The Running Of The Bulls

I was checking out The Running of the Bulls on the internet yesterday.  If you haven’t heard, that’s a festival in Pamplona, Spain where they set bulls loose in the streets of the city. Thrill-seekers get chased by the bulls, and every year the news shows someone getting gored by a bull’s horns and/or stomped on.  I found one site titled, “Running of the Bulls with Families,” and did a double-take.  They let kids run with the bulls too??!!

Fortunately, that website said children aren’t allowed in the streets when the bulls run, and discussed how families can reserve a balcony to see the fun.  It reminded me of our own Louisiana version of Running of The Bulls with Families which I call “Letting Kids Drive ATVs.”

ATVs (or 4-wheelers) and bulls have lots in common.  They are both over-powered.  Like bulls, ATVs are designed to go off road and pull farm wagons.  That requires a lot of power, too much for young children to handle.  Also like bulls, ATVs are difficult to control.  ATVs have high centers of gravity and go fast, making them easy to roll over.  They require hand-eye coordination and anticipation of hazards that children don’t have, which is why we don’t let kids drive cars before age 15.

And yet many parents put their children on ATVs anyway.  They even make 4-wheelers for kids!  I have treated ATV drivers as young as 5 years old in the Emergency Department.  It boggles the mind that these parents don’t see the potential for injuries.  Kids fly off them and hit their heads, sometimes sustaining severe brain injuries.  Kids roll the things, the heavy machine tumbling over the child, maybe causing organ rupture and internal bleeding.  Kids zip past trees and posts, smashing hands and ankles, knees and elbows.  Children who lose control sometimes run over their friends.

I have seen all these injuries in all degrees of severity. I have seen ATVs put children in the Operating Room and in Intensive Care.  I have warned in this blog, in the newspaper, and on TV about letting kids drive them.  Yet some parents can’t stop from indulging their children with 4-wheelers, no matter what experts say.

In fact, Federal Consumer Product Safety Commission (CPSC) seems to have given up cautioning against putting kids on ATVs, and instead has posted recommendations for “safe” ATV operation for kids.  As I list these recommendations, it feels like giving children safety instructions on smoking cigarettes (“Hey kids, be sure to smoke only filter tips!”).

The first tip on the CPSC fact sheet is to stay off paved roads.  ATVs are for off-road.  They go too fast, get harder to control, and are easier to roll over on pavement.  Also, roads are where the cars and truck are, and I’ve seen too many kids crash into the bigger, faster moving vehicles.  Another tip: never allow children younger than 16 on adult ATVs.  The CPSC states that more than 90% of child ATV injuries happen when they drive adult machines, given kids’ lack of size and developmental skills.  Thus companies make ”age-appropriate youth models.”  (Maybe It’s time cigarette companies come out with age-appropriate youth models too).  To be fair, the kid models have adjustable speed limiters, making it harder to go unsafe speeds.  Please keep the adjuster to a safe setting!

Kids (and adults) should wear helmets, goggles, gloves, long pants and sleeves, and over-the-ankle boots.  Going off road means tree branches, fence posts, and rocks, so wearing that stuff makes good sense.  Allow only one rider on single-rider ATVs.  Safe operation of ATVs requires the driver to be able to shift weight freely and a passsenger gets in the way, increasing the risk of roll-over or other crashes. Finally, if you must let your child drive an ATV, get them training!  Deaths and injuries happen when inexperienced drivers lose control, get thrown, roll over, or run into things.  Hands-on training can help your kid avoid bad situations.  FInd a course at the ATV Safety Institute, the ATV dealer, or the National 4-H Council.

Even better, save lots of money and heartache by getting your kid a really good bicycle instead.

Let’s Go For A Swim!

This week’s guest columnists are Dr. Kevin Morris and Dr. Richard Pearson, Family Practice residents at the University Health Center here in Lafayette.  Dr. Morris is a former paramedic, and knows of what he speaks:

It’s warming up and sunny, let’s go swimming!  ”Rescue 51, respond to the swimming pool in the Sunset neighborhood, 3 year-old drowning.”  This request no paramedic likes to hear.  Upon arrival, the girl is found lying next to the pool, having been pulled out by her parents.  She is unresponsive and has no pulse.  We work frantically to save her.  The family tells us they were having a reunion, with twelve children and thirty adults.  No one saw her go into the pool.  This potentially tragic event is avoidable, with simple steps.

