Febrile Seizure- Stay Calm?

This week’s guest columnist is Dr. Benjamin Fontenot, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

It was mango season on Saba island, Netherlands Antilles.  My wife and I were on the beach eating some, and we decided to give our 8 month-old daughter a taste.  She liked it, but then paradise turned scary- she became lethargic, turned blue around the lips, was twitching, and seemed to stop breathing.  We called 911 and the island police rushed her to the local ER.  By the time we arrived, she was awake, pink, and breathing fine.  And now had a 103 degree fever. This was our first “febrile seizure,” and it had nothing to do with the mango.  Our daughter had an ear infection, which caused the fever, which led to the seizure.

What is a febrile seizure?  Simply, it’s when a child has a seizure with a fever. The child suddenly goes unconscious, has rhythmic twitching of the face, arms or legs, and is unarousable.  The child’s breaths are so shallow that it’s hard to tell if they are breathing.  After a few minutes of seizing, the child relaxes and breathes normally, and though sleepy and confused-acting, can be aroused.  After 10 to 20 more minutes he becomes more awake.

Febrile seizures only happen to about 4% of kids, but they sure are memorable when they do!  It’s frightening to watch, but doesn’t cause lasting harm.  Intelligence and other aspects of brain development aren’t affected- these kids grow up fine.  And kids do breathe adequately during seizures, although it’s tough to tell.

More good news: most kids who have febrile seizures never have another.  About one third of these kids have more than one, but they all outgrow them by 6 years of age.

Febrile seizures happen between ages 6 months to 5 years.  How high the fever goes, or how fast it goes up, has nothing to do with having a seizure.  Thus if your child has a fever of 104, that does not mean they’re going to seize.  Some kids seem to get them, most don’t.  In fact, seizures usually happen before the onset of fever, so if your child is already hot, it’s less likely that they’ll have one.

During my second year of medical school, it happened again.  My daughter was 16 months at the time.  She was playing with the neighbor’s kids when she suddenly stopped, fell straight back on the floor, and began shaking.  The other mothers freaked out, but my wife assured them that it was “only a seizure.”  She sure got some strange looks!  Then the fever started, and it turned out to be another ear infection.

As we discussed above, febrile seizures are scary to watch, but are actually no reason to panic.  They don’t hurt child’s brain, kids breathe adequately during the seizure, and go on to grow up fine.  Easy to say, but what do I do if my child has one?

First, stay calm.  Roll the child onto his side, so if he won’t choke if vomiting. Don’t put things in the mouth.  Some people worry kids will “swallow their tongue” or bite their tongue, and think sticking something in will help- wrong!  Kids don’t choke during seizures, and shoving things in can hurt their teeth and mouth. Don’t try to stop the jerking either- you can’t, and again may hurt the child by trying.

Watch the time.  Seizures lasting past 5 minutes may require treatment. If the seizure is going that long, call 911.  Paramedics carry medication that can stop seizures.

Once the seizure is over, the child should see a doctor, to determine the source of the fever. Fevers are usually caused by viruses that go away by themselves, but sometimes kids have bacterial causes like ear infections, and need antibiotics.  Blood tests are mostly unnecessary after febrile seizures.

Can you prevent febrile seizures?  Regular dosing with acetaminophen (Tylenol) or ibuprofen don’t prevent them. Giving anti-seizure medication, like for kids with epilepsy, may help.  However, in most cases this is not recommended. Potential side effects of daily anti-seizure medications usually outweigh the benefits. Remember- febrile seizures are not harmful. The only danger is leaving kids in the bathtub unattended and they seize and drown.  But you shouldn’t leave kids alone in the tub anyway, seizures or not.

Febrile seizures are scary for parents.  Follow the plan above, recognize the signs and symptoms, and stay calm!

When Pediatrics Got Boring

It was 1990, my second year of residency.  I was in Emergency seeing a boy with swollen left eyelids.  I explained to his mom that he could have an infection that sometimes spreads into the eye socket, and the boy “might need a CT scan to see behind the eye.”

As I was talking, I pried open the boy’s eyelids to examine the eye itself and had one of those “Whoa!” moments: the eyelids themselves weren’t swollen, they were puffed out because the boy’s eyeball was sticking out of the eye socket; pushed out by infection. “He definitely needs a CT,” I corrected, not skipping a beat, “and possibly surgery to clean out the infection.”

