After our last encounter with After Hours Pediatrics (AHP), I requested a copy of Asher's chart. Why? It's my job. Literally. For hospice, I defend our patient's eligibility and review our clinician's documentation by performing extensive chart reviews. So when I realized that we were getting less than excellent (...less than poor, is more accurate) care, I wanted to review his chart.
Yes, hindsight is 20/20. But looking through the chart, not only is it clear that the staff at AHP did not take us seriously, they were negligent.
August 8th
Mom called because son has developed a cough and isn't eating well.
AHP Response: Told mom to run humidifier and give baby warm liquids. No visit needed.
August 9th
Mom brought 5 month old in because she is concerned about increased fussiness, crying when he nurses, refusing to eat, and weight concerns.
AHP Response: Asher has dropped from 50th to 25th percentile in weight. Diagnosis of "Weight Loss" and "Fussy Infant" given. Plan is for mom to discontinue breastfeeding and start formula feeding as we suspect her supply is not sufficient.
October 25th
Mom called to report patient is not sleeping and is congested.
AHP Response: Advised mom to run humidifier and give thin fluids. No visit needed.
October 25th
Mom brought in 8 month old son because he has had decreased appetite for 2 days and is very fussy.
AHP Response: Diagnosed with "Teething Syndrome". Plan is to provide reassurance and supportive care.
November 8th
Mom called because patient is not eating well, this has been going on for 2 weeks. He has had significant decrease in amount he will drink. Mom is worried patient is losing weight.
AHP Response: Told mom that she can bring him in for a weight check. Also told her to see the doctor next week to discuss feeding issues and possibly increasing calories in formula.
November 11th
Mom called because patient is increasingly uncomfortable and she doesn't know what else to do at home to help him. Mom doesn't want to continue giving tylenol and ibuprofen because it does not seem to be helping.
AHP Response: Appointment scheduled.
November 11th
Mom brought patient is for fussiness.
AHP: Diagnosed with "teething syndrome". Recommend homeopathic remedies.
November 14th
Mom called because baby was up all night crying and is not able to sleep. "Mom is at a loss on what to do".
AHP: Reviewed other causes of irritability with mom: infection, UTI. No signs of infections, told mom to give ibuprofen and tylenol and follow-up in 1 week.
November 14th
Mom called back. She reports that child cries and is much more uncomfortable when laid down on back.
AHP: Mom says that when she puts patient down for diaper change he starts crying, which isn't normal for him. Explained to mom it is likely ear infection. "Also a possibility that patient may be fussy because he does not want diaper changed, especially if mom takes him away from activity or takes something away from him to have diaper changed."
November 22nd
Mom brought patient in because he has had wheezing and cough for 3 weeks.
AHP: Patient either has upper respiratory infection or allergic rhinitis. Continue nasal hygiene, humidifier, tylenol and motrin, and start giving benadryl every 6 houdrs as needed.
November 24th
Parents here with 8 month old son, report that patient has increased congestion, cough, and has had trouble breathing over the last two days. Mom reports congestion is thicker, and that he always seems uncomfortable when lying down. Mom also notes Asher has not been sleeping well, has a decreased appetite, and is more fussy than usual. Supportive care (nasal hygiene, NSAIDs) work temporarily if at all.
AHP: Diagnosed with sinusitis. Started on Amoxicillin.
November 26th
Mom brought patient in because he has severe wheezing, and some diarrhea and vomiting.
AHP: Start steroid for croup.
November 30th
Mom called because she was advised patient should start improving after starting antibioitics and steroids, and that his symptoms are getting worse. Wheezing is worse.
AHP: Will pass message on to Dr. Jimenez.
December 4th
Mom called because Asher is now done with antibiotics and is still not better. Was expecting call back from doctor, did not get one. Mom reports cough and chest congestion are worse, and that Asher's respiratory rate increases with eating and activity. Asher is refusing to eat solids, is gagging on food, and has only had 5 oz of formula today.
AHP: Scheduled appointment, told mom to continue bulb suction, humidifier and to call back if he has difficulty breathing.
December 5th
Mom brought patient in for chronic cough (2 months) and congestion. Mom reports Asher has a history of possible GERD and tracheomalacia as newborn, seemed to resolve but she says he is spitting up more.
AHP: Diagnosed with "Cough, unknown etiology". Will do allergy testing to dogs and common household molds.