As temperatures rise, we begin to think about staying cool and having fun.  Both needs are met by jumping in the pool and we’re all for it!  It’s great exercise and play, and gets the kids outside.  And they certainly can’t bring a phone or video game in with them!  However, we all need to be aware of the danger.

According to the Centers for Disease Control (CDC), every day two children in the US die from drowning, and another ten go to the Emergency Department for non-fatal submersion.  Drowning is the second leading cause of death in ages 1 to 14 years, only behind car crashes.  There are many, easy ways to dramatically improve safety.

One of the most common reasons drownings occur is a lapse in supervision.  We all enjoy the poolside- barbequing, drinking, visiting, swimming, and making big splashes. All this distracts from the young non-swimmers.  When children are there, it’s important for one supervising adult to be distraction-free to watch the kids. The American Academy of Pediatrics recommends “touch supervision,” meaning that children are always within touching distance at the pool.

When it’s a party at the pool with adults and kids milling around, it’s impossible for any adult to stay 100% vigilant.  That’s how tragedies like our child above happen, even with a designated watcher.  Therefore life jackets are great for non-swimmers in the group. They are easy to use and really help.  Air-filled toys and “floaties” are adorable and fun, but just aren’t safe enough.

The girl from above had been at a pool that was fenced, but went through the gate unnoticed.  It’s not unusual to accidentally leave a gate open, so a self-closing and self-latching gate may save a life.  Sometimes children impress us with their craftiness and do things we never thought possible, like opening “child-proof” locks. Thus the gate latch should be at the top of the fence where small children can’t reach.  Also, pool fences should be on all four sides of the pool: having the pool open to a patio door invites disaster.  To see what your pool fence and gate should look like, check out hotel pools- many have great fence systems.

One of the best ways to protect children from drowning is teaching them to swim. Kids who have formal swimming lessons are safer from drowning.  Lessons are recommended for age 5 and up, but can be started earlier depending on the child’s maturity. The Boy Scouts have one of the best swimming programs, because it drills kids in pool and water safety as it teaches the actual swimming.

A word about another big group at risk for drowning: teenagers.  Teens, like toddlers, are natural risk takers.  They don’t think ahead, and spend time with their friends at bayous and lakes.  They may be drinking, jumping into unknown bodies of water, boating, and yet not know how to swim.  No teen should be at a pool, lake, bayou, or any body of water without being able to swim.  Talk to your teens about safety- not drinking, wearing life jackets, and not diving into shallow water, or water where you can’t see the bottom. Here in Louisiana everyone has a tragic story about water and a careless teen.

With these simple steps, playing in the water can be much safer for the kids and less stressful for parents.  Get out, stay active, enjoy the weather, and laissez les bon temps rouler!

Music and Medicine

Medical school applications require an essay and most pre-meds write about “why I want to be a doctor.”  All those missives begin to sound the same and can really bore the med school admissions committee.  When I applied back in 1984 I wanted my essay to be different, so I wrote how being a violinist would make me a better doctor.  I was proud of that little composition and wish I still had a copy.  Needless to say, I got in.

The gist of my essay was that learning and playing an instrument requires hard work and concentration akin to learning medicine.  However, while medical practice can drain one’s energy and soul, playing music can restore these, and help the practitoner cope with a career that often involves despair, tragedy, and death.

Music has health benefits for the patient as well as the doctor.  Music and our lives are already intertwined.  We listen to music while we work, in our cars, while we exercise, and then when we go out.  Movies, television shows, plays, and video games all have music accompaniments.  It’s no surprise that there are myriad interactions between music and health.

The health benefit of music starts with babies, even premature ones.  Infants in the Neonatal Intensive Care Unit are born to a noisy place- the hiss and whir of machines, the babble of doctors and nurses and therapists, the beeping of alarms.  These noises are stressful to babies that should otherwise be hearing a mother’s voice and lullabies. Indeed, researchers have found that playing music to premature infants soothes their vital signs and improves their eating and sleeping patterns. The music also soothes the stressed parents huddling around the isolette.

Beyond infancy, music has many other health benefits.  Science has shown that music can help treat depression (though probably not with “death metal”), reduce anxiety in patients before surgery or in the emergency department, and even improve the body’s immune function.  Music sometimes works better than medication to relieve anxiety or chronic pain.

