his justifications and explanations for what was contained in his article to be misleading.

UPDATE
See additional commentary about Mr. Dwyer’s articles here and here.

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Dear Mr. Dwyer,

When re-reading your article, I absolutely agree with Rory’s wish that no other child – and no other family for that matter – should have to go through what Rory went through. He sounded like a great kid and he obviously had a close family and a bright future. As you also mentioned, Rory’s uncle was a friend of yours, so I can imagine that this incident affected you more than most other investigations you have performed. This topic hit home for me as well. My daughter nearly died from an invasive pneumococcal infection when she was younger. She was hospitalized for a week in a university medical center on triple antibiotics. Very scary times and we thank God that things turned out well.

So let’s go through your article and responses you made to the criticism about your article so that we can determine how to prevent kids from dying from sepsis due to invasive organisms.

JIM DWYER COMMENT:
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.

Let’s look at the sepsis criteria according to the checklist that you posted. Then let’s apply them to children.
1. Pulse greater than 90. In children up to 2 years of age, a pulse rate less than 90 is considered too slow. In other words, ALL children up to 2 years of age should have a pulse rate greater than 90.
2. Respiratory rate greater than 20. In children up to 5 years of age, a respiratory rate less than 20 is considered too slow. In other words, ALL children up to 5 years of age should have a respiratory rate greater than 20.
So now in children who have entirely normal vital signs for their age, right away you have two of the three “danger signs” your article repeatedly emphasizes.
Add a temperature of 100.5 degrees which is essentially not a temperature at all.
Let’s give the child a runny nose which causes us to suspect a viral URI – the suspicion of an “infection” required by the criteria.
This two year old child, running around the room and laughing with his parents, with essentially normal vital signs for age, now has 4 of the criteria on the screening tool you cite.
According to the premise of your article, we must rigidly follow the criteria on the “screening tool,” which means that on every such child, doctors should get a mandatory serum lactate level, order immediate IV antibiotics, and hospitalize the patient. Heck, we should probably throw in a central line and urinary catheter as well to monitor central venous pressure and input/output.
Can you even begin to imagine all of the unnecessary added expense and adverse reactions from the antibiotics/invasive monitoring that would occur if every medical center in the country adopted Jim Dwyer’s rules of pediatric management? Every influenza season, there would be no hospital beds available for months as hospitals were forced to overtreat healthy well-appearing children while delays for care of other emergent patients precipitously increased.

The problem with your article, and something that you conveniently hid from your readers, was the disclaimer at the bottom of your so colorfully highlighted checklist

Doesn’t the disclaimer at the bottom of the checklist say something to the effect that it “should not be used as a substitute for clinical judgment”? Can’t really see the whole sentence because your placement of Rory’s labs just happens to obscure the rest of the wording. But I’ve read enough checklists and disclaimers to know that the disclaimer most likely states that the checklist should not be substituted for a physician’s clinical judgment.

Well, here, let me highlight the area I’m talking about. You can click on the image to get a bigger view if you want:

Yet, despite the checklist specifically telling you NOT to do so, that’s exactly what you did, isn’t it, Mr. Dwyer? You published an article asserting that regardless of the clinical judgment of a physician who has many years of training in medicine and who is described in your article as being “hyper-conscientious”, this protocol must be rigidly followed. You misused this guideline in order to inappropriately attack the qualifications of physicians you never met and to whom you never even spoke.

You state that the guideline and its literature made “no distinction between pediatric and adult patients,” yet you didn’t even know enough or didn’t care enough to ask what patient populations the guidelines were created for.

You keep asserting that Rory was the size of an adult. Fine. I agree. But he was still 12 years old. Unless you have evidence that the criteria have been validated in children – even adult-sized children -  don’t assert that the criteria are valid in children. You know darn well that if the situation was different, the medical treatment involved medications not approved in “children,” and Rory died after receiving the medications, you’d be the first one writing about “warnings ignored” in giving the medication. 20/20 hindsight is just crystal clear.

See a more balanced article about the same topic at ABC News.

