What does a pediatrician do when their own kids are sick?

I drafted this post weeks ago, but finished it tonight after spending the day at home with Rogue Three, who is sick (not seriously ill), so the timing couldn’t be better.

Many people have skills they develop for work that they end up using outside of their job.  Some of these skills may be mundane, some may be difficult to master, and some may be only tangentially related to their work.

Mechanics are probably asked by family and friends to help all the time with cars making strange noises.  Lawyers are asked by to help fix speeding tickets.  Accountants are asked if the cost of hot water from a shower can be tax-deductible.  Maybe you don’t realize it, but you probably have a skill you developed for work that you now apply in other situations, and maybe you do not always apply it willingly.

Physicians are no different, and may be the best example of this phenomenon.  We are routinely asked by friends, family, neighbors, and sometimes strangers, for medical advice.  Often on topics we know little about.

Asking Doctors for Advice

Often it’s a text or a phone call — a family member asking what to do when Johnny has a fever or if a laceration needs stitches.

Occasionally it’s at home – your adult neighbor fell and hit their head and the spouse wants to know if they need to go to the ER.

Or it happens AT work – a co-worker wants your opinion on joint pain, or a parent wants you to look at their rash while you are examining the child they brought to the ER and who is the patient.*

*These are only a few of the things that have happened to me. 

Recently while taking care of a child in the ER at ~2am, a father asked me to look at his own rash to see if he should be seen as a patient in the adult ER next door (I work in a pediatric ER in a children’s hospital) 

The father didn’t want to be registered as a patient, he just wanted to know if he needed to be seen as a patient elsewhere.  Physicians have different philosophies on this, and many would refuse to examine someone who wasn’t officially a patient in a non-emergent situation (there are good reasons for this).   

I agreed to help dad out.  It turns out this 6’4″ 300 pound father didn’t have a rash.  When I asked him a bit more detail, he said he had a bump on his buttocks that had become bothersome and itchy.

In for a dime, in for a dollar.  He turned around, dropped his pants/underwear, and showed me his rear.  It was obvious (to me) he had a giant abscess – a skin infection with a walled off area of pus inside .  It would going to need a procedure to drain the pus.

 I told him he likely needed an incision & drainage, and he should have it taken care of quickly given the size.  He said he would get it taken care of elsewhere.  I discharged his son, in the ER for a minor complaint, and sent them on their way.  It was something better handled by my adult ER colleagues next door.

Treating Your Own Kids

Sometimes it’s your own kids with the complaints – they wake up in the middle of the night puking, or with a fever, or with an asthma attack.  In the case of Rogue Two, last month he had all three at once.

It seemed to be his “typical” asthma, being trigged by a virus.  We dutifully followed his asthma action plan (from his pulmonologist).  During the day I examined him (I keep a stethoscope and otoscope at home), and finding nothing concerning, we decided to give it time.

When my kids have a non-emergent illness that’s clearly within my regular work as a physician, I often do the initial evaluation, and occasionally prescription (regular antibiotic, steroid for croup, etc) on my own.  Essentially if it’s something that shouldn’t require a test or procedure or consultant (or obviously a hospital stay), I take care of it myself and update their pediatrician about it later if necessary.

On the 5th day of waiting it out — still with fever and a persistent cough, now with rigors in bed at night, enough was enough.  While he looked fine when the fever decreased, 5 straight days  was a tipping point (5 days of fever is a magical number for those of us in pediatrics, though Kawasaki’s Disease was not on my differential).

While he was hydrated and breathing comfortably (coughing is his main asthma symptom), we were concerned he may have something I hadn’t picked up.  Or to be blunt — I was worried I was missing something, such as pneumonia.

I took him to his pediatrician.  I made no suggestions — I gave the details of the illness, but I did say I wanted someone else to look at him to make sure I wasn’t missing something, given he had not improved as expected.

The pediatrician looked him over and essentially said the same thing — he looked and sounded fine.  However she suggested a chest x-ray to check for pneumonia.

