Published: January 7, 2013
The New York Times
Cuomo Plans New Rules in Fight Against Sepsis
By Jim Dwyer
Gov. Andrew M. Cuomo will announce in his State of the State Message this week that every hospital in New York must adopt aggressive procedures for identifying sepsis in patients, including the use of a countdown clock to begin treatment within an hour of spotting it, a state official said.
The new steps could save 5,000 to 8,000 lives annually, state health officials say, and reduce the long-term costs of the condition.
In a related development, state regulators will develop new procedures for parents to “play a meaningful and informed role” in decisions made about care for their children, according to a draft of the message to be delivered by the governor.
Both initiatives were prompted by the case of Rory Staunton, a 12-year-old Queens boy who died of severe septic shock last year after being sent home from the emergency room at NYU Langone Medical Center.
Rory’s parents, Ciaran and Orlaith Staunton, said they did not realize that the results of blood tests ordered for their son had not come back at the time he was discharged.
Those results suggested that he could be critically ill, but the Stauntons learned about them only when they received a laboratory bill after Rory’s death.
Sepsis is a runaway response by the immune system to an infection.
In pushing forward on sepsis screening regulations, New York is adopting standards similar to those recommended last year for the entire country by the National Quality Forum, a consortium of health care experts that provides guidance to hospitals and the Medicare system on best practices.
The state health commissioner, Nirav R. Shah, held a conference on sepsis in November and advised Mr. Cuomo on the reforms, according to the state official, who spoke on the condition of anonymity because the governor’s message had not yet been formally presented.
Mr. Cuomo’s message notes that experts have been calling for action on sepsis for more than a decade, and that simple screening tools used by Kaiser Permanente in California, and Intermountain Healthcare in Utah, two hospital chains, had drastically reduced sepsis mortality rates.
The Society of Critical Care Medicine is announcing revised guidelines later this month, and the governor’s message says that hospitals must use a protocol that “aligns with proven best practices.”
To date, no other state has taken regulatory action to require that such guidelines be used, according to New York officials.
The Staunton case is cited in the governor’s message as bringing new urgency to the efforts.
“I think this is a great step for Governor Cuomo to take,” Mr. Staunton said.
“You cannot just hand-wring any more and say, ‘We’re doing our best.’ This has to be tackled.”
The proposal by the governor on parental involvement in their children’s care was not spelled out.
Ms. Staunton and her husband have urged that state law mandate that hospitals inform parents about test results as well as other diagnoses that were considered.
“Most doctors already do that,” Ms. Staunton said, “so it shouldn’t be a problem to require it so that they all do it.”
Published: December 29, 2012
It Could Happen To Any Child Anywhere
By Brian O’Connell
Since his son Rory died of sepsis, Ciarán Staunton has raised awareness about the condition
Last June, I sat in a bar in New York waiting to meet the owner, Ciaran Staunton. I was there to talk about his work campaigning for visa rights for Irish emigrants in the US. The interview had been arranged months earlier and throughout it Staunton, usually a vocal and focused interviewee, seemed distracted, and I noticed regulars kept interrupting to shake his hand.
At the end of the interview he turned and asked whether I had any children. “One. A 12-year-old boy,” I said. “And you?” I enquired. “I had a son, Rory. He was 12 years old. He died eight weeks ago,” Staunton replied.
Naturally, I was absolutely floored as he told me through reddening eyes about the tragic death of his son. He didn’t want to cancel the interview, and when I expressed condolences and asked how he and his wife, Orlaith, were holding up, he replied: “It is a daily living nightmare.”
Soon, a larger audience would come to hear the story of Rory Staunton, who died from sepsis, having fallen and grazed his elbow on March 28th at a basketball game in a school gym. Ciarán began a campaign to bring about changes in medical procedures relating to sepsis. One of the reasons the Stauntons went public was that Jim Dwyer, the Pulitzer Prize-winning New York Times journalist, was a family friend and had known Rory personally.
“It was not an easy decision, says Ciarán. “But we wanted to make sure no other parent has to go through the torture we are going through. You can’t half go public and so we released all Rory’s medical records to the journalist Jim Dwyer. Rory knew him and he knew Rory, and he wanted to get to the bottom of what happened.”
