Assembly-Line Medicine

This week’s guest columnists are Drs. Ashanti Smith and Ravi Alagugurusamy, Family Practice residents at the University Hospital and Clinics here in Lafayette.

It’s a common scenario now in Lafayette, and nationwide: The child wakes up feeling awful- tired, whining, feverish.  Her throat hurts, and she shivers from chills.  She’s also been coughing.  Mom gives her some ibuprofen, a glass of juice and…she goes back to sleep?  That’s really weird in this normally rambunctious kid, so mom brings her to the doctor.

The waiting room is packed with snotting, sneezing, hacking tots and their bleary-eyed parents. To add variety, one kid throws up.  After hours of waiting, they get a room, the doctor zips in, and proclaims the Influenza swab was positive.  He rattles off an obviously oft-repeated lecture on Influenza, what it is, how to treat it, and how long she’ll be sick.  A long time.  He dashes off to the next goopy patient.  Mom’s handed a prescription, a school excuse, and a paper describing Influenza.

Welcome to assembly-line medicine during flu season!  Doctors and nurses have to crank patients through as efficiently as possible- there’s so many to see!  Let’s unpack what happened above.  First, what is “Influenza?”  It’s the “flu” that you get a flu shot for, and have been hearing a lot about from friends, schools, and the news.  It’s a highly contagious virus that ravages the country every year between October and April- and this year’s been particularly active.

Highly contagious means that you catch it easily, and it’s easily spread to others.  One awful fact: if a kid with the flu coughs in a room, the tiny virus-laden droplets he expels will land on surfaces and remain infectious for 2 hours.  Thus if you touch a table or arm of a chair with the virus within that time, then lick your finger to turn a page, you’ll get it.

This is why the CDC recommends everyone get the flu vaccine every year.  You could inadvertently get it anywhere- school, work, the grocery store.  Okay, so it’s super-contagious.  So what? Isn’t it just some cough and congestion, maybe some fever, and lasts just a few days?

If you’ve ever had Influenza (the “flu”), you now get the vaccine every year, realizing it’s not just a bad cold.  Besides a hacking cough and pouring nose, you have the worst fever of your life- shivering under blankets and quilts despite ibuprofen.  Your head really hurts.  Your throat feels like you’ve swallowed glass shards.  Everything aches.  You have cramps and diarrhea, maybe vomit too.  You wonder- am I dying?

Even worse, it’s been three days with this misery.  At the doctor, more bad news- it can last 7 days before abating!  This is when you make deals with yourself and God.  I’ll never take feeling good for granted again!  I’ll get the flu shot next year!  Make it stop, I promise I’ll be good!

Our hurried doctor from above, running from room to room, stamps out prescriptions and school excuses left and right.  Got to keep the assembly line going- there’s so many miserables to see.  What’s he giving out?  Tamiflu.  Influenza is one of the few viruses for which there’s a medicine that makes it better.

However, it’s not a miracle drug.  Your kid’s not going to pop out of bed next day turning handsprings.  It shortens the course a little- a day or two.  It makes you a little less sick, and also importantly, a little less contagious to those around you.  But you’ve got to start Tamiflu within 48 hours of symptom onset, or it won’t help.

You wonder when you have the flu, am I dying?  Unfortunately, sometimes the flu does kill.  It’s particularly worrisome for the elderly, the pregnant, and the sickly.  Children who are already medically vulnerable- asthmatics, ex-preemies, special-needs kids, kids with heart conditions, are at high risk.  This is a big reason doctors, the CDC, and state health departments insist people get vaccinated.  With the vaccine and hand-hygiene, deaths are preventable!

So get your kid their flu vaccine now- it’s not too late.  Make sure they wash their hands.  And for goodness’s sake, if they have a fever, keep them out of school and get them seen at their doctor’s.  For their sake, and yours!  

The Mundane Epidemic

The big medical news recenlty is either about Influenza (the “flu” you get a flu shot for), or measles, which has had recent national outbreaks in undervaccinated communities.  However, we’re also having a local outbreak of “stomach virus”.  Though it’s certainly a more pedestrian illness than measles or influenza, try telling that to the parents of kids who re-enact the pie-eating-contest-vomit-fest from the movie Stand By Me.

Vomiting is distressing.  It’s just plain disgusting, and many parents get nauseated themselves at the sight.  And they have to clean it up!  Nausea and vomiting are miserable for kids too- it feels lousy.  Parents often have a more profound worry- what if he won’t stop vomiting and gets dehydrated?  That’s when they come to the Emergency Department.