Learning music also improves concentration.  Just look at the faces of kids learning a new instrument and you’ll see.  When I was first learning the violin, I used to play with my mouth wide open, partly from concentration, partly so my jaw would hold the instrument under my chin.  I looked like I was being constantly surprised.  My teacher at the time did me one better- she told me she used to drool on her violin, so busy was she with the notes and the fingers and the bow!

Music-improved learning starts, like with our premature baby from above, in infancy. Researchers have found that hearing music enhances a baby’s language acquisition.  It seems that infants hear people speaking like they hear music- they listen to patterns and tone rather than listen for meaning.  Only later does the meaning of words and inflection get attached to the sound.  And the more sounds, music or talk, that a baby hears, the faster their brain gets at interpreting the sound.

When kids get to school, music remains an important aid to learning.  The National Association for Music Education lists 20 benefits of having music education in school. Here are the ones important to me as an Emergency Department doctor:

1.  Stress Relief- whether the stress is in me, or in the many patients I see with anxiety and depression; music soothes, and playing music soothes even more.

2.  Playing music improves coordination- I was a klutz as a kid and was always getting hurt.  Learning an instrument teaches a kid to concentrate on coordinating his body as much as learning a sport.  Better coordination and fewer accidents mean fewer broken bones and lacerations in the ER.

3.  Playing in a band or orchestra leads to success in society- playing together requires teamwork, and band members learn to get along and belong while making music. Students in band or orchestra are more likely to be successful in life, and less likely to abuse drugs or alcohol.

So let’s keep music education strong in schools.  Not every kid can afford private lessons, and learning music helps kids be smarter, healthier, happier, less stressed, and more capable.  That’s certainly as important as math, US history, and football.

Feeding New Babies New Foods

This week’s guest columnist is Dr. Nichole Miller, a family practice resident at the University Health Center here in Lafayette.  Dr. Miller has a four-month old baby, and know of what she speaks:

Brandon’s mom was excited, her baby is 6 months-old, sits up without much assistance, and is now interested in food.  Great!  What a big step in little guy’s development.  But now: “Which foods should I start with?  Is he really ready to eat foods?  What if he has food allergies?  Sheesh, why is it so complicated?”

Every parent’s journey includes the exciting time of feeding foods for the first time.  This new adventure comes with those questions.  According to the American Academy of Pediatrics (AAP), babies are ready for solids when they can hold their heads up, sit with minimal support, and open their mouths to food.  Easy enough, right?  But again, what foods to start?  Start with simple puree foods, like baby cereals.  Vegetables should come before fruits.  No highly allergic foods, like foods containing peanuts or egg.

Give one new food at a time and wait three days before introducing another new food.  This helps identify any food allergies your child may have- if baby starts with a bad rash, vomiting, or diarrhea after eating that new food, stop serving it.  If you give new foods too close together, you can’t know which one caused the rash.

Let’s fast-forward: Brandon is now one year and his mom is at the next hurdle, the picky eater stage.  Every parent worries about picky eaters.  The AAP reminds parents that toddlers sometimes just aren’t hungry.  Brandon may eat all his breakfast and not touch lunch or dinner.  Instead of fighting about food, offer a variety of foods and let your toddler choose.  Whatever he doesn’t eat, offer it at the next meal.  Remember the four main food groups: meat, dairy, fruits and vegetables, and breads and cereals.  Offer items from each group.  Avoid highly processed foods, which means foods which are highly packaged and have ingredients you can’t pronounce.

That covers the “do’s” of feeding toddlers food, let’s talk about the “don’ts.”  Say Brandon still won’t eat any foods, only drinks milk.  Milk is good for a kid, right?  So mom feeds him all the milk he wants- four 8-ounce bottles per day.  Since he won’t eat meals, she lets him snack all day.  This is common with new parents and toddlers, and reveals three don’ts.  First, no bottles after one year- kids should drink from sippy cups.  Second, toddlers shouldn’t drink more than three 4-ounce cups of milk per day- more than that kills their appetite for foods, and filling up on milk robs a kid of important food nutrients.  Finally, snacking also kills appetites for meals, and snack-grazing behavior contributes to obesity.

