What should I do after hours when my child is sick?

Parents often fret about whether or not to go to the ER (or urgent care center or walk in clinic) for a child's illness or injury. This week the American Academy of Pediatrics released a position statement against walk in clinics. Many parents don't realize the difference between a pharmacy walk in clinic and an urgent care or ER staffed with pediatric - trained physicians, nurse practitioners, and physician assistants. I believe that urgent needs do arise after office hours, and we are fortunate in our area to have pediatric urgent cares and ERs that can fit that need.

This post is written with my own practice patients in mind. There are variances in what is available in any community and what  a pediatrician is comfortable seeing in the office and what they refer out. Please speak with your own physician about what to do after hours in your situation.

photo source: Shutterstock

I also know that many parents take their kids to walk in clinics for convenience. Sometimes even when our office is open. I think that really fragments the healthcare of the child and I cannot support going outside the medical home when unnecessary. I've blogged about this before. Please visit Urgent Cares for Routine Illnesses... Yes or No for more on that topic.

When to call for after hours advice

Over the years I have found most of my patient families to be very respectful of after hours phone calls. They recognize that I am trying to spend time with my family or that they woke me from sleep. They often apologize for bothering me (which isn't necessary, it is my job). Only on rare occasions do they call for things that should have been called during office hours or in true emergencies where they should call 911. It is a reasonable call if you need help managing the symptoms your child has, especially if you can't find your answer on our searchable website. If you want a diagnosis or prescription, your child will need to be seen and evaluated.

Things to avoid calling the on call provider about:

• To schedule an appointment. We don't do that. Leave a message at the office or request an appointment on our portal.
• To cancel an appointment. Leave a message at the office for the office staff.
• Any billing question. 
• To ask when we open. That information is on our website and our office outgoing voicemail message.
• To discuss a chronic issue that you have been working on with your primary provider -- unless symptoms have worsened and you need treatment advice.
• To discuss treatment from another office, such as a walk in clinic not in our office or a specialist that is managing a chronic illness. If you question something done by another provider, talk first with that provider. If you want to discuss it with your primary physician, call during office hours or send a message through our portal. 
• Prescription refills. It is a very unusual circumstance that we would call out a refill for you.
• A diagnosis and prescription. We cannot make a diagnosis over the phone and cannot prescribe a new medication for something that hasn't been seen.
• Rashes. See below.
• Symptoms that have been ongoing for days but not worsening. If symptoms have been stable for days, it can wait until we are open for your child to be seen.
• Routine growth, development, or behavior questions.
• Routine lab results. Sometimes our nurses call with lab results, but must leave a cryptic message. (Due to HIPAA laws they do not leave specific information on voicemail-- another reason to be sure each of your children are registered on our password protected portal-- we can leave specific details there!). If it is a result that requires notification of the parent urgently, they will tell the on call provider to call you or they will give you instructions to call back (with the knowledge of the on call person). If they say to call back during business hours, the on call person does not have your results on hand.
• To "document" suspected abuse. These kids should always be taken to a place that can see your child directly and has staff specifically trained for that purpose. We usually recommend an emergency room, such as the ones at Children's Mercy campuses. A phone call is hearsay and would not help your case.
• Directions to an urgent care or ER. I don't give good directions, just ask my husband. Call them, look online, or set a GPS.
• Prior authorization before going to the ER or an urgent care. We cannot do PA's after hours and they are not needed for insurance companies.
• To learn if a particular location is covered by your insurance. Call that location or check with your insurance company. We won't know. 
• To ask if an urgent care or walk in clinic provides a particular service, such as possible urinary tract infection in a toddler or stitches. We won't know. Call them for information about what they do.
• Anything that needs to be treated urgently. Calling us delays care. We can be notified later. Just go. 
• And one last request. Please don't call from the ER or urgent care waiting room to ask if it's okay to leave because the wait's too long. If you thought symptoms needed to be seen in the first place, I would never feel comfortable telling you to leave. Ask someone there who can see your child.

How can you find answers if you don't want to call after hours? 

• For our patients, using our online portal allows parents to ask routine questions at any time of day/night, as long as they can wait up to 5 business days for a reply. 
• Our website has a ton of information to treat many symptoms and parents can search there before calling. (Parents will often say, "I looked on the website but didn't find..." so I know they try! Thank you for trying!!! It not only helps the on call provider not be bombarded with another call, but you will often get more thourough advice, especially in the middle of the night.) 
• Online searches can be helpful ONLY if you know the site you are using. Besides our own website, you can use HealthyChildren, KidsHealth, or recognized hospital websites, such as CHOP.

