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):

http://www.thevirtualpediatrician.com/fever1.html

and especially at:

http://www.thevirtualpediatrician.com/fever5.html


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



Brett

8 comments:

Tim Scammell, PTech said...

Excellent and informative blog Brett. Thank-you very much for sharing this.
Especially since I'm another of those who would stand there watching my child sleep.
Stay well,
Tim Scammell

optimom said...

Thank goodness someone has finally given advice that makes some sense!! Go with your gut parents!! I have been talking about a balanced perspective on this "pandemic situation" and this article finally talks to that. I am not a healthcare practitioner but a mom who follows her instincts when it comes to illness in their child.
Thank you,
Laurel Crossley-Byers, B. A. founder Opti-Mom - Mom of 2

Suzanne Melanson said...

My nephew was recently diagnosed with H1N1. He's feeling better, but how long will he/could he be contagious to others?

moplans said...

thanks!

Anonymous said...

Thanks for the well-thought-out explanation. I live in the US, but would love it if my health professionals were as detailed and interested as you seem to be in helping families. Great service. Bless you.

Quirkymom said...

I know H1N1 can kill, but I don't know how it is doing that? Are the kids getting too high of a fever, is it shutting down their organs, are they getting too dehydrated - what is it that is doing the killing?

Brett Taylor said...

Hi Suzanne;

"My nephew was recently diagnosed with H1N1. He's feeling better, but how long will he/could he be contagious to others?" ...

We generally say that after the fever is gone, the child is not contagious. By then, most kids are still coughing, but the head and muscle aches, sore throats and energy loss are gone too.

Brett

Brett Taylor said...

Hi QuirkyMom:

"I know H1N1 can kill, but I don't know how it is doing that?"...

Generally, fatal flu is a respiratory death. The lungs become involved to an extent where breathing is simply impossible.

This usually happens over a period of time (i.e. not minutes, but at least hours and often days). Again, this is quite rare.