Most vomiting lasts only a half day or so.  However, parents often panic at the first vomit: it seems like so much!  In their disgust, they overestimate the actual volume, seeing the kid from that movie spewing gallons of blueberry smush.  Then after a few more vomits, parents worry about intake, and push too much liquid, or worse, food.  This taxes the stomach, and more yakking ensues.

However, kids do have some reserve; there’s time to work this out.  After vomiting, wait an hour for the stomach to settle.  Then start small amounts of fluids like pedialyte, sports drinks, or dilute juices.  This means just an ounce or two.  Wait a half hour, then give another few ounces.  Then another.  When those little bits are staying down, then gradually increase the volume.  Your child may start begging for more as she starts to feel better, but be strong and be patient- better to hold down a little than throw up a lot.

This method, called Oral Rehydration Therapy, is one of the greatest medical inventions.  It seems simple, but before ORT, the pediatric death rate from third world cholera and dysentery epidemics was astounding.  These are much more violent infections than their benign American counterparts, and doctors were amazed how many kids could “feed through” these illnesses without needing expensive and scarce IV treatment.

My family is fortunate that we haven’t had many stomach viruses.  One time we did we were vacationing in New Mexico, and my wife and I had gotten a babysitter to go out to dinner.  When we got back, the babysitter looked like hell, having cleaned up vomit from our two daughters. Only our son seemed unaffected.  I went to tuck him in, and there he was with the covers pulled up to his chin.  “Dad, I hate to tell you this,” he piped in his 8 year-old voice, smiling sheepishly, “but I just had diarrhea.”  In the bed.

Parents are grossed out by diarrhea, just like with the vomiting we discussed above.  It can also be accompanied by painful cramps.  And like with vomiting, parents start to worry about dehydration, particularly when they feed the kid some fluids or food, and it seems to pour right out the back end.

Kids typically absorb enough fluids to get by though, even if it seems to run right through.  In fact, the quickest way to get your child better is get them on their regular diet as soon as possible.  They won’t feel like eating much at first, so like with vomiting, start with fluids like pedialyte for babies, sports drinks or dilute juices for older kids.  No full strength fruit juice- that sugar load can act like a laxative, and make diarrhea worse.

When your child can eat, back to their regular diet.  A generation ago we were told not to give milk with diarrhea, but now the thinking is when you’re eating your regular food, including milk and yogurt, your guts get “back in balance.”  No heavy, greasy foods like fast foods though, whose fat loads can also worsen diarrhea.

The best treatment for stomach viruses is prevention. Kids contract these bugs by putting contaminated fingers in their mouths (don’t go “ew,” you do too!).  Thus they should wash their hands before eating and after using the bathroom. If your child vomits more than 12 hours, or has diarrhea for more than 4 days, call your doctor for medicine that can stop vomiting.  Unfortunately, there’s not great medicine for diarrhea.  Pepto-bismol or Imodium may slow it down some, or help with the cramps, but they’re not miracle cures.  Typically you just need to….let it pass.

Unsociable Media

This week’s guest columnists are Drs. Meghan Gaddis and Mark Carreras, Family Practice residents at the University Hospital and Clinics here in Lafayette.

I’ve been thinking on how things have changed for kids in recent decades.  It seems  the days of riding bikes to friends’ houses, playing outside until the street lights come on, and having water balloon fights on hot summer days, are gone.  Parks and playgrounds in my hometown that were once packed are now empty wastelands.  Kids no longer rely on their imaginations for play, some even repulsed by the thought of going outside and getting dirty.

As adults, we’re witnesses to a generation growing up not doing the same things we did. One of the culprits that’s robbed our kids of such adventure is the advancement of technology.  Kids don’t have to deal with the disappointment of riding bikes to a friend’s house only to find him not home- they just text to communicate.  No waiting for Christmas or birthdays for a toy they’ve been yearning for- just a few clicks and Amazon brings it to the doorstep.

Of couse there’s good and bad sides to technology.  While computers have taken over a large part of children’s play, they’ve also enhanced parts of our lives.  Modern medicine relies heavily on technology and its advancements.  It was an old joke about doctors’ bad handwriting in their notes and prescriptions, which was sometimes a medical risk if a pharmacist mis-read instructions.  Now it’s all printed and legible.

A hidden risk for kids is the accessibility of a potentially dangerous side of modern tech- social media. In the United States, 77% of the population has a social media profile, on Facebook, Instagram, Twitter, etc.  Social media is taking over a large part of our lives.  We’ve all enjoyed social media’s benefits.  I’ve connected with many old friends and family I haven’t seen in years.  I’ve also been able to network with other professionals with similar interests.  But just as we’re able to access a world of others, so can our kids.

