Author: All Pediatrics

ACUTE AND EMRGENCY CARE

Today I am going to take a break from coronavirus, and talk instead about acute care, with an emphasis on when to use and not use the emergency room.

There are five main sources for acute care:  the emergency room, 911, our office, walk-in clinics, the phone/internet, and the Poison Center.  If there is one take-away message from this blog, it is the following: IF YOU DO NOT FEEL A NEED TO CALL 911, YOU PROBABLY DO NOT NEED TO GO THE ER RIGHT AWAY.  Instead, you have time to call and get advice first.

I equate rushing to the ER with 911 calls.  When needed, which one takes priority depends on several factors, including how close you are to the ER, traffic, your ability to drive when stressed, and whether you need one person to drive and one to attend to your child.  Around here, 911 generally responds very quickly, and is usually the better choice.

What sorts of issues require 911?  Severe trauma is an obvious choice, by which I include such things as extensive burns, fractures sticking out of bones, near-drownings, and head trauma with loss of consciousness.  Head bumps where a child is feeling well do not require a 911 call, even if there is a large bruise or the noise of the collision was very loud.  The most common non-traumatic condition requiring 911 would be stopping, or severe difficulty in, breathing.  Note that high fever in and of itself, hives without beathing problems or vomiting, bee stings with just local swelling and pain, rashes, and vomiting without the sudden onset of unremitting pain (as opposed to nausea) leave you time to call someone for advice first.

Seizures, surprisingly, will not usually require 911.  They are most often seen in younger children in association with a high fever, and tend to be benign.  In order to cause problems, a seizure needs to go on for at least 20 minutes, and most will stop within ten.  As such, I recommend waiting five-ten minutes into a seizure and then calling us if it stops, or 911 if it does not.  That having been said, a seizure is incredibly hard for a parent to watch, and calling 911 is a reasonable, and understandable, reaction.

If you are uncertain what to do with an acute, but not serious condition, I suggest calling or using the internet as the first step.  We have triage available 24 hours a day (but prefer you call during office hours for non-emergent issues).  If we are backed up, many insurers also offer an 800 number you can call for advice.  Our web page also has a very useful section (Child Health Library) which discusses various symptoms, and what do for them.

Going to an emergency room is an expensive undertaking, and is often associated with long wait times.  As such, for most illnesses that need to be seen, our office, or a walk-in clinic, is a better choice.  When to use us versus a walk-in clinic?  As a general rule, we prefer you see us.  We know your child, have access to his medical records, and are experts in pediatrics.  A walk-in clinic does not have those advantages, and the providers there feel, understandably, that they have only one chance at your child, and had better not miss anything.  As such, they are more likely to order potentially unnecessary blood tests and X-rays, and prescribe unnecessary medications (usually antibiotics).  If you do feel a need to use a walk-in clinic, I strongly recommend you use a pediatric one; there are many in the area.

When is a walk-in clinic a better choice than our office?  The most obvious situation is when we are closed or fully booked.  We do have some evening and weekend hours, but are not open as much as a walk-in clinic.  Potential infections, even if the child is hurting, can usually wait until we are open; for example, an antibiotic for an ear infection does not work right away, and the important medicine at night is the pain relief and not an antibiotic.  I do understand that there are times when it is impractical to come during office hours, in which case a pediatric walk-in clinic makes sense.  Another time when they can be a better option is for trauma when an X-ray is clearly going to be needed, as they have that available on-site, while our office would have to send you out.  As a counter-example, though, many apparent injuries will not necessarily need X-rays; jammed fingers, and ankle injuries where a child can walk, even if limping, often do not require X-rays, and can often be avoided by seeing us first.

Lastly, there is the Poison Center at 800-222-1222.  A simple overdose, where for example one parent gives a dose and the other gives a second one shortly thereafter, is very unlikely to cause problems; you can call us for that.  The more potentially dangerous issues are when a child has taken large doses, or an unknown substance.  Although our call center can handle many of these, the Poison Center can handle pretty much all of them, and I recommend it be on speed dial on your phone.

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Just a quick update on the vaccine for younger children, and masks.

Approval for the vaccine for children 6 months to 5 years hit a snag this week. It is not a question of safety, but effectiveness. There is no point in giving the vaccine if it is not going to be useful, even if it is safe. I do not see the FDA/CDC rushing to approve it until we have sufficient documentation. Once it has been shown to be of value, I will be recommending it, even though the virus is slowing down, and mild. There are two main reasons for this. The first is an everyday practical one. A child with COVID, even if not particularly ill, needs to be in isolation, and can spread the disease to other family members. This can cause major disruptions, as well as having the potential for more serious illnesses. Preventing this is of value. The second reason is that we do not know what the next variant will yield. If it is going to cause major illness, I would like children to be vaccinated ahead of time, rather than having to scrounge around for a vaccine when we are in crisis mode.

The other issue I will be discussing is that of masking. I expect mask mandates to be illegal in this state, even at the local school level, with appeals denied. (I would at least hope that an exception would be made for health care facilities, such as our office). Given how mild the omicron variant is, and how rapidly the numbers are dropping, this is not unreasonable at this time. (For comparison, we have never had mask mandates during flu seasons, and the coronavirus situation AT THIS TIME is better than a typical severe flu season). The bigger concern for me is putting the genie back in the bottle if a more deadly variant comes along. With a law on the books, the legislature will be unwilling to overturn it when mandates become essential again.

