Needing something more than talking heads telling us about how important and safe the coronavirus vaccination is, maybe these little jingles might help
I got the prick and the bubble got bigger
Don’t blow the bubble; get the prick
As a doctor I have both an advantage and disadvantage.
I have a medical education (thanks Flinders University) and years of experience in various emergency department and general practices (such as Darwin, Nhulunbuy, Kangaroo Island and Mackay) to know when a child is sick.
Apart from my own, I do not what your child normally does, acts and how he or she responds when stressed by illness or strangers (ie me). I have to rely on the parent to what is normal for their child.
There are some (maybe) universal fundamentals that I rely upon. It is a truism that a medical consultation begins as you watch the patient move from the waiting area to the consulting room. First impressions are important from the worried look on the parent’s face, to the way a child is held in their carer’s arms. A child who smiles and skips into your room is almost always reassuring. My heart sinks when a floppy pale child is carried in a frightened parents arms. We definitely need help for this child.
Thankfully most of the time I have the opportunity to sit and listen to the story, only sometimes do I have to start with taking vitals and sometimes reaching for the a vomit bag,
Watching how easily a child breathes is always easier with a layer of the child’s clothes off. The effort, noise, rhythm and rate are what I look at. Subconsciously, I sometimes I find myself breathing at the same rate as the sick child, my that’s fast!! A talkative child is reassuring. If …. a …. child…. has …. to …. breath …. between …. each …. word …. I worry. A pulse oximeter used to measure capillary oxygen levels can provide extra information, although it may take a bit of fuss to get it to work. Or be rejected outright by an irritable child. I had one flicked across the room once. Yep , stopped working, thankfully they are much cheaper these days.
A rough guide for normal breathing rate per minute is
- birth to 1 year: 30 to 60
- 1 to 3 years: 24 to 40
- 3 to 6 years: 22 to 34
- 6 to 12 years: 18 to 30
- 12 to 18 years: 12 to 16
Non contact thermometers have made checking a temperature less disruptive and generally provides a reasonable estimate compared to traditional methods. I don’t use rectal, axillary or oral thermometers.
Assessing hydration comes from what I’m told about intake and outputs and what I can see. Are the eyes sunken, is the mouth dry, are there tears? How irritable or lethargic is the child. This along with pinching the skin testing turgor gives me an idea if dehydration is a problem. Dribbling, drooling and snotty noses are all taken into account.
A gentle hand on the belly can tell a lot, confirming an irritable and frightened child, reveal a source of pain, and confirm an elevated temperature.
How is the child interacting with me. Happy and chatting, screaming every time I look in their direction as though I have about to eat them for lunch, or a glazed far away look. Maybe they are sleeping comfortably, or is that unconsciousness. An acronym we use is AVPU. Short for Alert; eyes open and responding to Voice, eyes open to Pain (a finger squeezed or a rub on the chest) or not responding at all, Unconscious. For a parent, anything less than “A” may be an indication that extra help is needed.
Many illness may present in a similar way in children. For example, the list of things that cause vomiting varies from benign eating too much, posits after breast feeding, to more serious viral fever, gastroenteritis, a twisted testicle, to really serious things like poisoning, meningitis and sepsis. And it is alas true, children can get sick very quickly, but there are usually clues to found from a doctors examination.