December 15th
Mom called because Asher has had low grade fever, has stomach upset, very fussy.
AHP: Advised mom it is likely stomach virus and that no visit is needed.
December 16th
Mom called because she is concerned about bad coughing and wheezing that patient had during the night. Mom states coughing and wheezing have gotten worse. Patient has raspy breaths when breathing.
AHP: Recommended that mom start antibiotic for diagnosis of viral illness. Mom says she does not agree with plan to treat viral illness with an antibiotic, refuses treatment.
**To Minnesota for 3 weeks over Christmas**
January 8th
Mom called to see if food allergy is a possibility because symptoms get worse when patient eats.
AHP: Encouraged mom to keep food diary. She has an appointment with allergist in 2 weeks.
January 14th
Mom emailed Dr. Jimenez recorded sounds of Asher's wheezing and raspy, wet breathing.
Dr. Jimenez response: "I'm hearing stridor and congestion. The stridor is caused by floppy throat and will get better with time. If his respiratory rate goes above 60 bpm or he has retractions when breathing, we should probably check him out."
**I call and make ENT and pulmonology appointments for Asher at the University of Minnesota (for the first week in March) after realizing we are not getting the help we need in Albuquerque**
January 15th
Mom called because patient has severe wheezing, congestion, and increased respiratory rate. He is unable to clear everything in his throat, has a bad cough, and is not sleeping. Mom is unsure what to do, is currently doing all supportive care recommended by us.
AHP: Advised mom to bring patient in to assess 02.
January 15th
Mom brought son in to check 02. Patient has wet cough and coughs until he vomits. Has no history of fever or diarrhea. Mom is concerned that his lungs aren't clear and that his 02 sats might be low as he is coughing until he vomits. Mom notes cough is worse when laying down. He starts coughing and choking on what seems to be mucus in his throat.
AHP: Diagnosis "Allergic Rhinitis". Push thin fluids, run humidifier, use nasal saline.
January 20th
Mom called because patient cannot sleep at night, but now can't sleep during the day. Cough is so bad when he lays down he is not sleeping at all. Mom wonders if there is anything that can be given for his cough to help him sleep.
AHP: Told mom that cough suppressants are not given to infants and to continue humidifier, nasal saline, and clear fluids.
**I email pediatrician in Iowa City for second opinion, she recommends trial of nebulizer treatments based on wheezing and stridor**
January 22nd
Mom brought patient in with persistent cough, congestion, and wheezing. Mom brings recorded breathing sounds that sound like wheezing and raspy breathing. Wants to know if starting nebulizer treatments is a good idea.
AHP: Diagnosed with "Wheezing". Will try Albuterol.
January 29th
Mom called because patient has severe cough and congestion with no improvement. Cough is waking patient up at night. When patient eats or drinks, cough is worse. Mom reports patient has short periods where he stops breathing while eating, and has episodes of apnea during nighttime. Mom says the congestion seems to be in his throat, and that nasal suction isn't helping. Patient has vomited twice in the last 24 hours due to coughing. Mom is attempting all supportive care with no improvement.
AHP: Called mom back and told her doctor recommends nasal saline, suctioning his throat, patting his back, and putting Vicks Vapor Rub under his nose. Doctor does not need to see patient, but says if mom wants they can start patient on antibiotic. Mom does not want patient started on antibiotic without being evaluated by physician. Mom refuses treatment.
January 30th
Asher goes to Emergency Room because he stopped breathing while eating.
January 31st
Asher seen by ENT who immediately says reflux is the likely culprit and starts him on Zantac.
February 5th
Asher goes back to the Emergency Room after coughing up blood, x-ray shows aspiration pneumonia.
February 6th - 8th
Asher is hospitalized and treated with IV antibiotics and fluids for pneumonia. Pediatrician in hospital immediately suspects chronic aspiration is causing ongoing cough and other symptoms. Makes appointments with speech pathology and pulmonology.
February 14th
Asher has swallow study done that confirms aspiration and reflux.
So yes. Hindsight is 20/20. But the evidence here is pretty damning. Asher slipped through the cracks. And there will be consequences for it. The doctor we saw yesterday said that the wheezing and discomfort/issues eating are all classic reflux. The fact that everything got worse when he would lay down is also clear cut reflux.
Grrrrr.
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