JIM DWYER COMMENT:
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.

No, actually Rory probably didn’t have lactate levels done because they weren’t indicated. This is part of the problem with your article and with your argument. You have little or no idea how medicine is practiced, then you create fact patterns which make little prospective clinical sense in an attempt to justify your position. Again, knowing that a child died from sepsis, of course the conclusion (completely tainted by hindsight bias) is that a lactate level should have been ordered.
What if the lactate level was normal? Would you have discounted that like you did the normal strep swab and his essentially normal serum chemistries?

JIM DWYER COMMENT:
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.

Here, we agree. A band count of 53% is concerning and may very well have affected Rory’s care. The problem with your article is that it doesn’t focus on the real problem with the elevated band count. According to your article, labs were drawn on Rory when he arrived in the hospital. We don’t know whether the doctors even knew they had been ordered and I’m sure you didn’t ask. But a CBC which takes less than 15 minutes to run took more than 5 hours to be reported. That’s a system problem that needs to be addressed. Who is at fault? We don’t know and you can’t say. Follow up of abnormal labs is another system function that needs to be addressed. I’m sure that NYU had some system in place for following up abnormal labs. The question becomes where the system broke down. No one can say whether Rory would have survived if these breakdowns were not present. His chances of survival most likely would have been greater, but no one could predict the outcome.

JIM DWYER COMMENT:
3. [sic] 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.)

Regarding the 106 citation, here is just one article that studied more than 130,000 pediatric patient visits. 103 of those 130,000 had fever >106 (hyperpyrexia) and of those 103, 20 had a serious bacterial illness, and only 11 had bacteremia – similar to but likely not as severe as the “sepsis” described in your article. If you look through the types of patients who had bacteremia, almost all of them had urinary tract infections as the source of their infection.
It would have been helpful if your article cited literature stating that a temperature of 104 degrees that drops and rises two degrees after “receiving fluids and tylenol [sic]” is related to “something dangerous happening.” Unfortunately, you won’t find such an article.
However, here are a few “Myths” and “Facts” about fever “in the view of” not Anonymous, but the American Academy of Pediatrics:

MYTH: If the fever doesn’t come down (if you can’t “break the fever”), the cause is serious.
FACT:
Fevers that don’t respond to fever medicine can be caused by viruses or bacteria.  It doesn’t relate to the seriousness of the infection.

MYTH: Once the fever comes down with medicines, it should stay down.
FACT:
The fever will normally last for 2 or 3 days with most viral infections.  Therefore, when the fever medicine wears off, the fever will return and need to be treated again.  The fever will go away and not return once your child’s body overpowers the virus (usually by the fourth day).

MYTH: If the fever is high, the cause is serious.
FACT:
If the fever is high, the cause may or may not be serious. If your child looks very sick, the cause is more likely to be serious.

MYTH: The exact number of the temperature is very important.
FACT:
How your child looks is what’s important, not the exact temperature.

Medical recommendations for evaluation of a febrile immunized child more than 2 years old stop at “obtaining a history and performing a physical examination,” while “specific workup and/or treatment is based on the clinical findings and suspicion of disease.” This same article also notes that, in evaluation of febrile children, “several factors indicate an increased risk of bacteremia and/or sepsis, including age less than 2 months, an immunocompromised state (eg, neutropenic or underlying malignancy), being unvaccinated or undervaccinated, hypothermia (core temperature < 36.8°C, or 98°F), and hyperthermia (core temperature >40.5°C, or 105°F). Rory had none of these – at least according to your article.
Your article perpetuates the myth that “fever is the enemy” when, in fact, very few children with fevers have any serious bacterial illness, much less the sepsis from which Rory died.

JIM DWYER COMMENT:
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.”

Here, you’re again showing your unfamiliarity with the topics you are writing about. Neutrophils and bands are white blood cells. Quoting another person who stated that the rate of production of these WBCs was “very abnormal and would suggest a serious bacterial infection” is absolutely implying what the other blogger stated.

JIM DWYER COMMENT:
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.

