Welcome To My New Blog!

My blog has moved to a new home.  Entries from my old blog came over, and can be found in the archive in the column to the right of this page.  As before, my emphasis is to help you understand what is an emergency, and what is not.  Too many parents bring their kids to an emergency room for things that are not emergencies.  Hopefully reading some of my columns will help you take care of your sick or injured child at home. 

Please feel free to comment on what I have to say, ask questions, or add your own stories.  As before though, I can not give advice on individual patients- that is your own doctor’s job!

Belly Pain- Is it an Appendix?

A common reason for parents to bring their kids to the ED is belly pain.  Doctor’s offices and “quick care” urgent care clinics also send us a lot of kids with belly pain.  Everyone has the same  basic concern- is it appendicitis?  Does the child need an operation?

I often encourage families to stay home or wait to see their doctor for things that are obviously not emergencies.  Runny noses, fevers, diarrhea, rashes, even ear pain- Stay home!  Give ibuprofen!  Belly pain, though, should not be waited on very long.  Belly pain lasting more than a few hours needs to be discussed with a doctor, first on the phone, and then in the office or E.D.

What is appendicitis?  The appendix is a tiny pouch that usually hangs off your intestines in your right lower side.  Appendicitis is when poop gets trapped in the appendix, gets infected, and the appendix slowly swells like a boil.  With swelling and infection comes pain, fever, and nausea.  A “ruptured” appendix is when the appendix bursts and the pus and infection spread throughout the abdomen.  We always hope to diagnose appendicitis and get it out before rupture, but that is sometimes just not possible.

Though most belly pains turn out to be stomach virus or constipation, the diagnosis of appendicitis can be tricky.   Early on appendicitis can act like stomach virus and fool the doctor.  Sometimes the child is admitted to the hospital, the doctors and surgeons debate and ponder, and finally days later the surgeon decides to take the patient to surgery for the pain.  Only then, with the patient opened up, does the surgeon look in and go “ah-ha” and make the diagnosis.

With belly pain, first call your doctor.  Some doctors are comfortable making the diagnosis in the office and then sending the patient right to a surgeon.  Some refer the family to the ED for diagnosis.  Make sure you take your child to a hospital that cares for children and has surgeons available.  In Lafayette, that is Lafayette General Medical Center and usually Women’s and Children’s Hospital too.

What does a child with appendicitis look like?  First, the pain starts as a steady, slowly worsening pain.  Often the pain starts in the middle of the belly, under the belly  button, and later is more in the right lower side.  Kids with appendicitis lose their appetite and sometimes vomit later in the illness.  They also often have later fevers.  This is usually unlike stomach virus, where kids vomit first, have early fevers, and have crampy belly pain that comes and goes away.

At the hospital, the ED doctor and surgeon often make the diagnosis and decide on surgery by just taking a history (hearing the “story” of the illness) and examining the child.  Few tests are needed besides a few blood tests.  CT scanning is usually unnecessary.  One estimate is that only 10% of appendicitis cases need a CT to make the diagnosis.  CT adds a lot of radiation exposure, and sometimes can miss an appendicitis or mislead the doctors with extraneous information.

The surgery itself is usually uncomplicated and safe, as long as the appendix hasn’t ruptured.  The child often goes home in a day or two after surgery.  If the appendix has ruptured, that means recovery takes a week or two of antibiotics and care in the hospital.

So if your child has belly pain, but is walking, smiling, eating and the pain goes away soon, it probably is not appendicitis.  If he or she starts with pain that is steady and worsening over some hours, come on in!

Picking A Doctor For Your Child

Every day several families bring their kids in to the Emergency Department with non-emergencies- runny noses, rashes, diarrhea.  Then many times the mom, perhaps sensing our impatience with the inappropriateness of that visit, state “I called my doctor and they were too booked, and told me to come here.”  Or worse, they might say “I don’t have a doctor for my child.”

Having your own doctor for your child is important.  You know you have a doctor who cares, and listens.  That doctor knows your child too, and has all the child’s past history at their fingertips.  You have a place to go for check-ups, sports physicals, shots, and questions.  If you go to an Emergency Department or quick-care clinic, its pot luck.  Maybe the doctor will care and listen well, maybe not.  Maybe they know kids, maybe not.  They certainly won’t know your child well.

