Your child seems half dead to you, but you’re frozen with uncertainty. Are they just being whiny? Is that fever going to pass quickly? When do I know if my child needs an emergency assessment? When do I know if they need emergency medical care?
I recently got involved in just a situation with one of Mrs. Happy’s friends. She has a young child, about four years old who came down with a fever a week ago. The child has a history of asthma and a history of supraventricular tachycardia. The child was meandering along doing fine when one day his condition changed.
The mother took her child to his pediatrician saying that the child seemed to be rather weak. He was still having fevers and was now wheezing. At the pediatrician’s office the oxygen saturation was found to be about 90-91%. As any physician knows, the oxyhemoglobin dissociation curve drives clinical oxygen management. Once the PO2 drops below 60, the clinical oxy-hemoglobin saturation drops quickly. This is why a 90% oxygen saturation is used as the safe clinical cut off for clinical oxygen assessment. Anything below 90% requires an emergency assessment and emergency medical care should be initiated.
After obtaining a chest xray in the clinic that suggested pneumonia, a shot of antibiotics was administered. The mother was instructed to take the child home and to watch him. If her son was no better the following day she was instructed to bring him back.
Several hours later the child was complaining of a mild headache, was having a bout of diarrhea and was not interested in moving or eating or drinking. He was still wheezing and he was still having fevers. The mother was conflicted. Her physician had told her to go home and basically wait it out. The mother’s family was telling her to follow the physician’s advice. The cost of of an emergency assessment and emergency medical care was weighing on her. She contemplated taking him to the cheaper urgent care center.
While I hate to give advice without doing a clinical evaluation, some times the obvious needs to be stated. When I heard about how the child was acting, how his oxygen saturations left no wiggle room for safety, how he was complaining of a headache (which could be a sign of low oxygen levels), how he sounded lethargic, how he had a history of asthma and SVT, and how the H1N1 virus was disproportionately affecting the young in adverse ways, Mrs Happy and I recommended that she ignore her physician’s advice for watchful waiting and take her child in for an emergency assessment and emergency medical care. I could see no possible way that an emergency assessment would not lead to emergency medical care in the hospital. I suggested the urgent care center would simply recommend transfer to the emergency room for emergency medical care and admission.
I couldn’t think of any reason why this child should not have been admitted from the pediatrician’s office, as I would have done the same had I been asked to admit the adult version by an emergency department physician.
I thank the Heavens that mother took her child to the emergency department for an emergency assessment and emergency medical care. The doctors took one look at the child and didn’t hesitate about admitting him. The next morning the pediatrician acted like the child had a dramatic change in condition, which they didn’t (according to mother). That’s just pathetic. The red flag symptom in my book was the low oxygen saturation in an otherwise normally healthy child. I would never send anyone home in that condition. Why this pediatrician did is beyond me.
In the hospital, the H1N1 swine test came back negative, but we all know that it’s not a very sensitive test. After 48 hours, the child remains hospitalized with hypoxemia, on 4-5 liters of oxygen, IV fluids and antibiotics. We’re told the hunt is on for other respiratory viruses, although I’m not sure that finding another virus would change the management. After over a week of fever at home, any antiviral is unlikely to change the course of the disease process. The mother remains distressed. Her experience with the nursing staff has been one of rudeness and borderline incompetence at times. Her trust in her pediatrician appears gone. That’s a horrible way to experience the illness of your child.
How is a mother to know when an emergency assessment and emergency medical care is required for their child? Unless the mother has a detailed background in science through nursing or physician level education, few mothers would know anything about an oxy-hemoglobin dissociation curve. Few would know much about what is considered safe and what isn’t from a physiology point of view. The point is, you just don’t know. If my child had an office oxygenation level of 90% and my child’s pediatrician recommended going home, I would find another doctor and go to the emergency department for admission.
As the mother, you have to do what you think is right. That means if you think your child is in danger, you take them in for an emergency assessment and emergency medical care, regardless of what anyone else says, including the physician. For the lay public, often times they are left with Google and their gut instinct to guide them in for an emergency assessment and emergency medical care of themselves or their loved ones when everyone around them gets it wrong. I’m just glad Mrs Happy and I were there to help her do the right thing for her child. We hope he gets better quickly.
*This blog post was originally published at The Happy Hospitalist*