rcdavis Posted July 2, 2013 Share Posted July 2, 2013 Okay. I have been on the forum for awhile, was a moderator for awhile, and have engaged in multiple appropriate care discussions, without trying to be too judgmental... Now my most important job is grandfather.. In south Carolina, to a 7 week grandson living in San Diego. Term child. Agar 5/5. Uncomplicated preg labor and very easy delivery. Home with mom. Normal birth weight and growing well. Breast feeding exclusively. Sweet baby, no colic. Today, around 1300 my time, had short term generalized shaking ( apparently not tonic colonic) , associated with two vomiting spells and "froth" sputtle in mouth, followed with prolonged (30-60 minutes) decreased responsiveness ( no eye contact, shallow breathing). Unable tell incontinence. Apparently afebrile Pediatrician called. Referred to "pediatric hospital" in San Diego. Driven there. Vitals intact. Oximetry normal. Tele monitor for couple hours normal ( by son's and daughter-in-law's report. Seen by what my son feels was a medical student ("had local medical school ID"), who "regularly would consult back with the attending physician... Attending arrived just at discharge and reported that the monitors were all normal, that they were not sure what the spell was, and to take grandson home to careful observation. All okay, except no labs were taken No glucose determination. No CO2, ( in the least), no SMA6 and calcium. No urine, no CBC. Nada. Whole determination based on medical student PE and several hours of monitoring. 7 week old. my WTF factor is spinning out of control. This child would never. Never. Be discharged From my ED without at least the glucose ( and maybe magnesium), calcium, and lytes drawn. Maybe simple observation is okay in the clinic, but this is an ER !!! Any of you experienced PAs have comments which would assure me that the west coast doesn't have a clue how to do peddy EM.??? Currently, I am awaiting call from Peds attending.. Interested in your thoughts. Thanks Davis ( "poppy" ) Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 2, 2013 Moderator Share Posted July 2, 2013 sounds like inappropriate workup. kid would have been admitted everywhere I work for a big workup with eeg, septic workup, peds neuro consult, etc Link to comment Share on other sites More sharing options...
rcdavis Posted July 2, 2013 Author Share Posted July 2, 2013 E, thanks. I agree. We will see what she says. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 2, 2013 Moderator Share Posted July 2, 2013 this is metabolic/toxic ingestion or new sz d/o until proven otherwise....could make a case that this should be worked up as an ALTE too.... Link to comment Share on other sites More sharing options...
primadonna22274 Posted July 2, 2013 Share Posted July 2, 2013 Agree with Poppy and E. sorry this happened to your little guy...I can't think of any ED where a med student's work up of a 7 wk infant with weird spells isn't closely repeated and scrutinized by the attending...the Ddx is quite large and I agree the kid and parents deserve close observation at least for 24 hr. Link to comment Share on other sites More sharing options...
ATCLATEMTB Posted July 3, 2013 Share Posted July 3, 2013 ALTE? Could you expand for those who are allergic to pediatrics? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 3, 2013 Moderator Share Posted July 3, 2013 ALTE? Could you expand for those who are allergic to pediatrics? Apparent Life Threatening Event. the classic symptom is an apneic event with cyanosis . read all the way to the bottom for the ddx and workup. http://pediatrics.uchicago.edu/chiefs/inpatient/ALTE.htm Link to comment Share on other sites More sharing options...
primadonna22274 Posted July 3, 2013 Share Posted July 3, 2013 ^^^bookmarked for my peds rotation, thanks E!! Link to comment Share on other sites More sharing options...
Acebecker Posted July 3, 2013 Share Posted July 3, 2013 I have to agree. No way this kiddo would sit in our clinic or the outpatient setting for one, and secondly there's no way this kiddo doesn't warrant further w/u. Link to comment Share on other sites More sharing options...
bradtPA Posted July 3, 2013 Share Posted July 3, 2013 My experience, under 8 weeks buys an admit and possibly septic workup.... Link to comment Share on other sites More sharing options...
Hemegroup Posted July 3, 2013 Share Posted July 3, 2013 ... I agree the kid and parents deserve close observation at least for 24 hr. Good catch. http://www.nlm.nih.gov/medlineplus/ency/article/001555.htm I wrote a paper on it in an upper div child psych class in undergrad. Observation cameras have caught vitals changing when the parent entered the room. As has been stated, huge dDx here. But I'd also try and remember not just simple observation but clinical observation as well. Not by the student, likely, but hopefully by the Attending (altho we all know that can mean various things). I'm no Pediatrician, but I did do a Preceptorship in Peds as well as have been working 50% Peds FP/IM for the past 8 months. Kids vomit. Hell, I shake when I throw up. Draws are traumatic to kids in more ways than one and bring their own share of risks. 7 weeks is too young to gauge eye contact in such a situation. Heck I examined a 2 month old today who could barely focus on me. However, most important to me on discharging that family would have been a talk on potentially toxic substances. http://organicgrace.com/non-toxic_baby Sorry to hear as well about the little guy as well, rc, hope everything is well and fine. Link to comment Share on other sites More sharing options...
