Hospitals Are Cool

I think hospitals are cool.  When I was a kid and went to visit someone, I was impressed by the big, maze-like structures, mysterious things going on inside.  The halls were full of strange smells, odd noises, futuristic equipment.  When I got older and entered the profession myself, they became my work home, magnificent buildings dedicated to researching and combating illness and death.

Many have the opposite feeling- they hate hospitals.  When I meet friends occasionally at work, I’ll see them twitch and glance about.  ”What’s wrong?” I’ll ask. “Hospitals give me the willies,” they’ll say, looking as if they expect the mummy or Frankenstein monster to pop out of, say, the Radiology suite.

I see their point.  Hospitals are places where people go when they’re suffering. You hear moans of pain from rooms, overhead calls for “Code Trauma” and “Code Blue,” and staff talking gravely in hushed tones.  Hospitals are also easy places to get lost in. They grow organically.  Is there a new specialty and technology? Throw up a new wing over here. Need more beds?  Stick an annex there.  They’re maze-like not to purposely confuse outsiders; that’s just how they evolve.

Hospitals are certainly safer than in the past.  They’re no longer places where people regularly catch infections, or get the wrong limb sawn off. Initiatives in the last decades have made medicine as safety-conscious as aviation. Checklists, safety-training, and protocols have erased much of the haphazardness of medicine.  Patient safety is now as much of staff education as drawing blood or using the computer.

You can help make your kid’s hospital stay safer too.  First, choose a hospital that’s appropriate for kids.  Some hospitals take care of lots of kids, some don’t.  Second, choose an academic hospital- one that’s affiliated with a medical school and trains medical students and residents.  Statistically, patients at teaching hospitals do better- have more accurate diagnoses, go home sooner, and generally get better care.  There is something about that environment, where multiple doctors at various levels of training put their heads together, discuss cases, teach each other, that helps them figure out what’s wrong.

In the Emergency Department at Lafayette General, I occasionally interact with one bunch of those doctor teams, the surgeons.  Surgery teams are an odd bunch.  Busy, harassed by nurses and non-surgeons like me, they bustle around in packs of five or six. They come in all sizes, levels of training, and stages of grooming; tall, short, medical students, residents, some with hair and scrubs rumpled like they’re just out of bed, some coiffed and wearing clean, starched lab coats.  Their boss is the Attending, the surgery professor who breezes into patient rooms with authority and bon vivant, reassuring all that they’ve got it managed, their minions scribbling down orders in their wake.  Not the pretty picture seen on Grey’s Anatomy.

LIke we discussed above, being a patient in “academic” institutions like Lafayette General or University Hospital and Clinics has advantages.  Patients get better quicker when they have more than one doctor puzzling over their cases, discussing it with each other, researching together.  However, keeping all those doctors straight can be tough for patients, and parents.  Which doctor is which specialist, responsible for which issue?

It’s always a good idea for a patient to have an “advocate.”  Best if this person has some medical knowledge, and can keep everything straight.  Usually pediatric patients come with an advocate already- their parents.  However, parents are also emotionally involved with their child’s case, worried sick.  Already overwhelmed, often the parent needs a cool-headed advocate themselves.

There’s a lot for a patient, parent, and advocate to keep straight, besides which doctor is responsible for what.  There are multiple medications and tests.  Where are we with the diagnosis, what’s the treatment plan?  And did you wash your hands before touching my child?

These are important things to monitor.  Even with computer-controlled drug dispensing, you still want to ensure that your child is getting the right medication and the right dose. The radiology tech comes to pick up your child for xrays- ask why this test, what will we learn from it?

So after you and your pediatrician pick your hospital, and your child must stay, have an advocate to help you navigate the complexities of medical care.  And to keep all those characters in scrubs straight.

Real Animals Are Not Cartoons

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

Mom’s in the yard when her 5 year-old son Logan runs over. “Something bit me,” he cries, “it hurts!”  Blood drips down his arm.  He’s rushed inside and while mom washes the arm in the kitchen sink, the story comes out.  Logan was next door at his friend Tommy’s, when they saw some animals in the bushes. They went to get a closer look, and Logan got bitten. It was a small animal, that looked to Logan like a rat.

Just then Tommy’s mom calls to check on Logan, and that she saw ferrets in the bushes lately.  ”It was a ferret!” chimes in Logan, “One of the teachers at school has one in her classroom!”  A ferret and a bleeding bite wound, mom thinks, what do I do now? Go to the Emergency Room?  Call Animal Control?