While the Stauntons were still coming to terms with the death of their son, if that can ever happen, they also now had large media as well as medical interest in the case to deal with. “We never heard of sepsis before Rory died,” says Ciaran, “and it is one of the largest killers of children in the world.
“We had no strategy. We just did what we felt was right. The torture and trauma we went through; we don’t want anyone else to experience that. One of the most important questions we could have asked was, ‘Could this be sepsis?’ We knew about meningitis but not this. We never heard about sepsis until he was almost dead.”
Did the family have to deal with any negative publicity? “The only negative publicity is that our son is dead. There isn’t any more negative you can get.”
In recent months, Ciaran has been invited to speak at several major conferences in the US on the issue of sepsis, and already he has commitments that emergency-room training and awareness will improve in relation to the condition.
While the family work through their grief, there is some consolation in the fact that by going public they may have prevented other deaths.
“After Rory’s death, we tried to make sepsis a word everyone knew about in the media. The other thing is we wanted to make sure all parents with young children know about it,” says Ciaran.
“Rory’s death has been written about in 14 countries and I have emails from parents saying that the media interest has saved their child’s life. This happened to our son in a hospital in the heart of New York. It could therefore happen to any child anywhere.”
Published: December 20, 2012
The New York Times
One Boy’s Death Moves State to Action to Prevent Others
By Jim Dwyer
Prompted by the death of a 12-year-old Queens boy in April, New York health officials are poised to make their state the first in the nation to require that hospitals aggressively look for sepsis in patients so treatment can begin sooner. Under the regulations, which are now being drafted, the hospitals will also have to publicly report the results of their efforts.
The action by New York has elated sepsis researchers and experts, including members of a national panel who this month formally recommended that the federal government adopt standards similar to what the state is planning.
Though little known, sepsis, an abnormal and self-destructive immune response to infection or illness, is a leading cause of death in hospitals. It often progresses to severely low blood pressure, shock and organ failure.
Over the last decade, a global consortium of doctors, researchers, hospitals and advocates has developed guidelines on early identification and treatment of sepsis that it says have led to significant drops in mortality rates. But first hints of the problem, like a high pulse rate and fever, often are hard for clinicians to tell apart from routine miseries that go along with the flu or cold.
“First and foremost, they need to suspect sepsis,” Dr. Mitchell M. Levy, a professor at Brown University School of Medicine and a lead author of a paper on the latest sepsis treatment guidelines to be published simultaneously next month in the United States in a journal, Critical Care Medicine, and in Europe in Intensive Care Medicine.
“It’s the most common killer in intensive care units,” Dr. Levy said. “It kills more people than breast cancer, lung cancer and stroke combined.”
If started early enough, the treatment, which includes antibiotics and fluids, can help people escape from the drastic vortex of sepsis, according to findings by researchers working with the Surviving Sepsis Campaign, the global consortium. The tactics led to a reduction of “relative risk mortality by 40 percent,” Dr. Levy said.
Although studies of 30,000 patients show that the guidelines save lives, “the problem is that many hospitals are not adhering to them,” said Dr. Clifford S. Deutschman, director of the sepsis research program at the Perelman School of Medicine at the University of Pennsylvania and the president of the Society of Critical Care Medicine.
About 300 hospitals participate in the study, and the consortium has a goal of having 10,000. “The case is irrefutable: if you take these sepsis measures, and you build a program to help clinicians and hospitals suspect sepsis and identify it early, that will mean more people will survive,” Dr. Levy said.
At a symposium in October, the New York health commissioner, Dr. Nirav R. Shah, said that he would require state hospitals to adopt best practices for early identification and treatment of sepsis. Gov. Andrew M. Cuomo intends to make it a major initiative in 2013, said Josh Vlasto, a spokesman for the governor. “The state is taking unprecedented measures to prevent and effectively treat sepsis in health care facilities across the state and is looking at a wide range of additional measures to better protect patients,” Mr. Vlasto said.
