Thursday, April 16, 2009

ASS-U-ME

So you probably all know the old saying about what happens when you assume, but just in case anyone is coming late to the game, I'll remind you: when you assume, you make an ass out of u and me. Nowhere is this truer than in medicine.

My 5 year-old son has a life-threatening allergy to eggs and peanuts. His allergist told us ominously a few years ago, "Kids with known peanut allergies have a life-threatening event every 4 years on average." Ever since then, we have been holding our breath, thinking that we are past due. We have been extraordinarily cautious since learning about his food allergies when he was only 4 months old. We have no peanut-containing products in our house ever, period, and have eggs at home, but keep them far from my son and cook with them only under very controlled situations (since his egg allergy is less severe). He attends a "peanut-free preschool." We have Benadryl and Epipens in every bag and car and never leave home without them, even to go for a walk down the street. We have stopped flying airlines that serve peanuts. Everyone in his life, from family members to friends to our nanny to his preschool teachers, knows that we have to read the labels on every food every time. Most of them are far more conscientious about this issue than I would likely ever have been before it touched my own life, and many have gone to great lengths to learn where to buy or how to prepare foods for him safely.

My son's preschool teacher is one of the most endearingly over-cautious individuals of the bunch. She will often dash outside on mornings when I am dropping him off to make sure that the candy they will be using for the buttons on a snowman is safe for him, even though the ingredients are literally "sugar and Blue #4". Our nanny is also meticulous about keeping him safe, having chased after me more than once when I left his Epipen behind as I headed out to the car with him, and having noticed that the same cookies we have been buying every week for 2 years, which have always been safe, now say "May contain peanuts". I really don't worry about his safety when he is in their care, and they are pretty much the only two adults I ever leave him alone with for any length of time as a result.

Yesterday was the 4th birthday of one of my son's preschool classmates, Anna. Unbeknownst to me, Anna's mother had asked their teacher weeks ago if she could bring cupcakes. The teacher told her no, not unless they were made without eggs. Apparently she also inquired about bringing in a variety pack of mini candy bars, which his teacher also rejected not only because of his allergy, but the fact that the preschool is officially peanut-free and many of those would surely contain peanuts. Anna's mother, determined not to give up, went to Costco and bought a big container of gourmet jellybeans, which she divided into little snack sacks for each of the kids and sent to preschool in Anna's backpack. Their teacher helped Anna to pass them out to each of the children, including my son, at the end of class.

I am in clinic on Wednesdays, so our nanny picks up my son. When she got there, he had his head down on the table and said he didn't feel well. She noticed that his bag of jellybeans was mostly full, unusual for my son who is a sweet fanatic. He had eaten only a couple of them, he told her, since he felt kind of sick to his stomach. But then he asked to be able to stay and play with his friends in the adjacent play area, so she forgot about it. After playing for awhile, he came back to his goodie bag and ate a few more jellybeans. Within 5 minutes, he was complaining of nausea and saying he needed to put his head down. Noting that his "nausea" coincidentally occurred as they were being asked to clean up, she didn't make much of it. By the time they got back to our house, less than 2 miles away, he was coughing and wheezing, complaining that his throat was tight, and dry-heaving. She promptly gave him Benadryl and called my cell phone, Epipen in hand. By the time I answered 3 rings later, his face was noticeably swollen. She knew he was having an allergic reaction, but to what, she said, she had no idea. He hadn't eaten anything that should have peanuts or eggs.

When I talked to my son about what had happened later that day and asked him what he thought had made him sick, he said without so much as a pause: "those speckled jellybeans I ate at Anna's party". When I asked him how he knew, he said, "the package didn't have any words on it, which means there could always be peanuts," a rule I have repeated over and over to him for the last 5 years of his life. At least he has been listening.

Ultimately with treatment, my son was fine, but how on earth did this happen? My son is extraordinarily aware of the seriousness of his allergies and routinely surprises me with his own cautiousness about foods that didn't come from our home. He was in the care of multiple people who know him, love him, and are frankly paranoid of messing this up. I called his preschool teacher later that day, quite distraught, to tell her what had happened and to let her know that he was fine, in case she had already heard through the grapevine. She had and had immediately called Anna's mother, who checked the label of the jellybean container and confirmed what I already knew: peanuts, plainly listed among the ingredients. In fact, one of the gourmet jellybean flavors was PB&J.

It turns out that Anna's mother JUST ASSUMED that jellybeans would be safe, so she never actually thought to read the label or bring the original container to preschool. Understandable. Who would suspect jellybeans might have peanuts in them? I wouldn't. His preschool teacher JUST ASSUMED that Anna's mother must have checked the label since she had asked so many questions about which foods were safe to bring to school for Anna's birthday, so she never actually asked her whether the jellybeans were definitely peanut- and egg-free. Understandable. Anna has been in preschool with my son for months, and his allergies were widely known in the class. My son JUST ASSUMED the jellybeans were safe since Anna had brought them, and his teacher had handed them to him, so he never actually asked. Understandable since he is just beginning to read and has learned he must rely on a few trusted adults, one of whom is his teacher, to tell him if a food is safe for him to eat. Our nanny JUST ASSUMED that the jellybeans must be okay for him since a friend's parent had brought them and his teacher had let him start eating them, so she never actually asked to see a list of ingredients. And our nanny JUST ASSUMED that, because he had already eaten some and was apparently okay that, when he began demonstrating the earliest signs and symptoms of anaphylaxis, which she knows very well, it could not have been the jellybeans.

