Monday, January 31, 2011

Sick-kid Season

I love kids. Always have and always will. And when it comes to sick kids, I feel fortunate to have been trained in a demanding EM residency program where the pediatric emergency department was directly attached to the main trauma center. As a result of such exposure, treating ill kids became as natural to me as treating ill adults. Those little buggers, with their fevers, snotty noses, abdominal pain, and piercing shrills, don't scare me. Some get an "A" for effort, though, pulling out all of the stops in their vain attempt to get me out of their room. Regardless, because of my comfort, I try to see the really sick kids that come through our doors during my shift.

Over the holidays, with the flu season in full swing, I treated many children who were swept up in the epidemic. Some parents simply needed reassurances that they were giving their little Johnnie and Susie all the proper care, while other parents, with their heavy concerns, were right to bring their children in for a workup, including some IV hydration and anti-emetic medication. All-in-all, there was a much heavier flow of pediatrics than what we typically see.

Walking into Room 22, then, thanks to an alert by the nurse, I knew I was about to face another sick child. "This one is 'punky', Doc," she had said, "he hardly flinched when I started his IV." Never a good sign.

I quietly pulled back the curtain to the room and entered, finding a fatigued two-year-old boy sprawled on his back on the medical cot with his cotton sheet kicked into a ball at his feet. His oversized hospital gown had one loose tie in front, opened to reveal his skinny frame. His blond bangs were sweaty, matted to his forehead, and his skin was pale. Before introducing myself to his parents, I walked up to him and felt his forehead with the back of my hand. He was "burning up," as we say and, more importantly, didn't even shrug to a stranger's touch.

I shifted my focus to his parents, walking up to the young mother sitting in a chair alongside her son's cot. She looked as wiped-out as her son, the livelihood of her existence threatened by her son's illness. She was tearful, a mother's angst clearly etched into her face. I took her right hand in the both of mine, squeezing it reassuringly. "We'll get him feeling, better," I said, nodding to her sleeping son as I spoke. She dabbed her eyes with a Kleenex and gave me a feeble smile.

Next, I walked up to the father, his disheveled baseball cap barely clinging to his head as he paced three steps back and forth in a tight corner of the room. We shook hands and I held his gaze for a few extra seconds, trying to silently reassure his concerns. He, like the mother, was young, worried, and quite upset over his son's circumstances. He looked me in the eyes and took a deep breath. "Can you really make him better, Doctor?" he asked, a glimmer of hope escaping his watchful eyes.

"Let me talk to you both, do a thorough exam of your son, and order some tests and treatment for him, okay? But yes, I do think we'll get your son to feel better by the time we are done treating him." Their son looked like several other patients we had recently treated for influenza.

Between the two of them, I learned that they were first-time parents and married. Although neither of them were ill, their son went to daycare two days a week, where they thought "a bug" was going around. He had been born full-term and was up-to-date on his immunizations. This was his first major illness, barring a few past ear infections. Over the past few days, they watched their son eat and drink less, urinate less, become less active, and start a fever that they couldn't control. Eventually, all of their son's symptoms worsened and became boggled in their minds, totally confusing them (like any first-time parents) as to what symptoms were most serious and needed addressed immediately.

That's where we came in.

After a thorough exam on this patient, I had no suspicions for focal illnesses (such as pneumonia, bronchitis, or strep throat) on this patient. His temperature was quite high (103.7) and he appeared clinically dehydrated, so we treated him with a Tylenol suppository, aggressive IV hydration, and some IV Zofran, a God-sent anti-emetic that helps control nausea and vomiting. Then we sat back and waited--one, to see how the child would respond to our interventions and two, to review the results of our blood and urine tests as they returned.

Within the hour, I was walking into my work station with another patient chart only to find Dad standing at the counter, waiting to talk to me. He was smiling.

"He's doing better already?" I asked. "Come take a look," Dad said, practically grabbing my hand and pulling me towards his son's room.

We got back to his son's room and, before opening the curtain, the father stepped aside, sweeping his arms as if welcoming me to step into his home.

