Hot Seat Case # 98: 3 year old female with hypoxemia
Posted on: September 4, 2017, by : Jeremy Root
Jeremy Root, MD Children’s National Medical Center
with Rosemary Thomas-Mohtat, MD Children’s National Medical Center
3 year-old female presenting with respiratory distress. Mother reports patient has had cough and rhinorrhea x 1 day. Due to worsening respiratory symptoms, she presented to your ED where she was febrile to 101F and hypoxemic. In triage, she required blow-by oxygen to maintain O2 sats in the 90’s.
ROS: Taking PO well, normal UOP, + congestion, + rhinorrhea. Denies vomiting or diarrhea, denies rashes.
PMHx: Prematurely born at 34 weeks, developmentally delayed, reactive airway disease, sickle cell trait
Exam:
VS T 36.6, HR 132, RR 30, BP 120/79, SpO2 85% on RA
GEN: sleepy, but interacts when awakens
HEENT: PERRL, EOMI, normal conjunctiva, no discharge. OP clear. TMs clear.
CV: tachycardia, regular rate, no murmurs or gallops, < 2 sec cap refill
PULM: intermittent expiratory wheezing, coarse breath sounds, moderate subcostal retractions
ABD: soft, NT, no HSM
NEURO: developmentally delayed, non-focal neuro exam
MSK: no joint swelling or limited ROM
SKIN: no pallor, no rashes
LYMPH: no cervical, axillary, or inguinal lymphadenopathy
She receives three 2.5 mg albuterol nebs, atrovent and tylenol. CXR read as viral process vs. reactive airway disease.
It is 3a in the morning and mother is refusing to let you or the respiratory therapist (RT) apply nasal cannula because she says it is very irritating to the patient. After discussion with your RT, you convince the RT to try a ventimask @ 30% FiO2. Over the course of 90 minutes the patient has persistent saturations in the low 80’s, dipping into the 70’s at times. Despite you and your RT’s best efforts, the mother is still refusing a nasal cannula.
You instruct the mother that the patient is at risk of hypoxic brain and tissue damage with oxygen sats persistently in this range and she must apply the nasal cannula. The mother refuses and says she wants to leave AMA. You have called the legal team to discuss, but the options are pending.
Security is called to prevent the mother from leaving. The legal team says to call CPS. CPS says they cannot take temporary custody overnight. Meanwhile the patient’s respiratory distress is worsening and you are considering trialing HFNC or BiPaP.
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Interesting, I guess I hadn’t realized that the only way to legally continue to treat the patient despite the mother’s wish would be to obtain emergency CUSTODY of the child… And I’m surprised that CPS’s response to a provider saying “I have a parent who is requesting me to endanger their child’s wellbeing” is “sorry I can’t take emergency custody overnight”. How is that different from when we call for a concern of child abuse by a parent in the middle of the night and don’t/can’t discharge the patient in the parent’s care? A patient who is noted to have belt marks and tells the provider their mother or father inflicted the injuries wouldn’t be discharged “AMA” to the parent until CPS has evaluated the child, so how is this different?This seems to me like an emergency situation where a provider would be negligent if they allowed a hypoxic patient to be taken away from the hospital.
Most of my experience with these situations were in residency in NYC; we never had CPS wash their hands of child endangerment in the middle of the night…
Also, don’t we have MPD stationed in the waiting room? Could we technically inform the parent that they will be escorted out of the hospital by MPD and immediately arrested if they continue with their plan to remove the patient from the hospital? It seems silly to “call the police” when the “police” are already in house.
Great case!
I agree with Monica (and we had to do this once in residency) – since the police were physically at the hospital, we instructed family that they would be followed out if they left and that as soon as they crossed the door threshold that the parent would be arrested and the child would be taken back into the hospital. This is such a tricky situation when the child is legitimately ill and should be comforted by the parent, but instead has their care obstructed. I am also surprised that CPS didn’t take custody overnight in this situation.
Thanks for the case!
I forgot that we have MPD on hospital premises. I guess that would change my vote to allowing mom to “leave” while informing her she will be arrested as soon as she walks out of the hospital.
