Wednesday, January 24, 2007

Promise

I spoke over the phone to the answering machine. "Ms. Doe, please either call me or bring your baby in for a jaundice level. We want to be sure the jaundice doesn't get so high that it causes brain damage." Normally I wouldn't want to alarm parents by using the words "brain damage," but it seems that sometimes you have to try to scare them to get them to do what is needed. Besides, what I said was true.

This baby had gone home 4 days before, after being treated with phototherapy for jaundice caused by a B-O blood group incompatability. (Mother's antibodies get into the baby's system and break down blood cells, leading to an increased level of bilirubin, which causes jaundice. Too much bilirubin causes brain damage.) At discharge, mother had promised to bring the baby back in two days for a jaundice level (bilirubin level), so we could make sure the jaundice wasn't worsening again, but now it was four days past discharge and we hadn't seen her. The previous day the nurse had called her and left a message. Earlier this day she had called again and paged her, to no avail. Finally, a couple of hours after I called her, the mother called back. She promised me that she would bring the baby in that day for a bilirubin level.

Chances are the level will be okay. Usually the jaundice doesn't worsen too much after stopping phototherapy. But occasionally it does, and it only takes one baby with brain damage from jaundice to ruin your day - and potentially lead to a large malpractice suit against you.

If there is one thing that drives doctors crazy, it's when patients don't do what they are supposed to do, especially when they have promised to do it. Before I discharged her baby, I asked the mother if she was sure she had a way back to the hospital for the jaundice level and made sure she understood its importance. She was young but seemed reliable. I knew there was a chance she wouldn't bring the baby back, but, except in the worst social circumstances, we simply can't keep babies in for days until we're sure the jaundice level is okay.

When I talked to her on the phone, she told me that she was really sick two days before, when she was supposed to bring the baby in. Maybe so, but that didn't explain why she didn't return our calls or have someone else bring the baby in. I know that many of my patients don't have cars or a lot of friends with cars, but if they can't bring the kid back, they should just say so and we'll figure something else out. Work with us, folks. We really do want what is best for the child.

I'm waiting for her to show up as I write this. I hope the baby's okay. She probably is, but I'll have just a little less acid in my stomach when she shows up and we can make sure of it.

7 Comments:

Anonymous Chris and Vic (CAK) said...

Doc, it seems you have options:
1) Mrs. Doe's ped can take over (if you call him);
2) A visiting nurse can go to the home--she would be going for follow-up anyway, right?;
3)Your discharge planner can follow up;
4) Perhaps the follow-up clinic people can follow up, if they are already making phone calls---or if the nursing staff follows up, they can make a call.

Dr. Clark B wrote something similar this week, where he himself was trying to find a ped for 5 patients who had not selected a ped at the time of discharge from the hospital. It seems to me that these tasks are not the best use of your time and expertise. Delegate them, as above.

I work with a demographic similar to yours. When visiting nurses go out to the homes, these families have neither calendars nor clocks in many cases---not to mention sufficient food in the fridge. And YOU know that transportation is iffy, as well.
(We used to provide bus tickets; and cab vouchers for hospital visits . . . now only bus tickets.) Also, you can see that it is getting towards the end of the month,and everything runs out at the end of the month . . .

Also, this young mom may have gone home to her own mom's house, or her sister's or "cousin's," who might well have said that they think the baby looks okay. And the mother may be in the awkward position of having to choose your advice (her promise to you) as opposed to Grandma's.

I think we cannot imagine the lifestyle of some young moms who are poor, whose lives are "chaotic".

Besides, what you are asking and assuming that everyone does/can do is "executive function" stuff: time mgmt, prioritizing, planning ahead, etc. I think that "chaotic" implies a lack of the above skills or a lifestyle that doesn't value these skills.
Chris and Vic (CAK)

9:24 PM  
Blogger Cathy said...

Personally, I think what you did was very admirable. I don't know many doc's who worry about their patients after discharge. The fact that you do says alot about you and the kind of person you are.

I don't always agree with you but you are a good doc.

4:55 AM  
Anonymous Anonymous said...

chris and vic have an excellent suggestion,ahve home health check on the baby.please try not to worry too much neodoc.

8:28 AM  
Blogger Ex Utero said...

I admit it. I vascilate. You have to gauge in your mind whether or not the parent is trust worthy and create your discharge plan around that. If the parent is on their 3rd child but the first one to go home rather than CPS custody, nothing is left to chance before discharge. If it's a third time mom... bilirubin check? No sweat. But it's the one's in between that get you, throw you a curve. They did everything right in the NICU then they fall of the map when they walk out. Drives me nuts.

10:54 AM  
Blogger Donna said...

Both my children (38 and 40 years old) jaundiced terribly, and I guess back then nobody thought anything of it. I certainly didn't know there was a possibility of brain damage. Learn something every day.

5:27 AM  
Blogger neonataldoc said...

Cak:

1. Yes, if she knew who her pediatrican was. But he would have had no relationship with her at all, and what can he do to get her to come in that we can't do?
2.Yes, we sent a visiting nurse out - but she might not go until next week.
3. What can the discharge planner do that we can't?
4. Handing the problem to someone else doesn't solve it.

Your point about her possibly getting conflicting advice from a relative is well taken. I'm sure that happens a lot, and they have to live with their relatives, not with us.

Cathy, you might be surprised. More docs than you think worry about their patients after discharge.

Ex utero, "drives me nuts" sums it up pretty well.

10:44 AM  
Anonymous Anonymous said...

dear sir,has she still not shown up? how is the baby?

12:56 PM  

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