What if you are a new parent, or new in town?  Or what if you want to change doctors?  Here are the things that help you find a good doctor for your kid:

1.  The doctor is “Board-Certified” in Pediatrics or Family Medicine-  The national boards only certify doctors who have demonstrated through testing and credentials that they are keeping up-to-date in their field.

2.  Full-time Practice- It is important that your doctor, or covering partners, are available as much as possible.  The best practices have evening and weekend hours for working parents.  And of course, the practice should have doctors with around-the-clock phone availability in case of emergencies.

3.  Reputation- it is nice that people you know recommend a doctor, but a bad comment doesn’t necessarily mean the doctor is bad.  Even the best doctor can’t please everyone all of the time.   However, recommendations from other doctors carry a lot of weight.  Doctors work with each other all of the time and know who are the hot-shots and who are the slackers.

4.  Fellows of the American Academy of Pediatrics or American Academy of Family Physicians-  These doctors will have the initials after their name FAAP or FAAFP, as in Scott Hamilton, MD, FAAP.  This designation is icing on the cake of Board Certification.  This means that the doctor is a member of the national professional organization that provides the most up-to-date information in their field.  The AAP and AAFP work with the national boards to develop practice standards.  The AAP and AAFP also are active politically to help governments in the United States and abroad provide the best care for children.

5.  The doctor is a good listener- as I have stated elsewhere in this blog, most diagnoses are made from the patient’s story, so your doctor needs to be a good listener to be a good doctor.   There is an old adage that you would rather have a mean doctor that knows the latest cures than a nice, hand-holding doctor that will kill you through incompetence.  In truth, wouldn’t you rather have both?  Professionalism demands that doctors be both good and kind listeners, and up-to-date in their practice.

These days, with blitzes of advertising of doctors, clinics, and hospitals, these are the hints that can help you find a good medical home for your child’s care.

Should I Order a Test, or Listen First?

It happens at least once per week that a family brings their child in with a frustrating problem.  The complaints are vague, like mild fever off and on for weeks or months, or headaches or belly pain, or odd rashes.  The problem has usually been going on for weeks or months and no doctor has been able to give the family a solid diagnosis.  The family asks me: “There has got to be some test to figure this out!”

There is a myth that the sophisticated technology of testing, whether it is blood tests, CT scanning, or MRI scanning, can diagnose all ills.  Patients and families believe it, and many doctors also fall into the habit of relying on batteries of tests to help them feel better about their diagnoses.

But this is not true.  The vast majority of tests provide us only with a hint that our diagnosis is on the right path.  Some tests, particularly CTs and MRIs, give too much information.  It happens regularly that we order a CT scan, find something that looks funny, and chase a phantom with further tests.  It is not unusual for a doctor and his patient to get caught in what I call the “medical vortex,” where one test leads to another.  After thousands and thousands of dollars of painful testing, the doctor finally says “nothing serious is wrong.”

When it comes to making a diagnosis, the old wisdom we all learned in medical school holds true: you make 85% of your diagnoses from taking the medical history alone.  As the father of modern medicine, William Osler, said almost a hundred years ago, “listen to the patient, he is telling you his diagnosis.”  The next 10% of diagnosis comes from the physical exam.  That leaves only 5% of cases where the test makes you go “Ah-hah, so that’s it!”  Again, tests mostly just hint.

Thus if you ever have a family member with a medical problem that they just can’t figure out, make sure first that they are asking enough questions.  Make sure that the doctor is getting a clear picture of what is going on with the patient.  A thorough enough history almost always shows where others have missed a vital clue.

If the doctor starts doing tests, he or she should have a firm idea of how the tests are going to help make the diagnosis, rather than a vague notion that they will shed some light somewhere.  Before the tests, the doctor should have listened carefully to your story, asked questions exhaustively, and examined you thoroughly.  If so, he or she then probably doesn’t need the tests in the first place!

Do you have a story about missed diagnsosis, testing misadventure, and medical frustration?  Click on comments below and tell us.

