Thinking Thursdays TIPs : A Lesson in High School Chemistry?

After checking in at my daughter’s local hospital emergency department seeking help for my five-year-old grandson whom had been vomiting for about 24 hours and still couldn’t hold down liquids, here’s a conversation between the emergency room doctor, my daughter, and myself soon after receiving blood work results.
Keep in mind there are some preexisting medical conditions related to the care of my grandson; a) he suffered a brain injury a few months after birth, b) has been diagnosed with cerebral palsy, and c) has visited this particular emergency department on other occasions because of his medically fragile condition, which includes a tendency to become easily dehydrated. 

Doctor:  “His blood levels are a little off.”
Me: “What exactly is a little off?”
Doctor: “His blood acid levels are high and his pH levels are low, however, that could be normal considering he is dehydrated.”    
Me:  “What would be considered the normal range and where are his levels.”
Doctor:  “7.32 to 7.42 would be a normal range, currently he is at 7.02”
My Daughter:  “What does 7.02 mean exactly?”
Doctor:  “It’s basic high school chemistry, as acid levels go up, pH levels go down”
Me: “We understand the relationship between acid and alkaline, what we’re asking is, with a pH level of 7.02, is that something we should be concerned about?”
The exchange above got a little tense, brought about by the doctor’s tone inflection and demeanor as he made reference to “high school chemistry”.  Quite frankly, the tone inflection felt condescending, as if; a) we had not attended/graduated high school, or b) we were just too ignorant to understand the basics of high school chemistry.  
Doctor: “Considering his dehydration, a 7.02 reading could be normal.”
My Daughter: “OK, that’s good that it’s normal — what are our next steps?”
Doctor: “We are transferring him downtown to do some intense LAB work.  Also, has he been into any thing like paint thinner or any thing that might have caused his blood acid levels to be out of whack?”
My Daughter:  [with some degree of shock, my daughter answered] “I can’t remember any thing like paint thinner that he may have got into.  We did help some friends over the weekend do some painting at their house, but we didn’t use any paint thinner.  Would breathing normal latex paint cause the problem”
Doctor: “No, breathing latex paint or even breathing paint thinner would not have caused this problem — he would have to have actually drank the paint thinner and ingested it.”
There were several more minutes of questioning from the doctor directed toward my daughter.  It was obvious that my daughter and I were becoming a little distraught and anxious, as a result of the doctor’s probing about paint thinner.
Doctor: “It’s nothing to worry about, it’s just something that I have to ask so that I can check a box.”
Me:  [at this point, I addressed the doctor by name, and was very direct].  “What we are hearing here does not add-up, for example, you described my grandson’s dehydration and that his blood levels are normalconsidering his condition, then you immediately advise us that he will be transferred downtown for intense LABs, and right behind that, you asked about paint thinner to the point it began to feel like an interrogation, and then, you said, ‘it’s nothing to worry about, it’s just something that I have to ask so that I can check a box”.
Me:  “What do you mean by “intense” LAB work and where exactly downtown is he being transferred?”  If the type of LABs needed are routine for a child with dehydration, why the need to transfer him downtown, can’t he be treated here?” 
Doctor: [instead of telling us the name of the downtown hospital where my grandson was being transferred, the doctor quoted the street address of the hospital, without ever mentioning the name of the hospital.  He seemed to be playing some sort of verbal  tit-for-tat game with me in that he answered my question when I said, “where exactly is downtown”.  
Me:  “So, if this is normal for children with dehydration, why the need to transfer him to the hospital downtown, why not just admit him here?” 
Doctor: “The downtown hospital can perform the intense LAB work that will be required throughout the night”.
Me: “Is that LAB work different than what can be performed here?  Will the downtown hospital be able to perform more sophisticated LABs?  I’m not sure what intense means”.
Doctor: “Downtown they can perform the LABs that are going to be needed throughout the night.  I’ve called upstairs and talked to the pediatricians on-duty and they advised me to transfer him downtown”.
Me:  “By intense you’re meaning LABs on a more frequent basis?” 
Doctor:  “Yes, they can perform the LABs that are needed”
By now the tension in the room was thick.  The doctor left the room and my daughter and I began to collect our things as we prepared and waited for the EMT’s to arrive to transport my grandson to the downtown hospital, by ambulance.  My daughter went to the rest room and while on her way back to the exam room she passed by the nurse’s station and noticed that the emergency room doctor was on the telephone, and appeared to be talking with the pediatrician on-duty, upstairs, which was mentioned earlier in our conversation.
Doctor: [on the phone]  “…it sure would be nice if I didn’t have to transfer every patient downtown tonight…”
When my daughter mentioned to me that she had overhead the conversation, we both remembered that we had observed at least two other children leaving the ED via ambulance stretcher, evidently on their way to the downtown hospital.
When the nurse returned to the exam room with my grandson’s discharge/transfer papers, I asked her if the hospital’s pediatric floor was full, and is that the reason that so many children were being transferred downtown?  The nurse said, “this hospital is not allowed to have specialist physicians cover our pediatric floor overnight, so, it’s really best that your grandson go to the downtown hospital, just in case a specialist is needed”.  I think I said something like, “really, that’s too bad.  You’d think a hospital like this would have the specialists that are needed”.  The nurse’s reply was, “it’s all about money, we don’t get the specialist because of the cost”.
As we began to put two-and-two together, it seemed like my daughter’s local hospital was understaffed and was not able to admit the children that had arrived to the ED that evening.  I cannot be 100% sure that “staffing” or lack of staff was the reason, but it sure seemed that way to us.
After my daughter and grandson arrived to the downtown hospital my daughter asked one of the attending physicians at the downtown hospital his opinion regarding why my grandson was transferred.  The physician explained that the local hospital’s children emergency department is more of a walk-in clinic.  Keep in mind that my daughter’s local hospital aggressively advertises that they are well equipped to handle and treat children, and have both adult and children emergency departments.  I agree with the downtown hospital physician, the children emergency department at my daughter’s local hospital operated more like a walk-in clinic.
All that to say, had the ED doctor not started off with the high school chemistry comment, and had he been a little more honest, open and transparent with us, and simply said, “we are not adequately staffed tonight to give the kind of care needed that your grandson needs — it’s best if your grandson transfer downtown”, we wouldn’t have been necessarily happy about that answer, however, we would have understood and would have been a lot less confused and anxious. 
A summary statement from my daughter as we wrap-up:
  “I felt like the doctor did not take into consideration any preexisting medical conditions or that my son’s special needs plays a huge role in my son’s on-going treatment.  The article below about doctor burnout was exactly the vibe I got from him”.
If you have experienced similar situations, or know providers that seem to be less-than-compassionate from time to time, below are a couple of articles that may be useful.  
By the way, high school chemistry was not one of my favorite subjects, even so, I learned a lot about how not to treat patients from an emergency department doctor that felt compelled to point out to us, condescendingly, “it’s basic high school chemistry, as acid levels go up, pH levels go down”.  


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Have a great Thinking Thursday! 
Jerry
 
Jerry L. Stone
Co-Founder/COO
MedicalGPS, LLC

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