Play ‘Til It Hurts

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

“Winning isn’t everything, it’s the only thing.”  This quote, made famous by Vince Lombardi, is a mantra for generations of athletes.  This attitude permeates all sports, even at the youngest level.  If you watch Esquire Network’s “Friday Night Tykes,” you’ll understand how intensified kid sports and sport-related injuries have become commonplace.  You’ll see football coaches yell at children like they’re college phenoms, and then watch the kids get seriously hurt.

Every year, more than 3.5 million children under age 15 require treatment for sports injuries.  This evolution from mere games to full-on quests to turn kids into tomorrow’s superstars has caused a rise in injuries.  What are the perils of youth sports today, and how can we avoid sports-related Emergency Department visits?  One peril is concussions, particularly when kids are charging at each other with extra zeal.

Bailey was a 14 year-old soccer player.  In one tight game she came head-to-head with not another player, but her greatest opponent, the ball itself.  She took her eye off of it for a split second and it struck her in the forehead.  As she lay on the ground, all she remembered was the brightness of the lights and the hush of the crowd.  She tried to stand up but felt too dazed, and began having a headache and nausea.  The coaches were worried she had a concussion, so her parents took her to the ER.  Hours later, after a CT scan of her head, she was discharged with instructions to not play or even work out for at least a week.  Intense play resulted in a long time on the DL.

The American Academy of Pediatrics recommends kids who sustain a concussion be evaluated by a doctor before returning to play.  They need “brain rest,” to resolve the symptoms and let their brains heal.  This means physical rest and “cognitive” rest, relieving the thinking part of the brain.  Cognitive exertion, like homework, video games, or school work may worsen headaches, nausea and fatigue, and make them last longer.  Some kids need weeks or months for these to go away.

12 year-old Bradley was at bat.  Bases loaded, bottom of the ninth, he envisioned his  hit sailing over the outfield wall.  Instead he took the pitch to his ring finger.  He missed the post-game festivities, finding himself in the Emergency Department getting x-rays.  The finger was broken.  

Besides broken bones, or concussions like Bailey’s story above, kid sports injuries often happen less dramatically.  While Bailey and Bradley’s mishaps could happen in sports at any level, the intensification at youth level often leads to overuse injuries we used to see only in college or professional athletes.

Take Little League Elbow.  This didn’t exist when I was young, but now happens to kids who throw too much.  It mostly affects pitchers, but anyone who throws baseballs or softballs a lot can get it, stressing the ligament on the inside of the elbow.  The ligament becomes inflamed, swollen, and hurts.  In extreme cases the underlying bone can come apart, or kids can develop arthritis.

To prevent Little League Elbow, everyone’s now aware of the pitch count.  There’s tables to tell how many pitches children are allowed by their age, but coaches need to be careful.  The school coach may hold his pitchers under their counts, but does he factor how many pitches the kids are throwing at private lessons, or with a select team?  The sum of all those should be under the safety number.

Better prevention of overuse injuries, and more fun, is to vary children’s sports.  If a kid loves sports, she should do a variety- soccer one season, running another, baseball another, etc.  Also, parents and coaches need to dial back the intensity.  The science is clear- too much training is more likely to lead to an injury, rather than to a college scholarship. Kids should learn injury prevention skills like hydration, warm-up exercises, warm-down stretches.  They shouldn’t be pressured to play hurt, but instead encouraged to speak up when in pain.  Then they need adequate rest and rehab.

Preserving young athletes’ health is everyone’s responsibility: coaches, teammates, parents, and physicians.  It’s a balance between keeping kids out the ER, and heeding the call to ”Put Me In Coach!”

Killing Time Constructively

A friend’s son wanted help picking out his sister’s Christmas gift.  “What are her hobbies?” the son asked.  My friend was stumped: “Buying clothes?  Talking on her cell?  Eating at Whataburger?”  After a good laugh, they got serious.  She liked to run, and she loved to cook.  Get her something for the kitchen?  A kit for baking something extravagant maybe?

Everyone’s busy, kids too.  My own daughter in college is stressed with school work, her campus job, and sorority duties.  I worry that when my kids are adults, will they be too busy to have fun, to re-charge and enjoy the world, rushing through life and wondering where it went?

Hobbies are fun things done for their own sake, and they’re important for being healthy.  It’s time spent forgetting worries, doing something only for the sheer joy of it.  I see many kids in the Emergency Department with anxiety and depression, who have no fun.  To be fair, they aren’t unhappy just from a lack of hobbies; they have plenty to be miserable about.  There’s bullying, in-born mental illness, living in abusive households.  But even for them, maybe if they just had something to escape to….

