Tuesday, January 28, 2014

Docs, do you prescribe for your kids?

Genmedmom here. I did a bad, bad thing this weekend.

Both of my kids, Babyboy age 3.5 and Babygirl age 2, have had upper respiratory boogery junkiness for weeks. Both are in some sort of school, hence, they're both sick all the time. We deal with that; it's to be expected. They were either sent home or kept out of school all last week with boogery junky coughs. Saturday: they were pretty good, on the mend, even! Sunday: horrible.

Babyboy woke up very early Sunday morning complaining of a tummyache. Then, ear pain. Then, he started vomiting. He'd hold his right ear, howling and whining, then vomit. He's had ear infections before, and this is his presentation. Prolonged congestion, followed by malaise and tummyache, followed by ear pain and vomiting.

It was kind of scary as he did something I haven't seen him do before- he was grimacing, crying, holding his right ear with one hand, and then hitting the couch with the other hand. Like, hitting the couch with the pain.

Usually, I am a stickler about bringing my own kids to their own doctor to be evaluated for anything. Yes, I am Med/Peds trained, and I passed the Pedi boards, um, ugh, nine years ago.... but no, I do not practice Peds. I hate examining my own kids; I don't have the heart to hold down anyone's head to try to look in their ears.

But.

It was Sunday. It was really, really cold out. Babyboy was absolutely miserable. And it was so, so obvious that he had an ear infection. I knew that if I called his Pedi's office, they would (probably correctly) recommend some sort of eval. On a weekday or Saturday, they are awesome about making same-day appointments happen. But on a Sunday, it's going to mean a ride into the city and a looong wait in a crowded waiting room full of kids sicker than mine.

So, I made a diagnosis. I did examine him, sort of. I listened to his heart, normal. Lungs, clear. I felt his tummy, soft. I tried to look in his ears. He screamed and pulled away. I waited until he dozed off and tried to look in his ears: He screamed and pulled away. He's not that protective of his ears generally, so I figured that was further sign of ear discomfort.

I did talk it over with another doctor, an experienced GP turned oncologist turned internist, who was our own default emergency pediatrician growing up. That would be my dad, still in solo practice after all these years. And, I got a second opinion from a very well-trained internist who happens to work at my same hospital...That would be my brother. And the diagnosis was further confirmed by our informally-trained healthcare provider, my mother, who said something like, "They're been sick for weeks. Get them on some antibiotics already." It was my dad who called in the Amoxicillin, though I figured out the dosing.

Babyboy got some Ibuprofen and Amoxicillin and slept on the couch most of the day... When he woke up around 3 pm, he sat up, rubbed his eyes, hopped down onto the floor and started playing Legos. "Can I have juice?" he asked. Ha.

I felt guilty, though. Was I wrong to diagnose and treat my own kid?

Then, more horrible. Babygirl was a bit off all day. She didn't eat well. She fell asleep pretty early at 6 pm.

Then, around 8 pm, she awoke, screaming. We tried rocking her, tried to soothe her, but she kept screaming this shrill, high scream, kicking her legs in convulsive spurts.

And holding her left ear. Actually she was sticking her finger in her left ear, digging at it, like she was trying to get something out of it. We got Ibuprofen into her and waited for it to kick in. Minutes ticked by and still she was sreaming, convulsively kicking, digging at her ear, screaming, kicking, then "Mama mama mama aaaaaah!" It was pretty awful. I was trying to think what to do. We didn't have any Auralgan... The last time I asked our pediatrician about it, he said he discouraged its use, and told us to use Ibuprofen or Tylenol instead. I thought about... Ciprodex.

Back in the old days, like, when I was a resident, the standard prescription for an ear infection was oral antibiotics plus something like Ciprodex, an antibiotic/ steroid ear drop. Research then showed that the drops didn't do much for otitis media, so the dual prescription fell out of favor. Except with my dad, who had called it in along with the Amoxicillin. So, Hubby ran to get the bottle, and out of sheer desperation, with a sweating, almost crazy with pain Babygirl writhing in my lap, I squirted a good amount of the room-temperature drops into her left ear canal.