Both are good ideas. Any time an animal bites and breaks the skin, the child is at risk for infections.  The bite can cause other problems too- disfiguring scars, tendon and nerve damage, and pain.  Your first step is doing just what Logan’s mom did- wash the wound. This rinses out harmful bacteria and viruses that might cause infection. Some bleeding is good- blood washes bacteria out too.  After a good washing, stop the bleeding with direct pressure.

Call Animal Control.  The animal should be captured and quarantined to see if it has rabies.  This goes for pets, stray animals, and wild animals- any mammal can carry rabies, and rabies is deadly!

Then at the Emergency Room, the team can further clean the wound, assess for infection and damage, prescribe an antibiotic, and consider if rabies vaccine is necessary.  Though deep lacerations are usually stitched, this isn’t always the case with bites.  While face bites are often sutured to minimize scarring, wounds on hands, arms, legs, and feet are commonly left open to continue to drain.  Stitching those increases the risk of infection by trapping bacteria inside.  Finally, the child’s tetanus vaccine status is assessed. Tetanus is another deadly infection, and kids who aren’t up to date need a booster.

Preventing animal bites is the best way to avoid complications like above.  Consider what your child watches on TV and in movies concerning animals.  Most animals in kid shows talk, are friendly, and are really cute.  These shows inadvertently teach your kids that animals are pretty much all great.  So, they might think, why not play with every real animal they see?

Well, in real life wild animals are more like people in a big city- some are mean, some have nasty infections, some bite.  You wouldn’t want your kid going up to every stranger and touching them, would you?  Thus you need to teach them to be wary of animals too. Even a neighbor’s dog that you don’t know well may be skittish with strangers, and bite when confronted.

Caution with animals is particularly important given the nastiness of animal bite infections. The scariest of these is rabies.  Rabies is a fatal viral infection.  It infects the brains of animals, causing them to be very aggressive, and attack other animals and humans. Rabies is passed along in the biting animal’s saliva, and all infected animals eventually die. Likewise with humans, rabies just about always kills.  There have only been 13 known survivors in history, compared to 65,000 deaths worldwide per year.

So which kid needs rabies prophylaxis?  Factors include prevalence of rabies in your region, if the child’s skin was broken by a bite (bad) or paw scratch (less bad), and of course- could the offending animal be carrying rabies?

Domestic animals can have rabies- not all have had rabies vaccines.  Wild animals are at high risk of carrying rabies, particularly bats, raccoons, skunks, foxes, and coyotes. And these wild animals can bite and transmit the virus to pets.

So as we said above, if your child is bitten, call Animal Control.  They can help you and the doctor decide the risk of rabies.  In the best case, they can capture the animal, take it into quarantine, to see if it develops rabies.  If the animal turns rabid, your child can start the vaccines.  If the animal turns out to be safe, so is your child.

Drama In Real Life

April 29th was a bad day in Lafayette.  Around midnight at Festival Internationale, two people began arguing.  Possibly fueled by alcohol, the fight escalated, someone pulled a gun, and one person ended up dead, and two injured by stray shots.

Interpersonal drama brings many kids to the Emergency Department too, particularly teenagers. Someone says the wrong thing, feelings are hurt, punches are exchanged, and we see the ensuing facial and head injuries.  Teens are particularly vulnerable to these escalations.  Already at an emotional age, with hormones surging, feelings are raw and easily chafed. Teens are also often in the early stages of learning conflict resolution. They are unskilled in managing feelings and arguments without resorting to shouting and violence.

Several outside forces can inhibit teens from maturing into rational adults too.  A lot of media these days portrays immature behavior as something fun to watch and emulate. Reality TV consists of knuckleheads gossiping about each other on camera, making wars out of simple disagreements.  Then the assailants confront each other and scream obscenities for the enjoyment of the TV audience.  And the combatants are always so good-looking, just like teens want to be.  

Social media amplifies drama as well.  When I see fights brewing at festivals, it’s not just two teens having a tiff.  There’s usually a crowd of “friends” swirling around, egging them on, joining the shouting.  With social media, the crowd is even bigger, with unlimited gawkers available through screens and sites, taking sides, trading barbs. Simple arguments become electronically-enabled riots.

Some teens learn poor conflict resolution at home too.  When some parents fight, their negotiating skills look like the Jerry Springer show. Rather than a calm discussion of differences, these parents try to intentionally hurt the other’s feelings, verbally “aiming to kill,” instead of speaking respectfully.  When kids grow up living with such behavior, they rarely learn a better way for themselves. 

Like we discussed above, social media can fuel conflicts between people.  Once on Facebook, I saw a picture of a friend’s teenage son at a party.  His round smiling face, his arms draped around two friends, reminded me of actor Jonah Hill  (a cute Jonah Hill, not the overweight creep he sometimes portrays). So, bonehead that I can be, I said so in a comment. The backlash from he and his parents, and my wife, still makes me cringe with embarrassment.

