The teenager was transferred from the local inpatient psychiatric facility to the emergency department of Children’s Hospital. There had been repeated episodes, witnessed by their nursing staff, during which he became unresponsive, even to sternal rub. There was no cyanosis during the episodes, and no incontinence. There have never been any injuries from falls associated with the onset of these events.
Careful history in the ED indicates these events have been going on for months. Initially they were solely occurring at school, but they have increased in frequency and duration. Neurology examines him and concludes these aren’t seizures. They do not recommend any testing and don’t want him on their service, so the ED admits him to the general pediatric service overnight. Cardiac exam is normal. EKG is normal. Overnight telemetry shows no arrhythmias or vital sign changes. Neurologic exam is normal. The clinical medicine team concurs with the diagnosis of pseudoseizures, although malingering and conversion reaction remain in the differential. The inpatient psychiatric service would be the best place to investigate and treat this. The resident relays the findings to staff at the psychiatric hospital, and an ambulance takes him back.
However, while this is occurring, there is a changeover in the attending of record at the psychiatric facility. The new physician is not satisfied with the mere clinical opinions of the neurologists. She demands testing to prove these episodes are not seizures. The ambulance brings him back to the Children’s Hospital, where he is readmitted. Neurology, under duress, performs an EEG the following day, which is normal. However, no unresponsive episodes occur during the EEG. On discussion with the other facility, the stakes are increased again. Should a video EEG of 24 hours, or even 72 hours be done? What about a Holter?
Pseudoseizures are not the only diagnosis causing these conflicts. The psychiatric facility frequently sends children with intractable abdominal pain in for evaluation. I haven’t found a case of appendicitis yet among that group. I’ve certainly admitted many children with chronic abdominal pain who I believe would be better treated by a psychiatrist.
The interactions and transitions of care between subspecialty services are fraught with anomalies. Business people refer to it as silo mentality, which is at best inefficient, at worst a cause of failure. When I did locum tenens in one small town, the ED nurses were surprised that I, a general pediatrician, would discharge a child with abdominal pain without a consult and examination by a surgeon. Two months later, at another facility, a general surgeon made it clear that until there was a CT scan with a radiology reading confirming appendicitis, he wasn’t coming in from home. There is wide variation in customary care.
As a hospitalist, part of my time is dedicated to improving the system. Reviewing sentinel events such as readmissions is part of the quality improvement process. A round-trip ambulance ride is clearly not good care. Fixing the problem, however, requires finding the right tool.
One option is the morbidity and mortality (M&M) conference. While surgeons find that approach useful, I observe it to be frequently dysfunctional. Somebody sees something that didn’t go right. They propose a new policy which will prevent that problem from recurring. Nobody does research to prove that the solution really works. They never consider, much less measure, whether this new practice causes more problems than it solves. Then, years later, no one can quite recall why we began doing things this way, which makes dysfunctional procedures very refractory to correction.
Another tool is a peer review committee which investigates cases. On that committee, I strongly advocate that before any decision is made, a request for information letter be sent to the staff involved to hear their side of the story, which frequently isn’t captured in the documentation.
In any human endeavor, differences of opinions will occur. Professionalism is an art of resolving these differences while keeping the focus on what is best for the patient. If the physician at the psychiatric facility truly thought these events were seizures, and that neurology had not adequately investigated them, I as a hospitalist needed to find a way of addressing that concern. There is a limit, however, to allowing a physician of one specialty to insist upon a test being done by a different subspecialist.
If you were expecting this column to end with a nice, tidy description of the solution I found to keep this particular situation from happening again, I’m sorry to disappoint you. I’m an engineer and a pediatrician, not a miracle worker. As a hospitalist, I patch together a quilt of different subspecialty services to form a blanket that will cover all the patient’s needs. Sometimes, quick-on-my-feet problem-solving is more effective than policies and procedures. I do advocate for a policy that, as long as the patient is on my service, consultants are advisers and ultimate decision-making responsibility rests on me. Still, I wish everyone would play together nicely in the sandbox.