Saturday, 30 May 2015

In Praise of Doing Nothing (Easter Egg – good safety-netting and saving lives)

When I ask parents if they have seen their GP about an illness they often reply, “Yes but they didn't do anything.”  I am most encouraged whenever I hear this.  So, no-one has done any tests or prescribed any treatment?  “Excellent” say I, “and your child is the healthier for it.” 

Here's why:

So, if you are one of these clinicians who are doing a lot of nothing, you have my thanks and admiration, because I know how much work it takes.   All I would like to do is add my top tips for making sure that the child with… let’s say a viral URTI, is sent out into the world with the best possible advice and safety-netting.  Why?  Because safety-netting is what makes all the difference when a child with an uncomplicated viral illness develops a secondary infection (or other complication).
  • Try not to say the words ‘just a virus’ or ‘only a virus.’  Parents will tend to feel that you have not recognised how unwell their child is.  Acknowledge that the child is unwell and explain that viruses can make children quite unwell.
  • To balance this, (lest they ignore signs of serious illness) explain that the hallmark of viral illness is that the child will intermittently pick up and look reasonable, often quite suddenly.  Children with sepsis and meningitis do not go from playing to lethargic and back again every few hours.
  • Explain that children with a viral illness do sometimes get another infection added on which is usually more serious.  For this reason they must seek reassessment if the child is not picking up or if new problems develop such as abnormal breathing etc.  This part is especially important as occasionally I will see children brought in who are severely septic and the parents have delayed seeking another assessment because they were given what sounded to them like an ‘everything is fine and will be fine’ appraisal by the clinician that they saw.
  • Advise regular paracetamol, fluids and to avoid overdressing the child.
  • Do not tell parents that if the illness continues they should go to their emergency department to be assessed.  If they are well enough to be sent home then persistence of symptoms does not really warrant an ED attendance.  Save the ED option for the child who is worsening despite paracetamol etc.

It is truly an art to get that balance between being reassuring enough and safety-netting well.  However the worst possible thing would be to add tests to uncertainty or treatments to cover improbabilities.  So thank you and please keep doing nothing.

Edward Snelson

Disclaimer:  Safety-netting was invented by Roger Neighbour or possibly Houdini.  Check Wikipedia if you want.

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