Decision To Treat

Not all ear infections need strong medicine

As a result of several studies, done mostly in European countries with national healthcare systems (and thus more control over provider activities) US physicians are being discouraged from using antibiotics to treat childhood ear infections.

It has been shown that much of our current abuse of antibiotics occurs with overtreatment of this common condition.

That grumbling sound you hear is from many US physicians saying, "Oh yeah! Try telling the mother of four, two of whom are crying with an earache, who left the house a mess to come to my office and wait two hours in a room full of other people with sick kids, 'Well, good news! Johnny and Susie don't need anything but Tylenol to get well.. The good doctors in Sweden just told us antibiotics don't help.' "

Here's a cautionary tale: Two excellent physicians in a small Montana town diagnosed appendicitis in a 5 year old girl with abdominal pain, and proceeded to operate on her. They found enlarged lymph nodes in her belly, due to an infection elsewhere, but, since they were there anyway, took out her normal appendix. On the first post-op day, after she had a seizure, they discovered she had meningitis, the result of an untreated ear infection. Proper antibiotics were administered, and, much to the relief of the parents AND the doctors (AND their malpractice insurance carrier), the child got well. When this event was reported to the hospital staff at a later meeting, all of us said, "Nice save!" out loud, and under our breath, "Thank God it happened to you and not me!" Their patient may have subsequently had deafness due to the meningitis, but we don't have that follow-up information here in Arizona 40 years later.

Children now receive vaccines which effectively prevent ear infections due to two of the common bacteria that may also cause meningitis, and both are less common. The Montana child would probably not have gotten so ill if her doctors had diagnosed and treated her ear infection earlier with antibiotics, since vaccines weren't available then.

But we should have no complaints, since times were tough for all of us, doctors as well as patients, and we were better off than in the pre-antibiotic era. We often had to make holes in bulging eardrums with a teeny diamond-shaped knife to drain the pus (just like lancing a boil, only on a squirming unhappy child) from an infected ear. How many of our current well-trained primary care providers have to do that?

The correct answer is. "None". They wouldn't try it anyway - they'd refer any child needing the procedure to the nearest ENT specialist, even though it might take a few hours and a long drive for the parents. That's "defensive medicine", and THIS is a serious digression from our principal topic.

Now we are told to avoid antibiotics for acute ear infections since most of them just go away after a while, leaving no serious consequences. This represents a major shift in the way of doing business and will require more than simply giving advice to physicians. We have to re-educate a generation or two of parents, whose first response to this blasphemy is usually, "I know what my kid needs and it ISN'T TYLENOL!!!"

A captive patient populace, in a national healthcare system or in HMOs, can be managed fairly easily. All you have to do is tell 'em this is the new policy, and they just have to live with it. In private fee-for-service practice, a little bit more is needed, and there are some good ways to do it effectively. In some of the studies resulting in the "no antibiotic" recommendation, parents were given a "rescue" prescription for an antibiotic, to be purchased and used if there was no improvement in 48 hours.

Education of all parents is essential, and many options are waiting fuller use. They range from a written newsletter to web based discussion groups (weblogs) and actual group sessions involving several patients / parents and a provider.

Something else needs to be done - improve the after hours availability of someone (nurse, provider, etc) to discuss the progress of a child's earache or any other problem, with advice or reassurance given as necessary. This vital resource could be a modest after-hours clinic, promptly answered e-mail, or telephone contact with a nurse or physician. An answering machine message to "go to the ER" is a CYA thing for the doctor, encourages huge expense, wastes a lot of time, and does nothing to improve care or enhance the doctor / patient relationship.

All of this high-minded talk is just chit-chat unless we can do something about the problems of small town docs already facing big obstacles, city clinics with an "our way or the highway attitude", malpractice concerns, and governments' burdensome rules. We can do this together, and it's time for trials of patient and provider friendly, prevention oriented, less costly healthcare cooperatives tailored to local and regional needs and desires. National healthcare with all its drawbacks is the unfortunate alternative.