Pediatric patients: the gray zone vs. the end zone

July 2006

It’s Thursday afternoon at 3 p.m. I amiably saunter into room No. 6, which is filled with a young mother and her two children.

“Good morning, Gail. From my nurse’s notes, I see that your baby has been coughing and cranky. Well, let’s get a look at the young man.”

I proceed to examine the 9-month old, who seems quite skeptical of my examination initially, but quickly warms up to my charm and funny-looking nose. Although the cursory auscultation of his lungs is initially clear, I proceed with the gentle but firm chest compression, or as I like to term it, the “squeeze–a-wheeze” tactic, which I perform on any child with clear lungs and significant history of cough. They almost never breathe deeply.

Aha! That is why the baby is coughing so vigorously. The lungs are full of wheezes and rhonchi when the chest wall is compressed. Then I bring out the otoscope, and somewhere in the recesses of his short-term memory, he remembers this thing may be more ominous than the stethoscope. He begins to struggle and cry. As the mother restrains his arms and legs, I firmly press his head against her chest and begin my diligent search for a possible acute otitis. Both tympanic membranes are indeed full of pus and slightly reddened.

“Gail, today John has some wheezy bronchitis and both ears are infected. Since he has wheezed two previous times — each time responding nicely to the nebulized albuterol and steroids — I would like to prescribe him a nebulizer with albuterol again along with some steroids for five days and antibiotics for 10 days. Your medical card will cover them. We may have to label him as mild asthmatic. He appears to have the usual infantile form of viral induced wheezing which is reversible. By the way, your other son sure has been behaving very well while I examined the baby.”

Something is bothersome about the mother’s own appearance though. In between glances at the baby, I noticed that the mother has a noticeable reddened angry boil on the zygomatic process of her face just lateral to her eye. While trying to assimilate the degree of illness in her baby, the antenna also begins beeping in my cerebrum. This young mother is appears to feel bad, and looks somewhat ill.

I inquire: “I noticed you appear to have a boil on your face. Are you feeling bad? Has any doctor examined you recently?”

“Oh yeah, I went to the free clinic yesterday, and the doctor gave me some capsules that begin with the letter ‘K’.”

“Do you mean Keflex?” I query.

“Yeah, that’s it.”

“Well, are you any better than yesterday?” I asked, certain that the answer was no. If she looked any worse, she would be in the hospital.

“Your infection seems to be causing some peri-orbital edema of your eyelids. Have you noticed any puffiness of your eyes?”

“No, but I feel like I have some low-grade fever now.”

“I think that you need to see the doctor again, and real soon. That skin abscess on your face looks as if it may be festering worse, and it may be traveling into the first stages of an even more serious infection we call periorbital cellulitis.”

“But Doc, I do not have a regular doctor. And I have no insurance. I cannot afford to go to the ER. That would cost me $400 or $500.”

“How old are you now?”

“21.”

“Perhaps, maybe I can help you get into see your last doctor that you visited. Who might that be?”

“It was you, Dr. Block. About 6 months ago.” Oops.

“So no one since then?”

This is one of the perils or graces of practicing pediatrics for 24 years in the same small rural community as I have. I have probably seen most of the parents as patients themselves in the last two decades.

Her personal war-zone

Yes, I remembered her quite well as my patient during her rebellious teenage years. Her father was never available to her, and her mother worked as a nurse. Her mother was often working too much. Left alone frequently, she found the ephemeral “love” in the bed of an adolescent male. She also frequently fought with her younger sister and she even moved out at age 16 in a fit of anger and hostility toward her mother.

I could not convince her to use any contraception reliably at age 17, thus the 3-year-old son for this 21-year-old mother. But at least she would come into the office to see me for her routine illnesses; pre-pregnancy and in between pregnancies, and – I remember now — even post-pregnancy. She was temperamental, often reticent and occasionally hostile in the office as well. But having raised four adolescent daughters in my own household, I had a healthy respect for the forces and stressors weighing upon any young lady in a stable intact household. Not to mention one as tumultuous as hers!

So she was currently one of the 45 million Americans without insurance. She was not a statistic. She was a nice young lady struggling to survive along with her two children. She had a sick child at home needing her attention and care, no regular recent doctor and no job. She felt bad and was and on the verge of major worsening of a facial abscess unresponsive to cephalosporin. As is typical in our area, probably less than 30%-40% of abscesses seen in the office are -lactam responsive.

