What would Flea have done?

At about 3 AM a young couple brings in their 2 year old. She ‘s been vomiting repeatedly since about 8pm after dinner. Both mom & dad alternate giving the history. I ask if she’s tried to eat or drink anything. Mom says they’ve been giving her water. I ask if she’s taking little sips or gulps. Simultaneously, Mom says sips and Dad says gulps. Then mom says sips and gulps. Then dad shakes his head and says, “She’ll drink as much as you let her.” The problem is that she would vomit it back up within about 30 minutes. I continue with the history, it turns out dad stays at home with the kid and mom works during the day.

The girl looks very dry, her lips are cracked and wrinkled, her hands and toes are so cold that the pulse ox doesn’t even register, she’s got poor perfusion. But her capillary refill is great and she’s awake and cooperative.

I describe to mom & dad the difference between oral and IV hydration. I describe that there have been several studies done in ERs showing that the effectiveness of either is the same and that the time it takes to rehydrate a child is the same regardless of the method. I explain to them that the secret to oral rehydration is small sips…a teaspoon every few minutes and no more. Dad’s eyes light up in understanding. Mom scowls.

Dad agrees to try oral rehydration. I calculate a wieght based dose of oral pedialyte and the parents dutifully follow instructions and the girl is doing great. I recheck her and her lips look more full, her hands and feet are warming up. Mom tells teh nurse she wants teh IV to speed things up because she has to go to work in the morning. I explain that the oral rehydration is working, and the IV won’t be any faster. The nurse brings in the 2nd half of the pedialyte and minutes later dad comes out saying that she just threw everthing up.

The second half of the pedialyte that the nurse brought in is empty. It appeared that Mom had let her guzzle it because mom wanted to get home sooner…and the little girl vomited up everything she’d just drank.

The girl WAS looking better, and I could have sent her home right then, but with this mothers parenting style, I was not convicned that the girl would get appropriate hydration at home and she’d just be back later in the afternoon.

I ordered the 2nd half of the rehydration dose as an IV, explained to the parents that all we were trying to do was make sure that she was adequately hydrated, that she may continue to vomit at home, but if she did, to continue the frequent small sips they had done on arrival, pointing out that it had indeed worked. Dad was thankful and actually had a smile on his face. mom continued to scowl.

I was really irritated with this mother. Naturally they were both concerned or they would not have brought the child in to the ER at 3AM. But the mother seemed deceitful, lied about the history to give us the ‘right’ answer, then didn’t follow instructions ending up with the girl vomiting again, and pushed for the IV, which is painful and stressful for the child, parents and the staff.

Part of my job as an ER doc is to educate. If I can educate patients on proper care at home in order to avoid an ER visit, then I’ve done a good job. But all of that seemed lost on this mother. At least Dad learned something, and hopefully next time she’s sick, Dad will take charge and attempt proper oral hydration strategies and save the whole family a visit to the ER.

As I dictatedup the chart, I kept wondering, “What would Flea have done???”

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