This condition is called orbital cellulitis, and was quite common due to the bacteria Hemophilus Influenza (a.k.a. “H. Flu,” and no relation to the viral Influenza we get “flu shots” for).  But that year of my residency, the vaccine against H. Flu came out.  Vaccines had already existed against some viruses and a few bacteria like tetanus, but H. Flu was different, and required a pharmaceutical breakthrough.  That same breakthrough enabled invention of vaccines against Pneumococcus and Meningococcus, two other bad bacteria that caused lots of meningitis, blood infections, and pneumonia.

In the 26 years since, pediatrics has gotten, well, kinda boring.  Wards that used to be filled with sick and dying children infected by these bacteria, emptied out. You could almost hear the crickets chirping.  Which is great for kids.  However, the success of these vaccines and their predecessors- measles, diphtheria, pertussis, etc- has led to complacence about their need. Everyone used to know of a child who died or had brain damage from one of these diseases.  But now, “out of sight, out of mind.”

A recent poll of parents who don’t get their child vaccinated has revealed this false sense of security.  Many parents are afraid that vaccines are dangerous, but now even more think that they are just plain unnecessary.  But the scientific fact is that vaccines are safe, safer than riding in cars.  They may seem unnecessary just like seat belts might seem unnecessary when you’re just driving around-  right up until you get in a crash.

When kids get lacerations and need stitches, we always check if they are up-to-date on tetanus.  If they’re not vaccinated, we ask the parents to allow a tetanus shot. Tetanus infects deep wounds, and is deadly.  If parents are reluctant, I tell them about my experience in the Philippines.

In medical school I spent a month there, where for many, vaccines are an unaffordable luxury.  During that time I saw two kids die of tetanus- one teenager who stepped on a needle, one newborn who had her umbilical cord painted with some concoction by a village healer.  Tetanus is also called Lockjaw because it causes muscles to freeze up, including the jaw and chest muscles used for breathing.  When those lock up, the child slowly dies of asphyxiation.

Despite pediatricians’ recommendations, some parents won’t get their kids vaccinated. Some think they’re unnecessary, like we discussed above. They’ve been lulled into complacency, since they don’t know anyone whose died of the diseases we vaccinate against (see how that worked?).

Some worry that vaccines are dangerous.  They hear vaccines cause autism, or contain poisons.  There are even internet sites which claim vaccination is a money-making conspiracy between drug companies and doctors.  I’ve had moms whisper to me, “What’s really the truth about vaccines?” like it’s a big secret.

The truth is vaccines are simply a modern technology, like cars and cell phones, and everyone seems comfortable with those.  Vaccines have been extensively studied and tested for safety.  In fact, vaccines are safer than riding in cars, and we certainly know more about vaccine safety than we do about cell phones!

It’s frustrating for pediatricians trying to convince these parents otherwise. There’s a psychological phenomenon called cognitive dissonance, wherein if someone has a set belief, no amount of facts will sway that belief.  This phenomenon explains why people support political candidates despite data, or the candidate’s own past words, that highlight that candidate’s insincerity.  If you’re pulling your hair out because your political opposites just won’t see reason, that’s how pediatricians feel when discussing vaccines.

So give your pediatrician a break- get your kids vaccinated.  Oh, and you also might save their lives.

 

A Stitch In Time

This week’s guest columnist is Dr. Blake McDonald, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

One night while I was on duty at the hospital, a surprise call came not from the wards, but from my sister!  Her 6 year-old son, Finn, had been playing by the fireplace, tripped, and hit his forehead on the brick mantel.  My sister was panicked: He’s bleeding and does he need stitches!!??

Sometimes it’s difficult for parents to tell if a cut needs stitches, and sometimes a judgment call the parents and doctor make together.  So what lacerations need stitches?  The goals of wound care are to stop bleeding, avoid infection, minimize pain, and minimize scarring.  With these in mind, here’s some guidelines.

First, stop bleeding.  Apply pressure to the wound for several minutes with a clean cloth or gauze.  Keep pressure on the whole time; if you keep lifting the cloth to see if the bleeding’s stopped, you won’t give enough time for a clot to form.  Once bleeding has stopped, then clean the wound. Dirty wounds are at greater risk for infection, which worsens pain and scarring.

Gently scrub with plain soap and water, and rinse plenty.  If there is lots of imbedded dirt, peroxide can be used to foam out debris.  But just once- too much peroxide poisons tissue and slows healing.  If there’s just too much junk and it hurts too much to clean, that’s a reason to get seen.  We can anesthetize the wound to decrease pain and get the cleaning done.  In kids this is often achieved with an anesthetic ointment we place in the wound and after 45 minutes it’s numb- no shots necessary!