She could not afford a visit to the emergency department, and was in desperate need of incision and drainage and a switch of antibiotic to cover for methicillin-resistant Staphylococcus aureus (MRSA).

Gray zone of pediatrics

I had encountered the gray-zone of pediatrics: the upper age limit of our population. Often, I must examine a young mother during the same visit with her baby. This means if she does not bring a car seat, I must hold the baby or toddler while I examine the mother’s lungs and abdomen. For me, it is just another excuse to hold a cute baby.

At what point do we relinquish the care of our patients? Most certainly, the answer is during the pregnancy. But what about post-pregnancy for adolescent or single mothers? After all, they are still teenagers or young adults.

I surmised the following:

• She was still young enough for my practice.
• I had quite an expertise in the problem she was dealing with — MRSA and I&D. (Our office medical policy: all outpatient moderate or worse abscesses require I&D and MRSA antibiotic coverage. Forget the I&D alone — nothing but failure these days.)
• I had excellent rapport with the mother.
• I could make extra time for her visit.
• She was definitely in need of immediate medical care.
• Her medical options were limited due to cost and a capable physician being available.
• And I could afford limited or no reimbursement from someone in true need.

Otherwise, as I explained to her, she was likely to wind up in the hospital within 24 hours with at least a $10,000 bill if she did not obtain appropriate treatment.

“Let me see what my schedule looks like for the rest of the afternoon. Never mind. If you do not mind waiting a bit, or going to get your child’s prescriptions filled, I will make sure that you are taken care of promptly. Today.”

“How much will it cost? I cannot pay you today.”

“Don’t worry about it. Our most important rule is: take care of the sick patient first. Worry about the bill later. You just pay when you can, and only if you can. I will only charge you a ‘brief visit’ reduced charge any way. The office manager in the billing office may have a fit, but I have the luxury of being the boss today.”

I found a spot in the schedule for her that afternoon. I warned her that I would need to make a small incision of about 5 mm to release all the pus built up in the abscess. “It may scar a tiny bit.”

End zone of pediatrics

Sterile prep and drape, 3 cc of 1% lidocaine injection superficially, small nick with a #11 blade, gentle firm squeezes, oozing of 5 cc of pus, probing and breaking of the adhesions with an instrument, bandage.

“Can you get this prescription for a different antibiotic filled?”

“No, I have no money.”

“Not even borrowing it from your mother? (Too estranged still.) “I have some samples of trimethoprim-sulfamethoxazole for free. However, I have major problems with this drug failing when the abscesses are this deep and involve some cellulitis. It just does not penetrate that well. I would prefer to use clindamycin, but it is somewhat expensive ($60) and you would have to obtain it at the pharmacy immediately. You cannot wait to get it later or tomorrow. Any delay, could put you in the hospital.”

“I think I can talk my boyfriend into getting me some cash.”

“I need to know for sure.”

“Oh, he will give it to me, or he will be in trouble!”

“You must come back tomorrow, and so I do not want you to worry about any charges for that visit. I must ensure that your wound and abscess are improving.”

When she returned the following day after promptly obtaining her clindamycin, the periorbital cellulitis had now become apparent, but the swelling and redness of the abscess had dramatically improved. The culture appeared to have an MRSA organism, which I asked the lab not to report and to toss it to avoid incurring any additional cost for her. (By the way, the baby had also improved dramatically.)

She returned the following day, and all signs of the periorbital cellulitis had dissipated, the skin over the abscess was slightly pink, and her malaise had resolved.

Some days it is downright nice to be able to practice like a country doc. Yet one must keep up-to-date with the continuing evolution of medical care in order to successfully reach the End zone. One wonderful aspect of practicing medicine is in the healing, not the money, for some of us. Saving the government more than $10,000 by avoiding her hospitalization and her subsequent requirement for Medicaid, reminds me that, in rural pediatrics, offering free care when needed to those who need it has its own rewards.

As Sister Christine Lesousky portended to me as a senior in high school: “Block, Noblesse Oblige.”

(Look it up on Wikipedia.com!)

For more information:

• Stan L. Block, MD, has a pediatric practice in Bardstown, Ky., and is a member of the Infectious Diseases in Children editorial board.