Sometimes we doctors are prone to do too much to our patients, especially in high-tech environments like the PICU. The bewildering array of all the tests and therapies we have can confuse us more than enlighten us. Robert Loeb, a well known physician and medical educator at the College of Physicians and Surgeons at Columbia University long ago offered a simple way to cut through all the confusion, offering what have come to be known as Loeb’s Laws. We all learned them in medical school, but now and then need to be reminded of them. Here is one formulation of them:

1. If what you are doing is doing good, keep doing it.
2. If what you are doing is not doing good, stop doing it.
3. If you do not know what to do, do nothing.
4. Never make the treatment worse than the disease.

Dr. Loeb was not a surgeon, so one occasionally hears a tongue-in-cheek substitution of his fourth law that goes something like this: “If at all possible, keep your patient out of the operating room.”

Sixty years later, Dr. Loeb’s wisdom is still often useful.

Offhand you would not think a child with severe viral pneumonia and one with a major head injury are much alike, but they are. Together they illustrate a great truth of pediatric intensive care medicine, which is much of what we do is not specific treatment for the child’s problem; rather, it is what we term “supportive care,” because it supports the continued functioning of the child’s vital organs and systems while the problem runs its course and the child heals.

Both of these children often require very sophisticated technology to provide that organ support, things like mechanical ventilators and devices for measuring pressures inside the brain, but that technology doesn’t actually cure anything. But if it doesn’t cure anything, what does it do?

One of the most important principles of supportive care in the pediatric intensive care unit is that we make sure what we are doing does not make the problem worse. A good example of that is the child with a severe head injury. Although there are a few things we do to help the situation, a key aspect of what we do is the maneuvers we go through to make sure the brain is given a chance to heal without further stresses. For the child with severe pneumonia, the sort of child who is often on a mechanical ventilator machine, we do a similar thing — we use the machinery in such a way to minimize the chances that the ventilator itself does no harm, although this is not always possible.

This kind of watchful waiting at a sick child’s bedside is something parents have done for millennia. What the PICU often offers is simply an updated version of that time-honored vigil.

Adolescence is a tough time of life for many children — and their parents, too. Being a teenager is difficult enough without also having to deal with a chronic illness. One of the most common serious chronic health problems of adolescence is diabetes.

Diabetes, or diabetes mellitus as it is formally called, is a disorder of how the body uses energy in the form of glucose. For your body’s cells to use glucose they need the hormone insulin, which is made in the islet cells of the pancreas. If there is insufficient insulin present, the amount of glucose in the blood goes up, and this can lead to a host of acute and chronic problems. There is an enormous amount of educational information available on the internet about the two most common forms of diabetes, so-called Type 1 and Type 2. In the first of these the body has a total lack of insulin; in the second the body is resistant to the effects of insulin. I’m not writing about what diabetes is; if you want more information, here and here are good places to start. I’m writing about some of the special challenges faced by adolescents who have diabetes.

I often see adolescents with diabetes in the PICU. The usual reason for this is their blood sugars are out of control and they develop an acute derangement in their blood chemistries called diabetic ketoacidosis, or DKA. The condition can be life-threatening. Most of the time their diabetes is out of control because they are not taking their insulin correctly; sometimes they are not taking it at all.

It is a cliché of psychology that adolescents regard themselves as immortal, which is why they can do dangerous things without worrying about the consequences. They are also establishing their independent, unique selves as adults but are simultaneously obsessed with being like everybody else. For teenagers with diabetes, having to take insulin every day is like being reminded every day they are not like everybody else, and that they are mortal because they need to take insulin to stay alive. More than a few rebel by refusing to take care of their diabetes. When they do that they often end up seeing me and my colleagues in the PICU.

This mental stage, like all those of adolescence, mercifully passes with time. But meanwhile teenagers with diabetes can do themselves serious harm. Parents of these children often become extremely frustrated with the situation, but it does pass. Our goal is to get them through it as best we can, recognizing that ultimately the emerging adult will need to be entirely responsible for his or her own health. If you are interested, you can read more about many of the psychosocial issues confronting children with diabetes and their families here. If you are a parent of such a child — it will get better.