Other reasons that kids need to get seen: full thickness lacerations on faces, particularly eyelids, lips, and ears.  These can have worse scars without stitches.  Deep wounds of joints, hands, or feet are at risk for infection and loss of function if not cared for properly.  Crush injuries, or other lacerations that could involve bones need attention too, for the same reasons.  Animal bites also can get infected and transmit rabies.

Finn got three stitches (a.k.a sutures) that night, and it was an uneventful experience.  He wasn’t too scared, but many kids freak out when they hear “stitches,” because they think “needles.”  But like we discussed above, the anesthetic gel we put in the wound often numbs the cut completely and injections aren’t needed.

Three days later I got another “consult” call from my sister.  She had been instructed to bring Finn back in 3 to 5 days to get the sutures out.  ”Really,” she asked, “is that long enough?”  She also was told to wash the stitches with plain soap and water. Surely there’s more to it than that?

Timing of suture removal depends on where the cut is.  Places with great blood supply, like the face and scalp, heal quicker than places with less, like hands and feet.  Blood brings oxygen and nutrients that skin uses to build new tissue.  Blood also brings blood cells that fight infection.  Therefore, cuts on faces and scalps don’t need antibiotics because the blood keeps things clean.  But cuts on hand and feet should get antibiotics because of less blood supply, and hands and feet tend to be dirtier than faces and scalps. Also, animal bites always get antibiotics, no matter where the bite is, to prevent infection.

Face sutures can be removed after 3-5 days, scalps 7 days, arms and legs 10 days, and hands and feet 14 days.  If we leave the sutures in longer than that, the suture material can irritate and make worse scars.  We’ve all seen scars with the row of white dots lining the sides of the scar- don’t want that on a face!

It’s also important to wash the cut once daily, and yes, plain soap and water is enough. But a brief wash: no long tub soaks or swimming with stitches.  After washing, apply antibiotic ointment and a bandage.  If the skin gets red and itchy from the bandaid, you can use paper tape.  Or if it’s only a few days before suture removal, leave the bandage off.

Kids like Finn play and get cuts, and sometimes need stitches.  But you needn’t freak out about pain and having to care for sutures.  It’s as easy as the adage, “A stitch in time…”

Arachnophobia

As a kid, spiders freaked me out; even touching a picture of one gave me the willies.  The worst was in 1983, when I was on a mission trip to Haiti.  One night I was getting in bed, when I decided to pull back the covers first.  I peeled the sheet back a little, and a large black beetle ran out. Weird, I thought, what else is in there?  Peeling back a little more, a lizard ran out. A little more, another beetle.  Tired of that game, I yanked the sheet all the way back and there was a scorpion.

Hairs standing on end, I thought, “what if I had climbed in without looking?”  After 5 minutes I worked up the courage to flick the bottom sheet to toss the beast on the floor, where I kept stomping and jumping back, I’m sure yelping too, until it was dead.  Then for the only time in my life, I said, “I need a drink,” and sought a bar.

While we do have the rare scorpion in Louisiana, far more worrisome arachnids are ticks. Ticks encounters are more common in the fall, when they are most active and their human targets are back outside in cooler weather.  Ticks don’t sting like scorpions, but they can transmit some nasty infections.  The two deadliest are Rocky Mountain Spotted Fever and it’s cousin, Erlichiosis.  After a bite, the victim develops fever, headache, and fatigue. Days later a rash of tiny spots appears all over, and the patient gets deathly ill.  Another tick-borne infection is Lyme disease.  This starts with a rash that looks like a target- central redness surrounded by a pale ring, in turn surrounded by a red ring.  If undiagnosed, Lyme can later cause joint pain and swelling and heart and nerve damage.

Fortunately, all these infections are more rare in Louisiana than other states.  Lyme is found more north, and despite it’s name Rocky Mountain Spotted Fever is mostly in the mid-atlantic states.  However, you can get them, so avoid tick bites.  If hiking in the woods, use bug spray on your socks and pants, and tuck your pants into your socks (ticks climb upward).  When showering later, inspect yourself for ticks- they can be tiny and sneaky.  If you pull them off within 24 hours, you greatly decrease your chance of disease.

Enough about scorpions and ticks; we need to talk about the most common arachnid we encounter- spiders.  Spiders have an undeserved reputation as bad guys. But only once in 24 years of practice have I seen a bite from the worst of American spiders- the Black Widow.

The 15 year-old farm boy had left his boots in the barn.  That morning when he put them on, without socks, he felt a pinprick between two toes. Thinking nothing of it, he went to work.  That afternoon he began to feel lousy- sweaty, crampy, and weak.  He came into the Emergency Department pale, damp, and breathing hard.  After hearing his story, it was pretty clear what happened.  We admitted him to the Intensive Care Unit for fluids, muscle relaxers, and pain medication, and he eventually recovered.

