Happening in real time…I’m pediatric hospitalist at a community hospital with no pediatric expertise at any given time besides my humble self or my partners—we take 24 hr call. Most of the work is term babies and special care level 2 nursery for preemies 1500g and up and we admit routine pediatric stuff up to age 18 on a Neuro/ortho floor with no Peds nursing experience. Pediatric centers are located about an hour away and another one about two hours away.
‘Eddoc’ called about 10:45 PM with a 14-year-old girl with three hours of immediate onset, significant (10/10), unrelenting (morphine not touching her) pain —generalized abdominal pain and intractable ‘yellow-green, not green-green’ vomiting with a normal CBC and CMP Amy/lipase and u/A, neg serum hcg and a CT with contrast (rectal and IV) that radiology read as “partial bowel obstruction with clear transition without mass in distal pelvic ileum, normal appendix, ovaries normal” No hx of abd surgery.
Eddoc has not called surgery attg. but wanted to let me “know.” (We don’t have residents or fellows here). Eddoc said he figures it’s probably just an ileus. I assume he was suggesting that I admit the patient with surgical consultation at our podunk hospital.
I explained that I was in the C-section room for a delivery and will be glad to come and see the patient after he had a discussion with the surgeon as we needed to rule out an acute surgical emergency first given the presentation and the reading by the radiologist—whether or not the reading proves to be incorrect. I further explained that I would not be comfortable with that patient on my service but would be glad to consider pediatrics consultation to the surgeon if they requested that after surg admission. Eddoc suggested the surgeon would have a less than happy response to my plan. He asked me if I had worked with ‘Surgdoc’ before. I explained that I didn’t really know Surgdoc but that it didn’t change my opinion and it didn’t matter much if he were a very nice guy or not as she clearly needs a surgeon right NOW and not a Peds hospitalist.
Further I explained that if the patient were my daughter I would want her at a pediatric hospital where I think more appropriate resources are available given the possible diagnoses and outcomes and her excruciating, unrelenting pain and vomiting. I mentioned perforation and gut loss, etc. Ideally Surgdoc should see the patient immediately and talk surgeon to surgeon for smoothest transfer. It would be safer to be conservative and assume that she does have a small bowel obstruction given the rads read, the presentation and the obvious CT appearance for all to see! Did he place a NG? No. Her CT was very impressive. Did Eddoc look at it? No. NICE transition point there, believe me. No obvious mass.
I further explained if Surgdoc actually sees the patient, you know, examines her and feels it’s very appropriate to admit and then wants to discuss that with me and convince me then maybe I’ll get on board with that plan. Maybe not. Probably won’t. Will certainly review with parents first if I did. I suspect Eddoc would have me admit the pt and let her sit on my service all night (potentially losing bowel and or perf) until Surgdoc can see them in the morning. I mean what business do we have keeping a pediatric patient like this at all here at Podunk? The attitude is admit to Peds first and then ask questions later. Wrong! Gets the patient out of the ED and Surgeon gets to sleep, right? I strongly encouraged Eddoc to also discuss matters frankly with the family and find out what the family might have to say about all this.
Eddoc calls me an hour later. Patient left by POV (omg) to a real Peds hospital with a vomit bag in her lap. Surgeon supposedly reviewed the CT from home and said “Ileus” and went back to bed. Never saw the patient. Eddoc, meanwhile, had apparently finally got a look at the CT and says “Gosh, that looks bad!” I swear to God he says that to me.
I was a Peds ED doc for 15 years. I know what it feels like to be in the middle. You may buy scratch-offs. You may be a gambling addict. But you don’t gamble on people’s lives or their kids’ lives. For the love of Mary!
Will be interesting to follow up her case tomorrow. So glad I’m not the peds director. She will be pissed. But sadly she will again find no one in administration who gives a rat’s ass whatsoever. More meaningless meetings I pray I will be spared from. Bang head here X.
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