In the “normal” range

Over the past 4 years, I’ve been trying to write a PhD thesis that’s vaguely related to patient safety, but was really an excuse for me to go to talk to lots of children and families about life. (I got some great book recommendations, a fair few cat snuggles, and some really good apple cake along the way). I’ve also continued working as a paediatric registrar.  And along the way, as this blog has made clear, I’ve had some professional/emotional/personal questions.

But now I have a really simple medical one: how do we use “normal” values if they’re not “normal” for you?

Patient safety initiatives tend to look at deviations from normal – such as a higher than expected mortality rate – and then investigates the reasons for these deviations.  Medical interventions to improve patient safety have tended to do the same, such as asking patients to report deviations from their expected care (“have you washed your hands?”)

One of the big things that’s come out in paediatrics over the past few years is the development of early warning scores.  These use the routine observations that are recorded by healthcare staff (temperature, breathing rate, heart rate), compared to a chart of what the normal values for that age-range are.  Deviations outside the normal range score a point, and a high score acts as an early-warning/alert system that something might be wrong.  There are lots of different variations, but that’s the basic premise.

For many children, that works well.  But what if the charts of “normal” values aren’t the “normal” for that child?  What if your child doesn’t normally get a temperature when they’re unwell?  What if they usually drop their body temperature when they get an infection?  What if their normal body temperature is lower than average, and so when their temperature is in the “normal” range it’s actually not normal for them?

None of these children would raise any alarms on a warning score based solely on “normal” values.

But maybe I’m worrying about nothing, right?  After all, normal values are used because that’s where most people fall.  Most children will have a normal body temperature of 36.5 – 37.3 celsius when they’re well, and will develop a fever with infection.

So, why does it matter?

It matters because the children who don’t follow these “normal” patterns are arguably the most at risk.  They’re the children with complex medical conditions, maybe without a clear diagnosis or idea of how their disease journey will go.  And as healthcare improves, and we see more and more children who’s bodies behave differently, then making sure we don’t miss the warning signs becomes even more important.




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