Ghost Stories vs. Rational Worries

Occasionally I am surprised by some parent’s beliefs.  There are a lot of “old wive’s tales” out there which I am used to: fever curdles milk in baby’s stomachs, fever will cook baby’s brain, blowing cigarette smoke in ears is good for ear pain, etc.  One day, however, a mom asked me “do cats really steal babies’ breath?”  I had a millisecond hesitation that a mom could really believe that, but recovered and answered the question like this:

Cats like to sleep in warm places, and I am sure some time in the past a cat jumped into a newborn’s crib, snuggled up to the warm infant, and accidentally smothered it.  This is how crib death happens- baby smothers by rolling face down in thick bedclothes or a pillow and is not mature enough to be able to roll back.  Once the cat did this, the act became myth- that cats, already associated with the supernatural, have the ability to “suck” the life out of babies like in horror movies.

It is natural for people to try to explain how things happen, and make the explanation more supernatural and exciting.  When it comes to child care the explanations sometimes become too exciting and lead to needless anxiety.  One of the main reasons I write this blog is to help parents separate the wild fears that bring them to the Emergency Department from the real worries.

Here is a quick list of things NOT to worry about, in addition to those already mentioned: children hitting their heads and dying after a long interval of looking well, children choking to death on blood from bloody noses, babies choking to death on mucus, babies and children choking to death on vomit, swallowing tongues during seizures, spotty rashes being measles.  For further explanations of these, look to the appropriate Category on the right of this blog page.

Real trouble looks like this: children getting increasingly lethargic and unresponsive, breathing hard and fast, head injury with loss of consciousness and vomiting, fever in a baby under two months old.  These are the right reasons to go to an Emergency Department, rather than because baby has rattling breathing from a runny nose.

Of course, when in doubt call your doctor.  They can help you separate the real worry from the wild fear over the phone.  And besides not sleeping with baby in your bed, keep the cat out of the room too.

Keeping Kids Healthy and Fit, so They Can Be Kids

This past Thanksgiving I spent a day at one of my favorite havens- Boy Scout Camp.  No TV, plenty of outdoor activity for the boys, and limited junk food.  However, this past visit had its disappointments- many of the kids I taught were already obese.  There were kids surfing their iPhones around the campfire.  The Trading Post did brisk business in candy bars and soda.

I usually don’t mind the Trading Post or iPhones.  However, most of those kids already have a steady diet of soda, junk food, and electronic entertainment every day of the year.  Goodies that were once a special treat away from home have become the norm at home.

This over-consuming of junk food and entertainment leads to other medical problems besides being merely fat and idle.  These kids feel bad about themselves.  They do worse in school.  They fill doctors’ offices and emergency departments with complaints of stomach pain and constipation.  They will grow up to have early heart attacks, depression, diabetes, strokes, gall bladder attacks, cancers, knee and foot pain.

Obesity is not entirely our fault.  Humans and other animals were biologically programmed eons ago to eat, store fat, and rest when food was plentiful, as a hedge for when food was scarce.  Now, in our modern society, times are always good when it comes to finding calories.  And biology had no need in the bad old days to provide us with an off switch for eating and resting.

Our biological bent to obesity is now also aided and abetted by the food industry.  In the 1950s the industry had a dilemma: how do you convince an already well-fed people to eat more, in order to accelerate profits?  They invented “food science,” where chemists manufacture additives to make food more delicious and more delicious-looking.  They invented advertising based on psychology to sell us that food and get us hooked, like addicts and their first taste of heroin.

And it worked.  Who doesn’t love junk food, myself included?  Even in France, where they are famously fussy about their good food, McDonald’s does its biggest business outside of the US.  So how can we save our children from what we have wrought on them?  And what about our planet, which is groaning with the burden of  supporting our junk food habit?  And what of the unfairness, the sin, where billions in the world still go to bed hungry?

The answer is that our brains must take charge over our biology.  The hard work starts at home- don’t buy junk food and soda!  Don’t bring it into the house!  Make sure your kid gets a fruit with every meal.  Give them a vegetable with lunch and dinner- if only a handful of carrot sticks (my favorite go-to vegetable).  All grains should be high fiber- whether it is wheat bread or high fiber breakfast cereal.  Dinner should be eaten with all the family members together, talking about their days and their lives, practicing conversation, stimulating each others’ brains,  rather than watching TV.

More hard work- be firm with your kids about the TV.  It should not be turned on at all on school days.  Computers should only be used for school work on school days- not for surfing, watching videos, or playing electronic games.  Kids should never have a TV,  computer, or game system in their bedroom.

