Tuesday, March 31, 2009

Mother of the patient

I thought maybe my 14-month old son woke up on the wrong side of the crib from his afternoon nap. He wasn't acting like himself. He had no appetite. He was burning up. And he was breathing noisily. I had thought he was getting better from his cold that started several days ago but now he looked sick.

I took out my stethoscope and listened to his lungs. Coarse breath sounds, rhonchi, and wheezes. It sounded awful in there. In my little baby boy. My sweet, angel of a boy. It seemed so wrong that such sounds would be coming from his lungs.

I grabbed his sister's albuterol inhaler and spacer and gave him a couple of puffs. Which did nothing appreciable to his breathing. He also wasn't the most compliant of patients.

It was Sunday afternoon. Of course. It would be the ER. Now, or in the middle of the night, I thought.

I made the executive decision to have him be evaluated in the ER. We should go. Now.

At the front desk, I insisted to be the one to fill out the triage paperwork (as opposed to my husband, not in lieu of the nurse!) Reason for coming: wheezing, tachypnea, fever. I needed to "sell" him as someone who needed to be a priority. I needed them to know I knew.

Rectal temperature in triage: 102.9 F. Pulse 180s. O2 sat 93% (!) RR 42/min (!)

It wasn't very busy and we got into a room right away. They set up a neb for him right away and had me administer it to him, knowing that I was a physician.

JL did NOT like the nuisance mist machine all up in his business all the time and fought it sadly, crying, twisting. I watched as the nebulized mist battled his thumb that was firmly planted in his mouth. He was burning in my hands.

I told the ER physician right away that I was an internist. We needed to be on the same page. Because of that, her way of dealing with me changed, giving me a lot more power in the physician-parent relationship. She told me her thoughts, but then wanted mine, and ultimately left certain choices up to me. X-ray or not (no). Antibiotics are not (yes). I couldn't bear the thought of his little body soaking of radiation - and for what? To definitely know he had a pneumonia? Would I be satisfied if it was negative to not give him antibiotics (no)? But, I worried about some focus of bacterial infection since he was getting better from his cold and then turned for the worse. Bloodwork or not (no). Ceftriaxone IM x 1 (no).

I appreciated having the chance to weigh in so heavily, although I do wonder if I was completely clinically "on" given my duress having a sick child in my arms. Not any sick child. My sick child. But we decided this would be our management. He would be given an acute follow-up appointment in the peds clinic the next morning.

At the follow-up, the pediatrician examined his ears and saw a very clear-cut ear infection in his right ear. This was never done in the ER. I had wondered to myself if someone was going to look in his ears for the sake of completeness, and even entertained the idea of taking a look myself with the otoscope in the room, but quickly brushed the thought aside when JL had pried open the red biohazard container of the floor exposing some kind of urine hat. Plus, the ER physician didn't think it was necessary.

Perhaps I led the ER physician down a diagnostic pathway due to my own suspicions, and maybe coming from me, was persuasive enough not to veer her too far off that path. I know how to give a compelling story for whatever process I think is going on. Isn't this only natural? But, I'm wondering whether she would have done exactly the same with a parent who wasn't a physician. Would she have been more complete? Would she run more tests?

Anyway, JL is doing better, on antibiotics. He's defeveresced but still with a "junky" chest exam. His antibiotic dose was increased since apparently the dosage is higher for an ear infection than pneumonia (wow, peds was that long ago).

And I'm left wondering how much I help and how much I complicate when it comes to the health of my own children. I hope it's heavily weighted towards the former.

15 comments:

  1. I usually keep my mouth shut about being a doctor when my daughter or I am the patient. Because telling your doctor that you're a doctor means that they always put the decision-making process in your hands. And if I wanted to be the one making all the decisions, I wouldn't have gone to the doctor in the first place.

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  2. I chose my daughter's original health-care provider because she was the only person I trusted to treat my daughter, and not act on her assumptions about what I wanted. I don't often "out" myself with other providers unless there's a systems issue I can resolve.

    It isn't just our kids; I'm quite sure my mother is getting a different kind of treatment from her PCP because she's a doctor's widow and a doctor's mother. I'm not sure "different"="better". I'm not even sure "different"="as good as".

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  3. I have no choice in our ED/clinic as we live in a small town and EVERYONE knows who I am. however, I stay out of the decision making as much as possible. If I wanted to make the decisions on my son, I would just try to diagnose him myself.

    I'm not saying anything you did is right or wrong, but I think there is a strong bias in your own family.

    I don't treat my husband either. (I should note I am a surgeon)

    Hope your little one gets better soon.

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  4. In the end, he received the care he needed from his PCP. Kudos to you for following up that ER visit!

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  5. As to what Fat Doctor said, I do think it's kind of funny the basic things that an ER can miss that any PCP would probably get. I was postpartum and went to the ER with a fever of 103 and they told me to avoid motrin while BFing because it would close the ductus arteriosus. I was like, "I hope that's already closed...."

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  6. Was that really a doctor in the ER? Can't imagine a febrile baby and not looking in his ears. Fault is strictly with the ER. You did the right thing by taking him in and the right thing by announcing you're a physician. That usually prevents the ER from blowing you off. But the responsibility for a full exam falls onto the examining physician. I take care of lots of physician patients, and I always say "this is what I plan". If they object, like any one else they can opt out, but I never leave the initial choice with them.

