Evan Sherman MD, Children’s National Medical Center

The Case
A 7yo F presents with an asthma exacerbation and an irate caregiver. This case and its responses showed a diversity of opinions for even a basic asthma exacerbation.

Here’s How You Answered Our Questions:

First, what to do with an asthmatic who was hypoxic and wheezing for EMS but comfortable after a duoneb en route:

If the same patient were to develop respiratory distress and require an hour-long albuterol treatment in the ED, but responds well to the treatment, how long do you observe for?

And finally, do you push back when her parent threatens to leave?

Discussion:
The poll results and comments reflected a (perhaps unsurprisingly) broad range of risk tolerance for this wheezing patient. Our live discussion group was similarly split, with some advocating for a speedy discharge for this relatively well appearing, albuterol-responsive patient, and others opting for further observation in the ED. As usual, our attendings’ extra years of experience made them a bit more comfortable with a mildly ill child, and they were less likely to push back if a parent wanted to take their child home.

This case inspired a robust discussion. Dewesh Agrawal reminded us that the initial exam can be an important determinant of disposition: if the patient was in severe distress on arrival, a provider might be more likely to lean towards a longer period of observation, even if the exam improved after treatment. Theresa Walls added that for asthmatic patients who are “on the fence,” putting them through a few jumping jacks or a brisk walk around the ED can demonstrate exercise tolerance (both to the provider and to the parents!). Joelle Simpson reminded us that involving the PCP in the discussion (and even conferencing them in with the family) can be worthwhile, especially if the PCP has a good relationship with the family.

Teaching attending for the week Emily Willner posted an excellent overview of the thorny medical and social aspects of this case.

Denouement:
At the ED provider’s insistence, the patient was observed for two hours after the albuterol treatment. The patient’s mother became increasingly confrontational, at one point taking off the patient’s pulse oximeter and preparing to leave. Security was called, and the ED provider contacted Child Protective Services to file a report. Two hours after the albuterol, the patient was again wheezing and retracting, with an O2 sat of 89%, so she was given 5mg albuterol and admitted to the hospitalist service on q2h albuterol. She remained on q2h albuterol overnight, but was spaced to q4h the following day and discharged home on a new asthma controller medication. The patient’s mother remained adversarial to hospital staff throughout the admission and repeatedly requested discharge, but did not attempt to abscond with the child.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.