Developing hobbies is important for kids. Video games and other screen times don’t count.  I also in the ER see the consequences of too much sitting still- obese kids, some already with adult-type diabetes and high blood pressure.  I’m talking about activities where the brain and the body are engaged, rather than the computer.

There’s various sports to try, but kid sports can be too highly organized.  Super-competitive school and select teams often become another chore for kids, organized and run by adults.  Maybe something less regimented, like skiing, hiking and geocaching, biking, fencing, surfing.  There’s other non-sport things to consider- sewing, gardening, bee-keeping, carpentry, car repair.

Trying things doesn’t always mean success.  It took several activities for one of my daughters to find her fun thing, suffering through hours of soccer and piano lessons before she discovered karate.  My other daughter slogged through years of violin before she and we gave up, and left her to what she really loved- soccer and softball.

Some people readily take to hobbies, loving everything.  That was my father: cycling, bee-keeping, sailing, model trains, carpentry, cross-country skiing.  We all were included in his activities, so we could spend lots of time with him.  He was so busy playing, I’m surprised he got any real work done, though he did have a lauded career as a professor.  Some guys have all the luck.

Fortunately for our appetites, mom did the cooking, an activity not on Dad’s list.  She didn’t grow up cooking, but learned later in life, and enjoyed it.  She most liked the gardening that put fresh food on the table, and baking desserts.

We discussed the importance of hobbies above, and one that will apparently never lose popularity is playing in the kitchen.  There’s now whole cable networks devoted to cooking, with competition shows about making food with weird ingredients under eccentric conditions.  Kind of like mom used to.

“Eating in” is now what many call cooking.  In the last century, eating at restaurants or bringing home prepared foods was a luxury few could afford.  Dining out was too expensive.  Even birthdays, when I was a kid, were a home activity, including a scratch-made cake.  For mine and most families, going out to eat was a once-per-year treat, if that.

But then McDonald’s and the rest of the fast food industry made eating out inexpensive, and wildly unhealthy.  Now this cheap, fatty food has made obesity the new sign of poverty, rather than thin, underfed kids.  And fast food has made my job harder.  I see lots of obese kids coming in to the ER with complaints of belly pain.  When I ask what they had for their last meal, it’s invariably “Burger King” or “Taco Bell.”

So get your kids interested in the kitchen, and yourselves too.  When you cook, you know what goes into your food.  You control the ingredients, the fat content, the portion sizes.  Kids learn a life skill, have fun, and get to eat!  Also consider this when shopping for Christmas gifts for your kids.  My kids used the heck out of their Easy Bake Oven, and they still love the kitchen.

Having a Hard Go

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

“Something isn’t right.  My baby only poops every three days, and all my friends’ babies go every day.  What’s wrong?” -First time mother of a four-month old in my clinic.

Constipation is common: Whew!  You’re not the only one with a constipated kid!  Almost one third of children have constipation some time in childhood.  The definition of constipation varies with age.  For the baby above, skipping three to four days between stools is normal.  Straining to poop may mean constipation, maybe not.  However, passing hard stools that hurt, that’s constipation for sure.

Besides not stooling for days, moms worry that when their infants strain and grunt, they’re having a hard time (literally?).  However, if baby finally goes and it’s soft, that’s normal.  Consider this: babies must have bowel movements while lying down, so it’s going to take some straining.  You probably haven’t tried since you were that age, but it is!

Older children can suddenly have constipation, after going regularly and easily. There’s some times in life this commonly occurs.  The first is when one year-old’s transition to solid foods and cow’s milk.  The new toddler can get constipated from too much milk, which has no fiber, and not eating enough fiber-containing foods like fruits and vegetables.  Moms think: milk is good, give him all he wants.  This kills baby’s appetite for other foods, and then comes the painful consequences.  Thus, at one year babies should only get three or four 4-ounce sippy cups of milk per day.  This lets them be hungry for more fibrous food.

The next common constipation “milestone” is potty training.  When confronted with the unfamiliar potty, toddlers often get stage fright: “You want me to do that, there!?”  Sometimes they’d rather just hold it until you give up and put the diaper back on.  If this stubbornness goes on for more than two weeks, maybe she isn’t ready yet, and should go back to diapers for another few months.