If your kids are bored and whining and start to fight, stay strong!  That boredom is incentive for them to go out and start exploring and making their own fun, which is how kids grow good brains and strong bodies.  That is when they learn to love books, friendships, board and card games, sports, and outdoors.  Soon the no-TV/computer rule becomes easier to enforce.

Play is the work of childhood.  It is now harder and harder to protect your childrens’ play from the onslaught of advertising, junk food, and electronics.  But this is part of the hard work of parenting, so your kids can be kids again.

Tis The Season For RSV Wheezin’

We can tell by the paramedic’s voice on the radio if a child is truly sick.  This time his voice has that urgency that says “be ready.”

Moments later they come trundling in, oxygen cylinders hissing, monitors beeping, and the little baby in the big stretcher struggling to breathe, chest heaving.  Into the trauma room, baby is lifted onto the ED bed, trailing monitor wires.  Nurses and techs move in, changing oxygen tubes, starting IVs, hooking up monitors, putting on stethoscopes.

After a brief talk with the parents and a quick exam of the baby, I see that the baby has Bronchiolitis.  The breathing treatments we give have little effect- baby still struggles to breathe.  Baby is admitted to the Pediatric Intensive Care Unit for IV fluids, oxygen, and monitoring.  She will get better eventually, but it will take time and care.

Bronchiolitis is a common winter ailment for infants and toddlers.  Many people recognize this ailment when it is called RSV, but the RSV virus is only one of the many viruses that can cause it.  Bronchiolitis starts as a cold, with runny nose and cough.  In some little kids it progresses to fever, wheezing (a whistling sound from low in the lungs), and trouble breathing.

Bronchiolitis is one of those frustrating illnesses where modern medicine offers little to stop its progression or ease its distress.  Plenty of fluids help, maybe a vaporizer at the bedside, and Tylenol for fever and comfort.  Sometimes nebulizer treatments help, but like in our case above often they don’t.

The good news is that most babies with Bronchiolitis just have a bad cold.  The treatment for that is described in the “Colds in Babies” category, which you can access from the Categories column on the right side of this page.  A few babies wheeze like an asthmatic and need more attention.  Very few babies need to be in the PICU and it is rare for one to die.

So if your baby has a cough and runny nose but is breathing and drinking comfortably, all is well.  Start the vaporizer and Tylenol, maybe have your baby sleep sitting up in a car seat or swing  (no propping on pillows!).  If you think baby is wheezing or tugging for breath, or is having trouble sucking a bottle for its work of breathing, come right in and see us.

 

Cold Medicines- Still in the cowboy days

When I was in medical school, one of my professors told a story of when he was snowed in in a cabin in the woods, and one of his kids got a cough and runny nose.  He had no cold medicine with him, so he mixed his own like they did in the cowboy days- whisky, honey, and lemon.  “And by God,” he told us, “it worked!”

The science of treating coughs and colds has not come very far since those days.  There is still no medicine that science has shown helps much for coughs and runny noses from cold viruses.  When the drug companies come out with a “new” cold medicine, like they did most recently with Mucinex, it is just the same ineffective ingredients in a new package.

Now, some people swear by their favorite cough medicine.  “Works every time!” they crow about their Robitussin or Dimetapp.  However, what is working is the Placebo effect, a psychological trick where if you believe in the medicine, it seems to work.  When you test the medicine in a blinded study, where you can’t tell the medicine from a dummy fluid, patients report no difference between the medicine and the dummy.  In 2007 scientists tested honey against dextromethorphan (the “best” of the cold remedy ingredients).  Guess who won- honey!

Most prescription cough and cold medicines are no better.  Most of these are anti-allergy medicines, and if your cold is from a virus instead of an allergy, good luck.  The only prescription that has been shown to really help for coughs is codeine, and that really only for dry, hacky coughs.  And you can’t give codeine to a kid under 3 years-old.

So next time your child gets a cold, try the things I talk about in the “Cold in Babies” category.  Don’t ever smoke in the house.  And feel free to try your favorite grandma remedy- chicken soup, honey, lemon.  Just please leave out the whisky!

Worried about the Flu? Don’t!

There is a lot of press and a lot of worry out there about the current flu.  When there is a lot of worry, people clog the area emergency departments, often with kids who do not need to be there.  Crowded ER waiting rooms also are great places to catch the flu.  Here is some information to help you not to panic, and to avoid the hassle and risk of an unnecessary ER visit.

