Pediatric emergency care during a time of strict social isolation

I am a pediatric trained emergency physician working in a level 1 trauma center.  Our region is not an epicenter for COVID-19.  Like many pediatric departments, our volumes are returning but were less than half of normal for months.  Social distancing has not only flattened the curve for COVID-19, but it has also made our usual summer viruses all but disappear.  Where are all the enteroviruses?

In pre-COVID times, after a good history and physical exam on a well-appearing, febrile child, I could confidently say, “It’s a virus.”  I could also confidently say the same on a listless child who perked up after antipyretics and oral fluids.  Most of the time, I was right, as the odds were on my side.  In my personal experience over the last few months, my confidence in this statement, “it’s just a virus,” has waned.  I believe that this is because the odds have changed.   I have no data to back up this opinion, although I have colleagues who share it.

First, I am finding it more difficult to reassure parents that their child has a virus when they have been careful to socially isolate.  Obviously, there are still grocery carts and handrails, so the incidence of viral infections is not zero.  Many families, however, have been good about staying home and limiting contact.  Curiously, I find myself siding with the parents and saying, “I share your concerns.  Where is the fever coming from?  Could we be missing something else?”  I recognize that I am in a higher alert state.  We all are.

With less person-to-person contact and infections being less common overall, the percentage of more serious infections seems to be higher.  Since the pandemic started, I find that a febrile child with no obvious source is much more likely to have a UTI, occult pneumonia, or a tick-borne illness.  I find myself wanting to check blood work when I have spent my career educating others on the lack of utility of such tests in healthy children.  The other day, when a child did not perk up as quickly as I expected, I ordered a CBC and blood culture, and then considered a dose of Rocephin.  I felt like I had time-warped to the 1980s.  I can feel my practice changing, at least temporarily.

Sick children have always existed.  The art of pediatric emergency medicine is in finding the preverbal “needle in a haystack.”  We strive for a healthy balance of doing just enough to save the one who needs it but not too much for those who will improve on their own.  I suspect the research that we usually use to decide the relative risk is not as accurate during this unique time in history.  For example, I would make an educated guess that the percentage of patients who present with abdominal pain who have acute appendicitis is higher currently.  Similarly, the baby who has a fever and vomiting is more likely to have a urinary tract infection today than she was six months ago when acute gastroenteritis was prevalent.  Research and guidelines will have trouble keeping up with our dynamic clinical environment.

The other contributing factor is the public’s fear of seeking health care during the pandemic.  They are weighing the risks and benefits of coming to the emergency department in a way that they have not had to do before.  The last thing that they want is to come in with a stomachache and leave with COVID-19.  Theoretically, this has also decreased the number of lower acuity cases, making serious diagnoses that require acute intervention more likely.

I imagine that as schools resume, our epidemiology will revert closer to normal.  I hope that my instincts and confidence return as quickly.  I had become comfortable practicing pediatric emergency medicine in the pre-COVID, post-vaccination era.  During these unchartered times, I will continue to be a bit more suspicious and perhaps more cautious before diagnosing an acute viral illness.  I believe that this practice change is justified and perhaps necessary.  At the very least, it is understandable.

Lisa Uherick is a pediatric emergency physician.

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