She startled, screamed some more, still holding the ear, then, slowly, relaxed. Whimpered, cried out a few more times, then fell alseep.

Hubby and I looked at each other like, Okay? Is that it? I tried to think how the drops might have worked so well, so quickly. I didn't expect the anti-inflammatory effect to take so fast. But perhaps they did nothing more than equalize the pressure in her ear. If the tympanic membrane was bulging out, some warm fluid might have helped ease some of the distension. After all, as my mom pointed out later, an old remedy for an earache used to be warm olive oil poured into the ear canal.

Or maybe the Ibuprofen kicked in. Or maybe she had exhausted herself. At any rate, she had been insanely flailing with pain for almost 20 minutes, and now, was resting quietly. We were so glad. I was almost in tears, actually.

Then we went and pushed our luck. We had two big fresh bottles of Amoxicillin for Babyboy (with alot extra, as the pharmacist had told us to discard the leftover half bottle). We logicked it out: this is also likely an ear infection, let's get her some antibiotics as well. So, I calculated her dose, and tried to slip some into her mouth with a syringe. The first two mls went fine. She sort of gulped and took it.

The last 3 mls didn't go so well. She gagged, and then vomited all over. Ugh.

She fell back asleep and we decided to let well enough alone. She was awake several more times during the night, and we did eventually get both Ibuprofen and antibiotics into her. This morning, she is cheerful.

So both kids are now committed to a full 10-day course of Amoxicillin for ear infections, and neither has seen an actual practicing pediatrician.

So am I a bad, bad mommy? Or will the rest of you 'fess up that you've done the same in similar situations?



14 comments:

  1. Yup. I did it. And I am not a pediatrician (internist). When Eve was about 8, she had a bad cold and Sam stayed home with her. He called me that afternoon and said she was complaining about her ears, and could I bring my otoscope home - the weather was miserable and he didn't want to take her out if he didn't have to. I got home at 5:00. It was dark. It was cold. Freezing rain. She had a temp of 101.5 an hour after ibuprofen. Her tonsils were exudative and her left TM was bulging and red. I said "Sweetie, we need to take you to the doctor". She looked at me, burst into tears, and said "But YOU'RE a doctor and I feel TERRIBLE and I don't want to go ANYWHERE". Her doc was closed; I knew taking her in would mean urgent illness, where I'd refuse whatever antibiotic-of-the-month the doc suggested and insist on amox....so I looked up the dose, weighed her, did the math, made Sam double-check the math, and called it in.

    The next day I confessed to my boss, a family doc (I work in hospice now). He said "You never did that before? I did it ALL the time".

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  2. I'm only an ms3 but growing up, my mom, an adult intensivist prescribed meds for us all the time. It's not ideal but common

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  3. I had my hubby bring in my 2 1/2 month old to clinic to see me on Christmas Eve in my small town when he called me to tell me she was putting her hand over her ear. I was the only doc in that day because I was on call for the ER and it was a holiday, so her only other option would be to drive 20 minutes away to a bigger city. I figured, why not have my insurance company pay me to treat my own child? I couldn't have come home anyway that day. It ended up not being an ear infection after all, just a cold.

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  4. I'm not a doctor, I just happen to follow Genedmom, so I'm not actually clear on the rules, here. But it strikes me that while it's a good ethical principle not to treat your own family, it doesn't seem like the kind of principle you'd want to take as absolute. You have all balanced it with other principles, such as, don't make the patient suffer unnecessarily, and avoid unnecessary bad side effects (for example not taking a kid to an emergency clinic with a germy waiting room so that he gets even sicker). Seems like good medicine to me! Of course it's good to think 2 or 3 or 4 times about it before breaking the no-treating-family-members rule. But these seem like appropriate compromises.