The other “bad” spider in our area is the Brown Recluse. This spider’s bite is also rare. When bitten, the victim usually feels nothing.  However, over the next few days the bite site can get red, swell, and develop a bluish blister of dying tissue.  It looks like an abscess (or “boil”), but with blue-black tones and an open wound where the skin has died.

Because of what the Brown Recluse bite looks like, many assume every boil is a spider bite.  Day after day kids and adults come to the Emergency Department complaining of a “spider bite,” when the vast majority of these are due to other skin traumas like cuts and scratches and mosquito bites, that become infected.  

Though unusual, you don’t want a spider bite in the first place, so it’s best to avoid putting your hands and feet where spiders live.  Both Brown Recluses and Black Widows like dark areas, only biting when their hiding spots are invaded.  So wear heavy gloves when putting your hands in wood piles or other dark spaces.  Keep household and outdoor storage uncluttered- spiders love to hide in old yard debris piles and stacks of bricks.

And keep your boots indoors!

When Vacation Follows You Home

This week’s guest columnists are Drs. Michael Johnson and Sam Defigarelli, Family Practice residents at the University Hospital and Clinics here in Lafayette.

The family returns from a cruise ship holiday in the Caribbean.  Everyone, including 10 year-old Gavin, had a blast.  He loved snorkeling, going down the waterslide on the ship, and even the exotic food at ports-of-call.  But even before the bags are unpacked at home, he says “Uh-Oh!” and runs to the bathroom, just in time for the watery explosion from below.

Traveler’s Diarrhea is a condition that develops soon after returning from trips to resource-limited countries.  Gavin has three potential whammies in his scenario.  These countries often don’t have sewage treatment, and snorkeling is a potential contact with contaminated run-off.  Cruise ships and water-parks are known risks for catching diarrhea.  And improperly prepared food could make him sick as well.

The biggest concern with diarrhea is dehydration.  Most only have a day or two of loose stools, but some also have nausea, vomiting, cramps, fever, or bloody stools.  When there’s lots of vomiting and diarrhea and worries about dehydration, kids should get seen.

Most kids only need home treatment- plenty of clear fluids like pedialyte for infants, sports drinks or dilute juices for older kids.  Avoid full strength fruit juices- these can worsen diarrhea.  For copious diarrhea, rehydration solution packets are available at pharmacies, to mix with clean water.  If kids aren’t having cramps, nausea, or vomiting, they can eat and have milk.  Bland starchy foods are best- fast food and other heavy greasy food can prolong symptoms.  We say ”feed through diarrhea;” don’t restrict food if they’re hungry!  The sooner they eat, the sooner their guts get back in balance.

You’ll want to control the spread of infection to you and your family, so that you aren’t cleaning up after multiple kids and feeling rotten yourself- a total nightmare!  Wash your hands frequently with soap and water- better than hand sanitizers.  Make sure kids aren’t touching or drinking after each other.

Prevention while traveling is even better.  Only drink from unopened bottles.  Avoid ice- it could be made with contaminated water.  Eat food served hot, and avoid salads (ingredients washed how?).  And parents, alcohol won’t reliably sterilize water or ice, so avoid having your cold one on the rocks.

Here is a different scenario than above. It’s June, the annual family reunion picnic, with all the aunts, uncles, and cousins . The grills are going and the sides have been put out: coleslaw, potato salad, macaroni salad.  There is a lot going on: pick-up football, pets running about, tables knocked over, umbrellas and chairs being set up, conversations all around.  The hamburgers are late getting on the grill and the sides have sat in the sun.  Everyone’s hungry so the burgers are a little under-done, but so what?

Any dangerous situations in this story?  It’ not the football- it’s the mayonnaise-based sides warming in the sun, incubating bacteria like Staphylococcus.  And undercooked hamburger can contain E. coli, a potentially disastrous infection.

Food poisoning is all too common in children.  Usually it’s just some diarrhea for a day or two and maybe some vomiting if your unlucky.  However, food poisoning with certain bacteria can have worse consequences.  Staphylococcus (a.k.a.”Staph”) often has a quick onset, within hours of ingestion, and can lead to dehydration and fatigue, especially in younger children.  There are many strains of E. coli too, the worst of which can lead to Hemolytic Uremic Syndrome, a deadly disease involving kidney failure and coma.

Treatment of these bacteria infections isn’t just giving antibiotics.  In fact, sometimes antibiotics can make the symptoms worse.  There’s no treatment besides fluids and rest, and for the really sick kids, hospitalization.  So better to prevent infections than have them!

