Tim : Emergency medicine is such a humbling fulfilling you know,
difficult path that we have chosen.
We see people at their worst and sometimes they can rise to the occasion
and be at their best, but we have to also rise to the occasion, be at our
best and give them what they need.
And if that's information, if that's reassurance, if that's
guidance that's what we try to do.
Sam (2): Hi everyone, and welcome to another episode of EMplify.
I'm your host, Sam Ashoo.
Before we dive into this month's episode, I want to say happy
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Get a free $50 Amazon gift card for spending $300 or more in the
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a wonderful Holiday . And now let's jump into this month's episode.
Tim : Good morning, Sam.
I'm Tim Horeczko.
I'm very happy to be here with you.
I'm from Harbor, UCLA where I am the program director for the Pediatric
Emergency Medicine Fellowship.
And more importantly, and to your own heart, I am one of the co-editors in chief
of pediatric emergency medicine practice.
So I'm very happy to be here with you and maybe even give you a little
bit of a behind the scenes of how we were able to develop this article.
Sam: Awesome.
Thank you so much for agreeing to be on the podcast.
Today we are talking about the pediatric emergency medicine
practice article from November, 2025.
This one is specifically on the management of measles, mumps, rubella, and varicella,
which you would think would be mostly historical, but in light of recent events,
I thought the timing was actually perfect.
This was authored by Dr. Sarah Cavalero was an excellent review,
I think, of all of those diseases.
And so thank you for agreeing to be on the podcast to discuss it with us.
It's an interesting topic, and I wanna start by saying in like my 20
years of clinical practice, I have seen varicella, I've seen chickenpox
I think I've seen maybe two cases of measles and maybe a handful of mumps.
Never seen, at least that I know of a case of rubella.
And certainly the cases of measles I saw were like very mild, and
it was kind of questionable.
And we got like a dermatologist involved and they're like, yeah, sure.
It could be like a mild, you know, and somebody who's been partially
vaccinated or something of that sort.
So this is an interesting time because in our country here in the
United States, there are outbreaks of measles in several areas.
Pretty large outbreaks of thousands of children involved.
And so.
If you're working in emergency medicine, these are diseases that we
previously learned about in textbooks and took for board exams that now we
have to learn to recognize clinically.
And I would say most of the physicians who worked in the pre vaccine era or in
the newly vaccinated era are all retired.
And so we've kinda lost that clinical knowledge.
We don't have a good core memory for what these things look like.
And I think today I would miss many of these things when they first
come to the emergency department.
So, I really wanna say thanks for agreeing to be on the podcast to talk about it.
'cause I think this is going to be a very important discussion and very
pertinent to many of our listeners.
Tim : Thank you, Sam.
I love what you do on the podcast.
You really bring it to life for people.
And speaking of which, you know, Dr. Cavalero took some oldies but goodies
and really made it very accessible to us and refreshed, I think, in our
memories especially, you know, recent epidemics, what our role is in the
emergency department from a public health standpoint, in addition to trying to
help that individual in front of us.
And you mentioned some good points about.
It's sort of like our, I would say the evolution of our experience over time.
I am gen X as well and so, you know, you see a little bit of the
bridging of the generations where, we would see pre varicella vaccine.
that's chicken pox, right?
That's there it is.
And I'm teaching my residents and fellows and we often will, if we see a case, it
will be the attenuated version, right?
This is somebody who would've already gotten the vaccine maybe, or even a
full -blown case, but you almost have to couch and say, in my day, you know,
no one wants to hear that phrase.
But I think it's important that we can continue to share our experience because
we never know when these oldies but goodies will come back and they are right
there in front of our face right now.
Sam: Yeah, and I think a lot of us, at least I did not have a good appreciation
for the severity of the diseases.
You know, we just assume, oh, we have a vaccine for it.
But we forget that the reason why we put so much effort into developing a vaccine
is because these were diseases that cause significant morbidity or mortality.
So the epidemiology section is always a fun place for me to
start, because I like the numbers.
And measles, I think of all of these is probably the most
striking the pre-vaccine era.
The, data we have from then said anywhere from 15 to 60,000 cases of
blindness 2 million deaths per year due to pneumonia or encephalitis as
complications of measles and young children less than five years old, and
adults over 20 were the ones who actually had the highest morbidity historically.
And.
In 2000, the United States was among 42% of countries that said
they had eliminated measles.
Meaning there's , no spread in the communities , or
country or person to person.
And then we've sort of backtracked since then.
So COVID kind of caused a large decrease in community vaccination efforts.
And then since then there have been some other political factors that
have even reduced them even further.
And now our cases are actually over 1500 cases in 2025.
And two deaths already, which is historically kinda unheard of in the last
25 years here in the US from measles.
Tim : Yeah, it is crazy.
You know, we, sort of joke about first world problems when we have
inconveniences that we don't like.
And we historically thought of outbreaks of measles, mumps, rubella,
et cetera, as a developing country problem because of course we have
all of the wonderful resources and blessings to be in a developed country
that we benefit from constantly.
And so we're sort of seeing this funny thing where we're not appreciating
what's right there in front of us.
These are the, again, tried and true vaccines that have proven themselves
to be very safe and effective.
of course, you can make arguments that there are always reportable complications
of any intervention that we have, but, you know, it's just as good as clean water.
are you gonna test every time we take a sip?
I don't know about that, but I think the thing is that we have to
be careful about how we communicate that to our people, right?
Because the patient in front of us just cares about trying to get better and
trying to survive whatever the problem is.
They'll come in worried about measles, mumps, rubella, varicella.
So we, you know, we as passionate as we can be about our hats of public
health and hats of emergency medicine, I think that our messaging has to be very
attuned to the patient in front of us.
There's some people that are very resistant, right?
They're very hesitant and they are not gonna listen to anything you say.
And the moment that you start to go into a diatribe, they will shut
off any communications and then anything that you wanna help them
for, supportive care, whatever it is, even just please stay away from
pregnant women, from immunocompromised, et cetera, they won't listen.
So I've changed my interaction with patients in that I will ask them if
the, let's just say the topic, the discussion gets to be around vaccinations.
I try to see where they are, meet them where they are, and I will
say, you know, what questions would you have about X, Y, and z about
vaccinations ? I don't have any questions.
Okay.
Well, I'm always here to help and I appreciate that you've Read about
or heard about different things.
I would just encourage you to make sure that you've heard from
various sources and sources are referenced and that you can trust.
And I'm very happy to speak with you about anything that you want to clarify.
There are some times there's more poignant where it is case of measles
that comes in and really we need to make sure that we have given some
post-exposure prophylaxis to the family.
it'll be more pointed and that we can talk about different things.
Sam, you tell me what direction you'd like to go in, but what I would say
about that is the connection with public health, these are all reportable diseases
Sam: Mm-hmm.
Tim : so, you know, every jurisdiction's gonna have their own way of reporting it.
In Los Angeles County, we have a pretty robust reporting mechanism.
But you know, measles, mumps, rubella, regardless of where
you live, are all reportable.
Varicella in general is mostly reportable if for hospitalizations or deaths.
But it comes into play when I have to worry about the little kid that needs to
be isolated from measles that goes home.
It's not just about that little kid, it's about every little child
or every little person involved because the r nought right.
The R zero meaning the average number of cases of infectivity
that one person can cause.
So little Johnny is three years old and he has measles.
He goes home to his family of five to seven.
He's gonna infect 12 to 18 people, little Johnny, which means that,
Johnny and Jane and whoever else will then infect another 12 to 18 people.
That is what we like to call an exponential growth.
Just as an example, we think we poo poo measles sometimes because, ah,
it's, you know, natural immunity or whatever people wanna say.