However, Brandons’ parents read our blog and he is eating a variety of foods and is doing great.  Now Brandon’s dad offers him grapes.  He eats one and begins to choke.  Mom panics, pounds him on the back, and he coughs up a barely-chewed grape.  Many small firm foods are choking hazards for toddlers because they don’t know how to grind their food while chewing.  The AAP recommends the following foods be avoided: un-cut hot dogs, hard candies, nuts, peanut butter chunks, popcorn, seeds, whole grapes, and the like.  Parents should take a CPR class to learn choking management like the Heimlich maneuver.

Another food concern is eating things that aren’t food.  Say Brandon is now 7 years-old and in T-ball.  He just finished a game and is enjoying some sunflower seeds like real baseball players.  However, unlike the guys on TV, he is swallowing the shells with the seeds instead of spitting them out.  The next day, Brandon has terrible pain when pooping.  The pain gets so bad he’s brought to the Emergency Department.  On x-ray, we see the shells stacking up and forming an impaction in Brandon’s rectum.  Also, the shells’ sharp edges hurt like broken glass.  Brandon has to go the Operating Room to get the horrible impaction out.

Parents, never let your kids eat sunflower seed shells- just the seeds please!  Leave the shell eating-and-spitting to the pros, who get paid to do that on TV.

Teen Pregnancy- A Big Accident Waiting To Happen

She really was in a fix.  She spoke only spanish.  She was a teenager alone in this country with only her father, and he was pretty mad right now.  She was having belly pain and didn’t understand why- until I broke it to them that she was pregnant.  She would come to the Emergency Department two more times that month with the same complaint- pain and nausea.  After making sure the pregnancy was okay, I would again explain that this is how pregnancy is.

Sigh.  If only more teenagers would know this before they got pregnant.  Most teenagers are told at least once about the chores of pregnancy- pain, nausea, weight gain, fatigue. And about that screaming, pooping baby after.  But alas, teenagers aren’t good listeners.  Like toddlers, they are better explorers, and have to try things out for themselves.  But unlike toddlers, they get to try driving fast, drinking alcohol, staying out late, and sex.

Some parents abet their teenagers’ exploration.  These parents explain this way- better that my kid tries these things at home where I can monitor their safety.  They let their teen and friends drink at home, stay up, and even have a live-in boyfriend or girlfriend.  They believe this makes a friendly relationship with their teen, and they can be there when the teenager fails.

Unfortunately, with sex, the failing is pretty hard.  When a teen drinks too much, they usually can sleep it off and weather the hang-over.  When my daughter missed a turn and skidded off the road into a ditch, she was unhurt and it was only a bumper repair.  But when a teenager gets pregnant, the aftermath isn’t so easy.  Pregnancy is a life-changing event that can’t be shaken off like a hang-over.  What about the birth control I got my daughter, or the condoms I bought my son?  Well, just like driving a car safely takes experience, taking birth control pills daily or using barrier methods properly in the heat of the moment requires care to get right.  And if they don’t get it right…

So you ask, what can we do?  Teenagers want to try stuff- driving fast, drinking, sex.  You tell us that teens are going to try these no matter what we say- they are better explorers than listeners, right?  And like our permissive parents above, letting the teen do these things at home where we can watch is a bad idea, because we still won’t be there at the crucial moment to prevent pregnancy.  So again, what to do?

The first thing is to explain the facts of life before your kids are teens, when they are still good listeners, before they become eye-rollers.  Elementary school age is best to discuss safe driving, drinking, and sex.  This is when you teach about the miseries of pregnancy, and how the fun-loving teen years are over when baby comes.  How tiring it is to feed baby and listen to all that crying .  Dirty, stinky diapers.  Spitting up.  And how if you have a baby with someone, that binds you as parents for the rest of your lives.  That guy may be cute now, but do you want to be raising a child with him, stuck together forever in a loveless pseudo-marriage of co-parenting?

Second, for those parents who are permissive so they can monitor their teens drinking and partying, stop!  Teens don’t need their parents to be friends; they have friends.  Teens actually want a parent who is an authority figure.  Teens know they may act out-of-control, and a parent who sets guidelines is a comfort.  My wife and I are pretty careful about where we let our youngest daughter go, and once when we okayed her to go to a party, she did a double-take: “Wait, you’re actually letting me go?  What if there’s drinking?”  She seemed a little disappointed that we didn’t say no.

Teen pregnancy and parenting is a chore, thousands of times worse than having to do the dishes or make the bed.  Warn your kids when they are young and instill those guidelines, so that they are well aware of the Big Accident waiting to happen, before it does.