Imagine letting your child wander through the worst neighborhoods in a big city, all alone.  She might be threatened by strangers, certainly would be scared, and bad things might actually happen.  Modern technology has made this nightmare more possible for kids, in social media.  Kids can be bullied by scores of schoolmates, and strangers too.  Predators may lure them into unspeakable situations.

We see lots of victims of social media in the Pediatric Emergency Department.  Besides injuries and illness, we take care of psychiatric emergencies- depression, aggression, suicide. Often the bullying that finally drove the child to the despair of contemplating killing herself started online.  Consider these statistics:

-88% of teens have seen someone be mean or cruel to another person on a social networking site.

-15% of teens say they were a target of online cruelty.

-8% of teens got into a physical fight over something posted on social media.

–29% of sex crime relationships were initiated on social media.

These are the victims.  But any kid on social media is at risk if they have unregulated access.  More stats: 

-67% of teens know how to hide their online activity from parents.

-22% of teens log on to social media site more than 10 times per day.

-85% of parents with teens report that their child has a social networking profile

-29% have been stalked or contacted by a stranger

The best way to avoid this is to closely monitor your child’s online activity.  Frequently talk to them about what they’re seeing, and with whom they’re communicating.  Ask them if they’re being bullied, or recieving messages from stangers.  Get them used to talking openly about it, and see for yourself what they’re reading and writing.

Some teens argue that this is an invasion of their privacy, and fight monitoring tooth-and-nail.  And as we just stated, most teens know how to hide their activity.  The best way to avoid this is to early in their lives, before they’re teens, let them know that there’s no such thing as online privacy.  Explain to them this contract: from the first day they get access to a screen, if you’re paying for the access, you get to see it all.  And just like you wouldn’t let them wander through the city lost and alone, you wouldn’t leave them all alone in the online jungle either.

 

Live More Amish?

In her book “Animal Vegetable Miracle,” author Barbara Kingsolver describes a year where she feeds her family only locally grown food.  When she vacations at an Amish farm to see how they do it, her hosts are fascinated by her Prius.  In reality, the Amish aren’t against all technology. They just choose what won’t “change their lives for the worse.”  For instance, when milking machines could replace the need for repeated lifting of 80 lb. milk cans, difficult for children and small women, the community voted to allow them, so that the whole family could work together milking the herd.

When parenting, we should make similar decisions about what technologies to adopt for our children’s health.  Some fruits of technology are certainly harmful, like packaged snack foods and sodas, and polluted air, water, and soil.  Some technologies are undeniably good, like municipal clean water.  But with most, there’s a tension in doing more good than harm.

One such tension is the use of antibiotics.  In some cases, where a child has pneumonia or other life-threatening infection, antibiotics are a god-send.  However, antibiotics are overused, like when a child has a virus.  Antibiotics don’t kill viruses, but many parents and doctors want to use them anyway, “just in case.”  When too many antibiotics suffuse the environment, the bacteria they’re meant to kill develop resistance to them.  Then one day when a kid gets that pneumonia, the antibiotics won’t work.

Besides not insisting on antibiotics for that green runny nose, there’s lots more good choices you can make for your kids to keep them on the good side of technology.  Certainly the more home grown or locally sourced foods you buy, the better for them.  Supermarket foods’ packaging and advertising scream about their healthfulness, but  they don’t come close to the bread and produce from the farmer’s market at the Horse Farm.  Likewise, a pedal bike is certainly safer, and healthier, for your child than a powered one.

Finally, as we discussed last month, playing a game of tag or reading a real book at bedtime are better than video games and phones.  I’m not against these technologies- I’m writing at a computer right now.  But later I’m going to the library to check out a book.

Many in the world are forced to live like the Amish we discussed above- little technology, lots of hard farm work.  They must live this more “natural” lifestyle, rather than choose it as the Amish have, because of poverty. I just returned from my annual medical mission trip to Honduras, where I’m immersed in their world of cooking on open fires, sleeping in huts that let in weather and insects, and having to walk everywhere.  

While we enumerated the advantages of natural living above- home-cooked food, fresh air, and exercise, there’s reasons those in the third world have shorter lifespans.  Cooking fires fill the home with smoke, leading to asthma and burning eyes.  Insects brings itchy bites, disease, and sleepless nights.  Unending, back-breaking work wears out bodies.  And there’s no modern medicine nearby to bring relief for these problems.

And yet, the kids seem pretty happy.  WIthout smartphones, video games, cable, or even toys, they have smiles on their faces.  They play and carry each other around.  They innovate.  And they are resilient, putting up with dental extractions without a cry or tear.  When we bring paper and crayons, it’s a popular draw, almost more so than the dental, medical, or eyeglass clinics.