Thus one problem with social media: it’s easier to commit a social faux pas with a keyboard.  When you’re face to face with a person, you naturally edit what you say, to not offend.  There’s non-verbal cues that help you to not say dreadful things. This in-person behavioral check doesn’t operate when interacting online.

Secondly, when you’re angry at another person, this social media disconnect makes it easier to intentionally wound.  In World War II, fighter pilots were rarely troubled by killing their enemies, though viciously machine-gunning each other in one-on-one combat.  This was because they concentrated on the other plane, not the pilot inside. Likewise today, it’s easier to say the meanest thing that comes to mind online, because you’re saying it to a machine. But screens are like fighter planes- there’s a real person hidden inside that gets hurt.

So how can you counter the forces of Reality TV and on-line depersonalization, that turn your teen into a screaming drama king or queen?  Begin before your child’s a teen. In pre-teen years, games should be played less on screens, and more face-to-face. Board and card games, tag and backyard ball, are all conflict-resolution exercises for kids. Negotiating the rules, playing fair, keeping friends, all happen in those arenas, not in video games.

You must also model good behavior yourself.  Parents should have arguments that aren’t death matches, but calm settlings of differences. Feeling wronged and needing vengeance are innate human traits- show your kids how you bypass those cruder motivations, to stay friendly.

Finally, texting and messaging are certainly convenient, but elementary school kids should spend more time together in person than on screens. Phone and computer time should be limited, like limiting how much candy kids eat. And explain that there’s real people on the other side of the screen, not computer-generated enemies.  Then it’s easier to avoid comparing someone to Jonah Hill.  

Explosive Babies

This week’s guest columnists are Drs. Elizabeth Hunter and Alex Wolf, Family Practice residents at the University Hospital and Clinics here in Lafayette.

“Oh no, another one?” exclaimed mom as she inspected Jamie, her one year-old’s, diaper.  It was full to the brim and smelled horrendous, and this was the third since noon! It was 5:30 pm, the doctor’s office already closed. “What do I do now?”

This had never happened before.  Jamie was never sick. Mom looked up ”child with diarrhea” on the internet, tried to read the articles, but felt overwhelmed. However, Jamie, giggling and toddling around with her sippy cup, seemed to be taking it well. Mom wondered: What caused this?  Is she dehydrated?  Should I take her to the ER?

It’s a common parent scenario- your child’s pants explode and you begin to worry. Fortunately, most kids with diarrhea do well at home.  Step one, evaluate your child.  Is he playful, or at least awake and active?  Is he drinking? Is the inside of his mouth moist? If so, there’s little danger of dehydrating.

If however, she becomes progressively more sluggish through the day, starts vomiting, or begins to drink less and less, it’s time to call your doctor.  While making urine is the best sign that baby isn’t dehydrated, sometimes there’s so much watery diarrhea in the diaper that you can’t tell if there’s pee or not.  You have to go by those other signs.

Most diarrhea is caused by viruses caught from other kids, though too much fruit juice, antibiotics, or other infections can cause it too. Treating diarrhea is easy- keep the fluids coming, and food too.  If food and liquids look like their just running through baby and out the back end, keep it coming.  She will absorb enough fluids and nutrients to get by.  The slogan these days is “feed through” diarrhea.  Starchy foods are best- bananas, rice, toast.  Stay away from high sugar drinks like soda or fruit juice- these make for more acidy diarrhea, which makes diaper rashes worse.

You’re awakened in the early morning by a new sound: a gurgling from one of the kid’s bedrooms.  You rush in, flip on the light, and are greeted by the sight of a vomit-filled bed. Yuck!  While this is certainly a mess to clean up, more important worries crop up.  Is this just a stomach bug, or something worse?

Vomiting is an important protective mechanism, expelling toxins before they have a chance to harm us internally.  However, viruses often cause inappropriate vomiting. Rather than evacuating the virus, the virus uses vomiting to spread throughout the environment.  Like out of your child into her bed, potentially infecting you and your other kids.

When do you need the Emergency Department, when can you stay home?  Most kids who only have a few bouts stay hydrated.  What’s too much? Vomiting for more than 12 hours in a baby is worrisome.  For children between one and two years, 24 hours is getting too long; 48 hours for older kids.

It’s also concerning when your child stops drinking between bouts and becomes more lethargic- sleeping for longer periods and harder to arouse.  If he hasn’t urinated for more than 12 hours, it’s time to get seen.

