04 April 2011

Closer to Home

Not long ago I met a family in the ER who arrived by ambulance. Their daughter was clearly very ill. She was febrile and screaming. Ultimately, I would find that with some tylenol she would begin to look better and with a few other simple interventions she would look almost entirely well.

I didn't get that far. As I was leaning forward to listen with my stethoscope her parents demanded to be transferred to the Children's Hospital in town.

This is, I have found on more than one occasion, an interesting dilemma. When I ask my adult colleagues what they do in situations such as this they shrug. The consensus answer seems to be: "If a patient wants to go somewhere else, he wants to go somewhere else. Who am I to argue?"

Medicine is, it seems, not immune from the cliched motto the customer is always right. But in pediatrics who is the customer? Is it the child or is it the parents?

Obviously the parents are likely to be somewhat more verbal than a toddler or even, for that matter, a sullen fourteen-year-old. So it is tempting to assume that pacifying a mother or father, making them feel safe and well cared for, is just as important as doing the same for their offspring. But that is not always the case.

The child above, who would within a few short hours, be stable and ready for transfer up to the floor where she could eat popcicles and watch Dora the Explorer to her little heart's content did not need to be transferred downtown. She did not need to placed in another ambulance and made to wait in another ER to be seen by a doctor who would do the exact things we were doing for her already at the community hospital ten minutes from her house.

There has been a rash of news coverage of late questioning the ability of smaller hospitals to appropriately care for very sick children, perhaps in part spurred on by this case. Certainly moving children from one place to another, quickly and without delay, is one important part of my job. But mightn't it also be that not moving them, when they are already getting the care they need, is another important part? If every boy or girl with asthma or dehydration is transferred to a major Children's Hospital then there will be no beds left for those children who need renal biopsies and bronchoscopies and all of the other procedures that smaller hospitals don't have the appropriate staff to perform.

Because I now spend a good portion of my clinical hours forty minutes outside of the city, I have been forced (or maybe I've been privileged) to ask and try to answer the following question: What are those things that smaller community hospitals do better than their larger counterparts downtown. A few years ago, when I was enmeshed in my training and used to having cardiologists and endocrinologists and pulmonologists available to chat by phone even in the middle of the night, I would not have been able to answer this. I would not have seen the point. Why not have the best, the very best, for your child if ever they are in need?

Then I transferred a few families downtown for various reasons, children who needed a particular test from radiology or consult from a specialist that I could not get for them in the hospital where we were. And parents grumbled. I confess I was surprised. I assumed they would jump at the opportunity. But there I was, pulling out the stops and whistles, and I met resistance instead.

They wanted to stay put. Families had other children at home and needed to be able to pop out to drive a sister to soccer practice or pick another one up from ballet. They were used to having a private room, whereas downtown they would more than likely have to share. Moms loved being able to run home during the day to shower and grab fresh clothes, knowing the entire trip would take no more than forty minutes at most. Dads loved being able to come by the hospital after work. (Yes, moms tend to stay during the day and dads tend to go to work. I challenge dad out there to go ahead and prove me wrong.) It was easier for these families being close to home. It was less overwhelming. They felt safer and more in control.

So overall I have gotten in the habit of not being quick to transfer. Yes, I have called a helicopter for a child before even walking into her room, but only because the safest thing for her was to go. I knew this because the nurses told me so and nurses are always right. I learned that even before I learned the right dosing for ibuprofen.

But are parents always right? Usually, but not universally. They can't be because parents are often scared. How could they not be, seeing their child screaming and in pain? So the child, in that moment and until he or she is feeling better, has to be my patient first. I want parents to be happy. I want to treat the family as well as just the child. But first I have to treat the child. Then we can talk about whose gourmet italian ice she will get to enjoy from her hospital bed - ours or our mother ship downtown.

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