No, this SHOULD have been a narrative about important information not used. You could have even made it educational by informing your readers about the signs that a fever may represent a more serious disease. Instead, it came across to me (and to a good proportion of the 1600+ people who commented on your article at the NY Times web site) as a story about how some negligent doctors and a negligent hospital missed all this information clearly demonstrating that Rory was septic. These aspersions were cast based on the story of your friend – Rory’s uncle – and your friend’s family – Rory’s parents. While creating your story you knew or should have known that there was no way that the doctors would be able to respond with their side of the story to defend themselves.
How are the names of the doctors germane to Rory’s treatment? Did you name the nurses that treated Rory? Are they less “germane”? How about the lab personnel who analyzed his blood? Those people would seem really germane to me. What about the administrators who hadn’t instituted the policies that you think every hospital should have? You were out for revenge on these doctors and you got it.

JIM DWYER COMMENT:
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.

NYU has “announced changes”. Congratulations. When an inflammatory article about their emergency department has been published to millions of people, what do you expect any hospital to do? Of course they’re going to “announce changes.” They want to get out of the spotlight. Show me an example of a hospital that has received national attention for a bad patient outcome where the hospital didn’t “announce changes.” Did you expect NYU to do something different?

It’s also kind of underhanded that you repeatedly note how the doctors did not respond to a request for comments. Your article stated that one of the doctors “could not discuss the case,” and that another “could not be reached for comment through the hospital,” making it appear that they were trying to hide something. You know or should know that discussing a patient’s medical care with a reporter under these circumstances without consent of patient or guardian is a violation of federal law. Here is a summary of the “permissible disclosures” under HIPAA laws. Here are the full regs if you want to read them.
Instead of saying “I as a ‘journalist’ didn’t get written consent from Rory’s parents so that their doctors could speak with me and all other journalists about the case,” you make more insinuations to portray the doctors as trying to hide their involvement in the case. Did you even ask NYU about hospital policies for speaking to media? Of course not. Stating in your article that NYU has a policy that no employees may speak to the media wouldn’t villainize the physicians as much.

To me, you inappropriately used your article as a weapon to attack the medical providers in this case whom you believe caused Rory’s death. If that’s your definition of good journalism, go ahead and sign your name to it. Anyone who does an internet search for your name will be able to review your “signed” article (contained here as a .pdf just in case the NY Times decides to remove it or make it unavailable to the public), this discussion, and then make their own decision about your motives and your appropriateness as a journalist.

At least you got a chance to respond to the issues that were raised here about your professionalism – a courtesy that wasn’t available to the doctors that you flamed.

We will never know if Rory’s life could have been saved had his underlying sepsis been discovered earlier. Sepsis is a horrible disease and many patients who develop sepsis ultimately die. Despite my disagreements with the way you presented your article, my thoughts and prayers go out to Rory’s family. I hope that God gives them the strength to heal through what I know have been, and will continue to be, difficult times.

 

P.S. Please provide us with the name of the editor that approved your article. I think that would be very germane to this issue.

27 Responses to “Jim Dwyer New York Times Pediatric Fever Article Debate”

  1. ThorMD says:

    Well done WC.

  2. Lior says:

    I think the most important point here (and something most laymen don’t understand) is the difference betwenn the following two probabilities:

    1) The probability of a particular symptom given the disease. This is easy to measure, and is popular with untrained people like Dwyer. It’s well suited to public advocacy presentation. In particular, every disease has its “top ten list of symptoms” by definition.

    2) The probability of the disease given the symptoms. This is the only quantity relevant to the discussion, since the doctor only knows the symptoms.

    I won’t discuss how to compare the two probabilities (Google for “Bayes’s Law”). Rather, let’s consider the case at hand.

    The argument seems to be “most cases of sepsis are accompanied by fever and elevated heart rate. The patient had these symptoms, so he needed to be treated for sepsis “. But this is a basic fallacy (surely intentional by Dwyer). The real question is “what fraction of patients with these symptoms have sepsis?”, and the answer to that might be “very few; most have the common cold”, in which case no treatment is needed even if it will later turn out the diagnosis was wrong. (I’m a mathematician, not a doctor, so don’t expect me to get the medicine right — perhaps sepsis was the right diagnosis given the symptoms, but Dwyer did not cite any data on that)

    • Jim Dwyer says:

      You apparently are under the impression that the article was entirely about the boy’s irregular vital signs. That’s not true.

