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Stand There or Do Something

Baruch S. Fertel, MD, MPA, FACEP

It’s called collaborative care, and it works miracles

Wednesday, June 12, 2019

I

’m always happy to see my friend Zev, but not when he runs into the ER with a child flopping limply in his arms.

“Help me, something’s wrong!”

Immediately, a team coalesced around him. Zev’s son Ari, six years old, was sucking shallow breaths, limp, and lethargic. His skin was dry and papery. It looked like sepsis.

My partner resuscitated and stabilized him and arranged for admission to the PICU. I watched as they wheeled him up to a unit, Zev jogging alongside.

When my shift was over, I went up to the PICU. My badge didn’t work (to protect someone from abducting a child, pediatric care areas are restricted), and I needed a standard visitor’s pass to enter the PICU. Zev or his family had to approve it every day when I came to visit.

On the first day, Ari’s condition was tenuous. He lay unmoving, IV fluids and antibiotics hanging nearby, with additional medication to support his blood pressure.

On the second day things weren’t much better.

On the third day, Zev walked me out of the unit. “Listen, Baruch,” he said tensely. “Tell me the truth. I can handle it. He’s not getting better, right?”

Zev’s face was grey, the color that comes from living on Planet PICU for days on end while your kid dangles at the edge of a cliff with only yards of plastic tubing keeping him from falling.

I hesitated. “What does the attending doctor say?”

“Nothing. I don’t know. Wait and see. Wait it out. Stuff like that. Baruch, tell me the truth. Should I transfer him to another hospital?”

I understood him. He wanted his kid to get better, and it didn’t seem to be happening. So maybe another hospital could do more to help?

I work at a large academic medical center. We get transfers all the time, and often they’re very appropriate. If the patient is in a small rural hospital, they might not have the equipment or resources the patient needs. Even in a larger hospital, if the case is getting more complex or the patient needs advanced therapies like ECMO, you may need to transfer him so he can access appropriate care. If the patient needs a transplant, take him to a transplant center. Sometimes, for cases that require very specialized treatment, a patient may even need to be moved out of the country.

But as with everything in life, transfers carry risk. You have to move the critical patient, with life-supporting equipment, to a transport vehicle — which might be an ambulance or might be a helicopter or might even be an airplane. Things can get dislodged, there is exposure to the elements, stress on the patient. The equipment in the transport vehicle might or might not have the same level of capability as the hospital had. A 30-minute transfer via ambulance might not be a big deal. But a transport across the country — from the hospital to an ambulance to a helicopter to another ambulance over ten hours — is another story.

Before you expose the patient to risk you need to ask some hard questions: Who is recommending the transfer and why? What does the other hospital have that this hospital does not have? Is the second hospital better? How much better? What margin of “better” justifies the risk of the transfer?

I told Zev about Chaya.

Chaya had been in a top-tier hospital in another city. She, too, had developed sepsis following pneumonia and was being treated with antibiotics, IV fluids, and pressors when indicated — the standard of care for her condition.

Chaya was making slow progress, as was to be expected, and everything was under control, until someone who knew someone who worked in another major healthcare system decided that Chaya should be transferred to our hospital.

The medical team at the first hospital didn’t see any benefit in transferring. Chaya was progressing as expected, and there wasn’t any critical service available at our facility that wasn’t available at the first one. While Chaya was classified as stable, they didn’t think she was stable enough for transfer.

Chaya’s family hired a private medical transport service and signed her out AMA (against medical advice). The doctors and nurses looked on silently as the men in crisp uniforms swooped in and whisked Chaya away.

At the receiving hospital too, there was confusion. Since the transfer hadn’t been arranged in advance, Chaya was brought in through the ER. As we evaluated her, we picked up some alarming signs — Chaya was going into cardiac arrest.

Who knows whether the transfer didn’t cause harm?

I told this to Zev. He bit his lip.

“So when should I consider transfer?”

I get it. Your loved one is sick and you want them to get better and it’s not happening or it’s not happening fast enough and you feel like you need to do something. And arranging a transfer to another hospital is a big deal and definitely makes you feel like you’re doing something.

Every physician wants his patient to get well as quickly as possible. Most physicians will do the right thing and send patients to the best place for them. We know our limitations.

“If Ari is not getting better,” I said, “or if, G-d forbid, he’s getting worse, then you should consider transferring him. Or if the hospital he’s in doesn’t have the capability to handle the case. Then you work together with the team to identify a medical center that can provide what the original hospital cannot provide.”

There was desperation in Zev’s voice. “So who is supposed to decide? I don’t know anything about anything, and the doctors think they’re doing well, and you’re telling me an outsider is useless.”

“The best people to make the decision are the people who are here. You and the medical team. That’s who knows what’s really going on.”

It’s called collaborative care, and it works miracles. Many ICUs have multidisciplinary rounds where all the consultants and specialists collaboratively plan for the patients’ care. This system avoids compartmentalization (when practitioners naturally fall into a myopic view of the patient based on their own specialty). Many pediatric units, like in our hospital, have taken it a step further and introduced family-centered rounds where the patients’ family joins the rounds to hear the plan and gets the opportunity to weigh in and ask questions. The family is part of the team.

Zev needed to take advantage of that.

“Sit down, and talk to the care team,” I told him. “Avoid the tendency to listen to well-meaning but uninformed friends and advisors. They may be superb nurses, askanim, or even physicians, but chances are they don’t know the nuances of this specific case.”

In Zev’s case, and probably in Chaya’s too, there was an element of unrealistic expectations. The family wanted the patient to get better now, and no one had explained to them (or they weren’t willing to listen to) what the typical course of treatment and recovery would look like.

During rounds the next day, Zev met with the entire team caring for Ari. He asked good questions and reviewed the information with his pediatrician who was able to provide objective advice and with whom Zev felt comfortable. Ultimately they decided to keep Ari where he was.

Ari recovered slowly. The family continued to participate in the daily rounds. There was never any need to transfer him, and anyone who sees him now would never know that this time last year he was lying unresponsive in an intensive care unit.

Don’t just do something. Sometimes it’s best to just stand there.

Originally featured in Mishpacha, Issue 764. All names and identifying details have been changed. Patient profiles may be based on composite cases.

 

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