Hot Seat #62: 4 mos M p/w abscess requiring I&D
Posted on: October 4, 2015, by : Lenore Jarvis MD MEd
by Lenore Jarvis, Children’s National
with Jennifer Chapman, Children’s National
The Case
4mo FT previously healthy M presenting as a referral from PMD due to concerns for axillary abscess with need for I&D. The patient was admitted one week ago to the hospital for axillary cellulitis/phlegmon and placed on IV clindamycin during hospital stay. Has been on PO clindamycin >1wk. During prev hospitalization, Surgery was c/s, but was not I&D’ed as thought to not have drainable fluid collection on exam/ultrasound. For past 3 days, noted increasing swelling and fluctuance to the area. Deny drainage. Stable erythema. Seen by PMD with concerns for abscess & sent to ED for further care.
ROS: Afebrile. No N/V/D. Good PO intake.
PMHx: No PMHX/FHX of skin/soft tissue infections or MRSA. Immunizations UTD.
Social Hx: family recently moved from Senegal
PE: VS HR 120, bp 82/57, RR 24, Temp 37.1, sat 100% RA; 7 kg
General: Alert. appropriate for age. interacting.
Skin: 3x3cm area of fluctuance, underneath axilla and extending onto chest wall. No active drainage. 1×0.5cm area of induration adjacent to area of fluctuance. Overlying erythema extending ~4x3cm in size onto chest wall. Tender to palpation.
Cardiovascular: Regular rate and rhythm. Normal peripheral perfusion. Extremity pulses equal.
Respiratory: Lungs are clear to auscultation. respirations are non-labored. breath sounds are equal.
Gastrointestinal: Soft. Nontender. Non distended. Normal bowel sounds. No organomegaly.
Musculoskeletal: Normal ROM. moves all extremities.
The mom is mad that she is in the ED. She is refusing an IV and labs, and she is stating that she would refuse an admission. She feels that the admission last week was “a waste of time” and that “they didn’t do anything.” She is willing to have a Surgery c/s for I&D, but is asking how long it will take because she doesn’t want to wait.
You call the Surgery resident and fellow, but no one answers because they are in trauma resuscitations. In the meantime, you order an ultrasound. One hour into her stay you have been unable to reach Surgery. The mom is angry that Surgery has not seen her and is threatening to leave. You have also explained that Surgery is busy today, and apologized for the wait. You have explained your concerns/risks about the baby to mom in depth.
Questions for you:
Reexamination/ Reevaluation
US with 1.9 x 3.2 cm area of fluid. Surgery saw patient and will I&D at bedside. Mom signed consent. However, after the consent was signed, the Surgery Resident left and is waiting for the Surgery Fellow.
Four hours into her hospital stay, mom now refusing I&D. States that Surgery is taking too long. Mom tried to walk out of ED with baby. Had Security stop her. Risks/benefits/concerns discussed at length with mom by physician, surgery junior and senior, charge MD and SW. Discussed with PMD who was also concerned and wanting I&D. Surgery is now at the bedside, but mom continues to refuse I&D and admission.
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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Mom was clearly worried enough to see PMD and then agree to come to the ED. Suspect something other than the wait itself is causing her distress. May be about a difficult situation at home, her perception that he child is not being made a priority, or advice she is getting from a family member on the phone. It can help to explore. This would be a situation I would make an exception and go straight to the consulting attending to expedite care an show mom our level of concern for her child. Agree with involving PMD, who has relationship, and perhaps more sway with mom. Legal would be last resort, but a 4 month old with a serious bacterial infection can’t leave AMA.
Why does the baby need to be admitted? If it’s not being done in the OR, why does surgery need to be involved?
Don’t create hostile situations. Don’t let your consultants become patient managers. Almost every non-psychotic parent is reasonable at the end of the day if you sit down and relate on their level. This works from conversion disorders to angry parents. Build rapport, don’t threaten, and you’ll never have this problem.
It is always better to avoid threatening families with making them sign AMAs or getting legal and CPS involved. In this scenario I would I & D the abscess myself. If I wasn’t comfortable with the location or the patient’s level of stability I would re-admit the patient and request that surgery preform the I & D in the OR. That said, I agree with all of the comments of Dave and Anne.
Challenging case, because there are both medical and social issues involved.
To the medical issue, the differential diagnosis for an infectious enlargement is fairly broad, ranging from viral to atypical mycobacterial to a number of bacterial infections. The fact that there is fluid on ultrasound makes bacterial causes the most likely, and Staph aureus the most likely bacterial cause, since GAS and Bartonella cause more inflammation than suppuration.
The next concern is why does a seemingly healthy 4 mo have this infection recurrently. If the infection is Staph aureus, there may be resistance (inducible or otherwise) to clinda, and therefore the recurrence is actually a persistence of the initial infection. This would make me lean to Bactrim, or Vanco if the decision is to admit. There may also be a cyst that is vulnerable to infection, but these congenital lesions are found more often in the neck.
Any serious bacterial infection in an infant raises a concern for having a primary immune deficiency. Recurrent or initial serious bacterial infections are seen in children with T- and B-cell deficiencies, Ig deficiencies (X-linked agamm, Hyper IgM, others), and problems with phagocytosis (number of monocytes/granulocytes or activity of white cells, such as CGD). On review of hx, this baby is growing well and has not had any previous serious infections. This is a persistent infection, which may be a concern if the treatment was appropriate, but is not a concern if in fact a different antibiotic is needed. I would ask for a family hx of early childhood death, though if family is from underserved part of Senegal, children in the family may have died young of vaccine-preventable disease. An initial work-up can include CBC and QuIgs.
Now to the other significant part of this child’s care, namely the mother’s frustration with the wait and then refusal of care. Cultural issues may be a factor: as described in Prof Rounds recently, some families hold a suspicion that ‘western’ care is unnecessarily invasive and aggressive, to the point of experimenting on children (http://www.washingtonpost.com/wp-dyn/content/article/2009/07/30/AR2009073001847.html). Conversely, families from low-resource countries may have a false expectation of immediate and complete cure from illnesses, given the impressive survival of critically-ill children in resource-replete hospitals. These impressions are difficult to dispel, as there is some truth to both of these views.
With this as the background, we want to take care of this baby in front of us. I often go back to the end of the book The Spirit Catches You and You Fall Down, in which the writer recommends asking a number of questions to the parents: what do you think is going on; how do you think it should be treated; and for how long do you think it should be treated. This may show an understanding that differs from how the treating team sees the issue.
The next part to speaking to parents who are frustrated with long wait-times is to ask the obvious questions of what other pressures there are: parents often become upset with the wait around 230pm because they have to pick other children up at 3pm. Negotiating around the other pressing concerns in the parents’ lives may be a way to get to treatment. This may include overnight admission if the family needs to leave and the child needs ongoing care.
All of these steps were likely taken and the parents still wanted to leave. Since incision and drainage is the best way to heal the abscess, I would say this clearly to the parent— the treating team and the parents all want what is safest and best for the well-being of this baby, and the parents are pushing us to make a sub-optimal plan of care. If this is where the issue stands, then there needs to be a decision of whether not performing the I+D would endanger the life of the baby– doing it in the ED may not even be an option if the parents want to leave. From reading the vignette, it seems clear that the baby is not ill-appearing, is not febrile, and is eating well. It is difficult, then, to justify having a court intercede to remove this baby from the parents and force care on the family. In speaking with the family and the pediatrician, my approach is to discharge on antibiotics, with daily exams, and agreed-upon rules for more aggressive care: fever, lethargy, rapidly-spreading infection.