While vomiting is usually viral and is over in a day, sometimes it’s a sign of worse trouble. If baby vomits dark green, that’s concerning for bowel obstruction, go in right away.  If she’s having bad pain, especially in the lower right side of her belly, that could be appendicitis.  If a baby under six month’s old has projectile vomiting, meaning vomit sailing clear out of the bed, that could be stomach blockage needing surgery.

Otherwise, vomiting can be treated at home.  After your child vomits, rest the stomach for an hour before letting him drink.  Then start with only small amounts of clear liquid.  Water is okay for older kids, but babies and toddlers do better with drinks like pedialyte, or low-sugar sports drinks like Gatorade G2.  Half a cup is plenty at first- if you give too much, it may push the stomach to vomit again.  You can switch to larger amounts later when the vomiting has stopped.

Don’t worry about food. Few children starve during vomiting.  Your child can go days without eating, so don’t panic when she doesn’t have an appetite- she won’t waste away within a few days!

Throw Like a Girl

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

“You can’t beat me!” yelled Jacob, the ringleader of the third-grade boys who controlled the playground at recess.  He was yelling at me, the scrawny little thing in the ankle-length blue dress with flowers on it.

“Oh yes she can, and she will, even in that dress,” countered my friend Reggie.  I stood silently, waiting for the race to start.  Reggie and I had played lots of tag and touch football, he knew my speed, and that no dress would hamper it.  With the distance marked and the rules set, we lined up.  ”Go!”  I took off, blue skirt streaming behind me like a sail. Jacob had no chance.  He couldn’t catch me that day, and from then on the boys let me play as an equal.

This story raises the issue of young girls in athletics.  Multiple studies demonstrate that fewer girls participate in sports.  That number drops off even more once girls hit puberty. There are myriad reasons cited, including disinterest, teasing, body changes, lack of female athlete role models, and believing boys will like them less.  The sports drop-out rate for girls around adolescence is six times greater than for boys.  Only a quarter of high school girls are in sports, compared to over half of high school boys.

When we lose these girls to culture and peer pressure, they in turn lose valuable opportunities: to gain self-confidence, leadership experience, and of course better health. The science is clear that sports and fitness activities stave off obesity and heart disease, substance abuse and depression, and even lower rates of teen pregnancy. Participating girls tend to go on to have better lives, including chances at college scholarships, and better professional development.

Gender equality in physical activity starts in grade school.  Girls need to know that they have a right to enjoy sports, to feel strong and have fun playing.  This includes the right to that recess playground and the chance to run like the wind, even if she’s wearing a blue dress with flowers on it.

The Olympics in Rio last summer showcased many elite female athletes. Simone Biles won five gold medals in gymnastics, including the best and most fun floor exercise in a long time. Then on NBC’s Today show, she even eclipsed her celebrity crush, actor Zac Efron. He was invited on to surprise the gymnast and her team, but he was clearly awed himself. “They won gold medals, they were crushing it the entire Olympics,” explained Efron, “and I was like hiding in a closet waiting to come in.”

Like we discussed above, more girls need to be in athletics, having fun, staying fit, and living their own great moments.  It’s even better when girls play multiple sports, instead of being single-sport “specialty” athletes. However, kid sports have evolved to nurture hopes of creating stars. Sport-specific camps and select leagues provide opportunities for kids to slog away at one sport year-round.  Parents believe they’re doing their kids a service with the extra practice time and experience, grooming them for futures in the major leagues. In fact, the data shows the exact opposite.

Children who are channeled into single sports often burn out by high school. Not only do they get bored playing one sport, but injuries increase significantly.  We see these kids in the Emergency Department, when after going through the same motions year after year, they get worn-out, swollen and painful joints.  That’s no path to success. In fact, coaches like Nick Saban, Urban Meyer, and Brian Kelly prefer and actively scout multi-sport athletes. Most NFL quarterbacks played more than one sport in high school and college.

Changing sports broadens a kid’s peer group- more friends, more fun. Multi-sport kids get more overall fitness, training different muscles necessary for each sport.  And switching joint use spreads out the strain. Finally, kids get less bored not having to throw a zillion pitches day after day, if they get to tumble in the gym instead.

Next time, instead of enrolling your child in another select league, maybe encourage her to try a different sport that season. Who knows, maybe a miniature Alex Morgan will come out on the soccer field, having been hidden behind mediocre T-ball skills.

High Anxiety

My son’s transcript showed he had failed Business Law, a bad start for a kid considering applying to law school for…business law.  After emailing his professor to ask the particulars, he stumbled through the day in a haze of misery.  When he found himself enjoying something- a joke or nice weather, the happiness was quickly extinguished by the thought, “I’ve failed.”  One big worry: how was he going to explain this in a law school interview?