But when we think about the R noughts, the infectivity, the average number of
cases that one person can infect , we worry about things like tb, tbs only six.
We worry about things like COVID.
COVID is only four.
We worry about the common cold.
That's two to three people that you're gonna infect.
Ebola, nobody likes Ebola.
three is the rnot.
Sam: Hmm.
Tim : one case is gonna affect three people.
Do we like that?
No, but just the magnitude.
And then also I think our individual responsibility of living in a society
is that in order to have herd immunity for something like measles, which I'm
focusing on measles because this is probably the highest morbidity of the
diseases we're talking about today.
You need 90% herd immunity in a community in order for us to prevent an outbreak.
Trying to get 90% of adult humans in this world to do anything is hard.
Sam: Yeah.
Tim : I can get 90% of 'em to breathe.
That's probably all I could do.
So that's tough.
So it's a lot of like stepwise multifactorial, multi-tiered counseling
and public health interventions.
And our just every day just trying to connect with our
patients to get it to be 90%.
And then when we have other factors against us, man, we have to be
so ready to diagnose on site.
And now these diseases are all clinical diagnoses that your public health
mechanism may ask you to do a PCR or to do some serologies to verify, but we should
all be ready to diagnose these on site and be able to counsel people even if you
don't feel, you mentioned about, you know, hey, there's some cases of maybe measles.
The maybe measles.
I am gonna treat like measles until proven otherwise and say, listen, this
is what we think it is and we're gonna be careful for everyone involved.
Sam: Yeah.
Yeah.
So many good points there.
And you know, that's just measles, but the author talked about the
epidemiology of mumps causing permanent deafness or death due to encephalitis.
And that's something that's not so far removed historically.
The author mentioned an outbreak on college campuses in 2014 and one in
the National Hockey League in 2014 because of how highly infectious it is.
And you know, thankfully neither of those resulted in deaths but those are
outbreaks that had to be contained.
And probably involved emergency departments.
And then rubella a disease that at least, again, I don't think I've
had the privilege of treating in the emergency department, but primarily
devastating to fetuses, right?
So this is kind of in pregnancy where it's the most lethal but it causes a lot
of neonatal death, spontaneous abortions and then congenital rubella syndrome
which, you know, again here, the data in the article says in the US between
1964 and 1965, before vaccination, we had 12 and a half million people
with rubella, 11,000 women miscarrying 2100 newborn deaths and 20,000 infants
born with congenital rubella syndrome.
Tim : Yes.
Sam: Uh, And since 2012, 10 cases, so we've gone from like 20,000 in
a year to 10 cases in over 20 years because of the vaccine efficacy in
that scenario which is just a, an outstanding number to think about in my
brain for how effective that has been.
Tim : there's an old phrase.
You make your own luck.
And for example, rubella.
What you're saying is the hidden tragedy behind these
vaccine preventable illnesses.
Because rubella it is sort of the milder, the baby version of measles, right?
It's like German measles, it's called, by the way, it's called German measles,
only because it was first described by German physicians in the 18 hundreds.
It's nothing to do with anything in particular.
It is typically a milder course, milder course of just clinically
they're not as miserable.
Uh, In fact, measles comes from the old Latin miser, like miser in, you
know, in English, miserellu, uh, is like the little miserable one.
So measles is the little miserable one.
Rubella is like the little reddened one the, the ruberus one.
And I say that because , the actual disease itself in a child is often mild
and they're okay, but it's that hidden tragedy the mother doesn't realize.
And a blueberry muffin baby is born.
Totally devastated, as you mentioned.
And man, what a way to just prevent misery by these vaccines
that prevent these illnesses.
So, it's tough because again, you know, in the moment we are helping people
in the emergency department and people might not realize the long game here.
And we have that perspective.
So we try to balance out how much counseling does
this person need right now?
What part of me do they need?
Do they need my head, my heart, or my hands?
You know, what part of myself can I help them with?
Because again, you have to bring people along with you.
You can't lecture them into submission.
And you need to really win hearts and minds on this.
And part of that is, I think being open and honest, but also
compassionate when we see people who come in with these questions.
Sam: Yeah.
So difficult to do when you're trying to convince someone of
something who completely disagrees with you but very, very important.
Absolutely very important.
Tim : Yeah.
And a little story about mumps, right?
So, you know, of course we talk about measles and we see outbreaks.
Disneyland is not far away.
We get Disneyland measles.
Oftentimes, all the little kiddies have a magical connection.
And then they give it to each other.
The child him or herself is often okay.
And it's more about just making sure that the person who should never
get measles, nobody should, but the immuno immunocompromised will do okay.
Mumps is tough.
You mentioned the outbreaks.
I had a, this is all very you know, I'm gonna give you just the generics of it.
A young teenager comes in with groin pain.
Of course, like any teenage boy doesn't tell mom about his groin
pain 'cause it's super embarrassing.
Oftentimes we'll see delayed torsion for that reason.
And there's already ischemia.
So a kid comes in and everybody's already thinking, let's do an ultrasound.
Let's make sure it's not torsion.
You know, the poor sheepish guy explained a little bit more.
You realize he actually has mumps.
The family, just, you know, it wasn't an access issue to vaccines.
They just didn't really see the point and they just, it fell off their radar.
So here comes this boy who has unilateral orchitis and the mother
kind of also was feeling he'll get over this and they'll be fine.
And she's right.
And I, again, we talked about choosing the right amount of information or
interaction for each presentation.
And she kept pushing, is he gonna be okay?
What are the long-term effects?
And, you know, I don't want to be definitive when I'm speaking to these
families because what do I know?
I don't have a crystal ball and this is why longitudinal primary care is
so important . But she's asking me in earnest, I tell her, listen, the reason
why we worry about this is because of course you can have aseptic meningitis.
You have encephalitis.
I'm speaking to you in our terms, not in her vernacular.
I said, you're worried about infertility and so am I, I'm
worried about his sterility.
And Sam, she went from having sort of a, red faced sort of very frustrated
speaking about this issue to her face.
Just kind of had this gray curtain go over her and it's landed.
My only boy may not be able to have children and he's a young teenager
Sam: Hmm.
Tim : it just like was a moment and I just let her have the moment.
I'm not gonna sit there and lecture her.
And I tried to help her with as much as I knew.
And then of course this conversation shouldn't end here.
It should continue on with primary care.
But you know, on the bright side, we only had unilateral orchitis,
which is often a bit more favorable.
I believe the sterility rate is gonna be about 20% or so, which is not great.
If you have bilateral orchitis then you're looking at sterility, infertility
rates up to, you know, 90%, 80%.
, So the way I couched that was yes, that is always our concern.
And yes, we'll see how this goes and, you know, let's do what we can going
from here and helping 'em feel better.
And then I really would encourage a larger discussion with your pediatrician,
because I really don't want this to happen to anyone that you know or love.
And I kind of let it be again, she had some other questions.
I was okay.
But you know, these poignant moments come up and I think that this kind
of article is important for us because , forewarned is forearmed.
If we're ready already with some of this knowledge and some talking
points, and maybe the way that we're flushing this conversation out might
be helpful to someone when they have that next difficult conversation.
Sam: Yeah.
Yeah, absolutely.
Okay.
Let's talk about what these things look like.
So how about we start with measles?
Since I think that's probably the one we're most concerned about, at least
for its infectious abilities and for some of the outbreaks we've been seeing.
So, when we're seeing a child and we're suspecting measles,
what are the common symptoms?
There's a classic description.
Does that actually happen?
You know, does anything classically present anymore?
Tim : Yeah it's also hard because of course you have the three C's, the
cough, coryza and conjunctivitis, that will be looking like pretty much
any other cold right most of the time
Sam: Yeah.