“I”m really uncomfortable and haven’t had a BM all week.  I started a new construction job, don’t get to go in the morning, and can’t use the homeowners’ bathrooms.  I’m in the heat all day and probably don’t drink enough water.” -17 year-old in the Emergency Department.

Another time children get constipated is when they start school.  They’ve been using their nice, private bathroom at home.  Now they have to get out of the house early, often skipping going.  Then at school, they have to share the bathroom with other kids.  Many aren’t respectful of bathroom privacy, sometimes out of curiosity, sometimes to be mean.  Who could go in those circumstances? So these kids hold it all day, waiting to get back home.

When you don’t poop for a while and don’t drink enough water, your body scavenges extra water from stool.  The rectum absorbs the water, poop dries up, and compacts. Then it hurts to pass.

Fixing constipation depends on age and cause.  As above, babies who skip days pooping or strain, but it comes out soft, aren’t constipated.  If baby has hard poops that hurt, the easiest remedy is fruit juice, an ounce or two twice daily.  It takes a few days to work, but the fruit sugar is a laxative, and after passing the last “rocks,” baby should go smooth.  Babies over 4 months old can have strained foods with fiber, like cereals, vegetables, or fruits, to prevent constipation.  Also, breast milk prevents constipation compared to formula.

Babies transitioning to cow’s milk, like we said above, should get only three to four 4-ounce cups of milk per day.  More than that can constipate, and kills appetites for fiber-containing foods.  Kids should eat at least three fruit and vegetable servings per day, preferably more.

For potty-training kids, if you’re fighting to get your kid use a toilet, put him back in diapers and wait a few months.  Have foot rests for your adult toilet, or a toddler toilet.  It’s harder to go without a little leverage!

If your child is having hard painful stools, and you’re thinking about a suppository or enema, talk to your doctor first.  She can help you pick more effective, less traumatic fixes for constipation.

The Happiest Meal

Feeding babies manufactured formula in a bottle is a recent invention in human history. For hundreds of thousands of years, people fed their babies like every other mammal, with mother’s milk.  If mom or baby just couldn’t make it work, there were two options. One, baby died.  Two, employ a “wet nurse,” a woman who recently had a child and was still making milk, to feed baby.

For much of human history wet nursing was a respected and well-paid profession. Since medieval times wet-nursing was regulated and licensed in many countries. Then in the 19th and 20th centuries, the invention of formula that babies tolerated, along with glass bottles and rubber nipples, killed wet nursing.  The advance of technology that fostered such eager slogans as “live better electrically” and “better living through chemistry,” also led people to believe that formula could be as good for babies as breast milk, maybe even better.

Bottle feeding, like many technologies, seemed easier too.  Breast-feeding requires some initial training for babies and moms.  While most take to it readily, some don’t. But babies take bottles right away.  However, like many new inventions, the later problems with formula turn out to outweigh this temporary convenience.  Formula-fed babies have more colic, constipation, spitting up, and infections.  And now it seems formula feeding can contribute to obesity as well.

Then, these extra baby problems haunt us in the pediatric ER.  Moms come in night and day, their babies having colds, crying with passing hard poops, spitting up all over, and squawling at night from colic.  By then mom’s milk has dried up, and fretting and trying different formulas are their only options.

Changing formulas rarely helps with constipation, reflux, or colic.  But many families continue to believe the advertising that suggests formula is still as good for babies as breast milk. Theses ads are full of smiling babies in sunlit rooms. When babies have crampy guts, they give happy names to the next-try formulas; names like Gentle-ease, Total Comfort, and Good Start Gentle. There are even formulas for toddlers now, as if suddenly cow’s milk isn’t good enough anymore either.

Advertising is an attempt to change perceptions, and it’s part of why many believe the false claim that infant formula is as good for babies as breastfeeding.  As we mentioned above, formula is a relatively recent invention in human history.  Formula has only been around for about a hundred years.  For the previous thousands of years of human history, humans breast-fed like any mammal.

But breast-feeding always had a bit of a stigma.  From ancient Egypt on, nobility felt itself above breast feeding.  Queens and princesses often employed wet nurses, mothers who recently weaned their own babies, to feed their little heirs.  Then, when 20th century technology brought ordinary people the things that only royalty used to have- personal music, indoor plumbing, ready-made meals- it also brought formula.  Now, no one had to breast-feed.

Also, the formula manufacturers advertised their products as being as good as, if not better than, breast-feeding.  Formula feeding certainly seemed more convenient, and the companies promised that babies would be even healthier with their synthetic milk.  Even today there’s a misperception among consumers, and even some doctors, that recent advances make formula as good as breast milk.  Wrong.