I have stolen the following lists from https://www.kidshealth.org.nz/my-child-sick
When to call an ambulance for your child
- has blue lips and tongue
- has severe difficulty breathing
- has any episodes of irregular or stopping breathing
- has a worrying rash especially one that does not go away when you press on it
- is unconscious or you can’t wake them up properly
- has been in a serious accident
You should see a doctor urgently if your child:
- is under 3 months old – young babies need a different and more cautious approach
- looks unwell and you are concerned
- is very pale or feels cold to touch
- is floppy, sleepy or drowsy
- is becoming less responsive
- has an unusual high-pitched cry
- has trouble breathing, has noisy breathing or is breathing fast
- complains of a stiff neck or light hurting their eyes
- has a severe headache
- refuses to drink – even small sips
- is not doing wee
- vomits a lot – and cannot keep sips of replacement drinks down
- vomits green fluid (bile)
- vomits blood – this may be red or brown or look like coffee grounds if it is not fresh
- has black tar like poo or blood in their poo
- is in severe pain
- is not interested in surroundings (lethargic)
You should see a doctor if your child:
- is under 3 months old – young babies need a different and more cautious approach
- has a sore throat or joint pains
- is drinking less than half of their normal breastmilk or other fluid
- is having fewer than 4 wet nappies in 24 hours
- is doing wee that is very dark or has blood in it
- vomited half or more of their feed for the last 3 feeds
- has frequent and watery poo (diarrhoea)
- complains or cries when doing wee
- is in pain
- is getting sicker
- has a fever and is not improving after 2 days
- has had a fever for more than 5 days
You can look after your child with a fever at home if they:
- are drinking and feeding well
- are still interacting with you
- do not look sick
Where, apart from your GP, can you find more information about sick kids. These are my suggestions.
Just realised it has been nearly 12 months since I last posted to my blog. I did say occasional blogger!
In the last 12 months, I have done a few things
Worked in a respiratory clinic and swabbed more than 600 noses (maybe more, I have lost count) and not had a positive coronavirus swab. Lots of rhinovirus, RSV, adenovirus….
- Do you count one nose as two nostrils?
Despite what health bureaucrats and Channel Nine new may say, I have continued to see patient face to face.
Completed far too many Zoom and Team meetings, but have still completed my three year target for CPD with two years to spare.
Gained a certificate to be able to provide the Astra Zenica vaccination for my patients
Taken lots of photos
- Have a look at my Facebook Page
Written stuff, although sadly not on WordPress
- I see there have been some changed to the editor!
Still waiting to walk up onto an airplane.
Most information suggests that if you get COVID19, unlike influenza, you are no more likely to get sick than if you weren’t pregnant. And unlike Zika or Rubella virus, the placenta protects your baby.
The importance of hand hygiene and how washing washing washing our hands and our children’s hands is the most important prevention we can take to stop spreading this virus.
The advice not to stop breastfeeding or wean your baby until this crisis is over. Breastfeeding can provide a level of immunity to your baby and is not known to pass on the virus.
The usual immunisation schedules will still be more important to keep everyone as healthy as possible during this crisis, do get your children and babies to their regular appointments.
Do not allow anyone who has not washed their hands to touch your baby!
Make sure the information you are using to make important decisions comes from a reliable source.
Information for Mothers
Video from Associate Professor Rebecca Kimble, Clinical Advisor – Obstetrics and Gynaecology explains what you need to know if you or a family member is pregnant at this time of COVID-19.
For Health care providers
Perinatal care of suspected or confirmed COVID-19 pregnant women from Queensland Health. (26 March 2020)
Cochrane gynaecology and fertility – includes a spreadsheet summary of published papers
Podcasts to listen to
Two podcasts about COVID in Pregnancy by Penny Wilson, MD and Heidi James.
Covid-19: how does it affect pregnancy? Sarah Boseley speaks to Prof Sonja Rasmussen about how the virus might affect mothers who are expecting and their unborn child
Chris Stallman from MotherToBaby service regarding coronavirus exposure in pregnancy and while breastfeeding.
Good GP interviews obstetrician and gynaecologist Dr Robyn Aldridge on the impact of COVID-19 on pregnant women, pregnancy and the unborn child.
From Babytalk Alison McMillan the Chief Nursing and Midwifery Officer for the Commonwealth Department of Health and Adjunct Associate Professor Karleen Gribble from the School of Nursing and Midwifery, Western Sydney University.
2020 Baby – Caring for pregnancy women in the pandemic with Dr Pamela Douglas and Wendy Burton
Vertical transmission from mother to baby prior to birth
An early review of 31 cases and a smaller study of 9 cases reported in the Lancet found no vertical transmission found which is reassuring. But then a report of possible vertical transmission of COVID19 from mother to baby in utero. This was based on a baby having positive IgM which is not thought to cross the placenta. However PCR testing for the virus was negative. The accompanying editorial.
