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Why don’t you have separate sick and well waiting rooms?

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Written by Suzanne Berman MD. Dr. Berman is a practicing general pediatrician in rural Tennessee.

We’re occasionally asked by families why we don’t have separate waiting rooms for sick and well patients.  It’s a good question, especially given that many pediatric offices are designed this way.  There are several reasons why we chose not to do this.

 What ‘s a “sick” visit vs. a “well” visit?  

The first problem is one of definition.   While some kids are very clearly sick and other kids are clearly well, many of the visits we do don’t fit nearly into one category or another.  Is a depressed teenager “sick” or “well” ?

What about a 4 year old with a possible urinary tract infection?   An infant who’s not gaining weight?  An 8-year-old with belly pain?   A better way to separate the waiting rooms would be a “contagious” waiting room and a “noncontagious” waiting room.

However…

Parents often don’t know whether a child is contagious or not when they check in.  

We don’t expect them to be – that’s our job.   If a child comes in with a new rash, it might be eczema (not contagious at all), chickenpox (very contagious), or ringworm (only very mildly contagious, and certainly not enough to keep them out of school or sports.)   Fifth disease is contagious and causes a rash – but once the rash appears, the child is no longer contagious.

Knowing whether the child is contagious (and how contagious, and for how long) first requires a medical evaluation – and that happens after the child has been brought back, not in the waiting room.

What about siblings? 

We often see double or triple appointments in a family.   If Dad brings in a 6-month-old baby for a checkup (a well visit) and his two year old sister for a cough (a sick visit), what side of the waiting room should the whole family sit on?

We could put the well baby on the sick side (since he’s already been exposed to the two year old’s illness, presumably), or we could put the sick child on the well side (to keep the well baby well.)   There’s no good answer.

And I can’t put a number on the times I’ve seen a well child who was accompanied by a parent who was coughing and sneezing uncontrollably.

It actually can make crowding in the waiting room worse.

Our office’s single large waiting area measures about 20 x 30 feet.   Let’s say we divided it in half, to create separate sick and well waiting areas, each about 20 x 15 feet.

In the summer, when 70 percent or more of our visits are “well,” our patients would be crammed in a much smaller room while our “sick room” would be underutilized.

The exact opposite would be true in the winter months –a crowded waiting room of sick children half as big as it could be.   When we have a single large area, we can make the most of our space; families can sit wherever they wish, near or far away from anyone else in the waiting room.

Parents are sometimes not honest about their child’s contagious condition.

I once reviewed a malpractice case in which the plaintiff contended that the defendant pediatrician didn’t recognize a baby’s sickness. The defendant’s attorney asked the plaintiff’s grandmother (who had brought the baby to the office) whether the grandmother chose the sick or well side.

The grandmother said, “We sat on the well side.”  The defendant’s attorney asked, “If the baby was sick, as you say, why did you sit on the well side?”   The grandmother replied, “Well, she wasn’t very sick at the time – just a little sneezing and cough.  And I didn’t want her catching something from the sick side.”

Honest parents will admit that they’re usually more concerned about keeping their own child away from other sick children, rather than worried that other well children will catch their child’s illness.

Our receptionists don’t want to police the waiting rooms.

Colleagues with separate sick and well waiting rooms tell me that their receptionists spend at least part of each day helping parents decide which waiting room to sit in, moving patients from one waiting room to another, or settling angry squabbles between two families who are convinced the other’s child is in the “wrong” area.

Our receptionists would rather check in patients quickly – validating insurance information, updating phone numbers, and processing questionnaires — rather than serving as “waiting room police.”

There’s no evidence separate sick and well waiting rooms make a difference in controlling the spread of infection.

The American Academy of Pediatrics’ statement on controlling infection in pediatric offices states, “No studies document the need for, or benefit of, separate waiting areas for well and ill children.”

We believe that other commonsense precautions are more effective – like making masks, tissues, and hand sanitizer available in the waiting room; bringing children suspected of having an extremely contagious disease in through the back door; bringing extremely fragile/susceptible children back as soon as they enter the office.