• Remember: We are open 6 days a week and we offer walk in hours all open business hours. This allows you to come in to our office for most illnesses and minor injuries.

For more on how to get the best phone advice when you call our office or after hours on call provider, please read Help Us Help You.

Times to go to the ER or Urgent Care: 

The big question in a parent's mind is when does a child need to be brought to a walk in clinic or emergency room. If in doubt after reading this, call the on call provider for specific advice. Some generalizations to help make the decision:

• Any temperature over 100.5 in a baby under 2-3months of age. (I usually say at least 2 weeks after the 2 month vaccines.) A pediatric specific ER is best for this unless our office is open. (We can do the initial evaluation if we are open.)
• Any temperature over 100.5 in an under-immunized or immune deficient child. Be sure to tell the providers of the medical history that makes your child high risk. We can see these kids when we are open. An ER, ideally pediatric specific, is best for this when we are closed.
• Signs of dehydration. This includes no tears, dry mouth (not just lips), no urine in 6-8 hours. Dehydration can be managed in some urgent cares and all ERs. (Call the urgent care to see if it is within their scope of practice.) Walk in centers are NOT generally equipped to manage dehydration. Our office can see these kids if we are open. 
• A child who is urinating a lot but still seems dehydrated based on dry mouth, weight loss, sunken eyes, etc needs to be seen immediately. This is a sign of diabetes and needs to be seen in an ER if we are closed.
• Signs of respiratory distress. This includes breathing faster than 60 times / minute in children under 1 year, 50 times / minute in older children. This can be treated in our office when we are open, or in a pediatric urgent care or ER. Walk in centers should be avoided due to provider variations in competence with respiratory distress.
• Excessive pain. If you can't control the pain with simple measures, such as acetaminophen or immobilizing a hurt limb, it should be evaluated. ERs are more suitable if it is a possible surgical issue or if imaging will be required.
• Gaping skin. If an injury causes the skin to open enough that it looks better if you pinch it together, it probably needs to be repaired. Stitches, glue, or staples need to be put in as soon as possible because the longer the wound is open the more likely it will become infected and after several hours we can no longer close it up. ERs will always do wound repair. Some urgent cares will. Walk in clinics generally do not. During office hours we can do laceration repair, so you can save the trip to the ER if we're open!
• Altered mental status. If your child is so lethargic he can't lift an arm to drink, or doesn't seem to recognize you, or doesn't make sense when talking he needs to be seen immediately in an ER.
• Parental comfort. This is a vague one, but I am a big believer in the gut feelings of a parent. If you are worried and can't sleep, there might be something going on. Of course, you can't second guess every illness or injury, but if you are so worried you can't sleep: go.
• Call 911 and go to the ER if there is a severe illness or injury that may be life threatening.
• Go to the ER if you suspect your illness or injury might require surgery. 
• If you suspect an x-ray will be needed after an injury, use an ER or urgent care with the ability to do X-rays. During office hours our office can handle minor injuries. If you suspect a broken bone but the child is not in extreme pain, there is no obvious angling of the bone, and the skin is not broken over the area, it may be okay to wait until our office opens.
• A child who loses consciousness after injury or with illness generally should be seen. Call 911 if consciousness does not resolve quickly. (Note: many kids will "pass out" when standing in a hot room or singing, when toddlers cry hard, when kids see blood, or if they hyperventilate due to excitement or pain. They usually awaken quickly from these episodes. If they act normal after this brief passing out time, they can generally be seen in our office. Call for advice.)
• Eye injuries that involve a puncture to the eye, a possible fracture of the bone around the eye, unequal pupil size, bleeding from the eye, vision changes, or other serious concerns should be seen in an ER. (Minor eye injuries, such as a possible scratch to the eye, can be seen in our office or a pediatric urgent care.)
• Seizures should generally be seen in an ER (unless there is a history of seizures and home treatment is available). If your child is running a fever when the seizure starts, call for instructions. It might be appropriate to be seen in our office or a pediatric urgent care.
• Allergic reactions involving hives or facial swelling can be seen in our office when open, an ER or pediatric urgent cares unless difficulty breathing (in which case, call 911 and go to the ER). Even if your child has epinephrine available, they need to be seen after epinephrine is used.
• Severe difficulty breathing should be called to 911 to be taken to the ER.
• Severe headache should be seen in the ER.
• Severe abdominal pain that does not allow the child to move normally should be seen in the ER. This could be a surgical issue.
• If you are unable to drive your child safely for any reason but they need to be seen, call 911.

