Critical Incident…

For our Pediatrics rotation, all of us have to write about a “critical incident”….I’m posting mine.  But first, a warning.  This is not really as good as other things I have written – I felt obligated to write about peds and it was a very structured essay.  Ok, continue:

As I looked at the clock, I realized that it was already 5:45 PM on a Friday night. As letter “C” on my pediatric schedule, I was just about to finish up my 2 weeks of outpatient clinics with a few hours in asthma clinic. After a busy morning in the adolescent medicine center, I was looking forward to seeing a few cases and then going home to enjoy my weekend. I had made it to asthma clinic by 1 PM to find that our first few patients had cancelled. Around 2 PM, the scheduled patients began trickling in – many were simply checking in to report that the past few months had gone well. A few were referred by their primary care physicians for evaluation of undiagnosed asthma. Before I knew it, it was 4 PM and the sky had already begun to darken.

It was at 5:45 PM that our last patient has arrived, an 8 year old named T. Dr. S took one look at the name and said, “We are going to be a while. I’ve always had problems with this mother.” Before walking into the room, I took a quick look at T’s file. His problem list included moderate persistent asthma, obstructive sleep apnea and allergic rhinitis. On his last visit to the asthma clinic, the note had mentioned that T’s mother wished to stop all of his medications. T had also been seen by an ENT doctor, who had prescribed several nasal sprays to help with the allergic rhinitis and OSA.

As Dr. S and I walked into the room, we took a quick look at the vitals. T’s blood pressure was a little high. His OSA was probably a little worse than we had initially thought. As we started talking to T and his mother, it became pretty clear that for the last few months T had been receiving no medications. Mom reported that T was doing fine at school and home. On further questioning, we found out that T was having trouble breathing during recess. In games the involved running, he would have to sit out to catch his breath. Over the last month, he had used his albuterol inhaler once or twice. In addition, his mother noted that his snoring had worsened. She could now hear him through is bedroom door. He was also was a “noisy breather” when he was watching TV at night.

Dr. S and I carefully listened to mom as we examined T. He was a heavy 8-year old boy who no longer had adenoids or tonsils. Despite that fact, it was difficult to visualize his posterior pharynx. His lung exam was also full of wheezes. After this part of the visit, the nurse had come in to demonstrate the proper way to use an inhaler. Dr. S and I took this moment to leave the room and discuss the case. Dr. S promptly noted that he had gotten worse since his last visit. She and I were concerned that this little boy, who was suffering from several potentially treatable conditions, was doing permanent damage to his body. The meeting had been pretty clear – his mother was only administering medications when she was able to see that he needed it. Also, she was unwilling to admit that her son had any medical problems – to her, he was just like the other kids.

The nurse came into interrupt us while we chatted about this patient. Normally this happy older woman would deliver us great news about a successful teaching session but this time she seemed furious. When she had asked to see T’s albuterol inhaler to demonstrate the proper use of a spacer, he pulled a device out of his pocket. The nurse had taken one look at the dirty case and realized that his albuterol was being carried by a flovent case. She also noticed that his albuterol had expired over 1 year ago.

Soon, we got the results of the PFTs. He was 60% of predicted in almost every category, worse than the previous visit. Dr. S took one look at the results and stated that she was going to call DCF on the mother. “This is simply medical neglect,” she stated. She asked me to distract T while she talked to the mother about the possibility of DCF involvement. As I helped T pick out chapter books to take him with him, I was confused by the situation. Sitting next to me was a healthy appearing 8 year old boy with minor medical problems with the potential to become major medical problems. I couldn’t help but agree with the mother, her son seemed fine. He was talking and playing like a normal 8 year old boy. Although she had witness him struggling to breath, it seemed like something that would pass with age.

On the other hand, T had problems. He wasn’t like the other kids – he couldn’t run as far, he wasn’t sleeping the same, he was afflicted with several medical conditions. I was angry at his mother for deliberately neglecting problems that she been educated about for years. How did she know he was getting better? How did she know that he no longer needed any medications? How could she neglect his treatments when she was told multiple times that her child was not a normal, healthy 8 year old boy? Why did she not care to see him get better?

I was frustrated. In adult medicine, the solution would have been to involve other people in the patient’s care; tell the spouse, the children and other family and friends. T was too young to understand the importance of his asthma medications or nasal sprays – to him, it was something that made him different from the other kids in school. He only had his mother to rely on for support in this situation and she clearly did not understand the extent of the damage she was causing by withholding treatment. T had been seen by many doctors over the last few years and none of them were successful in providing his mom with information that would make an impact on her. Would we be able to get through to her?

I could just imagine what she was saying to Dr. S. She would probably be shocked and angry at the accusation of neglect. She clothed, fed and took care of her son’s needs – how was that neglect? She saw her child as normal, just like the other children. He could run and play. He was doing well in school. He was well-behaved. She was a single mom, providing for a growing 8 year old boy. Keeping track of his medications in addition to working and managing their lives on a daily basis was probably overwhelming. In addition, her son was seeing multiple doctors who were constantly altering his treatment regimen. It was all too much for someone that was trying to handle the role of mom and dad.

She had denied treatment for multiple reasons. A big part of her wanted her son to be normal. For years she was told of the various medical conditions that affected her son but she couldn’t see it. The best she could do was ignore the problems. When she stopped giving him the medications, there was no visible affect. He didn’t stop breathing, he didn’t have an asthma attack and he didn’t need to go to the hospital. He was fine, like he had always been.

Dr. S walked out of the room with a smile. We brought T back to his mother, who looked like she had been crying. They got their things together and left the clinic. The mother turned to us and said, “I understand now.” She thought that she was being the best mother that she could be – she thought she was doing right by her son. The possibility of losing him because of his medical conditions was the wake up call she needed. At that point it became clear, she was killing her child.

Doctors sometimes have to make tough decisions. While on inpatient medicine, I was used to taking care of the immediate problems and leaving the PCPs to care for the social issues that accompanied each patient. I used to think that deciding between Vancomyocin and another antibiotic was a tough decision but this experience proved me wrong. I had taken for granted all the social dynamics that are involved in patient care. Some mothers truly have their child’s best interest in mind when it comes to medical neglect. The key to communicating with them is to make their child’s condition a reality and a priority.

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