This is the 89th #WILTW

This week we learned about the tragic death of William Mead, a young boy who had sepsis. His mother writes extremely powerfully in her blog  and I was struck by this quote she used in a posting in early January

“The days will always be brighter,
because you existed.
The nights will always be darker,
because you are gone.”

Last year I reflected on the case of Sam Morrish where again the system failed to adequately respond to ‘red flag’ signs and symptoms. I have heard Sam Morrish’s mother speak and it is humbling to listen to the eloquence with which she describes her concerns at the time and how we (the healthcare system) didn’t hear her.

It appears, although the full report into William’s death isn’t available at the time of writing, that in both cases there was a dissonance between the features of serious illness the children had and the response to them.

Sepsis is not a simple, or indeed, binary condition. To die of sepsis infers you have an infection in your body that has overwhelmed your bodies abilities to fight it. However a human’s response to infection is not predictable. The same two children could have exactly the same bug and while one might actually clear the infection by themselves the other may become critically unwell [1].

The vast majority of children presenting to their GPs, urgent care centres or emergency departments don’t need any treatment. That is not saying their presentation is not necessary, parental concern is a vital component of the diagnostic process that clinicians use, but unwell children generally have simple viral illnesses that self-resolve. There is though a cross over between some features of illness such as an increased heart rate, looking a little pale, feeling miserable that may be present with either a virus or sepsis i.e it is not the case a child with a virus only has some features of illness and a child with sepsis has different ones. To compound the problem there is evidence that having a virus may increase your risk of catching a more serious bug that could cause sepsis. This means you could present to your GP (Family Doctor) on one day and have a virus but in a couple of days become increasingly unwell and be seen in a hospital with sepsis. It may be that the GP did nothing wrong to send you home in the first instance.

This is why safety-netting is of vital importance. The delivery of information to patients, parents and carers that lets them now what to expect if the health care professional is right with their diagnosis and what to do if the situation changes. Many organisations including the UK Sepsis Trust, NICE, individual hospital trusts and academic groups are working hard at creating systems that ensure we recognise and respond to sepsis in a prompt and timely fashion to reduce the number of children dying from it each year.

There are things we can do now though to potentially turn Sepsis into a eucatastrophe; a term apparently first coined by J.R.R.Tolkien to describe a turn of events which saves someone from meeting a predictably nasty outcome.

1. Health care professionals instead of asking simply what’s wrong should enquire: “what are you particularly concerned about in your child“. The question is the same but there is an important inference on determining whether it is the behaviour of the child the parent is worried about or a symptom. Parents of child with serious illness often describe knowing their child just isn’t right.
2. Health care professionals need to consider sepsis in every encounter with an unwell child however minor the symptoms seem to be. Documentation of the features which make sepsis unlikely are important. The restricted rule-out method is a great way of doing this.
3. We need to be more confident at discharging children who are well. There is a dichotomy at present. In the same day the #NHS is under pressure to be hyper-vigilant for sepsis but reduce the number of children presenting to Emergency Departments or being admitted to paediatric wards. This can only be squared if we don’t overload the system with children who have no features of illness. Starting from tomorrow senior medical staff, whether GPs, Consultants or clinical commissioners need to ensure their staff are sepsis aware but also know the features supporting discharge and how to give good safety net advice.

There will always be children who succumb to sepsis regardless of what health care professionals do. However we must be sure that we can have a eucatastrophe in all cases where it is possible to do so.

What have you learnt this week? #WILTW

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[1] I appreciate this is an old paper. I would be grateful for more up to date versions as I couldn’t find any in my quick medline review.