A child gets a minor scrape while playing sports at school. The child and parents ignore it, but the next day he is vomiting and has pain in his leg. The parents take their child to the emergency room.
Remarkably, decisions made by doctors at this point could mean the difference between life and death. And right now, the case of Rory Staunton, a 12-year-old boy who died after showing symptoms exactly as described above, has hospitals all over the country focusing on ways to make sure these cases don't end tragically.
In an episode first reported by the New York Times last week, Staunton died at NYU Langone Medical Center of a deadly condition known as sepsis. Such cases are rare, but not unheard of; sepsis, which affects at least 750,000 adults a year, can and does affect children. In 2007, a 13-year-old in Chicago named Tony Love almost died after experiencing nearly the same symptoms. Love's story is told at the beginning of Maryn McKenna's 2010 book Superbug about the dangers of antibiotic-resistant bacteria.
For doctors, the problem is recognizing what's wrong before it's too late.
Sepsis is the result of a body's overwhelming response to an infection. When bacteria get into the bloodstream, the body's immune system mobilizes to fight them. But if the infection is left unchecked, the body's own defenses can rage out of control.
"The body says, 'Hey, we have some attackers here, let's go fight them,'" says Dr. Nathan Shapiro, an emergency medicine physician at Beth Israel Deaconess Medical Center. "It makes chemicals called cytokines and other factors as part of the inflammatory response."
But as Shapiro explains it, if the underlying infection is not treated, the response itself can cause organ damage and death.
The problem is that, in its early stages, sepsis causes symptoms that aren't much different from those of a viral infection that will go away on its own. Consequently, sorting out who can go home from the emergency department and who needs quick hospitalization can be tough.
"The thing that people are always looking for is the crystal ball that will tell whether this kid who doesn't look all that sick really is," says Dr. David Gaieski, assistant professor of emergency medicine at the Hospital of the University of Pennsylvania. "Right now there's nothing that is 100 percent able to do that."
Beth Israel Deaconess' Shapiro agrees. "The tricky part is discriminating between someone who has an infection and is going to recover by themselves, and someone who is going to become really sick."
The stakes involved in this decision could not be higher, since treating septic patients early is the single most important element in their care.
"When the person shows up, the clock starts ticking," says Penn's Gaieski. "Those first six hours mean a lot."
Complicating matters further is the fact that guidelines developed to tip off physicians when they should suspect sepsis and start early treatment are most often geared toward adults. In children, these same rules may not apply.
"It's hard to apply sepsis criteria mentioned in there to pediatric patients," says Dr. Abhi Mehrotra of the University of North Carolina at Chapel Hill. "Vital sign criteria are age-appropriate. It's difficult to take criteria out of the clinical population in which they were developed and apply them to another."
In Some Cases, Sepsis Is Obvious; In Others It's Not
But there are some times when the signs are obvious. Mehrotra, assistant medical director of UNC's emergency department, related a recent experience in which a 12-year-old came in with a fever, high heart rate and abnormal white blood cell count. Mehrotra and his team immediately suspected sepsis, he says, because the patient had cancer and was on chemotherapy. In this case, the body's immune system was compromised, and an infection was one of the top concerns on Mehrotra's list.
In a child who has a normal immune system and is in otherwise good health, however, "there may not be findings to take you down the sepsis road," he explains.
Experts agree that there aren't any easy answers to the question of how to identify rare but deadly conditions in patients who are unlikely to have them. Mehrotra acknowledges that with so many patients coming to the emergency department with the same common symptoms, the problem defies blanket solutions.
"If we just hospitalized all of these patients," says Mehrotra, "we wouldn't be able to treat anyone else."