Typical things seen at urgent cares or walk in clinics are things that usually would be seen in our office when we're open. Many can wait until we're open if you can manage pain, hydration, and breathing at home.

• mild wheezing or difficulty breathing that isn't worsening
• minor burns and injuries
• abdominal pain that is minor without dehydration
• constipation
• pink eye
• ear aches
• sore throat
• vomiting and diarrhea without dehydration (as discussed above)
• fever in children over 3 months of age who are immunized and immune competent
• objects in ears or noses 
• insect bites
• mild allergic reactions
• cough and colds
• skin rashes
• urinary tract infections 
• sports physicals should ideally be done at your primary care office so that growth, development, safety, and other issues can be addressed
• vaccines should ideally be done at your primary care office to keep all records in one place. If your child gets a vaccine elsewhere, be sure to call the PCP office during office hours to update their chart.

A few common concerns that parents call about:

Fever

Parents typically spend a lot of time giving me a play by play of all the temperatures of the past week.  I really don't need to know every up and down of the temperature. What does it really tell me if a child has a fever? They are sick. That's about it. There is no magic temperature that I worry about for most kids over 3 months of age. If your child is younger than 3 months, is not up to date on recommended vaccines, or has an immune deficiency, they need to be seen for any fever over 100.5F. For other kids, I care more how a child looks and acts than the temperature itself. The goal of fever management is to keep a child comfortable and hydrated. The American Academy of Pediatrics recommends treating temperatures over 102F and for comfort. The goal is not to bring the temperature to normal, but to allow your child to feel more comfortable. For more on fevers, see my Fever blog as well as our website's Fever page.

Rashes

Rashes are notoriously difficult to describe. I have a hard time documenting them in the medical record and will sometimes simply take a picture to put it in the child's chart. Even a picture doesn't completely tell the story because it does not show the texture, temperature of the skin, or the evolution over time of the rash. After seeing the rash we need to look for other findings that could be associated with that type of rash (such as enlarged lymph nodes, swollen spleen, swollen tonsils, mouth ulcers, etc). In general a rash needs to be seen to be addressed. Phone calls for rashes (even during office hours) are not helpful. It only needs to be seen emergently if there are significant other concerns. If the rash bothers the parent more than the child, schedule an appointment.

Ear Pain

Earaches generally are not emergencies. If you can control the pain at home with an over the counter fever reducer, you can usually wait until office hours. The exceptions: other symptoms, such as dehydration, difficulty breathing, or Mastoiditis -- If the ear physically sticks out from the head more than normal, it is an emergency. For more on earaches, see our Ear Pain web page.

Vomiting and/or Diarrhea

Stomach bugs are very difficult to manage, but usually can be managed at home. Follow the instructions on our Vomiting and Diarrhea page. Signs of dehydration include: dry inside the mouth, extreme weakness, no tears, and decreased urine (except with vomiting from diabetic ketoacidosis - those kids make a lot of urine but they otherwise look dehydrated). If you think your child is dehydrated, he should be seen. Diarrhea that is bloody, severe abdominal pain, and painful urination with vomiting are other times that being seen as early as possible is warranted.

Sore Throat

Sore throats can be painful, but with good hydration and no signs of difficulty breathing, they can wait until office hours.

Medication dosing

Unfortunately many over the counter medicines don't have dosing listed for infants and young children. We have common medications on our Medication Dosing page. You can also ask the pharmacist when you purchase the medicine. I personally don't like to give dosing amounts over the phone, especially if you wake me from sleep. It would be too easy to give the wrong amount, which could be dangerous for your child. It is safer for you to always learn your child's dose when you buy the medication.

Continued illness despite treatment 

Sometimes parents call because they're frustrated that their child is still sick after a few days. Typically these are Sunday evening calls because the parent wants to get back to work Monday. I can't fix this over the phone. See Evolution of Illness for more on how illnesses evolve over time.

Walk In Clinic Etiquette

Cold and flu season always brings more people to the doctor or health clinic.  The pure volume can be overwhelming for any clinic, scheduled or walk in, but the nature of walk in clinics makes the volume unpredictable.   Sometimes no one in walks in, other times several come at once.  Walk in clinics are wonderful for the overall rapidness at which one can be seen, but how can you help streamline the process?