In fact, with their resilience and innovation, these kids often seem smarter and more capable than their American counterparts. If the natural life is so good for people and their brains, how did Europe and North America come to rule the world?  In his book “Guns, Germs, and Steel,” anthropologist Jared Diamond recounts being asked the same question by a New Guinea tribesman when Diamond pointed out how smart his people were. The book’s short answer: dumb luck. Europeans weren’t superior; they just happened to settle lands with richer soil and better livestock, which is the basis of a society’s wealth.

So be thankful you can choose your technology; but do as the Amish, being careful to use only that which makes you and your kid’s lives better, not worse.  Have them play freely, finding their own resources instead of having them provided by a computer.  They’ll get some exercise too. 

Island of Misfit Toys

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

I have fond memories of Sunday dinner at my grandfather’s.  We followed the same routine: mom brought the potato salad, grandmother made fried chicken, grandfather made the coffee.  And we’d play games: dad liked horseshoes, my brother… lawn darts.  Remember lawn darts?  They were comically-enlarged versions of traditional darts with a weighted end, to be tossed in the air at a target on the grass.  You may not remember them because of the Consumer Product Safety Commission, a government agency that banned them after several children were injured, some critically.

Many toys have been removed from the market over the years.  Some people think “they’re taking childhoods away from us!” Perhaps, but lawn darts had a proven record of hazards, and some toys prior to the Safety Commission’s founding were just flat-out ridiculous.  Look up the Gilbert Atomic Energy Lab, a toy marketed in 1950 by Alfred Gilbert (inventor of the more popular, and safe, Erector Set).  This set contained actual uranium ore which, besides producing cool effects, brought low levels of radiation into the household, and could cause radiation burns if handled improperly.  One play suggestion: secret the ore somewhere in the house, and play hide-and-seek with the included geiger counter.

Another obvious benefit of this agency was the removal from the market of Aqua Dots, an arts-and-crafts toy with beads manufactured in China.  After several toddlers were hospitalized with comas after ingesting the beads, they found that their chemical coating contained GHB. Popularly known as the “date rape” drug, GHB is particularly toxic to children.

A more routine responsibility of the agency is assigning age ranges for toys.  There’s a common misconception that the age suggestions are based on intellect or maturity level.  Thus parents buy the toy or game for their child who’s younger than the age range, thinking that their kid is advanced enough to enjoy it.  However, the age range is actually for safety’s sake, particulary for kids under age 3.  It’s decided by rigorous testing to assess the choking risk of small parts.

I recall when my brothers and I got our go-kart.  Back then, a go-kart was a glorified piece of sheet metal with wheels bolted on each corner, one of which attached to a small motor.  I vaguely remember a steering mechanism, but we ran into trees and dirt piles so much I can’t be certain.  It’s easy to remember the safety features though, because there were none.  Of course our parents didn’t make us wear helmets either.  I carry a reminder of that go-kart on my right elbow, a shiny white scar from when I jumped off while riding on the back, one thing mom did specifically warn us not to do.

Things have changed since then.  Go-karts and other motorized toys have become more complex.  While there’s been some focus on safety, they’ve also gotten more powerful, with new and different dangers.  With advancement in battery technology, there’s even electric dirt bikes for kids, though their size and speed don’t necessarily correlate with age-appropriateness.

Like we discussed above, the Consumer Product Safety Commission sets age levels for toys and games.  Though they base these assessments on proven algorithms, the science is still evolving concerning motorized riding toys.  For example, many of these are intended for use on dirt roads and isolated driveways.  They are unsafe on paved streets, particularly top-heavy and overpowered ATVs.  Another consideration is use of these toys by children with Attention Deficit Hyperactivity Disorder.  These kids have  decreased attentiveness and a penchant for risk-taking, so it’s important to keep in mind your child’s potential for accidents.  And bad injuries happen with these toys to any child, ADHD or not.

Parents can limit the use of these devices, ensure safety measures, and purchase them with their child’s capabilities in mind.  Helmets, elbow, knee, and wrist pads, and boots are helpful.  Designate safe areas for play, keeping kids off roads where they’re hard for cars to see and avoid.  Set use hours with the best visibility, for kids to see hazards and the hazards (cars) to see them.  Be there when your kids are riding or using potentially dangerous items.  We see castastrophes all the time in the Pediatric ER; don’t let your child be one of them.

 

Phone Zombie Children

Portable and “wearable” computers, according to designers, are supposed to enhance the human experience.  Like science fiction cyborgs with a fitting over one eye, the user goes through the world with “augmented reality,” being fed data about what he’s seeing.  So far though, the most ubiquitous portable computer, the smart phone, seems to de-augment reality.  The user walks through the world texting, until he caroms off a lamppost that reality put in his way.

