A Case of Winging It

I would like to describe an example of a doctor's thought process. I have encountered this actual scenario during my training. Hopefully I have never practiced in this manner.

The scene is an emergency room in the middle of the night. The patient is a toddler, say about 1.5 to 2 years old. He has a fever, cough, runny nose, and is irritable. He cannot sleep, and is keeping his parents up as well. Everyone is exhausted and feeling miserable. This is a very common situation. Just about any parent has been here.

Here is the parents' perspective: The child is much easier to deal with during the day because the parents are wide awake and rested. At 2am, when the parents are exhausted, the situation is intolerable, and that is what prompts the ER visit.

Here is the doctor's perspective: The child most likely has a cold or the flu. These are viral infections, for which there is no specific treatment. The only treatment is supportive, i.e. relief of symptoms using Tylenol for fever and aches, decongestants to reduce the runny nose, cough suppressants to help the child rest, and perhaps a vaporizer to keep the secretions from drying out and becoming more difficult to clear. On the other hand, the child could have a bacterial infection, in which case antibiotics should be used.

The main focus of the doctor will be to try to determine if there is a bacterial infection. First he may consider a bacterial infection of the lungs, i.e. pneumonia. By listening to the child's lungs with a stethoscope, he will try to detect fluid deep in the lungs. Fluid in the deep airspaces (alveoli) imply pneumonia, and this will give a characteristic fine crackling sound, as opposed to a coarser upper respiratory sound one hears with infections such as uncomplicated flu, which only infect the large airways. In between is bronchitis, which is an infection of the smaller airways, but not involving the alveoli. This will cause a mild wheezing sound. Bronchitis is generally a bacterial infection, and would also require antibiotics.

This works in theory, but at 2am, a two year old in an ER will often be crying and inconsolable. This may make it impossible to be confident about what you are hearing through the stethoscope. So the doctor may consider obtaining a chest x-ray. This, too, is not perfect. A chest x-ray is most useful when it is obtained with the patient taking in a deep breath. Good luck getting a two year old to do that. Most likely it will be obtained with the patient exhaling. This makes is difficult or impossible to detect bronchitis or a small area of pneumonia. Also, even a good quality chest x-ray may appear normal in the early stages of pneumonia. In ordering the chest x-ray the doctor must consider how suspicious he is of a bacterial infection, how useful the x-ray is likely to be, and the small but real risk of radiation exposure to the child. Some children are particularly prone to bad respiratory infections, and could end up with a large radiation dose over time. And, of course, the x-ray will increase the cost of the visit.

Another possible site for a bacterial infection is the throat, i.e. a strep throat. This can be checked for quickly with a throat swab. Not too easy to do in a two year old. And again, it adds to the cost.

Other serious things to consider are sepsis (a bacterial infection in the bloodstream), and meningitis, an infection of the covering of the brain, both of which are life threatening. In a two year old, these can usually be ruled out by examining the child.

So we may have a situation in which we cannot reliably tell by examination whether this is a viral infection or a bacterial infection. Perhaps we have spent some extra money on x-rays and lab tests, and still do not have a clear answer. The doctor should not give antibiotics if this is only a viral infection. Firstly, even though antibiotics are fairly safe, there is a risk of adverse reaction, possibly serious. And secondly, overuse of antibiotics leads to resistant strains of bacteria. This is the reason we now are forced to treat some infections with so called third generation, fourth generation, fifth generation etc. antibiotics, and with combinations of multiple drugs, each of which are extremely expensive.

So the doctor wants to do the right thing, but he is presented with limited information with which to make his decision. Another thing to consider is that if he decides not to give antibiotics, the parents may become angry. They brought the child to the ER in the middle of the night in order to receive some sort of treatment, not to be told to continue using over-the-counter medications, give him plenty of fluids, etc. So if the doctor can justify the use of antibiotics, everyone is happy, and he can move on to the next patient.

The solution to this problem is the ears. Middle ear infections are quite common in two year olds, are often associated with respiratory infections, and are an indication for antibiotics. Ear infections are diagnosed by looking into the child's ears with an otoscope and identifying a red, inflamed ear drum. Therefore, if the ear drum is red, the problem is solved.

One would think that this is a pretty objective determination, but not necessarily. If a child is doing a lot of screaming (which most two year olds will do at 2am), his ear drums may get red, just as his face gets red. This presents an out for the doctor. Pin the child down, put the otoscope into his ear, he fights and screams, his ear drum is red, and you declare him to have a middle ear infection. No one else sees the ear drum, so your word is law. If the child sees his regular doctor the next day, and the ears are normal, then the antibiotics worked!

I am certain that this sort of thing does not happen very often. However, most doctors encounter clinical situations with which they have little experience, and have no back up, so they are forced to wing it. For example, a doctor with little pediatric experience may be working alone in an ER, and fall into this method.

That's all for now. Until next time, stay healthy.