1.  Write down symptoms.  It sounds crazy to write down things since you know your child better than anyone, but if your child is sick you are probably sleep deprived and might forget important details.  Writing things down helps everyone summarize what is going on and get facts straight.  Very often the diagnosis lies in the history, and if the person bringing the child in does not know symptoms well, it is difficult to make a proper diagnosis.

2.  Expect to be seen for one acute problem.  Illnesses typically have more than one symptom, but they are a single illness.  It is appropriate to bring a child in for multiple symptoms, such as cough, fever, and sore throat.  It is not appropriate to bring them in for those issues as well as a wart and headache of 3 months off and on.

The nature of walk in clinics is that they move rapidly.  The number of patients checking in at any given time can be large, so each visit must be quick.  If you need more time with a provider, schedule an appointment.

3.  Do not attempt to get care for a chronic issue.  Chronic issues are always best managed by your Primary Care Provider (PCP).  This does not include sudden changes to a condition, such as wheezing in an asthmatic.  Your child can go to the walk in for the wheezing, but should follow up with the PCP with a scheduled appointment to discuss any changes needed to the daily medication regimen (Action Plan) to prevent further wheezing.  This is especially important if you went to another urgent care or ER for initial treatment so that your doctor knows about the recent exacerbation of a chronic issue.

4.  Do not add additional children to the visit. Many parents bring additional kids to the visit and ask if we can "just take a peek" in their ears. If you want them seen, check them in too.  Again, walk in clinics move quickly and the "quick" peek takes longer because the child is running around the room or fighting the exam.  The quick peek also does not allow for documentation of findings in the medical record, which might be helpful in the future.

5.  Have your insurance card and copayment ready at check in.  Streamline checking in by having everything ready.  It is amazing to me how many people must return to their car for their wallet.

6.  Try to bring only the child who is being seen.  It is difficult to focus on one sick child when another is running around the room, falling off the exam table, or constantly asking questions.  This applies to scheduled as well as walk in visits.  I know this becomes a childcare issue, but it can really help focus on the child being seen.

7. Bring medications your child has recently taken.  Often parents have tried treatments at home, but are not sure what was in the bottle.  Bringing all medications (prescription and over the counter) and supplements helps us advise on correct dosage and use of the medications.

8.  Go to a walk in clinic at your regular doctor's office if available.  I know not all doctor's offices have walk in hours and most are not open all night long, but most walk in type visits are not emergent, they can wait until the next business day.  Treating symptoms with home remedies is quite acceptable for most illnesses for a couple days.  This might even be beneficial to improve the immune system's ability to fight illnesses and to see how the symptoms change over time. Some kids are brought in at the first sign of fever, and look normal on exam, only to develop cough and earache over the next few days. When the symptoms change, so might the exam and treatments!

The benefits to going to your regular doctor's office to see your PCP or another provider with access to your child's medical record are many.  The record has your child's immunization history,  previous drug reactions, any underlying illnesses or frequency of illnesses (as long as you use them exclusively), as well as any other pertinent information.  Primary Care Providers and their staff also know your family and that alone can help!

Some walk in centers limit services or ages of patients.  The provider at the clinic may or may not have adequate training in pediatrics, and they often do not have others around who can help if a problem arises that is out of their comfort zone.   If a baby is crying, the eardrum gets red, but isn't necessarily infected.  A provider without a lot of experience will often err on calling it an ear infection. Giving a prescription for an antibiotic makes parents happy, regardless if it is necessary.  Better satisfaction scores for the clinic.  Faster turn around time since it takes longer to explain how to treat a cold than it does to write a quick script.  Everyone's happy, but antibiotics are overused.   They also do not offer follow up of issues to see if there is improvement.  They do not take phone calls if there is a followup related question.  You must call your PCP, but if we haven't seen the child for the issue, we are unable to give appropriate advice. 

There are gaps in care even at urgent cares where there is a pediatrician or midlevel provider with extensive pediatric training (there is more than one option in this area).  They do not know your child's full medical background and do not update your child's health record in the medical home.  Following in one office allows us to see the chronicity or recurrence risk of an issue.  If your child goes multiple places for every sore throat, the PCP only sees him for well visits and no one recognizes that a tonsillectomy might be beneficial. 