As we mentioned above, breast milk is far healthier for babies- less constipation, colic, and reflux; fewer infections, and a smaller chance of growing up obese.  And there’s one advantage to breast feeding that formula will never erase- the benefits of breast-feeding for mothers.  These mothers lose pregnancy weight more readily, have less post-partum depression, and have lower risk of breast and ovarian cancers.  Also, breast feeding moms don’t have to haul around all those bottles and cans!

Breast-feeding does require some training for moms and babies that bottle feeding doesn’t.  Fortunately, hospitals like Lafayette General recognize the health benefits of breast-feeding, and have special nurses to help new moms and babies from day one.  Infants are also designed to survive the first few days of low milk output and training- they are born with extra “water-weight” to get them through until mom’s milk is all in. But if you and your baby are one of the few who just can’t breast-feed, there’s still formula.

Or maybe find yourself a wet nurse. 

Extreme Adventures With Kids

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

Coming over a coral ridge, I saw everyone staring down at a rock.  That’s odd, I thought, what’s so fascinating?  Then I noticed a flicker of movement and a beady little eye peering at me.  The rock began to move and transformed into a giant sea turtle, complete with barnacles on his back.  He paddled past me and with one more glance back, disappeared into the blue.

This took place about 50 feet below the Caribbean Sea, one of many adventures I had since earning SCUBA certification.  The Professional Association of Diving Instructors (PADI) has courses for kids too, as young as eight years, in a class called Bubblemaker.  This is a safe and fun way for kids to learn diving, and paves the way to certification.  Ask about courses at your local dive shop.

But isn’t diving expensive and dangerous?  Well, there are front-end costs for courses, gear rental, and family vacations to diving spots.  However, certification is for life. Imagine the opportunities for your children to appreciate a natural world few get to see. And kids learn important lessons about conservation and responsibility.  You may also consider the less expensive alternative- snorkeling.

As for danger, SCUBA and snorkeling are far less risky than many things Louisiana kids do, like riding ATVs, motorcycles, or jet-skis.  Far more kids are injured on these vehicles than SCUBA.  SCUBA has the advantage of stringent classes that thoroughly drill safety and responsibility.  And while anyone can zip around on ATVs or boats without proper training or safety gear, it’s hard to find a dive crew that’ll take you out without PADI certification and proper equipment.

So if you’re looking for another way to get your kids away from their phones and video games and into the great outdoors, consider SCUBA.  You can have shared adventures and create some science enthusiasts in your kids.  They’ll see exotic animals and plants in another world, and you’ll have life-time family memories.  I’ve had the privilege of watching an octopus steal a Go-Pro, nurse sharks sleeping in their coves, and an eight-foot Moray eel eat a lionfish.  What will your child find under the waves?

Another time, I was jogging on my usual nature trail when POOF!  There was a tiny deer, a Bambi-incarnate, standing by the path munching grass.  He was maybe three feet tall, and not startled as I pulled up short. Soon he was joined by a second Bambi impersonator.  The three of us had a moment as I got my phone out and snapped a picture.  Then I took off to finish my run. The deer, less rushed than I, continued their lunch.

I share this story to maybe peak your children’s interest in the great outdoors. There’s many ways to get your kids outside, away from phones and video games, besides the SCUBA and snorkeling we discussed above.  One of the great joys of these sports is seeing exotic sea creatures like turtles, tropical fish, octopi, and rays.  But there’s also lots of animals on dry land , and kids love seeing animals in the wild.

Louisiana is a wonderful place to start your kid’s hiking career.There’s dozens of trails, long and short, throughout the state.  And with the heat soon to break, it’s a great time to get out there.  You can catch a family of raccoons scurrying up a tree, or spot a lone gator floating at Lake Martin.

Kids enjoying the outdoors not only makes them nature and conservation enthusiasts, but also helps fight the epidemic of childhood inactivity, obesity, diabetes, and hypertension.  The Japanese call hiking “forest bathing,” and the science is clear that hiking in the woods improves blood pressure, decreases stress hormone production, and improves overall well-being.

Hiking is also a family activity, so parents reap these benefits as well. You can start close by in a local park.  If you want more elevation and beautiful views, venture out to Tunica Hills or the Kisatchie National Forest.  For the really big animals and spectacular vistas, there’s always parks like Yellowstone and the Grand Tetons, to name just a few.  So get out there and have an adventure with your kids!  They could use one, and so could you.

