Do nothing without appearing there is nothing to do #WILTW

This is the 128th #WILTW

I suspect there are very few lectures in the first week of Medical School that discuss not treating patients. You expect to ‘do’ things: perform life saving surgery, manipulate fractures, counsel families and treat infections. Being told you’re not to provide any treatment for some conditions would be a bit of dampener during fresher’s week.

However there are lots of treatments that are ineffective and might actually do harm. This week the Academy of Medical Royal Colleges (the collective body of all the Medical Specialities in the UK) announced a list of 40 treatments and procedures that were of little or no benefit to patients.

You can search the list via each speciality. Below are 2 relevant to children.

  1. Children with small fractures on one side of the wrist, ‘buckle fractures’ do not usually need a plaster cast. They can be treated with a removable splint and written information. There is usually no need to put a plaster cast on, or follow these children up in fracture clinic as they will get better just as quickly without this.
  2. Bronchodilators should not be used in the treatment of mild or moderate presentations of acute bronchiolitis in children without any underlying conditions.

Bronchiolitis is a very common winter virus with essentially no treatment other than to support the infant through the illness with tender loving care. Children may need to come into hospital to support their breathing, or keep them hydrated, but most are easily managed at home.

It is a disease with frustrating symptoms though. Babies will be difficult to feed and keep their parents up all night either coughing or just needing constant physical contact to settle. The symptoms peak around day 3-5 of the illness which is when parents and carers tend to seek medical attention as they feel things are getting worse.

A common question they will ask: “Is there anything I can do?“.

It is truly sad that there isn’t anything that is going to alter the course of illness. This issue has been further complicated by the similarity of bronchiolitis to another condition called ‘viral wheeze’ which older pre-school children suffer from. Please read this excellent post by Dr. Edward Snelson which eloquently describes the difference and if you’d like to see some videos click here. Viral wheeze is treated with inhalers which have no effect on the outcome of bronchiolitis. However because inhalers in some small children (who have bronchiolitis not viral wheeze) can result in the appearance of a transient benefit the term “a trial of inhalers” is used.  It has no evidence base in bronchiolitis but I am guilty of having done it myself (I am not proud).

It has persisted not only because it appears to work but also because it allows you to give families a treatment. Unlike for the common cold which everyone, medical or non-medical, views as a self-limiting illness there is real sympathy on the part of the practitioner for the challenge the parents face. The more experienced clinician will have a well rehearsed narrative which empathises with the infant’s illness and its impact on the family, suggests feeding and sleeping regimes which might at least allow parents are rest and reassures them, with clear safety netting advice, that they are not simply being dismissed. This  is not something that can be credibly wrote learnt on day one by doctors or advanced care practitioners and hence the ‘crutch’ of a treatment is offered.

It took me 13 years of training to work out that my greatest contribution as a consultant was not my knowledge or practical skills but my ability to suggest doing nothing without it appearing that there is nothing to do.

What have you learnt this week? #WILTW

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4 thoughts on “Do nothing without appearing there is nothing to do #WILTW”

  1. Since posting previous comment have been on nights and this WILTW really helped me in an explanation to parents upon discharge as to why we were not sending them and baby home with a salbutamol inhaler. The doctor leading their management did a “trial” of 6 puffs salabutamol which showed no improvement in classic bronch symptoms. However as we had done this parents became anxious that the “treatment” was not to be continued upon discharge.After a lengthy conversation (largely based on your writings above) they seemed much happier prior to discharge. Thanks again 🙂

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