27 February 2011

Preventive Care

Last week I wrote about the preponderance of viral gastroenteritis in the community and encouraged young people everywhere to take the revolutionary step of washing their hands. Apparently this was such news that it was picked up by Boston's Universal Hub. I went on to suggest that it is not, in fact, such an unusual occurrence for children to get sick and that we, as parents and health care providers, are faced with the not particularly heroic and in fact rather mundane task of simply seeing them through to the other end.

In the course of seven days time this basic tenet has not really changed. Still, I do have to admit that not all kids get better, even from these sorts of viral illnesses that naturally run their course. Hence the need for ERs and IVs and nurses who can, metaphorically speaking, get blood even out of a stone.

An example. A four-year-old boy is brought into an Emergency Room with the usual vomiting and diarrhea that we all by now know is going around. Mom tells the story with her eye locked on her knees. She refuses to look up.

"What's going on?" I finally ask her.

"He's going to get dehydrated," she says. "It's always the same. You doctors say, 'He looks good, he looks good' and then you send us home. He's just going to get worse."

The problem, I only slowly discovered, was that this little boy had been hospitalized with dehydration during a similar illness two years before. As his symptoms progressed, he was seen by several doctors. They saw that he looked well. They treated his nausea, they encouraged mom to carefully give liquids. They sent him home. Later, when he no longer looked good, they again did the right thing. They treated him with IV fluids. They kept him in the hospital. Then, when he looked better, they let him go.

Mom's assumption was that if he had been treated with an IV at the beginning of his illness, the hospitalization might have been avoided. I looked over the notes. I saw that it was extremely unlikely that this was true. I tried to tell her this in the most honest way I knew how, pointing out that he had been sick in between and had perked up without an IV. Mom nodded, but did not seem to agree. There was no more I could say without seeming to blindly be supporting the medical field in general and so I put the past behind us and got back to the task of making my patient feel better on that day.

I treated her son with oral medicine. When he ate chili cheese fries and then vomited again, he got an IV. When mom and dad said they didn't believe they could care for him at home, he got admitted. When a family is telling me that they are overwhelmed, I generally listen. In the cases where I have not, the patient usually just comes back later. This was a lesson I learned quickly.

So I learned something from this little boy. He stayed in the hospital a short while, got better, went home. There was a lesson to be learned by his parents as well, though I am not sure they were ready to absorb it. First, cheese laden french fries are generally not the best food for a child with a stomach bug. But also, and more importantly, doctors are rarely in charge. We cannot control the course of all illnesses. We hope children will get better. They generally do. We count on their parents to watch them closely and to bring them back in if things start to look worse or simply fail to improve.

And yes, this sometimes asks of parents that they make many trips to their doctor's offices or ERs before a virus takes the turn for the better. Yes, I know this is cruel and unusual punishment for a family trying to take care of a sick child. On the other hand, I also know it would be worse to stick IVs in every child who threw up even once or had diarrhea. It would be worse to keep children who were eating and drinking in a strange hospital overnight.

The way we do things, with small gentle moves that rely heavily on parents to tell us when things do not go as hoped for, is not perfect. I promise when I invent a crystal ball equipped to see the future I will use it wisely and almost entirely for good. Until then, a little patience on all our parts may just be the best that we can do.

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