Later that afternoon his professor replied- it was just a mistake. My son’s final exam grade had not been entered into the system yet, which triggered the fail mark.  It would be fixed, and my son breathed an enormous sigh of relief.  But it took some time to shake that feeling of dread that haunted him for half the day.  Anxiety can be sticky.

Many teens, and elementary school kids too, are plagued by anxiety.  There’s school- worry about grades, fear of bullying, tense relations with teachers.  Home can make a kid anxious too- divorce, yelling, sometimes abuse. Many kids have concerns about their neighborhood- they have to live with the threat of crime, violence, and drug dealers on the corner.  Finally, kids see the news too, and worry about the world.  They hear stories about environmental collapse, threat of deadly epidemics, and the possibility of nuclear armageddon.

We are born with the tendency to be anxious.  Anxiety is a motivator cultivated by evolution, keeping us from getting eaten.  Worried about that sabre-toothed tiger eyeing you?  Good, run away!  Even animals as primitive as lizards have anxiety.  Just approach one, watch it twitch and scuttle about, before tearing off.

Some kids and adults are better at handling anxiety than others.  And many kids have manifestations of anxiety that look like illness.  That’s when we see them in the Emergency Department.  Sometimes the signs in kids are subtle- headaches, stomach aches, fatigue.  Sometimes they have more concerning symptoms, like chest pain or fainting. And occasionally we see true panic attacks.

When I was in high school, worried about getting grades good enough to be a doctor, I failed a french test.  The big red “F” on the paper burned into my brain at first period. But it wasn’t until fifth period that I became shaky, broke out in sweat, and was led sobbing to the nurse.  She called my parents to admonish them about putting too much pressure on me.  My mom replied, “It’s not us!  The stupid doctor thing is all his idea!”

Anxiety can make kids short of breath, and thus parents bring them to the Emergency Department. Some are just hyperventilating, but kids with asthma can have true attacks triggered by anxiety.  In fact, in the mid-twentieth century, when medicine was full of freudian theory, many thought asthma was a psychological disorder.  Even in the face of real wheezing, the noise was attributed to patients’ “suppressed cries for help”- wheezing was those cries fighting to get out. Fortunately, asthma is now recognized as true disease.

Sometimes it’s hard to tell the difference between a panic attack and medical emergencies like asthma.  Both kids have trouble breathing.  Both complain about chest pain and tightness.  And whether their shortness of breath is due to airway narrowing or panic, either kid looks anxious!  Occasionally it can be tough for even doctors to tell panic attacks and asthma apart, despite stethoscopes and oxygen monitoring.

How do we manage anxiety?  Kids handle anxiety differently.  Some aren’t bothered by stress, those proverbial ducks letting worries roll off their backs like water.  But some need help.  Counseling can help kids tell the difference between true medical problems like headaches and stomachaches, and those symptoms being triggered by worry. Many don’t recognize when they’re having anxiety, and knowing if you’re anxious, and why, is a big step in coping with it.

Counselors can also help kids identify management strategies.  For some, exercise helps “burn off” anxiety.  For others it’s prayer, meditation, yoga or other relaxation techniques.  A few kids need medication, to temporarily get them through rough patches as they learn to cope.

If you think your child is anxious, talk to them about their feelings, and maybe see their doctor to explore it more.  You want to do that before worry becomes panic attacks, and needing to come see me.

Sore Throats Hurt!

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

Dreaded words at 7 pm on Friday night: “Mommy, Daddy, my throat hurts.”  Doctor’s closed, nowhere to turn.  It’s a common complaint, especially in my house with three girls. You’ve had sore throats yourself, and know-they hurt!

Pharyngitis- doctor talk for throat inflammation- accounts for about 12 million office and ER visits yearly.  Pharyngitis has two main causes- viral (about 85% of cases), and bacterial (about 15%).  Many viruses cause sore throats, like adenovirus, rhinovirus, and influenza (“the flu”).  The most common bacteria is Group A Streptococcus, a.k.a. Strep Throat.

It’s hard to tell the difference between strep and viral pharyngitis.  Besides throat pain, both cause headache, fever, and fatigue.  However, viruses tend to have more cough and runny nose.  But having those doesn’t exclude strep!

There’s a few rules for doctors to separate the two.  First, strep throat happens mostly after age 3- red throats in babies and toddlers are rarely bacterial.  Second, if the child has a fine-bumpy, sand-papery rash on the trunk and face, that’s the “scarlet fever” of strep. The most important rule is that, according to the US Centers for Disease Control (CDC), it’s tough to differentiate the two without a strep test.

