Tuesday, November 24, 2009

Practice Pandemic: What we have learned to date

Two weeks after my last post, and although the days are still busy, we are actually seeing patients in the Emergency Department who don’t have flu-like illness  (yay!).  Flu assessment clinics are starting to come down, and maybe the peak for this phase of the pandemic at least has past.  Time to reflect on what we did right and wrong, and maybe how to do better next time.

I can hear some of you sigh from here.  Next time?  Will the fear mongering never stop??

It isn’t fear mongering, though, to plan wisely for events like this in the future.  The story of new illness in the last half century has largely been that of infectious or infectious-like disease; Ebola, AIDS, Kawasaki’s, Lyme disease, West Nile, SARS, now new forms of pandemic influenza and many others.  The apocalyptic view of these is almost certainly an over-interpretation.  Nonetheless, we will probably see striking surges in patient flow in the future related to new emerging illness.  Not planning would be foolish.

There are lots of issues, and no doubt we will be hearing more about this in the months to come. For now, though, here are three of mine:

1)      Should we have done anything at all?

The cost isn’t in, but it will be high.  We purchased enough vaccine to immunize an entire nation, we spent money on pandemic planning at every level from individual businesses right up to the federal government.  We hired all those folks to staff the flu assessment centres and poured money into public service messages, communications and doctor “tool kits”.  All that for a virus that, for most, was only minimally worse than the usual seasonal flu.  Did we over-react?

The retrospectoscope, they say, has 20:20 vision.  There are two ways to look at this process.  Canada spends roughly $180 billion per year on health care;  in those terms pandemic costs will likely not be a high percentage of the overall budget.  Also from everyone’s perspective, politicians to nervous parents, it is far better to be safe than sorry.  This was a new virus, and in the spring, when decisions had to be made, the hazard associated with it was just not known.  We have a model, only a century ago, of a similar event that had substantial impact. 

Wise leaders don’t roll the dice with population health.  No, I don’t think we over reacted.

2)      Was the immunization campaign appropriate?

During the week that peak patient flow (to date) was recorded at the emergency department I work in, we had immunized only 20% of the population.  Six year olds with cystic fibrosis were still not on the list to be immunized, while healthy four year olds were lining up for hours.  Did this make sense?

There were certainly problems.  In the pandemic planning process, the assumption was that anti-vaccine hysteria would be a stronger force, that the population needed to be informed about the benefits of vaccination.  With the unfortunate deaths in Ontario of three children due to H1N1, that was just no longer true.  Parents wanted their kids protected, and right now.  Public health practitioners were left making decisions on the fly about whether it was best to try to nip the pandemic in the bud, by immunizing the pre-schoolers who are probably a big reservoir, versus focusing on those who had high risk characteristics. 

What could we have done better?  A clear strategy regarding the rationing of immunization and treatment, laid out not just for the health care workers but also for the public in the weeks leading up to the flu’s arrival would have been very helpful.  Most healthy adults were happy to step back and let others get to the front of the line first, I think.  Individuals who were at high risk for bad outcomes, not just for catching the flu, should have had their needs met, at the same time as front line providers and, say, hockey players.

3)      Were medical professionals prepared?

I think we were as ready as we could be.  The nitty gritty details over who to treat with Tamiflu, who to admit for observation, who to worry about were to some extent issues that we needed experience with the virus in order to assess.  Once it became clear that most children were not going to suddenly deteriorate, our emergency times improved and so did the confidence in our treatment decisions.

What would have helped?  We should have all been logged into one big chat room at the end of each shift, with less worry about privacy and confidentiality and more about sharing knowledge and experience.  I know that our group initiated an email discussion within a few days of the onslaught, and, I think, established a reasonably uniform approach for each practitioner.  But others, particularly those in isolated clinical settings, were not so lucky.  We had  a lot of phone calls from excellent family physicians asking just how we interpreted the various guidelines.  We live in a world of highly linked social networks; something like this for the H1N1 surge would have been very useful.