9.  Please don't use walk in clinics to have health forms filled out.  I know it is tempting to get a quick physical just to have the sports form or work physical signed, but this breaks the concept of a medical home.  Your regular doctor doesn't get to see you for a comprehensive visit, reviewing growth, development, safety, immunization status, and more. We lose the opportunity to share what has happened in the past year and continue our relationship.   If the medical home does all the well visits and vaccines, we have up to date records and can update as needed.  Some kids have missed school because vaccines were missed and they can't return until they get them.  Others have gotten extra doses of vaccines because a record of a shot was missing and parents can't remember where they got the vaccine.  We request a well visit yearly (after age 2) within the medical home.  If in need of a well visit, please call the office to schedule! 

Help us help you!

Hello.  This is Dr. Stuppy.  I'm returning your call about...

That is how my phone calls start, then they take various turns.  Some are easy, some not so easy.  I'd like to discuss what makes a phone call to the doctor's office more productive, so we can help you better.  All examples are entirely fictitious, made up of 12 + years of phone call experiences.

Many calls start off like this:

Hi. This is Mary Sue. My son has a rash and I want to know what to do.

Me: ????? I must ask many questions for more information.  

Some callers don't seem to know what to say, so they only answer direct questions.  How old is your son? When did the rash start? What does it look like? Has it changed? Does it itch or hurt? Any other symptoms? What have you used to treat it? Did that help? Has he had any new ingestions, lotions, or creams? Does he have a history of allergies? Anyone else with a rash that looks like this? On and on...

Or like this:

Hi.  Thanks for calling back. My son Jack is 3 years old.  Well, really his birthday isn't until next month, but he's almost 3.  He has had a fever for 2 days, maybe 3 days because he felt warm but he wasn't acting funny or sick that first day he felt warm.  He actually was fussy last week, but I don't think he ever had a fever then.  I was thinking maybe he didn't sleep well last week, but I don't know why.  I took his temperature and it was 100.3, that was on Tuesday around 7am.  I gave Tylenol, and it went down to 97.9, but then 4 hours later it was back up to 99.7....  

My thoughts so far: Get to the point. 

Sorry, but that's true.  I care about my patients, but so far this phone call has taken me quite a bit of time and I really know nothing except this almost 3 year old has an elevated temperature (not even a true fever).  

When parents call, they need to summarize with pertinent facts.  While they shouldn't leave out important helpful information, they don't need to mention every time they took a temperature.

Much like the evening news: they can't do a play by play of every football game.  There's no time and it serves no purpose.  A few highlights of the game and the score.  That works well.  People get a pretty good idea of how the game went.  

It's the same thing with phone calls to your doctor's office or on call provider.  We have thousands of patients.  Not all call the same day, but during peak cold and flu season last year our office took 50-90 calls/day (the highest numbers on Mondays).  One phone nurse has 8 hours to answer up to 90 calls in addition to filling out insurance forms and other tasks.  (We have great nurses that help out if they have time, but if the phones are busy, I guarantee the office is busy too!)  They simply can't spend 15 minutes chatting about every detail.  That's for your friend and you to discuss over coffee.

After hour phone calls during the winter are also more frequent.  It is not uncommon for me to be on the phone with one parent and another call comes in.  This is at the same time I am trying to watch my son's game or go to the grocery store.  I really don't want to sit and chat.  I don't have time for play by play action.  Again, I really care about my patients, but I can do a better job at answering your questions if you are clear and concise.


Things that help us help you over the phone:

• Know what is going on.  When a parent calls and the child is at daycare or grandma's so the caller doesn't know details, we can't really help.  Write down the pertinent facts to get them straight if you need to.
• Start with your child's full name and birth date.  Include any significant past history, such as your infant was born at 28 weeks gestation, or your coughing 3 year old has a history of wheezing.
• Give pertinent facts related to the concern.  

• If your child has a fever, give the number of days of fever, the maximum temperature, and how it was taken.  If you have given a fever reducer, share that.
• Briefly describe symptoms and what you have done to help them as well as if your child responded or not to the treatment.  Remember treatments are not only medicines, but if you use a vaporizer or saline for a cold, or have stopped dairy and used G2 for vomiting, let us know. 
• If your child has a rash, it is typically best for us to see the rash, but if you call about a rash describe it in terms of location, color, and size (many find it helpful to relate to common objects, such as quarter-sized).
• Note if there is a pattern to the symptoms, such as headache every day after school or barky cough only at night.