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Let’s Talk About Pertussis Also Known as Whooping Cough

Written by Richard Lander MD FAAP

What is pertussis?

Pertussis is an infectious disease caused by bacteria. Sometimes referred to as the hundred day cough, it can be quite debilitating. The cough is persistent and recurs day in and day out. Once you hear this cough, you will never forget it. The cough is repetitive, easily lasting 30 seconds or more and has a whoop sound at the end of it. This whoop is what gives rise to its popular name whooping cough. If you are curious, you can hear the whoop sound on the internet.

Who gets Pertussis?

Many people do-all ages and from all walks of life including: young children, teenagers, adults in middle age and senior citizens.

Is Pertussis contagious?

Yes it is. I have seen Pertussis several times in my practice this year. I have seen it spread from mother to child, among siblings and even from teacher to students.

Treatment of Pertussis

There are different phases of Pertussis. When the diagnosis is made during the first phase of the illness, it can be treated with antibiotics. This may shorten the duration of the disease. Otherwise physicians can offer supportive care and medication to help the patient sleep.

Prevention

Pertussis is preventable by a vaccine. This vaccine, DPT (Diptheria, Pertussis and Tetanus) is typically given during childhood. The vaccine is given as a series of three injections in the first year of life, a booster during the second year of life and another booster before the start of elementary school. An additional booster is given at 11 year of age.

Because this last vaccine is relatively new, many children older than 11 year of age will be receiving it. Additionally the Tetanus booster which has always been recommended to be given every ten years has been change to include the Pertussis vaccine.

Therefore, adults of almost all ages are urged to obtain it even if you received a Tetanus booster a year ago. Many hospitals across the country are giving the vaccine to new mothers right after delivery and in some progressive hospitals the vaccine is being offered to new dads and to grandparents.

With this approach the State of California, which had seen deaths from Pertussis in the last few years, has dramatically decreased their rate of Pertussis. These dramatic results have persuaded many pediatricians to offer this vaccine to parents and grandparents of their patients.

Why talk about Pertussis now?

Pertussis is on the rise in the United States. From January through March in 2012 there were seven times the number of cases seen in Washington, D.C. than in the same time frame the year before in 2011. So why you might wonder: why this rise in Pertussis now? Several years ago we experienced a number of parents refusing to have their children vaccinated against childhood diseases including Pertussis.

These refusals were based on fears of the vaccines and components of the vaccines such as aluminum or mercury. Thankfully, these fears have been proven to have been unfounded. Unfortunately, once people stopped vaccinating their children, herd immunity was lost.

Herd immunity is gained when a majority of people in a geographic area receive a vaccine. These vaccines then protect even the few who were not vaccinated.

As the number of vaccine refusers climbed, we lost herd immunity. Hopefully today with increased knowledge through education, the number of vaccine refusers is beginning to decline and more people are again protected against infectious diseases such as Pertussis. Scientists are working tirelessly looking for clues to currently unanswerable medical questions.

Every day they race the clock in an effort to look for a treatment for currently untreatable medical conditions and diseases. Pertussis is not one of them. Pertussis is preventable with a vaccine It is criminal that there are people living in the United States in 2012 suffering from a disease they did not have to have. Please don’t be one of them. Ensure that you and your loved ones do not get Pertussis. Get vaccinated! Get vaccinated now!

Dr. Lander has been practicing pediatrics for 32 years in New Jersey and is the immediate past chairman of the American Academy of Pediatrics Section on Administration and Practice Management.  He says if he had to do it all over again he wouldn’t hesitate to be a pediatrician.

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Contagious Diseases and Siblings

Written by Jesse Hackell MD

In the fall of 1957, the Asian influenza pandemic was spreading across the country. My younger sister had just been diagnosed with that flu, and my grandmother had arrived shortly thereafter to help at our home when my mother entered the hospital to give birth to another sister. In those days, one could count of a solid seven days in the maternity hospital, even for an uncomplicated delivery.