There are probably many other areas of potential improvement, these are just my thoughts.  Any comments?  What was your experience of H1N1 like?  Let us all know by clicking the comments bar below.

Friday, November 6, 2009

An excellent article ...............

One of the big problems with the internet is that ignorance and fear are given a platform that is just as large as knowledge and wisdom.  One of the big problems with celebrities is that they are tempted to speak without knowing what they are talking about.  Combine the two, and children and families can be injured.

Worth a look.


Wednesday, November 4, 2009

H1N1: Two weeks in, and what to expect now ...

It has been two tiring weeks for anyone involved in the public or acute care health systems, whether as workers, patients or family members.

Tonight on the radio, I heard an announcer discussing the possibility that the immunization program in Nova Scotia might start to slow down the rate of new cases.  I noticed that the spokesperson for public health was careful not to support this notion ... she correctly pointed out that, although the immune system starts to react almost immediately on contact by the vaccine, it generally takes two weeks for the shot to generate maximum benefit.  We have just begun the immunization campaign in Nova Scotia; according to the CBC, about 9% of the population has been immunized to date.

From a viral perspective, in other words, there is still a lot of food to eat on the table.

Australia has it's peak flu season in our summer, so they have already been through one H1N1 season.  According to their surveillance data,  the peak of the epidemic occurred 9 weeks after onset, and the incidence of new cases only fell to below the level seen at two weeks (where we are now) after 15 weeks.  That's nearly four months, for those of you with plans to hold off on that immunization.  A long, long time to hold your breath in public.

Canada will probably do better.  The H1N1 vaccine was not available in July, when Australia was facing its outbreak.  Australia has a high quality medical system; nonetheless, their intensive care units were stressed by the load of patients requiring ventilators.  While this is a very rare thing in children with this disease, and very uncommon even in adults, if 1/3 or 1/2 of your entire nation is sick with the flu, the numbers of "rare" things start to become significant.  There is every reason to believe that the vaccine will reduce the overall rate of disease, and therefore the stress on critical areas like ICU's and Emergency Departments.

All this depends, of course, on us getting enough individuals immunized in time.  The Harper government was on record last week that Canada will be amongst the first to offer full immunization to its citizens, and that the current timeline to complete that process is .... Christmas.  I don't want to criticize public health officials, who have been working flat out on this problem since the spring.  But we do have to recognize that Christmas is 9 weeks into our national pandemic ... or at about the same time the Australians experienced their peak.

Finally, H1N1 isn't the only kid on the block.  Beginning every year in late December and peaking in February, a bug called RSV comes to town.  If during those months you have a nasty, snotty nose and a bad cough, or your baby / toddler is wheezy and hot, odds are good that you have RSV.  As a westerner I have always thought of RSV as the cash crop of emergency pediatricians ... February is certainly the month you find us toiling in the fields.  It is usually the busiest month of the year, with the greatest number of hot, coughing  children.  Sound familiar?

So ... my forecast is for a pediatric heat wave, with associated hack, wheeze and a whole lot of snot right through until April.  Get out your wellies, folks...

Tuesday, November 3, 2009

Whoops ........ you ARE writing to me .....

Just finally realized that some of you were writing me back (sorry ... new to blogger ...).  So I have published all the comments and have started writing my responses.  Check below!


Wednesday, October 28, 2009

Pandemic Panic: How to sleep soundly this week.

The fear is certainly out there.

Last night the tide of scared parents was high and rising in the emergency department.  Our beds were full, several patients were at some risk from their illnesses, and all of us, the nurses, front staff and myself, were running hard. There is always the worry in a busy emergency department that information might slip through the cracks.  Experienced workers deal with that by knowing how to run and look at the same time, by keeping their sense of humor and supporting each other.  A cup of tea and a piece of toast can be pretty important gifts at 4:00 a.m.  It's always easier, I think, in children's units because, frankly, the kids are much more likely to smile back.