Masks will not be illegal however. Even though fully vaccinated, I still wear mine when I go shopping. I intend to do so until the numbers drop a great deal further, and perhaps not even then (I am in a high-risk group). For school, I still feel in-person learning is superior. Thus, if the choice comes down to (as I think it will) in-person with being vaccinated and masking for oneself, even if others are not, versus on-line, I recommend the former, given the current level of virus activity.

As always, please do your part to protect yourself and others.

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Today I am going to discuss the omicron variant, from three perspectives: contagiousness, vaccination, and the concepts of isolation/quarantine/lock-down.

Omicron is clearly much more contagious than previous variants. However, it is also clearly milder. This is not unexpected. An infection needs hosts in order to replicate and spread, and if it kills off too many hosts, it will not be able to hang around. This is what happened with the Black Death in the 14th century, which eventually disappeared (but not without killing off perhaps 50% of Europe), without our having vaccines, medicine, or even a good understanding of hygiene. I do not expect Omicron to be as deadly as when COVID-19 first appeared, although that does not mean we should underestimate it.

(As an aside, as an indication of how people still do not understand the devastation COVID-19 can bring, I recount the following. Today, I overheard someone telling a friend “Omicron is no big deal. I had it, took some monoclonal antibodies” (which, by the way, were probably not medically indicated), “and only had sniffles. I feel fine now.” I almost expected him to add, “I don’t know why so many people choose to be intubated.”)

That brings me to vaccines. When COVID-19 first appeared, many people, including those in authority who should have known better, dismissed it as just like the flu. They were of course wrong. It was vastly more dangerous, and soon filled up hospitals, with high death rates as well. Omicron, does look more like the flu, being milder, but even so it is still expected to wreak more havoc, and more deaths, than even a bad flu season does. It is also more like the flu regarding vaccine effectiveness.

In a given year, the flu vaccine is perhaps only 50% or so effective at preventing disease. However, it is much more effective at preventing serious illness/complications, and highly effective at preventing death. The current vaccines for COVID-19 seem similar regarding their effectiveness. They do protect against illness, but nowhere near the numbers we would like. However, the vast majority of hospitalizations and deaths are occurring in the unvaccinated (even though they make up a minority of the population), because the vaccine is effective here. Please get yourselves, and your eligible children, vaccinated.

You have seen sports teams throughout the country decimated by the virus, even though, supposedly, the vast majority of athletes are vaccinated. Vaccine remains one component of prevention. With athletes, we have unmasked people in close contact with each other, breathing rapidly as they exercise and thus expelling more germs, and not constantly washing their hands. Hand washing, and particularly mask wearing, remain vitally important, even if not mandated (or even where actively discouraged, as in some parts of the country, which I predict will soon become the hot spots for the virus as it spreads).

Should we have lock-downs again? I hope very much not to have to resort to them this go around, and expect to be able to avoid them with this milder form, relying on methods of reducing, but not eliminating, spread. School lock-downs, in particular, are a major concern for me, and should be avoided if at all possible. They are disruptive to the economy, as parents have to stay home to care for their children. We learned last year that they are poor replacements for in-person learning. Lastly, they have, not unexpectedly, negative consequences on the health of children, not just in mental health (depression rates have risen), but also physical health (obesity, already a major health issue, has become more prevalent as well). Along the lines of keeping schools open, I do note that, in Northern Virginia, many private schools were able to stay open last year, before we had vaccines. They did have the advantage of smaller classes, and it was no doubt easier to enforce mask wearing and hand washing. I take this as an indication that we should be able to keep schools open this year.
The CDC has just recommended shorter quarantine and isolation periods (I will refer to just quarantine from here on out, but the principles are the same for isolation). However, not all jurisdictions are going along with this. The difficulty here is that the variant is new, and we are still collecting data, but decisions have to be made in advance of this, realizing that recommendations will almost certainly change as we learn more. From a point of view of keeping schools, and the rest of society, open, there are obvious advantages to shortening quarantine periods. On a theoretical basis, I am comfortable with the shorter periods, and for this I rely on studies from England starting in the 1940s, which used the ‘common cold unit’. In this, scientists would introduce cold viruses into the noses of volunteers under different conditions, and see what happened.

One discovery was that the temperature of the room did not affect whether a person would then develop a cold. This is why, when parents ask me to tell their child to wear a hat in the winter so they won’t catch a cold, I cannot comply. Colds are more prevalent in the winter not due to feeling cold, but to being indoors and in closer contact with people (less ‘social distancing’, in current parlance).

We also learned that it takes a large number of viruses, not just a handful, to cause a cold. This is true of most, but not all, viruses; measles, for example, can be picked up with a very small inoculum, to use the technical term, which is why it is so highly contagious. When you have a cold, you can start breathing out germs before you have symptoms, which is why you can catch a cold from someone who is not ill at the time. You continue to emit germs for some time, but the number drops rapidly, to an amount below that which tends to cause colds in others, which is why you are not contagious for long with a cold, even though the symptoms may linger for weeks. I expect the same to be true for omicron, although, as stated, we do not have sufficient data to back this up yet. If true, even though you may still be harbouring the virus, and have an antigen test which stays positive for some time, a positive test later on in the illness would not necessarily indicate infectiousness. (In contrast, a negative test, if accurate, does mean no virus, and confirms no contagiousness). The idea is therefore that, after five days, you are not producing enough germs to pass it along, and can come out of quarantine if feeling better. Of course, this is theoretical, and it will still be important to get vaccinated, wear masks, wash hands, and try social distancing when possible, all measures which have clearly been shown to be effective, while we wait for more data to appear.

Most importantly, still, everyone knows what they need to do, and should be doing, to prevent the disease in themselves and their children. Please do your part.
Have a happy and healthy 2022.

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