Could I have been a better advocate for my son in the emergency room?
March 30, 2016 2:54 PM Subscribe
This past week, my 4 yr old son had an accident and tore his ear lobe. The ER didn't do a great job on the stitches. Could I have insisted they call a plastic surgeon, in that moment?
The cut extended back behind the ear, making the stitches difficult. The nurse's first attempt looked, to my eye, very bad: the flesh wasn't meeting up properly, and there was a little nubbin of sticking out on the bottom. She tried to convince me that that was the best that could be done, and that they could cut the little nubbin off, if I wanted.
I asked for a second opinion and they called the doctor in. He told her she did it wrong and how to do it right. Her second attempt looked better, even though the little nubbin was still present. She said as the ear swelled up, that piece would come into alignment. I asked about a plastic surgeon, but she said I would have to come back the next day. We went home.
We went to the pediatrician two days later to check the stitches and she said they did a bad job and we should go see a plastic surgeon, who could recut the wound and set it right. I know nothing about plastic surgery, but when I called around for consultations, none of them had heard of ever doing that.
The ear is mostly healing fine, but he still has that little nubbin sticking out. We are getting the sutures out at the plastic surgeon's office, and will get the consultation then.
The whole thing was very traumatic, and I keep worrying that I missed the only opportunity to have "fixed" my son by not insisting they call for a surgeon, or that the doctor at least do it. This was my first real ER experience as a parent and advocate. Did I mess up? What were my options?
Thanks for any advice-
cgs
The cut extended back behind the ear, making the stitches difficult. The nurse's first attempt looked, to my eye, very bad: the flesh wasn't meeting up properly, and there was a little nubbin of sticking out on the bottom. She tried to convince me that that was the best that could be done, and that they could cut the little nubbin off, if I wanted.
I asked for a second opinion and they called the doctor in. He told her she did it wrong and how to do it right. Her second attempt looked better, even though the little nubbin was still present. She said as the ear swelled up, that piece would come into alignment. I asked about a plastic surgeon, but she said I would have to come back the next day. We went home.
We went to the pediatrician two days later to check the stitches and she said they did a bad job and we should go see a plastic surgeon, who could recut the wound and set it right. I know nothing about plastic surgery, but when I called around for consultations, none of them had heard of ever doing that.
The ear is mostly healing fine, but he still has that little nubbin sticking out. We are getting the sutures out at the plastic surgeon's office, and will get the consultation then.
The whole thing was very traumatic, and I keep worrying that I missed the only opportunity to have "fixed" my son by not insisting they call for a surgeon, or that the doctor at least do it. This was my first real ER experience as a parent and advocate. Did I mess up? What were my options?
Thanks for any advice-
cgs
It's okay that you handled this the way you did. Do not beat yourself up about it! You proceeded the best way you knew how with the information you had at the time.
Now, yes, you can request/demand a plastic surgeon. There may or may not be one available at the time. But yes, you have that right. You pretty much have the right to ask for anything reasonable in the ER, really. I always say that there's nothing to lose by asking.
And hey! Congratulations on getting to year four with only the one ER trip!!
posted by cooker girl at 3:06 PM on March 30, 2016 [6 favorites]
Now, yes, you can request/demand a plastic surgeon. There may or may not be one available at the time. But yes, you have that right. You pretty much have the right to ask for anything reasonable in the ER, really. I always say that there's nothing to lose by asking.
And hey! Congratulations on getting to year four with only the one ER trip!!
posted by cooker girl at 3:06 PM on March 30, 2016 [6 favorites]
I really don't think you could have known if you had any other options or what they were. You may have been able to demand a surgeon do it, but in that moment would you have thought they wouldn't have the right person do it? Would you have known it wouldn't turn out right? You asked questions and trusted the medical professionals. I wouldn't beat yourself up about it.
When I was little, I scrapped my knee and got a deep gash with a skin flap. My mom was out of town and my dad didn't know what to do so instead of cutting away the skin flap he just bandaged it all up. It healed fine, but I was left with a little nub. Eventually, I had a plastic surgeon remove it. These things happen. I'm sure you can have the nub removed.