      Rory Staunton’s blood was drawn when he was in the emergency room and the results showed that his absolute bands (a kind of immature white blood cell associated with infection) was almost 500% of the normal high value for an adult. There are other findings in his lab work that suggested this was not a viral infection (like the common cold) but was bacterial.
      Your entire thesis is wrong, and replicates what appears to be the error in treating him. You did not take into account his lab findings. These results were not seen before he was discharged from the hospital, nor did anyone contact his family after he had gone home about the alarming results.

      As for his vital signs, it should be noted that his heartbeat was two standard deviations above normal for a child, which is a trigger for sepsis investigation in a growing number of hospitals that have found early treatment significantly reduces deaths. (If the boy was viewed as a near-adult – he was 169 pounds, 5’9″ – his heart rate was even more dangerously elevated.)

      So Mr. Lior, I suggest you do this math work: what fraction of patients with explosive number of band cells, very elevated heart rate, and fever might have sepsis?
      I haven’t done the arithmetic, but many groups of hospitals have. They treat patients with these symptoms.

      • WhiteCoat says:

        Lior’s thesis is not wrong.

        You are blinded by your hindsight bias. Just because Rory died from sepsis, you and your article state that “Rory had these findings, therefore everyone should have known Rory had sepsis and should have treated Rory for sepsis.”
        False logic.

        Rory’s blood was drawn while he was still in the emergency department, but the values were not returned until after he was discharged. Yet you imply that those values should have been considered in determining whether to do more testing on Rory. Inappropriate assertion.

        What other values “suggested this was not a viral infection”? Cite your sources.

        Can you name a few of the “growing number of hospitals” that use heartbeat of two standard deviations above the normal for a child as a trigger for sepsis evaluation? I’m betting you can’t name one.

        Here is a list of just some of the things that can cause a high heart rate and a fever. Should every child with these symptoms be ruled out for every one of these disease entities?

        You try doing the math. What percentage of patients with a fever will have an elevated heart rate? Just about every one.

        What should doctors do with a well-appearing child who presents to the emergency department with a fever and elevated heart rate?
        That should be left to the doctors evaluating the patients and not a journalist who hasn’t done the arithmetic and who is blinded by hindsight bias.

      • Jim Dwyer says:

        To Birdstrike:

        You asked: why include the names of the doctors involved in the case of Rory Staunton?

        Just as reporters do when covering car crashes and plane accidents, I included the available names of the individuals and institutions involved in this calamity. Those are basic requirements in assembling a narrative.

        (The only person not named in the article was a senior associate of an emergency room doctor. That senior associate was anonymously quoted describing the ER doctor as “hyper-conscientious.”)

  3. 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.

  4. Shelby says:

    As an ED nurse, I have to wonder… when did doctors & medical staff become “infallible”? We’re human & don’t always do everything we should. Unfortunately, when we make a mistake or don’t act perfectly, someone might die. But people die when we do everything perfectly too. Whatever happened to the belief that someone was meant to die at the time they passed, even if they were young? Maybe it was his time to “go to God”. I’m very sorry for the family, it’s not fair that you lost your child, but, somehow, he has something to do somewhere else.

    I’ve discharged this patient many times myself. And none of them died. I’m not blaming anyone, but I always tell patients/parents, in cases like this, to return if there is no improvement in 24 hours or they get worse.

  5. defendUSA says:

    I hate journalists who don’t do thorough investigating and reporting. Clearly, there was willful blindness in order to smash the care received by the patient and then the writer’s projection of the physicians not doing what they were “supposed” to. People like that should not have a job. (can you say Brian Ross?)