Tim : And it's difficult when you see a lot of patients all at once
and you are just trying to do the best you can for the waiting room.
However, I would just say it is a good moment to pause and say, wow, how often
do you really see cough conjunctivitis and coryza all at the same time?
Oftentimes, you'll see it.
One at a time.
It'll evolve over time.
This usually comes all at once.
So what do we do with that?
I'd say anyone who comes in looking a little bit more miserable from their
cold, that they should, this is before the rash, cough coryza, conjunctivitis.
you go, Hmm, lemme look inside the buccal mucosa.
At that point though, I want you to put your mask on because
as we know, measles is not only airborne, but it's aerosolized,
you know, it flips in the air.
So anyone who in any concern whatsoever, I say slap an N 95 on and just go for that.
But let's just say you have your normal surgical mask on.
You should look at, some specific things we can find in the
buccal mucosa Koplik's spots.
Henry Koplik was a pediatrician in the late 18 hundreds in New York
who basically had a measles clinic.
This guy noticed all of these measles outbreaks and he was the first to
describe the bluish white, tiny little grain of salt on a slight little red
ring that you only see before the rash.
It goes away before the rash.
The moment that you have is with a cough coryza conjunctivitis that comes in.
It's so nonspecific.
Look in that buccal mucosa.
If you see little weird grains of salt, do not pass go.
This child has measles.
He has measles.
We've known this since 1896.
Thank you, Dr. Henry Koplik.
We should pay attention to these things.
And that's clinical enough because the next day or the day after will
start a little morbilliform rash.
It starts with a hairline, like some paint that's dumped on your head.
And it slowly, slowly drips to your face, to your trunk, to your extremities.
stay away from anyone who could be really hurt by measles.
And that is our real detective work that we can do.
Cough coryza conjunctivitis all at once in a miserable measles little one.
Look in that buccal mucosa, and you're gonna save 12 to 18 people from
being infected, the R nought measles.
Sam: And those koplik spots, those are gonna go away.
So we'll see them before the rash, but if the person already has a rash, no
point in even looking really, because we wouldn't expect to see the Koplik's spots.
Tim : Yeah, it's risk benefit Sam, because you do really wanna open that mouth
that's gonna shoot measles in your face.
So, you know, we look, when we see cough coryza conjunctivitis,
no rash, we look for the Kopliks.
But once the rash happens, Koplik is gone.
And also, you know, by this isn't talked about very often, which is
why I wanna emphasize it today.
People will sometimes see a weird looking rash.
They're not sure.
They'll look in the mouth and say, there's nothing in the
mouth, that can't be measles.
That's not true.
Koplik is gone by the time the rash happens.
Sam: Okay.
Yeah.
So very important to keep in mind in that scenario.
And then when we think about patients who might present to the ED with
complications of measles, now we've got a whole host of things that can happen.
Things like, otitis media, diarrhea, pneumonia corneal complications so
they can have corneal involvement.
And then immunosuppression.
Now this is interesting as the cause for all of these issues.
People who get measles and then recover are immunosuppressed for
quite a period of time, right.
Tim : That's right.
They're immunosuppressed from anything.
It's not just from the measles.
So, we treat them as relatively immunocompromised.
And that's why it's really important to get a good history for people who come in.
Often children will come in with serial URIs, serial infections, but it's
really important to say how has he or she been over the past several months?
There is something that, this is actually a relatively new description,
what's called immune amnesia.
We've only really had this documented for about the past 10 years or
so, and this immune amnesia that is kind of like a nuclear bomb to
your immune system, measles, for two to three years, it can last.
So in a young child who's susceptible and exposed to so many illnesses constantly
that is why they'll get the pneumonia.
That is the, the super infection.
The encephalitis is another mechanism.
And of course, long-term, more of a, autoimmune issue is the
subacute sclerosing panencephalitis, which, you know, you could have
the, totally boring measles.
It's a little bit of a rash.
Everyone gets upset for a week or so.
They go about their lives three years, five years, 10 years later.
They're neurologically devastated.
Those hidden tragedies of these vaccine preventable
illnesses continue to sprout up.
So those are the things that I'll sometimes point to when
people will be very hesitant.
Sam: Yeah.
And this complication, this subacute sclerosing panencephalitis,
thankfully is, is not very common.
This says five to 10 cases per million.
But this is a gradually deteriorating neurological devastation that starts,
you said, you know, anywhere from three to 10 years, even after measles
infection and is completely untreatable.
There's no way to stop the progression and it results in death for the child.
Tim : Preventable, but untreatable
Sam: that stuff just gives me the chills.
Tim : Emergency medicine is such a humbling fulfilling you know,
difficult path that we have chosen.
We see people at their worst and sometimes they can rise to the occasion
and be at their best, but we have to also rise to the occasion, be at our
best and give them what they need.
And if that's information, if that's reassurance, if that's
guidance that's what we try to do.
Sam: Yeah.
Okay.
So measles, cough, coryza, conjunctivitis, fever, malaise, maybe not eating well.
Koplik spots that are gonna be there a couple of days.
And then gone.
And then the onset of rash with maybe some lymphadenopathy, and then all of
those complications we just talked about.
Tim : That's right.
And for measles speaking to the family, of course, you know, you're
infectious, four days before the rash and then four days after the rash.
So it's not a get outta jail free card.
This child needs to be isolated, and this is why it's important
to get public health involved, because they will make phone checks.
They will continue to counsel people.
How many times have people forgotten what we tell them in the emergency department?
We try to write everything down, but that reinforcement later on with
the public, the wonderful public health nurses that are out there to
help us to keep our system running.
Sam: Okay.
And then mumps.
So, you know, we always think about the parotid gland swelling in the kid with
the classic swollen jaw on both sides.
But mumps really is going to infect any glandular organ in this scenario.
So they're going to get problems with pancreas.
They're gonna get problems with their reproductive organs.
They're gonna get problems with really , any gland in the body.
And it doesn't have to be just the jaw , but that may be the one symptom
that brings them to the emergency department that makes us think about it.
But you already mentioned like testicular pain or in a
female might be abdominal pain
Tim : You know, it can be surprising, and I'm glad you brought that up,
because again, mumps loves lacy tissue.
Anything that has that lacy glandular look to it from a histology standpoint.
So we should be aware that it can present in different ways.
The, case that I mentioned of this young teenager, he really didn't
have a lot of facial swelling.
You know, his habitus was a little bit larger, and so it
didn't really look much bigger.
His face didn't seem much fuller.
It was just unilateral swelling.
And his doppler was normal and it really, on exam, you could
tell that this was a bit swollen.
But, difficult because mumps, of course, you know, I love
etymology of words, as you can see.
And mumps comes from the old English of a grimace, pouty face is to mump.
Is to pout.
So we kind of think of someone as just like, you know, sour
face, their jaw line is down.
That's what we think of for mumps.
But man, we should be careful, right?
Is it orchitis?
Is it oophoritis?
Is it mastitis?
Is it pancreatitis?
Or this kid who's now seeming a little bit weird, why are you so weird?
Sir? Your utox is normal.
No trauma.
Oh no, you have aseptic meningitis because you have your mumps.
So, we keep our differential broad for that reason.
Sam: And then, equally catastrophic with the central nervous system
encephalitis and hearing loss myocarditis nephritis, multiple
other complications that can occur.
About a third of these cases of mumps are asymptomatic, but these people are
still contagious, so still out there passing it along to everyone else.
And so contact tracing may not be a perfect science in
this particular scenario.
Tim : Yeah.
You know, measles is very pathognomonic.
Mumps should be, but I, find that a lot of public health officials push
more for confirmatory testing in mumps.
So they'll ask for the PCR for the buccal mucosa, or even like an IGM serology.
