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Sometimes you have to act immediately and think about it later. This doctor and his wife didn't hesitate--and didn't miss.
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Sometimes you have to act immediately and think about it later. This doctor and his wife didn't hesitateand didn't miss.
We primary care doctors are supposed to formulate treatment plans with great deliberation. Only after obtaining all necessary information and weighing it carefully and logically do we choose among the available options. Crucial, split-second decisions are for surgeons and ED docs. But it can happen that a sudden emergency forces a drastic therapeutic decision onto even a family physician like myself.
On weekends, I have office hours at my suburban Long Island home, for the convenience of patients living in the area. Early one Saturday morning I came out of the shower to find my wife, Hanna, putting down the phone, scribbling a name on a notepad.
"Who was that, darling?" I asked.
"A Mrs. Ferrara," she answered. "Her child has a bad cold, so I told her to come in before the first booked patient."
"Just a cold, that's all?"
"Yes, but she sounded worried, so I told her we'd fit her in. Is that okay?"
"Sure," I said, "if it's fine with you." My wife, who is not a nurse, fills in as my assistant when I work out of our home. I shaved and dressed quickly, and we went downstairs to the office.
Mrs. Ferrara arrived soon thereafter, carrying her 2-year-old son, swaddled in a blanket. "What's the story with Jason, Ilona?" I asked her. The Ferrara family, patients of mine for many years, had fallen on hard times. The husband had abandoned them, and they were now on Medicaid.
"Jason's had this bad cold, doctor, for a few days. I'm so sorry to trouble you on a weekend, but he had a fever last night, and he won't eat or drink at all."
While I placed Jason on the exam table, and removed the blanket and his pajama top, I asked further questions of his mother. Yes, he had vomited, but there'd been no diarrhea. He had been listless, even floppy, the last 24 hours. He had been sweating with the fever. His cough was only slight, and there was no sputum.
The heat emanating from Jason's body was evident even through his pajamas. When I fully uncovered him, I was shocked at what I saw. He was gaunt, with his eyes sunken in their sockets and staring at the ceiling. On his body, a faint, spotty rash was discernible. I lifted his head up, half knowing what to expect. Jason's neck was rigid, and his legs jerked up in the classic Brudzinski's sign of meningeal irritation.
"When did this rash come out?" I asked Ilona.
"What rash?" she replied. Then, as she looked at it, she exclaimed, "Oh, my God, there was no rash when I called you!"
My thoughts whirled. In my home office lay a child severely dehydrated and practically moribund with almost certain meningococcal meningitis. Immediate treatment was imperative. Our local community hospital was less than 2 miles up the road. But I knew that on a Saturday morning the emergency department beds would be crowded with patients held over from the previous night.
I was also aware that, even with the outstanding medical and nursing care for which our hospital was renowned, at that hour there would be only one physician on duty in the ED, and only one medical resident on call for the entire hospital. There was no full-time pediatric fellow available then. By the time we reached one of our consultant pediatricians, it might be too late.
Like a sudden epiphany, an idea came unbidden to my mind, an imperative instruction that could not be dismissed. "Listen, Ilona," I said, speaking forcefully to the mother, who still held her hand over her open mouth, where she had clapped it when she saw my reaction to her son. "I'm sorry to tell you this, but Jason is very ill. It looks like he has meningitis. If we don't move fast it will be too late. Do you know where the Schneider Children's Hospital is?" It was 15 miles away, toward the opposite shore of Long Island. Fear in her eyes, Ilona nodded.
"Okay then. Put Jason in the back seat, and drive there as fast as you can. Don't waste a second! If the lights are red, drive carefully through them. Watch out for traffic though! If a cop stops you, point to the back seat, tell him the situation, and ask him to turn on his siren and lead the way for you. Go straight to the emergency entrance at Schneider. I'll call ahead."
They left in a cloud of exhaust smoke. With a silent prayer on my lips for their safety, I dialed the hospital and asked for the chief pediatric resident. When she responded I said, "This is Dr. Hodes. I am not on staff at Schneider, but I am sending you a child with fever, dehydration, stiff neck, and a rash. I'm sure it's meningococcal meningitis. Please alert your ED staff to expect it. The patient will be there very soon.
"Meningococcal?" she asked. "Are you sure? Have you done a culture?"
"No! There's no time for a culture!" I shouted, my voice rising several decibels. "This child is desperately ill. Please be waiting for it!"
"Well, doctor, uh, what did you say your name was?" came the response.
At that point, even knowing that I was possibly committing a breach of hospital protocol, I pulled rank on the resident. It so happened that the chief of the Schneider Children's Hospital and I had been friends for many years, even before we were medical students together in Cape Town. "Look, doctor," I said to her, carefully enunciating my words. "Please understand this. My name is Dr. Hodes, H-O-D-E-S. I am a personal friend of your hospital's chief. I want you to be ready and waiting in the ED, fully prepared for a calamity. Is that okay with you?"
Her tone and attitude changed noticeably. Perhaps she recognized my South African accent. "Of course, doctor, right away!"
My first booked patients were starting to arrive. After seeing the first three or four, I called Schneider Hospital to see how Jason was doing. It took some time to speak with the appropriate person, but I was informed that Jason had reached the ED, had been treated by the staff, and transferred to the ICU. His condition was "stable." Although it was difficult to concentrate, I continued to see patients.
Three hours later, Ilona called from a hospital pay phone. Between sobs, she recounted her morning. When she'd arrived at the Schneider ED, a team was waiting at the entrance with a gurney and a crash cart. Jason had needed resuscitation. He was on IV fluids, oxygen, and many medications.
A spinal tap confirmed meningitis. When Ilona had left the pediatric ICU, he was drowsy but responsive. Relieved, I finished office hours.
Then I tidied the exam rooms, and called the hospital again. It was difficult to find the actual doctor who was in charge of Jason's care. But the nurses assured me that the child was doing well on fluids and antibiotics. More importantly, the lab informed me that when they stained the spinal fluid they found meningococci!
I pondered the events of the morning. Thank Heaven, everything had worked for the best. But many questions beset me. Had I done the right thing by sending Ilona 15 miles by car with a desperately ill child? Had I been too impetuous? Shouldn't Jason have gone to the local hospital, to be seen by the pediatrician on call? Shouldn't I have waited for an ambulance? What if Ilona, in her terrified state of mind, had crashed her car? And thenwhat would have happened if my wife had told Ilona to bring her ailing child in after office hours?
This final thought was too frightening to contemplate. I reassured myself that, in this case, the end had justified the means. With silent thanks to Divine Providence, I went upstairs for lunch.
At the table, my wife asked me, "Did you fill in a coding slip for that Ferrara child?"
"No, darling, I didn't," I replied. "There's no point, reallythey're Medicaid. The fee isn't worth the effort to claim it."
A delicious chicken salad lay before me. I was hungry. There was no time to waste debating which particular code to use for that consultation. And there certainly was no code in the book that would cover the services of my dear wife, who had told a young mother to bring her sick child in early, and thus saved his life.
"Careful!" my wife exclaimed. "You'll knock over the salad dressing! Why are you kissing me right now? And why are you crying?"
Meyer Hodes. Credit my wife with saving my patient. Medical Economics 2002;7:89.