I wouldn't call around and ask plastic surgeons if they can do a specific procedure, instead I would just let a plastic surgeon look at it and decide what the course of action would be. Maybe it would be re-cutting it and letting it heal (what they did with my knee) or maybe it would be simply removing the nub itself.
posted by AppleTurnover at 3:14 PM on March 30, 2016
When I was little, I scrapped my knee and got a deep gash with a skin flap. My mom was out of town and my dad didn't know what to do so instead of cutting away the skin flap he just bandaged it all up. It healed fine, but I was left with a little nub. Eventually, I had a plastic surgeon remove it. These things happen. I'm sure you can have the nub removed.
I wouldn't call around and ask plastic surgeons if they can do a specific procedure, instead I would just let a plastic surgeon look at it and decide what the course of action would be. Maybe it would be re-cutting it and letting it heal (what they did with my knee) or maybe it would be simply removing the nub itself.
posted by AppleTurnover at 3:14 PM on March 30, 2016
I think you did great! I thought the same thing about how if there is a little nubbin or scar that it will be a great story someday. :)
I tend to look at experiences like this with a "what did I learn?" eye. What I would take away from this experience is that you *can* and *should* speak up when something doesn't feel right, when your instinct is setting your alarms off, etc. Luckily you are learning this with a 'superficial' wound so should you be in another unfortunate ER visit and you feel this again you will not be hesitant to speak up.
posted by CoffeeHikeNapWine at 3:14 PM on March 30, 2016 [3 favorites]
I tend to look at experiences like this with a "what did I learn?" eye. What I would take away from this experience is that you *can* and *should* speak up when something doesn't feel right, when your instinct is setting your alarms off, etc. Luckily you are learning this with a 'superficial' wound so should you be in another unfortunate ER visit and you feel this again you will not be hesitant to speak up.
posted by CoffeeHikeNapWine at 3:14 PM on March 30, 2016 [3 favorites]
The possibility of future cosmetic scarring is not an emergency, so it's not strange that a hospital wouldn't have a plastic surgeon on call 24/7. Going in later for a consult to review the actual scarring is more standard. Plastics surgeons fix what is already messed-up. You didn't miss your chance!
posted by ThePinkSuperhero at 3:28 PM on March 30, 2016 [10 favorites]
posted by ThePinkSuperhero at 3:28 PM on March 30, 2016 [10 favorites]
Don't beat yourself up about it! I used to work in a plastic surgery practice. We fixed torn lobes all the time. My advice, though, would just be to wait and see how it heals. Our surgeon did earlobes with only local anesthetic and that's not something I would really want to put a 4 year old through. Even if they said they would put him under, there's obvious risks to that as well. I vote with everyone else that it'll probably just end up being a good story for him! And yes, if this ever happened again, you can ask for a plastic surgeon.
posted by fresh-rn at 3:32 PM on March 30, 2016 [2 favorites]
posted by fresh-rn at 3:32 PM on March 30, 2016 [2 favorites]
A plastic surgeon can totally fix this later on. The ER messed up my split upper lip (REALLY badly, I was totally disfigured) and a plastic surgeon later fixed it to where you can hardly tell anything ever happened.
posted by HotToddy at 3:39 PM on March 30, 2016
posted by HotToddy at 3:39 PM on March 30, 2016
You got emergency medical attention for your kiddo and trusted the professionals. You totally did your job!
Plastic surgery would never have occurred to me when my son split his eyebrow open, but we went to the pediatrician (just as close as the ER and a block away from the hospital if they'd told us to go there). The pediatrician bandaged my son's whole head and sent us to a plastic surgeon that he also notified about our arrival that day.
My point is NOT that you made a mistake (I really don't think you did!), but that in the future you might want to call your pediatrician if you don't feel comfortable with the treatment your child is getting elsewhere. You're the kid's primary advocate, and a good pediatrician can be an advocate too, so don't be shy about keeping them in the loop.
I'm sorry about the scary experience! Be well!
posted by whoiam at 3:44 PM on March 30, 2016 [1 favorite]
Plastic surgery would never have occurred to me when my son split his eyebrow open, but we went to the pediatrician (just as close as the ER and a block away from the hospital if they'd told us to go there). The pediatrician bandaged my son's whole head and sent us to a plastic surgeon that he also notified about our arrival that day.