In April, Rory Staunton, a sixth grader from Queens, died of severe septic shock after he became infected, apparently through a cut he suffered while playing basketball. The severity of his illness was not recognized when he was treated in the emergency room at NYU Langone Medical Center. He was sent home with a diagnosis of an ordinary bellyache. Hours later, alarming laboratory results became available that suggested he was critically ill, but neither he nor his family was contacted. For an About New York column in The New York Times, Rory’s parents, Ciaran and Orlaith Staunton, publicly discussed their son’s final days. Their revelations prompted doctors and hospitals across the country to seek new approaches to heading off medical errors.
In addition, Commissioner Shah in New York convened a symposium on sepsis, which included presentations from medical experts and Rory’s parents.
At the end of the meeting, Dr. Shah said that he had listened to all the statistics on the prevalence of the illness, and that one had stuck in his memory: “Twenty-five percent,” he said — the portion of the Staunton family lost to sepsis.
He said he would issue new regulations requiring hospitals to use best practices in identifying and treating sepsis, actions that, he said, he was taking “in honor of Rory Staunton.”
The governor’s spokesman, Mr. Vlasto, said that “the Staunton family’s advocacy has been essential to creating a strong public will for action.”
Dr. Levy said New York’s actions were “bold, pioneering and grounded in good scientific evidence,” adding, “The commissioner has taken the first step even before the federal government.”
Dr. Deutschman said that initiatives like those in New York were needed to overcome resistance among doctors. “You’re talking about a profession that has always prided itself on its autonomy,” he said. “They don’t like to be told that they’re wrong about something.”
The availability of proven therapies should move treatment of sepsis into a new era, experts say, comparing it to how heart attacks were handled not long ago. People arriving in emergency rooms with chest pains were basically put to bed because not much could be done for them, said Dr. Kevin J. Tracey, the president of the Feinstein Institute for Medical Research at North Shore-Long Island Jewish Health System. Dr. Tracey, a neurosurgeon, has made major discoveries about the relationship between the nervous system and the runaway immune responses of sepsis.
If physicians and nurses were trained to watch for sepsis, as they now routinely do for heart attacks, many of its most dire problems could be headed off before they got out of control, he said. The Stauntons have awakened doctors and nurses to the possibility of danger camouflaged as a stomach bug.
“We are with sepsis where we were with heart attack in the early 1980s,” Dr. Tracey said.
“If you don’t think of it as a possibility, this story can happen again and again. This case could change the world.”
Published: October 25, 2012
The New York Times
Death Of Boy Prompts New Medical Efforts
By Jim Dwyer
Long before 12-year-old Rory Staunton set foot in a hospital in March, the paths to the catastrophe awaiting him had been heavily trod.
Told he had a minor bellyache, first by his pediatrician and then by a doctor in the emergency room at NYU Langone Medical Center, Rory was sent home with medicine to settle his stomach. Three days later, on April 1, he was dead from septic shock caused by an infection that had been present but not treated when he was seen by the doctors. Rory’s case has prompted doctors, nurses and hospital administrators across the country to make new efforts to head off the kinds of problems that may have contributed to his death — some specifically related to early identification of sepsis, and others, long lamented, that hobble treatment of many ailments.
Among them: critical test results that were not communicated, a lapse that occurs with startling frequency; important observations that vanished during the handoff of Rory’s care from the family pediatrician to the emergency room; and an initial diagnosis that fit some of his symptoms, but no sign that the doctors considered alternatives.
The fresh approaches now being put into place include simple measures like new checklists, as well as high-tech tactics like programming a patient’s symptoms into training robots. Some reforms, involving a mandatory pause to brief parents on test results, are being tried out in three emergency rooms in the New York area to see if they would work as the model for a “Rory’s Law.”
A symposium on detecting and treating sepsis, led by the New York State health commissioner, will be held Friday at the New York Academy of Medicine and will include a presentation by Rory’s father, Ciaran Staunton. The case will also be the subject of a panel next month at Johns Hopkins Medical Center during an international conference on medical errors.
For many doctors and nurses, Rory’s case resonated because so much of what seemed to go wrong was utterly familiar.
“I think it could have happened almost anywhere,” said Dr. Jeremy Boal, the chief medical officer of 16 hospitals that are part of the North Shore-Long Island Jewish Health System, which has run aggressive sepsis-detection programs since 2008. “It absolutely could have happened here.”
