Sunday, December 6, 2009

Observe or not observe: the importance of a safe medical decision making

Another day went by in the Pediatrics' ward.
Admitting a child to the hospital exclusively for observation purposes is a standard of care in order to be able to provide first hand evaluation and assessment of the child. This permits to ensure a safe discharge home and provide reassurance to both physicians and parents; likely, if a child does well during the observation period, will do well at home. The value of parental reassurance and documenting that after a short stay in the hospital the patient is able to safely be discharged home is very important. In Pediatrics, the medical decision making is based on the physical examination and appearance of the baby in the hospital.

Let's see a hypothetical case of an infant with a presumed "apparent life threatening event" or "ALTE"; the parents are distraught when witnessing first hand an unknown phenomenon such as a "staring spell" or "perioral cyanosis", etc. If the infant is well appearing in the Emergency room, with no clinical findings suspicious for a severe infection, the neurologic examination is non-focal, and the cardiopulmonary examination is unrevealing, it is highly likely that the patient will do well; however, safety is the main concern and priority in Pediatrics; obtaining basic studies including bloodwork and perhaps a chest roentgenogram (not necessarily the whole body X-Ray known as "babygram") and an EKG is in general sufficient. The next step is admitting the patient to the Pediatric ward to observe in a cardiopulmonary monitor for disrrhythmias, desaturations, apneas or respiratory changes such as the physiologic "periodic breathing". We can as well observe the patient's reaction to feeding, as well as the elimination pattern (urine output, bowel movements). A frequent cause of "ALTE" is gastroesophageal reflux - if a patient receives reflux precautions and antacids (such as famotidine) permits us observe if the phenomenon corrects; if not, then it is in place to rule-out other life threatening causes - from the CNS standpoint, obtaining an EEG and a head imaging (US or CT-scan); from the cardiovascular standpoint getting and echocardiogram; from the metabolic standpoint, documenting the value of glucose, bicarbonate and ammonium (if all three are normal, the likelihood of an organic acidemia is very low) as well as urinary organic acids; from the GI standpoint a swallow evaluation and an upper GI series (this permits an assessment of intrathoracic vascular anomalies such as a vascular ring as well as assess for reflux and malrotation); generally, the most frequently abnormal test will be the UGI series that reveals significant reflux.

The parents obtains reassurance from the thorough assessment (which apart from the bloodwork and the UGI, is in general safe and non-invasive) and the patient can start being treated in the hospital with observation of the medical intervention's outcome - for instance, changing the breastfeeding pattern, timing the feeds, permitting the baby take a breath between suckling, stimulating eructation, avoiding an immediate horizontal position after eating, having the head of the bed elevated 30 degrees - and if the events resolves, then the patient can be safely discharged home and have an outpatient follow-up.

It seems excessive but it is not.  Safety is the most important aspect in medical care, especially in Pediatrics. I emphasize with the Pediatrics residents in always think outside of the box; is there any potential risk of abuse?, is there any need for parental education about feeding?, is there any significant family history we need to be aware of?, and help them organize their thoughts and medical decision making based on each individual case needs; doing studies in a protocolized way should not be advocated unless there is a well planned medical decision making algorithm behind the protocol. I emphasize in a thorough examination and assessment of all variables in order to reach a diagnostic conclusion and pathway. At the very end, the residents appreciate their own ability to approach each patient individually and enhance a safe medical care and transition of care, following always our motto....primum non nocere.

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