I think also because, you know, orchitis of course can
be various infectious diseases,
Sam: Yeah.
Tim : From a public health standpoint, the agency is dealing with people
with varied degrees of experience.
And so they wanna make sure that our sensitivity and specificity is optimized.
So that's why we say, Hmm, is it really mumps?
And that's why they will tend to ask you for more testing.
And it is, you know, supportive care.
So it's not as infectious as the others but it's still something
that we need to pay attention to.
Sam: all right, let's move on to rubella.
So in this case, much like mumps, a large percentage up to 50% can
be asymptomatic, which again, is problematic for transmission.
But these in children are gonna present with fever, headache, cough,
congestion, sounds a lot like measles,
Tim : Mm-hmm.
Sam: and a rash.
And then this is also gonna have this prodrome for one to five days
before the rash appears right.
Tim : Yes.
And you know, that's why Rubella is the little red.
From a clinical standpoint, it is much milder.
It's sort of the baby version of measles.
and there may be cases where we call it measles, but it ends up
being rubella and we just never got the confirmatory testing.
But it's my understanding that we don't have a lot of cases of
rubella, at least in this country.
You know, I'm okay over calling it, but rubella often comes with this red rash
there's often arthralgias and they're just not as miserable as, our little
miserable measles in children are.
Having said that though, as you mentioned, the sensory neural
deafness can be devastating and then devastating to a fetus who is
exposed to this infectious disease
. Sam: And now the risk to a fetus here is probably, I think, the
highest of all of these diseases.
It says approximately 85% of fetuses exposed to rubella in
the first trimester are gonna develop some kind of birth defect.
Tim : Yeah.
And that's just not acceptable.
Right.
An 85% risk.
I mean, that's a no go of all the things we worry about in prenatal care.
People are so, assiduous about taking prenatal vitamins every day.
I love it.
So good.
But Wow.
You know, you're a little bit low on the iron.
We can get over that, but not so much on the rubella.
Sam: The rubella.
Yeah.
And mother's immunity is safeguarding for the fetus in this sense.
So as long as mom is vaccinated, that passes to the fetus.
Tim : yes.
Sam: Okay, so let's talk about varicella chickenpox.
Probably the one I'm for sure certain I have seen and had
actually as a child, I guess I'm old enough to have experienced it.
So this is another rash, right?
This one happens to be very itchy, right?
So fever itchy rash has those little vesicles that appear
multiple stages of ages because the rash comes in these waves.
And equally miserable.
But thankfully, actually probably , the one of these that actually
has some treatment options, right?
Tim : Yeah, , that's exactly right.
You know, varus in Latin is a pimple, so varicella is like little
pimples, little pimple disease.
So all these little, you know, pimple diseases are all over you.
And , I'm gonna just expose my own bias too, because again,
like when we were little, you know, everybody gets chickenpox.
There were chickenpox parties.
Sam: Yeah.
Tim : Get it all over with everyone.
And I think we took a little bit of a laissez-faire approach.
, And I think that we're all probably pretty lucky for that.
The problem is though, of course we have an effective vaccine that
can really decrease morbidity and sometimes mortality.
You know, varicella is often okay, but not in the wrong person.
And the person who can't get vaccines, immunocompromised, the chemotherapy
patients, what have you, we're really doing a service to ourselves as
well as our community by becoming vaccinated . But anyway, my bias
is like, it's just chickenpox.
It'll be okay.
So I have to remind myself, no, it's not, we really do have to be careful about
once we've diagnosed it to isolate because it is like all of , the things that
we're talking about, , it is airborne.
It's airborne and droplet and it's extremely infectious , and preventable.
Sam: And much like the other viruses we just talked about, you
get symptoms for a couple of days before the rash appears, and then
the rash scabs over in about a week.
And at that point, you're finally no longer infectious when you don't
have any more vesicles that can rupture and release the fluid right.
Tim : That's exactly right.
And then just kind of again, putting on our emergency medicine hat.
You know, here we are as clinicians who are trying to make sure that
everyone is safe in the department.
Oftentimes the nurses will call me and say, Hey, this is rash.
Can you please see this person in triage?
I'll run over there verify that it may or may not be measles,
varicella, what have you.
If it is in any way, potentially chicken pox I will say okay any of the
nurses that are in any possibility of becoming pregnant now or soon, get out
of here, I will keep them away from that patient and I'll make sure that we
have the right staff, for that patient.
And I say that, and it sounds kind of like, you know, literally chicken
little falling from the sky, but wow, what an easy thing to do often.
And if I just need to see the patient myself, I will.
Because often there's not a lot of nursing intervention to be done.
I can take my own vital signs.
Sam: Yeah.
Tim : but it's something simple that we can do to really help people.
And that's, that's how serious these things are because it's not just, chances
are in emergency medicine, we often don't deal with, chances are we just say,
listen, whether or not you, you know, we don't think about necessarily population
probabilities, like how likely it is?
Does this person have whatever we go, there's a possibility.
I need to look into it.
So we really deal with this sort of catastrophic mindset because
that's what society needs from us.
So I Want to have that same mindset for our own staff to keep them safe.
Any possibility of chickenpox?
Let's keep away the nurses, clinicians, anyone around the
techs that are of childbearing age.
Let's get 'em away from Potential chicken pox.
Sam: And do you do that even if they've been vaccinated and they're pregnant?
Tim : You know, I'm just, I'm a little bit overprotective maybe, but yes.
cause you Know who Cares, right?
These people are often fine and it's something that I can do.
gonna be a good bro to everyone.
That's what I'm gonna do.
Sam: I like it.
I like it.
And you know, speaking of the possibilities.
I thought that the appendix in this article, pages 16 and 17 lists like
this is, I think 26 different conditions that can cause fever and rash.
So if you're listening, we're not trying to oversimplify this.
, There's multiple diseases that we previously had excellent vaccine
coverage for, that were on the list, but you didn't really have
to put near the top of the list.
But now we've got 26 different things that can cause fever and
rash and we're adding to it.
The three or four things that we previously could kind of go, eh, you
know, they're vaccinated, not worried about it, or everybody's vaccinated,
I'm not so worried about this anymore.
Tim : Yes.
Wow.
What a humbling reframe.
Right.
And that's why again, this discussion and this article is so important to
refresh our minds about what to look for.
, And this sort of speaks a little bit about the difference between inductive
and deductive reasoning that we have in the emergency department, right?
Deductive reasoning will often say, Hey, there's a fever and a rash.
What are the 100 things that can cause it?
And I'm gonna narrow it down with my history and physical to 10 things,
and maybe I spend some time with them, or, or intervene or test.
And I've narrowed it down to the deductive one answer.
This is what we try to do.
This is when we, admit people to internal medicine so that
they have multiple days, right?
Or pediatrics or what have you.
So, we are trying to find for deductive reason the answer.
That's it.
There's only one answer.
We often, in immersive medicine have inductive reasoning, right?
Where we say, there's certain things that I am responsible for.
I'm responsible to make sure this is not measles, mumps, rubella , it's
really important that this person with chest pain doesn't have a PE aortic
dissection and a stemi, et cetera.
How likely are any of those things just given the chances
you're gonna throw some dice?
, they're not likely, they're o ur responsibility.
So we're using inductive reasoning, the sort of sharpshooter reasoning
of you send someone to a cardiologist and what are they gonna do?
They're gonna do an EKG and they're gonna ask about chest pain.
But maybe this is costochondritis, it's the cardiologist's job
to think about the heart.
It's the emergency medicine physician or clinician's job to think about the
dangerous things, inductive reasoning.
And that's why it's just sort of weird.
You see , this long list, you go, oh my gosh.
All these things.
