“Are you allowed to accept these buns?”… Ummm... I don’t know!
Not exactly one of life’s great uncertainties, but within the shackles of the NHS, I am never quite sure about treats or gifts from patients or families, particularly those of the edible kind!
It was a routine morning clinic. Well, the new sort of routine. Still in the midst of this seemingly perpetual COVID-era, the next patient was Ciaran*. A 14-year-old boy, near-man, who attended for review following a recent prolonged admission.
Calling him and his mum in from the waiting room, I was taken aback by how different he looked. Aside from the fact that this gargantuan adolescent resembled a modern-day Fionn MacCumhaill, he looked frail and worn out.
He did, however, look much better than when he was an inpatient. Back then he was very unwell. He initially complained of progressively severe lower abdominal pain with high fevers. The initial impression was of acute appendicitis. With very high inflammatory markers and an inconclusive CT scan of his abdomen, he was transferred for further input in the tertiary regional hospital.
Whilst children and young people are not the face of this pandemic, they are at risk of being amongst its biggest victims.
The story evolved, he developed severe diarrhoea, a generalised rash and bizarrely, very inflamed eyes. There was diagnostic uncertainty. It appeared similar, but different to other inflammatory conditions. Colleagues were called upon from across the country and further afield. Reports had started to emerge of this strange new condition, perhaps as a complication of COVID-19 - that peculiar new respiratory virus which had a predilection for adults.
Putting it all together, Ciaran was suffering from PIMS-TS, the novel, rare poly-inflammatory condition associated with COVID-19 in children. With a variety of names (including MIS-C) and a wide spectrum of disease, this condition has affected a very small number of children globally.
This rare syndrome pales in insignificance when compared to the millions of children and young people otherwise adversely affected by the impacts of this relentless virus. Whilst children and young people are not the face of this pandemic, they are at risk of being amongst its biggest victims. Physical, mental, emotional, educational and socio-economic impacts will leave a devastating effect on millions around the world and as ever, cruelly, the already vulnerable are disproportionally affected. We, as paediatricians, will deal with the after-effects for years to come.
In my early years, I naively thought it showed a sign of weakness or lack of knowledge. Through (very gradual and not yet complete) maturation, I accept that uncertainty is a part of life, and the most gifted clinicians skilfully manage this concept.
Ciaran was in hospital for nearly two weeks. His fever was relentless, and energy levels were at an all-time low. With cohesive multi-professional input, the diagnosis was prompt and treatment started. Gradually, he improved and was eventually able to return home with a gentle rehabilitation plan, although he was half the near-man he used to be!
At clinic, he was trying to be positive but it was clear he was fed up. Several months down the line, he expected to be better. The fevers and inflammation had long gone, but he had deconditioned - the low energy, lack of appetite and brain-fog were unbearable. Unable to go for a walk, not yet back at school with his friends and nowhere near being able to help out at his dad’s bakery, this previously effervescent teen was reduced to being house-bound - an exhausted body with a restless mind. An uneasy combination for any person, let alone someone at such an important stage of life.
“Will I ever fully recover?”, he asked in a typically direct manner, but with a resigned tone. Yet more uncertainty for me… Post-viral fatigue syndrome is well-described. Is there something else going on? What should I answer?
“Medicine is a science of uncertainty and an art of probability.” Sir William Osler
Throughout my training, I’ve tried to be self-aware about managing uncertain situations - be those personal, professional or clinical. In my early years, I naively thought it showed a sign of weakness or lack of knowledge. Through (very gradual and not yet complete) maturation, I accept that uncertainty is a part of life, and the most gifted clinicians skilfully manage this concept.
I now have no problem in saying, “I don’t know, but I’ll try to find out”.
I have learned a range of skills and attributes from watching my parents deal with many of life’s uncertainties. In work, I’ve witnessed lots of brilliant healthcare professionals and clinicians deal with this in a variety of settings - time-pressured acute inpatients, outpatients, safeguarding cases, neonatal and chronic disease.
Parents and patients crave honesty. It is fundamental to any meaningful relationship
Society and Medicine have become more tolerant of previously-derided signs of 'vulnerability‘. The myth of physician omniscience is thankfully no longer promoted nor accepted. It helps that hierarchy is flattened and a more inclusive and tolerant work culture is promoted. Parents and patients crave honesty. It is fundamental to any meaningful relationship.
Not losing eye-contact, Ciaran waited for a response. I paused, and said, “I really do hope so and I’m going to ask some colleagues to help you out. “… A few phone calls later, we were able to organise prompt physiotherapy and clinical psychology input. It’s a long road ahead for him but he’s up for the fight!
On reflection, for me, the most important ingredients for a (future) paediatrician of any age are empathy, honesty, humility and humour. Oh! And speaking of ingredients, I’m sure you were wondering…the buns were delicious!
Peter is a Paediatric ST8 doctor based in Royal Belfast Hospital for Sick Children. He is interested in Acute Paediatrics, Infectious Diseases and Medical Education. He is gradually getting better at dealing with most of life’s uncertainties…
- *. Names and other information that could identify someone have been changed.