Trusting Science, When It’s Convenient

Every once in a bad while, I diagnose a child with a brain tumor.  Usually she’s had some progressing coordination trouble, and worsening fussiness.  We do a CT scan, there it is, and I have to break bad news to the parents.  A common first parent reaction is denial.  ”It can’t be!” or, “Tell me you’re wrong!” are some first things I’ve heard from parents when faced with such trauma.  To help them past this denial, I show them the CT scan. It’s all there in black and white.

It’s easy to trust science when the facts are plain to see.  People also are glad to listen when it’s good news.  A glass of red wine is good for you?  Drink away! There’s going to be a cool eclipse?  Let’s go see! But when the news is bad, believing is harder, especially when denial is a basic human response.  Denial is even stronger when you can’t see the evidence for yourself, like on a CT scan.

That’s why denial is easy when it comes to issues like global warming or the benefits of vaccines. The evidence of these is wrapped up in reams of numbers and statistical analysis. Belief in vaccines or global warming comes down to trusting professionals who “live the data.”  Like vaccine researchers, environmental scientists are university professors or government employees, earnest and sincere, whose career success depends on generating good data that survives the scrutiny of their peers. Science is a self-regulating profession.  If your data sucks, you’ll hear it from your colleagues, as they publicly take apart your numbers, looking for faults.

So I trust the environmental scientists just like I trust my colleagues in the vaccine field.  However, it’s easier for me to trust the vaccine guys, since being in the profession I understand their data, and have actually met some of them.  Doctors are certain of vaccine benefits because part of our years of training and experience involve learning how to acquire data, interpret it, and use it.  We can be trusted to talk with authority on vaccines, because we also live the data.

However, I know of at least one doctor who doesn’t believe in global warming.  While doctors trust their own science, they may not trust others.  We’re only humans ourselves, subject to the same denial response as anyone.  Recently one of my residents was printing out climate studies.  I asked if she didn’t believe in global warming.  She did, but another of her professors didn’t, and he wanted to see some proof.  My resident further explained that this professor thought environmental science was involved in a conspiracy. He believed that climate scientists were being secretly paid by renewable energy companies to generate data that supported their industry.

As we discussed above, trusting science is hard when the news is bad and we just want to deny it.  It’s also hard when the data is wrapped up in sheets of numbers and statistics that we don’t understand.  It’s even harder when we actively decide not to believe- to take an end-run around science with conspiracy theories.

Trust in doctors, and in the medical profession, has taken a hit in the past few decades.  In 1966, 73% of Americans had great confidence in medicine as an institution.  In 2012, only 34% felt that way.  This follows erosion of public trust of other institutions like government, the church, the press, and other sciences.  This makes doctors have to work harder to keep individual patient’s and parent’s trust.

Many older doctors lament the good ol’ days when people took what they said as gospel and didn’t question them.  However, I trained in an era where some patient skepticism was viewed as a healthy thing, that patients and parents should be engaged in decision-making.  After all, it’s their bodies.

To maintain their patient’s and parent’s trust, doctors now are being pro-active.  They’re being more careful to be friendly and open-minded with patients and parents, to not deride their beliefs and denials, but work with them. After all, people rarely respond well when being told they’re stupid.  Rather, doctors should be positive and understanding, gain trust, to then better explain the science when it’s time.  This effort often works well for doctors, showing families that they care enough to meet them half-way, and the families become more inclined to trust when it counts.

And They All Came Tumbling Down

This week’s guest columnists are Drs. Anna Malesky and Alicia Ortiz, Family Practice residents at the University Hospital and Clinics here in Lafayette.

It was our sixth shift in the Pediatric Emergency Department when we began to notice a theme.  On the Adult side of the ER, we saw falls in the elderly- on the Pedi side, we saw even more in kids.  Usually the mother can barely tell the story while clutching her infant tight to her chest.  Parents often blame themselves, or each other- who was supposed to be watching?

On one shift we saw a three-month old who fell out of her car seat on to the street, while the seat was being transferred from the car to the stroller.  She had been unbuckled after the car stopped, mom assuming belts were only necessary when it was moving. In the next room was a six-month old who had rolled off his parents’ bed.  Both kids had fallen from high enough to warrant head CT scans, to insure they had no brain bleeding or skull fractures. Both CTs were normal, and the parents were relieved.