In July, Rory’s parents, Ciaran and Orlaith Staunton, provided his medical records and a detailed chronology of his treatment for an About New York column in The New York Times. Their goal, the Stauntons said, was to wring from their grief a measure of redemption in better care for other children.
In effect, they framed a challenge to the medical profession, Dr. Boal said: “It forced us to ask, if it could happen here, what can we do to make sure that it can’t happen in the future?”
Rory, a 5-foot-9, 169-pound sixth grader from Queens, cut his arm while diving for a basketball one spring afternoon in the school gym. He began vomiting after midnight. By the time he saw the family pediatrician later that day, he was running a high fever and suffering severe leg pain, and his skin was not returning to its normal color quickly when pressed with a finger. The vomiting and fever suggested a stomach bug to the pediatrician, who sent him to the emergency room at NYU Langone for fluids. A doctor in the emergency room thought he looked better after some intravenous liquids. He went home with an antinausea drug.
Rory’s body, however, was fighting an invader: a strain of bacteria that normally causes strep throat had gotten into his blood, apparently through the cut in his arm. His immune system was on the verge of a runaway, self-immolating response to the infection — a cascade of destructive processes known generally as sepsis.
A number of signs pointed to the gathering intensity of that fight: the mottled skin noted by his pediatrician; the persistence of a very rapid pulse at NYU Langone; an abnormally high volume of immature white blood cells and significantly low numbers of platelets found by the hospital’s laboratory.
Taken together, those signs suggested that he could be in the grip of something more worrisome than a stomach virus.
Yet those signs were not put together until much later, when his organs were failing. Nothing in the emergency room chart reflects the mottling skin found by his pediatrician an hour earlier. The decision to discharge him from the hospital was made before a final set of vital signs showed that he continued to have a very fast heart rate. And the lab report with alarming blood results was time-stamped three hours after he was sent home.
That report, whether or not it would have inevitably led to the discovery of his sepsis, should have been a “red flag,” said Dr. Gordon Schiff, a researcher on patient safety and the editor of “Getting Results: Reliably Communicating and Acting on Critical Test Results.”
NYU Langone will not say if the doctors who treated Rory in the emergency room saw the report, whether they were still on duty when it arrived or whether anyone in a position to take action was aware of the findings. The family pediatrician has said she knew nothing about the test.
The Stauntons say they did not know the blood work had been done until days after Rory’s funeral, when it was listed on a bill that came in the mail, tucked in with stacks of condolence cards.
Quick, reliable sharing of important information from tests has proved to be vexing. Two decades ago, a national study “found that only 51 percent of ‘life threatening’ laboratory results were treated appropriately,” according to the Massachusetts Coalition for the Prevention of Medical Errors.
“You would think this is low-hanging fruit,” said Dr. Schiff, an internist at Brigham and Women’s Hospital in Boston. “You’d think just getting the abnormal test result to the right person would be a straightforward matter.”
But, Dr. Schiff said, a barrage of automatic warnings has turned alerts from machines, laboratories and electronic records into the medical equivalent of the car alarm that is ignored because it never stops blaring. A leading hospital in Texas found that 99 percent of its alerts were overridden, he said.
Next month, Dr. Schiff will lead a discussion on Rory’s case with Mr. Staunton at the Fifth International Conference on Diagnostic Error in Medicine, being held at the Johns Hopkins School of Medicine.
NYU Langone, which said Rory’s death in their care was “a matter of great remorse,” will not discuss its procedures on the night that he was in the emergency room. “We are committed to learning from this event to prevent this or a similar situation from happening again,” Lisa Greiner, a spokeswoman for the hospital, said. She said the hospital had changed its discharge procedures to require that a doctor and nurse both check off test results and vital signs. She also said the lab would notify a doctor immediately if it found signs of infections.
Mr. Staunton and Rory’s mother, Orlaith Staunton, who have sued NYU Langone, say all hospitals need to go further. They were bewildered that NYU Langone had not included parents in their checklist. “Keeping parents out of the loop is shortsighted and will inevitably lead to more tragedies such as Rory’s,” Ms. Staunton said.
The Stauntons have called for a law that would require hospitals to tell parents what tests were done, the results and whether any were outstanding. Parents should also be told what other explanations for an illness were considered and what to watch for at home, they said.