We deal with this situation in the ER on a routine basis.  As the doctor, I am commonly advocating wait-and-see approaches.  We had been doing that at home without improvement, so in this case I think the x-ray was justified, regardless of what it found.  In some cases, more waiting may be appropriate.

As the parent, I was quite happy when the doctor suggested the x-ray, even if pneumonia was a low likelihood.

Therein lies the contradiction – when you take off the doctor hat and put on the parent hat, the perception of what your child needs can change dramatically.

As Dr. Dad, I wanted to examine the patient, consider potential diagnoses, devise a treatment plan that worked for the patient and which the family could follow, and counsel the family (myself and my wife) appropriately on what may or may not happen over the next few days.

As regular dad, I just wanted to make sure my son was okay, and I wanted someone else to do the thinking.*

*In a future post I plan to explore how having a children impacts my work as a pediatrician/peds ER doctor and as a dad.  You do not have to have kids to be a good pediatrician, but it’s definitely made *me* a better doctor.  I’m not sure that it’s made me a better (or worse) dad.

What’s the Diagnosis?

Below is the two-view chest x-ray we obtained.

So what’s wrong with these pictures?

It’s subtle, and hard to tell with these images, but my interpretation (I looked at it on my own immediately), and that of the pediatric radiologist, was a possible early pneumonia along the left heart border (for the non-physicians — look at the picture on the right, and along the RIGHT side of the picture you’ll see some fuzziness along the border of the heart).

The pediatrician started him on antibiotics, and within 48 hours he was essentially symptom free.

Soft call?  Possibly.  It could have been a virus that ran its course in the timeframe we started the antibiotics.  No way to know at this point.

Ground Rules for Treating Non-Patients as Patients

So what do you do if you are in a position of giving medical advice for someone who isn’t officially your patient?

You need to establish  some ground rules — first and foremost, decide if you are even willing to consider it.  Not everyone will.

If you are willing, then they are some obvious things to remember and some considerations.  This list is NOT exhaustive, just a few common sense things:

• Do not practice outside your speciality.  If you are an OB/GYN, do not give advice about treating chest pain, other than “go to the ER or call your doctor.”  As an ER doctor (though focused on peds), I have exposure to a wide variety of illnesses/ailments (including “adult” things such as heart attacks), but there are  MANY things I should not be doing.  If you’re eligible for AARP, it’s possible I’m not the best person to ask for advice.  I still know more on many topics than most lay people, so I  share what I know, however I will not give concrete advice if it’s outside the scope of my peds/peds ER training.
• Remember liability — your workplace malpractice insurance is not going to cover you hanging a shingle outside your front door and starting a clinic in your garage.  When I give medical advice to someone who isn’t a patient, I give enough caveats and/or cautions they likely think I don’t know what I am doing.  Friends and neighbors can misinterpret advice, or they can follow good advice and have bad outcomes, just like a patient in your clinic/ER/hospital.  They can sue you also.  This has never happened to me, but I’m putting my livelihood on the line (and my family well being) every time I treat a patient, whether in the ER or in my living room — it’s a responsibility that should be taken seriously no matter the setting.
• Keep a record — if you are going to treat someone, consider a folder with paper to jot notes so you have a record of the conversation, just as you would do in your regular practice setting.  I received this advice years ago and have never actually done this, but I probably should.

As I said, not an exhaustive list, just a few things that come to mind.  Medical ethics are tricky and I take my obligations as a physician seriously.  When in the ER, if I don’t know the appropriate next step, I call a consultant or send the patient somewhere else where they can get the answer.  Ultimately I’m a person first and a doctor second, so I generally help people when they ask, occasionally going a bit outside my comfort zone to do so.  However as with everything, know your limits.

What are your thoughts?  How do you balance your work knowledge and personal relationships?  As a reminder — nothing on this blog constitutes official medical or professional advice.  Listen to me at your own peril.