by Erin King-Mullins, MD, FACS, FASCRS
I decided to tweet about my daughter’s trip to the ER to highlight disparities in access to certain treatments and the importance of patient/parent advocacy. The response was quite unexpected and turned into an all-out #MedTwitter war!
Recently my one-and-a-half-year-old daughter fell at school, hitting her head. I got a call that she was injured and she should be taken to the ER. My fortunate circumstances include the childcare center being on the hospital’s campus, a children’s hospital is located just a couple blocks away, and my training as a colorectal surgeon. I picked her up from her daycare within minutes and when I saw her face I immediately went into trauma mode. I started asking the staff “What were the circumstances surrounding her fall? What did she hit her head on? What was the height? Did she lose consciousness?”
They gave me bandages to cover the wound and I rushed her to the ER. While I happen to have privileges at the facility, I didn’t call ahead to jump the line. I walked into triage and awaited our turn. I closely monitored her behavior, eyes, and coordination. I called my husband and filled him in so he could join us, and told him I would have to return to caring for my patients if there was no serious injury.
While it felt like forever, we were called back very quickly and a major head injury was ruled out, although she was left with a large wound across her face. As the EM physician and I discussed repair, I politely requested a plastic surgery evaluation. As a surgical sub-specialist I knew the nuanced repair involved with the depth and location of my daughter’s wound. As a Black person with a Black child, I also know how scars can later appear on dark skin. Now I was in full mommy mode. My decision to request a plastics and reconstructive surgery consultation included consideration of: risk of keloid formation on her darker skin, risk of being teased at school, self-consciousness, and potential effects on her future career. As horrible as we know this all sounds, we also know that we all judge people based on their appearance. And furthermore, if she developed an issue with healing or scarring later in her life, the plastics team would be the specialists to manage it, hence, my clinical judgment to ask for their involvement from the start.
As the call was being made, my husband and I switched out and he took over parental duties. Eventually, an upper-level plastics resident graciously came and skillfully repaired the wound in two layers using extremely fine sutures. She provided my husband with literature on wound care, when we would be starting scar massage, and techniques to prevent abnormal pigmentation and follow-up needs.
Reflecting on the entire situation I couldn’t help but think of how blessed and fortunate I was to have not only the education and knowledge to assess her wound, but to also ask for a specialist and to be in a place where a plastics consult was accessible. Knowing the disparities that exist across medicine as a whole, I decided to take to Twitter to post about my experience, intending to serve as a voice for those who may not know how or what to advocate for:
“Very scary moment this week. My daughter fell at school & had a decent gash on her face. Pretty deep involving the eyebrow. Although the ER physician felt confident in being able to repair it, I asked for the professional courtesy of calling plastics. The @EmoryMedicine plastics fellow came & repaired it in 2 layers & I know she will do well. I’ve thought a lot about the situation this week for 2 reasons. First, I’m blessed to be in a position to know the benefits of the repair by plastics & to be able to make that request. Second, the knowledge that a poorly healed scar on my daughter’s face will significantly affect her future socially, emotionally & even economically based upon what career she may want to pursue. Not thinking abt modeling but more about sales & any other client facing career. This all comes back to the discussion about #healthequity. Unequal access to care that leads to the best healthcare possible goes beyond a single #healthcare encounter. WE HAVE TO DO BETTER….”
Most replies to my Twitter thread offered support and thanks, but there were some pretty angry dissenters, especially within the EM specialty. They felt that when I asked for a plastics consult I was saying something negative about the EM specialty and their expertise. Some assumed I purely took my daughter to the ER for the cut as opposed to the trauma situation.
I fully acknowledge their points about the skill and scope of practice of those serving us in the emergency department. I also fully acknowledge that the restraints of character limits on Twitter may not have allowed me to adequately convey the full scope of the situation. But my post was meant to empower patient advocates rather than belittle an entire medical specialty. The fact that my position allowed my request for specialty consultation to happen inherently portrays my point that inequities exist in medicine across race, gender, ethnic geographic, and socioeconomic lines. As a colorectal surgeon, I know the woes associated with lack of access to my specialty and how that plays a role in colorectal cancer surgical care. Patients who present with rectal cancer that don’t have access to a colorectal surgeon are much more likely to end up with a colostomy. Studies show survival rates of colorectal cancer patients are higher when their surgery is performed by a colorectal surgeon as opposed to a general surgeon. There are equity issues in all medical specialties and as the chairperson of the newly formed Diversity, Equity and Inclusion Committee of the American Society of Colon and Rectal Surgeons, I have dedicated myself to the work of mitigating these types of issues.
It is amazing how things come full circle. As a child I slammed my finger in a door and the tip of my right index finger was barely hanging on; you could see bone. The EM provider told my mom they needed to amputate. My mom said “Hell no you won’t. Sew it back up and let’s see what happens.” No hand or plastics specialist was called. We weren’t even referred to the children’s level one trauma hospital that was only 30 minutes away. They finally listened to my mom and sutured it. Purely by the grace of God my finger healed. I do remember getting the sutures removed. The nurse ripped and pulled. I was an 8-year-old screaming and my mom was told to keep me quiet.
Now there are 2 points to my anecdote:
1. The EM physician successfully repaired my finger. There is a scar, sometimes I have a little difficulty with feeling in that fingertip but I still function well as a right-handed surgeon.
2. I was never initially offered the care that I should have been.
I would hope all physicians would exercise a little humility in dealing with patients and their advocates because the ramifications of every single healthcare encounter extend well beyond that singular visit. We must pride ourselves on truly providing patient-centered care, which sometimes leads us down a path of care we would not choose for ourselves. There are cultural and social differences that go beyond purely practicing medicine and to fully provide patient-optimized care these must be considered. I advocated for what I thought was best for my child, as did my mother. Patients should feel empowered to do so. Maybe some of the anger from the EM physicians came from a place of frustration. Maybe some of it was egocentric. These are precisely the things we cannot let get in the way of treatment recommendations or honoring a patient’s request.
Lastly, I want to say a special thank you to ALL healthcare workers during such a trying and demanding time. I hear you and I see you, and just ask that you do the same.