Streptococcal Sepsis: Rare But Dangerous

July 23, 2012
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The tragic story of Rory Staunton received national attention, as well as scrutiny on physician-only discussion boards.  To recap, this otherwise healthy 12 yr-old suffered a seemingly innocent arm scrape playing basketball.  He soon felt ill and was seen the next day by his pediatrician, who referred him to the ED.  There he was rehydrated and discharged.  He did not improve.  When he returned, now gravel

The tragic story of Rory Staunton received national attention, as well as scrutiny on physician-only discussion boards.  To recap, this otherwise healthy 12 yr-old suffered a seemingly innocent arm scrape playing basketball.  He soon felt ill and was seen the next day by his pediatrician, who referred him to the ED.  There he was rehydrated and discharged.  He did not improve.  When he returned, now gravely ill, he was hospitalized but succumbed to sepsis.

This is a tragic and unsettling story for several reasons.  Simply put, we live in a world of bacteria.  Any time a small injury occurs; there is a very small but real chance of a serious infection developing, should the body’s initial immune-system defenders fail in their job.

The bacteria at issue here were once far more feared.  In the pre-antibiotic era, this infection was very often lethal.  It was staphylococcal sepsis that in 1924 killed Calvin Coolidge Jr., son of the then-President.  Today in otherwise healthy people, it is very treatable, except in unusual circumstances.

As a disclaimer, Monday morning quarterbacking is not science.  Any commentary by those who did not directly participate in the events is speculative and based only upon whatever information is publicly available.

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From the coverage and board discussion of the events, it appeared that when the child presented to the pediatrician, he was felt to have dehydration and gastrointestinal distress.  That seems a reasonable initial impression.  After all, hoofbeats usually mean a horse, and not a zebra.  Referral to the ED made sense if he was felt to require significant rehydration.

Diagnosing streptococcal sepsis at this stage would have been hard, and the far more likely diagnosis was presumed.  But, the appearance of the arm was suspicious.  Usually, people with such wounds are covered with antibiotics if the wounds require suturing, or if not sutured, coverage might be prescribed if any redness or surrounding cellulitis is seen.

In cases such as this, it usually takes more than one missed opportunity to have the outcome turn tragic.

At the ED, reports describe difficulty standing and walking, fever, and a pulse of 140.  That sounds fairly ill to me.  On the discussion boards, Emergency specialists sparred with surgeons over whether this is a typical appearance commonly seen with dehydrated kids.  I have to side with my surgeon-colleagues who said that it should have been apparent that something was really wrong with the young man.

The most concerning thing about the ED visit was the discharge without checking the blood work.  Rory had a significantly elevated white count with a major left shift.  That strongly suggests a systemic infection.  It is this point for me that is the most concerning, and one that deserves more scrutiny.  Were the labs forgotten?  Was it presumed that they were probably normal and therefore not an issue? Did someone read the wrong lab report?

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The public expects a medical system incapable of error or untoward outcome.   But before blame is assigned, questions need to be answered.

Was this a system problem or an individual problem?  How busy was the pediatrician’s office?  Were they distracted by the non-medical minutiae required to practice medicine today?  Was the ED awash in non-emergent cases and understaffed?  Did the report get lost or mislabeled?

Cases such as this tend to result in calls for more rules, more scripted procedures, and more ways to try to perfect an imperfect system.  But sometimes the answer is not to add complexity to the process of undertaking a clinical encounter, but to simplify it.  In this case, just be sure to take a look at the big picture, and don’t forget to check the labs.

And sometimes the hoofbeats really are from a zebra.