Knowing the extremely contagious nature of the flu (she had lived through the devastating influenza pandemic of 1918), my grandmother set out with every weapon known to modern grandmotherhood to prevent my father and me from getting sick, fearing the consequences for my mother and newborn sister. With isolation, chicken soup and constant scrubbing and disinfecting, my father and I were spared the disease, as were my mother and sister, and, as long as she lived, my grandmother delighted in telling the story of how she confounded the pediatrician who had predicted that we would all very soon be ill.

Flash forward fifty-four years to 2011. What are the risks to siblings today when one member of a family contracts a communicable disease, and how should we respond? I think that the answer depends on many factors, one of which concerns the nature of the particular illness that one person has contracted.

Viral Illnesses

Some viral illnesses are highly contagious, even without direct contact. Certainly chicken pox and measles used to spread through families like wildfires, but immunization has largely reduced the occurrence of these diseases, primarily by greatly reducing the amount of disease in circulation, and, further, by producing immunity in children who might somehow be exposed. The same goes for influenza, the bane of my grandmother; since universal influenza immunization was recommended a few years ago, the burden of disease has been reduced, although not as much as it could be if everyone actually did get their flu shots.

Contagious Illnesses

How about other types of infectious, contagious illnesses? The common cold is just that, common, and most people will suffer one or multiple episodes each year. Unfortunately, there is no effective preventive immunization, and it does tend to spread readily; fortunately, it tends, in most people, to be relatively  mild and of short duration.

Strep Throat

Strep throat is another common contagious illness, especially in children. There certainly are families where multiple members will get strep in close temporal relationship to each other, and these may be the result of spread within the family.

But it is also possible that multiple family members were exposed at school or work, and contracted the illness elsewhere.  But strep is harder to spread than some of the illnesses discussed previously, and there are many cases where one family member gets it, and no one else becomes sick. This is one illness where good handwashing, and avoidance of sharing of food, utensils and so on, can be a useful preventive measure.

Infectious Mononucleosis

The same can be said for infectious mononucleosis–”mono,” also known as the “kissing disease,” primarily for its reputation as a common occurrence during adolescence. Yet in most of the families where one child has mono, it is very uncommon for other siblings to also contract it. Thus simply sharing a room, or time at the dinner table, is generally not enough to transmit an illness like mono.

Pneumonia

Pneumonia in children is also common, and the vast majority of cases are viral in origin–and they are often caused by the same viruses which cause the common cold. I tend to think of most cases of pneumonia as “a common infection in an uncommon place,” and generally feel that, while another member of a family might catch the same virus, it is far less likely to be caught as pneumonia. Rather, it might cause a head cold, sore throat or ear infection in someone else.

So why does this matter?

Rare is the day which goes by that I am not asked a question like “his brother has strep (or pneumonia of the flu or…), so why can’t you just treat all my kids for it without having to see them?” In response, it is important to point out that every person who gets a fever after being in contact with someone who has strep is far from guaranteed to have strep as the cause of that fever; most illnesses are just not that contagious, and most fevers require individual evaluation regardless of the person’s exposure.

The same thinking goes into my response to the schools who send home notices every time someone in a class is diagnosed with strep, ostensibly warning parents to be on the lookout for strep in their children. About the only thing these notices accomplish is the wasting of paper.

I would far prefer that parents react to each of their children’s illnesses in a vacuum, paying no attention to what the child might have been exposed to (assuming, of course, that the child has been fully immunized, thus pretty effectively–but not 100% completely– ruling out those preventable illnesses as a cause of the fever.)

What to do when your child is ill

When your child is ill, pay more attention to how he or she is acting, how sick he or she appears, and how well the illness is being handled by the child, than to what diseases he or she might have been exposed to.  Discussing that information with your pediatrician will enable you to better decide what y our next course of action should be for evaluating the illness in that child.

 

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.