The test is a throat swab that indicates if strep bacteria is present. It’s a good test, but not perfect, catching about 85% of strep throats.  Thus your doctor must weigh the symptoms, the exam, AND the strep test to decide if your child has strep.  If it’s strep, he needs an antibiotic.  If it’s viral, antibiotics don’t kill viruses.

This is the kicker for parents.  Sore throats hurt, and everyone wants them gone. Many want antibiotics, thinking they will help.  But they won’t stop viruses, and we don’t give unnecessary antibiotics for good reasons.  Antibiotics have side effects- yeast infections, stomach upset, and possibly allergic reactions.  Most importantly, when your body is exposed to antibiotics, bacteria can develop resistance to the antibiotics, and when you do need them to fight that bacteria, they won’t work.

We’ve all had throat pain, and it’s miserable.  Dr. Hamilton tells of having yearly sore throats as a teenager.  When he got them, he remembers praying for the pain to go, counting the days of misery, and vowing to never again take feeling good for granted!

Like we mentioned above, there’s no cure for viral sore throats.  The virus must run it’s course, typically 2 to 4 days.  If it’s a bacterial strep throat, which again is the minority of cases, only then will an antibiotic help.  So how to treat those viral illnesses that your child must “ride out?”

Dr. Hamilton doesn’t remember taking medicine for his sore throats, besides throat sprays and lozenges.  And often when we see kids in the Emergency Department, parents haven’t given anything for pain either.  For your child’s sake, please do!

There’s two medicines for pain and fever, perfectly safe for kids: Acetaminophen (brand name Tylenol) and Ibuprofen (Advil and Motrin).  These come in many forms and flavors to make them easier for kids to take- liquids, chewable tabs; and for toddlers who spit out medicine instead of swallowing, acetaminophen rectal suppositories. No prescription necessary.

Many parents, afraid to overdose their kids, don’t give enough medicine for the pain or fever.  Again, it’s quite safe to give what’s advised on the box for your child’s age or weight.  Still unsure?  Call your doctor’s office to double-check dosing.

Give lots of fluids to help your kid feel better.  She may not eat much, and that’s okay. Fluids are more important, and she’s not going to starve in a few days.  If she does want food, light meals are best, like grits, oatmeal, or soup.  Popsicles and ice cream can soothe throats too.

Keep your child out of school or daycare- don’t let them spread the illness to others. They won’t feel like learning anyway.  If your child has strep, they must stay out of school for at least 24 hours after starting antibiotics, since it’s highly contagious.

If your kid keeps getting strep after strep infection, your doctor can refer him to an ENT surgeon for tonsillectomy.  For the vast majority of sore throats though, 2 to 4 days and things will pass.  Push fluids, give pain medicine, and don’t take feeling good for granted again.

Training Dogs and Toddlers

My feisty little poodle, Milou, is all dog.  He’ll fetch endlessly, race around the yard chasing squirrels, and occasionally catch one in a lightning-fast wrestling match. Unfortunately he has a shrill bark that annoys everyone, especially my back-fence neighbor.  When he’s yelling at squirrels there’s no shutting him up.

One morning I was shouting “Come!” to get Milou inside.  Ignoring me, he continued yapping at squirrels through the fence, no matter how angry I got.  Why wasn’t he answering the command we had drilled and drilled?  Then I realized, I wasn’t using the same voice I did in practice!  Instead of a harsh, loud “Come!”, I usually used an upbeat happy voice; and practiced “sit” and “stay,” before walking away a few feet, and then “come.”

So I called out, “Sit!”  His head came around, yapping cut off.  ”Stay?”  His front paws came around.  ”Come?”  He tore back up the lawn and into the house, squirrels forgotten. I had re-learned the old training rule- dogs listen to voice tone more than actual words.

I remembered this some nights later at work, as I heard a mom shout at her 18 month-old daughter, “Sit down!  Shut up!”  I couldn’t see what was going on behind the exam-room curtain, but apparently the toddler wasn’t listening, as mom continued her tirade. The problem with dogs and toddlers, I thought, is that they don’t really speak English.

Silly as it sounds, training dogs and toddlers is similar.  Neither understands the meaning of words- meanings must be demonstrated by action.  Both want to please their parents, they just don’t know how, and need to be shown.  Both need consistent, kind guidance, with positive reinforcement of good behavior.

Take potty training.  First, your toddler sees what you do on the toilet.  Then you sit her on the potty, and wait patiently through many sessions until she poos or pees. When it finally happens, you reward that desired behavior with praise, and in the case of my daughter who loved band-aids, a pink band-aid stuck on her arm. You repeat that cycle for more sessions until she gets the hang of it.