The latest generation of kids are growing up with much of their reality supplanted by screen time.  Phone apps and tablets designed for toddlers are perhaps teaching them, mostly entertaining them, certainly keeping them quiet.  The proponents of this technology brag that it enhances their learning, teaching them words and math, making learning fun. The detractors worry that these devices are raising a generation of zombies: drooling slaves to their screens, unable to have a conversation, much less hold down a job.

The scientific jury is out on this subject.  We won’t know for another 10 years how this generation will turn out.  There were similar worries for my generation, the first raised with television, and we haven’t seemed to make more zombies than before.  However, small screens are different than a TV set.  Instead of just watching it in a room and then walking away to do other things, now you bring the screen with you everywhere you go.  And you interact with it- ask it questions, communicate through it, play games with it.

One thing we do know- these devices can be addictive, which affects at least some people, which we’ll go into more below.  For your child’s mental development, well-being, and happiness, stick with the American Academy of Pediatrics guidelines for screen use, applicable to TVs, PCs, phones and tablets.  Don’t allow your child under 3 years-old to use these much at all.  This is a time of critical brain development, when the abilities to learn, to practice interactions, and to love and be loved, are hard-wired.  It’s best for the human parent to do this, since the computer as child-rearer is nowhere near a “mature technology.”

Everyone knows of a computer addict.  It’s often a teenager or young adult, raised on video games, who can’t quit.  Holed up in their rooms, they play and play, not showering or doing homework, mawing junk food without thought. They don’t get jobs or boyfriends or girlfriends.  Their parents wring their hands, torn between enabling their kids’ addiction and the horrible behavior that ensues if they cut them off.

Like drug addicts, these kids become monsters when their devices are removed. They scream that the parents hate them, and that they hate the parents back.  They break things, steal and lie, then leave the house to get their fix on a friend’s computer, or a stolen phone.  Even toddlers can display this behavior when their tablets or phones are taken away, throwing violent tantrums until the parents acquiesce.

Like we discussed above, the science is still out about how harmful screens- computers, games, and phones- are to children.  One question: will they turn only some people into zombies; like alcohol, where a few people get addicted, but most people drink in moderation?  Or are they more like heroin, so addictive that any exposure is risky?

There’s no doubt that these devices are helpful to busy parents, keeping the toddler quiet when necessary, like when waiting in an office or the DMV.  Otherwise the parent must keep the toddler quiet themselves, when simultaneously trying to have adult conversations.  But when are screens too much?  What’s the line between raising an intelligent, happy, and loving kid; and letting the screens turn the kid into a computer zombie?

While waiting for more science, The American Academy of Pediatrics has put out guidelines for children’s “media diet,” based on what we do know.  Babies under 18 months-old should have no screen time.  Kids between 18 and 24 months can have a little, but it needs to be “high quality” (think PBS), and parents should sit with the child to monitor and talk about what they’re seeing.  Kids between 3 and 5 years should max out at only one hour per day, again high quality, with the parent present.  Over 6 years, the screen time should be limited to not supplant more important activities like family meals, reading, playing with friends, and sleeping in a screen-free bedroom. 

Opposite of Obesity

This week’s guest columnists are Dr. Jacob Sellers and Dr. Anna Malesky, Family Practice Residents at the University Hospital and Clinics here in Lafayette.

Imagine this.  Your teen has been experiencing months of headaches, dizziness and fatigue.  You’ve been to countless doctors, had blood tests and EKGs, and finally she has a diagnosis.  “We don’t know exactly how it happens,” this last doctor explains, “but untreated, there’s a 1 in 10 chance it could be fatal.”  Your heart sinks.  Bad news continues: “It will take many months, even years, for your daughter to fully recover. She should be admitted to the hospital now to start treatment.”  The diagnosis: Anorexia, a psychological illness that’s more common than you’d think.

Anorexia is an “eating disorder,” wherein the teenager sees themselves as overweight, and goes to extremes to lose weight.  Even when skinny, anorexic teenagers still think they need to shed more pounds.  Their intense fear of weight gain leads to severe dieting, purging through vomiting or laxative use, and calorie burning through vigorous exercise.  Anorexia has the highest death rate of any psychiatric disorder, about 10%.

Bulimia is the other common eating disorder, consisting of uncontrollable overeating, followed by distress and guilt.  This leads the teen to purge by vomiting, laxative use, and extreme exercise.  Eating disorders affect girls ten times more than boys, and these girls tend to be intelligent and capable, enabling them to achieve life-threatening feats of weight loss.