My point is NOT that you made a mistake (I really don't think you did!), but that in the future you might want to call your pediatrician if you don't feel comfortable with the treatment your child is getting elsewhere. You're the kid's primary advocate, and a good pediatrician can be an advocate too, so don't be shy about keeping them in the loop.
I'm sorry about the scary experience! Be well!
posted by whoiam at 3:44 PM on March 30, 2016 [1 favorite]
Honestly, this is a 1 on a scale of 1 to 10. It's behind the ear? I doubt it needs anything right now.
The most important thing is that your son got what he needed, when he needed it.
We all have our scars, and you both can make up cool stories to tell about how he got I. Pirates. I'd go with pirates.
posted by Ruthless Bunny at 4:05 PM on March 30, 2016 [3 favorites]
The most important thing is that your son got what he needed, when he needed it.
We all have our scars, and you both can make up cool stories to tell about how he got I. Pirates. I'd go with pirates.
posted by Ruthless Bunny at 4:05 PM on March 30, 2016 [3 favorites]
someday someone will love that little scar.
posted by andrewcooke at 5:53 PM on March 30, 2016 [20 favorites]
posted by andrewcooke at 5:53 PM on March 30, 2016 [20 favorites]
Did I mess up? What were my options?
I wouldn't say that you messed up at all. A trauma involving your child is fraught with anxiety. You absolutely had the right instinct to question the nurse and get the doc's opinion. Should you have pressed the issue about a plastic surgeon or had the doctor do it? Maybe. Hindsight says yes you should have , given your pediatrician's opinion.
BUT in the moment at the ER with an injured child we tend to follow the doctors professional opinion. I think you did a great job and you are in good hands and on the right track now! And even if you had insisted on a plastic surgeon or that the ER doc do the stitches himself you might have been turned down.
I had a very similar situation and in hindsight I really wish that I had made a major scene in the ER but I didn't due to trauma, stress, and generally feeling that I shouldn't question the doc and they sent me home and I almost lost my finger because of it. Every doc that saw me after that was appalled that I was sent home.
So if this ever happens again you will be armed for bear to be an advocate for your family or yourself. Best wishes to you and mini cgs!
posted by futz at 6:00 PM on March 30, 2016
I wouldn't say that you messed up at all. A trauma involving your child is fraught with anxiety. You absolutely had the right instinct to question the nurse and get the doc's opinion. Should you have pressed the issue about a plastic surgeon or had the doctor do it? Maybe. Hindsight says yes you should have , given your pediatrician's opinion.
BUT in the moment at the ER with an injured child we tend to follow the doctors professional opinion. I think you did a great job and you are in good hands and on the right track now! And even if you had insisted on a plastic surgeon or that the ER doc do the stitches himself you might have been turned down.
I had a very similar situation and in hindsight I really wish that I had made a major scene in the ER but I didn't due to trauma, stress, and generally feeling that I shouldn't question the doc and they sent me home and I almost lost my finger because of it. Every doc that saw me after that was appalled that I was sent home.
So if this ever happens again you will be armed for bear to be an advocate for your family or yourself. Best wishes to you and mini cgs!
posted by futz at 6:00 PM on March 30, 2016
Best answer: Most hospitals do not have plastic surgery available on call 24/7 (except maybe by phone), or sometimes even during business hours. Except with life-threatening issues (stroke, heart attack, massive bleeding, need for imminent surgery) it is unusual for a specialist to come see a patient themselves in the ED off hours; some specialties will be available by phone and can recommend the patient either be admitted or held until morning when they can evaluate the patient if really necessary. The exception is big academic hospitals to some extent who might have a resident in that specialty in house overnight, but I would not advise that route because the wait time will be longer (more sicker patients) and there are other tradeoffs. (Unless you happen to live right next to a children's hospital, in which case I might use their ED for your kid.)