My daughter who loved bandaids as a potty-training treat, hated time-outs.  No surprise, as time-outs are a punishment.  But she really hated them. When we put her in the chair, she would jump back out, until we strapped her in. When we turned her to face away, she would kick at the wall to knock her and the chair over.  After a few scares, we kept the chair just far enough away.

Time-out is another action-based training technique useful for teaching toddlers and dogs (and hockey players).  Instead of giving a positive reinforcement like treats or praise, time-out removes positive reinforcements from the trainee to show that a specific behavior is not desired.

Most parents use time-outs, and they are much more effective than harsh punishments like spanking.  However, a recent study in the journal Academic Pediatrics reported that 85% of parents do at least one time-out technique incorrectly.  64% made multiple mistakes.  Such errors included talking with the child while he was in time-out, giving multiple warnings before time-out, and allowing him books, computers, or toys while in.

To be most effective, you must remove all interesting interactions from time-out, including facing a wall so there’s nothing to look at. The child should be put in immediately for bad behavior, no warnings.  Multiple warnings only teach toddlers that they have multiple chances at bad behavior before punishment.

Place the child in with minimal emotional input- a firm voice telling them simply why she’s in time-out, no embellishments or scolding.  If your child wants to deny it or start arguing, ignore that.  Your toddler wants conversation and attention, so silence between you and him is the rule.  And no toys or screens in time-out- it’s supposed to be no fun! Time-out should last one minute per year of age: 2 year-olds get 2 minutes, 3 year-olds 3 minutes, etc.

Finally, all training, whether positive reinforcements with rewards, or time-outs with removal of rewards, requires consistency.  Like we mentioned above, dogs and toddlers don’t really “speak english;” they don’t understand the meaning of words.  Meaning must be taught by action, again and again, until it sticks.  And the amount of persistence equals the amount of good behavior you can expect from your toddler.  Or your dog!  

Rashes- The Home Triage

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

The nurse’s note read “rash.”  When I walked into the exam room, the mother’s eyes were wide with fear.  ”Doc, over the past 2 days he’s been having a reaction to the antibiotic he got earlier this week.  I gave Benadryl this morning and the rash is still there!  Is he going to be okay?”  Meanwhile, the patient, an 8 year-old boy, was lying in bed laughing at cartoons on TV. The rash certainly wasn’t bothering him much, unlike his mother!

Rashes can be distressing for parents of infants and children. They can appear out of nowhere, cover a large part of the body, and look awful.  The good news is that most rashes are not life-threatening and don’t need immediate attention. Some are caused by direct irritation of the skin, some indirectly like with allergies, and some by infections from viruses, bacteria, or fungus.

In the case of the boy I saw that Saturday night, his rash wasn’t a sign of anything bad, though it certainly looked weird.  It consisted of flat, paisley-shaped red blotches all over his body.  It didn’t hurt, didn’t itch, and he didn’t feel too bad. This rash, called erythema multiforme, turned out to be due not to the antibiotic,but from an infection called mycoplasma, a.k.a. “walking pneumonia.”  We changed his antibiotic to cover that infection, and off he went.

Every year there are about 12 million visits for rashes and other skin concerns.  68% of these are with the patient’s own doctor, leaving 32% to walk-in clinics and Emergency Departments.  How do you know if your kid can wait to see their pediatrician, or needs immediate attention?

First, don’t panic at the site of a rash, no matter how much of your child it covers.  Rashes are like fevers- the height of the fever and the amount of rash don’t correlate with severity. It’s more about how your child is acting with the rash.  If she’s calm, drinking easily, breathing comfortably, and awake and with it, then it’s not an emergency. Give benadryl for the itch, call your doctor for reassurance, and chill out.

This advice about how to respond to your kid’s rash, brings up an experience I had in my last year of medical school.  It wasn’t about a pediatric patient- it was ME!  I woke one morning after an itchy night.  I turned to my wife to ask if she had used a new laundry detergent on our sheets, and was met with a look of shock: “Justin, ARE YOU OK!?!” Besides being a little itchy, I felt fine.  ”Look in the mirror!  I think you need to go to the hospital now!”

I was covered with a rash from head to waist, my face beet red.  A little startling to see, but then I remembered my training.  When did it start?  During the night I guess.  Was I breathing okay?  Yes.  Were my throat, tongue, or lips swollen?  No.  Was it getting worse? Didn’t seem so.  Did I feel ill or have fever?  No. There, no emergency honey.