Pushing aside the curtain, I was extremely happy to find their son sitting upright in bed, licking an Italian ice while watching a cartoon on the TV. He looked at me with apprehension, turned to his mother who gave him a reassuring wink, before turning his attention back toward the TV, continuing to lick his popsicle. He was a new kid.

The mother jumped from her chair, then, and rushed me, giving me a big, grateful hug. "I can't believe how good he looks," she said, muffling her words into my shoulder. "Yes," I said, happily agreeing with her, "he looks great!" She left my side and went back to her cot-side chair, sitting clumsily down before wrapping her hands back around her son's torso. Her face held the most genuine expression of thankfulness and love that could ever be.

Within the next hour, as the patient's labs returned with adequate results, the nurse and I took turns going into the room to educate the parents and answer their questions.

How frequently are they supposed to use Tylenol and ibuprofen?
What doses of Tylenol and ibuprofen are they supposed to use?
How should they use the Zofran prescription we'd be sending them home with?
What type of fluids should they give their son?
What foods would be okay to reintroduce back into his diet?
How much sleep should they let their son get?

It's easy to see how confusing it can get the first time your child has a serious illness. Their questions for us were endless and repeated several times, but we, in the medical field, all know that education and knowledge is most empowering to recover from an illness. Our patience in the parent's education is paramount. Besides making sure each of their questions were answered, we also wrote down their instructions for them to take home.

By the time we were ready to discharge this patient, he was a new kid, running around his room, drinking watered-down juice, coloring the staff pictures, and covering himself in the stickers we gave him.

To us, another successful but predicted response to our interventions with a child with the flu. To the parents, though, this was nothing short of a miracle. The clouds had parted, the rays of sunshine had dispersed before refocusing on the head of their sick child, and the gods had sung. Anyone who has had a sick child recover knows these feelings of exhilaration that follow the many pangs of doubts that haunt us during our child's illness.

I've been there...have you?

The nurse and I stood together at the counter and watched this young family walk out of our ER after being discharged. Three big smiles, plus two more if you count ours.

It was another good day in the ER...

As always, big thanks for reading. I appreciate the nominations and support for the 2010 Medgadget awards for best medical weblogs...thank you, thank you. I hope this finds you well...


Laanykidsmom said...

Yes, we were like this when our first child was a toddler and was very sick with a fever and flu. Now he is 13 and hardly ever sick. And after dealing with our daughters, one of whom has heart defects and has had 2 open heart surgeries, while the other one began having seizures at age 6 and was diagnosed with epilepsy, fevers are small potatoes. I long for the days that the flu was our biggest concern! But I know everyone has troubles of different sizes, and I appreciate caring doctors like you and the ones that care for our daughters!

Katie said...

"She's really sick. If you have time between classes, go back and check on her." That's what the text I got last week said. I had the time but didn't want to go back. I had intended to spend my hour on a public couch with a book. Well, that didn't happen.

She was sleeping when I got back but woke up within a half hour. I got her water, changed her pillow, rewetted her washcloth... what I felt like wasn't much.

I was five minutes away from leaving for class when I heard a quiet, panicked, "Katie? I need help!" Not going to lie, that was the scariest fifteen steps of my life. I had no idea what I was going to find when I rounded the corner.

I don't panic in moments of crisis, but I need instructions. Saying, "I feel like I'm going to faint" doesn't mean anything to me because I second guess myself. Saying, "I'm really, really hot; get me some ice" helps tremendously. Questions similar to the ones you mentioned ran through my head. Honestly, I was grateful to go through a near-fainting experience before it's my child. Then I might have panicked.

She's fine now, by the way. And, I'm kind of proud of myself for being able to keep her conscious... She swears she would have died if I hadn't been there. That's not entirely true.

<>< Katie

Cal said...

Ibuprofen is rather magic, amazing how a feverish kid can look so down, and then spring up to playfulness after a dose.

Karen said...

