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President's messageIn support of the pediatric health care home

2004; Elsevier BV; Volume: 18; Issue: 1 Linguagem: Inglês

10.1016/s0891-5245(03)00295-5

1532-656X

Michael P. Brady,

Healthcare Policy and Management

I am sure that many of you saw the film My Big Fat Greek Wedding and laughed over the tactics of family life that were portrayed. You didn't have to be Greek to enjoy the movie. Most who saw that film could relate to some incident in the storyline that was reminiscent of their family culture and the joys and tears that family members share as part of their lives. I wanted to share a family experience with you that I'm sure will make most pediatric health care providers say, “Been there, done that.” It is part of the culture of being a health care provider. So here is my story, entitled “My Dear Irish Relatives” (you can change “Irish” to fit your needs). When I became a nurse, the extended family was thrilled. They said, “Our girl became a nurse! That's great.” When I said the Nightengale pledge those many years ago, I was thrilled that I would serve my patients faithfully as a nurse. It just never occurred to me that my faithful service would include “the Family.” The Family knows that I'm a PNP, but I still get those “big people” questions. I generally start off those “health care advice or concerns” conversations with the caveat, “You know that I'm a PNP. I do pediatrics, my malpractice insurance does not cover adults.” Like most of you, I always listen to my relatives, discuss their concerns, and then help them develop a plan of action. Alas, when a member of the Family has a pediatric question, I'm at their mercy. They start by saying to me, “I know you're a PNxP.” Those well-child consultations are during my designated Family Office Hours of 6 to 10 PM weeknights and all day during the weekends. Now, when it's a serious concern about one of the children, the Family has me 24/7. I'm sure that most of you have experienced a frantic call or two from relatives. There is panic in their voice, and often a few tears are shed, as all good mothers are wont to do when their “babies” are ill. It just never occurred to me that my faithful service would include “the Family.” Thus, my story begins about a series of my latest family telephone consultations. Cousin Mary calls me at 5:45 AM frantically telling her story. Her fourteen-year-old son, Sean, had a terrible coughing and choking spell around 11 PM, the paramedics were called, and off went mom and son to the local Emergency Room. I asked what was the diagnosis. Mary replies, “I think they said sinusitis.” By now I'm fully awake and starting to ask my next series of questions. “What did they do for him?” Between tears, she answers: a “steam treatment” because someone heard a “wheeze”, an antibiotic (can't remember the name), an oral steroid to take for three days, and an inhaler for wheezing. She ends by saying that she was told to contact his regular pediatrician. By now she is crying and telling me that she was so scared. “It was like he was having a coughing spasm, couldn't catch his breath, and was choking.” She tried to “do a Heimlich” on Sean and thought he was going to die, because he started vomiting “thick mucous stuff and some food.” I calmed her down and asked some more questions. The history was a bad cold and hacking cough for seven days prior to the event. I thought, “Sort of strange; he must have a major sinusitis; wonder why he was given an albuterol inhaler for a ‘wheeze’ with no prior history of wheezing?” I knew that it was a very frightening experience for them all. I knew I had to listen and help her talk through the frightening experience. In the end, I confidently advised her to call for an appointment with the pediatrician and let me know how he's doing. Mary's phone report came that night. Chest X-ray clear; sinus films show “bad sinusitis;” new and more powerful antibiotic needed; don't give cough medicine; continue steroid; and forget the albuterol inhaler. Scene three in the saga. It's now 5 AM the next day and the phone rings. Mary says, “It happened again. Sean started coughing and vomiting and he couldn't breathe, but he's OK now. I'm scared. What should I do?” I tell her to go call the pediatrician and ask to have him seen. I say to myself again, “This is strange, must be a ‘bad post tussive vomiting’.” The phone message that night is, “Call me first thing tomorrow morning! Doctor saw him and says it is a bad sinusitis with possible gastroesophageal reflux. Metoclopramide is now added to the treatment plan.” Scene 4, next day at 4 AM. Phone rings, frantic cousin sobs. “It happened again. Sean had a coughing spell; it was like a spasm, he threw up, and he couldn't catch his breath.” Mary sobs that she is so scared because now Sean said he's afraid he's going to die. Suddenly, the lights go on. I tell her, “Go to the pediatrician; I'm concerned that Sean may have pertussis. Give me a call tonight.” Cousin Mary calls that night and leaves a message on the phone answering machine: “Doctor said he doesn't think it's pertussis. The diagnosis is still sinusitis and reflux.” This sounds like pertussis to me, and I decide to call the pediatrician myself in the morning. Next morning's call at 7:15 AM reports that Sean had another spell, not as bad as the others. However, the doctor had just called to say that he had been rethinking Sean's symptoms. The doctor now thinks that the diagnosis is pertussis and wants to see Sean in his office in an hour. Yes, the story ends with the diagnosis of pertussis and successful antibiotic treatment. Sean is back in school, and the rest of the Family is thrilled to have him healthy again. This story illustrates the importance in listening to the clues that a history reveals. Unfortunately, pertussis is still around! It was through listening to and working with Sean and his mom that the correct diagnosis was made. In this “family case study,” I thought of pertussis before the pediatrician. In my clinical practice setting, I have consulted with pediatricians who have helped me make a correct diagnosis. Who first thought of the diagnosis of pertussis is not important. Successfully treating Sean and helping his family during this difficult period of time were the important issues. As a side note, Canada's National Advisory Committee on Immunization recently recommended the use of dTap to replace the adolescent booster dose of Td (Hailey, 2003Hailey J Pediatric Notes: The Weekly Pediatric Commentary. 2003; 27: 152Google Scholar).Physicians and nurse practitioners shouldn't keep score; they should focus on partnerships among themselves and with the children and their families. Physicians and nurse practitioners shouldn't keep score; they should focus on partnerships among themselves and with the children and their families. Partnership among parents, children, and health care providers is the key ingredient for successful well-child care and the diagnosis and management of illnesses in children. Every child should have access to a pediatric health care home. Whenever I hear the term “medical home” for children, I can't help but think that the child and family focus is somehow lost when the qualifying adjective “medical” is placed before the term “home.” Children and their families need a pediatric health care home where the Family of pediatric health care providers—pediatricians and PNPS—works together in a partnership. Using this broader terminology of pediatric health care home does not lessen the significance of the pediatrician's role in caring for children. Rather, this terminology just keeps everyone child-focused. That is why NAPNAP supports the concept of the pediatric health care home for all children and their families.