One common thread from last night that both heartened and dismayed me: the number of people apologizing for showing up.  A couple of children have died in Ontario this week from H1N1, and several parents said that once awakened, they just couldn't go back to sleep again.  "I know that I am being silly!"  One parent said.  "But if anything ever happened to her ..."  Her daughter, just pre-school, solemn, flushed and beautiful, blinked back and forth between us, not quite sure what the hell was going on.

So just so you know, folks, in case there was any doubt, I will let you in on a not-so-secret:

It's okay with us if you love your kids.  Really.

David Butler Jones, Canada's Grand Poobah of public health has been on the radio today saying that parents should avoid local emergency departments where possible.  We should be "reserving those resources" for children who are really sick, he says.  Now Dr. Butler Jones is a pretty smart guy, and I respect a lot of what he has done.  But his request is a bit difficult to actually implement, isn't it?  How are you, Ms. Accountant, or Mr. Business Man, or Ms. Mechanic, or Mr. Chef ... how are you supposed to know whether your kid is "really sick" or not?  Doesn't that take a bit of expertise in the first place?

In technical terms, what you are being asked to do is parent triage.  Without any training, and with often conflicting ideas as to what constitutes "sick", we (the Canadian health care industry) are asking you to essentially bet your child on your competence with a new and highly hyped viral illness.

To do this we give you telephone help lines that have been shown to actually increase visits to emergency departments time and time again (if you have ever watched "The Emperor's New Groove" this is a "Why do we even HAVE that lever!?" moment -- If you haven't seen it, makes a great "sick kid" movie).  In any case, those lines have long, long waiting times, and the people giving you advice?  They don't get much feedback.  We don't call them up from the ED and say "Frank!  Good call!  Glad you asked that child to come in!  Keep up the good work!"  Nope.  These poor folks are stuck, not seeing your child, working from decision trees that minimize legal liability and maximize efficiency.  Nearly an impossible task ... when I criticize outcomes, it isn't the nurses on the end of those lines that I am complaining about.

Here, then, is another not-so-secret to share with you ....  At three a.m., even if you manage to get through to the help line, you are the one that has to look at your child and interpret the degree of illness you see.  You are on your own in that bedroom with that hot kid.  You have to make up your own mind what to do.

So how do you do this?

First: is your child high risk?  Chronic illness like moderate to severe asthma, other lung, kidney, nervous system diseases and illnesses that affect immunity like cancer are all linked to higher risk.  Don't think.  Be seen.

Also linked to higher risk is pregnancy, but the issue here is getting seen and possibly treated for H1N1 ... usually best to call your family doctor and schedule that.  However, if your pregnant adolescent looks sick (see below) you might consider an emergency visit.

Age is another risk.  Basically, under two years the younger your child the higher the theoretical risks.

All children under three months should be seen without question and immediately if they have a fever or other symptoms of H1N1.  Don't think about this ... just come in.  This is a good use of emergency department resources.

Most of us would want babies between 3 and 6 months seen within promptly (i.e. today), immediately if they look significantly unwell (again, see below).  Above 6 months?  Depends on who you ask.  If your child is less than 2 years old, my personal advice would be to be seen by your family doctor with any symptoms, and to come into the ED if your child's degree of illness makes you too nervous.

How should you decide how nervous to be?   Try not to judge your child by any numbers.  I don't really care how high the fever is, or how many bouts of diarrhea or vomiting there have been ... these are distractions for most parents, not true grist for the decision making mill.  A more important measure is to stop, step back, and look at the whole kid.

What is your child's attitude like?  Is your kid crabby, whiny, upset, fatigued?  Is your child breathing hard (fast, with increased effort, as if she has just run a race)?  If any of these are true, and if treating with acetaminophen or ibuprofen doesn't make your child almost normal, a visit to the emergency department should be considered.