Yes, that is already pre-programmed into your mind as a clinician.
this discussion is more about how do I use my inductive reasoning when it counts?
Oh no, there's something that's weird about this.
I need to explicitly make myself stop and think about measles,
mumps rubella and varicella.
Oh, there no, doesn't, doesn't match any of those.
Great move on.
But this is why , that's important for us to hyperfocus sometimes and then relax
back when we haven't found any red flags.
Sam: Yeah, and I thought the author did a particularly good job of
reminding us that none of these diseases are supposed to cause purpura.
So if you see a purpuric rash, then, even if you're in the midst of one of
these massive measles outbreaks, stop and reframe and make sure you're not looking
at somebody whose sepsis has you know, meningococcemia or something of that
sort as a cause for underlying sepsis.
, The purpuric rash is not a normal complication of any one of these diseases.
Tim : Touch your patients.
Look for capillary refill.
look for blanching of those petechia and purpura.
Put gloves on 'cause you know no one likes meningococcemia.
Sam: Yes, yes.
Please put gloves on.
Okay.
Let's talk about our pre-hospital colleagues.
So, there are some who listen and appropriately are concerned about
themselves and their patients.
And so if you are an EMS colleague and you are now transporting a child
with fever and a rash or, you know, maybe not tolerating this URI very
well and seems to be a little bit more distressed than usual, and you happen
to notice a rash, what are some of the things they need to keep in mind?
Tim : Yeah, , our watchers on the wall, our front line, and these guys
have to go into crazy environments.
People are upset, there's bad lighting.
No one knows anything.
They get 'em into the rig and they turn on the lights and go, oh, no, I
just see something I'm worried about.
So, this is a good example of our continuing this conversation with our
EMS colleagues and just, taking 'em aside after they bring a patient in
and saying, Hey, how was it for you?
And giving 'em that little kind of tidbit.
If they're in any way concerned or we are concerned, we should communicate to them.
And that, in fact, I would push it even further to say that we should
make sure that their medical director.
And the EMS agency they came from knows about this because public health takes a
few days to track people down who go home.
But I want that medic to know that he maybe needs to be isolated because he
was just exposed to measles or not.
Or I just say, Hey, have you been vaccinated for measles?
And if he is, we'll wait and see.
But if he hasn't been, because there are some people, as you
know, Sam, who can't be vaccinated.
Or the vaccine doesn't take to them.
Those are the people I worry about even more.
And those are the people also can get the the post-exposure prophylaxis vaccine.
so, just kind of to answer your question though more broadly is that I think the
most important thing is that we just cultivate those relationships with the
medics that we see on a regular basis.
So they feel comfortable asking us, and we feel comfortable to say, Hey,
by the way, you know, gimme your number, gimme your supervisor's number.
I'm gonna check in with you because if I'm worried enough that this case is
a morbilliform rash that is now to the chest, it was at the face yesterday
I'm gonna call you later on with our final thoughts or stick around.
Let's make a decision right now.
Other things they could think about, of course is just this is a good
opportunity if you are interested in jumping into being more involved
with pre-hospital education.
I'd say as a community clinician, jump in, talk to the EMS agency.
Hey, can I give my little CME?
again, that, ongoing relationship I think is more important.
'cause in the hustle and bustle of what we do, you may forget, oh my
gosh, they, they're already gone.
oh no, this kid has measles.
And then you've missed that opportunity.
But if you have that relationship with people, they're much more likely
to recontact you, you recontact them and have us be a cohesive spectrum.
'cause EMS care to emergency care, to hospital care, to even outpatient
care, is all a long spectrum.
And we should all be as unified as possible.
Sam: Yeah.
And if you are an EMS person and you know, in advance you're going in
to pick up a child with fever and a rash, then, you know, a PPE an N95 is
probably called for until you know for sure what it is you're dealing with.
And then decontaminating the rig afterwards.
So you've gotten the patient out, now you have to decontaminate everything.
The viruses can live on surfaces for a short while, so you've gotta be
really good about cleaning all of those surfaces, especially if they were
coughing in the back of your ambulance.
And then having that good handoff.
I always like to get a direct report from paramedics, but it's not always practical.
Sometimes it does come through nursing channels but if at all possible
sticking around the extra couple of minutes to just make sure that the
physician has the same report, so nothing slips through the cracks.
I've found always to be helpful.
Tim : and just hearing what you're saying too, Sam, makes me think of
how many times have you been in a case where, you know, we don't have a room
and the poor medics are hugging a wall for, you know, 20, 30 minute longer.
Right.
And somebody's coughing in there.
Look, they have a rash.
It's important for us to just say, listen, maybe this is an issue.
And put a mask on everybody.
Put a mask on everybody.
And.
I love what you say about decontaminating the rig because of all of these, you
know, measles is the airborne one.
It will be suspended in the air for long periods of time.
And I would say that, I mean, I'm not an expert at this, but I would say that that
particular vehicle should probably be outta commission until they've completely
decontaminated the should be wide open.
It should be terminally cleaned.
Sam: Yeah.
Tim : But it also goes to the fact where people are always worried
about, well, what's aerosol?
What's airborne?
What's respiratory droplets, what's contact?
It's so confusing.
It doesn't do us any service to try to be so specific.
But just broad strokes, when we talk about aerosol, we're talking about
these little tiny fine particulates that float in the air measles, when
we talk about respiratory droplets.
They, you know, are spittle that just like flies on people's faces in their eyes.
Those are larger molecules, and that's where we're talking
about mumps and rubella.
And then varicella can be both aerosol and droplet.
You know, when you're in a rig in front of someone's face, in their home as a
medic or in the emergency department, one of us comes in and sees people,
there's no magical curtain that's gonna stop people from being airborne versus
respiratory droplet versus contact.
We should just treat all of these as potential airborne until we can peel back.
And so that's an N95.
And that's maybe even wearing a face shield too
Sam: Yeah.
Tim : for the high risk cases.
I'm not advocating going into every patient room with that get up, but I don't
like to try to split hairs and say, what's a respiratory droplet and what's aerosol?
You know what, when you're that close to someone's face, it's all aerosol.
And then you can kind of take a moment once you've made your diagnoses
and you can then counsel people.
You can just, you can say, okay, well, you're infectious.
You're not as infectious.
Here.
You wear a surgical mask.
You wear an n95 you go home.
You need to stay, but you need to stay in a negative pressure room.
Sam: Yeah.
Yeah.
And I'll add one other point.
If you happen to be picking up the patient and you do suspect something
like measles on the way in, notifying the ED ahead of time so you don't end
up waiting on the wall when spreading this everywhere so they can get you
directly to that negative isolation room would be exceedingly helpful.
So that, you know, somebody can get in there quickly, examine the child and
make sure nobody else gets exposed.
So on that note, they're in the ED.
We've got a bunch of questions we're gonna ask, and I thought the author
did a great job just listing them.
There's like 20 questions here.
Everything from how long have you had fever, what did the initial rash look
like, if there's already one, how did it spread from where to where did it occur
in crops or did it spread gradually?
Is it itchy?
Is it painful?
What kind of other symptoms were associated before the rash?
Are they having any respiratory symptoms?
And then kinda like screening for complications.
Are they having any mental status problems, headaches?
Are they acting funny?
Are they having difficulty walking?
They've been exposed from sick contacts at school.
Who else is at home?
And now we're kind of expanding these questions to who
else may have been exposed.
You know, is there anybody sick at home on chemo?
Has cancer, is immunocompromised or is this patient have
any of those risk factors?
So a whole bunch of questions you gotta ask for the very quick and simple,
Hey, here's a fever and a rash kid.
Tim : Yeah.
Sam: it's like, well, it's the quick and simple visit because I don't have to order
a lot of testing, but I actually have a whole lot questions I've gotta ask.