Because North Shore has aggressive programs to search for early signs of sepsis, the Stauntons met with several officials, including Dr. John D’Angelo, the vice president for emergency medicine for the network. Their ideas were common sense, Dr. D’Angelo said, and North Shore drafted a four-point checklist incorporating them. It is now being tested by three hospitals in the group, Lenox Hill in Manhattan, Cohen Children’s Medical Center in Queens and Glen Cove Hospital on Long Island.
Going over the tests with parents is routine practice “probably 99.99 percent of the time,” Dr. D’Angelo said. But, he pointed out, emergency room physicians can be interrupted dozens of times every hour. They may think they have gone through all their usual mental checkpoints, when they have actually missed a step.
“Stuff falls through the cracks; I can guarantee it does, occasionally,” Dr. D’Angelo said. “It’s not that there are bad people caring for the patient — it’s just the reality of a complex environment.”
Dr. Boal said the benefits of the checklist would go to any children seen in emergency rooms, not just those with possible sepsis. “Their idea would reduce the risks for all children who go to the emergency room with something serious,” he said.
Every year, between 600,000 and one million patients in the United States are sent home from emergency rooms only to return within 72 hours because of medical errors, according to Dr. Michael Weinstock, an associate professor in the emergency department at Ohio State University. During a career of 30 to 35 years, the average emergency doctor “will send home 17 patients who will die an avoidable death within seven days,” he writes in “Bounceback: Medical and Legal,” a book on such situations. He plans to integrate the Staunton case into training materials for emergency doctors.
In its early stages, sepsis can look just like the body’s ordinary response to infections. Rory’s symptoms have been programmed into robots that will be used for simulation training of medical residents in more than 40 hospitals and urgent care centers in the Carolinas HealthCare System. The robots “talk, sweat, vomit, seize and have changing vital signs,” said Dr. Jo Anna Leuck, the director of simulation for the Department of Emergency Medicine at the Carolinas Medical Center in Charlotte, N.C. “I have also hired an actor to be the parent.”
While the Carolinas teachers were preparing the lessons, Dr. Leuck said, they realized that their children’s hospital lacked a sepsis protocol specifically tailored to pediatric patients. Dr. Leuck said she hoped to start a program similar to one at Baylor Hospital in Houston.
Several years ago, Baylor began to screen children for possible sepsis by watching for a single abnormality: persistent, excessively fast heartbeat. Doctors and nurses must then consider the possibility of early sepsis, and be ready to quickly begin giving fluids and antibiotics, said Dr. Binita Patel, a pediatric emergency physician at Baylor. The screening tool results in false positives, she says, but it has significantly shortened the time to start treatment, improving the child’s chances of survival. “Our steps to improved care began when we stopped pointing fingers at each other,” Dr. Patel said.
In New York, after the Staunton case, a consortium of 55 hospitals in the Greater New York Hospital Association began “serious, substantive discussion about pediatric screening” for sepsis, said Brian Conway, a spokesman for the association.
The Stauntons have started the Rory Staunton Foundation to increase awareness of the risks of sepsis, a leading cause of hospital deaths. Two days after they made the details of Rory’s care public, Nate Byington, 12, of Jacksonville, Fla., came down with a case of swimmer’s ear and was given antibiotics. When the pain got worse, he went back to the doctor and to an emergency room, and was told it would take a while for the drug to work, said Nate’s mother, Cara Byington. “His ear continued to swell and became hot to the touch,” she said. Once more, they returned to the emergency room. “The attending nurse and doctor took one look at him and said, ‘Possible mastoiditis,’ ” she said. That is an infection that has spread to the bone from the ear, and comes with the possibility of major complications, including sepsis.
“The E.R. doctor told me that we were probably down to hours before he was in serious trouble,” Ms. Byington said.
After 24 hours of intravenous antibiotics, Nate was well enough to go home.
“Rory’s story made me inclined to be skeptical when the pediatrician kept, in my opinion, blowing off my concerns,” Ms. Byington said. “I will always credit Rory’s parents’ willingness to tell his story for my son’s life.”
