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Anything But Routine

Published:April 30, 2020DOI:https://doi.org/10.1016/j.acap.2020.04.010
      There is a multisensory hum that becomes second nature in a busy pediatrics clinic. At any given moment, there could be an infant wailing, a child tearing apart the paper on the exam table, and the muffled voice of a phone interpreter all happening simultaneously in the same room. As I take a history, my eyes dart to the toddler walking toward the electrical outlet, the infant putting the telephone cord in his mouth, and back to the toddler who I think may have a fragment of paper in his mouth.
      Today marks 1 month of adapting to the coronavirus pandemic as a primary care pediatrician in an academic medical center that has been hard-hit by this crisis. It has both rocked my world and reinforced the things that matter most. The atmosphere of our clinic before coronavirus which could best be described as organized chaos is—dare I say it—desperately missed.
      Coronavirus quite literally turned the mute button on in clinic. Department leadership made the difficult decision to close our clinic to all but essential well visits for infants. Parents became reticent to come anywhere near the hospital due to concern for possible exposure to the coronavirus. Despite efforts to keep the clinic safe, their fear was not irrational as our hospital was seeing a significant influx of patients with COVID-19. The silence in clinic was initially paralyzing. Background noise was obliterated and my over-stimulated senses went into acute withdrawal.
      Phone outreach came first as a way to continue to provide needed care. I admit that talking about developmental milestones or constipation while a pandemic was taking hold felt relatively insignificant, but soon enough the calls started changing. The parents of my own pediatric patients started testing positive for coronavirus and they wanted to talk. A parent of a toddler with significant behavioral health issues who had just started making progress with therapy called. The mother could barely say a few words at a time between coughing fits, but she needed help with several things, including getting food to her home. Another mother, recently recovered from COVID-19, called because her daughter was now complaining of headaches and stomach aches. She broke down in tears, ridden with guilt that she may have brought the illness home to her family.
      I listened and reassured and harnessed the power of our team of social workers and navigators to help with behavioral health support and door-to-door food donations. Absent were the things I usually relied on—facial expressions, a box of tissues, and the inevitable toddler mischief that could infuse a needed dose of humor. Precoronavirus, these were the types of visits that would prompt an in-person huddle with our incredible team where we could brainstorm but also support each other. Sitting at a desk with a phone left me feeling alone and worried.
      In the face of the worsening surge and associated fears, our clinic leadership swiftly collaborated with a local ambulance company to procure an ambulance and emergency medical technician to take us into the community to conduct mobile physicals and administer immunizations. “Routine child health maintenance” is a term we use to describe well-child visits or physicals, but this felt anything but routine. Many parents were absolutely panicked. You could see it in their faces when they met us in front of their homes. One mother was even afraid to come out of her house. Our nurse was able to gently explain the purpose of the visit over the phone and she ultimately came outside. It took further reassurance for her to go inside to get her daughter who was due for vaccines.
      We spoke about the lockdown, how families were coping, and whether parents were letting their children outside for fresh air. We also spoke about colic, feeding, jaundice, and child development. I allowed the parents to guide the conversations with their concerns and I followed their lead. While I was talking with the parents, the nurse weighed and measured the babies inside the ambulance which had been repurposed as a mobile clinic. I then performed my physical exam. Not only was it cramped inside the ambulance, but I was in full protective gear so that only my eyes were visible to the babies. As I was examining a 6-month-old boy, I was just about to discuss how infants instinctively respond to facial expressions. What a shame, I planned to say, that mine were obscured by my mask. At that very moment, the infant, with his 2 adorable bottom teeth, made eye contact with me and started smiling and laughing at me.
      I watch infants smile every day in clinic but this expression of joy gave me pause. We are wired from the start to connect with each other. If anyone needed proof, here it was. I realized at that moment why this mobile clinic matters. Yes, it is about the vaccines. After all, we can't fixate on the development of a coronavirus vaccine and be blindsided by a preventable measles or pertussis outbreak. Perhaps even more so, it is about maintaining connection. Isolation is saving us but it is also destroying us. Parents have questions and worries and it has always been our job as pediatricians to answer the call. We too as pediatricians have a relentless yearning, particularly in times like these, to advocate for children, meet families’ needs, and make babies smile.
      This crisis has already taught me more than I ever wanted to learn, but I hope to come away with 2 guiding principles. We don't need a pandemic to set aside time to silence the noise, question the status quo, and adapt to whatever our patients may need at the time. I hope telemedicine and home visits can remain a part of our practice for those patients who may need them most. We should also never take for granted the innate beauty and power of human connection, even while wearing masks and face shields. We can and should use this crisis as an opportunity to learn from each other and help each other. In the meantime, we shall continue to carry on the powerful mission of pediatrics, perhaps in ways less routine.

      Acknowledgments

      Thank you to Eileen Costello, MD, Sara Stulac, MD, Tami Chase, RN, Jack Maypole, MD, and Robert Vinci, MD for their inspiration, leadership, and feedback.