November 19, 2017

Paediatrics: Take 2

Now that I’m in Year 5, I’m having my second go at Paediatrics. One would think that, this time around, we’d be more prepared and comfortable in the rotation. Well, the senior doctors certainly assume we are; they keep saying things like, “Well, you should’ve read that book from cover to cover back in Year 4.” To that I usually shift guiltily in my shoes and try to avoid making eye contact, because I never did get around to finishing that textbook!

Another new development, since we’re now in our final year, is that we keep getting the same speech from everyone: “When are you graduating? In a few months, right? This time next year, you will be the new interns.”

But apart from having my heart stop beating every time someone mentions “exams” and “graduation”, things actually are a bit better this time around. Slowly but surely, it’s dawning we might be becoming real doctors. The other day my friends and I saw a patient in the Paediatric Emergency Department, and we did the whole 9 yards: took the patient’s history, did a full exam, reviewed the case with a senior doctor, and sent the patient off with a stamped prescription. Sure, it was a simple case that didn’t require the patient to be hospitalized; and yeah, the 5 of us collectively made up 1 doctor, but we still did feel quite pleased with ourselves.

And it really does feel like the things we’re learning now we’re learning for life. I’ve been grilled so many times about the management of an “acute exacerbation of asthma” that I’m having dreams about being chased by oxygen masks and nebulizer equipment. But, on a serious note, asthma is one of those things you’re guaranteed to see at least a couple of kids come in with every day, so it makes sense that we should really know about the management of asthma.

And before patients are discharged from the hospital, they usually have to be counselled about how they’re going to manage their asthma when they’re home. They’re advised about avoiding triggers, to prevent setting off another asthma attack — things like cigarette smoke, pets, dust, and mould. The parents are advised to avoid having carpets and heavy drapes around the home, because those might trap dust. When taking a paediatric patient’s history, we usually ask if anyone smokes around the child. And fairly frequently, I get the response, “Well their _____ smokes, but he/she doesn’t smoke inside the house or around the child.”

But that still counts as exposing the child to cigarette smoke. Because cigarette smoke clings to smokers: it clings to their hair, to their clothes, to their breath, to their skin. So there’s a chance your cigarette smoking could still act as a trigger for an asthmatic child.

For a lot of kids, their first symptom of asthma is a cough that just won’t go away. Many parents go to their local pharmacist and they’re recommended an expectorant for the cough. Some doctors may also prescribe an expectorant for the cough. But if the child actually does have asthma, an expectorant won’t be a good long-term solution. Expectorants are “mucolytics”– they ‘break up’ mucus that builds up in the airways. They don’t treat the underlying problems of asthma that cause that mucus build-up in the first place.

For the long-term management of asthma, drugs like inhaled corticosteroids and bronchodilators have been shown to be very effective. For each child with asthma, an asthma action plan should be agreed upon, with options that work best for that child. And I don’t think paediatrics is as bad as George Clooney says it is: “After doing “One Fine Day” and playing a paediatrician on ER, I’ll never have kids. I’m going to have a vasectomy.”

He was just acting…the real thing is more satisfying!