The Tough Decision

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One busy night, the EMS crew pulled a stretcher which had carried a mother with her three young children. DCFS (department of child protective services) and local PD (police department) officers came along with them. The charge nurse sent them to the waiting area after she had done her preliminary screening. University of Chicago hospital’s nurses went on strike so of course, It has impacted other local hospitals. The waiting area of ER was full than usual.
Around 10 PM, all three children were brought inside the ED. There were only two hours left for my shift to end, so I was trying to wrap up which included discharge, admit or transfer. We do our best not to leave anything pending for the next shift. The charge nurse came with the request if I could see those patients quickly. The charge nurse was confident that I would able to discharge three kids in 2 hours. Of course, it was not a big deal. Sometimes, the DCFS cases are just for a well-baby exam so they could place the children in the foster care. However, this case was so not simple and easy. as we thought. I had to face the dilemmas where I fought myself to decide thinking about being a mother and a medical professional. Two hours were not enough to make the decision. It was not only my solo decision. I ended up to involve at least four other hospital’s emergency rooms and their neurologists.

This was the first case when I had stayed three hours overtime. After working 12 hrs in a busy ED, you are just wanting to be out on time instead of staying 15 minutes late. My case was totally different. My shift used to end at 0700 but Altaf always called me around 0659 am. He won’t stop calling until I answered his call. Most of my workers used to tell me, “answer your loving husband otherwise he will be continued calling and we won’t be able to get proper report”. Of course, I was unable to concentrate if he had continued to call. So, most of the time ended up leaving on time to save me from his interrogation. I still wait for his phone exactly at the same time even everything has changed. I still look at my phone waiting for his call during reporting to the next shift. Everything has changed now. Nobody cares or waiting for me or ask me if leave on time or not.

There is no lack of patience in me, so I was not hurried to leave the department that day. I am not sure if it was a duty, empathy, or my own pain of separation that I went beyond my limits. I did not feel comfortable signing those patients to the next shift doc. The case was so complicated. My one mistake could separate the kids from the mother, or the little girl could end up having permanent brain damage. I was confused as hell who is right; Is the mother right or Is the medical team right? Living with my brilliant hubby, I have learned some detective work too which have helped to solve this case.

The local police and child protective services had brought these kids for medical screening against a mother’s advice. The social worker of DPS was not concerned about six- and four-year-old children. His main concern was 23 months old baby girl who was diagnosed with seizure/epilepsy at the age of six month due to some congenital abnormalities. Per social worker, the mother took the child from a children hospital against the medical advice this morning. The medical provider has a right to decide against the parents’ wishes if there is a danger to the child’ health. So, the other hospital has informed the local police and child protective services. Mother did not allow the staff to give her daughter a medication. Mother also refused to perform an MRI. Now it has become my problem waking everybody during nighttime. Not to mention, we don’t have a pediatrician in my hospital. We take pediatric patients in our emergency department only to treat basic illness. However, we need to transfer the children to the local children hospital if they require hospitalization.

I did my initial interview with the mother. She said, “My daughter does not have epileptic disorders then why doctors keep giving her anti-convulsant medicine. I googled the medication and it has many side effects. Why my daughter needs the medication if her EEG was normal and already seen two different neurologists”. Mother stated that her daughter had a febrile seizure, so she was shaking and was not having a seizure. It is very common for the child less than five years old could have a seizure with high-grade fever. The mother said, “One neurologist said the shaking was due to high fever, but another said no, her daughter has a real seizure disorder, so she needs anticonvulsant. They have made a wrong diagnosis and now doctor not accepting his error. I want to press charges and sue the dame doctor for making a wrong diagnosis”. The mother was little hot-headed and won’t ready to listen to anybody which could make her lose her children.

For a while, I was also become confused if the doctor trying to hide his wrong diagnosis or mother is not accepting the reality about her daughter’s epileptic diagnosis. This was the child’s first visit to our hospital, so I did not have the previous record about the patient’s medical history. The patient was neurologically intact and hemodynamically stable and did have a normal physical exam. I did clear her both siblings medically. However, the youngest was my challenge. Meanwhile, I already admitted my two sick patients to ICU, so I was having enough time only for this little girl. I had a day off the next three days, so I did not care how long I needed to stay for making the right ethical decision.

First, I called the hospital where the patient was admitted yesterday. I spoke with the pediatrician who gave me the child’s past medical history, “the child was brought to the emergency room in a postictal stage first in Jan 2019. The mother told the doctor that she had not given her daughter medication since the past couple of days. Pt did not have any URI or fever at that time. The child was also taken again to the same ED in May while the child was unconscious after prolonged seizures. Pt was kept in the same hospital for one week to do all the required testing. First EEG did show slow brain activities but no active seizures and neurologist marked the impression, Abnormal”. The second EEG was done one week later continue monitoring of brain activities which also shows slow brain activity but no acute seizures, which was also marked as an abnormal by another neurologist. June the child had another activity. The external medical records show the patient was also seen in another three different hospitals for the same problem”
The same pediatrician told me about the current medical history, “The child was admitted again one week ago, seen by two neurologists and both recommended increase doses of anticonvulsant, and do the MRI. Then again yesterday the child had seizures type activities which were observed by the medical staff and was got caught in the camera of the nursery unit. Pt did not have any symptoms of infection includes fever. We think that mother not giving the child medication which causing the recurrence of seizures. This was the reason we had informed the protective services. We think that the patient requires her medication”. I sipped my coffee which has made me energetic. My gut told me that someone is lying somewhere.

I told my unit sec to call another three hospitals to obtain the medical record. Well, what you will get when the medical record department is closed in the middle of the night. sometimes professional courtesy works so the unit clerk was able to get an emergency room. So far, all evidence was against the mother. I gave her an appropriate decision that, “continue giving the anti-convulsant until the neurologist will make his final decision. This way you won’t lose your kids”. However, mother has started to get little aggressive with us, “You guys are just wanting to kill my daughter by giving the medication which had a lot of side effects”. I asked the mother if she observed any side effects which her google doctor had told her. No, mother was just being stubborn. I was confused and afraid to make the wrong decision. Who would understand the pain of separation than me?

I had only one choice left calling the neuro doc during the nighttime which is similar to calling the tiger to offer your meat. Neurology department is the worse one to call during nighttime. I don’t blame they have to work hard day and night. They are the grumpiest people in our medical family. Anyway, the senior neurology resident called me who was very sharp, and fortunately, also had treated this kid. His recommendation was very firm, “The child needs to get a higher dose of medication”. Well, the neurologist has done his job and mother was still stubborn as a rock.

After consulting everybody, I have made my decision to give the patient loading dose intravenously, then twice a day until the neurologist will see the patient, and pt needs blood level drawn every 48 hrs to make sure mother is compliance with the medication”. My job was done with my recommendation. Now it is was up to the child protective services to decide if the mother continues to refuse. I left the emergency department after reporting the case to the night shift doc. I could hear mother cursing me and using all kind of worse words, which I have ignored completely. Believe me, all of us are used to hear those cursing nasty words when we don’t do what patients’ want. It does not matter how much you explain to them.

I followed with the night doc after a couple of days, “Hey, what happened to the child. Did mother let you give the medication or what?”. Of course, the mother had refused giving a medication to the child. The protective services ended up removing the children from her custody.

I had made a recommendation to ensure the safety of the patient’s health. I was feared the mother might won’t take the child back to the hospital if the child has another seizure activity, which may lead to permanent brain damage. However, I felt sorry for the mother who had lost three children to protective services. The protective services had done their job to take custody of all children. This is not an end yet. Now I have received the letter from the court to testify.

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