Boys Dies after Minor Cut Leads to Sepsis Shock and Goes Undiagnosed in ER

NYU Langone Medical Center is in the spotlight for sending home a seriously ill 12-year-old boy after spending hours in the emergency room. The child ultimately died four days later from sepsis shock. So what went wrong?

The child received a minor cut during basketball practice. The coach applied a band aid and the boy went home. Sometime during the night, he began vomiting and complaining of leg pain. By morning, the 12-year-old was running a 104 temperature, could not keep down liquids or solid foods, and was still complaining of leg pain. By the time he was seen by the pediatrician, the child was so ill that his mother had to help him walk; he could not hold himself up. His skin was blotchy when pressed. The pediatrician recommended the boy be taken to the emergency room.

As part of NYU Langone’s stop Sepsis program, patients are screened for three symptoms of sepsis out of a possible eight. Initially, the child showed two signs – he was breathing 20 times per minute and his pulse was 143. Lab work was performed, but prior to receiving the results, the doctor diagnosed the child with the flu and dehydration and release papers were prepared. Before he was discharged, the boy’s temperature spiked to 102 – a third warning sign of sepsis, yet he was still sent home. His parents were never notified that he showed three signs of sepsis. A few hours later, the lab results showed significant signs of infection in the boy’s blood, another warning sign of sepsis. Once again, the parents were not notified. The following day, the child’s skin turned blue around the nose and he experienced significant pain at the touch of his skin. The pediatrician recommended the boy be returned to the ER. Despite all efforts, the child died of severe septic shock.

Dr. Scott Weingart, co-chair of the STOP Sepsis Collaborative, said that this case highlights the importance of parents being proactive and following their instincts. He said, “If your child looks much sicker than you would expect from a simple virus, cold or flu, you should contact your pediatrician or visit an emergency room.” Isn’t that what these parents did? They contacted the pedestrian, and then followed her recommendation to go to the ER. Why did the hospital release this child if he showed three warning signs of sepsis? Why was he released before the lab results were in? Furthermore, why were the parents not notified to bring the child back to the ER once the lab results showed an infection in his blood? And, why didn’t the lab notify the attending ER doctor immediately about the results? Could this child have been saved if doctors did not send him home when he developed a third warning sign of sepsis? Could he have been saved if the parents were called after the lab results were reviewed? Absolutely; sepsis is common and easy to treat in early stages.

People don’t actually die from the infection, but rather the body’s response to it. Unfortunately, the confusion between infection and sepsis is responsible for delays in identifying sepsis, delays that can result in tragic outcomes. What do you know about sepsis? The Mayo Clinic says these signs of sepsis are something everyone should know.

• Fever above 101.3 F (38.5 C) or below 95 F (35 C)
• Heart rate higher than 90 beats a minute
• Respiratory rate higher than 20 breaths a minute
• Probable or confirmed infection

Unfortunately, many patients who find themselves with these symptoms question whether or not they are sick enough to seek help. If you feel sicker than you’ve ever felt before and you feel that you’re getting worse instead of better, seek medical attention. If you exhibit at least two of the following symptoms, seek medical attention immediately. Besides misdiagnosis, some of the most dangerous situations for a patient are when there is poor communication between the patient and their health care “team”. Some healthcare professional suggest mentioning your concerns of sepsis shock based on symptoms you or your loved one is experiencing. It is a matter of life or death that healthcare providers improve coordination and promote accountability, but most of all make a special effort to work together improving communication.

Following are a few tips on preventing an infection that can ultimately lead to septic shock.

• Wash your hands frequently and properly.
• Get vaccinated, including vaccines for influenza, pneumococcus, and meningitis – all infections that can cause sepsis.
• Clean cuts and scrapes immediately and watch for signs of infection.

For more information on how to recognize sepsis, visit the Mayo Clinic web page.

Mark Bello has thirty-five years experience as a trial lawyer and thirteen years as an underwriter and situational analyst in the lawsuit funding industry. He is the owner and founder of Lawsuit Financial Corporation which helps provide legal finance cash flow solutions and consulting when necessities of life litigation funding is needed by a plaintiff involved in pending, personal injury, litigation. Bello is a Justice Pac member of the American Association for Justice, Sustaining and Justice Pac member of the Michigan Association for Justice, Member of Public Justice and Public Citizen, Business Associate of the Florida, Mississippi, Connecticut, Texas, and Tennessee Associations for Justice, and Consumers Attorneys of California, member of the American Bar Association, the State Bar of Michigan and the Injury Board.