I read Rory’s story in the NY Times today and it has touched my heart in several ways; from his common love of aviation and interest in my landing on the Hudson River, to my own passion and interest in patient safety issues. I have been advocating tirelessly on preventing medical error, and doing all I can to bring awareness to this issue. There are major changes in the medical industry that can and need to made to ensure this does not happen again. Please accept my sincere and deepest condolences for your family’s loss. Rory sounds like an amazing kid.
Warmest regards, Capt. Sully Sullenberger.
A Florida woman has written describing how the coverage of Rory Staunton and how he died from a bacterial infection heavily influenced her to demand for her son get prompt attention in an ER after her pediatrician had dismissed her concerns.
Cara Byington wrote to New York Times writer Jim Dwyer who revealed the story of how NYU hospital in New York misdiagnosed 12 year-old Rory, the son of Irish immigrants, and he died as a result. The hospital has now admitted their emergency procedures need to be improved dramatically.
Rory Staunton’s parents Ciaran and Orlaith described their happiness that the message on toxic shock is having an impact.
“We are happy for this family and we know telling Rory’s story will help many other parents recognize this deadly killer,” they said. “Rory would be delighted that he has helped possibly save a life.”
Ms Boyington wrote to Dwyer, “I read your heartbreaking story about Rory Staunton online Saturday night, and had no idea how close to home it would hit so quickly.
“I can’t even think about what the Stauntons must be going through. And I have no idea if knowing that their son’s story helped my child would be a comfort or not, and I would never want to cause them any more pain.
“You mentioned you knew the family so — if you think it would be helpful to them to know how much they helped us, please feel free to share our story with them. If not, I wanted you know how important your story was, not only for the greater good, but for individual lives as well.
“On Friday, my 12-year-old son was diagnosed and treated for a simple swimmer’s ear infection. He woke up around 2 am Sunday morning with even more severe ear pain and since he did not seem to be getting better, I took him to the ER. They prescribed oral antibiotics to go with the antibiotic ear drops his pediatrician had given him on Friday, but they didn’t do any blood work.
“On Monday, his ear started swelling away from his head. Back to his pediatrician, who did not seem to take it seriously. I asked about mastoiditis and cellulitis and was told that’s rare. Continue with the antibiotics and bring him back tomorrow if he’s not better. Sometimes this takes a while to get under control.
“I took him back home and could not get the Rory Staunton story out of my mind. His ear continued to swell and became hot to the touch. I rushed him back to the ER at our children’s hospital here (Wolfson’s — Jacksonville, Florida) where I was prepared to demand blood work. But the attending nurse and doctor took one look at him, said “possible mastoiditis” and quickly had him on IV antibiotics and scheduled for a CT scan to make sure the infection had not spread to his bones or his brain.
“We were very fortunate. It was still isolated to the skin in and around his ear and had not yet spread beyond that.
“The ER doctor told me, though, that we were probably down to hours before he was in serious trouble. He spent about 24 hours in the hospital under observation and on IV antibiotics. He’s still on pretty stiff doses of oral antibiotics, but watching him today bouncing around like any almost-13-year old, you wouldn’t know he was sick enough to be hospitalized two days ago.
“I don’t know what would have happened if I had let it go for another day as the pediatrician suggested. Probably nothing good. But I do know that if I hadn’t read Rory’s story, I would not have been so quick to act decisively, so conscious of the possibility of septic shock, and so ready to take him to as many hospitals as necessary until someone took me seriously.
Letter Received by Jim Dwyer, The New York Times
I’m writing to you with my 12 year old son Ian at my side. My sister sent us your article in July and due to that we acted quickly on what was also sepsis due to a wasp bite last Saturday night.
Please pass along our sorrow to the Stauntons about the loss of Rory, and tell them that because of his passing my son sits beside me today. We will never forget them.
Elaine and Ian Hooker
P.S. Ian was so touched, he helped me compose this email. I wish I could wrap my arms around your family. Thank you for being so generous as to share your sad experience.
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Published: July 14, 2012
The New York Times
By Maureen Dowd
RORY STAUNTON was always looking up.
As soon as he could walk, he wanted to fly. The exuberant freckle-faced redhead from Sunnyside, Queens, yearned to be up in the romantic night sky where, as the French pilot and poet Antoine de Saint-Exupéry wrote, the stars are laughing.