Safe food handling is paramount.  Always cook meat thoroughly, particularly ground meat.  Be careful of your meat source- meat from a single farm, ground in the store, is much safer than meat from multiple feed lots, pre-ground and packaged when it gets to the store.  Never leave mayonnaise-containing food unrefrigerated for more than one hour.  Be sure to wash vegetables and fruits thoroughly- they might be from fields fertilized with manure that contains E. coli.

So be careful when you travel, and when you cook at home.  An ounce of prevention is worth several pounds of diarrhea, when vacation follows you home!

 

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Ghost In The Graveyard

There’s only about 4 weeks left of summer vacation here in Louisiana.  Summer’s been terrific, but now family vacation and your kid’s camps are done.  You’ve made some good memories, but now the kids are bored and have reverted to lounging about playing video games.  No one goes outside, with the heat during the day and the mosquitoes at dusk.

However, it’s not too late to continue a great summer, have fun with the kids, and generate some more memories.  Sometimes to find ideas for this blog, I check the New York Times Wellness Blog, and recently found their series called “The Intentional Summer.” They’ve come up with more ideas for parents and kids to beat boredom and salvage what’s left of summer; and get the kids outside for more exercise.  So I’m going to shamelessly borrow from them.

I asked my three kids, now grown, if they’d ever played a game called “Ghost In The Graveyard.”  The older two replied, “that rings a bell,” and my youngest had no clue. This reflects studies that kids now spend more summertime indoors than outside, as opposed to my generation who spent more time out than in.  We didn’t have video games and only 5 or 6 channels on TV, so we had to play outdoors with the neighborhood kids to avoid boredom.  Many of those kid-run games have gone forgotten.

Now it’s up to parents to revive the games of their youth, for their kids. Get your kids and their friends together and teach them the classics- Flashlight Tag, Capture The Flag, and Ghost In The Graveyard.  If you don’t remember the rules, look them up online.  Once you set the kids loose, they won’t be able to stop, particularly with Ghost In The Graveyard. This game has suspense, hide-and-go-seek, and lots of running.

Sending your kids outdoors takes some planning.  To beat the heat, they’ll need plenty of water, and perhaps playing in the evening when it’s cooler.  But evening is when mosquitoes are worse, so you’ll need bug spray.  But it’s worth it, for their health and happy brains.

When reading the New York Times ” Intentional Summer” series, I found an excellent family activity they called the Quest.  I had done several summer quests as a kid myself, as you probably have too.  It’s time to use what summer you have left to get your kids outside on their own adventures.

One of my summer quests was what I’ll call The Quest For the Six Pack Of Coke.  My parents did not buy soda, so once when I wanted some Coca-cola (about age 8), I had to get it myself.  First I had to earn the $ 1.00 it cost.  I went around the neighborhood drumming up jobs, and after raking grass and pulling weeds I had four shiny quarters. Then I had to plan the bike ride, an all afternoon trek to the supermarket and back. It became a sunny day ride through seldom-traveled neighborhoods that seemed like foreign lands. Like all quests it was more about the journey than the destination.

Send your kids on their own quests.  Half the journey is the planning, and you can help  with that: bicycle maintenance, planning routes to balance safety and adventure, and the road home.  Instead of a six pack of soda, the quest can be a specialty store like one that makes in-house chocolates, or similar exotic destinations. There’s a modern version of the scavenger hunt called Geocaching, where fellow scavengers have hidden little prizes all over the country. Look up online how to go find the prizes, in parks and neighborhoods, and join your kids on a ready-made adventure.

Another version of the Quest is the Excursion, where your family visits a familiar destination like the library or grocery store.  But instead of driving there, you walk or bike. Again, half the fun is the planning:  what route to take, where to stop for ice cream and drinks, carrying groceries, managing heat and mosquitoes.  You’ll need water, hats or bike helmets, bug spray.  Then adventure happens when you find yourself in places that look familiar when whizzing by your car window, but are totally new when you walk or bike them.

So save summer from boredom and the computers.  Send your kids on a Quest or take them on an Excursion.  Or closer to home, help them find The Ghost In The Graveyard. 

BZZZZZZZZZZ

This week’s guest columnist is Dr. Allan Olson, a Family Practice resident at University Hospital and Clinics here in Lafayette.

It’s mosquito season again- never far away in Louisiana.  Usually bites are harmless, causing some redness, itching, and swelling that goes away within hours.  Ten years ago mosquito bites were just a nuisance, but now the news is full of stories about Zika and Dengue, and remember West Nile virus?  So when to worry?