In the future if you have similar concerns the best you can reasonably do in the moment is to ask the ED doc (attending) to do XYZ themselves. There is a chance they'll say no (because they have other sicker patients they need to see or whatever), but they'll frequently agree. You should always bring up your concerns, though! It's hard to know as a patient what is or isn't possible.
posted by ellebeejay at 9:04 PM on March 30, 2016 [3 favorites]
In the future if you have similar concerns the best you can reasonably do in the moment is to ask the ED doc (attending) to do XYZ themselves. There is a chance they'll say no (because they have other sicker patients they need to see or whatever), but they'll frequently agree. You should always bring up your concerns, though! It's hard to know as a patient what is or isn't possible.
posted by ellebeejay at 9:04 PM on March 30, 2016 [3 favorites]
Response by poster: Thanks, everyone! This has really helped.
posted by cgs at 6:13 AM on March 31, 2016
posted by cgs at 6:13 AM on March 31, 2016
I see you've marked best answers, but I'm an ER doctor so I thought I would give you some thoughts as well, because "how can I be a good advocate in the ED" is a good question.
Thoughts on this specific case:
- You didn't do anything wrong. There is very rarely any reason to request a plastic surgeon for a laceration repair. Emergency department doctors (and PAs and NPs) do laceration repairs multiple times a day every day and are very comfortable with that procedure. I wouldn't demand a plastic surgeon for my own child, although if it looks like a complicated wound, I would ask that a senior member of the team that's available take care of the repair if possible. I have definitely seen on the internet the implication that "you should always ask for a plastic surgeon for any wound at all because you must have only the best for your child!" Almost suggesting there's something wrong with you as a parent if you didn't demand plastics. That's silly. You'll stay 3 hours longer to get an end result that's exactly the same. An uncomplicated laceration repair is a procedure that a medical student can do a great job on.
- If you demand a plastic surgeon in my large, tertiary care academic center, we will consult plastic surgery to make you happy, but it will prolong your stay in the emergency department by many hours, the final result will likely be exactly the same, and the "plastic surgeon" that you get is a resident, not an attending - in fact it may not be a plastic surgery resident or even a surgery resident (emergency medicine residents rotate on the plastics service as an elective sometimes - it always gave me a little smile if someone demanded plastics and actually got an EM resident instead of the attending they could have had otherwise).
- There will always be a scar. Plastic surgeons can't make there not be a scar. The best way to minimize scarring is to completely protect the wound from sun exposure until it is fully healed.
Thoughts on how to be a good advocate for an emergency department patient:
- Generally, similar to ways to be a good advocate for yourself or a family member in any medical setting. Don't develop an adversarial relationship with your doctor. Try to approach them as a partner, and to ask for more details when you want to understand:
"Why do you recommend approach X instead of approach Y?"
"Why is this the best way of doing things? I've heard things about other ways. Can you explain why you recommend this?
"Is this what research supports for treatment for this problem? I understand that sometimes practical realities don't always line up with what the literature says. Can you tell me briefly whether there's any research on this and what it suggests?"
"How often do you do this procedure? How often do you see this problem?"
"If I/my child/my parent were your family member, what would you do?"
"I've heard of an approach to medical treatment called shared decision making. Are you familiar with that? I'd like to know the risks and benefits of the different options." (I particularly recommend this if you have any background in statistics, epidemiology or healthcare - because generally folks have a lot of trouble estimating or weighing risks and benefits on an individual level - for example, knowing that a terrible complication could happen 5% of the time, people still press on with major lawsuits if that complication happens with the argument that "I still didn't think it could happen to ME!")
When patients approach me out of a genuine place of caring and concern with questions, I will stay in that room as long as it takes to give them answers, and I will stay late after my shift or go the extra mile to make sure they get whatever they need. When people start screaming at me that they're going to sue me, demanding to 'speak to my supervisor' or to talk to 'head specialists', or angrily telling me that I'm wrong because they found something on the internet that says the opposite of what I say - this makes me want to try to escape that room and avoid going back in at all costs (now, I generally am able to stay calm in the face of people cursing and shouting abuse at me, and grit my teeth and do whatever needs to get done, but it definitely doesn't help the patient get better care - in face, the vast majority of the time what I see happening is that patients get unnecessary testing or treatment, like CT scans and antibiotics that weren't medically indicated, because family members were trying to 'advocate' for them and were bullying or harassing their providers and it's easier to just do the thing than to keep arguing - and unnecessary CT scans and antibiotics are not benign for patients).