It’s important to keep infants strapped in their car seats anytime they’re in them, not just in the car. It drives our nurses crazy when parents bring a baby into the ER, swinging them in their car seats, unbuckled- an accident waiting to happen.  Also, never leave babies on beds.  It’s no fun to discover that they can roll over by hearing a thud and a shriek from the bedroom you left “for just a minute.”  In that vein, babies should never sleep with parents on couches or beds either.  Not only could they roll out while you’re sleeping, but it’s also a risk for SIDS- babies can smother to death in bed or on couches with adults.

Infants also shouldn’t be carried around by younger children.  Kids in their pre-teen years and younger just aren’t strong enough, or reliable or careful enough, to be trusted with such a precious cargo.  Heck, even many teens can’t be trusted either.  Ask yourself, would you let that child or teen carry around your favorite 15 pound china bowl?  How much more valuable is your baby?

Keeping kids safe from falls is not limited to infants or toddlers.  Last week we had a pediatric trauma case, a nine-year old, who was riding on the back of a bike.  A seventeen year-old was steering, not looking where he was going, and ran them into a parked car.  Both kids flipped onto the car roof.  Neither were wearing bike helmets. Fortunately the nine-year old, after a lot of x-rays and CTs, ended up only with some cuts and scrapes.  Others aren’t so lucky.

According to the U.S. Centers For Disease Control (CDC), “injuries due to transportation were the leading cause of death in children” for 2016.  This includes kids killed in bike accidents, many of which would be prevented by bike helmets. Louisiana regularly ranks as the top second or third state for bicycle accident deaths. Earlier this summer Dr. Hamilton was showing friends from Maine around New Orleans. They were appalled at how no one was wearing bike helmets- apparently everyone in Maine does.

The other important tip to avoid injuries from falling off bikes, is not to fall off them! When they first start riding, children should be taught the rules of the road for bikes- riding with traffic, staying in bike lanes, obeying the same rules as cars. This means stopping for red lights and stop signs, and checking both ways before crossing, unlike our kids above. Supervise your kids on their bikes until you’re confident they’ll be safe. Make it a “family ride” when you do this, to bond with your kids, get in some exercise, and keep them out of harm’s way.

Finally, your kids will eventually turn 16 and get a learner’s permit.  While this affords them some independence and frees you from chauffeur duties, it’s important that they know that motor vehicles are dangerous, and can cause significant harm to others.  You don’t want your teen making other bicyclists and pedestrians fall- by being hit by your car!  When riding with your teen, besides enforcing the rules of the road, teach them vigilance for pedestrians and bicyclists.  Of course, vigilance means no texting and driving- ever.

How Doctors, And Parents, Talk

Many doctors, including me, go “harumph” when parents bring their child to the Emergency Department with non-emergencies, like rashes or insect bites.  Non-emergencies are what doctors’ offices are for.  However, often when I talk to the parents, they relay a hidden fear that they feel couldn’t wait for their doctor.  ”My father-in-law had the flesh-eating bacteria and almost died!”, they’ll say.  ”Does my child have it too?”

This illustrates the importance of good communication between doctors and parents. When doctors go into exam rooms with bad attitudes, glance at the rash, grumble about parents wasting their time, and zip out, they don’t get a chance to hear why the family’s there and allay their fears.

Doctors make about 85% of diagnoses by the history of the patient’s illness alone. This is also why communication is important- doctors need to be good listeners to make accurate and helpful diagnoses. Taking histories is a special skill doctors learn in medical school, polish in residency, and hone throughout their careers. I’m sure I take better histories now than I did, say, 10 years ago.

However, doctors are often pressed for time, particularly in ERs, and feel they can’t take lots of time to listen.  Here’s the data- a patient or parent, given about 90-120 seconds, will tell the doctor most everything she needs to know to make the correct diagnosis. Not a real time sink!  However, data also shows that most doctors interrupt the patient’s story after about 15 seconds, start asking yes-or-no questions, and shut down the patient’s narrative.

Specialists are another group besides ER doctors, that may not listen to a patient’s whole story. Since they have patients referred to them from other doctors, some feel that the patient’s story has already been told, is in the record, and doesn’t need repeating.  However, the best specialists take their own histories from the beginning. Who knows what new clue the patient will reveal in the retelling, that may make the diagnosis the referring doctor missed?

