A reader sent me this story – East Bay girl’s death leaves parents mystified. An 11 year-old girl died of streptococcal shock syndrome, probably from an undiagnosed strep throat.

The Toys say Emily first complained of a sore throat and neck after a softball tournament May 23. She was lethargic, and team manager Kelly Jones noticed she hadn’t played 100 percent.

Wendy and Alan took their daughter to the Pediatric Referral Group clinic in Walnut Creek, where a rapid strep test came up negative. Emily had a virus, the Toys said they were told, that would run its course. She was sent home with some ibuprofen to help with the pain.

But Emily got sicker. She ran a fever of 103 degrees and couldn’t hold down food. She slept all day Sunday, missing a softball game.

A May 25 visit to the same clinic (her regular pediatrician was off for Memorial Day) yielded another negative rapid strep test and an assurance that Emily would soon be over the worst, her parents say.

“How did we know?” Wendy Toy asked.

Dr. Jake Sinclair, who oversees the clinic where Emily was seen twice, said the strep test she was given returns results in minutes and has a 97 percent sensitivity rating — and that it’s impossible to say why it didn’t catch the infection.

Readers know that I started a year ago giving a Grand Rounds titled “Adolescent and Young Adult Pharyngitis: Morbidity and Mortality.” This talk discusses the “long tail” of pharyngitis. I focus on the errors that lead to morbidity and mortality.

Without seeing medical records, one cannot accurately criticize care. However, these issues concern me:

1. The first visit appears correctly done
2. I consistently emphasize that return visits should cause increased concern
3. Rather than thinking, the clinic just repeated the strep test, and followed protocol.
4. The rapid test does not have a sensitivity of 97%, it probably is more in the range of 85%-90%.
5. A fever of 103 should cause concern.
6. Viral pharyngitis does not look like strep pharyngitis

I write this while watching Morning Joe.  I just heard Secretary Sebelius state that we need physicians to follow protocols.

Here is the danger.  Excellent physicians know when the protocol does not pertain.  An 11 year-old with persistent symptoms and a fever of 103 no longer fits the protocol.

Pharyngitis improves over the course of 3-5 days.  Routine pharyngitis does not worsen.  This patient represents the long tail of strep throat.

This story saddens us all.  Good medical care requires that we learn from mistakes.  We must analyze such stories.

The point that I have tried to make this week is unfortunately made through this story.  Good medical care requires that we understand proven guidelines and protocols.  We should not follow guidelines and protocols blindly.  We must know when to deviate.

Related posts:

1. Natural history, guidelines and performance measures
2. Antibiotics for strep throat?
3. “just a sore throat” is a dangerous phrase
4. Sore throats – steroids and @medpedshosp
5. The week of pharyngitis

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