- Ask for what you need, because we are there to help you. If you are hungry or thirsty, or cold, please let us know. Don't apologize for being there or feel like you can't take a moment of our time because you think other people are sicker and you're wasting our time. We might be busy with someone critically ill but if that's the case, we can just explain that and we'll get to you as soon as we can. I'd much rather know if something is bothering you than get a Press Ganey back a few months later or a "Rate Your Doctor" review with a list of complaints and think "she never said anything to me about this!" If you're thinking of conducting a smear campaign online or to medical authorities against a physician, please consider contacting the physician or office beforehand to see if they can help to explain it or make it right (this is typically appreciated by any business or service provider out there who you might publicly review).
Feel free to MeMail me if you're curious to know anything more about emergency department care.
posted by treehorn+bunny at 8:31 AM on March 31, 2016 [16 favorites]
Thoughts on this specific case:
- You didn't do anything wrong. There is very rarely any reason to request a plastic surgeon for a laceration repair. Emergency department doctors (and PAs and NPs) do laceration repairs multiple times a day every day and are very comfortable with that procedure. I wouldn't demand a plastic surgeon for my own child, although if it looks like a complicated wound, I would ask that a senior member of the team that's available take care of the repair if possible. I have definitely seen on the internet the implication that "you should always ask for a plastic surgeon for any wound at all because you must have only the best for your child!" Almost suggesting there's something wrong with you as a parent if you didn't demand plastics. That's silly. You'll stay 3 hours longer to get an end result that's exactly the same. An uncomplicated laceration repair is a procedure that a medical student can do a great job on.
- If you demand a plastic surgeon in my large, tertiary care academic center, we will consult plastic surgery to make you happy, but it will prolong your stay in the emergency department by many hours, the final result will likely be exactly the same, and the "plastic surgeon" that you get is a resident, not an attending - in fact it may not be a plastic surgery resident or even a surgery resident (emergency medicine residents rotate on the plastics service as an elective sometimes - it always gave me a little smile if someone demanded plastics and actually got an EM resident instead of the attending they could have had otherwise).
- There will always be a scar. Plastic surgeons can't make there not be a scar. The best way to minimize scarring is to completely protect the wound from sun exposure until it is fully healed.
Thoughts on how to be a good advocate for an emergency department patient:
- Generally, similar to ways to be a good advocate for yourself or a family member in any medical setting. Don't develop an adversarial relationship with your doctor. Try to approach them as a partner, and to ask for more details when you want to understand:
"Why do you recommend approach X instead of approach Y?"
"Why is this the best way of doing things? I've heard things about other ways. Can you explain why you recommend this?
"Is this what research supports for treatment for this problem? I understand that sometimes practical realities don't always line up with what the literature says. Can you tell me briefly whether there's any research on this and what it suggests?"
"How often do you do this procedure? How often do you see this problem?"
"If I/my child/my parent were your family member, what would you do?"
"I've heard of an approach to medical treatment called shared decision making. Are you familiar with that? I'd like to know the risks and benefits of the different options." (I particularly recommend this if you have any background in statistics, epidemiology or healthcare - because generally folks have a lot of trouble estimating or weighing risks and benefits on an individual level - for example, knowing that a terrible complication could happen 5% of the time, people still press on with major lawsuits if that complication happens with the argument that "I still didn't think it could happen to ME!")
When patients approach me out of a genuine place of caring and concern with questions, I will stay in that room as long as it takes to give them answers, and I will stay late after my shift or go the extra mile to make sure they get whatever they need. When people start screaming at me that they're going to sue me, demanding to 'speak to my supervisor' or to talk to 'head specialists', or angrily telling me that I'm wrong because they found something on the internet that says the opposite of what I say - this makes me want to try to escape that room and avoid going back in at all costs (now, I generally am able to stay calm in the face of people cursing and shouting abuse at me, and grit my teeth and do whatever needs to get done, but it definitely doesn't help the patient get better care - in face, the vast majority of the time what I see happening is that patients get unnecessary testing or treatment, like CT scans and antibiotics that weren't medically indicated, because family members were trying to 'advocate' for them and were bullying or harassing their providers and it's easier to just do the thing than to keep arguing - and unnecessary CT scans and antibiotics are not benign for patients).