Specialists often get patients with complex stories referred to them.  After all, if the diagnosis was easy, the generalist would have made it already, right?  But one complex issue generalists often see is abdominal pain.  The abdomen is full of different organs, hidden deep inside, and each organ has several ways to go wrong. Many times a certain organ’s symptoms mimic it’s neighbors.  The ovary on the right side hurts when it develops a cyst, but that hurts a lot like when the adjacent appendix gets infected, or nearby bowel gets full of gas.

As we mentioned above, specialists should often have patients repeat their complicated stories to reveal clues the referring doctor missed. But all doctors should take careful, thorough histories with belly pain. Sometimes after I’ve taken the history of a teenager’s abdominal pain, done the exam, and discussed it with her and her family, I’ll return later with new questions.  I’ll be writing in the chart and think- “did I ask about urinary symptoms?”  I’ll pop out of my chair and revisit that with the patient. After tests come back, they might suggest another possible diagnosis, and I’ll go ask about that. And every once in a while, say on my third or fourth trip into the patient’s room, they’ll give me the crucial clue, like “Well, she is seeing a GYN doctor for her ovarian cysts.” Why didn’t you tell me that two hours ago???

Effective communication is a two-way street.  Doctors need to listen to the patients’ stories, and parents and patients need to be prepared to tell the story too. If the doctor interrupts because he’s interested in some point that’s brought up, be sure to continue the story after briefly answering his question.  If the doctor seems not to be listening, call him on it.  It’s okay to say, “Are you listening?” if he seems distracted.  Also, its okay to tell the doctor if you think he’s missing something.  You can say something non-confrontational like, “I’m worried my baby might have diabetes.  What do you think?”

Finally, it’s best to choose a doctor who’s a listener, before your child gets sick and it’s crucial.  A doctor receptive to your story is important to figure things out.  As the father of modern medicine, William Osler, said over 100 years ago, “Listen to your patient.  He is telling you the diagnosis.”

Scary New Babies

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

It’s 10 pm and Sarah is pacing the floor, holding newborn Charlie.  Charlie seems to be spitting up more, and sometimes he coughs.  She worries: is this normal?  Is Charlie sick?  Is he eating enough?  When Charlie coughs he occasionally gags and chokes, and this scares Sarah the most.  Should I take him to the ER, or wait to see the doctor tomorrow?

We see many new parents in the pediatric ER with these concerns and more.  Let’s discuss common feeding worries first.  Babies often spit up after feeds, sometimes freaking out moms, who worry that if baby vomits while lying on his back, he will choke to death.  The good news is that coughing, gagging, and swallowing reflexes clear babies’ airways to prevent bad things.  And despite all that spitting up, just about all newborns hold down enough calories to grow.

Parents can also be alarmed by how baby breathes, especially with so much talk about Sudden Infant Death Syndrome (SIDS).  Many newborns have light snoring, since they breathe through their noses.  That noise can get worse with some dried mucus in the back of the throat, and baby can gag on that mucus too.  All that noise can really freak mom out- is she going to stop breathing!?

More good news- gagging on vomit or mucus, and noisy breathing, don’t cause SIDS.  Again, babies are designed to handle these.  What they can’t handle is the real cause of many SIDS deaths- smothering in thick blankets, pillows, mattresses, or against adults in bed with them.  When baby’s face gets covered by heavy bedclothes, or ends up face down on a soft surface, baby doesn’t have the ability to roll over or use his arms to clear his face. Thus babies shouldn’t sleep on mattresses, couches, pillows, or with parents, siblings, or animals (live or stuffed).  They should sleep face-up on thin mattresses with thin blankets.

Sometimes even doctors who aren’t pediatricians get freaked out by things newborns do.  Dr. Hamilton tells of a phone call from an outlying ER, the doctor saying “Scott, I’ve got a real ‘fascinoma!’”  Fascinoma is doctor-talk for an interesting, weird problem- literally a “fascinating lesion.”  The doctor had a newborn with apparent breast development.  ”Then when I squeeze the breast, milk comes out!” he exclaimed.

Dr. Hamilton reassured the doctor that this was normal.  Pregnant women make a hormone called prolactin, which starts their milk production.  Babies get some prolactin through the placenta before delivery, and for some weeks after can make milk themselves, before the hormone washes out of their system.

Parents can get weirded out by more mundane things, like stooling.  Lots of moms wonder if baby poops enough.  Baby may skip a day or two of pooping, seem to get fussy, and then mom worries that baby is in pain from constipation. However, not all babies poop daily.  Some may go 3-4 days without stooling and that’s normal.  If the stool comes out soft when baby finally does go, that’s not constipation.  And babies at that age fuss for lots of reasons- wet diapers, gas pain or colic, hunger, or just wanting to be swaddled and held.  It’s important to know that breast feeding decreases the chances of colic and days without stooling, besides being generally healthier for infants.