Tim : Absolutely.
And again, this is a good example of like, if you've front loaded your
mental work like we're doing right now, then it'll become natural because
you'll see, you know, fever and rash.
You're okay, you have a viral exam, goodbye, you go home but
fever and rash, and there's something in you that resonates.
There's something a little spark in you because you remember Dr. Ashoo saying,
wait a minute, ask these questions.
That's when you should stop and then try to remember what you
can and look up what you can't.
Because again, we can't remember everything off the top of our heads.
A lot of our education just goes, and our training goes back to, is there
something else that I'm missing?
And you take that pause, that moment that you have to say, is this more
than just a typical viral exanthem?
Then you start thinking about measles, mumps, and varicella.
And if it doesn't pass any of those red flags in your mind, great.
If it does.
Hey, pull up this article, look things up, ask the right questions,
because there's no way in a busy shift that we're gonna remember these
things off the top of our heads.
Sam: Yeah.
And speaking of that busy shift, your examination equally
important may occur in triage.
And it may not occur to you to check things like the inguinal area for
lymphadenopathy or the scrotal area for testicular tenderness or swelling
if you're considering orchitis.
And so some of these things may be difficult to check out in the waiting
room, and you may need to take that extra effort and go, I'm gonna bring you over
here where there's a curtained area, and then I need to do this kind of exam.
Tim : Mm.
Sam: you may get a funny look from a parent going, why are you undressing
my child who come in with a, you know, a cough congestion and a rash?
And you go, okay, well let me explain what's going on here.
Tim : We are very thorough here, ma'am.
Sam: but for the right reasons.
Tim : For the right reasons.
You know, it also goes to our dynamic approach.
We have an iterative way of seeing a patient, right?
We don't wanna anchor and say, ah, fever and we're done.
With the new information we have now, what are the new things I need to think about?
And that's a great example.
They come in and then the triage may also bias us.
Triage is meant to just say, are you okay?
Can you wait?
Right?
But we should really take that, read the nursing notes, read the triage notes.
There's lots of little nuggets that sometimes are not repeated, but
great opportunity to just rethink.
Does this make sense?
Why are you complaining of belly pain when you have a, you know, a little bit of
arthralgia and maybe a cough or something?
Oh, no, you have bronchitis as an example for mumps.
Sam: And then we talk about diagnostic testing.
We like to order a bunch of tests.
These are mostly clinical in their presentation, and if you can identify
the rash, that is sufficient, but if not, and there's a question, there
is PCR testing for these viruses.
Tim : Yeah.
You know, and just to give you a little bit of a, kind of a behind the
scenes of how we think about this when we're developing an article as editor
in chief, we wanna make sure that this is scholarly and this is very
helpful, but also practical, right?
So we are always very careful about the messaging that we have, and Dr. Cavallaro
did a fantastic job of balancing that out.
So there's a lot of good, scholarly, nerdy things that we talked about.
But when the rubber hits the road, what do you do?
It's all clinical, so that I want to be the main message.
You should trust your eyes and your ears, and if you're not sure, you can
look up different reference images.
So if at any way you're worried, treat it as if it's measles, mumps, rubella,
varicella, because these tests won't necessarily come back immediately.
However, either your public health department will ask for it or you're
just, you know, let's just put it in the record or you're not sure.
Most of these are PCR.
So for example measles is a PCR in the nasal pharynx or oral pharynx.
You can do it in measles, IGM serology.
So the IGM as we remember is the early version of your
IGs as opposed to your IgG.
the IGM is better after the rash has actually come into view.
Whereas the PCR can be at any time.
'cause as we mentioned with measles, you're infectious four days
before and until four days after.
So PCR will work for any time for measles.
The IgM is more specific after the rash.
Four, most of the time that's when you're doing serologies because you see the rash.
What i s this rash?
For mumps similar thing you can do PCR mumps again, I encourage us to look
these things up because, you know, you're you're asking me now, and I'm
telling you, you ask me five hours from now when my coffee is worn off.
And I don't know if I'm gonna tell you this, but mumps, the PCR is a
buccal swab, specifically buccal swab, and then IGM serology for mumps.
But if the person is vaccinated, it's not as reliable.
So there's all these like ins and outs, intricacies, shout out, public health
rubella similar thing is also the PCR.
You can do either IgM or IgG for rubella.
And then varicella of course is really kind of pathognomonic to be honest with
you, but you can do PCR for that as well.
Sam: Now I am curious, in your hospital you have PCR available for
these or are they all send outs?
Tim : These are all send outs for us, and I think that's true of most
hospitals, I would say, unless you're at a tertiary facility that has, you know,
research capability immediately there.
So , we send that out.
And the serologies for sure we send out.
I work in a county hospital.
We have a lot to offer, but, still , we need to send it out for
any community hospital for sure.
They're not gonna know right away, which is why I really emphasize
trusting your clinical diagnosis.
I would rather you be overprotective than underwhelmed.
It's always better to get people excited and the worst that we've
done is that we've taught the people around us to consider and just
sort of refresh the anxiety that we should have about these illnesses.
Sam: Okay.
And then there is the reporting responsibility.
So know your public health rules in whatever county you're in, but
all of these diseases should be reportable, especially, and that's
reportable based on suspicion.
You don't have to have a, you know, I am kind of hammering a nail and I've
made this diagnosis for sure, but if you're clinically suspected, that's
good enough for reporting and isolation.
And then treatment.
So what do we have in the way of treatment?
Let's just start with measles.
Tim : I'll just mention that your public health will ask there'll
be different tiers of reporting.
So measles is so bad, they need a phone call.
They need you to pick up the phone and call whomever.
There's always gonna be someone who can pick up the phone
even at three in the morning.
Something like Rubella, oftentimes, at least in Los Angeles
County, is a snail mail report.
They just kind of wanna know, just for your information et cetera.
So just be sure that you have that awesome chart plastered somewhere
on , your wallpaper of, of algorithms that you have around your doc box.
But getting back to what we do, let's say, I think this could be measles.
What do we do?
Measles, as you know, is going to be supportive.
In developing countries the morbidity increased with people who don't have
a lot of vitamin A in their diets.
And so the idea was in these resource countries, vitamin A supplementation,
that recommendation I've seen shift to the point where give vitamin A for anybody.
, And that's fine.
It's not going to save lives, but it may make them feel better.
It's just two doses, 24 hours apart, boost up their vitamins.
It's good for you.
I do have a really just brief case of this.
Family came in, in Los Angeles County we have people come to us
from all over the world all over the nation, come and go all the time.
So we're always sort of thinking about these things.
Family came from Pakistan.
They were so worried about measles.
No one had been vaccinated.
And I'm saying, ma'am, can I ask why are you, what is your concern?
And the child had had a rash, you know, two weeks ago in Pakistan.
That is completely resolved.
And just wanted us to make sure that it wasn't measles.
And I'm thinking to myself, okay, you know, I'm gonna try my
best, but I can't see anything.
She was so anxious that I said, listen, the only one thing that I
can do based on where you're coming from is to give you some Vitamin A.
And she was very happy with that.
Right.
Got her, got her door prize for coming in the emergency room department.
Everyone's great.
And , I wasn't concerned.
What she was describing did not seem to be something that I would associate
with measles, but it also keys into our anxiety that we've been talking about.
So the funny little twist to the story was that an old school pediatrician
later on saw this patient and chastised me for giving her vitamin A because
there's no evidence, et cetera.
And I, I just go, okay, great.
Like anything in emergency medicine, I'm happy to be wrong.
Or not, I'm happy to be criticized or not.
I'm just trying to be the best I can with what I got.
So a little bit of Vitamin A can't hurt you.