These kids rarely seek help- they want to lose that weight.  Parents can miss the early warning signs too, being so busy with their jobs and other kids.  Teens often have vague complaints that mimic other common illnesses- headaches, fatigue, dizziness, abdominal pain.  They also have behavior changes that are passed off as normal teen “phases”- moodiness, wanting to be alone, body image concerns, frequent trips to the bathroom.  More obvious changes are noticeable weight loss, wanting to eat alone, and only eating at certain times.  Affected kids will refuse to eat favorite foods, not eat at restaurants, and not eat at holiday gatherings where the rest of the family is stuffing themselves.  If you notice these signs, get your child to their doctor for a weight check and evaluation.

Teen girls are more susceptible to eating disorders, because mass media has always shown the ideal girl to be skinny.  TV, movies, and even Barbie dolls depict girls with unrealistic proportions, leading kids to have unrealistic expectations for their own body image.  Thus one facet of eating disorders, where even skinny girls still perceive themselves as overweight.

Social media has complicated the issue with the rise of blogs and websites that encourage eating disorders.  These websites, often called “Pro-Ana” for anorexia promotion and “Pro-Mia” for bulimia, aim to support kids with this behavior by putting a positive spin on it, providing “thinspiration.”  They post tips on how to vomit, how to dose laxatives most effectively, how to think about food to make it less appetizing, and most darkly, how to hide this behavior from parents.

Like we mentioned above, teens rarely seek help for eating disorders.  Often they hide it so that no one interferes with their weight-loss efforts.  However, these behaviors can be life-threatening: 10% of anorexics will die if untreated.  Anorexia became a much better known illness after the famous singer Karen Carpenter died of heart failure at age 32 as a result of her weight loss.  Eating disorders can cause dehydration, heart arrhythmias, low blood pressure, slow heart rate, and low temperature.

Thus it’s important to be vigilant for the signs of eating disorders.  If your teen seems to be getting skinnier and skinnier, get her seen.  But some signs are often passed off as healthy activities, like dieting and exercise. Other signs can be attributed to teen “phases,” like moodiness and wanting to be alone.  Physical symptoms include always being cold, dizziness and fatigue, and headaches.  Starvation also leads to thinning hair, brittle nails, dry and discolored skin, and loss of menstrual cycles.  Like we mentioned above, red flags are peculiar eating habits, like only eating at certain times, wanting to eat alone, or not eating with everyone else at restaurants or holiday gatherings.

These are difficult illnesses to treat.  The sooner you recognize your teen’s eating disorder and get her evaluated, the more successful the treatment, and the likelier you’ll be to save her life.   

Stressed Teens, Stressed Parents

The parents brought their teenager into the Emergency Department because she was acting bizarrely.  The normally cheerful, outgoing girl was suddenly sullen, irritable, and lashed out at the slightest provocation.  She also seemed paranoid, suspicious of everyone around. Usually ready to hug, she now acted afraid of any contact.  During my physical exam her eyes darted back and forth, and she flinched when I reached out with my stethoscope.

The onset of mental illness can seem sudden.  In medical school they called it “the psychotic break,” where previously well teens become paranoid or delusional, often when faced with new stress, like moving away to college. This break was thought to herald life-long illness like schizophrenia or bipolar disorder.  However, it turns out that most teenage psychological troubles have a slower, more subtle beginning; and if treated early, can have a happier ending.

Seemingly dramatic changes in behavior are often preceded by symptoms that are missed or denied by teens or parents.  These include weight loss and drop in appetite, plummeting grades, chronic abdominal pain or headaches, irritability and combativeness.  These can easily be dismissed as normal teen “phases,” which they often are. Unless they’re not.

Other signs that your teen is coping badly are…having to cope.  Profound stress can push your teen to depression or other maladjusted behaviors.  Are parents divorcing or having other troubles, like infidelity?  If you as a parent think you’re stressed by the situation, it’s as bad or worse for your kids.  Love and security that they counted on their whole lives has now blown up.  Many divorcees state that they wouldn’t have divorced if they’d known what it would do to their kids.  Other profound stressors include moving; a parent’s job loss or other economic hardship; and death of a loved one, like a friend or close grandparent.  If your kid’s facing these issues, be ready to get help.

The more distressing symptoms of mental illness, like our girl above, are clearer signs that it’s time to get help now.  These include alcohol and drug use, sexualization or being sexually abused, eating disorders, or paranoia and hallucinations.

It’s no fun dealing with angry parents who make their teen’s mental illness a battleground.  Often they bring their kids to the Emergency Department demanding that they be drug-tested, to “win” the fight over suspected abuse.  In the most recent instance, after I told a mom that we could not legally force a drug test on a teen, she stormed out of the ER, yelling that it was her right to know.  Fortunately, the teen stayed behind, and we had a good talk about her drug use, her depression, and how she could get help.

