Published this in 2018. Not much has changed expect for the volume of patients!

We are firmly in the throws of bronchiolitis season. So that means, as a pediatric ICU doctor, for the last month I’ve given the same speech several times a day to each parent with a child admitted to my ICU. I’ve gotten pretty good at it. So I thought I’d share it in a blog.

 

Bronchiolitis is ubiquitous in the winter. Everybody gets it, pretty much every year. The most common cause of bronchiolitis is Respiratory Syncytial Virus (RSV), but there other causes that we don’t routinely test for, so not every child with bronchiolitis is “positive” for RSV.

 

Not all bronchiolitis infections are serious. Most are really minor and just seem like a “cold”, especially in adults, older children, and toddlers. But in some infants, these infections can be serious and can require hospitalization. Each year in the state of Connecticut, where there are about 40,000 infants under a year of age, we admit about 350 children with bronchiolitis to Connecticut Children’s for the treatment of severe breathing issues.

 

Most of those admitted to the regular hospital ward need supplemental oxygen, delivered through a nasal cannula (small nose prongs). Sometimes these children need breathing treatments, intravenous fluids, or help with feedings and most go home in 1-3 days. But 1 in 7 of these children admitted to the hospital need to go the intensive care unit (ICU) for the treatment of more severe respiratory disease and difficulty breathing.

 

Of the 50 children admitted to our ICU each year with bronchiolitis, most need what is called non-invasive positive pressure. This provides support for their breathing and is typically delivered using a heated high-flow nasal cannula (sometimes just referred to as “high flow”). This involves a somewhat larger nasal prong that fits just inside an infant’s nose and allows us to give more support than a regular nasal cannula. In some children, even more support is needed than “high flow”, and a slightly larger nasal prong is used to provide “CPAP” or continuous positive airway pressure.

 

A small number of children need even more support than can be provided non-invasively. These infants are more acutely ill and have more severe respiratory distress. About 1 in 10 children admitted to the ICU (or about 5-6 per year), need to be “intubated” or to have a breathing tube placed in their throat so that we can provide invasive mechanical ventilation (aka life support). But the best news about bronchiolitis is that children very rarely die of this disease. Even children who need to be intubated generally do very well, although it may be a long road to recovery in these children.

 

Most children admitted to the ICU with bronchiolitis are admitted for 2-3 days, plus another 1-3 days on the regular ward before discharge (so 3-6 days total). But that’s an average. So some kids only need 1-2 days of hospitalization. And some kids need 1-2 weeks. Each child is different and responds differently to the infection and the treatment. It is hard to know up front how quickly children some children will recover.

 

So why are some kids so sick from bronchiolitis while others are home with a more mild illness? This is a question I get asked a lot. There are some risk factors for more severe disease. For example, children born very prematurely (before 34 weeks), and children with heart disease have a greater risk of more severe bronchiolitis. But the vast majority of the infants we admit to the hospital each year have no risk factors and are previously healthy.

 

So again, why do only some kids get so sick with bronchiolitis? The short answer is we don’t know. For lack of a better description, it’s essentially bad luck. But there is a longer answer. One possible explanation to why some kids might have more severe disease is that they might have an immune deficiency or be more prone to severe diseases in general. But we’ve followed children admitted to the hospital with bronchiolitis. And they don’t have immune deficiency when we’ve tested for it. And for the vast majority, this is the one and only time they’ve ever been admitted to the hospital. Even the children who need to be intubated go on to live long and happy lives free of recurrent illness. Could it be some super strain of virus that these children are infected with? The answer to this is also “no”. We’ve done studies of the viruses infecting these children, and they are infected with the same stains as everyone else.

 

So we’re left with just a bad interaction between this year’s strain of the virus and that child’s immune system. We’ve seen this in other infectious diseases, and we’re starting to tease out these relationships with RSV as well. Just as each of us responds differently to medications, people respond differently to infections. Unfortunately, someone has to be on the more severe end of the disease spectrum. We are conducting research at Connecticut Children’s into how these interactions affect infants with RSV, but we are years away from answers that will change clinical care.