The umbilical cord also concerns many parents.  First, it looks gross, initially gelatinous, then drying up like a piece of jerky.  Sometimes when it falls off, there’s blood and wetness underneath- normal!.  Parents are afraid to touch it, afraid to pull on it. No worries- it won’t tear off and guts come sliding out. It’s also not necessary to put any special lotions or creams on it.  Plain water is the best thing to wash it with, and fold the front of the diaper down so it won’t get irritated or pooped and peed on.

Worrying about newborns is normal for new, or even experienced parents.  Second babies can do different odd things than first ones, upsetting parents who thought they saw it all the first time.  Read up on babies, with books or reliable on-line sources recommended by your doctor.  Knowledge helps keep normal babies at home, and out of the ER. 

A Wet End for Scott?

The Louisiana Health Department has made child drowning prevention a priority for 2017, since our state has the second highest rate in the nation.  Though I always cared deeply about this, it’ now more important for me since I recently almost drowned off Grand Isle.

On a beautiful day at the beach, our teenagers were congregating off shore on their inflatable “island.”  They insisted on dragging it out to the second sandbar, requiring a swim to reach .  After quaffing a beer, I decided to swim out to visit them.

Though I’m in pretty good shape, I’m not a strong swimmer (“suck” best describes my aquatic prowess).  As I paddled out the wind was blowing against me.  I rolled on my back to rest, but waves kept breaking over my face.  I was running out of gas and beginning to struggle and still wasn’t near where I could touch bottom.

Let’s pause and examine what I did wrong.  Being in the water is fun, but for some their desire outmatches their abilities.  Some kids will jump into the water even if they can’t swim.  Some, like me, overestimate their ability and go too far. Drinking and swimming is also a bad idea.  Alcohol impairs judgement, whether you’re going for the swim, or if you’re tasked with keeping the toddlers safe around a pool.

Here’s what I did right, postponing my funeral. Out on the party island was my friend Dayle.  Dayle grew up swimming on swim teams, and worked every summer as a life guard.  I knew that if I did have trouble, help was 30 yards away. So when I began to splutter and panic that the end was near, I yelled “Dayle, help!” and in seconds he was buoying me up and towing me to safety.

The lessons are clear.  Know how to swim; get your kids lessons.  Swim within your abilities.  Don’t drink and swim.  Make sure there’s a lifeguard, though it doesn’t have to be your best friend Dayle.

More than I hate drowning myself, I hate it happening to kids.  When a child comes in in full arrest from drowning, we almost never get them back, and it’s horrible to have to tell a family that their child’s dead. When a child survives an episode, it’s called “near-drowning.”

Last month I had this case of near-drowning:  The 4 year-old child was home in the pool with friends.  Later they came in the house to mom, yelling that the child had choked when his face went in the water.  Fortunately, he got out of the pool and seemed alright. But mom had heard about “secondary drowning,” and brought the child to us.

Secondary drowning is when a child almost drowns, but is plucked out, revived, and seems fine. However, the child gets a little bit of water down their windpipe (a teaspoon is enough), and goes awhile without oxygen. This combination can injure lung tissue, where fluid weeps into the airways, a process called pulmonary edema.  The patient begins to have trouble breathing through that fluid, needs oxygen support, and is admitted into the hospital for observation.

I examined the child and thought: I could declare him fine, which he probably was, and send him home, but run the risk that he could get sicker.  I could admit him for observation, which was probably overkill, when the kid’s fine and will just jump up and down on the hospital bed all night.

I took a middle route.  After hearing no sounds of lung wetness with my stethoscope, I did a chest xray.  When there were no signs of pulmonary edema, I reviewed the risks. By report this kid didn’t go without oxygen- never turned blue, didn’t stop breathing. His mom was cool-headed, and could be trusted to come back if he worsened.  And pulmonary edema onset is slow- mom would have plenty of warning that the child needed to return to the hospital.

Never let drowning happen to your kids.  Get them swimming lessons.  Don’t have a pool or pond that toddlers could slip into unnoticed, or gate it if you do. Have someone remain sober at pool parties, whose only job is to watch the kids and not be distracted by conversation and beer.  And know CPR- near-drowning survivors are resuscitated at pool side.  Not in the ER.