• Let us know any medications your child typically takes in addition to ones you have tried for the current symptoms.  
•  Leave out details that don't help.  Trends and generalizations work well.  If we want more details, we can always ask. 

Examples of good call starters:

• I am calling about Joe Smith, birth date 9.12.08. He has had a fever for 3 days, up to 101.3 under the arm. It comes down with ibuprofen, but is right back up in 6 hours.  He also has sore throat and headache. He's drinking well but not eating much for 3 days.

• Sally Smith, birth date 9.12.11, has vomited 6 times in the past 12 hours. If I give formula it immediately comes up. She is now dry heaving and hasn't had a wet diaper in 12 hours. She doesn't have a fever but looks tired and it is hard to wake her to drink. She doesn't have diarrhea. Her older brother had the stomach flu a few days ago but is now better.

• John Smith, birth date 9.12.11, was in the NICU for 2 months due to prematurity. He has been fussy all day and is now breathing fast and hard and is not able to drink more than a few sucks at a time. He doesn't have a fever, but I'm really worried. 

Remember:  Our website has many pearls of wisdom.  Often when we give advice it is already stated on our site.  Parents sometimes call multiple times because they can't remember what we said.  This is frustrating on both ends of the phone.  We wrote it down for a reason.  Use our site!

Things that cannot be done by our on call providers:

• Prior authorization for an ER or urgent care visit.  These must be done during office hours, and most of the time our office is not involved.  These are typically done by the location at which your child is seen.
• "Allow" you to leave a busy ER.  It sounds silly, but I have had many calls from the waiting room at ER/Urgent Cares with parents asking if I think it okay that they leave due to a long wait. If you thought it necessary to go in the first place, I would be open to a malpractice lawsuit if I told you to go home without being seen.  You should ask their triage nurse who can make that assessment.
• Refill medications.  We typically expect that your child is seen prior to most prescription refills for best medical care.  If it is urgent that your child have a refill, such as an inhaler, they should be seen to evaluate the concern. There are exceptions to every rule, but don't be upset if the on call provider refuses to call out a prescription. 
• Make a diagnosis.  We cannot see the ear, listen to the lungs, or feel the belly over the phone.  A physical exam and sometimes labs or radiology studies are needed to make a diagnosis.  If your doctor claims to be able to diagnose by phone to call out prescriptions, I would suggest that they are not doing the best of care.

Some things are best done with a visit for further evaluation.  

• Difficulty breathing.  If a child is having difficulty breathing and you don't have treatments at home that work, he needs to be seen as soon as possible.
• Dehydration.  An infant who hasn't urinated in 6-8 hours or an older child who hasn't urinated in 12 hours might be dehydrated and should be seen as soon as possible.
• Some fevers. Temperature above 100.4F under the arm in an infant under 3 months or under immunized child can be serious and should be seen as soon as possible.  Fevers lasting more than 3-5 days or with other concerning symptoms require an evaluation.
• Uncontrollable pain.  If you have used standard pain relievers and your child is still hurting, we cannot do anything by phone that will improve the situation. A careful exam might find a treatable cause of pain.
• Most rashes.  Though these don't necessarily need to be seen emergently unless there are other concerns, rashes cannot be evaluated on the phone and a physical exam is needed.
• Chronic problems.  If your child has been dealing with anything for more than a few days, it might help to schedule a visit with your usual provider.
• Diagnosis vs information.  If you want a diagnosis, we need to see your child.  We cannot tell if the ear is infected or if your child has Strep based on symptoms alone.  If you want advice of what to do with symptoms, we can generally give advice.  Remember that our website also has most of this information too!
• Behavior problems.  These are best discussed with your usual provider, not an on-call provider who doesn't know your child. Most of these build up over time and are not emergent issues.
• Injuries.  If your child has a moderate or severe head injury, possible broken bone, laceration, or other injury symptoms they require evaluation.  Lacerations must be repaired as soon as possible, so don't wait until office hours the next day!

Help me help you!  Let me know what else you need to know to be an educated caller.  I'd be happy to answer questions about when to call, what to ask, and what to expect.  If I left any questions unanswered, please ask!

Dr S

Cold and Flu Season is Upon Us!

photo source: Shutterstock

As cold and flu season approaches, I have been thinking about how our kids are managed when they become sick.  Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care.


We are a busy society.  We want things done now.  Quickly. Cheaply. Correctly.  Resolution so we can get back to life.