Throw Me Something Mister- I’ll Try Not To Swallow It!

This week’s guest columnist is Dr. Libby Going, a Family Medicine resident at the University Health Center here in Lafayette.

Mardi Gras is here!  That means celebrating with floats and parades, king cakes…..and beads.  Edible treats quickly come to mind when we thing about Carnival season, but occasionally kids try things that are not edible.

Part of baby development is learning about objects by putting them into the mouth.  The mouth is one of the most sensitive parts for babies, so they use it to explore their world as much as they can.  This means every parent has had to grab something inedible out of baby’s hand or mouth.  ”Don’t eat that!” or “That’s not food!” are common phrases for parents with small children.

Many iconic Mardi Gras items have great appeal to a baby or toddler who already wants to put things in his mouth.  Sparkly, smooth, multi-colored beads, small plastic babies (looks just like me!) hidden in king cakes, and shiny gold doubloons- what more could a little one want?!?

So how do we keep this natural behavior for kids from becoming a 911 call or Emergency Department visit?  First, many bakeries now help out by not putting the baby into the king cake before purchase.  Parents can decide to place the inedible object into the cake or not.  Please decide not!  Let’s face it- toddlers will at the very least lick it, and maybe eat it. An idea for the older child who “just has to have the baby” is to put the baby on top of her piece and then take it back soon after.

Coins (or gold doubloons at this time of year) and button batteries are also favorites for trying in the mouth.  Thus you must be vigilant about not letting those in baby’s reach. Beads are also a serious choking hazard, so don’t be careless about leaving those around either.  But babies will be babies and sometimes just get ahold of these things, so it is important for parents to take a CPR class.  There you can learn the Heimlich maneuver, which works great for choking and can be life saving.

Even when Mardi Gras is over, kids will still put interesting things in their mouths and maybe swallow them.  If they do swallow something, and maybe gag and choke, this is one of the worst experiences in parenting!  This fear brings a lot of kids and their folks into the Emergency Department, even when the kid looks fine and swallowed something seemingly innocent.

When a child has swallowed what we call a “foreign body,” he may have increased fussiness, only want to drink liquids, vomit, complain of throat or chest or abdominal pain, or have a different sounding cough or gagging noise.  With any of these signs, your child needs to be evaluated.  Button or disc batteries are particularly dangerous because even if your child seems fine after they swallow one, batteries can cause serious internal burns. We often use xrays to show the culprit and where in the body it is.  Even if the parent doesn’t know exactly what was swallowed, the object’s shape on xray can tell us what it is.

Most foreign bodies pass harmlessly through the gastrointestinal tract and appear at the opposite end.  Sometimes a couple of xrays can be used to monitor the journey of that very interesting object.  However, some objects may require removal, usually by endoscopy.  This is a flexible fiberoptic tube with tiny tools and a light at the end, through which the doctor can see the thing and grab and retrieve it.  Some things that need to be removed include batteries and objects that are stuck and not moving through.

One important note to remember is never give your child something to drink or a snack once you decide to bring him in.  Children need to have empty stomachs for surgery, to have anesthesia safely.  Also, trying to feed a child with a blocked esophagus can cause vomiting and further choking hazards.

Mardi Gras can be a great time for the whole family, toddlers included, but some precautions must be taken to ensure that the fun does not end in the Emergency Department.  Laissez les bon temps rouler!

Backache? You’re Only 16!

I just returned from my yearly medical mission in Honduras.  And I thought I had gotten away with it- no missed flights, no lost equipment, no bad stomach bugs for the team.  But the next morning I sat down at work and YOW- my lower back clenched up!  This happens every couple of years for me, particularly when I have been abusing my back.  All week in Honduras I was hauling duffels, riding rocky mountain roads in old pick-up trucks, hunching over hundreds of patients.  The next few days I walked like a crippled cowboy until things loosened up.

Every week at home I see a kid with back pain too; it’s not just for old guys like me. Sometimes it’s a dramatic injury, like the weight-lifter whose back went POP! after dead-lifting 315 lbs, or the cheerleader who fell off the pyramid onto her tailbone.  Sometimes it’s a dancer who only strains a muscle but keeps on dancing, aggravating the injury further.

Teenagers also abuse their backs outside of sports.  They slouch.  They slouch in school chairs.  They slouch in the car. They slouch all day on the couch at home. Then they go back to school and haul a dump-truck load of books in their school bags.