  6. doc99 says:

    And they wonder why Doctors practice Defensive Medicine …

  7. Gary says:

    I am a subscriber to the electronic NY Times, and an emergency physician. So of course this article caught my attention. After reading Emergency Physicians Monthly’s thorough analysis of the professional healthcare and the unprofessional journalism, I am now seriously considering dropping my subscription to NYT. I feel empathy for both the patient’s family and the treating healthcare professionals. I feel disdain for the NYT writer. Thank you for providing a quality service to your readership correcting the disservice done by the NYT writer.

  8. J says:

    ER (err ED) doctors are so stupid. How can you not predict the future? Here is another one:

    http://www.foxnews.com/health/2012/07/24/what-need-to-know-before-bringing-your-child-to-er/?intcmp=features

  9. James Farrell says:

    have to say you ed doctors are wonderful at covering your asses. You miss the most obvious point — THE DOCTOR NEVER READ THE BLOOD TEST RESULTS THAT SHE ORDERED THAT SHOWED THE ALARMING BANDS — thats is why the child died

    • Seth Trueger says:

      Disagree. Needle vs. haystack. Young healthy kids with non-dangerous viral infections can make bands, too.

    • VinceD says:

      As a point of clarification, it was an infection that killed young Rory, not another human being. Yes, the lab follow-up could likely have been handled better, and I’m certain that all parties involved would give anything for a different outcome, but the fact remains that the patient had an infection, and all infections carry a certain mortality.
      I’ve seen patients, who I was certain would perish, walking out of the hospital a week later, while others have gone into cardiac arrest in front of me mere minutes after we were engaged in light-hearted conversation.
      There are no guarantees in medicine, so it is a gross miscalculation to assume that even if Rory had been admitted and treated with antibiotics, he would still be guaranteed sixty more years to live his life. To then pin such a loss on a single person is reductionistic and inflammatory.
      So please, by all means, advocate for better processes to ensure that lab values are seen and recognized by the right people, but acting like this tragic outcome is the fault of a single person is wildly off-base and does nothing to improve the care of future Rory Stauntons.

      • Jim Dwyer says:

        Commenting on Seth Trueger and VinceD posts.
        Seth Trueger says the Staunton case was a “needle vs haystack,” and that “healthy kids with non-dangerous viral infections can make bands too.”
        Here are the lab values: bands, 53% (normal high 15%); lymphocytes 3% (normal low 28%).
        Aren’t these results strongly suggestive of a bacterial infection, not a viral one?
        This needle wasn’t in a haystack. It was in a lab report that no one read. The letters “H” are printed next to the results for his bands and neutrophils, and “L” next to the results for his lymphocytes and, btw, his platelets (117, vs normal low of 150).
        H for high, not haystack.
        Aren’t these tests done to find out things just like this?
        VinceD writes, “the lab follow up could likely have been handled better.”
        There was absolutely no lab follow up, so I’d have to agree that it could likely have been handled better, since it wasn’t at all.
        It is true that Rory Staunton might not have survived the Group A strep infection if he had been treated for it.
        Therefore?

      • Seth Trueger says:

        Absolutely not. Bands indicate host response to infection (or other stressor) and do not help differentiate between underlying causes, ie viral vs bacterial. see, among others: http://www.jfponline.com/Pages.asp?AID=4998

      • WhiteCoat says:

        James makes one potentially erroneous assumption and then Mr. Dwyer takes the ball and runs with it:

        “BLOOD TEST RESULTS THAT SHE ORDERED”

        Did “she” order them? Did “she” even know that the blood tests had been done? If you review the sepsis guidelines in Mr. Dwyer’s article, they refer to the “NURSING Sepsis Panel Orders” if the proper criteria are present. Mr. Dwyer apparently never asked who ordered the tests or who saw the results.

        Even if we assume the results of the tests were seen while Rory was still in the emergency department, what is the proper management for an “improved” child with these symptoms?

        Rory’s symptoms occurred near the high point in influenza activity in the country. http://www.cdc.gov/flu/weekly/
        Should all children or other patients with an influenza like illness, including fever and tachycardia, receive sepsis treatment and early antibiotics? If not, which children should and should not receive antibiotics?