Illness doesn't work that way.  Most childhood illnesses are viruses and they take a few weeks to resolve. There's no magic medicine that will make it better.

Please don't ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.  

Don't ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.  

Don't ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.  

Antibiotics simply don't work for viruses.  They also carry risks, which are not worth taking when the antibiotic isn't needed in the first place.

Many parents in this community have grown accustomed to using after hour urgent cares  because they are convenient.

Convenient isn't always the best choice.  Many times kids go to an urgent care after hours for issues that could wait and be managed during normal business hours.  I know some of this is due to parents trying to avoid missing work or kids missing school, but is this needed?  Can it hurt?

Some kids will get unnecessary tests, xrays, and treatments at urgent cares that don't have a reliable means of follow up.  They attempt to decrease risk often by erring with over treating.  Our office does have the ability to follow up with you in the near future, so we don't have to over treat.  

Urgent cares don't have a child's history available.  They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective).  They might not recognize if your child doesn't have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age.  We know that parents can and should tell all providers these things, but our own new patient information sheets are often erroneous when compared to the transferred records from the previous physician... parents don't think about the wheezing history or the surgery 5 years ago every visit.  It is so important to have old records!

There is some evidence that treating things too soon does not allow our bodies to make immunity against the germ.  A great example of this is Strep throat.  Years ago we would go to a doctor when our sore throat didn't get better after a few days.  They would swab our throat and send the swab for culture, which took 2 days. We would treat only after that culture was positive.  That delay in treatment allowed our bodies to recognize the Strep and begin making antibodies against it.  Now kids are brought in the day they have symptoms, and if the rapid test is positive, they immediately start antibiotics.  The benefit? They are less likely to spread Strep to others and they can return to school 24 hrs after starting the antibiotic.  The negative? They might be more susceptible to recurrent illness with Strep, so in the end are potentially sick more often and end up missing more school.

Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick.  Is it time for further evaluation of immune issues?  Is it time to consider ear tubes or a tonsillectomy?  If we don't have proper documentation, these issues might have a delay of recognition.

Urgent cares and ERs are not always designed for kids.  I'm not talking about cute pictures or smaller exam tables.  I'm talking about the experience of the provider.  If they are trained mostly to treat adults, they might be less comfortable with kids.  They often order more tests, xrays, and inappropriate treatments due to their inexperience.  This increases cost as well as risk to your child.  We have been fortunate to have many urgent cares available after hours that are designed specifically for kids, which does help.  But this is sometimes for convenience, not for the best medical care.

Cost.  As previously mentioned, cost is a factor.  I hate to bring money into the equation when it comes to the health of your child, but it is important.  Healthcare spending is spiraling out of control.  Urgent cares and ERs charge more.  This cost is increasingly being passed on to consumers.  Your co pay is probably higher outside the medical home.  The percentage of the visit you must pay is often higher.  If you pay out of pocket until your deductible is met, this can be a substantial difference in cost.  (Not to mention they tend to order more tests and treatments, each with additional costs.)

What about our urgent care in our office?  We offer a walk in urgent care as a convenience for parents who are worried about their acutely ill child.  It is within the medical home, which allows us access to your child's chart. We can keep all treatments within this medical record so it is complete.  Our staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols our physicians and midlevel providers have agreed upon.  Essentially we have a high standard of care and want your child to receive that great care.

So what kinds of issues are appropriate for various types of visits?  
(note: I can't list every medical problem, parental decisions must be made for individual situations)

After hours urgent care or ER:

• Difficulty breathing (not just noisy congestion or cough)
• Dehydration
• Injury
• Pain that is not controlled with over the counter medicines
• Severe abdominal pain
• Fever >100.4 rectally if under 3 months of age
  

Pediatric Partner's Urgent Care:

• Fever 
• Ear ache
• Fussiness
• Cough
• Sore throat
• Vomiting and/or diarrhea
• Any new illness

Issues better addressed with an Appointment in the Medical Home:

• Follow up of any issue (ear infection, asthma, constipation) unless suddenly worse, then see above
  
• Chronic (long term) concerns (growth, constipation, acne, headaches)
  
• Behavioral issues
  
• Well visits and sports physicals (insurance counts these as the same, and limits to once/year)
• Immunizations - ideally done at medical home so records remain complete 

If your child gets a vaccine at any other location, please send us documentation (including the date, brand, lot number, and place administered) so we can keep the records complete.

Remember our website offers answers to questions and many treatments to try at home for various illnesses and conditions!