It really won't save you.
But , the thing to really think about is the post-exposure to
people who have not been vaccinated.
So if you have never been vaccinated, and let's say, I'm gonna make up the
scenario you know, little Johnny is three, has measles is okay to go home,
but his sister is five years old and no one's been vaccinated in the family.
She should get the MMR vaccine within 72 hours if she's an
otherwise healthy person.
Now we worry about people who can't get the vaccine, like for example
the immunocompromised, et cetera, or infants less than six months of
age they should get the IgG because that's gonna be more protective of
them, the immunoglobulin six months.
So, just to back up a little bit, you know, your first dose, you
typically get as an infant from 12 to 15 months, and that's gonna be
a really robust immuno response.
Your second dose is gonna be a booster in four to six years.
There are some people that can get it.
If there's an outbreak, you can get it you know, at six months of
age is early six months of age.
And that's really the earliest we'll often give it, but that first early
dose, as an exception, doesn't count as part of the two dose regimen.
So the idea is that infants just don't respond as well to the vaccines.
These things are all very calibrated over time.
We should really trust our decades of experience on this.
So if the kid comes in, let's say this is another case in which there's
international travel or an epidemic and someone's really interested in
getting it as an infant at seven months, eight months of age, 10
months of age, that's that's fine.
And that's okay.
It'll cover them probably for a few months, but they still should go
back on the regimen of the 12 to 15 months, first dose and their second
dose at four to six years of age.
So, to answer your question, more mostly supportive, but all of those
little intricate questions, as you mentioned in the appendices, make
sure that they get their follow up.
Make sure that you've kind of thought about this person thoroughly
and whoever else is in the family.
And then think about just, you know, good hydration.
That's the number one thing that's gonna hurt people that
are well enough to go home.
And then secondly is to make sure nobody else needs a post-exposure mMR vaccine.
Sam: Okay.
Two things, two questions.
First on the vitamin A issue.
So, if you're gonna provide some kind of supplementation, you do also have
to warn the family that they shouldn't overdose their child on vitamin A.
That's one of those that can be toxic,
Tim : yes.
Sam: and can build up.
So very important to mention that.
And then second, the IgG, like this immunoglobulin is not, I mean, I haven't
never actually asked my pharmacy to see if they even have it, but is that
something that's difficult to get or do you have to get that from like the health
department or where does that come from?
Tim : immunoglobulin, Is good for Kawasaki disease.
It's good for, you know, any of these things where you need to have a
biochemical mop in your blood, right?
Just like mops up all the junk.
Right?
So, it's available in many hospitals.
Sometimes if you have a, let's say a smaller community hospital, oftentimes
they'll have a network where the pharmacist can call either a satellite
pharmacy or an affiliated institution.
And you can have that shipped over within hours.
I wouldn't let the person go until they've gotten it.
So immunoglobulin it does cost $10,000 a shot, so you wanna really think about it.
But it's important in the people that are vulnerable.
But it's not so uncommon, Sam, it's not such a weirdo thing.
It's just something you gotta ask for.
Sam: Yeah, and this is not immunoglobulin that's specific to measles.
It's the generic immunoglobulin you'd give for multiple other
conditions, and Hopefully it's got some antibodies from measles in there.
Tim : that's right.
Sam: Perfect.
Tim : Infectious mop,
Sam: Okay.
Mumps.
So again, no treatment for mumps.
This is kind of one of those things.
You diagnose it great, but we don't have anything we're gonna
do to make it go away any faster.
Right.
Tim : Yeah.
Don't take any family photos in the next couple weeks.
Basically, you're gonna have a pretty swollen face, but it's supportive.
It's, you know, NSAIDs, it's lots of fluids.
You could try ice packs.
Although, you know, depending on how old the child is, they
may or may not tolerate it.
Sam: This is ice packs to their face.
Tim : Ice packs to the face.
You could even do ice packs to the groin.
No one likes any of these things, but you just do the best you can.
You could if it's really bad orchitis you could also wear, like, for example,
a jock strap, something supportive for males , and really just kind
of, you know, weather, the storm.
Sam: And no steroids.
Tim : and no steroids.
No steroids.
Yeah.
That won't, that won't help them potentially harm.
Sam: Okay.
Yeah, and I saw that the author mentioned the steroids might actually
decrease testosterone concentration and worsen testicular atrophy,
which kinda seems like a big deal if you're already concerned about that.
Tim : we need you to be strong like bull.
Sam: Yeah.
Uh, Okay.
Then rubella again, no treatment.
Just supportive care.
And make sure you isolate the people who are most at risk.
Tim : yeah, that's right.
And you know, full disclosure, I don't know that I've seen
a case of rubella either.
And again, it's not as common in this country, and maybe I called
it measles and it was rubella.
But it is reported to be a much milder version.
And for any of these children, I just worry about their hydration status.
So , that I think merits a quick, just a little discussion.
I think a lot of times people come to us in emergency care and they
just, even though we feel like it's obvious or pedantic or like too much,
you know, they just feel reassured.
We're like, Hey, listen, this is what I want you to do.
I want you to take a tablespoon of apple juice mixed with water,
and I want you to give a little sip every three to five minutes.
Or, what's a sippy cup?
What do they like to have, you know, or even like, Hey, will this child
take a popsicle great anything to get hydration in this child because of any
of these really inflammatory diseases, the child is gonna feel you know,
fussy and really cranky and not want to take in, and it's the dehydration
that hurts a lot of these children more and faster than anything else
Sam: Fantastic.
Okay.
And then Varicella.
So this is one where we actually do have a treatment that might be indicated, right?
Tim : we do.
And, you know, again, I always look this up because I feel like it's
changed over time and I will not try to.
commit it to memory.
Having said that, though Sam most cases don't need anything, really.
It is mostly supportive care.
But again, I, will look up myself this article and say, Hmm, what are the
indications for, for varicella treatment, 90% of the cases are gonna be isolation
Don't pick at the scabs, wash your hands.
Can't go back to school until all of the pimples are scabbed over.
Don't share toothbrushes like a, you know, a chicken pox party.
And that's pretty much it.
Sam: Perfect.
Okay.
And in the article, it looks like the author has said that the children at
highest risk who might be candidates for post-exposure prophylaxis are the
children who are unvaccinated and age over 12 in persons who are pregnant in
people who have chronic cutaneous diseases or chronic pulmonary disorders or those
with exposure, interestingly to long-term steroid therapy or salicylate therapy.
So,
Tim : yes.
You know, the older that you are when you first have varicella
chickenpox, the more miserable you are and the sicker you can get.
And again, like in a weird epidemiological way, the older
people before the vaccine have robust immunity because they got chickenpox
and they mostly did okay with it.
Uh, I wonder what it's gonna be like, and I don't know the answer
to this, but, you know, the MMRV is only a couple decades old.
And so I'm wondering what we're gonna see in the next 10 to 20 years when
these mostly millennials have gotten the MMRV and Gen Z, et cetera, and
they, in their middle age, how they're gonna do, because when they do get
chickenpox, it's the attenuated version.
It's a very mild version of it.
And sometimes it's hard to say, like, is that chickenpox?
And again, it's just trying to be more sensitive than specific.
, It's still important to go through those lists of risk factors as you
mentioned and verify and, I would err on the side of treatment, especially
since a lot of these diseases as they should be more and more rare, I think
that we should not kind of like rest in our laurels and say, it can't be fill
in the blank because fill in the blank.
We should just be open to it.
And I would rather over isolate overtreat over vaccinate because
they're becoming more rare.
Hallelujah.
But that means that we can let our guard down.
Sam: Perfect.
And this is one of those diseases where you can get post-exposure
prophylaxis with the vaccine.
