Casting pearls

“Should I have my daughter get the swine flu vaccine?” this mother asks.  She stands next to her toddler who sits on the exam table.  The little girl has had difficulty gaining weight.  Now two years of age, she barely tips the scale at 23 pounds.  Otherwise, she’s been a healthy child.

“The vaccine is available and indicated for her age group,” I say, attempting to disseminate the information in a non-biased way.

“I know, but should I do it?  What are the risks?  It’s so new.  You hear so much about problems with vaccines these days.”

“It will protect her against the swine flu.  The vaccine is manufactured by the same companies that have been formulating flu vaccines for years.  It’s been field tested and found to be safe.  Apart from some minor side effects, it’s a good vaccine.”

The look on this mother’s face tells me she’s not convinced.  “What will happen if she doesn’t get the vaccine and comes down with swine flu?  Will she die from it?”

I take a deep breath and recite my litany:  “She’ll get sick with fever and feel lousy for a few days, but she’ll most likely recover.  Of course, there are no guarantees; but chances are good that she’ll make it through fine.”

“So I’m not a bad mother if I don’t have her get the vaccine?”

“No, you’re not a bad mother if you decide not to have her immunized.”

The mother averts her eyes and reaches for her little girl’s shoes.  “I guess I’ll hold off for now,” she says.  “If I change my mind, can I have her get it later?”

“Of course—assuming the vaccine supply lasts.”

I step out of the room, toss the child’s medical record on my desk, reach for the next chart in the bin and step into the adjacent room to greet an adolescent boy.  His mother has brought him in with complaints of a sore throat.

I glance at the vital signs:  no fever.  I ask a few questions and proceed with the examination.  As I expected, he exhibits signs of a mild scratchy throat.  There are no significant swollen glands in his neck.  I prescribe a course of saline gargles, acetaminophen, throat lozenges and warm fluids.  Afterwards, I ask if there are any questions.  “Can he get the swine flu shot today?” his mother asks.

“Right now he isn’t eligible for the vaccine.  He doesn’t fall into one of the high-risk priority groups.”

I can see the look of disappointment on her face.  “Can he get the regular flu shot?  I heard that that might give some protection.  Is that true?”

“The regular flu shot will protect him against seasonal flu, but it won’t be effective against the swine flu,” I tell her.  “And at this juncture we’ve exhausted our current supply.  We should have some additional vaccine next month.  If you call the office, we can have him come back for the shot.”

“I can’t believe that there’s not enough vaccine to go around.  Everyone says to get the flu shot this year.  What are we supposed to do?”

I shrug my shoulders.  “I share your frustration.  We’re at the mercy of the vaccine suppliers.  Unfortunately, there’s been a shortage this year.  We can only work with what we’ve got.”

I step out of the room and walk to the front office.  All of the telephone lines are busy.  Each time one of the receptionists hangs up a phone, it rings again.  Everyone is exasperated.  “We don’t know what to tell the patients any more,” one medical assistant says.  “Everyone asks if we’re recommending the swine flu vaccine.  When we tell them that there’s not enough to go around, they go off on us.  One lady used such foul language, I told her that I was going to hang up!  I’ve never done that before in fifteen years.”

My third patient of the morning is a 12-year-old girl who has come in for her annual physical examination with her mother.  At this age the child is due for a number of inoculations:  booster shots for tetanus and chickenpox, as well as the meningitis vaccine.  I review the chart and note that the girl has a history of asthma.  “She should also get a flu shot today.  With her asthma, she’s high risk.”

“She’s never had a flu shot in her life,” her mother tells me.  “I haven’t either.  We don’t get the flu in our family.  Besides, three shots are enough.  Aren’t they going to tax her immune system too much?”

Once again I explain the reasoning for my recommendation.  The child has a history of asthma.  If she contracts swine flu, she would be more likely to develop a secondary pneumonia, further compromising her respiratory status.  The vaccine is available; it makes sense to give it to her today.  And in answer to her last question, no—one more vaccine won’t compromise her immune system.

“Can’t she have the vaccine that you squirt up the nose?  At least that would save her a shot.”

“The nasal vaccine is formulated with live virus.  It shouldn’t be given to someone with asthma.  And right now we’re only authorized to administer the nasal preparation to children below six years of age.”

The mother looks at her daughter, who pleads silently with her mouth:  No, not another shot!

“Well, if you think it’s a good idea, I guess we’ll do it,” the mother says, avoiding her daughter’s misty eyes.

I scribble a note in the chart and think:  How will I ever get through this day, let alone the next five months?  At times like these I wonder whatever possessed me to opt for a career in primary care medicine.

My last patient of the day is a 6-year-old boy.  I’ve known his mother for years.  The boy has brittle asthma.  She knows how to treat it when he gets sick.  Today he has a fever, cough and runny nose; he looks ill.  “I have an appointment to have him get his flu shot day after tomorrow,” she tells me, with a concerned look in her eyes.

Thankfully, the boy’s lungs are clear.  I take a nasal swab specimen and test it for swine flu.  Ten minutes later the tell-tale red line appears on the test strip.  There won’t be any need to vaccinate him now.

I write a prescription for Tamiflu, a drug that will blunt the viral infection surging through his small body.  His mother remains calm while I explain the treatment.  At the end of the visit she thanks me with an easy smile.  “I’m glad you were able to see him today,” she says.  “It’s a comfort knowing you’re here when we need you.”

And suddenly once again I remember why I elected to practice primary care pediatrics.

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2 comments on “Casting pearls

  1. ~ t says:

    It is very frustrating for those of us who need flu shots, but are unable to get them. Unfortunately, too many have no comprehension regarding the manufacture, distribution or administration of vaccines (among other things).

    For the record, I hate shots too ……

  2. DJE says:

    Fine piece; captures the frustrations well — but it is our job to “swallow [our] own smoke with an extra draught of hard work” and you are walking that walk. Hopefully, you will recharge your batteries over the weekend. Best, D

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