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All Hat's Are Off

Aimee Stumpo, FNP

Being a medical provider and a mother is a mixed bag of emotion. When it comes to family, I set an internal agreement to not treat them medically as this can lead to ethical dilemmas, with the exception of an emergency. When it comes to my children, the line is drawn. I don't want to treat my own children. I want to be able to take my clinician hat off and simply be a concerned mother. I often hesitate to disclose that I am a Nurse Practitioner, simply because I want to be treated and educated just like everyone else. Sometimes I think when providers are treating providers, there can be miscommunication and a nuance that the other knows everything they need to know.


Rewind to 12 days ago, my husband gets Flu A and graciously passes it along to my asthmatic son, who then proceeds to cough in all of my mucous membranes all night long.


Yep, you guess it, I got the flu too. It was a doozy, and frankly, I am still not 100%. Several doses of albuterol and fluticasone later, my son is back to himself. That only lasted about 48 hours until he became febrile again. This fever took him out. He was lethargic. He went from running around in the morning, to sleepy by noon, to lethargic and febrile by the evening. Things turned the corner quickly. It is in these moments that I just want to be a mom, but I can't exactly turn my clinician brain off.


I decided to take him to urgent care (it was Saturday night). I already know what the Differential Diagnoses are, 1. not good 2. not terrible and 3. not ideal. I'm joking. I wish my brain worked like that. I went in knowing that we should be leaving there with a prescription to treat either Pneumonia or an ear infection. As I said, I just wanted to be a concerned mom and let the medical providers take care of us.


So here it goes, a medical visit from Hell. And only I know that it is a medical visit from Hell because anyone without any medical knowledge would have thought otherwise, which is the other issue I will address.


Before I lay out the rest, I want to say that I have a deep respect for those who work in the medical field, I know that it isn't easy and it takes a lot of self-sacrifice. I am also a very exhausted mom who has been taking care of my family while being sick myself, and I am also angry and disappointed.


Anyway, the Medical Assistant walks in, I can tell she is over the day, she's ready to go home. She begins to ask what brings us in, verifys allergies and what medications he is taking. She forgets to ask about his medical history, so I graciously add that in for her. (eye roll) I haven't disclosed that I work in the medical field, because I don't want to, I just want to be the mom. I give her a run down of what has been going on in our household over the last week or so and then she suggests that my son "probably just has a virus". Insert eye roll #2, because the medical assistant has ZERO business diagnosing my son and ZERO business mentioning that to me. She then decides to test him for the flu and COVID after I had already told her he had just gotten over the flu. Insert eye roll #3, however, I got over this one because whatever. Side note, I didn't actually roll my eyes any of those times because she is doing her job the best way she knows how and I appreciate her being there. Flu/COVID test comes up negative (duh), which is why I said "insert eye roll #3".


In comes the provider who only gives her first name and not her title so I am unsure if this person was a Nurse Practitioner, Physicians Associate or MD/DO. But, also whatever. I knew it wasn't just someone off the street..... or was it.....


She approaches us, takes a glance at my son and begins to tell me that he just has a virus. And I'm thinking (insert eye rolls #4-#1000), "she didn't even assess him", "she didn't even listen to him", "she didn't even acknowledge his asthma history", "she didn't even ask about his breathing", "did she even see that his heart rate is up and oxygen saturation is down?".


At this point, my mom hat is coming off and the clinician hat is going on. Was she basing her diagnosis on what the Medical Assistant said and the test right in front of her, I guess she was. But we all know that a physical exam rounds out the picture. I also don't take what my Medical Assistant says verbadeum (unless they're amazing and I've worked with them for a while, shout out to the GOATS), I DOUBLE check with the patient. Yep, sorry patient's I know that is annoying but you will understand why I am so annoying by the end.


So meanwhile, while my thoughts are rapid fire and anger is starting to brew, I put my mom hat back on and ask "you aren't concerned for an infection of some sort?". She responds by saying "let me get my stethoscope" (insert eye roll #1001, yeah you better) and "let me take a look in his ears" (yeah you better). Why did you walk in here without the tools to examine my son in the first place?!


