Kintropy In Action

OK, let's take two hypothetical patients:  one, an almost six-year-old boy (we'll call him Patient G); the other, a three-and-a-half year old girl (we'll call her Patient H).  As I said, purely hypothetical.

Patient G:

A week-ago, had a runny nose and some wheezing.  A week later, runny nose is gone, but wheezing has turned to coughing up sticky yellow phlegm.  Needs albuterol a couple times a day.  No fever.

Possible diagnosis:  viral infection, bronchitis (viral or bacterial), etc..

Possible treatments:  continue with albuterol.  Add an antibiotic at a week given that symptoms are continuing and progressing.

Patient H:

A week-ago, had a runny nose and some wheezing.  A week later, runny nose is gone, but wheezing has turned to coughing up sticky yellow phlegm.  Needs albuterol a couple times a day.  No fever.  

Oh, Patient H uses a trach and, as needed, a ventilator for support.  Parents report more regular suctioning and an increased heart rate - usually a sign of infection in this child.  Patient H has also shown skin outbreaks that were common with strep the last several cycles.  Patient H has a history of harboring strep and psudeomonus in her body.

Possible diagnosis:  viral infection, bronchitis (viral or bacterial), strep, etc..

Possible treatments:

    First visit - ignore nurses notes regarding wheeze and breathing treatment prior to visit (as well as parental input regarding standard Patient H pattern last year during same season).  Ignore skin irritation.  Pronounce her well.

    Follow-up phone call from parents (five days later) requesting a revisit and/or antibiotic - panic!  advise her to go to hospital (but refuse to dispense antibiotic)

    Additional follow-up phone call from parents - OK, approve a culture for infection from trach sputum, but no antibiotic until pathogen identified.

    Additional, additional follow-up phone call from parents - Fine.  It's been a week.  We'll call in an antibiotic; just stop calling.  Maybe she does have a bacterial infection like strep, maybe, or pseudomonus (yes, actually she's had that quite often, hasn't she?).  You could be right - maybe....

***

As I said, purely hypothetical (mainly because Patient G never came down with the symptoms above -er, ah, you know what I mean by hypothetical, right?).  I don't blame the doctors for trying to avoid an antibiotic; this is a good, general strategy.  But a few observations:

• Treat the patient, not the literature.

During the first visit, I heard "well, typically" and "most kids" a lot in describing Patient H's symptoms and ways to deal with it.  That laptop in front of you:  it has her chart.  Open it and read it.  I'm a data analyst by trade; trust me, she has quite the infection pattern when it comes to skin irritation/breakout/redness + respiratory symptoms + phlegm.  The pattern is very reliable, particularly during the Fall and Winter seasons.

• Understand that the extra equipment supports Patient H; it should not be used to delay care most kids without supports would receive.

I'm pretty sure Patient G would have received an antibiotic after a week without 1) a panic call to toss the patient over the wall to hospital care (our favorite place to renew our MRSA subscription BTW), 2) a request to test the phlegm to confirm the infection prior to prescribing antibiotics after a week of infection and bronchitis and/or pneumonia symptoms.

• Listen to the primary caregivers (including home nurses in Patient H's case) & the patient.  They spend a lot of time with the patient and might be just a wee bit more informed of her health status than you.

We have a lot of nurses that read our blog, and I'm sure not every single parent is a reliable source for info on the health status of their kids.  But I'd be willing to bet most are.  All parents should give input, and that input should be digested along with the observable symptoms.  Together, caregiver input + observable symptoms should inform the diagnosis and the treatment path.

So Patient H now has an antibiotic on board - certainly a better interim step that hospital admission when that is not warranted (at least at this stage).  Let's work together, doctors, to keep her well, shall we?

-- Dad (without his morning caffeine, I might note in my defense)