Having proof that your teen is using drugs won’t make him or her snap-to.  Looking back, I could have handled the situation better by asking the mom, “how will a positive test help you and your child?” and explore the issue from there, rather than shut her down with the law.  If the girl’s behavior already made mom worried that she’s abusing drugs or alcohol, that behavior is often evidence enough that she needs help, better than a drug test.

Like we discussed above, symptoms of depression or other mental illness can be subtle, or not-so-subtle- weight loss, plummeting grades, chronic headaches and abdominal pain, drug use and promiscuity.  Now that you’re properly scared, where to get that help?

If you belong to a major denomination church, clergy and staff often have training and offer competent counseling.  Your child’s doctor should have a list of mental health services, and some even do counseling and anti-depressant prescribing themselves.  School counselors also should know their cohorts in the community.  You’ll want a counselor that partners with a psychiatrist or other provider who prescribes.  Anti-depressant or mood-stabilizing medication often helps get teens through a bad patch, and keep them steady as they learn new, healthier habits with thinking and interactions.

If you find yourself getting angry at your teen’s behavior, when they’re combative, sullen, or just plain lazy, take a step back.  Maybe they’re not acting this way to piss you off, maybe they’re crying for help the only way they know.  Laziness may just be laziness, or that inability to get off the couch could be depression.  Don’t take it as a personal affront, take it as a call to action.  

AIEE! I’ve Hurt My Eye

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

It’s a pumpkin-decorating party, and the carving tool seems safe.  The edge is serrated, but the tip is blunt and it’s plastic, not metal.  But when you turn your back, your 8 year-old girl screams “OWW!”  She’s got her hand over her right eye, and yells, “I poked myself in the eye!  I can’t see!”

In the Emergency Department, the doctor sees a defect in the cornea, that clear dome in front of the iris and pupil.  If it’s a hole, he explains, that’s serious.  He calls the eye surgeon, who recommends starting IV antibiotics, and she’s on her way in.  Your girl may need surgery.

Eye injuries can be worrisome.  Often it’s just a scratch that heals fine, but sometimes eye pokes can lead to vision loss. The simplest injury is a scratch to the cornea, called a ”corneal abrasion.”  This means the cornea is scraped on it’s outer layer. These hurt so much that it’s hard for the child to open her eye.  They require pain control and infection prevention.  We’ll prescribe an antibiotic ointment that soothes the scratch and stops infection, and advise ibuprofen or tylenol. If not cared for properly, sometimes abrasions can become ulcerated and leave a permanent scar on the cornea, which impedes vision.

Another simple injury is the subconjunctival hemorrhage.  This is when the white of the eye gets poked, and blood pools in the outer layers.  It’s essentially a bruise of your eyeball, but the tissue is so thin and white that it’s bright red, unlike the usual blue bruising of skin.  These heal fine, though it takes a week for the blood to reabsorb.

If the eyeball is penetrated, this is serious.  Surgery may be necessary to save vision, with possibly some permanent vision loss anyway.  Even the other eye could be endangered, a phenomenon called sympathetic ophthalmia.  When one globe is penetrated, the immune system sees the eye’s interior as foreign, attacks the injured eye, and attacks the good eye as well.  Unchecked, the child’s immune system can damage both eyes.

Toddlers are explorers.  Unfortunately, many families keep poisonous substances under the kitchen sink, where toddlers go.  They grab the cleaner or dishwasher pod, open it, and poof or squirt it in their eyes.  Screaming ensues.

Chemical burns to the eye, like the poking traumas we mentioned above, can have serious consequences.  They initially impact the cornea, that clear dome in front of your iris and pupil, and burn it, causing intense pain.  Left unchecked, they can penetrate the cornea and damage deeper eye structures.

First things first-wash it out!  This is hard with toddlers and even older kids, but it’s crucial to stop the damage.  Often it takes two people, one to hold the child and another to hold the eyelids open and pour in lots of water.  After that initial wash-out, head to the Emergency Department.

In the ER, we put numbing drops in the eye to make further wash-outs less miserable.  Then we wash with saline solution multiple times, because chemicals can hide in the lacrimal sac, a tear-collecting reservoir between the corner of the eye and nasal bridge.  After one wash-out, chemicals can squirt out of that sac back into the eye and cause further burns. After this is over, we refer to the eye doctor to assess the extent of injury.

