Tuesday (5/13) night after the banquet, Zhewei thought Skyler seemed overly warm again at bath time. During the night, he woke up several times, fussy, with abbreviated cries, and was definitely hot. We were pretty sure he had a fever again. We had been to the Children's Hospital for fever on 5/3, and on that day he was improving; the next his temperature seemed normal. In the interim, he had an occasional cough (I noticed 2 or 3 a day); it seemed like leftovers from the respiratory difficulties of whatever viral infection he had. His behavior has been normal, and we hadn't been giving him any drugs.
Since this new fever showed up, we gave him some pain reliever, ibuprofen in suspension, which brought his temperature down for about 8 hours each time we gave him a dose, and his temperament would appear normal happy playful self. After about 8 hours, his temperature would rise again, and he would become fussy. This went on all day and night Wednesday. Thursday morning, as his last dose was wearing off, his temperature rose again. It didn't seem as hot to me as before, but hard to gauge since there were residual effects from the drug.
We decided to take him to the doctor again just past midday. We had just given him a partial dose, and his temperature and behavior were resuming normal. We took a taxi to the children's hospital. After registering again (10Y) we went to the consultation room to discover the doctors were on lunch break until 2.30p, so we had about 50 minutes to wait. We went downstairs and got his temperature taken (38.1C again), for which he was more tolerant than last time, then went outside to wait. Once the doctor arrived, yeye called down and we put our booklet in the queue (a pile of booklets with numbers sticking out of them) at position 8. We waited another 15 minutes, then went up into the room. Nainai was watching the doctor's consultation room like it was TV. Skyler and I got looks and stares from kids and parents alike.
Finally it was our turn. Zhewei described what Skyler's condition and remedies had been last time, and currently. The doctor listened and didn't ask much. He also never looked us in the eye, but rather down at the booklet all the time. The only time he looked at Skyler was in the throat with a tongue depressor. He listened to Skyler's breathing from front and back. It was the same with other patients, really. He sent us downstairs for a blood test. We paid the fee, got a voucher, went to the blood test station. The nurse pricked his left ring finger, more deeply this time than last, filled a little tubule, and Skyler cried for a few minutes while we struggled to hold the cotton against his finger, until the pain subsided enough we were able to distract him with umbrellas (it was Sunny and hot), buses, and the usual.
The blood test results show a bacterial infection this time:
WBC 18.7 (normal range 3.85-10.0)
PLT 438 (100-320)
NEU 11.7 (1.08-6.7)
MONO 1.1 (0.26-0.8)
HGB and HCT were slightly low, and RDW-CV and NEU% were slightly high.
Back upstairs, we got in to consult. The doctor recommended the antibiotic IV, just like last time (for the viral infection). I asked about identifying the infection: for that Skyler would have to be hospitalized, 99% of Chinese patients would just opt for the antibiotic. I asked about oral antibiotic: Chinese people believe IV is more effective, different countries have different practices. I asked which would be faster acting: the IV would be faster. I sat on a stool with Skyler, even with his eye level behind the desk; he never looked at me during this conversation that Zhewei translated. Yeye also asked some questions; both Z and yeye stooped low at the front of the desk to see his face, but still the doctor never looked at them.
I agreed to the IV although I still preferred oral. First, however, we had to make sure Skyler was not allergic, so we went to another station on the first floor where kids are given small subcutaneous injections in the forearm near the wrist and sent to wait 20 minutes for a reaction. Skyler didn't like that one bit, either. There was no reaction; after the allotted time we returned and waited a bit while two other kids were injected in front of us. Skyler started crying just like the other kids did, probably he realized by this time that that woman HURTS people and he wanted to get away! She glanced at his arm and gave the all clear stamp on his paperwork.
We went to pay for the IV prescription (54Y) and then up the escalator again to find the IV station. This was a scary room: little kids being given intravenous drips. The smallest ones, infants and toddlers, were typically given IVs in their foreheads. Mothers were holding their kids down on their backs, immobilizing them while the nurses found and inserted the needles. I understand the reason for foreheads, but I was really reluctant to do that to Skyler. Our turn came, and sure enough, they went straight for his head; I said no, and asked about the hand. They strapped his hand and tried looking for a vein but couldn't find one. Then we asked for the foot. They went looking and found one. Zhewei and yeye and one nurse held him while the other nurse inserted the IV needle into his foot. I did my best to keep him from looking at what they were doing. He cried hard - it may have been 7-8 minutes or even less, but it felt like a long time, finally quieting when Z began to nurse him. Yeye held the IV bag up high, I was holding his leg to keep him from kicking and twisting it. At this point, nainai offered us ice cream cones she'd bought outside. My initial reaction was not very grateful -- it just seemed like the absolute wrong time. She fed Zhewei ice cream and cherry tomatoes. I ate mine quickly, really didn't enjoy it, went to rinse my hands, and returned to take the bag from yeye.
