Tuesday, October 14, 2008

Should you trust your pediatrician?

I was over at Whitecoat Rants and was reading his post about pediatric cold medicines that spilled over into a post about the over-prescription of antibiotics. This reminded me of an older post of mine entitled updates skip down to point number three and it'll help explain where this post is coming from. You really need to read it to understand the rest of my post.

A yeast infection is one thing. Killing a kid with lack of knowledge is entirely different. I'll admit I've tended to blindly follow doctors orders, assuming they knew more than I did, but that all changed about a month and a half ago.

We had a known 11 yr old leukemic patient visit our ER a month or so ago. The kid had a super low platlet count. I think it was 5000 or so. He also had a slightly decreased hgb and hematocrit.

The Er Dr. contacted one of the patients specialists in a larger city about 3 hours away and called me to order an obscene amount of blood and platlet products. I called the E.R. doc and he admitted it sounded like alot but the patient was being admitted so he didn't want to deal with it. Fair enough.

I waited untill the child made it to the floor and asked the nurse to verify exactly what the orders were. I don't know if there was a mix-up in communication or if people just follow whatever protocol they make up, but, she read to me that the Dr. ordered 15 ml/kg of both PRBC and platlets. the kid weighed 50 kg. His hemoglobin was 10. Frankly I couldn't figure out why they were transfusing PRBC in the first place but 750 of PRBC is alot for a 50 kg kid. They also ordered the equvilent of 4 plateletpheresis, which is an ungodly amount. Because of the highly concentrated nature of a platletpheresis product normal protocol is to infuse one unit and perform a platlet count. a more acceptable transfusion ratio is about 5 ml per kg. this ratio should raise the platlet count by about 50,000.

The goal in these scenarios is really just to get the patients platelet count about the spontaneous bleeding threshold of 20,000. The goal isn't to reach "normal" levels again.

I realize I've given entirely too much backstory. So I ask the nurse to please have The Dr. call me to hash out exactly what this kid needed. The Dr. that calls me back is my son's pediatrician. I thought pretty highly of her so I was sure this would be smooth sailing. Not so much. It took me an hour to convince her that giving that much volume to this kid would certainly produce Circulatory overload . I had to fax her an entire chapter in the AABB technical manual to help her make an informed decision.

I'll admit a 50 kg 11 year old with leukemia is a tricky situation not knowing wheter to follow pediatric or adult guidlines considering his weight.

I think I was most troubled by the fact that while I was talking with the Dr. she seemed to sway back and forth and really have no idea what I was talking about. I tried explaining the differences in plateletpheresis and random donor platelets, And I tried explaining that 750 ml of prbc would spike a normal adults HGB about three grams and it would function differently in a 50 kg child.

I understand that as a DR. you can't know everything but It just seemed like this Dr. should have known transfusion protocol for children if she's a peditrician, especially one with leukemic patients.

I just swithced to her because of the whole antibiotic mess, I didn't think she was an idiot, and I hope she's not. I just wonder how much I trust my child's Dr. right now. Pediatricians want to take cold medicines off the shelf because they think parents are too stupid to properly dose their child. In the last year I've had two differnet Dr's make equally stupid decisions. Who can you trust if you can't trust you're child's Dr?

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