An X-ray Likely Would Not Have Changed Sam’s Outcome: Sick vs Not Sick

A critique of a recent article in the lay press that deals with clinical reasoning, written by a master in the field, what’s not to like?

Adam Cifu

There are few losses more devastating than that of a young, otherwise healthy person seeking help and being sent home twice, only to die days later. The recent death of Sam Terblanche, as reported in The New York Times, rightly struck a chord in the diagnostic excellence community. His story has quickly become a lightning rod for public debate, mostly centered around one theme: Why weren’t antibiotics given?

But to reduce this tragedy to a question of antibiotics (or sepsis management) is to miss the deeper lesson — and risk repeating it.

As physicians, we must acknowledge a harder, more uncomfortable truth: the fundamental error was not the absence of a diagnosis (which is unclear even in hindsight), but rather the absence of hospital admission. Sam should not have been at home. He was clearly sick — even if we did not yet know why.

In medicine, diagnosis may take hours, days, or even months. But recognizing how sick someone is should not be delayed until autopsy. And in this case of presumed “viral syndrome,” that delay in advocacy failed to prompt the action that saves lives when we are uncertain: observation in a hospital setting.

We owe it to Sam, his family, and every future patient to reframe the conversation away from diagnostic acumen and towards uncertainty management. This is not about blaming a group of clinicians for not getting to the answer sooner. It is about confronting a system-wide erosion of one of the oldest and most sacred skills in medicine: knowing when someone simply does not belong at home.

Sepsis Screens Aren’t the Answer

Much public discourse has revolved around the care team’s failure to follow the sepsis bundle. It’s true, multiple physicians ignored a sepsis alert on Sam. It’s common to do so. More on that later. But even if a chest X-ray had been ordered, would it have changed management? I don’t think so, and here’s why.

We do not know—even after autopsy—what caused Sam’s premature demise. The blood found in his lungs and white blood cells in his urine remain the biggest clues of systemic inflammation, and it is tempting to call it sepsis, especially if a sepsis flag was ignored. But that may be too narrow a frame. It could have been a rapidly progressive pulmonary-renal syndrome, novel post-COVID autoimmune inflammatory disorder, catastrophic antiphospholipid antibody syndrome, or a severe variant of walking pneumonia with extra-pulmonary manifestations. In all cases, a chest X-ray may not have shown much initially, especially since he did not present with hemoptysis, sputum production, or a cough (amongst conflicting reports).

He was dyspneic *and* anemic, which suggests this was not a chronic process. Add in thrombocytopenia, and suddenly you have a picture of bone marrow suppression or hemolysis—enough to make any internist lose sleep.

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Mycoplasma Pneumoniae — A Common Illness with Uncommon Faces

My opinion? The most plausible, parsimonious, and probable explanation is that Sam had Mycoplasma pneumonia complicated by acute, inflammatory, systemic end-organ damage.

Plausibility:

If he had a lobar pneumonia with a typical bacteria, it would have declared itself more emphatically with findings more evident on exam, labs, or blood cultures. He had no leukocytosis, and his cultures were sterile. Walking pneumonias like Mycoplasma pneumoniae often appear deceptively mild, do not mount a white count, and do not grow on standard blood culture media. As the smallest bacteria known to man, Mycoplasma has an insidious onset — even prior to severe complications. Ruling it out requires a full multiplex respiratory pathogen panel—not the limited “COVID/RSV/flu only” assay that was reportedly collected. Finally, Mycoplasma is an opportunist of sorts, co-occurring with viruses at surprisingly high rates in hospitalized patients. It’s plausible that the COVID infection Sam was recovering from weeks prior may have weakened his immune system, opening the door for Mycoplasma to enter.

Parsimonious:

Key extrapulmonary manifestations of Mycoplasma pneumoniae include:

• Headache, nausea, low-grade fevers: viral-like prodrome

• Sterile Pyuria & Hematuria — reflecting immune-mediated renal inflammation

• Cytopenias — including hemolytic anemia or marrow suppression

• Liver damage

All of these features were present in Sam’s case. That said, these can be present in any systemic inflammatory state, so why Mycoplasma?

Probable:

The base rate of Mycoplasma pneumoniae is much higher in college-aged males. The reason Walking Pneumonia is underrecognized clinically is because it disproportionately causes mild imaging results relative to the breadth of its systemic inflammation. Finally, there are also at least 5 case reports of diffuse alveolar hemorrhage precipitated by Mycoplasma, so it’s not without precedent.

Would a macrolide or respiratory fluoroquinolone have saved Sam’s life? Hard to say, but it would’ve been ill-advised to send him home with antibiotics even if Mycoplasma was found on PCR testing or an x-ray showed atypical infiltrates.

So what’s the clinical take-home point:

1) Regardless of the specific etiology, this is not a routine emergency room case. It’s rare. Sam’s family unfortunately got no closure from the autopsy, which emphasizes the point that it was not a straightforward process.

2) Red flags were missed. Acute cytopenias, dyspnea, and hematuria in the setting of systemic inflammation are objective signatures of life-threatening pathology. As mentioned, many lethal illness scripts come to mind. Perhaps the most concerning prognostic foothold, though, was a young patient who does not typically frequent the ER returning within 24 hours of initial presentation.

Conclusion — “Sick” Is Still the Most Important Diagnosis

Early recognition of sepsis is important, but it’s not the take-home point in this tragedy. Yes, most hospitals and emergency departments have automated Sepsis Early Warning Systems (SEWS) built into electronic records. These tools are meant to identify patients at risk of deterioration—but in practice, they are blunt instruments, with a positive predictive value hovering around 13%. That means most “sepsis alerts” result in more alarm fatigue than action. Put differently, we live in a clinical environment where even real danger sounds like background noise.

I’m not saying SEWS (or other sepsis notifications) are useless. Because alerts can signal as often as every 15 minutes, it can redirect hospitalist teams to clinically evaluate a patient with a possible clinical status change. Just because the tool is overly sensitive does not mean the warning is meaningless.

While a positive screen should not automatically trigger antibiotics, it should trigger concern. It should demand human appraisal. It should force us to ask, out loud: Is this patient sick? What am I missing? Should I call an admitting team for consultation?

In medical education, the very first test of whether a resident is ready for independent practice hinges on their ability to triage “Sick vs Not Sick.” Long before we name the syndrome, classify the pathology, or start the workup, we learn to look at someone and make a global disposition judgment. And when we don’t yet know what to call an elusive syndrome but suspect sinister pathology is afoot, there is a phrase many of us use instinctively:

“I’m worried this patient is Sick.”

That phrase is supposed to be enough. It is not an admission of ignorance — it is an assertion of responsibility. But today, that phrase too often collides with bureaucratic words like “utility,” “justification,” or “reason for hospitalization.”

Unfortunately, when algorithms and payers become gatekeepers, they sometimes replace judgment rather than inform it. This is not a failure of individual clinicians — it is a failure of culture. One we all own—and one we must collectively repair.

Sam’s case is an equally chilling reminder for internists and other admitting teams to respect the ER’s call for help. No alert, protocol, or score will replace our role in advocating for the patient who is Sick, even when we don’t yet know the diagnosis.

We have to be willing to say, “I don’t know what this is. But I know they don’t belong at home.”

Cory J Rohlfsen is a hybrid internist, core faculty member at UNMC, and the inaugural director of Health Educators and Academic Leaders which focuses on competency-based approaches to developing future leaders, scholars, and change agents in health professions education. The view and opinions expressed her are his own.