- Ask for what you need, because we are there to help you. If you are hungry or thirsty, or cold, please let us know. Don't apologize for being there or feel like you can't take a moment of our time because you think other people are sicker and you're wasting our time. We might be busy with someone critically ill but if that's the case, we can just explain that and we'll get to you as soon as we can. I'd much rather know if something is bothering you than get a Press Ganey back a few months later or a "Rate Your Doctor" review with a list of complaints and think "she never said anything to me about this!" If you're thinking of conducting a smear campaign online or to medical authorities against a physician, please consider contacting the physician or office beforehand to see if they can help to explain it or make it right (this is typically appreciated by any business or service provider out there who you might publicly review).
Feel free to MeMail me if you're curious to know anything more about emergency department care.
posted by treehorn+bunny at 8:31 AM on March 31, 2016 [16 favorites]
My kids have gotten some poor treatment in the ER in the past from the doctors -- the nurses were 24K -- and at the time I didn't think I could push back. When I made the tiniest motion that way, and someone noticed (once a nurse, once the attending physician), I got exactly what I needed.
It's weird. I felt terrible at the time for having the temerity to speak out, but when I did everyone (besides the jerk student doctor) was totally OK with it. And I didn't feel bad later about not having spoken up right away, because who thinks they can tell an ER doc what to do?! So you did your best at the time -- you're all right. :7)
(And when at the hospital or doctor's office, I also listen carefully, take a lot of notes so I don't get confused, and I do my best to build some kind of rapport with the people treating me or my family.)
posted by wenestvedt at 1:21 PM on March 31, 2016
It's weird. I felt terrible at the time for having the temerity to speak out, but when I did everyone (besides the jerk student doctor) was totally OK with it. And I didn't feel bad later about not having spoken up right away, because who thinks they can tell an ER doc what to do?! So you did your best at the time -- you're all right. :7)
(And when at the hospital or doctor's office, I also listen carefully, take a lot of notes so I don't get confused, and I do my best to build some kind of rapport with the people treating me or my family.)
posted by wenestvedt at 1:21 PM on March 31, 2016
I think you went above and beyond on this.
I have a small scar between the eyes I got it when I was about 4 or 5 year old, can't remember. I fell head first on a stone stair, every witnesses say I was covered in blood. My mom almost fainted.
I was stitched up by a countryside doctor with heavy wire, you almost can still see the holes where he put the wire in.
I love this scar, I don't remember seeing my face without it. And I would hate for it to disapear.
I'm not saying that your son is going to feel the same about his scar, but maybe he's going to love this weird nubbin because that's a part of him.
posted by SageLeVoid at 5:30 PM on March 31, 2016
I have a small scar between the eyes I got it when I was about 4 or 5 year old, can't remember. I fell head first on a stone stair, every witnesses say I was covered in blood. My mom almost fainted.
I was stitched up by a countryside doctor with heavy wire, you almost can still see the holes where he put the wire in.
I love this scar, I don't remember seeing my face without it. And I would hate for it to disapear.
I'm not saying that your son is going to feel the same about his scar, but maybe he's going to love this weird nubbin because that's a part of him.
posted by SageLeVoid at 5:30 PM on March 31, 2016
Response by poster: Some followup: The plastic surgeon "revised" the scar three weeks after the ER visit and it looks great now. That procedure went super smoothly (by giving him gas before the general anesthesia) and we are really happy with the results.
Thanks for all the advice!
posted by cgs at 2:30 PM on May 19, 2016 [1 favorite]
Thanks for all the advice!
posted by cgs at 2:30 PM on May 19, 2016 [1 favorite]
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I also would encourage you to be kind to yourself. Kids get hurt, they go to the ER, stuff happens and there is a point at which you just have to roll with it. Now that the initial issue is over and resolved, the injury doesn't sound disfiguring or dangerous - if either, please ignore my advice.
posted by nkknkk at 3:06 PM on March 30, 2016 [21 favorites]