Blunt eye trauma- punches in the eye, or blows to the face with a ball, are easier.  These often don’t injure the eyeball, because it’s protected by the eyelids and brow.  Simple bruising, black eyes, and swollen eyelids are treated with ice or cool compresses, and pain medicine like Tylenol. Check your child’s vision. Blurry vision needs an eye doctor, since the shock wave from blunt injury can damage structures important for seeing.

Eye “foreign bodies,” like sand or eyelashes, can cause intense pain, and lead to corneal abrasions like we discussed above. Though they usually don’t cause serious damage, they really irritate!  If you know it’s something simple like dirt, sand, or an eyelash, washing the eye out often removes the object.  If you can see it, sometimes you can dab it out with a cotton swab.  If pain continues after removal, or your child has blurry vision, come on in! 

Thanksgiving

Sometimes I wonder what I’d be like if I was born in 1800.  I’d be crippled, since I have an arthritis requiring regular medication.  Once the arthritis affected my eyes and without medication, I might’ve become blind.  Then one time a mosquito bite on my calf got infected, my knee swelled up, and it took surgery and a month of antibiotics to clean up.  In 1800 the cure for this infection, to save the patient’s life, was a mid-thigh amputation.  Without anesthesia.

Modern medicine gives me lots to be thankful for, not being a one-legged, blind, crippled guy.  In the late 1800s anesthesia was invented, so patients didn’t have to be strapped down and shriek through their operations.  Also at that time aseptic technique was discovered, so that patients wouldn’t get infected during surgery.  Before that, surgery was a last ditch effort to save people, since many died from bacteria introduced in surgery.  Then in the 1930s, antibiotics were invented, another breakthrough that made today’s whole Scott possible.  Finally, the 20th century brought anti-inflammatory and non-narcotic pain medication.  In the 1800s the only pain medications available were opioids like laudanum, which was opium dissolved in alcohol.  That would’ve made me a one-legged, blind, crippled narcotic addict.

My pediatric patients have lots to be thankful for as well.  When I was a kid, if a child developed leukemia, the most common pediatric cancer, he was certain to die within months of diagnosis.  Today, leukemia has cure rates above 90%.  The majority of my cohorts who had cystic fibrosis, sickle cell disease, congenital heart defects, extreme prematurity, were dead by the time I had my fifteenth birthday.  Today most of these kids will live into old age.

Finally, in 1900, one in ten babies died before their first birthday due to infections like diphtheria, tetanus, and, pertussis.  One in three were dead before age 5. Thanks to improved living conditions and vaccinations, these deaths are rare.  During my own 26 year career, the invention of  meningococcus, pneumococcus, and H. Flu vaccines have emptied pediatric wards that were once filled with kids with meningitis and blood infections.  Modern medicine has kept me whole, and countless of my own patients.

What if there was an apocalypse, and technology reverted back to the way things were in, say, 1800?  The best-selling book, Station Eleven, explores what life might be like if a flu epidemic wiped out the majority of the world’s population, and civilization collapsed.  The book jacket come-on asks, “What would you miss most?”  Coffee?  Electric lights at night?  Recorded music?  Air-conditioning?

If this sounds like science fiction, don’t get too comfortable in that thought.  In 1919 the Spanish Flu epidemic was unimaginably huge.  One in four people on the planet got sick.  Millions and millions died.  In some towns, so many were sick that there weren’t enough able-bodied to bury the dead.  Today, when things go bad with water supplies after hurricanes in parts of the world, there are still cholera and typhoid epidemics.  One bad virus could turn the whole world into post-Katrina New Orleans, with few left to keep the lights on, bury the dead, and maintain order.

The movie Contagion, with an all-star cast including Gwyneth Paltrow, Laurence Fishburne, and Matt Damon, tells a more likely scenario.  In this film, the flu epidemic wipes out a lot of people and whole cities are quarantined, with resulting movie mayhem.  However, the CDC and government keep a lid on things while struggling to isolate the virus and develop a vaccine.

So this Thanksgiving, be thankful for the good things modern medicine has given us.  Like we discussed above, medical advances have kept so many more children alive than a hundred years ago- kids with infections, cancers, sickle cell disease, cystic fibrosis, and extreme prematurity.  Don’t let thanksgiving become complacency either. Though we rarely see kids with diseases we vaccinate against- meningitis, pertussis, polio- doesn’t mean they’re not out there, waiting.  Make sure your kids have their vaccines.

When I worked in the Philippines in 1998, where many don’t have the luxury of vaccination, I saw two kids die of tetanus.  One was an un-vaccinated teenager from a rural village.  He had stepped on a sewing needle, which inoculated him through his foot.  He died a slow death by asphyxiation, as his chest wall muscles spasmed and wouldn’t allow him to breath.

Be thankful for vaccination!