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  5. Am I the lone voice of dissent here? I think it's just too difficult to evaluate your own kid objectively, especially if he/she is in pain. And what if you made a wrong decision and caused harm?

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  6. i think it's definitely a gray area. that said, i'm kind of with OMDG. i am a board certified ped (though i am in peds endo now, so don't do gen peds anymore) and took my 21 month old in for diaper rash last week. yes I AM THAT MOM. i always use our ped for things like ear infections and such. i just feel like a) i'm not objective; b) i may not be up to date (despite finishing gen peds residency in 2010!), c) i would feel horrible if a choice i made wasn't the right one.

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  7. Have I done it? Yes. Does it happen routinely? No.

    Most of the time I send daughters and hubby to urgent care for evaluation, especially if it is a new problem.

    Thinking back to times I have prescribed to my family:

    1) daughter with nasty pink eye, and school won't take back unless they have eye drops

    2) my mother, who couldn't get her PCP to refill her albuterol without an appointment, two weeks away (I could hear her wheezing on the phone).

    3) Hubby ran out of his imitrex while travelling, woke up with his typical migraine.

    To be honest, these are cases where I would also prescribe over the phone to one of my regular patients. For family practice, these are "easy calls."

    Times I'm glad I didn't prescribe, and sought consultation:

    1) big bump on daughter's leg, I was sure it was MRSA, friendly pediatrician diagnosed "mosquito bite."

    2) hubby with "classic flu symptoms," turned out to be double pneumonia and hospitalized for 4 days

    3) school age daughter with a nasty rash on one butt cheek, I was thinking allergy or yeast, urgent care doc pointed out it was vesicular and dermatomal, treated her for shingles.

    I'm not very objective with my family.

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  8. As a new family doc, I've not yet done it. Throughout my training, whenever I had to take one of my three children in for something like you describe (i.e. acute illness when I though antibiotics or specific treatment was required), I always felt awkward, like I was wasting the time of my colleague. However, I'm glad I did, because I was occasionally surprised by the results. Two of my children had diarrheal illness around age 15 months (not twins, these events are three years apart)... I recall neither had peed in over 24 hours, there were no tears when he / she cried, my daughter in particular was quite mottled, her mouth was dry, etc.... I thought they needed IV fluid.... nope. Another time I was concerned about fever over 40 C (approx 104 F), despite being fairly convinced my daughter had a viral illness (she has a robust febrile response and routinely spikes a decent temp when ill) and knowing that "the number" on the thermometer is not as important as the child's symptoms. I brought her in anyway, just in case.... pneumonia, requiring antibiotics.
    Those cases are the exceptions, though. Most of the time I have the children assessed for an acute illness, my diagnosis / judgement matches that of the treating physician.
    There is no moral to my story, I suppose Genmedmom, except to say that I haven't done it yet.... and in your case, you did consult other docs, you obviously put a lot of thought into this, it is not something done casually or routinely, and you certainly have the mom and doc judgement to bring your kids in if they are getting worse and not improving after your "treatment", so yeah, I think that on balance, what you did was a reasonable, defensible choice (that many others have made before you, and will make in the future). I think it is a grey area - "wrong" on paper, but sometimes "right" in certain circumstances (like many topics in medical ethics)..... great post.....and I'm glad to hear your kids are feeling better!

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  9. I haven't done it, but if the choices boiled down to going to the ER for a non-emergent thing vs. prescribe myself, I'd choose the latter. I take my kids in like a regular old mother (I'm board certified in med and peds) because I refuse to look in their ears. My younger got ear infections frequently and I always KNEW when he had them, if I had been on vacation or it was a holiday and the office was closed, I'd have probably prescribed the abx.

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  10. Great post, as always!