        Mr. Dwyer repeatedly fails to take any type of a medically sound *prospective* stance in what should be done in the future to address issues like those that occurred in Rory’s case.

        Act upon any lab result with an “H” or an “L” next to it. Don’t use clinical judgment, just act … if you were even aware the lab results existed, that is.

        Everyone gets it. The lab results weren’t followed up. You failed as a reporter in investigating how the lab results were missed. And your article repeatedly and inappropriately focused on sepsis guidelines that didn’t apply to children and that specifically stated they should not be used in lieu of clinical judgment.

        Will your next article be about some other doctor who failed to diagnose a patient’s heart attack and how all patients from 8 months to 180 years of age with any type of chest pain should undergo cardiac catheterization?

        I hear that a “growing number of hospitals” are using that chest pain criteria to diagnose heart attacks these days.

        And people wonder why there is so much defensive medicine in this country.

      • Birdstrike says:

        Mr Dwyer,

        For a man of your journalistic expertise, answering this question should be much easier than arguing the intricate medical details of CBCs, bands, and pediatric sepsis with medical doctors:

        From a journalistic standpoint, in what way was printing the names of the physicians involved necessary to accomplish the goals of your article?

  10. Matt says:

    While I certainly am not disagreeing with the analysis of the physicians here, I do find their outrage regarding the author bring uninformed due to not actually practicing medicine more than a little ironic.

    • WhiteCoat says:

      Nice try, counselor.
      The issue isn’t that the author was uninformed because he doesn’t practice medicine. The issue is that the author was simply uninformed.

  11. Jim Dwyer says:

    Hmm — I tried to post a reply to Birdstrike’s query, but it ended up posting under someone else’s comment. Sorry for the confusion.

  12. Jim Dwyer says:

    (this is a reposting to what I hope is the right spot on the page)
    To Birdstrike:

    You asked: why include the names of the doctors involved in the case of Rory Staunton?

    Just as every news organization does in covering car crashes and plane accidents, I included the names of the individuals and institutions involved in this calamity. Those are basic requirements in assembling a narrative.

    (The only person not named in the article was a senior associate of an emergency room doctor. That senior associate was anonymously quoted describing the ER doctor as “hyper-conscientious.”)

    • BirdStrike says:

      Mr. Dwyer,

      Thank you for the reply, it is greatly appreciated.  However, I asked a very different question and much deeper question, I think, than your paraphrased version of my question.  I asked this: “From a journalistic standpoint, in what way was printing the names of the physicians involved necessary to accomplish the goals of your article?”

      Often times, I’ve noticed in the examples you mention such as car crashes and other calamities, one does see a disclaimer such as “names have been with held until further investigation….,” or “names have been withheld until family has been notified”. You even site an example of withholding one physician name, but not others, in your own article.  Why withhold one name and not the other?  If the unnamed person wasn’t pertinent enough to the events to be mentioned by name, why mention them at all? I am not a professional journalist so I won’t claim to know or imply that I know the right answers to these questions.

      Would the article have lost any of it’s stated or implied goals or effectiveness if the physicians were not mentioned by name?  Might it have been equally as effective?  More effective? I don’t know, and you don’t even have to answer as far as I’m concerned.  These are just the questions that have interested me as I’ve watched the arguments fly back and forth about bands and CBCs.

      Thank you for the replies.

      • Jim Dwyer says:

        BirdStrike,

        The prime goal in all articles, not just this one, is to provide sufficient detail to give the readers confidence that the account is grounded in reality — that real people were involved, at an actual place, on particular dates. Such details make it possible for others to do the same reporting and replicate, repudiate, or revise the results.
        You ask if it’s effective to include the names, and I don’t know the answer to that. The use of such particular details is, in the view of virtually all American journalists, the path to reliability.
        You’re right that names are withheld from articles, typically when a fatality is involved, as in a car crash or in a combat situation, to provide enough time for the authorities to notify family members. Clearly, that circumstance did not apply here.
        Finally, the individual I quoted anonymously in this article, who said the emergency room doctor was “hyper-conscientious,” provided a perspective on the ER doctor that I thought would be helpful to the readers.
        Thank you for your consideration of this.