We were about 2/3 of the way through the bottle of 100ml when we decided to move to the IV observation area, where a nurse monitors the IVs and removes them when they are done. They also had convenient hooks for hanging the bags; how convenient! This room was almost as scary as the IV station room, filled with kids with IVs in their heads, hands, feet. Several were crying the whole time we were there. Nainai kept Skyler busy by giving him cherry tomatoes to eat. A cute little girl next to us had an IV in her hand. I smiled and waved at her but didn't get a smile. Nainai asked the girl's mom and it turns out she was returning for 5 days in a row of antibiotic IV's. We began to wonder if we were supposed to do the same thing; the doctor hadn't told us what to do after the IV: return for another consultation or go home? Come back after how many days? We decided we had to go back and talk to him again.
Finally the bottle was empty, we called the nurse over. I held Skyler's leg and foot to prevent him from flexing it while she carefully removed all the tape and finally the needle, placing a bandaid over the spot and instructing us to apply pressure. Skyler cried again for a couple minutes until nursing calmed him again. Those kids in that room are so brave.
Back upstairs, sure enough, the doctor said we had to return tomorrow and come every day for five consecutive days. I was concerned if that meant 5 days of antibiotics IVs, because I certainly wasn't going to agree to this unnecessary suffering if oral antibiotics were available. Certainly I now understood that the one dose of antibiotic couldn't be a full course, and specifically asked if we can get the oral antibiotics prescription now, and return for checkup at the end. But no, he said he would not prescribe the oral antibiotics now, because Skyler already had antibiotics in his body. Furthermore, he was not prepared to predict Skyler's condition and needs more than one day in advance: at each of the five daily visits a doctor would consult, evaluate, and decide on treatment.
We went home.
I suspected each time they would put us through exactly the same routine: temperature, blood test, and finally an antibiotic IV prescription. I can't understand why, after seeing and hearing the suffering inflicted on all those kids, so few Chinese parents would opt for the oral antibiotics -- unless they simply don't know about the alternative? What's going on here? I can think of several factors at play.
- Chinese patients basically never question their doctors, because questioning a learned person, why, that's disrespectful, and he is trying to help you after all! Going along with this is the fact that most Chinese patients generally don't know much about science or medicine. A doctor prescribes them an IV of "antivirus" if they have a cold or flu, and that's accepted at face value. Doctors rarely explain anything, or try to educate patients. Practically speaking, decisions are never really in patients' hands, because they're not informed enough to make decisions.
- Each day you show up at the hospital you pay another small registration fee. I wonder if the cost of 5 days of antibiotic IV is higher than equivalent oral antibiotics cost. I think that's also playing a role: the doctor increases his income, sure, but also patients think the more expensive treatment must be better. That's why they pay for the more expensive consultation, right?
- And just maybe, giving patients an IV in the hospital, where they are supervised, ensures they get the antibiotics properly. Giving patients pills requires that they are responsible enough to take them in proper amounts at proper times and, most importantly, for the prescribed period. This is an issue in American medicine, and in China it would be worse, I think, in part because of lack of communication between doctors and patients.
The pain and discomfort isn't my only concern. There's the added risk, too. Each time his skin is punctured it's a new chance for infection. Of course they do swab skin with iodine and needles come from sterile packaging. But every waiting room is filled with sick kids -- a risky environment. And this is also a place with flies throughout finding food crumbs, fruit peels, empty drink bottles, open garbage cans (including those containing medical waste), where the floor is littered with all such things including cotton swabs with blood spots on them, plus urine and even feces. Many of these kids are in potty training, and yes, some parents hold their kids legs open and let them just go right there on the floor. Some at least held their kids over open garbage cans to go, others carried them outside, if there was time. But even older kids, say 5 or 6 years old, who certainly had control of their evacuative faculties, I observed walking outside and peeing on the steps or sidewalk, instead of finding the actual bathroom on the second floor.
I wonder if people know that hospitals are a major _source_ of infectious disease?
We talked to Zhexiong, who has a young daughter, by phone. In his experience with his daughter, there will always be at least 3 days of the antibiotic IV. He also says he tried oral antibiotics before, but it caused stomach problems with his daughter (not sure at what age), and the diarrhea became a new problem to deal with. If serious, this seems a valid reason to prefer intravenous administration.