Moderator ventana Posted July 3, 2013 Moderator Share Posted July 3, 2013 having a 9 week old at home it was a hard transition to make from provider to dad (or in your case grandad) Screw politics, be a PIA to the staff and demand a work up, re-work up. I can say once I left my professional hat at home, and just put on my dad hat I was much better - didn't matter rather it was an NP or MD I talked to (except one MD's answer of "i said so" didn't sit right with me) I was an advocate to my son........ put on a show and defend the medical care you grandson deserves! Link to comment Share on other sites More sharing options...
Guest JMPA Posted July 3, 2013 Share Posted July 3, 2013 sue them for deviation from standard of care Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted July 3, 2013 Moderator Share Posted July 3, 2013 How is he doing, RC? Link to comment Share on other sites More sharing options...
maryfran123 Posted July 3, 2013 Share Posted July 3, 2013 RC, Hope your grandson is doing well and that you can get some answers that make sense to you. I am no expert in Peds but my gut tells me that a 24hr admission at least would be warranted to rule out a host of nasty possibilities. Jeepers, we admit far LESS to our trauma service!!!!! Link to comment Share on other sites More sharing options...
rcdavis Posted July 3, 2013 Author Share Posted July 3, 2013 Thanks for your advise and support Suing only works if there is injury.. Not POTENTIAL for injury.. Even if the standard of medical care is not met, if there is no injury, even gross negligence is not suable. I spoke with the director of the ED and house supervisor. Both confirm there are NO medical students allowed in the ED nor the ICU, The only signature on the chart is the attending.. So, unless they are outright lying, I have to assume the attending was the attending. I am not sure who my son saw was evaluating the child. The hospital's take is that there was a different sequence of events; child spit up , apparently choked/aspirated which led to shaking. That's the hx they recorded. During the observation period, they watched the child "vigorously" breast feed without problem, and felt that the cause of the alte was reflex and bronchospastic response to aspiration. They had no answer to my question as to why no labs, at least screening glu, or further workup. As we have said before, it is all in the history, man. All in the history. Even with there take on the historical sequence of events, I still think a chest X-ray ( if they are positing aspiration) is warranted , and other labs. We agreed to disagree on this point. I did mention that I felt they really were in an awkward position which is pretty indefendible, if there did turn out to be a different primary cause of the event, or adverse sequelae to the event. And mentioned that no way would knox's chart pass an M&M screening in any of the multiple ERs I am affiliated with, including CMC, whose chairman is john Marx, now principle editor of rosens... Again, we agreed to disagree. Knox is fine. Weathered the storm well, and apparently is no worse for wear. I have asked my son, should knox have to return to any hospital in the future, to call me before discharge so hat I can make long distance assessment of the care, and become more directly involved, as Ventana suggests. So, in my opinion, in spite of terrible proactive care by the ED , my grandson survives. And I am keeping the level of disapproval of what happened to myself, so as to not scare my daughter-in-law any more than she already is. Thanks everyone, for there opinions. Reaffirms my faith in west coast capacity. Link to comment Share on other sites More sharing options...
cbrsmurf Posted July 3, 2013 Share Posted July 3, 2013 I have a friend's husband who is currently a resident at Rady's as to what kind of workup they typically do and whether they use students in the ER. I'm pretty sure UCSD medical students do rotations through Rady's, but not sure about their ED. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted July 4, 2013 Moderator Share Posted July 4, 2013 RC- good to hear he's doing well. At least they were willing to have an in depth conversation with you about everything. As you noted they've certainly opened themselves up for total liability in the event that, God forbid, something bad happens. Bottom line is that he's doing well, and we can only hope he continues to do well. Link to comment Share on other sites More sharing options...
kargiver Posted July 4, 2013 Share Posted July 4, 2013 RC, Sorry to see that you are stuck traveling this road. I have had similar issues with other members of my family being treated in the ER and blown off, when further W/U and obs are warranted not only as good medicine, but as the standard of care. It seems to me that this was an ALTE and requires at least 12-24 hours of obs and basic labs. Unless other signs are manifesting itself to suggest sepsis, the rest of the W/U (UA, culture, etc) can be debated with literature supporting both camps. For kids, I err on the side of caution. Most of the peds attendings I know however are moving away from it, so long as follow-up is legit. I am glad to hear that all turned out ok - It gets very scary and confusing when we are on the other side of the stethoscope... Be well, G Link to comment Share on other sites More sharing options...
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