Header image for the Sickest Children by Dr. Susan Kuo, featuring the Doctor, a painting by Luke Fildes, 1891.

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The Sickest Children
by Dr. Susan Kuo

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Over a century ago, Dr. William Osler, who is often described as the Father of Modern Medicine, wrote, “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”

I have practised as a family doctor in Richmond, B.C. for 30 years. When I started here, Richmond was rural. All the family doctors did deliveries, looked after their own patients in Richmond Hospital (RH), assisted with surgeries, and even saw patients in the Emergency Department (ED). RH was a very small hospital, and I knew many of the staff by name.

Times have changed. Now, RH has become a big teaching hospital with specialists, emergency physicians, and hospitalists (doctors dedicated to hospital inpatient care). So, although I still visit my patients in the hospital, I now mostly work in my own office. 

Being a family physician is always challenging. It has become even more challenging during the ongoing COVID pandemic, which is now compounded by a seasonal flu epidemic and the multiple other viruses circulating in our community. Here is a glimpse of what my days in the office have been like recently.

It’s only 10:15 am, and my Medical Office Assistant (MOA) tells me that we already have seven sick patients that we need to fit in tonight. This includes three children with coughs and high fevers. The parents have rapid tested their children daily for COVID, but so far the results have been negative. My office is fully booked until 6 pm, but I tell my MOA to contact all of them, and schedule them for the end of the day. It’s going to be another long one.

By the time I call the first mother, it’s seven in the evening. Her son is a immunocompromised ten-year-old boy who was exposed to grandparents who were unknowingly infected with COVID-19. He has been coughing for two days and has had a fever of 40°C for the last four days, with no relief from acetaminophen. On the Zoom call, he looks pale and is breathing fast. Mom and I search online and find BC Children’s Hospital (BCCH) ED‘s wait time to be very long, while the Richmond Urgent Care Centre (UCC) is still open and has a shorter wait time. After a chest x-ray, his parents are told that he has pneumonia. Despite his history of immune compromise, being exposed to COVID positive grandparents, and having pneumonia, the mother is told that the UCC no longer does viral PCR tests. My young patient is given a prescription for antibiotics and a steroid, and mom is advised to take him to BCCH if he gets worse.

The second child is a three-year-old on her fourth day of a high fever and cough. Her parents are worried that she is sleepier than usual. We decide that she should be taken to the BC Children’s Hospital Emergency Department. There, after a long wait, she is examined and found not to be sick enough to require hospitalization and therefore does not meet the hospital’s PCR testing criteria. The family is told to come back in three more days if she is still sick.The ED report I receive says Viral Infection.

The third child is a three-year-old who has been sick with a fever and cough for six days. Looking up the hospitals’ wait times, all are excessive. She gets booked for an in-person office visit the next morning. The toddler is still feverish when I see her. Listening to her chest, there is the unmistakable sound of bronchiolitis (inflammation of the small airways) and possibly pneumonia. She looks very ill. The family lives in North Vancouver, and she is taken to Lions Gate Hospital’s ED. There she has a chest X-ray which shows pneumonia. She is sent home with an antibiotic but no PCR test. I follow up the next morning. The child is still febrile, coughing and wheezing but has not started the medication. I add inhalers to her prescription. 

From the day a child is born, a parent tries to protect them from harm. During the COVID-19 pandemic, parents face their worst nightmare of having a very sick child with no way of alleviating the child’s suffering. Who would have imagined that there would be no children’s acetaminophen to alleviate a child’s fever, and that the most basic antibiotic, amoxicillin, would be in short supply or unavailable in pharmacies across Canada? 

As a parent, I worry every day when I drop my child off at school whether today will be the day that she gets infected. In the last few weeks, this has become a real possibility, with classrooms often half empty, and children and staff sick at home due to the triple whammy of COVID, flu, and RSV hitting B.C. classrooms.

I am also a doctor. Because of what I have learned about the disease, I know that if my child gets even a mild case of COVID, she may develop Long Covid, or a new post-Covid condition such as of type 1 diabetes, kidney failure, pulmonary embolism, or cardiomyopathy (a disease of the heart muscle).

Studies show that repeated SARS-CoV-2 infections are not benign. Every infection increases the cumulative risk of being hospitalized, developing a post-Covid condition, and even dying. Evidence is also accumulating that SARS-CoV-2 impairs the immune system. An impaired immune system makes it harder to fight off viruses, bacteria, and other pathogens. Many suspect that the widespread impairment of people’s immune systems following one or more COVID infections is causing our pediatric hospitals to fill up with sick children.

If my child becomes really sick, I know we will have to brave long waits in a crowded emergency department. In doing so, we may be exposed to COVID and other respiratory viruses. That’s why it is so ludicrous for the chief medical officer of BC Children’s Hospital to “urge parents not to bring their children into the emergency department unless it’s absolutely necessary”; which parent would brave what are often 9 to 10 hour waits in an emergency department unless they truly believed their child was seriously ill? Let’s also remember that for many families in BC, there is no alternative to going to the ED with a sick child.

After 30 years in practice, I have known many of my patients for a long time. I have delivered some of their babies, cared for them in hospital when they were ill, and sat with them at their parents’ bedsides as they were dying. I have known some patients all their lives after bringing them into the world. From all these experiences, trusting relationships have emerged. Some of my patients tell me I am like a family member. This is why, as a family doctor, my worst nightmare is to be helpless, unable to care for my patients- especially sick children.

A CTV news report revealed a leaked memo outlining the new BCCH policy of refusing to perform PCR swabs unless a child is sick enough to be admitted, or is immunocompromised with a respiratory infection or an acute febrile illness. As a doctor, I am trained to take a detailed medical history, examine the patient and then based on my differential diagnosis, order specific tests to confirm the diagnosis and determine what treatment is needed. Over the last few months, every day I have seen patients with all the classic symptoms of COVID, including fever, sore throat, cough, fatigue and even loss of taste and smell, yet I am unable to access the test needed to confirm that diagnosis.

BC Public health has done such a poor information campaign that many patients still don’t understand when, where, and how to swab with a COVID Rapid Antigen Test (RAT). Worse still, it can take several days of illness before a RAT turns positive. The PCR test can detect not only SARS-CoV-2, but also other viruses including RSV and influenza. Testing is particularly important in high risk patients to determine if they have influenza and would benefit from early treatment with oseltamivir (Tamiflu). Confirming whether someone has COVID or influenza also gives them an opportunity to inform their contacts.

For COVID positive patients who meet high risk criteria, I can prescribe antiviral treatments such as Paxlovid (oral) or Remdesivir (intravenous), but only within a narrow time frame after symptom onset. Additionally, I can only offer these potentially life saving treatments if I know what the diagnosis is. If I cannot test, I cannot diagnose, and so potentially life-saving treatments may be withheld from those who need them.

Since Dr. William Osler’s time, there have been great advances in science and medicine. He had no access to antibiotics, Paxlovid, acetaminophen, or PCR tests. Yet even with all of our 21st century resources and scientific advancements, keeping people healthy throughout this pandemic has become difficult because it has been made political. When the government intentionally limits access to testing to align with the false narrative that “COVID is mild”, and the urgent pursuit of “getting back to normal” at any cost, it’s challenging to practise the art of medicine effectively.

In this pandemic, I feel at times like I am in the 19th century myself. Back then, all a doctor could do was to sit at a sick child’s bedside, as in the famous painting above. It is the 21st century, and I should be able to do more than just offer empathy.

Please note that all families referenced in this post have provided consent to share their stories.

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