Making every drop count for pediatric kidney transplant patients.

Abstract

> “I stood at the head of the bed holding the screaming 2-year-old as gently as possible. As I held him, his bedside nurse spent 20 minutes milking blood from his heel to obtain the necessary tacrolimus level. The patient had received a living donor kidney transplant 7 days before, and his tacrolimus level had clotted both of the previous days. Our team needed this information to appropriately dose the immunosuppressive agent that would prevent rejection in his new kidney. Unfortunately, high levels of the same medication could also cause kidney injury. His mother muffled sobs as she tried to comfort him, and his father stormed out of the room with tears streaming down his angry face. As I held the child, I envisioned this same scene unfolding with every transplant patient for whom I had cared for over the course of my first year of fellowship on every day that I had ordered a tacrolimus level. After all of that trauma, the blood specimen clotted, and we were again left without the necessary information to make a sound clinical decision. His family later told me they would not allow another heel stick to be done on their son.” There has to be a better way. This mantra reverberates in the minds of trainees throughout medical school, residency, and fellowship as they try to understand why certain decisions are made, how specific processes became standard work, and why these processes vary so greatly between institutions. When faced with inefficient, unsafe, or low-value care, we often fail to question or take action to find and implement a better way. Trainees face an intimidating culture of hierarchy, which often hinders their drive to speak up about patient safety issues or raise questions about a process.1 This environment can also limit their desire …