Many apologies to those of you who want to read my rambling posts, in that I have not written for ten days. Whenever I go more than a few days without a post, I feel awful. Unfortunately, the week that just ended was so busy I hardly had time to breathe, eat, sleep or ....well, you get the point.
So, last week was a week "on-service" which I have described in the past.
This particular week was quite a busy one.
With 24 possible beds on the pediatric floor at the Carilion Clinic Children's Hospital at Roanoke Memorial Hospital, most of the week, between 16 and 19 of those beds were filled with patients for whom I was ultimately responsible.
Children were in the hospital with a variety of illnesses, but predominantly fevers associated with breathing difficulty or a diarrheal disease. Some of the children with breathing problems had a problem called bronchiolitis, which is caused by a virus--most commonly RSV. Some of the children with diarrhea had another very common viral disease called rotavirus.
But many of the children who were admitted did not have any specific diagnosis that I could pinpoint. Having a sick child in the hospital is stressful enough for parents, but much more so when their doctor (me) can't figure out exactly what is causing that illness. All the more stressful if your child is having very high fevers (one 15 month-old child had a fever as high as 106 degrees), or if they have other symptoms such as trouble walking, changes in their mental status, etc.
The more the parents worry, the more they want to know exactly what is wrong and how and when it will get better.
The more the parents worry, the less patience they have with a doctor who can't tell them the answer. In addition, the busier the place becomes, the more the patients need to be placed in semi-private rooms, and they become even more stressed.
Such was my week last week. Too many children for whom I didn't have an exact answer. Too many children who had to be placed in rooms with other children (always keeping infected children together, and non-infected children together), causing their parents to get less sleep, and enabling conversations to be overheard, despite our attempts to maintain confidentiality.
Of course with increased illness running rampant in the community, the staff also has problems--too many nurses and others calling out sick, which means that sometimes we didn't have as many nurses as we would like to have, or sometimes they were nurses who were unfamiliar with the routine on the pediatric unit, or who didn't know our doctors well.
As I struggled to find answers for some patients, their parents became frustrated and demanded transfer to other institutions, or wanted to remove their child from the hospital ("you aren't doing anything for us here." "I have to go to work on Monday, and there is no one to care for my other children." "I don't believe you really know what your are doing."
These things are hard for a doctor to hear. Firstly, because we are usually doing as much as possible to find the answers and be certain we are doing the right thing for the child (at least I know that was the case with me last week). Secondly, because we know that the families are under a tremendous amount of stress and we want to be able to ease that stress, but we are not able to. Thankfully we have others to help us. The social worker with whom I work most, was very helpful in most of these cases, to ease family concerns as possible, offer assistance with transportation and helpng to trouble shoot other issues such as child care and work excuses.
It is very hard under the conditions that I described, to continue to practice "evidence-based medicine." It is very tempting to prescribed some medication, such as an antibiotic, to a child with a likely virus infection, knowing full well it won't work, but just to ease a parent's mind. Several long conversations took place as I explained over and over again, that I would not prescribe an antibiotic for an unknown disease. It would have been much easier, and consumed much less time if I had just given in and gave the antibiotics.
So, what was causing all this illness in the Roanoke Valley?
I have to say that I still don't know for sure. I believe that some of the fevers we were seeing were probably influenza viruses that were not idenfied on our typical tests. We have to remember that all tests are not 100% effective. Also we have to remember that H1N1 is not idenfied by the routine nasal swab used to detect typical influenza A or B. I may never know, but as long as the children got better (and those still in the hospital do seem to be improving), I am not sure that it really matters.
I would love to hear from the parents out there who have been in the situation of being worried about their child, not knowing exactly what is wrong, and how you handled it.