July 2021: Abstract: The ongoing coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global public health problem. The SARS-CoV-2 triggers hyper-activation of inflammatory and immune responses resulting in cytokine storm and increased inflammatory responses on several organs like lungs, kidneys, intestine, and placenta. Although SARS-CoV-2 affects individuals of all age groups and physiological statuses, immune-compromised individuals such as pregnant women are considered as a highly vulnerable group. This review aims to raise the concerns of high risk of infection, morbidity and mortality of COVID-19 in pregnant women and provides critical reviews of pathophysiology and pathobiology of how SARS-CoV-2 infection potentially increases the severity and fatality during pregnancy. This article also provides a discussion of current evidence on vertical transmission of SARS-CoV-2 during pregnancy and breastfeeding. Lastly, guidelines on management, treatment, preventive, and mitigation strategies of SARS-CoV-2 infection during pregnancy and pregnancy-related conditions such as delivery and breastfeeding are discussed.\
April 2021 Conclusion: A systematic review of published studies confirm that the course of COVID-19 in pregnant women resembles that of other populations. However, there is not sufficient evidence to establish an idea that COVID-19 would not complicate pregnancy.
Jan 2021 Abstract: There are many unknowns for pregnant women during the coronavirus disease 2019 (COVID-19) pandemic. Clinical experience of pregnancies complicated with infection by other coronaviruses e.g., Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome, has led to pregnant woman being considered potentially vulnerable to severe SARS-CoV-2 infection. Physiological changes during pregnancy have a significant impact on the immune system, respiratory system, cardiovascular function, and coagulation. These may have positive or negative effects on COVID-19 disease progression. The impact of SARS-CoV-2 in pregnancy remains to be determined, and a concerted, global effort is required to determine the effects on implantation, fetal growth and development, labor, and neonatal health. Asymptomatic infection presents a further challenge regarding service provision, prevention, and management. Besides the direct impacts of the disease, a plethora of indirect consequences of the pandemic adversely affect maternal health, including reduced access to reproductive health services, increased mental health strain, and increased socioeconomic deprivation. In this review, we explore the current knowledge of COVID-19 in pregnancy and highlight areas for further research to minimize its impact for women and their children.
Conclusion: In mothers infected with coronavirus infections, including COVID-19, >90% of whom also had pneumonia, PTB is the most common adverse pregnancy outcome. Miscarriage, preeclampsia, cesarean, and perinatal death (7-11%) were also more common than in the general population. There have been no published cases of clinical evidence of vertical transmission. Evidence is accumulating rapidly, so these data may need to be updated soon. The findings from this study can guide and enhance prenatal counseling of women with COVID-19 infection occurring during pregnancy.
Early report of the effects of COVID 19 on pregnant women
A narrative review
Commentary from AOCG
If you want to do you own medical literature search
Non medical commentary
The COVID-19 pandemic could have huge knock-on effects on women’s health, says the UN – World Economic Forum April2 2020
Pregnant in a time of coronavirus – the changing risks and what you need to know – The Conversation March 28 2020
COVID-19 Is No Reason to Abandon Pregnant People – Scientific American March 26 2020
Stuff I have been watching and learning from with science without hype. I won’t weight down with quantity, my previous post has more details.
Coronacast from Dr Norman Swan and Tegan Taylor
Ian M. Mackay, a working Scientist and an adjunct Associate Professor (University of Queensland) has a PhD in virology, his blog is virologydownunder
Dr Wendy Burton has a blog call GPs-Can
From the USA
With Dr Mel Herbert, Jess Mason amongst others
Video and audio files to take in with an evolving text at here.
Great science and drawing boards with Dr. Roger Seheult
From the UK
The Centre for Evidence-Based Medicine develops, promotes and disseminates better evidence for healthcare.
I reckon that will do for now so I will leave you with the message about social distancing.
PS always remember to wash your hands.
Nothing from politicians here as they just get me angry.