    It's such a tough call, being a parent and a physician. I have prescribed for my kids twice since becoming a parent. The first time, my daughter had a cold for over a week and while we were away at a cottage, in the country (nearest hospital over an hour away), she complained of ear pain and spiked a fever. A look in her ear confirmed AOM. I gave her Amoxil but after the week's course she wasn't any better, so off to the pediatrician we went. She reminded me that daughter had been on antibiotics (Amoxil) in the previous 3 months (which I had forgotten) and she was in preschool. I had given her the wrong antibiotic and got a gentle reminder that I probably should have consulted with another physician.

    The last time was this past Christmas with my daughter, again. It had been over 2 years since her last infection.Yeah, no such luck. After having rhinorrhea, cough and on-again, off-again fevers and complaints of ear pain, I tried to get her in to see her Pediatrician at 4pm on the Friday before Christmas. You can well imagine what the receptionist told me. Having examined her ear and seeing the pus making her drum bulge, it was a no brainer that she needed treatment but I decided to wait it out another few days. By CHristmas eve she was no better, (but no worse, either), so I consulted with one of my colleagues who agreed I should treat her and was kind enough to call in a script for Amoxil. I didn't feel good about it, but her ear looked awful and just couldn't justify a long wait in a WIC when I already knew what was wrong.

    Was it right? No, but given the circumstances and time of year and how busy we were (and I was, with a 3 month old baby), it was the only thing I could do.

    As a general rule, I try not to be the kids' doctors, but as a parent and a physician, often the line blurs.

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  11. I don't do it regularly - I've done it once for Eve and once for Sam (when we were traveling). If their regular docs are available, that's who they see - because I trust their regular docs and don't have to second-guess them. That's the thing. I can't turn off what I know or who I am. I just completed successful surgical treatment for debilitating sciatica, and I did obediently see my doc and do what she said....well, I did what she said after a conversation (which meant I took the dose of gabapentin I wanted to and had Valium rather than Flexeril for my anti-spasmodic).

    My father was a doc and was way too involved in our care (he was my mother's PCP for years and that was just wrong). For the first 20 years of my career, I NEVER prescribed for a family member. Now...once for my kid, once for my husband, and my mother's psychiatrist consults with me about her meds for dementia with agitation and anxiety (that's my wheelhouse, anyway). And I'm WAY less involved than most of my friends, who are much more like my dad....

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  12. I once treated my daughter's clear ear infection with amoxicillin. Then it turned out it was a resistant bug and I felt like an idiot explaining to the pediatrician. Even though he would have done the same thing. That taught me to avoid treating her most of the time.

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  13. I am a family doc, but pretty much all I check out on my own kids is their ears. I have an otoscope at home. However, I still usually bring them in to see someone even if their ears look bad to me. One time our son was on amoxicillin and our daughter started having symptoms and had a bulging TM,so I gave her a dose of our son's med and had one of my partners send in a script for her, too. I've never actually prescribed medications for my own kids. I feel sometimes like my mommy brain takes over and my doctor brain just doesn't work as well. When our son was 3 months old he had a fever and cough. He wasn't feeding as well and got dehydrated. It was a Sunday and I finally came to the conclusion that he needed to be evaluated in the ER. He ended up hospitalized for 3 days as he had RSV. He was hypoxic and dehydrated. I think if I wasn't a doctor I would probably have brought him in sooner, but it's hard to know when it's your own kid.

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  14. I'm a pedi resident, haven't prescribed for my daughter yet but my mom (family doc) used to prescribe stuff for my family occasionally while I was growing up and still does occasionally.

    In your case, I don't think what you did was wrong. I just have one question: why didn't you look in their ears??? Get someone to help you hold them down and steal a glance at their tympanic membranes! Then you'll have the objective data to make an objective decision and wouldn't feel so bad about it. I know holding fussy kids down for ear exams isn't fun, but surely you must have some experience under your belt as med-peds? I wouldn't beat yourself up too much about it, but next time you might not feel so bad about it if you try to get the objective data to take the subjective out of it.

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