When a teen’s back begins to hurt, sometimes they complain, sometimes not.  They blow it off and continue to strain their spines, or continue their sports.  They may take an ibuprofen or two.  Maybe the ibuprofen works, maybe not, because they only use it sporadically, and they keep on slouching and playing. Eventually they tell somebody and get brought in.

So how to ease that angry back?  For me, it was two ibuprofens around the clock, and my return to Red’s gym was delayed a week.  At work I sat upright in my ergonomic chair, and slept with a pillow under my knees.  And these things are the keys to easing your teen’s back pain too.

Like we detailed above, teens will continue to abuse their backs despite the pain.  Many kids (adults too) do not put two-and-two together when it comes to caring for their spines, or any other joints for that matter.  Their backs hurt, but they still slouch.  Their knees hurt, but they still play basketball or soccer.  They play hurt, and sit hurt too.

Thus is the first clue to taking care of a sore back- stop abusing it!  Take the strain off by sitting upright with feet flat on the floor, thighs flat on the chair, spine tucked against the chair back.  If the chair does not have a lower back, or “lumbar,” support, use a pillow to put a slight arch in your back.  When in bed take strain off your back by sleeping with flexed knees.  That means putting a pillow under your knees when on your back, and a pillow between your knees when lying on your side.  Standing strains the back too, but you can ease it by putting one foot up on a step.

And for goodness’ sake take a break from sports!  I’m all for sports and exercise in kids, but if you’ve hurt something, you’ve got to let it heal.  That means no basketball, P.E., dance, or running.  When professional athletes get hurt, do they keep playing?  No, they go on the Disabled List and start therapy.  No pros want to kill the golden goose, which is their million-dollar athletic ability.

Pain medicine helps.  Ibuprofen or tylenol can take the edge off back pain, as long as you take enough and start caring for your back.  You can ice your back too, just like you’d ice any injured joint.  An ice pack against your lower spine, ten minutes at a time, three times daily, can ease pain and inflammation.

If rest, medicine, and ice don’t make things better, see your doctor.  Some kids who have been abusing their backs for a long time need physical therapy.  Sometimes they need tests to be sure that their pain is not from something else besides muscle strain.  But often, kids just need to sit up straight.  You may only be 16, but take care of your back so that it takes care of you.

 

 

Hey…Stitch This!

This week’s guest columnist is Dr. Frank Betanski, a Family Practice resident at the University Health Center here in Lafayette.

“OUCH!!” (ou-ch); exclamation; a four-letter word indicating urgency and anxiety when children get a cut.  It raises questions with parents that are often confusing and overwhelming: “Does this need stitches?”  ”Should I go to the ER?”  ”Oh Lord, what is THAT??!!”  My mother faced these questions when I returned home from the movie “Edward Scissorhands.”  I grabbed the cutlery and literally started running with scissors.  So let’s discuss the how-to’s (and don’ts) of skin injuries.

First, some terminology:

-Laceration: tear into the skin with blunt force.

-Avulsion: A chunk of skin is removed, exposing a hole in the tissue.

-Puncture: stab through the skin

-Incision: laceration made with a sharp-edged object (knife, glass, scalpel, etc)

You’re thinking: “Thanks for the vocab lesson, doc, but what to do right now with all this bleeding?”  FIrst, apply pressure to the wound with a clean cloth or bandage.  Pressing for several minutes will stop most bleeding.  Remember, constantly lifting pressure to check if the bleeding has stopped will just prolong the bleeding.  Be patient, hold that wound for a good five minutes before checking.  If the cloth becomes soaked with blood, put a new cloth on top of the old one.  Should the bleeding not stop, head to the ER.

Once bleeding has stopped, wash your hands and remove dirt by running water over the wound.  Don¨t scrub the wound yet.  The old faithful hydrogen peroxide can help clean. Peroxide kills germs and can “bubble up” dirt and dead skin.  Only use peroxide once. Multiple uses can poison good tissue and delay healing.  Soaking open wounds in a mix of water and betadine also kills germs. If there is no more bleeding for áwhile, then you can gently scrub the wound with a washcloth if ít has embedded debris.

We see a variety of lacerations in the Emergency Department, and a variety of parental questions about management.  Sometimes the child has a tiny scrape the size of an eyelash, with Dad asking if we should call plastic surgery.  At the other extreme, the kid comes in with a mangled hand that looks like it was attacked by a bulldozer, with Mom wondering if it needs a bandaid.