So if you are un immunized age over a year and you've been exposed, you
have, you know, three to five days to go and get a vaccine and hopefully
prevent you from getting the illness.
Tim : That's right.
Again, that, that's gonna be a little tricky because, in a perfect world someone
who has, you know, great insurance, everything works out great for them.
they get in to see their PMD within three to five days?
Maybe, maybe not.
And so we have to rethink like uh, is this plan gonna work?
And, I'm not a big fan of doing things that are not necessary
in the emergency department.
And sometimes, you know, giving vaccines and all this kind of stuff is like,
oh, I've lost the opportunity for that primary care longitudinal care.
But this might be the case in which you say, let's order that vaccine
in the ED and just get it done.
Sam: Yeah.
Tim : make sure that I've written a little note or make sure they've communicated
that to the primary care physician.
This is what we did.
Please make a note of it.
Please update the vaccine record.
Sam: All right.
And on that note, there has been a lot of discussion, especially recently about
adverse events associated with vaccines, and I thought the author did a pretty
good job of tackling that in the article.
Where does that controversy come from?
What does that controversy surrounding you think?
Tim : Oh, we all know about our buddy who loved to have a falsified
article about autism I won't give, won't breathe life into the name.
But that's where that comes from, number one.
Number Number two, I think this also, I don't wanna get too philosophical with
you today, Sam, but think this also just goes to our role in our patients' lives in
public health and in the larger discourse.
I think it's important for people to see us as fighting for them
and individuals and not having any particular you know, espousing certain
beliefs or certain sides of whatever.
I think we just need to go like, what does this patient need in
front of me and just follow suit.
But we've broken trust, I think with , a lot of the public and
they don't believe us because they get news from different sources.
People don't believe.
They believe their own family who might have different ideas.
And that's, for pro and con.
They can be way too pro, like everyone needs all of these extra vaccines
and maybe they do, maybe they don't.
long story short, I would say this there is skepticism and that ties
into what I was mentioning before about our interaction with patients.
People need to see that we're there for them and that we're not there for a cause.
We're there for them.
And the reason I'm worried about you is because you as an individual
can get really hurt by measles mumps, rubella and varicella.
And I'm glad that you came in.
I'm glad today it's not measles.
But I'm glad today that we had a discussion because I would never want
you to have to go through what people went through, what our, grandparents,
great-grandparents had to go through.
We are so lucky.
This is a great opportunity.
I want you to talk to more people about it.
I encourage you to talk to your physician about it.
And I just kind of leave it at that.
'cause I wanna be seen as an asset.
I don't want to be seen as somebody who divides.
I wanna be seen as someone who can be supportive of them.
And I have to kind of navigate that discussion.
Again, this is just me, Sam, and i'm interested to see what your
thoughts are on the interaction.
But, you know, that's my strong feeling is that I do my best
to give what that person needs.
Do they need my heart, my head, or my hands.
And I try to fill in that blank as best as I can.
And I think people, when they see that you have good
intentions, they'll listen to you.
When you are just sort of speaking kind of at them, I don't know
how much they're gonna listen.
Sam: Yeah, I've always found that the strongest thing I could ever
say in that scenario was that all my children were vaccinated.
And I just kinda leave it at that.
I go, you know,
Tim : same here.
Sam: I do it for my children, so I would do it for anyone else's child.
Tim : I love that.
Sam: I think the author did a really good job of kind of just laying out the
evidence there, talking about things like febrile seizures and are they more common
with the MMR or the MMRV, you know, should a parent decide to split the MMR , from
the Varicella component and do those in two separate, you know, as long as you're
getting the vaccine, I don't really care.
It just means more trips to your pediatrician and maybe less compliance.
and then I thought the author also did a great job of just kind of
laying out the controversy there around autism and vaccines and the
history of it and all of the things that happened around that one article
that was redacted and the author who eventually had their license suspended.
So it's a great section to read.
It's good for your own education if you're a listener to understand
the history of that argument.
And then, you know, it gives you something to say about how the House of Medicine
responded to it which I think is helpful when people are genuinely concerned
and want to have a discussion about it.
Now, if they don't wanna have a discussion about it, there's no point
in reiterating all that information.
But if they do, it was a helpful section.
Tim : Well, you know, what would Mark Twain say?
He would say that a lie can get halfway around the world before
the truth puts his shoes on.
So , the damage is done.
And I think we need to recognize that.
And again, our personal relationship with patients is helpful, and I love that idea.
My children are vaccinated, your children.
I mean, it's a great way to connect that way.
Now, that's not to say that of course, MMR does have a big immunogenic response.
There's some kids that come in and I see after they got their MMR, their
whole little chunky thigh is red.
That's normal.
That's okay.
That's what we expect from MMR whether we separate or not.
You know, that's okay.
The old school pediatricians will say it's better to have just one bad day
than a multiple semi not good days.
Meaning you know, It's not fun to have a shot, then you might get
a little mild fever, et cetera.
That's normal.
That's good.
That means your immune system's working is so great that your immune system
says, I'm gonna do something with this.
That's a great thing.
So I think kind of normalizing what we expect contextualizing
for patients without overselling it, just balancing out the best.
And again, like there's some people who are like to have very niche vaccine
schedules and they have some conflict.
They check the star charts and the moon charts and decide when it should happen.
You know what, God love them.
As long as they get longitudinal care and they get it in, great.
I won't opine on that.
I'll just say, listen, there's a reason why we have a schedule.
It's cool.
Just keep going.
It's fine.
Sam: Yep.
All right, well that brings us to the end.
If you are listening and you are a subscriber, then this is the
peds EMP November, 2025 article.
It's got figures, pictures of the measles, the mumps and the rubella rashes.
The neonatal complications.
You can see common presentations and the exceedingly helpful appendix
of differential diagnosis for fever and rash on pages 16 and 17.
I highly recommend you just kind of keep this article close at hand.
There's so much information packed in here that it would be exceedingly
helpful the next time you see a child with fever and a rash.
And I wanna say thanks Tim for being on the podcast.
Tim : Sam, thanks for having me.
Been meaning to come on for a long time.
I'm glad we finally got a chance to connect and I love what you're doing.
Keep it up.
Sam: Yeah.
Thank you very much.
This is a exceedingly important topic and definitely something
we're gonna see more of in the ED.
Before we leave, tell me about your podcast.
Let's hear about it.
Tim : you.
Uh, The Pediatric Emergency Playbook.
So I'm your host and coach there.
We do a monthly podcast where I think of this way of all the things
that I keep telling my residents and fellows and lecture about.
I go, wow, wouldn't it be nice if I just spoken to the mic
as if I'm talking just to you?
And I say, let's talk about, we just had a talk on congenital heart disease.
So , I try to make it, you know, a bit of a conversational type of tone.
I try to bring up cases, bring up the latest research, I tell
you what is established research and what is my practice and I
just wanna get it out there.
It's in a 152 countries out there in the world, and I love that
I'm able to just shout it out.
It's so amazing, and you get the same thing too Sam, is that you get people
from all over the place saying, I listened to this and I applied it the
next day, and it's just so fulfilling.
Please have a listen or tell me what you'd like to hear more of, less of.
And I, I'd love to be there to meet your needs.
Sam: Awesome.
And we'll put a link to that in the show notes.
If you are not a current listener, I'd highly recommend you go
become one and improve your pediatric emergency education.
Thanks again for being on the podcast and until next time, be safe everyone.
And that's a wrap for this month's episode.
I hope you found it educational and informative.
Don't forget to go to ebmedicine.net to read the article and claim your CME.
And of course, check out all three of the journals and the multitude of
resources available to you, both for emergency medicine, pediatric emergency
medicine, and evidence based urgent care.
Until next time, everyone be safe.