The last bit of pain-reliever we gave him was just before we left for the hospital, around 1.15p. It was only a half-dose, but it would have offered benefit through about 8.30p. His temperature seemed a little warm as he was going to sleep. I wasn't sure really whether the antibiotic he received today has helped yet, but it seems it may have.
Sometime in the night, Skyler was sweaty but his head seemed normal temperature. This morning, Skyler's temperature seems normal. He's not on any pain reliever. His fever is broken. We took him outside to play for a while.
We mulled whether to take him back to the hospital in the afternoon. I didn't mind returning for more antibiotics; if he needs them at all, Skyler should have a full course. But I definitely was not going to accept unnecessary suffering. I intended to demand oral antibiotics.
After Skyler's afternoon nap, just about at closing time, we took him to the nearby hospital, rather than heading to the big children's hospital. This local one has a pediatrician, but hours and services are limited compared to the children's hospital. I also felt it might be a little more sanitary, perhaps an unfounded impression. At least it wasn't full of sick kids, though, and adults have a little more discretion about coughing on each other and do use the restrooms! We didn't have to pay anything for registration, but we had to buy a records booklet (1Y). We went straight to the pediatrics room, where one little girl patient's father was already consulting, and no one was waiting! We actually recognized the father from our trip here on Tuesday morning, who had a cough and took the intravenous antibiotic that day. Maybe his daughter caught it from him? The girl wasn't happy, they'd probably just pricked her finger 15 minutes earlier, and I guess she knows these places are Not Fun*.
We explained Skyler's situation and that he had no current symptoms, but we understood he should take 3-5 days of antibiotics. This doctor looked at the blood test results from Thursday and the notes written in the other hospital's booklet, and agreed he should take two days more antibiotics. We also explained why we didn't want to return to the Children's Hospital, mainly emphasizing further risk of infection. He was patient and explained the reasoning for a full course of antibiotics despite symptoms disappearing within a day (which we already fully understood, but were glad to listen anyway), and also agreed about avoiding the risk of "cross-infection" at the Children's Hospital. He listened at Skyler's chest and back, and looked at his throat. He also examined Skyler's wrists and feet quite carefully (not explaining why).
At first he misunderstood, thinking we wanted intravenous, saying that Skyler would need a skin test for allergy, and the office that does that closed at 4.30p. When we explained we wanted oral, he was happy to write the name and dosage for us, and said it was available OTC (over-the-counter) at any pharmacy. It was Amoxicillin. I did ask about alternatives, but he said "they prescribe this in US too" and that's what they always use (for anything, apparently), and I was happy to go with that. That was all! No other charges. Another patient had arrived and was waiting, so we thanked him and I shook his hand (he seemed surprised and honored by that, standing up to receive it); we left.
We walked a block to a pharmacy and bought Amoxicillin in powder form for children, one packet three times a day, dissolved in water. Somehow the taste is bearable, too (I tried it). Cost: 14Y for two days worth.
Later I realized the doctor was checking Skyler's hands and feet for the EV71 outbreak of Hand, Foot, and Mouth disease the government has been rallying local governments and health care professionals to fight aggressively. I already had a good impression of this guy: he looked us in the eyes, he explained things, and had patience to answer questions. He seemed confident in his knowledge and skills, whereas somehow the other guy didn't deal well with people asking anything -- maybe it's just the volume of patients? Now I appreciate this doctor even more. The doctor at the Children's Hospital hadn't checked Skyler's hands and feet at all -- and the national government has really been pressing on the EV71 outbreak, which has appeared in eastern Hubei (although few cases in Wuhan).
We gave Skyler his first packet Friday night -- he didn't want to drink it, so we had to use the dropper and some coercion. But even three times a day this was much less harrowing that the needle in the foot.
On Saturday Skyler's feces was quite runny. Nana suggested by email it may be because the antibiotic kills a lot of the natural flora in the digestive tract. But he didn't eat a lot at that meal, either. We decided to only give him the medicine if he ate a pretty good amount at a meal, and waited minimum of 20 minutes or so after he finished eating. His next bowel movement was also somewhat runny but not as bad as the first one. We tried getting him to drink some yogurt, but he didn't go for it. Subsequent ones were better still. Our decision means we skipped some of the prescribed 3 packets a day, but extended the period of antibiotics a little.
We gave Skyler a final packet of Amoxicillin after dinner Sunday night. We actually have one more we haven't used, but I think we'll skip it.
Skyler has had no further symptoms and behavior is normal. That ends this episode, we hope!
* Have you ever flown a kite in bed?
Have you ever walked with ten cats on your head?
Have you ever milked this kind of cow?
Well, we can do it. We know how.
If you never did, you should.
These things are Fun, and Fun is Good. -- Dr. Seuss