A word about that choice:  I prefer ibuprofen but there is controversy about this.  Acetaminophen (Tylenol, Tempra, others) has been used for about 10 to 15 years longer than ibuprofen in kids, so there is a longer record of use, and we (the medical profession) know it better.  Acetaminophen is very safe; the problem is it just isn't as effective against pain as ibuprofen.  For younger kids, who can't verbalize their discomfort well, ibuprofen (Motrin, Advil) is an excellent pain killer.  I use it in otherwise healthy children over 10 months of age who are not significantly dehydrated, with no allergies or other specific medical conditions (e.g. kidney disease).

An hour after giving something for the fever and pain, your kid should look pretty good, almost normal.  The fever may be up, but that's just a number, and I would ignore it.  More importantly, judge the parameter that you are an expert in .... what is your child's attitude like?

If your child is now happy, playful, exploratory, DRINKING, essentially normal in attitude, and your child is not breathing particularly fast or hard, it is reasonable to consider staying at home.  Your own level of anxiety should determine what you do next ... never let a blog tell you what to do!  But if your heart tells you that your child is settling and not in danger, and your child's response to anti-fever and anti-pain medication also seems to point that way, you can trust yourself.  If you need further advice, you can try the help lines, or better try your family doctor's office to speak to the on-call physician.  Or, if things don't look right, you can come in to the emergency.

Critically, two points:

1) Reassess, reassess .... if you are reassured now, take another look in an hour or two, and again frequently throughout the day.  Your measure as to whether your child is getting worse or better will be more accurate the more often you look.  If the trend is stable, or improving, great.  If your child seems to be getting less bang from the ibuprofen or acetaminophen, or if there are other issues that worry you, call your family doctor.  If things are really concerning, come to emergency.

2) Always listen to yourself.  In particular, don't let my words or any other online resource make you feel guilty about seeking care if you are worried.  If you are still concerned, if you are going to be up watching your child sleep, for example, or if you just can't quiet that nagging voice that says he might be sicker than you think .... well come on in and wait with the rest of them :).  There really is only so much you can do at home.

There is more on this on my website (sorry about some broken links ... these are being fixed as fast as I can):


and especially at:


Let me know what you think!  Click on the "comments" link immediately below this post.


Tuesday, October 27, 2009

Taming the Hog: Immunization or Not for "Swine Flu"

This week many people have asked me what my advice is regarding immunization for H1N1 flu. I thought it was probably easiest to just put this up on the blog, and let the conversation go where it wanted. So here is my view of things.

First, H1N1 is not a "killer flu" for the vast majority of patients who come down with it. However, it is a royal pain in the butt, carrying a great risk of missing work, sleepless nights, and attendant worry about your health or the health of your children.

H1N1 has increased risk for some demographics, most notably pregnant women and asthmatics. That doesn't mean that the risk is high, just higher. For some people, particularly those with significant lung, heart or immunity issues, any influenza can be downright dangerous, and H1N1 is no different.

On the other hand, the H1N1 vaccine is just another flu shot. There isn't anything particularly new about it ... except that it carries cut up and inactive parts of H1N1 flu instead of other types of influenza. The other (non-viral) components are frankly very similar or identical to vaccines that we have used before. Like other flu vaccines, it is grown on chicken eggs, so those individuals with egg allergy should probably discuss its use with their physician. But, otherwise, it is almost certainly a safe tool to help prevent infection.

People often get bent out of shape by the fact that injecting virus fragments into your arm doesn't seem quite .......... natural. To my mind this is fuzzy thinking. When your body encounters a live influenza virus, your immune system does all that it can to destroy the invader, which basically means chopping it up into components and then destroying those. When all the viral agents are disposed of, and the body's system is tuned to fight any new ones it encounters, the illness ends.

The difference, of course, is that the live virus has a window of opportunity in the healthy host to replicate (causing the fever, headache, sore throat and cough) and then to move on. The symptoms from the vaccine, on the other hand, include a sore arm, maybe mild muscle aches for a day or two. I have had the flu, and I have been vaccinated .... getting shot is better.

