In Defense of the Mom in the Emergency Department

I was asked to give medical advice by phone to the mom of an 18-month-old who suddenly had blood and mucus in her stool. Obviously, I couldn’t really examine the child. So, I gave what I thought was correct advice. Go to the emergency department.

Later, the mother told me that the staff in the emergency department acted like they didn’t know why she was there and gave her major attitude. The child was ultimately diagnosed with constipation. So, yeah, she’s lady who brought her kid into the emergency room for constipation. And I’m the one who told her to do it.

Making Prudent Recommendations

In general, I usually ask my patients to go to urgent care only if they have illnesses that can’t wait to see me in my next appointment. I typically get people in same day or next day so I’m not asking them to wait for a week or anything crazy. But, if I think the patient has a condition that could potentially result in hospitalization, I asked them to go to the emergency room.

In this case, it was bleeding. A lot? A little? There’s no way to really determine that by phone. Muggles have no idea what is a significant amount of blood. And when it’s blood coming out of your child, it always looks like a lot. But when I talked to this mom afterward, she said she felt like the doctors expected her to know the difference between a serious GI bleed and an anal fissure.

To ED or Not to ED?

The question isn’t whether or not constipation is a potentially hospitalize-able condition. Personally, I’ve hospitalized some patients for constipation in the past, but it’s got to be pretty bad. So in general, the answer is no. But, the real question to ask is whether or not blood in the stool of a toddler is a potentially hospitalize-able condition. And answer is yes. It’s probably an anal fissure related to constipation. But without a physical exam, imaging or labs, I can’t rule out things like intussusception or Meckel’s diverticulum. And left untreated, those could kill a child.

I think sometimes we, medical professionals, forget what his common knowledge versus what is medical knowledge. I think it’s reasonable to ask patient’s to seek care in the appropriate location based on the severity of the illness. But, that distinction is not to be made based on the condition the patient actually has. It’s about the condition the patient might have.

Be Careful What You Wish For

We’ve all had patient interactions in the urgent/emergency setting when we’ve been left asking “Why are they here when this could have waited?” In my early career days, I was guilty of this as anyone. And I’ve also been surprised by a couple of kids who were crazy sick despite an eye-roll inducing triage assessment.

As families become increasingly medically savvy, sometimes we expect too much of them. Parents don’t know the difference between a life-threatening intestinal hemorrhage and an anal fissure. They can’t always tell the difference between bronchiolitis and a cold. And I don’t want them to make that distinction by themselves.

If a parent calls me and asks me what they should do and they perceive that the baby is having difficulty breathing, I’m going to refer them to urgent care or the emergency department. Now, that child may or may not have difficulty breathing as I would define it. But I don’t expect parents to make that expert-level assessment by themselves. On the phone, I have to go with what the parent is telling me. And, I need consider the worse case scenario and try to keep that child alive until the next time I can see them.