Was the rash raised and itchy?  Yes- thus probably allergic.  Was there peeling, crusting, pain, or weeping?  No- therefore probably not an infection.  Were there tiny red freckles that didn’t blanch when pressed on?  No- again not a serious infection.  What was different in the past few days?  Soaps, detergents, food?  Wait, I’d been stung by a hornet yesterday! The rash I had was urticaria, commonly called hives, a delayed reaction to the sting. When I saw my allergist later that day, she prescribed steroids, an antihistamine, and in two days I was better.

When deciding whether your child’s rash can wait for the pediatrician, or needs to be seen immediately, remember the important questions:  Does he appear ill (looking past that awful rash!).  Is there lip, tongue, or throat swelling?  Is she not breathing comfortably? Are there tiny red freckles that don’t blanch when pressed?  If yes, proceed to the nearest Emergency Department.

If no to these questions, relax!  Give benadryl, tylenol, or ibuprofen for itching, fever, or other discomfort.  Call your pediatrician if you need further guidance.  Like fevers, rashes are generally not emergencies.  Take a deep breath, take two benadryl, and call me in the morning. 

A Tale of Two Teenagers

Hard to believe, Amy loves the Army.  She’s in boot camp, enjoying lots of exercise, full days, new jargon to learn, and she even likes the lectures on Army protocol. It’s stressful to be sure; it’s supposed to be tough.  Some girls are fainting, some are washing out because they can’t hack it, some stay up too late and lose sleep. Amy has her eyes on the prize- graduating and moving up.  When she gets anxious, she swallows it and moves on. Uncharacteristic for her, she’s eating well and going to bed early.  Her parents are proud, not only for her accomplishment but for how far Amy has come.  Her life wasn’t always this way.

From an early age, Amy was having a rough go.  She had trouble paying attention in first grade, though she was highly intelligent.  She angered some teachers with her pointed, seemingly rude commentaries, though other teachers “got” her. She was tried on ADHD medications, which helped for a time, but then began causing side effects where Amy acted confused and panicky.  By high school, it was clear Amy was depressed.  She was sullen, didn’t get along with most of her classmates, and scraped out poor grades. Despite grasping the material, she just didn’t care enough to get papers in on time or study for tests.

Amy had no obvious reason for depression.  She had two loving, educated parents and two happy siblings.  At the first sign of trouble with attention or mood, she got the best doctors and therapists.  As Amy got older and was able to verbalize what was going on inside, it seemed her depression was “chemical:”  she was just born that way, with no external reasons like bullying or her looks.

Anti-depressant medication helped, as did continued counseling.  Her parents cheered her on through thick and thin, and as she got older Amy’s life began looking up.  College was much better than high school as far as academics and having friends. She had positive dreams for her future.  Joining the Army wasn’t her parents first choice; heck, even with a bachelor’s degree she enlisted rather than take on the responsibility of being an officer. But now they were singing a different tune.

Sharon has it much worse than Amy.  I saw Sharon in the Emergency Department last month.  She came by ambulance after being beaten by a gang of boys.  They ran up behind her, knocked her down, and kicked her repeatedly in the head and chest. There had apparently been some bad blood between Sharon’s friends and other factions in the neighborhood.

From our computer record I saw that Sharon had had a tough life already, though only 15 years-old. She had been seen by us twice for sexual assaults, another time for being beaten up, and once to be admitted to a psychiatric hospital for suicidal thoughts. She came from a rough house in a rough neighborhood.  Her mom obviously had mental illness of her own, from the pressured speech of hyperactivity or drug use, to her peculiar tattoos.  Mom yelled a lot, at Sharon and us, though this seemed to be not from anger but how she usually spoke.

Certainly Sharon’s depression has not gotten the attention that Amy’s did.  Though she had been in hospital for depression, Sharon isn’t on anti-depressants and isn’t in counseling.  Chaos rules her home life: her father’s gone, and she bounces between mom’s and the homes of several other families. Her school and neighborhood aren’t safe.

Despite all this, I have some hope for Sharon.  Kids can be resilient, and Sharon still had an occasional smile and some spunk, despite what just happened.  Mom also did seem to care about her, as did an aunt with her who seemed more emotionally stable.  They agreed that counseling was a good idea, and to see her doctor about a psychiatric referral.

Some kids like Amy are born with depression.  Some like Sharon, besides having inborn depression, also have life stresses that contribute.  Both kids need attention- counseling and maybe medicine to get them through bad patches. If your kid seems depressed, telling them to buck up and act happier isn’t enough.  You should ask about suicidal thoughts, why he is depressed, and see his doctor.  Depression is rough, so better that your kid gets the attention that Amy got, rather than Sharon’s.