She does her exam and responds with, "everything sounds great, I really think he just has a virus." I start to feel a little 'smartass-ness' coming on, and I respond tight lipped with a "so what do you think he has then?" ..she says "RSV".. She then proceeds to provide recommended treatment modalities, important educational points and closes with "we will be here tomorrow if you need us". The point is to not need you, but ok.


She never spoke about his asthma or about what to do with his inhalers. RSV is a respiratory virus after all.. (insert eye roll # who knows at this point). I dropped a lot of hints during that visit but never told her that I am a (very pissed off) Nurse Practitioner. I even emphasized how much my son was not acting like himself.


Curtain closed, we left. No prescription. For a moment, I gaslighed myself. "He could have another virus..". And then my clinician hat slapped my mom self right in the face... "No he doesn't, you know better, 5 year olds with RSV don't present like this!" "Go back in there and get an antibiotic".


We got home, I was pitching a fit, telling my husband about our subpar experience. I kind of felt like a baby because "I didn't get what I wanted". But here comes my clinician hat, this time it put me in a choke hold "you know better!".


As much as I hated it, my mom hat was off. I busted out my stethoscope and pulse oximeter and met my sweet little patient in his room. I hated coming at him with my tools, because what I wanted was to come at him with the best cuddles. I hated that this felt like my job, when I justed wated to be the mom. After a thorough listen to his lungs, sure enough, diminished breath sounds on the right, with course crackles to the right medial lobe (bingo! pneumonia) What exactly was the urgent care provider listening to, because I could hear all of this with Blippi Wonders blaring in the background.


The provider had commmented that she didn't hear any wheezing or notice any labored breathing, and I am thinking YEAH, that is because he has been using his inhalers regularily because he recently had the flu and had been coughing his a** off. But you wouldn't know that because you weren't listening when I told you that.


Clinician Hat engaged, I decide to call the provider directly. With every breath of patience, I let the cat out of the bag and said "Full disclosure, I am a Nurse Practitioner and I do not agree with your diagnosis, my son has pneumonia, he has crackles on the right side and we need an antibiotic, are you going to call that in or do I need to do it myself?".


I didn't want to say any of that. I kind of hated it, after all, I wanted to just be a mom. But I know how quickly these things can spiral out of control and I wanted him to start on something ASAP. The urgent care provider DID NOT hesitate and responded with "yeah he looked really sick, I didn't listen that thouroughly to his lungs (!!!), I will call it in right now."


Why does any of this matter?

It matters for a multitude of reasons. The first being, what if that wasn't me and my son? What if it was someone with no medical background? They would have left and their son would have decompensated over night, likely needing emergent care. Second, this is a prime example of bad medicine and could be a case study of "what went wrong?". If the clinician did a proper HPI and an exam without bias, we possibly would have left there with the correct diagnosis and prescription. Third, I am a parent of a sick child and we deserve to be cared for by competent and safe clinicians. I should be allowed to take my clinician hat off and trust the process.


For my clinician friends...

5 year olds with "RSV" don't present like this on day 1 of illness, as a matter of fact, they might not even present at all because RSV doesn't affect 5 year old the same way it affects a 5 month old. And don't go overboard with your "antibiotic stewardship". You are no steward for witholding an antibiotic if it means your patient might end up in the ER later. Like the provider said "we will be here tomorrow if you need us", NO actually, I shouldn't have to "need" you.


My son's case couldn't be more cookie cutter. He has a PMH of mild intermittent asthma requiring both ICS and SABA when sick. This is day 1 of "re-sickening" s/p Flu A 1 week prior, with rapid onsent of malaise, fever, lethargy, didn't have his flu shot this year (yeah I know, insert eye roll # 1 million). I forget what his vitals were exactly but his HR was 138 at rest and his SpO2 was 94% and tachypneic. On EXAM, he had diminished breath sounds and crackles on the right. Pneumonia LOVES to hide in the right medial lobe, you HAVE to listen along that midaxillary line. These patients can decompensate quickly, so treat accordingly.


This is a simple yet great case study. So if you want to use it for learning purposes, send me an email and I will forward you the formal write up.


This matters because this is a platform on which I stand, advocacy. Unfortunately, medicine in the U.S. is driven by many things such as time, money, insurance, just to name a few. You have to ask the questions, you have to tell your story and retell over and over. There are great providers out there who can let you "take your hats off" and just be, it is a matter of finding them.

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