So when should you bring your child in?  Here are some examples: heavy bleeding that doesn´t stop after 5 to 10 minutes of direct pressure.  Deep (down to fat or muscle layers) and/or longer than one inch.  Large, gaping cuts on the face.  Animal or human bites that break the skin.  Dirty wounds that you can’t get all the debris out. Signs of infection like increased pain, spreading redness, swelling, or drainage.

Many wounds heal themselves without stitches, and sometimes doctors prefer to leave wounds open to heal “from the bottom up.”  For example, we don´t stitch most animal bites, so that the stitches don’t trap infection inside the wound.  We stitch cuts mainly to minimize scarring and improve how the scar will look. Stitching wounds also can stop bleeding, increase scar strength, heal cuts faster, and decrease pain.  Face and forehead wounds can particularly need stitches for the best cosmetic result.  On the other hand, cuts inside the mouth and on the tongue, even deep ones, rarely need stitches. The inside of the mouth heals miraculously, closing big wounds in a few days.

We have many methods to close wounds: stitches (a.k.a. sutures), medical glue, staples, steri-strips (sterile tape).  Glue is good for clean, no-tension incisions.  If the wound cannot be easily closed by gently pushing the edges together, or has shaggy edges, then stitches are better.  Staples are best for areas where scarring is not an issue (inside hair lines). By the way, don’t remove medical staples yourself with an office staple remover.  Paper and medical staples are different animals.  Been there, saw that, saw the scar….

When in doubt, call your doctor, or maybe even send a picture from your phone.  Doctors can often tell you over the phone if a wound needs stitches, but sometimes we just gotta see it for ourselves, to know if we need to…Stitch This!

Addicted To Diagnosis

Last week we saw a 7 year-old girl with eight days of sore throat and fever.  Her parents were frustrated: they had seen their doctor twice, another ED once, had three flu tests and two strep tests and blood tests that were all negative, had two different antibiotics that didn’t help, and still no answers.  She was getting more miserable, with worsening throat pain, continued fever, and now a swollen face and neck.  So, I’d like to take credit for making the clutch diagnosis, but my nurse Natalie beat me to it.  She assessed the girl first and made the call: “It’s mono.”  I went in, saw the girl for myself, and agreed.  The mononucleosis test came back positive.

The parents were overjoyed.  First, Natalie impressed them with her thoroughness: “You were the first to feel her neck glands.”  Second, they felt like we really listened to their story.  Finally, they had a diagnosis, knowing what was wrong and what to expect for the future.  Unfortunately it was more of the same- fever and throat pain. Mononucleosis is a viral infection that causes fever, fatigue, sore throat, and swollen glands.  As a virus, antibiotics can’t kill it- it must run its course, and mono can last weeks. We could only offer a course of steroids.  Sometimes steroids decrease the throat inflammation, pain, and swelling; sometimes not.

This story illustrates how people need answers for their pain and misery.  Ours was the fourth visit the family had in 8 days in their search for a diagnosis.Test after test had been run.  This craving for answers is a natural desire in patients and families and of course in doctors.  We all find comfort in diagnosis- finally to know what is wrong, and what to expect in the future.

Unfortunately, parents’ and doctors’ zeal to find answers can hurt.  A natural inclination when the diagnosis is uncertain is to order more tests, to try more medicines to see if something helps.  But tests have a price.  Too many xrays and CT scans mean radiation, which can cause cancer later in life.  To kids, blood tests mean needles, dread, and pain.  And needles and catheters can cause infections, invading the body with devices that introduce germs where they can thrive.

Starting medicines like antibiotics without a firm diagnosis can also cause harm. Antibiotics have side effects.  They can cause allergic reactions; vomiting, diarrhea, and cramps; and yeast infections.  Antibiotics don’t kill viruses, so giving them in cases like our girl above increases risk for more misery, with no benefit.

Another consequence of needing diagnosis is a phenomenon called “The Vulnerable Child,” where the diagnosis scares the parents into thinking their child is fragile.  This often starts with a benign diagnosis like allergies. The parents are happy to be given an answer, but then believe that their kid is now sickly. They become overly protective. They don’t let him go out to play or do sports. They limit his friends.  He grows up with less fun, more isolation, and less exercise. Though the child’s body is fine, the parents don’t see it that way, even after being told that he is basically healthy.  The Vulnerable Child can start with diagnoses like asthma, prematurity, even simple heart murmurs.