What about those individuals who "always get sick when they get a flu shot"? Well, most of those folks are getting their shots during flu season. They almost certainly are not getting sick from the shot, but because they are one of the up to 75% of the population that gets the flu each year, and the immunization hasn't had time to work yet.

Finally, what about those who are healthy, and "never get the flu anyway"? Well, as I said above, H1N1 is not a terrible disease for most, and for some it actually has quite mild symptoms. Some, undoubtedly, don't have the fever, or much of a cough or sore throat. So these individuals don't stay at home. So they can brush up against the pregnant woman, or the guy with leukemia at the bus stop, and pass the virus along. In that context, it seems to me, the responsible thing to do is to go get shot, so that you aren't a reservoir for others in your community.

Bottom line:

1) The disease isn't terrible, don't panic. But it is at least a big pain and, for some vulnerable people, maybe a lot more than that. Many un-immunized people will be missing work, school and sleep because of this virus.

2) The vaccine is not some scary, rushed process, but rather an example of tried and true techniques applied to a new virus. This is intelligent, competent medicine that will almost certainly reduce the risk of infection, not a FrankenShot here just in time for Halloween.

3) My advice: unless you have severe allergies,go get shot! And shoot everyone in your family too.

Click on the "comments" link immediately below this link to let me know what you think about this ...


Wednesday, October 7, 2009

Barking and Gasping .... Croup!

My 18 month old son has had a runny nose and mild cold symptoms for about a week, but yesterday he began to cough. We didn’t think much of it, but in the middle of the night he suddenly woke up unable to breathe! He was barking with a harsh, horrible sound, and he couldn’t seem to catch his breath….each time he took a breath in, there was this gasping sound. We were terrified! We ran him into the emergency department, but by the time we got there, he had stopped gasping and was playing with the triage nurse’s stethoscope. They probably think we are idiots…

Nope. We don’t think you are idiots. We think that you made the right call by coming into emergency with a child who was showing signs of upper airway obstruction (barking and gasping when trying to breathe in). We want you to do exactly the same thing, if this happens again. We don’t want you to get into a car accident because of panic, though….if you are so scared that you shouldn’t drive, call an ambulance next time.

This is croup. Croup is a viral infection of the part of the trachea (wind-pipe) just below the vocal cords. Actually, it is a viral infection of the entire trachea, and sometimes even the larger tubes that branch from it into the lungs. But in smaller kids, the symptoms come from the area just below the voice box.

In adults, the narrowest part of the trachea is the vocal cords themselves, so to put this in perspective, if you had this illness, your voice would be gone, you would have that characteristic barky cough, and you would call it “laryngitis”. In a toddler, though, the narrowest part of the trachea is just below the vocal cords; the first symptoms occur when the virus causes swelling in this area and this already narrow, slightly floppy tube sucks in on itself during a big inspiration. The walls of the tube vibrate, making that awful gasping noise which we call “stridor”.

Parents often come in saying that their child “can’t breathe” during these episodes, and that is probably why many are so frightened on arrival. Remember, though, that 
a child who is making noise is breathing. It can’t really be so otherwise. Also, with croup, most children wake up in the middle of the night upset (maybe in pain? … we usually can’t ask them). With the big gulps of air that these kids take while sobbing, the stridor is much more obvious. Once the kid settles down in a parent’s arms, the stridor usually gets better. Taking the child outside into cool air is thought to be helpful, although studies can’t seem to prove this.

What should you do?

  • First: come into the hospital. There are many other things that cause these symptoms (fortunately, rarely) that are very, very dangerous. Be seen! Also, at the hospital, if your child is determined to have croup, a drug called dexamethasone will be offered to you. This medication will decrease the chance of further frightening gasping episodes. We can’t treat the virus directly, but with dex we can diminish the impact it has on your family.