Your 10 year-old son played outside this afternoon.  When he came in for supper he had two itchy, raised, red areas on his arms and one on his neck.  Other than some rubbing and scratching, he seems fine.  Should you be concerned?

Not yet: your boy is behaving normally, has no fever or other symptoms besides the bites.  You tell him to stop scratching- good luck with that!  When mosquitoes bite, they inject an anesthetic so you don’t know they’re biting and can’t swat them.  But then later some people develop a tiny allergic reaction to that anesthetic, and thus the spot of swelling and itching.  And when kids itch, they scratch, and no words can stop that.

To get rid of the itch,  use anti-histamines like Benadryl, Claritin, or Zyrtec.   Ibuprofen or Tylenol can take the edge off itching too, and can safely be taken with an anti-histamine.  Also, keep your kids fingernails cut short.  If they tear the skin with scratching, that broken skin is an entry for bacteria, and infections and pus can result.  If your child has extra sensitive or dry skin, keep it moisturized with lotion and moisturizing soap, making it less itchy and less easily torn by fingernails.

Even better, keep those bites from happening!  Mosquito buzzing is no reason to stay inside all day playing video games.  Kids need exercise (besides their thumbs) to stay healthy, not to mention wearing them out so they’ll sleep at night.  Have your kids wear light, long sleeved clothing and pants, with cuffs tucked into socks.  Too hot for that, or too dorky for your kid?  Repellents with DEET or picaridin can help keep insects away.  Avoid being outside when mosquitoes are most active- dusk, dawn, and after rain.

Here’s a different mosquito scenario than from our boy above.  Your teenage daughter goes on a mission trip to Central America with her church.  She was helping out at a clinic in a remote village, and gets some mosquito bites.  Two days after coming home she begins to feel bad- with fever, headaches, nausea.  Her body aches and she’s tired.  Knowing that many infections transmitted by mosquitoes get better on their own, you give her Tylenol and have her drink plenty of fluids.  So when to worry now?

These days with Zika virus in the news, heck, you’re already worried!  So you take her to your doctor or the ER.  Most of the time though, these mosquito-borne infections are viruses that run their course and leave your daughter fine.  Occasionally, kids may need tests to look for one of the bad infections like West Nile, Dengue, or malaria. They may need fluids for dehydration or specific medicine for pain.

Many countries in the Caribbean, Central America, or South America have increased risk for mosquito-borne diseases like Zika, Chikungunya, yellow fever, West Nile, Dengue, or malaria.  If you or your kids are working or vacationing there, preventing these illnesses is way better than getting them!  Sleep under mosquito netting, in a room with screens on the windows.  Air-conditioning helps: you can sleep in a more sealed room, and the cool air makes mosquitoes less active.  Use repellents and protective clothing as mentioned above.

Before you go, check the Centers for Disease Control website (www.cdc.gov).  The CDC lists the disease risks for every country in the world, and what you need before you go.  If yellow fever is prevalent, get vaccinated for that.  For malaria prevention, the site tells you what antibiotic to get from your doctor, when to start taking it, and when to stop.  It’s a pretty cool site (at least we doctors think so), so check it out.

Don’t let those mosquitoes disrupt your kids’s outdoor fun or travel plans.  Take these steps to help them have a great summer at home or on the road.  And so you don’t have to panic when you hear BZZZZZZ.

Stay Outdoors This Summer!

My college required students to take four blocks of Physical Education, much like high school, except we chose the sports.  We also had to pass a swim test to graduate.  My roommate Brian, who’d never learned to swim, had to use his PE blocks to take swim lessons until he passed that test.  So while the rest of my buddies and me were horsing around in floor hockey or golf lessons, Brian was off to the campus pool in swim trunks, towel around his neck, trailed by jokes about playing in the “kiddie pool,” and “don’t forget your water wings.”

Learning to swim and playing in the pool are great ways to spend the hot summer. It’s good exercise and though kids are outdoors, they stay cool.  And they have fun!  More importantly for we in Emergency services, knowing how to swim is good drowning prevention.

Proper swim lessons, like in the Boy Scouts, don’t only teach swimming.  They also teach water safety, because even good swimmers can get into trouble, like my buddy Walt. Walt is an ER doctor who had been in the Air Force Pararescue, or “PJs.” This elite team’s mission is to rescue downed pilots, particularly in water. Needless to say, Walt was as capable in water as any Navy Seal.  One day at the beach, however, he and his 8 year-old son got caught in a riptide and were taken out to sea.