One of the early medical student days, hidden by the mists of time, I was taught by an Infection Control nurse how to wash my hands. Of course I “knew” how to wash my hands. My Mum had been making me doing it since I learnt how to wipe my bottom. In fact, I had a reasonably good idea from the years of preparing total parenteral nutrition and cytotoxic infusions in hospital pharmacy but that’s a different story.
Back to the mist, as a test we had to wash as normal, and then plate out the hand on an agar filled petri dish. It was shocking to see what grew!
Remember that virus are far too small to be seen and won’t grow as visible colonies amongst the bacteria and moulds on the on agar plate.
Imagine shaking that hand. So maybe a simple social hand wash is not enough to prevent spread of infection. With the imminent pandemic of coronavirus, everyone is telling you to wash your hands, but do you know how and what to use?
This helpful guide from the World Health Organisation describes the essence of a good hand wash.
In most cases soap and water is preferable, but if there is none, the alcohol hand rub that contains at least 60% alcohol, is a suitable alternative, especially if it increases the likelihood that something will be done.
Although, soap and water is better at removing Clostridium spores and non-enveloped viruses such as Norovirus and Rhinovirus. However, 60% alcohol does is effective against enveloped virus like Coronavirus.
Just remember, not to mix your alcohol gel with water!
Now when do you wash your hands? These times seem pretty sensible to me.
Before and after examining a patient makes sens for me as a doctor. But this list also seems pretty sensible.
- Before, during, and after preparing food
- Before eating food
- Before and after caring for someone at home who is sick
- Before and after treating a cut or wound
- After using the toilet (especially if the world runs out of toilet paper)
- After changing a nappy and cleaning up a child who has used the toilet
- After blowing your nose, coughing, or sneezing, especially if you sneeze or cough into your hand. This about using the cubital fossa (doctor speak for the inside of your elbow)
- After touching an animal, animal feed, or animal waste
- After handling pet food or pet treats
- After touching garbage
and maybe even
- Before or after shaking someone’s hand
This article from The Conversation explains why I’m not being rude by not shaking your hand, just protecting you and me from possible infection.
I have been frustrated by the media’s propensity to exaggerate, stretch the truth, add hype and mislead and scare the public. For examples, the headlines in the Weekend Australian (1/2/20) states “Virus Deadlier than it Looks”. So where to find information without the hysteria?
By way of introduction, human coronaviruses have long been considered inconsequential pathogens, causing the “common cold” in otherwise healthy people, a little like rhinovirus. However, 2 pathogenic coronavirus have emerged from animal reservoirs to cause global concerns. You may recall from 2002 severe acute respiratory syndrome coronavirus (SARS-CoV) and and in 2014, Middle East respiratory syndrome coronavirus (MERS-CoV). In December 2019, another pathogenic coronavirus, now known as 2019 novel coronavirus (2019-nCoV), was recognized in Wuhan, Hubei province, China, and has caused serious illness and deaths. This outbreak evolving.
Coronaviruses are large, enveloped, positive strand RNA viruses Four human coronavirus (HCoV 229E, NL63, OC43, and HKU1) are endemic and account for 10% to 30% of upper respiratory tract infections in adults. Coronaviruses are ecologically diverse and bats are suggested reservoirs for many of these viruses. Rumours that snakes were involved seem to be unfounded. Other mammals may be intermediate hosts, facilitating recombination and mutation events with expansion of genetic diversity. The surface spike (S) glycoprotein is critical for binding of host cell receptors and is believed to represent a key determinant of host range restriction. This maybe the focus of a vaccination, although none are currently available.
Symptoms resulting from 2019-nCoV infection at the prodromal phase, including fever, dry cough, and malaise, are nonspecific. It could be a wide range of viral or bacterial illnesses. A number of people go on to develop respiratory symptoms (cough and shortness of breath) which is some are severe and potentially life threatening without respiratory support, ie ICU. Fatality rates are thought to be lower than SARS CoV and MERS CoV infection and influenza. Testing can be done if you are symptomatic or a close contact and involves sampling nasal (not comfortable), pharyngeal secretions and sputum (not saliva). A blood test may also be done. Testing see if you are safe to return to school or work is not recommended unless the criteria in the links above and below are satisfied. Just because your boss or school principal tells you need to be tested doesn’t make it so. I wont copy out the case definition criteria here as they may well change.