The best way to make diagnoses then, without unnecessary tests and drug trials, is with a thorough history.  Your doctor should get a complete story of your child’s illness, detailed from start to finish.  This takes lots of listening and lots of questions. The doctor then needs to do a thorough physical, looking for all the clues to confirm what the child’s history has suggested.  Doctors make 85% of their diagnoses by history alone; physical exams and tests usually only confirm diagnoses, not make them.

And patience is needed.  It can take time to make a diagnosis; disease can be slow to reveal itself.  Consider our girl from above with the sore throat- first impressions of cold viruses or strep throat are usually right, but it took eight days of treatment failure and negative tests and progressing symptoms to have “mononucleosis” jump out at us. A lot of those tests and the antibiotics could have been avoided.  So, don’t let an addiction to diagnosis get in the way of, well, the diagnosis.

“He Bumped His Head And Went To Bed…”

Today’s guest columnist is Dr. Jesse Livingston, a family practice resident at the LSU-University Health Center here in Lafayette.  

Kids fall and hit their heads a lot.  Though most children with head injuries are fine, some need evaluation in the Emergency Department.  The parent can have difficult decisions to make, while at the same time dealing with a crying baby: Is the brain okay?  Does my child need a CT scan?  Can he nap?  We have all heard the nursery rhyme about the old man who bumped his head, went to bed, and couldn’t get up in the morning.  What about your two-year old, who despite every effort will “fall and go boom?”

The decision is easy for the worst falls.  If a child loses consciousness, has a seizure, vomits repeatedly, has a severe headache, is lethargic or confused, then she needs to be seen.  The doctor can decide if tests are needed, or if observation is enough.  We need to consider the “mechanism of injury,” meaning how it happened and what force was involved.  A child may seem fine after being struck in the head by a baseball, but such high-speed impacts need evaluation regardless of how well the kid is acting.

Here are more criteria for needing to get seen now: car wrecks where the child is thrown from the car, another passenger in the car dies, or the car rolls over.  If he is hit by a car while walking, or while riding a bike without a helmet, that’s concerning.  Kids under two years old need to be evaluated if they fall from over three feet; kids over two, falls higher than 5 feet.  If an infant or toddler under two gets a “goose egg” swelling anywhere but the forehead, that is worrisome.

However, most kids who hit their heads are okay and can stay home.  Kids who fall from their own, standing height, are usually fine.  Kids who hit their heads but are not knocked out and go back to playing are okay too.  Toddlers who run into walls also don’t generate enough force to hurt themselves badly.

Several times per week in the Emergency Department, we see a baby who rolls off the bed or falls from the stroller.   Mom is understandably freaked out- “I just left the room for a second, she has never rolled over before!”  Most falls occur at home and are usually either from falling off beds or other furniture, tumbling down stairs, or from being dropped. Interventions used only weeks ago to keep baby safe are now obsolete due to the child’s developing abilities.  Add to that the distractions of other children, pets, dinner on the stove, and the rest of the household confusion, and stuff will happen.

Like we said above, after most falls the child doesn’t need an Emergency Department visit.  If baby fell from a height less than three feet, then he is probably fine. Further, if he is acting normally, doesn’t have any “goose egg” swelling on his head (except for the forehead- a goose egg there is okay), doesn’t vomit, and is acting well, he is okay.  If you are unsure, call your doctor.  The doctor can help decide if baby can be observed at home or needs to come in.

Many parents believe they must keep their child awake after a fall to prevent coma. However, this is an “old wive’s tale.”  Naps after a minor fall can be restorative and comforting.  If there is a question about how bad the injury was, we do like an observation period where the child is watched for warning signs (severe headache, vomiting, changes in behavior, confusion).  During normal waking hours this is easy. However, if it is nap or bed time baby can go to sleep, but you should wake him up hourly for a few hours.  If the child is alert after waking (as alert as a child who’s just been awakened can be!), then okay.  If she seems overly groggy or lethargic, call your doctor or come in.

Unlike the old man in the nursery rhyme, most kids who bump their heads and go to bed are perfectly fine- they are not old men!  Someone needs to write a new nursery rhyme for kids who bump their heads.