Hundreds of yards off shore, Walt saw a current that would sweep them back, but the stream he was in prevented him from swimming there.  After hours of trying to break through while holding up his son, growing exhausted, he resigned himself to throwing his son to the beach-bound current before he himself drowned.  Just then a rogue wave slapped them into that good current and they got home.

After that, Walt never went to the beach without numerous flotation devices and a long rope.  Good swim lessons likewise teach about safety and rescue strategies like having flotation and other equipment handy.  They also teach the buddy system so everyone is accounted for in a crowd.

Playing outdoors in the summer is great exercise too, though not as cooling as swimming.  Kids can get overheated, especially if they are in sports practices.  Several times in July and August we get football players in the Emergency Department with heat exhaustion.  The boys start to get muscle cramps, and then can become sleepy and sometimes confused.  When they are confused or difficult to arouse, we worry about heat stroke, a life-threatening emergency.

Dr. James Andrews, a famed sports orthopedic surgeon, wrote a book called “Any Given Monday: Sports Injuries and How to Prevent Them.”  In that book he advocates kids cutting back on organized sports when they are young, to avoid repetitive injuries that he used to see only in college and professional athletes.  This allows for more unstructured outdoor play for kids that’s easier on their joints.  Kid-driven play also helps avoid heat injury.

In regular play, there’s no training agenda to drive kids past their comfort zone.  Kids can goof around outside all they want, and when they get hot and thirsty come in to get drinks and cool off.  They take breaks whenever they want.  In coach-driven sports, kids are pushed to the limits of their endurance to improve performance.  Sometimes they are pushed too far, and get over-heated.

However, organized sports practice can be made safer. Coaches should allow unlimited water breaks.  Heat injury happens with temperature and dehydration working together to punish; plenty of fluids prevents that.  Breaks should be in the shade.  Teams should practice in cooler times of day, early morning and late afternoon or evening.  Football practice should start with shorts and tee-shirts, with endurance and equipment gradually added in following weeks.  Finally, coaches should watch players for signs of heat exhaustion, just like they watch for signs of concussion.  If players acts groggy, they should be rested and hydrated in the shade.

So let your kids play freely outdoors. They should get swimming lessons and have lots of pool time to play and exercise.  If they are outdoors in the yard, be sure they take plenty of water and cooling-off breaks, and have sprinklers to play in.  Come to think of it, maybe football practices should have lots of running through the sprinklers too!

Don’t Choke: Learn CPR!

This week’s guest columnist is Dr. Kevin Morris, a family practice resident at the University Hospital and Clinics here in Lafayette.

My wife and I sit down to enjoy dinner with our boys- the three year-old in a booster and the 8 month-old in a high chair.  We are chatting and relaxed when the baby quits making sounds.  He had inhaled to cough and sucked in a piece of teething biscuit, completely blocking his airway!  I pulled him out of his high chair and used three quick back blows taught in basic rescue classes.  The piece popped out and tragedy was averted.

Most people understand the danger of non-food items causing choking, like coins or rocks, but any object in the mouth is a hazard.  This is especially true for infants and children, who explore with their mouths and aren’t careful about chewing. The National Safety Council Injury Facts 2016 reports that choking is the fourth leading cause of unintentional death.

What to do?  First and foremost every adult, parents or not, should take a Basic First Aid/CPR course.  In these you’re taught important life-saving maneuvers, including the Heimlich maneuver.  There are different techniques to use depending on the child’s age, and you practice hands-on.  Call the American Red Cross, American Heart Association, or your local Fire/EMS for a class, or navigate their websites.

The most obvious way to avoid a choking episode is to make sure there aren’t small, non-food items within the child’s reach.  This includes marbles, rocks, small toys like lego pieces, button batteries, etc.  ”Within reach” is a big place for a toddler- they explore by crawling and walking wherever they can.  Since their mouths are one of the most sensitive parts of their bodies, they lick and taste new things they find, and pop them inside for a really good going-over.

Thus to keep children safe from choking, parents, grandparents, and other sitters need to be diligent.  Caregivers should periodically get on their hands and knees and explore the house and yard like a toddler would- finding and cleaning up all small things that the child might ingest.  You can look on-line for all sorts of other ways to “toddler-proof” their world.

Keeping non-food items out of your child’s mouth is one thing; but food is also a choking hazard.  My boy, who choked on the teething biscuit as a baby, had a second episode when he was 5 years.  When we were leaving a restaurant he grabbed a peppermint from the bowl on the counter. Once in the car I was backing out of the parking space, looked over my shoulder, and saw a scared look on my son’s face.  His hands flew to his throat, the classic sign of choking.  Since he was older, the back blows I used when he was a baby were no longer appropriate.  I jumped out, grabbed him from his seat, and administered the Heimlich maneuver. After five abdominal thrusts the peppermint was expelled and my son was breathing again.