When my daughter was 2, she was hospitalized for 11 days on IV antibiotics for osteomyelitis. Longest 11 days of my life. That was 1984; of course now it'd be an outpatient procedure. Yes, parents are very grateful for calm and reassuring nurses and doctors.

Anonymous said...

Makes me look forward to a life in medicine. Thanks for sharing Doc.

Empress Bee (of the High Sea) said...

oh good, a happy ending in the er! good for you doc! i sure remember mine being little and sick and feeling so helpless. one had asthma and we did so many things to help him but he just got worse. now he is 40 and still has it sometimes but not too bad. but it's scary stuff!

smiles, bee

Maha said...

This is what i LOVE about my job - seeing the immediate effects of our interventions and happy people at the end :)

Wren said...

Nice post, Dr. Jim. I can well appreciate that young couple's fear for their child, and their relief and delight when he recovered his strength and vitality so quickly. When my daughter was six, she caught a stomach bug that was going around at her school. I kept her home for a couple of days, thinking she'd improve, but she didn't. Couldn't keep anything down and, as time passed, she felt so awful she wouldn't try to eat or drink. She was running a very low grade fever, which (in retrospect) I took to mean she wasn't seriously ill.

On the third day she was so low, unresponsive and weak that she frightened me. I took her to our local military ED (we were living in Germany, working for the Army). They took one look at her, said "dehydrated," and immediately started her on IV fluids.

Like the little boy you wrote about, my daughter seemed "cured" within an hour. She was sitting up, talking, bright-eyed, interested in life again, and ever so much stronger. I will never forget my relief--and how grateful I was to the medical staff there, doctors and nurses in camouflaged uniforms, used to caring for big, tough, full-grown soldiers. They were gentle, kind, and so very caring.

They, and you, have all earned hugs from me. :D

littlepretendnurse said...

Thanks for sharing as always! It's good to remember sometimes the miracles that we forget we can do. Makes the hard times just a tiny bit easier.
Good job!

Holly said...

I remember those days. Our children are precious and it is so scary to see a busy, normal child become so sick. To have a professional reassure us and help to bring that active, interested baby back is priceless.

Another thing this post reminded me of, is how very very lucky we are to have the pharmacutical arsenal we do. 100 years ago.....this might have been a far less happy outcome.

Anonymous said...

I'm still terrified when I see a kid come in like that and amazed to see how they turn around so quick with fever reduction. But it still makes me nervous to send them home when they looked that bad at first.

coulrophobic agnostic said...

Aww, poor little fella. And his poor parents! I gave my parents similar scares twice, once when I was old enough to remember, and I actually remember when all the nasty rehydrating stuff they gave me kicked in and it was like someone had flipped a switch. I went from feeling like a zombie to feeling FREAKING AMAZING.

I do NOT look forward to my future kids' first 'big sickness.' I will no doubt completely go to pieces. I suspect my kids will also play me like a fiddle and get every single crazy demand met while they're sick. I really hope the future Mrs. CA is a hardass, because I'm a complete sucker. Are there any good over the counter anti-emetics? Besides Emetrol, which is a godsend for general nausea, but when you're actively hurling it's hard to get down and keep down.

Also STILL JEALOUS that your ER involves individual roomlets and TVs. Last time I was in one for almost 24 hours and all I had was a bed and curtains separating me from the vomiting lady in the next bed.

As always, I got my damn flu shot and am now sick. IT ALWAYS HAPPENS, ALWAYS! You'd think I was licking things in the doctor's office. oh well, I'm sure I'd feel a lot worse if I hadn't gotten the shot.

Bibliotekaren said...

With all that you see, it must be comforting to see such caring and sincere parents. Parents eager to learn what they can do to make the situation better.

Have Myelin? said...

Thanks for a happy ending type story. It makes me feel all is not lost in ER. I love the way you make your patients feel like people, or so it seems. I usually feel like a commodity when dealing with a doctor, lol.

Winking Doll said...

Thanks for the post. Reminds me of why I loved pediatric nursing.