  • Second: don’t worry too much. Croup (if it is croup) is a very safe condition. Virtually no one gets into serious trouble, although a small minority of children with croup will worry even experienced emergency pediatricians.

  • Third: don't worry too little! Despite what you might be told, there is absolutely no way to prove that your child has simple croup. The diagnosis is made based on your doctor's experience, which always means that an error can occur. Watch for the signs of dangerous disease:

    • Increasing pain in the throat. Every child with croup has mild discomfort, but ibuprofen or acetaminophen should take that pain away. Pain that requires more than simple, over the counter medication, or pain that is getting worse should prompt a return to the hospital.

    • Stridor (gasping) that doesn’t settle down in a few minutes. Picking your kid up and cuddling, especially outside in the cool night air, should settle the gasping down fairly quickly. Children who don’t settle should be seen in the emergency department.

    • As always, if you are concerned, as always, come in to be seen.  Don't let a website or blog keep you at home if your child seems more sick than he or she should be.

  • Finally, cough syrups and decongestants are probably useless. Use a humidifier at home (it may help) and ibuprofen or acetaminophen may help, but otherwise, this is a virus, you just have to get through it.
Many kids who get croup as toddlers will get it repeatedly during their pre-school years.  Don't be surprised to see this illness again.

Write with your comments or questions ... just click the "comments" link below this post.

Tuesday, October 6, 2009

Getting Wacked! A Head Injury Primer for Coaches and Parents

'The phrase "head injury" can mean different things to different people; when an emergency doctor talks about "minor head injury", we mean those injuries to the head that result in any of the following:
* a period of unconciousness
* confusion
* amnesia
* a change in behavior
* significant headache
* vomiting
Another term sometimes used for "minor head injury" is "concussion". Any one of these symptoms means that your child has experienced a minor head injury (at least) and needs to be assessed immediately...'

Click here to read more ...

Monday, October 5, 2009


"Roughly half of those who present to a children’s emergency department come in with a history of fever. Fever is frightening to parents, because it changes the appearance and behaviour of our children, and because as parents we are very aware that some fevers are associated with dangerous disease. Physicians know that the vast majority of fevers are caused by simple viral illness, and that most can be managed safely at home ..."

Click here to read more.


Getting Started: The First Post

Hello World :)

... Or at least that portion of the world with tired crusty eyes from being up last night, bruises from teaching a three year old to wrestle, or a chronic, adolescent inspired nervous tic ......

Yep .......... Hello, parents ..............

I work in a children's emergency department in Halifax, Nova Scotia. The thing about emergency pediatrics is this: while it is true that every week (sometimes each day) you see something as a physician that you have never seen before, at the same time most of the patients you see have the same old bread and butter problems ... issues that are new to them (and therefore sometimes pretty distressing) but which are old hat to even the newest clinician.

Most of us have given the croup talk, or the asthma talk so many times that we forget sometimes which parts are the hardest to hear. We may not have time in a busy department to do these topics justice, and many times the parents are too frazzled to remember completely what we say. Result: for a number of reasons, we may not communicate well.

Its a version of the 80/20 rule: most of our cases are caused by a small number of conditions. If we could communicate better about a relatively small number of illnesses, we could improve the care for the majority of our patients.

So that's what this blog is about. This is where I try to write down the information and advice that I would give parents in the ED if I had no time constraints. Check the archives to find a listing of topics I have already discussed; more will be added from my increasingly defunct website as time goes by. Use the Google search bar at the top to look for a condition you are interested in. If you don't find one, post a comment requesting it!

And give me feedback! I don't do well talking to myself. If you disagree with me, you will find that I want to hear your point of view. (I review the posts prior to letting them go up because I want to keep the language and mood positive here, so don't be surprised if it takes a little while to show up). Ideally, this would be a place where discussions amongst parents can be nurtured as well.

That's it! First post. Let me know what you think.