2016 FSA Posters

P011: DIFFICULT PATIENTS, DIFFICULT FAMILIES
Sonia Mehta, MD, Stefanie Vallancourt, DO; University of Florida

Case Presentation: A 7yo M with CHARGE syndrome was scheduled for dental cleaning and extractions.  The anesthesiologist educated the mother of the child (MOC) about the risks of anesthesia, including postoperative intubation.  The MOC had a large number of questions and concerns that were addressed prior to intraoperative course.  The surgeons requested a nasal endotracheal tube (ETT) to facilitate procedural access.  After induction, the patient was obstructing and the obstruction was not overcome by continuous positive airway pressure, oral airway device, or changing the patient’s positioning.  Therefore, a decision was made to maintain spontaneous ventilation during intubation.  Nasal intubation was attempted with multiple modalities including a fiberoptic scope, but it was impossible to pass the endotracheal tube through either nare.   After discussion with the surgeons, a decision was made to place an oral ETT.  Oral intubation was straightforward with video laryngoscopy.  Due to multiple attempts at intubation with resultant airway edema, it was decided to keep the patient intubated and transfer to the pediatric intensive care unit (PICU) for corticosteroids and observation.

Postoperatively the team spoke with the MOC and explained her son’s intraoperative course.  She became understandably upset and demanded to see her son immediately.  In her rage, she started to yell and curse at the attending anesthesiologist, as well as call the anesthesiologist incompetent and berate her.  The anesthesiologist politely explained to the MOC that extra precautions were taken to ensure the patient was as safe as possible.  The anesthesiologist spoke with the PICU team about the mother’s feelings and contacted social work and the patient representative to come speak with MOC.

Two days later, the patient was brought to the operating room for extubation.  The PICU team, Dental team, and ENT team all advised the mother that the initial anesthesiologist would be best suited to take care of her son’s airway and could help navigate the difficulties but mother refused.  The patient was extubated without event in the operating room and was subsequently discharged the following day.

Discussion: What can we do differently?  Despite a lengthy conversation with MOC and case delay, the mother did not want to accept the potential challenges in her son’s care.  We could have facilitated better communication with mother of child about potential difficult intubation and extubation given his history of CHARGE syndrome and possible atresia of nasal choanae.  When do we need to escalate things to the next level?  When a patient or family member threatens bodily harm, verbal abuse, legal actions, etc.  In our hospital we have a patient representative.  Patient representative’s purpose is to come talk to the patient to see if they can alleviate the situation.  The next level that can be contacted is risk management.  Despite wanting to do what is best for our patients, we cannot expose ourselves to physical or emotional harm.  Risk management can be involved to protect us as providers.