Here is what you can do to reduce your risk of not just 2019-nCoV, but also other viral and bacterial infections. Just remember that is you have any fresh cuts or your hand, the alcohol gel will sting!
Remember if you think you need medical attention, please call ahead to your GP or ED, don’t just turn up to potentially infect a waiting room of people, clinic staff and your health practitioner. I say this, as a number of communications encourage people to see their GP immediately.
Here is a list of my sources for reputable information without the media hype.
This also contains the address of state based health departments which may have relevant information for the state you live in. I’m not going to say which one has the best or right information, but I do know that Health departments which suggest you should immediately visit your GP are not my favourite. Maybe in time they will hand out PPE that I need for me to do my job safely.
If you are travelling overseas, the Smartraveller website offers sensible advise.
There is likely to duplication of information on these sites
For science rather than hype here are few links
- Here is a PubMed search for newly published medication information about 2019-nCoV
- For New England Journal of Medicine articles
For British Medical Journal articles
- Easier to read, The Conversation has published a series of news reports on 2019-nCoV and this blog written by a real virologist at Virology Down Under.
- Roger Seheult does a great job of keeping up a series of Youtube Videos on COVID19
Finally coronavirus has nothing to do with beer.
Everyone wants a quick fix, so would you rather have a doctor examine you then prescribe appropriate antibiotics or just pop into the pharmacy and pick a box of whatever a potted history may suggest may be suitable for you?
Personally, I am much more comfortable with the financial disconnect between prescriber and dispenser, that is the current situation in Australia. And I say that having worked as both community retail pharmacist and as a general practitioner
Prescribing is influenced by the marketing of drug companies. This makes absolute logical sense as why would drug companies spend billions of dollars for the flash brochure, pens, personal visits and other inducements. In fact, it has been suggested that more money is spent on marketing drugs than actually gets spent on research and development. Any physician who suggests they are not influences is deluding themselves. That is why I don”t see drugs reps. When you add in the profit from the direct sale of medications from the prescriber to the patient, the situation surely becomes even more conflicted.
This Swiss paper by Kaiser and Schmid published in Health Economic concludes that the above scenario leads to an increase drug cost of some 34%.
Park et al. showed that after the the introduction of a physician dispensing ban in 2000 in South Korea, there was a significant reduction in antibiotics prescribing. The economic incentive to both prescribe and dispense was removed.
Following the reclassification of chloramphenicol eye drops to be available over the counter, there have been significant increases in the supply in the UK. Surely, there hadn’t been a coincidental epidemic of conjunctivitis? As an aside, as highlighted by Dr Casey Parker from BroomeDoc, most children presenting with acute infective conjunctivitis will get better by themselves and do not need treatment with an antibiotic.
In Australia, codeine was rescheduled to prescription only in 2018 This has lead to a massive decline in codeine use in Australia. And more importantly, a drop in harm from over use of codeine as described in this paper by Cairns et al.
Dr Mark Taylor, eloquently argues for maintaining the status quo for oral contraceptive prescribing, that is, the disconnect between prescriber and dispenser to ensure women receive safe contraceptive advise. There may be savings, but who will pay the price of under-screening for sexual transmitted infection, cervical cancer, hypertension, early pregnancy, depression etc.
When the prescriber becomes the dispenser, where are the checks for errors. I have to put my hand up here and admit to making a prescribing error or two over the last 20 years. A call from an alert pharmacist has saved our patient from harm. It is well known that medication errors contribute to patient harm. The authors, showed that 2-4% of hospital admissions were medication related and deemed three quarters potentially avoidable. In both community and hospital practice pharmacists and physicians work better collaboratively, and need to improve that collaboration.
Of course, the biggest evidence for not increasing the scope of pharmacist practice is to wander up and down the shelves of homeopathic remedies, multivitamins and herbal concoctions all for sale with most having absolutely no evidence of benefit. Oh except to the proprietor’s profit margins. Webpages such as these make helpful, profit rising strategies to upsell products. I like this counterfactual from JAMA.