  13. Jim Dwyer says:

    White Coat

    To state the obvious, we have different perspectives. To you, I failed glaringly by not saying whether one doctor or another, one nurse or another, ordered the blood tests for Rory Staunton and didn’t read them.

    I don’t know whose job it was. I tried but couldn’t figure that out. Someone or some ones — his pediatrician, his ER doctor, the nursing staff, a physician assistant if one was involved — should have read them.

    Perhaps, as with the causes of an airplane crash, multiple failures will emerge in time.

    To me, the most significant fact is not who didn’t read or follow up on the lab work, but that it wasn’t used in looking after the dire needs of Rory.

    Most non-medical people believe that when blood is drawn for tests, that someone in the chain of care will read and rely on the results in order to make judgments about how to proceed. It is dumbfounding that they would not be. Perhaps it happens all the time and there’s usually no bad outcome. People often take their eyes off the road when driving. Only once in a while do they crash.

    NYU (and other hospitals) are taking steps to try to make sure it doesn’t happen again.

    I realize that I have not answered all the criticisms you level, but you attribute many things to me that I didn’t write, and also accuse me of failing to do things that I, in documented fact, actually did. A constructive dialogue that tried to untangle insinuation from supposition from legitimate criticism would consume time and energy but probably not shed much light. People can read the original article on Rory Staunton (it’s here: http://nyti.ms/NjLrPH)
    and decide if it’s a responsible account of a serious lapse or an act of journalistic ignorance. Perhaps it’s best to conclude my comments with that.

    Thank you for having posted my replies, however truncated, naive or dishonest they may seem to you.

    • WhiteCoat says:

      No, Jim, you failed for several reasons.

      You didn’t explore many of the assertions you made in your article. You led your readers to believe that things were done wrong when you didn’t explore the facts.

      You misused sepsis guidelines that were intended to apply to adults, then you hid the disclaimer at the bottom of the guidelines, then, when you were caught, you tried to justify your actions by stating that Rory was “adult sized.” None of those assertions was medically appropriate and you either knew or should have known that before making them.
      Even if you did contact the hospital and ask for the doctors’ side of the story, offering releases from Rory’s family, you knew that HIPAA and or hospital policies would prevent the doctors from being able to speak candidly to you. And you hid that fact from readers who don’t know the intricacies of patient privacy laws and hospital policies.
      You were correct in noting that labs were not addressed. Yet you have no idea who ordered them, who saw them, when they were seen, and whether they would even have made any difference.
      Finally, you selectively published names of physicians who treated Rory and subjected them to public harrassment when, in all likelihood, they behaved appropriately. We don’t have enough information to make a conclusion one way or another on that point, but it was entirely inappropriate to do that to those doctors without more conclusive evidence. And you didn’t name the other people whose role in this story was much more definitive.
      Because of all of this, you’ve dragged doctors through the mud and you’ve dragged Rory’s family through a vetting of his care that they neither expected nor deserved.
      Through Rory’s death, you were able to capture your readers’ attention. You had the opportunity to teach millions of people about sepsis, how sepsis develops, warning signs of sepsis, even how antibiotic overuse contributes to more dangerous types of sepsis. You could have created such a positive influence to honor his memory. Instead, you used your words to cast blame and public hazing.

      How are people going to remember Rory because of your article? Some will remember that he was a great kid whose life was cut short by a terrible and rare disease. Some will probably think that the horrible doctors and hospital system killed Rory. All the medical community will remember about Rory Staunton is that some journalist wrote a poorly-researched article about his death and got his pound of flesh from the docs who treated him.

      Congratulations.

      This is the end of the discussion.
      Comments are now turned off on these posts.
      If someone chooses to perform a search on Jim Dwyer’s journalistic integrity or Jill Abramson’s editorial integrity, they’ll hopefully have much more information on which to make that determination after reading these posts and comments.

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