 

A part I never get to in my speech is how do you prevent bronchiolitis in your infant? The short answer is that you probably can’t. But the long answer is that there is some good common sense things parents can do to try to reduce the risk of infection. Parents should avoid contacts with sick people. (Spoiler. That’s a big reason so many babies are sick this time of year: sick relatives kissing babies at Thanksgiving and Christmas.) Don’t invite sick people over to see the new baby. Don’t let sick people hold or kiss the baby. Have people wash their hands before holding the baby. And if you have other children at home, try to wash your hands and their hands frequently, and to clean surfaces (in the kitchen, the bathrooms, door handles, etc) to try to prevent the spread of germs.

 

I’ll freely admit that I’m the type of doctor no one wants to meet. As a pediatric ICU doctor, I see parents at the worst points in their lives. But fortunately, the vast majority of children recover from bronchiolitis, and never return to the hospital again. So keep sick people away from your infants if you can. And I hope you’ll never have to meet me in the ICU.

More and more healthcare practitioners are turning to social media for their medical education. Fellows are learning ultrasound from Snapchat, nurses are learning how to insert NG tubes from watching YouTube, and learners are learning pathophysiology from blogs and podcasts. To reach this audience with credible and reliable content, it is important for medical educators to be present where the learners are, and that means social media.

 

Users are also looking for entertaining ways to learn and engage with content. “Gamification” is a technique used making activities fun as well as beneficial by turning that activity into a game. Studies have found that gamification increases learner engagement, improves knowledge absorption and retention, and enhances the overall learning experience for all age groups. This strategy applies to medical education as well.

 

Many of us (myself included!) have fond memories of the Choose Your Own Adventure series by Jay Leibold from the 1980’s. Thus summer, Sarah Lascow did a piece in Atlas Obscura on how the author mapped out his stories. Fascinating graphic description of how these books were put together. A couple of days later, I saw a scenario that @NasMaraj posted on Twitter called “Intruders”. It was simple thread, but a clever idea. And I thought, this would be a fantastic tool for medical education! So on a long flight to Alaska, I put a case scenario together using the Pediatric Advanced Life Support (PALS) Guidelines and mapped it out on paper. Then I spent about an hour or so tweeting and linking the tweets.

 

The response to these scenarios has been amazing. The first scenario had more than 11,000 interactions within the first few days, with hundreds of positive comments from doctors, nurses, and trainees thanking me and telling my how much they liked them. That’s been incredibly gratifying! Amy Coopes (@coopesdetat) helped me coin a name & hashtag for them: #ChooseYourOwnMedventure. Since then, I’ve published four different scenarios and collected them in a Twitter Moment.

Making these threads is not hard, but it can be time consuming in the beginning. But I’ve learned a few things that may be helpful to others looking to do this. First, I would suggest mapping each tweet out ahead of time analogue style with paper! Plan how each tweet should link to the others, because once you start, you’ll need to refer back to that map so you don’t get lost. There are two ways that tweets connect in these scenarios: by replying to the one above it, and by starting a whole new thread and copying the link to that new thread into another thread. This is key. Starting new threads and copying the link into a reply into another thread allows the user click down new pathways, and hop back and forth between the threads for the “Click here if you choose…” options. If you simply reply to the tweet above or don’t link the tweets at all, the scenario will not display correctly for people trying to “play” the game.

 

Take a look at this example. In my plan, each tweet is in its own text box. I’ve used bold font to indicate the start of a new thread, a black arrow to indicate a reply to the tweet, and a blue arrow to indicate that I’m copying the link to that tweet. So the thread starts off with the tweet “You are called to the bedside…”. The next tweet (“Your initial impression…”) is a reply to the first tweet. And the third tweet (“You decide to…”) is a reply to the 2^nd tweet. To set up the choices, you start a new thread for each of the two choices “You decide to do your job…” and “If you choose to grab a donut…”. Then you need to copy the link for each of these new tweets in a reply to the tweet that asks for your choices. Once this is done, you can proceed to expand the threads for each of the choices by replying to the first tweet in that thread. As you can see from this graph, this trick about copying the link for the tweet, and pasting it into a reply a tweet can enable you to hop around between threads.

Be sure to test out your threads as you’re laying it out. It is very easy to make mistakes! Think about including photos, graphs or links that might be useful for education. Also be aware that your timeline will appear very disjointed while constructing these scenarios, but should work well if you start at the beginning!

 

Hopefully this will inspire you to do one of your own! Innovation of teaching tools that engage the learner is crucial in today’s medical education environment. The Choose Your Own Adventure style scenarios have been fun to make, fun to use and easily adaptable for a variety of medical scenarios. Good luck!