This could all have been prevented had anyone NOT JUST ASSUMED. This is why two OR nurses count sponges at the end of a case, to make sure none get left inside a patient. This is why two oncology nurses independently verify the chemotherapy dose the medical oncologist has written before giving it. This is why the blood bank requires that the nurse check the hospital bracelet of the patient she has been caring for all week and match it to the name on the bag of red cells before starting the infusion. These policies realize explicitly that when you assume, it is only a matter of time before you make an ass out of u and me. And if you're a health care worker, you might kill someone in the process, too.

As I tried to think of medical examples for this post, I was struck by one thing. All of the ones that quickly came to mind involved nurses. The reality is that, on this issue, they are light years ahead of doctors, who may have historically been too proud to acknowledge their potential for error...and who in many cases remain so. The attention recently given to the alarming prevalence of medical errors has led to some positive changes in physician behavior, such as surgeons initialing the correct side of surgery while a patient is still awake before a planned amputation or joint replacement, for example. But we still have a long, long way to go before these double-checks are built into every important medical decision. And finally, let us remember that all of these practices arose from the terrible tragedies of patients, most victims of health care workers JUST ASSUMING.

If you are a medical student or a nurse or a physician in training, there is a lot of unspoken pressure to just assume that someone "superior" knows what he or she is doing and not to question that person. If you are that someone "superior," there can be a lot of unspoken pressure to appear to know what you are doing and not stop to question yourself. Please, for everyone's sake, don't assume anything. Stop to question. I can promise you that it is only a matter of time before your questioning will save someone's life.

10 comments:

  1. Great post, as pertaining to food allergies and in the medical field.
    My son is allergic to wheat, rye, barley, oat, egg, peanut and tree nut. I try never to assume that something is safe, BUT I can think of a handful of times that I've done that. Just last week when we visited the Easter Bunny, they were handing out Safe-T-Pops. He's had those before, but there was no package to check. Were they the SAME Safe-T-Pops? Did manufacturing change? I don't know, but I assumed they were safe (and frankly, I didn't want to say no to a sucker from the Easter Bunny. It just seemed wrong).
    I'm glad that your son was fine! Scary though and a great reminder for all of us.
    And a great reminder for all of us in every part of the medical field. And as a patient, never assume that the doctors and nurses can read your mind or can remember every detail of your medical history.

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  2. I'm so glad that everything turned out okay with your son. Thanks for yet another reminder. We've discovered peanut products in orange juice and dairy in asthma medications.

    You just never know and can't assume anything.

    You're a great mom taking so many precautions. Unexpected things like this happen...to all of us.

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  3. I'm so glad he's okay, T. Your nanny sounds really wonderful and knew just what to do.

    But, you're good for the next 4 years, right?

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  4. You are right that nobody can assume anything.

    But you were prepared for the worse. Although this slipped by, you had everything in place to handle the mistake. So things did work out.

    The thing to assume is that mistakes will be made. That's why they count those sponges and check that ID bracelet/birthday even when it seems stupid.

    I thought the accepted strategy for this kind of situation was for day care/school to have a little supply of treats that you've supplied and when everybody is having the celebration they give your child one of those goodies. It's not quite as fun as having what everybody gets but it beats feeling sick.

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  5. So totally true. I think the most important thing I learned from my last rotation was that if you think something with the patient is off, SAY SOMETHING. Tactfully of course. Fortunately, most of the attendings and residents have been good about listening, though occasionally you get an a**hole who thinks you're too big for your britches if you point this stuff out.

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  6. I'm a nursing student. I am currently being trained to question EVERYTHING. I hope when I get out into the world, doctors don't feel like I'm being a jerk. I'm just doing what I was trained to do. Case in point: I was testing out on NG tube insertion and removal. Removal comes along and I start getting my stuff ready. Right when I'm about to take it out she asks if I would check if the patient was ready for it to be removed. I had done one thing and she asked what else I would do. She asked if I would just trust the doctor that it can be taken out now or if I would make sure the patient wasn't ganna puke all over me. I definitely don't want to be puked on any more often than I have to be. Great post!

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  7. What a great post. I am physician mom with a son with a peanut allergy, and this post spoke to my heart and mind more than anything I have ever read. THanks.

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  8. My friend and I had a discussion on the subject of allergies earlier this morning. She has a peanut allergy she developed later in life. Well, it occured to me that since I regularly babysit for her kids, I had better find out what kind of allergies (if any) her kids have.

    Its amazing how one little misread on a label can cause so many problems. Its also scary how there are many allergies that go undiagnosed because a person may not have been exposed to a food or medicine which would cause the allergy to surface.

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  9. Hi-I am a pregnant medicine resident who is about to match in oncology with a physician/military husband-I am so thrilled to find your blog since you address concerns I will have. I am considering withdrawing from the match b/c I want to make family my priority but I love oncology. Do you have any advice for me?
    sarahvcolonna@gmail.com

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