Like we said above, prevention is the best medicine for choking.  The American Academy of Pediatrics recommends avoiding these foods for young children: hard candies like that peppermint, un-cut hot dogs, nuts, peanut butter chunks, popcorn, seeds, whole grapes.  You get the idea: any firm object large enough to block your child’s airway.

Grapes are good for kids, they just need to be cut into halves or quarters.  Hot dogs need to be sliced.  Children don’t always chew food thoroughly, and aren’t yet able to reliably keep food from falling to the back of their throats.

Another important rule is never let toddlers and small children walk and eat.  It’s hard for a kid to do both when they’re still new to those activities.  When kids walk, they breathe harder, chew less, and thus increase choking risk.  And when they’re walking, they can walk out of your sight and choke to death without you even knowing it!

Therefore, all kids from infancy to elementary school should sit while eating, where they can be monitored by adults.  And as I have repeated, we highly recommend that every parent, caregiver, and babysitter take a BLS/First Aid course to have the skills to save a choking child.  Like I did twice with my son, you may save a life very important to you!

Becoming A Doctor

Many kids want to become doctors, and many doctors want their kids to be doctors too. Once I had a great opportunity to show my son how cool it could be.  I spend a week each year in Honduras working in remote mountain villages, and take one of my kids along.  It was the end of the day, we were packing the trucks to head back to town, when I heard shouting from the road, “El doctor, el doctor!”

Two villagers were coming up, carrying a makeshift litter of two tree branches draped with blankets. Inside the blankets was an 8 year-old boy, face twisted in pain. Peeling back the covers, I saw a huge chunk of flesh missing from his right thigh.  Excited voices informed us that he had just been bitten by a pig.

We unpacked the trucks, moved back into the schoolhouse we had been using, and pushed school tables together to lay him on.  One of the other doctors, an anesthesiologist, injected a nerve block in our patient’s hip to numb his leg.  While I was arranging my surgical tools, I thought, “Great, my boy will see his Dad be a hero,”  like an episode of the TV show MASH.

However, as I started working, I noticed my son at the far side of the room, his back to us. When I called him to come see, he said he’d rather not.  Instead of exciting him, the blood, the wound, and the child’s pain made him sick.  So much for Dad The Hero and his son the doctor; my boy was going to go another way.

None of my kids want to be a doctor, though they occasionally like the idea of being a doctor.  Many feel that way: it sounds fun to have the prestige and income, to help others in a meaningful way, to have some excitement.  But my kids know better- it takes a lot more, at least 11 years of school and training, than just liking the idea.

It takes perseverance.  What helped me was that I loved science (unlike my kids). Studying biology and chemistry was just plain fun.  Also, I wanted to care for others using science, and was undaunted by the long hours.  I wanted adventure too, and medicine promised that.

I wanted to be a doctor since sixth grade, but some decide that later.  One resident of mine failed college after his first semester, already not your typical path to an MD!  His dad was a nursing home administrator, and while he was moping about his academic disaster, his dad said, “While you’re doing nothing, come spend time with some of my patients. They’re so lonely.”

The first patient he went to see had cancer, as well as being elderly.   He sat down with the man, they started talking, and hours later he was still there.  They became fast friends for years, until the man’s death.  That visit stimulated this resident to continue his dream of patient care.  He became a paramedic, and after several years with EMS, got serious about college, and went on to medical school.  In 4 weeks he graduates residency to be a full-fledged doctor.

Though we discussed above that becoming a doctor means loving science, it’s really about taking care of people.  Often that ideal is lost in the rigors of the eleven year training, where student live and breathe medicine and science.  Patients become subjects of study, rather than people in need.

But immersion in medicine, becoming a “medical nerd,” is pretty much required.  First, students need all A’s and B’s in four years of college, usually in a science degree.  Then, only one-third of medical school applicants get accepted to go on. The next four years in medical school are even harder- 50-plus hours per week of class, study, and hospital time, instead of the 15 to 18 hours class time in college. After medical school comes residency, where the “resident” doctor works 80-hour weeks apprenticing in a specialty. Residency takes three years for the basic specialties (pediatrics, adult medicine, family practice), more years for OB/GYN, surgery, or subspecialties.

But if you are not dissuaded, and want a life of profound duty and fulfillment, service and excitement, and have a capacity for delayed gratification (I was 29 years old when I finished school and training), go for it!  Just don’t forget about your patients.