It Is Not Enough

The following tragedy was recently reported by many newspapers. As described, the care that this young man received was poorly handled.  The case demonstrates the chasm between the technology of medical care in 2012 and the system in which it is provided The response from the major medical center where he was treated in the middle a major city was inadequate.  Such a vacuous correction confirms that the hospitals responsible for providing the care do not understand the problem.

NYU Langone Medical Center announced on Wednesday significant changes in its procedures after the death by septic shock of a 12-year-old boy who was sent home from the center with fever and a rapid heart rate.
Three hours after the boy, Rory Staunton, left the emergency room, a laboratory test showed that his blood had extraordinarily high levels of cells associated with bacterial infections. He subsequently went into shock and experienced organ failure, and died three days later, on April 1. His parents said they were not told about the lab results and were unaware of how seriously ill their son was, having been assured that he was suffering from a typical stomach bug.
In a statement, the hospital said that emergency physicians and nurses would be “immediately notified of certain lab results suggestive of serious infection, such as elevated band counts.” Rory Staunton’s bands, or a type of white blood cell, were nearly five times as high as a normal level.
The hospital has developed a new checklist to ensure that a doctor and nurse have conducted “a final review of all critical lab results and patient vital signs” before a patient leaves, Lisa Greiner, a spokeswoman, said in the statement.
“In the unlikely occurrence that a clinically relevant test is only available after the patient is discharged from the E.D., the patient will be called, and the information will be shared with referring physician,” Ms. Greiner said.
The family pediatrician, who sent Rory to the hospital to be given fluids for dehydration, said she did not know about the blood work.
Ms. Greiner said the steps were taken in direct response to Rory’s death.
“Keeping our patients safe is our first priority, and we want to prevent this situation from happening again,” she said. 

It is not enough to change hospital procedures how a critical laboratory value is handled to prevent other Rory Stautons from needless deaths. It is baffling that knowledgeable people who administer major medical facilities, such as NYU Langone Medical Center, believe a simplistic checklist can solve such a complex problem. This might have been an adequate correction seventy-five years ago, but not in an era of technology capable of communicating  with a man on the moon.

I entered the medicinal profession fifty years ago and have witnessed technological discoveries that transformed how we diagnose and treat patients. In contrast, during the same time there have been minimal advances in how physicians share clinical data. Failure to attend to how physicians communicate has lead to unnecessary loss of lives as well as to redundancy and excessive cost.

Medicine is not a fail-safe profession. There always will be patients who do not respond to treatments and others whose symptoms we cannot translate. There may even be clinical data that is lost. However, no patient should suffer because we have neglected to modernize our communications. Requesting clinical data to assist diagnosing our patients’ illness and then not use a critical result has no place in an age of robotic surgery, facial transplants, or gene therapy. The imbalance between technological advances and outdated methods of communication is glaring. It is a challenge that cannot be resolved with  ‘new checklist’.

It is one thing for patients to await a cure for advanced coronary heart disease or metastatic tic cancer. They should not have to wait for our profession to stumble its way to effective communication.