So why then is the Australian Government listening to lobbying from the Pharmacy Guild to permit pharmacists to increase their scope to prescribing antibiotics for example. Of course, in the ideal world, the lobbyists would argue, that with proper training and accountability, a pharmacist would be suited to hand out antibiotics for infections. But as we all know, the ideal world doesn’t exist. Pharmacist are pushed by proprietors to upsell, delegate sales to less trained pharmacy assistants, GP pressed to fit a 20 minutes consultation into ten minutes. Politicians are elected on the platform of honesty and integrity end up handing out grants to sporting clubs in marginal seats to bolster elections outcomes. It is far from an ideal world.
Currently, I consult my patient in the privacy of a closed room. When I hark back to my pharmacy days it was in an open shop, across a counter of next to shelf full of shiny tablets and potions. Where would you like me ask some really personal questions?
It just seems logical and sensible to maintain the status quo!
AusDoc reports a bunch of people saying watch out for DKA in patients on SGLT2 inhibitors who may be having surgery or are unwell. You know those tongue twisters dapagliflozin, empagliflozin, ertugliflozin, etc. These drugs block sodium-glucose cotransporter 2 in the kidney to inhibit renal glucose reabsorption through an insulin-independent mechanism, which in turn lowers glucose levels through increased urinary glucose excretion. More details on the pharmacology can be found here. Thus SGLT2 inhibitors helps control diabetes type 2.
Now if you believe the pharmaceutical industry hype these drugs will prevent diabetic patient from having heart attacks and keep them off dialysis. For more useful information on this have a read of this post on BroomeDocs by Casey Parker.
These drugs have had their problems. After overcoming my fears of bladder cancer and concerns about increasing toe amputations and Fourniers gangrene, this new hazard may reduce my enthusiasm for these drugs.
So how does a drug which works to make you pee out sugar cause DKA? It would seems that this is a different type of DKA, and as none of the warning letters satisfied my curiosity for Why, I’d thought I’d hunt for a theory or two.
I am used to managing DKA in DMT1. You know, the teen who thinks that 24 beers on a Saturday night is cool and forgets to take his insulin for the next 2 days. Gets dumped in ED by his concerned mates, looking very sick (abdominal pain, shortness of breath, fatigue, nausea, and vomiting) with a glucose of 30 and pH of 6.9. Or, a young 5 year old whose parents have missed the gradual weight loss, drinking lots, peeing lots and then turns up with belly pain. This kind of DKA happens because there is no insulin to help metabolise sugar so the body switches over to fatty acid metabolism with ketoacids (eg., acetoacetate and β-hydroxybutyrate) being produced. The result is metabolic acidosis.
DKA caused by SGLT2 inhibitors is a little bit different. Glucose levels decrease with SGLT2 inhibition because you pee it out. Because glucose triggers the release of insulin, the drop in glucose levels results in less insulin production. This is good, and helps explain the drugs beneficial effect on weight unlike diabetes drugs which just make the pancreas work harder, like sulphonylureas. SGLT2 inhibitors also act independently on pancreatic alpha cells, further increase plasma glucagon levels and stimulate hepatic ketogenesis. It has also been speculated that they may decrease renal clearance of ketone bodies (making a urine dipstick for ketones less reliable), further increasing the concentration of ketones in the body. Thus a new acronym arises to describe euglycaemic or euDKA. This paper explains more of the science of this problem.
There is a also a case report of empagliflozin unmasking type 1 diabetes in someone who was originally thought to have type 2 diabetes. In such a person, positive GAD antibodies would change the diagnosis to LADA.
So, now I need to tell my patient who are on these drugs to come in for a checkup when they are sick and not eating or drinking well and to make sure their surgeon and anesthetist know what they are taking.
Finally for all you herbal fans, the first non selective SGLT inhibitor was extracted from unripe apples and the bark of apple trees way back in 1835. Unfortunately, it is broken down in the stomach and one if its metabolites causes severe diarrhoea making it not very useful to treat diabetes.