One of the hardest parts of pediatrics after the trauma of residency is trying to figure out patients you don’t know and can’t see at 3 a.m. when you’re on call from home. And among these stressful calls, one of the hardest is dealing with parents calling because they’re anxious.
Sometimes, they’re anxious because the child is really sick and, of course, that’s one of the scariest parts. You are anxious, too, not to miss sending to the emergency room a child who really requires it.
But what about the parent who is more anxious than their child’s illness warrants?
Dr. Barbara J. Howard
Sometimes, this is a child with a very complicated medical problem, and neither you nor the parents can really tell how sick they are. Children in that category include medically fragile children with a tracheostomy, or preemies and children with serious neurologic problems such as autism or profound mental retardation who react in idiosyncratic ways to illness and really can’t report their symptoms.
Sometimes, the problem is that the caller doesn’t know the child very well: their 4-day-old infant, or, worse yet, a preemie with complicated medical problems.
One of the most aggravating calls is from a person who doesn’t take care of the child very much – the new foster parent or a grandparent. It might even be the father, but he usually promptly hands the phone to the mother!
The newest anxious group is people who scared themselves silly by listening to the fear-mongering evening news or well-meaning friends or Dr. Google, and their nerves finally peak in the middle of the night. They need education, but we just wish they could hold their questions until the morning!
Like many practices around the country, I care for parents from myriad cultures. Different cultures historically view certain illnesses with more concern (diarrhea in Africa can kill), tend to be overly anxious about their children in general, or have different expectations of what they think the availability of doctors should be. In Russia, one gets care by showing up early and banging on the counter until being seen.
So why do they call at 3 a.m. – the worst possible time as it falls in the lighter early morning sleep cycles, effectively making it impossible to get back to sleep even if the case isn’t serious at all?
I’m hearing from parents who have just gotten home, and discover that their child is sick. They deal with their guilt for not being there by calling for advice.
Another newer trend in my practice is the parent who has to leave for work at 4 a.m. and needs to determine at 3 a.m. whether they should go to work that day or not. Some parents may not even be aware that you’re not sitting there awake at a desk waiting for their call!
But there are other reasons that people are up at 3 a.m. thinking about their child and his illness. One of them is that no one is there to help them stay calm and think rationally. The lonely silence of the night is scary for everyone.
But I think the most common reason for a call that turns out not to be urgent is that the parent is anxious by disposition. And one of the inherent characteristics of anxiety is a brain that rapidly goes to the worst-case scenario. It’s not only appropriate, but actually necessary to ask (tactfully) what it was about the child or their situation that made the parents call at that time. Rather than being reluctant to ask this potentially confrontational question, think of it as an important opportunity to gauge the severity of their concerns. When they say, "I thought she was handling the wheezing okay with the nebs, but now she looks like she is struggling," any disgruntlement you felt will disappear. On the other hand, if they say "The rash Dr. Jones said was from the virus spread down onto her stomach," you have a different task.
One of the biggest differences of dealing with an anxious parent when you are on call is that you probably don’t know her or her judgment abilities, and she doesn’t know you or have a history of trusting you.
So how do you quickly establish a relationship that allows you to both determine the child’s degree of illness and provide enough reassurance so that you can go back to sleep?
Of course, determining severity is a skill gained from clinical experience. Does it fit a pattern of illness? What illnesses are going around? If it were the worst case in your differential diagnosis, how bad could it be to make it wait? In the back of your mind might also be whether this sounds like someone who might sue you, which is another reason to make good notes while on call.