First, the current flu virus is the “swine flu,” which the experts are calling “novel H1N1 influenza.”  The influenza virus gives you a cough, runny nose, fever above 101, headache, sore throat, body aches, upset stomach, and sometimes red eyes.  It appears not to be any more serious than the regular influenza we see in the winter.  Of the very few children who have died from the current flu, two-thirds were already very sick from severe chronic diseases that often kept them bedridden.  Children under 5 years old and those with chronic diseases like asthma are those who have some increased risk if they get the virus.  Shots for the swine flu will not be available until at least November.

WHEN TO STAY HOME:  If your child has a runny nose and cough, but no fever, he likely does not have the flu.  Stay home.  If there is influenza in your school or apartment building, but no fever in your kid, stay home.  If your child has a fever but is drinking and breathing comfortably, stay home.  Some parents have reported to me that their kids have been sent home from school for simple colds and require a note to return.  However, the national Center for Disease Control (CDC) have given the schools guidelines with the following language:

“Simple runny noses without fever is not influenza.”

“Do not require a physician note to return to school.”

When in doubt, call your doctor.  They are there to help you decide if you need to be seen in the office or the ER.

WHEN TO SEE YOUR DOCTOR:  When your child has a fever over 101 for more than 3 days, or acts sick with fatigue, poor drinking, or complains of pain.

WHEN TO GO TO THE ER: When your child is short of breath, difficult to arouse, or has stopped drinking and has not made urine for 18 hours.

 

 

Give Me Antibiotics! No?

Every pediatrician has come to know The Look.  The parent’s face falls.  They are obviously disappointed, sometimes angry.  It happens when the parent came in expecting that the doctor will prescribe an antibiotic for their child’s illness, only to be told an antibiotic will not help.  There are only two times in my 17 year career that I have been yelled at and insulted to my face by a parent.  Were they at times of terrible stress and tragedy, a diagnosis of cancer or a death?  No, they were both when I diagnosed a viral illness in a smiling, obviously not very sick child and told the parent that an antibiotic was not necessary.

This October the national Center for Disease Control (CDC) is declaring a Get Smart About Antibiotics week.  From October 5 to 11 they will be having a media campaign to promote better public knowledge about when patients need antibiotics, and when they don’t.  October is a good time for this, given that child illnesses will be rising as kids swap germs at school, and the flu season starts (as if it already hasn’t!).  Many kids will get sick and their parents will be hoping for something to make them better.

Most of those illnesses will be caused by a virus, and antibiotics don’t kill viruses.  Viruses are those bugs that cause runny noses (even green runny noses), coughs, vomiting and diarrhea, most sore throats, and most fevers.  These illnesses get better on their own in 3 to 4 days.  Their treatment is to ease the symptoms with vaporizers, fluids, fever and pain medicine, and such.  For more information on these, see the Categories column on the right side of this page.

Antibiotics are for treating infections caused by bacteria.  These are the bugs that cause some ear infections, skin infections and boils, Strep throat, certain pneumonias, and bladder infections.

So many parents wonder “why not just give an antibiotic, just in case?  What’s the harm?”  Many doctors hate to disappoint parents, give in to this argument, and prescribe unnecessary antibiotics when pressured by families.  Well, here is the harm:  antibiotics are not entirely safe drugs.  Patients can have allergic reactions to antibiotics, sometimes severe reactions.  Sometimes if a patient gets an antibiotic and then stays sick, the antibiotic can negate the ability of later tests to tell the diagnosis.

The biggest reason not to give antibiotics is the risk of bacteria developing resistance to antibiotics.  This has been happening for decades and has given rise to bacteria resistant to multiple antibiotics.   Some patients get very sick with these super-resistant bugs like MRSA and VRE.  The newer antibiotics to attack those infections are so strong that the patient can get sick from the antibiotic too.

Experts worry that the day may come when all bacteria develop resistance to all antibiotics.  This is why the CDC, the American Academy of Pediatrics, and other expert groups are anxious to get doctors to stop prescribing unnecessary antibiotics; and to get parents to stop pressuring their doctors for them.

Next time your doctor says your child has a virus, be patient.  Give it a few days of fever medicine, vaporizers and throat sprays, chicken soup and honey.  If your child is not better then, it is fair then to call your doctor about getting another look.

Feel free to comment about your experiences with viruses and antibiotic disappointments!