His parents told him he’d have to wait until he was 16 to take flying lessons. But it’s hard to tell a determined 5-foot-9, 169-pound 12-year-old what to do.
He dreamed of being the next Captain Sullenberger, practicing on a flight simulator on his computer and studying global routes. He read and reread Sully’s memoir, thrilled to learn that the flier’s hair had once been red. He found a Long Island aviation school that would teach 12-year-olds.
On his 12th birthday, his parents shuddered and let Rory fly with an instructor.
How could you resist that sweet Irish face? Sure, Rory drove his parents nuts, sneaking downstairs late at night to gorge on episodes of “Family Guy,” and pretending to do his homework when he was really devouring political stories in The Times.
“He wasn’t the kid who looked at porn online, he looked at CNN online,” said his uncle, Niall O’Dowd, my friend who publishes several Irish publications in New York.
Rory protected underdogs against schoolyard bullies. He revered Rosa Parks and Martin Luther King Jr. And at the Garden School in Jackson Heights, he led a campaign to curb the thoughtless use of the word “retarded.”
“The last conversation I had with him, he got right in the face of my brother, Fergus, the government minister in Ireland with the mining portfolio, about fracking,” Niall recalled. “And he wrote the Swedish ambassador to North Korea asking for an explanation about why North Korea fed their big army while their people were dying of hunger.”
Rory was so roaring with life, it was impossible to believe how quickly life drained out of him. On Wednesday, March 28, he fell while playing in the school gym and scraped his elbow, opening a cut. As Dr. Jerome Groopman wrote in The New Yorker in 2008, the most aggressive superbug bacteria often lurk in gyms and on artificial turf.
The following Sunday, Rory died of septic shock from a strep infection, his parents curled around his body in the hospital bed.
Orlaith and Ciaran Staunton are Irish immigrants who embodied the American dream. Ciaran owns O’Neill’s bar on Third Avenue, where Rory made his first visit at 3 days old, and the Molly Blooms pub in Queens.
Every parent’s nightmare unfolded at warp speed, as the Web site Everyday Health reported and as Jim Dwyer heartbreakingly revealed in Thursday’s Times. Rory might have been saved by a swift dose of antibiotics but instead perished in a perfect storm of false assumptions, overlooked data and overburdened doctors.
Despite the cut, severe leg pain, blotchy skin and other clues pointing to sepsis, Rory’s pediatrician surmised that the vomiting, 102-degree fever, 140 pulse and 36 breaths a minute spelled a stomach bug and sent him to the NYU Langone Medical Center emergency room. Doctors there discharged Rory with an antinausea drug, even though his vital signs were alarming. The lab tests that were ordered came back three hours later showing abnormal production of white blood cells, a sign that infection could be raging, but that red flag was ignored.
“Nobody said anything that night,” his mother told Dwyer. “None of you followed up the next day on that kid, and he’s at home, dying on the couch?”
By Friday, Rory’s body was covered with blue streaks, and a touch made him scream. When Ciaran reached the pediatrician, she advised going back to the E.R. Rory was put in intensive care, where doctors valiantly tried to save his life, even suggesting amputating his nose and toes. But he was turning purple and black.
“For anyone that has carried their son’s or daughter’s coffin, it’s unnatural,” Ciaran told Sean O’Rourke on Friday on RTE, the Irish radio network. “A child who loses a parent becomes an orphan. If a man and wife lose each other, they become widow or widower. It’s so unnatural, there isn’t even a word for families who lose a child.”
Rory’s idol, Sully Sullenberger, was touched and left a message on the child’s tribute page. The hero of the Hudson is now an advocate for applying “lessons learned in blood” in aviation safety to patient safety.
“If something good comes from Rory’s death, it will be that we realize we have a broken system,” he told me. “Patient care is so fragmented. For the most part, medical professionals aren’t taught these human skills that some deride as ‘soft skills.’ So there’s insufficient sharing of information and ineffective communication.
“Some in the medical field look upon these deaths as an unavoidable consequence of giving care. But they’re inexcusable and unthinkable.”
Rory is up there now, with the laughing stars. But even before he got to heaven, he knew, as Saint-Exupéry wrote, that “One sees clearly only with the heart. Anything essential is invisible to the eyes.”