What about those facilities that do not have a police presence on campus? At the end of the day the provider cannot let this significantly ill child leave the hospital and risk permanent injury or, worst case scenario, death. So in that situation, could you instruct your security to physically restrain mom, or physically remove the child from the mother so as to provide appropriate care until the legal team/CPS caught up with the current situation?
This would be a very difficult situation. And I agree with Monica- I don’t see a difference in not allowing a kid with obvious signs of physical abuse return to the home in the custody of the person causing them direct harm by abuse versus allowing a kid to return home in the custody of the person causing them direct harm by negligence of medical care.
Good case!
Tough situation, we’ve all been there with versions on the theme of obstruction to care. This is how I’d approach it.
First, we need to make sure the parent understands the problem. It’s our job to arm the family with information on the disease process, plan going forward and general expectations of possible scenarios. I always ask families, “How do you think your child is doing?” to see if the family sees the illness in the same way that I do; rare is the person who thinks their child is fine when they have retractions, WOB or hypoxia in this case. If they think their child is fine then it’s our job to point out the abnormalities. We often get resistance from folks who don’t want to be admitted with the response “I can do nebs at home.” In this case they cannot do oxygen at home, with hypoxia as an objective finding, rather than work of breathing that may be more of a subjective finding/a difference of opinion.
Second, resistance to medical intervention may be rooted in any number of motivations. I try to get at WHY they don’t want things done. Is it that they are worried about their child’s discomfort? Is it that they can’t miss work, they have other kids to care for/pick up from school, negative prior healthcare experiences, or something they heard happened to someone else, the cost, they haven’t sleep in days, they’re hungry, they don’t feel in control, you rubbed them the wrong way for some unknown reason…. Fill in the blank. If the reason is something that can be addressed, it helps deescalate and reestablish a relationship with you.
Third, get help, you don’t need to battle this alone. If at CNMC, then asking Concierge Service and Social Work to see if there is something mom needs help with that she’s not telling you. I’d also consider getting another physician involved- when the relationship between a provider and mom deteriorates this much, it would be helpful to get another physician to weigh in, evaluate the situation, talk to mom, think of other ways to go. Maybe consensus among providers, reinforcement of the medical issue and a fresh face may help mom accept the situation. At UMC, unless deep in the night, you usually have another provider or social work who can help. You can call Main campus and talk with other provider on. If there is abusive language or threatening body posturing from the parent, then you should definitely have security presence near you because that is not acceptable under any circumstances, and the parent can be escorted out for that.
Fourth, depending on the scenario, we need to consider all options for medical management. How else can a problem be addressed? In this scenario, medically the patient would benefit from another round of albuterol that would give 100% oxygen. Can we leave on the ventimask? While the exact FiO2 won’t be known, it is not the worst thing. Is the child very anxious and would benefit from an anxiolytic? Is the issue the admission? Can you manage in the ED for longer and then the child will improve?
Finally, our professional response is everything. What we bring to the bedside at any given moment is based on all the human factors that we are not immune to. Is it your third overnight in a row, it’s a tough service month, you have a sick family member, you yourself are sick, you have many more patients waiting to be seen and this person is taking up all your time, you have multiple deadlines pending… fill in the blank. It may be more about the way you’re saying something more than what you’re saying. We are not immune to appearing/being frustrated, angry, apathetic, feeling superior, or dismissive in our weaker moments. In times of stress, parents with limited coping skills, especially when they don’t feel in control, can be very sensitive to your approach, tone and demeanor. They may also feel that by yelling and screaming and refusing a nasal cannula (maybe for potential discomfort), they are actually advocating for their child- and yelling and screaming is the only way they know how.
In the end of it, I would reinforce that the provider and the parent both want what’s best for the child, and work together to make sure that the child is safe and on the right path. In the meantime, start another round of albuterol please.
One additional element to focus on – assuming you are stuck going down the CPS route (see Rosemary’s comment above, it is interesting that whenever we have similar polls it skews to more experienced providers feeling like they need to use legal/CPS threat less often than Fellows), it is worth noting we might not/do not always agree with the recommendations/disposition they suggest. Even when you run it up the authority line to CPS supervisor etc.
Caleb