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When powders and potions won't do

Maurer, Brian T. PA-C

Journal of the American Academy of PAs: December 2015 - Volume 28 - Issue 12 - p 66
doi: 10.1097/01.JAA.0000473378.07777.64
The Art of Medicine
Free

Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com. The author has disclosed no potential conflicts of interest, financial or otherwise.

Tanya Gregory, PhD, department editor

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From where I sit in my office I can hear the conversation floating down the corridor from the examination room.

A young mother is speaking above the cacophony of children's voices, struggling to answer the medical assistant's questions.

“My youngest—she's 18 months old—hasn't slept in the last 2 nights. She cries until I go in to pick her up. Over the past 3 weeks she's had two courses of antibiotics—one for an ear infection, one for a sinus infection—and now she's got another runny nose with yellowish discharge. I don't know what I'm going to do if she has to go on another course of antibiotics. She's horrible at taking medications: she spits them out or chokes and makes herself vomit.”

The medical assistant duly records the chief complaint, asks if there are any allergies to medications and beckons the mother to step out to the scale to weigh the toddler.

“The physician assistant will be in shortly,” he says. A few moments later he hands me the encounter form. “Good luck,” he says. “There are four kids in that room and they're all whining at the same time.”

When I step through the doorway I recognize the mother as someone I have seen before. She has eight children in all, ranging from 13 years down to 18 months old. She's married to the father of these children—seemingly a rarity these days—and with the help of her husband does a reasonably good job of parenting them.

“Well, it's the curly girl!” I say. “What brings her here today?”

The mother repeats the litany that I have already overheard, nearly word for word. Except this time she pauses frequently to intervene with the other three children, who don't seem to be able to sit still. “If you keep talking, I can't hear the doctor,” she says to them. “Please be quiet.” This verbal intervention works for about a minute before the commotion starts anew.

“So you're worried that she might have another ear infection?” I ask.

The mother nods her head. “She had a long string of them over her first year. I'm hoping we're not in for a repeat performance this cough and cold season.”

“Let's have a listen,” I say, popping the stethoscope into my ears. The child squirms in her mother's arms. Although it's difficult to hear her breath sounds, her color is good and she seems to be aerating fine.

“Let's have you sit on the table and hold her in your lap,” I say, directing the mother to give the little girl a bear hug. I sneak a peak in each ear—enough to satisfy myself that the eardrums are clear—and then examine her throat. Thankfully, the child screams, affording me an excellent view of the posterior pharynx. The other three children cover their ears with their hands and giggle. I toss the unused tongue blade into the trash.

“Well, at this juncture it looks like nothing more than a little head cold,” I say.

“Her ears are clear?” the mother asks.

I nod my head. “Ears and lungs are clear. Nose is a little stuffy, nothing to write home about. Her oxygenation is excellent and there's no fever.”

“What can I do for her?”

“Just keep her comfortable, well-hydrated; perhaps run a vaporizer in her bedroom at night. The head cold will drag on for about 10 days, but I imagine she'll do fine.”

“She doesn't need an antibiotic?”

I shake my head. “Not this time,” I say.

The other children are back at it, shoving one another for a seat on the two chairs. “You are losing your PlayStation privileges,” the mother says. Momentarily, they whine, then quiet down.

“I'm so glad she doesn't need another round of medicine,” the mother says. “She's a pill to give medicine to. That's one additional stress I don't need.”

“I don't like to prescribe antibiotics if they aren't indicated,” I explain to the mother. “Call the office if she develops fever or a sudden change in disposition.”

“And,” I say, directing my voice to the other three children, “you kids have got to learn to listen to your mother. That's why God gave you a mother—to take care of you. And you can help your mother take care of you by listening to her when she tells you to do something. Okay?”

The children nod their heads and silently filter out of the room.

“Thank you so much!” the mother beams as she follows her brood down the hallway and out the door.

Practicing good medicine does not always mean prescribing medication. When powders and potions won't do, sometimes education, a little reassurance—and advocating for the caretaker—go a long way.

Copyright © 2015 American Academy of Physician Assistants