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  7. Fizzy- I've kept my being a doctor to myself when it's my appointment occasionally, but it has never worked out. At some point, they inevitably ask me what I do for a living and when I say I'm an internist, they usually look like they want to die. Especially after they painstakingly describe something in layman's terms.

    Jay- I think sometimes "different" can be more conservative. I went to my PCP when I was getting presyncopal while exercising (while nursing) and got 1) echo 2) ETT 3) cardiology consult in short order. It was kind of embarassing.

    kellie- I don't want to treat him or diagnose him, but I want to help by giving the best history possible. She did ask me if he was pulling at his ears, which he wasn't. He's a lot better, thanks.

    FD- Luckily, there wasn't too much difference in management...and yes, we wouldn't have missed that f/u appt for anything!

    Fizzy again- that reminds me of another ER story. Husband was having terrible strange pain, turned out to be piriformis syndrome which has no objective findings on exam or imaging. We didn't reveal we were physicians but were pretty calm during the visit - I was doing some work in the chair next to him. You know what they did? Sent a u tox on him thinking we were a pair of dependent drug-seekers.

    Dr Nana- She said, "I'm the doctor." ID was turned around so I didn't know if that meant "attending", "intern" or what.

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  8. KC, more conservative is precisely what I meant. My mother had a long drawn out eval for an "abnormal CBC" last year. She had a viral syndrome, bad enough that she landed in the hospital for a night with dehydration, and the CBC was repeated too soon, leading to a CT scan which showed marginal splenomegaly (after a viral syndrome with elevated LFTs two weeks before) and a heme/onc consult and a f/u CT three months later. It was a loooong three months, and I think the early f/u CBC and the onc consult both resulted from her PCP's anxiety about doing "everything" for a doctor's mother, doctor's widow and doctor's daughter.

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  9. Agree with all of the above comments; looking at your last paragraph "..wondering how much I help and how much I complicate..." - we all help and complicate every component of our kids' lives. And I think we all hope that in every aspect it's weighted to the former.
    A

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  10. Tough to find the right balance. Not sure I have the energy to comment now as a pediatrician, but definitely have the energy and motivation to comment as a MIM friend... that I am glad JL is improving (might have improved with or without antibiotics, oops there's the pediatrician commenting) and agree with Artemis as parents (and here, physician parents) of our dear children, it is all complicated, but rest assured you are doing what you need to do as a mother. Sigh.

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  11. Having now taken my eldest 2 to the ER a total of 4 times, I feel like telling the physician that I'm a pediatrician had had both positive and negative effects. As has been said earlier, I have found that the ED docs maybe weigh my opinion more than they should b/c I"m a pediatrician when in fact the course of treatment (and probably the better one) would have been followed if they had not known. However, twice now, I have been condescended to b/4 the ED physician realized who I was: the first time was when my son hit his head on the floor at 3wks of age. The physician told me that I should not be dropping new children on their heads......??huh??!!
    The 2nd time was a situation similar to yours, KC. Except I went in at 4am and received a lecture by the physician of why my child's current sx's were not approp. for a 4am ER visit.

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  12. Hope JL is getting better! Like T & Mommy Doc, I'm Peds & struggle with seperating mom & Peds. Youngest had influenza 2 weeks ago & my mind was whirring the whole time. "he's vaccinated, what happened?" "he still has a fever on the 3rd day, does he have something else?" Blah. Blah. Blah. He just wanted me to sit with him and keep him company while he watched a movie & viola! the fever broke. I underestimate my mommy karma every time.

    Our ED docs here are great - they're not Peds so they occasionally miss some ped-oriented stuff like RSV & forget to send urine cultures for UTIs. And sometimes I get the impression that they'd rather see major trauma & MIs instead of fevers. I do rely on them to be fresh eyes & ears for after hours and weekends especially when I was in solo practice. Funny how I never thought of myself as a specialist until an ED doc called me for my opinion in my first job.
    Sorry for such random thoughts - but post struck several chords.

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  13. I can't believe you had a baby in a room with a doctor and they didn't look in their ears. That's not a matter of tests, it's a matter of looking for something that half the kids in the universe have a problem with.

    Had he never had an ear infection before? I don't think my kids were ever sick like that with a temperature that they didn't have an ear infection.

    If I didn't know that it won't happen to you again I'd say you'd have been better off at some minute clinic.

    Isn't there some saying among doctors about hoofbeats and donkeys not zebras?

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  14. Always a tough balance...it is so hard to have a sick loved one, and we all want to do everything we can to see they get the best possible care.

    You have probably been on the other side of the equation once or twice, and thus been witness to the ways in which other physicians cope with having a sick family member under YOUR care. Maybe it would be helpful to think about behaviors of the docs that really helped you provide better care for their parents/spouses/kids and consider if there is something there that you can model...this technique has been really helpful for me.

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  15. I do think the ears should have been looked at, and that knowing your opinion probably swayed her. That said, as someone else commented, abx haven't really been shown to make much of a difference in ear infections (and in many European countries, ear infections don't get abx at all!).

    As an emergency physician, though, I also have to stand up for my specialty. (Although I do understand the ire.) I plead with you all to not condemn all emergency physicians, or all EDs, based on this story. Our residencies are just as rigorous and competitive as yours, and many of us could have matched in any specialty. Of course there are less-than-thorough folks in every specialty; and we *all* make mistakes. So give this poor doctor -- and, more importantly, emergency physicians as a group -- a break?

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