SaveUHC.com

Many days in the Pediatric Emergency Department at Lafayette General, I am joined by a Family Practice resident.  Residents are apprentice doctors, graduated from medical school, who spend the first years after school in “residency,” programs that teach new doctors their specialties, like Family Practice, Pediatrics, Surgery, or adult Internal Medicine.  Our Family Practice residents learn a lot of their pediatric care on my unit.

Every weekday their lunch hour is Noon Conference, usually a lecture.  Sometimes Noon Conference is a business meeting involving schedules, preparation for upcoming exams,  or new training requirements.  Last week, the Tuesday conference was about what happens If University Hospital and Clinics (UHC), the residents’ base hospital, closes.

If you haven’t heard the news, the Louisiana Legislature has an upcoming $692 million budget shortfall.  The current plan is to make drastic cuts in state spending, particularly to Louisiana healthcare expenditure.  These cuts would close many hospitals around the state, including UHC.  With less than two months before the deadline (June 30), the Legislature still has no plan to save UHC.

Besides being a base for resident training, UHC sees about 50,000 patients in it’s Emergency Department per year, and has 116 beds for hospitalized patients.  It also has outpatient general and specialty clinics.  But it’s biggest mission, with the assistance of units like mine at Lafayette General, is to train Acadiana’s next doctors.  That’s the “University” in UHC.

Most residents, in Lafayette and around the country, stay in the community where they trained.  A good 75% of Family Practice residents at UHC get a job in the Acadiana area.  That’s lots of new doctors.  They’re needed to replace doctors who retire, and there’s already a shortage of doctors to see all the patients in need.

If UHC closed, that’s no more new doctors for the Lafayette area.  The shortage of doctors seeing patients would get worse. Imagine having to wait months to see your doctor.  And what if you got sick?  What would happen if you needed to go to the ER, or be hospitalized?

Here’s what would happen.  It’s mid-June (a month from now!), and the state Legislature still hasn’t budgeted to save Louisiana’s healthcare system, with it’s doctors, hospitals, and training programs.  It’s looking like the worst will come.  Hospitals around the state, like UHC here in Lafayette, that train doctors and medical students and see the poorest and sickest patients, will close.  

Since resident doctors, those apprentice doctors we discussed above, start their academic years on July 1, they’ll have to be placed elsewhere.  The surviving programs in New Orleans and Shreveport will absorb as many residents as they can.  Those they can’t take will have to go out of state.  The residents and their families will make moving plans.  As we discussed above, that’s it for new doctors for the Lafayette area.

When the resident programs close on June 30, they can’t reopen if the Legislature suddenly decides to come up with the money on, say, July 10.  It takes years to get a residency program accredited, and if the doors close, there’s no re-opening them days later and saying “just kidding!”  Training doctors is serious business, and those who regulate it don’t tolerate poor planning, and capricious closing and opening.  Whosever fault it is, Legislature or elsewhere, residencies require stability and competency.  So if the UHC residencies shut down, that’s it.

Now it’s July 1.  UHC is shuttered, the lights out, the residents gone to programs in other cities.  The patients in the hospital have been transferred to the other area hospitals.  Lafayette General Medical Center and Lafayette General SouthWest, UHC’s sister hospitals, fill up first.  Then Our Lady of Lourdes, Heart Hospital, and Women’s and Children’s are next.  With the beds all taken, their Emergency Departments begin to be populated by patients who are “boarding,” awaiting room in the hospital upstairs.

Then the patients who would be served by UHC’s ER and clinics begin to come to those other ERs, already full of boarders.  Wait times to get seen in those ERs skyrocket.  Waiting rooms and hallways overflow.  Ambulances stack up at the ER entrances; the paramedics can’t get their patients off their stretchers and back in service.  It starts to look like an apocalyptic movie.

Go to saveUHC.com, push the Take Action button, and let your legislators know.  We must save UHC.  Or else.

Water Works

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

8 year-old Ted finished his last baseball game of the season.  To celebrate, mom and dad took the family to the new burger bar in town.  Ted picked the biggest burger on the menu, his attempts to devour it leaving everyone in stitches.  Dad thought the meat looked a little too pink, but didn’t want to interrupt the good time- it was probably fine.  Later back home, Ted yells from the bathroom: “It’s coming out like water!”  Then comes the sound of vomiting.

Diarrhea and vomiting are difficult topics for parents, because they’re gross, and it’s sometimes hard for parents to know when to worry.  It’s a big mess when it happens and they just want it over!  But the real questions are- does he need to go to the doctor?  Is this a stomach virus that will get better on it’s own, or something worse?  When will it end?  When do I worry about dehydration?

We see a lot of kids in the Emergency Department who, when they have one or two vomits or diarrheas, are rushed right in.  Then as the parent goes on about how sick their child is, the kid is dashing about the room, opening the drawers and jiggling the bed controls.  In fact, these are good signs that the child doesn’t have something bad, like a blockage, or appendicitis, or dehydration- walking, talking, and playing.  If the child is not eating, but is drinking, that’s another good sign.  Kids who make wet diapers and urinate, even if only once or twice per day, or make tears when they cry, are getting enough fluids to not worry about dehydration either.

Here’s the worrisome signs that your child needs to get seen- diarrhea with lots of blood, abdominal pain so bad they cry, and non-stop vomiting, like for hours and hours.  Finally, if kids are so lethargic that they have trouble staying awake, or even sitting up, you need to talk to a doctor.  These could be symptoms of worse things than a run-of-the-mill stomach bug, like appendicitis, blockages, severe infections, or serious dehydration.

Back to our story of Ted from above, having vomiting and diarrhea after eating undercooked hamburger.  He continued to vomit all night, into the next day, with diarrhea.  By the afternoon he’s looking like a limp dishrag- tired, pale, and sleeping a lot.  He also looks grey and sunken around the eyes.  TIme to visit the Emergency Department.

Dehydration is the most serious complication of vomiting and diarrhea.  Diarrhea alone usually doesn’t do it- if children drink and hold fluids down, dehydration is unusual.  Some parents worry that fluids are “running right through” a kid who drinks and then immediately has diarrhea.  However, kids typically absorb enough to get by.  “Feed through” diarrhea is the rule: keep it coming from the top, even if it seems to come right out the bottom.

However, if the child is also vomiting, or not drinking, dehydration is a worry.  Ted is showing us the signs- worsening fatigue, pallor and sunken eyes.  If he doesn’t make urine for 8-12 hours, that’s another clue that he needs to come in for IV fluids.

The best way to avoid dehydration is drinking clear liquids.  Fluids that contain some sugar and salt are most efficiently absorbed- sports drinks, or pedialyte for babies.  But don’t use full-strength fruit juices- they can worsen diarrhea.  To avoid vomiting, start with small amounts of fluid, to not challenge the stomach too much.  Give babies just a few ounces, older kids a half cup.  If that stays down after a half hour, give another little bit.  After a few hours where small amounts are staying down, you can give larger amounts.  Then about 6-8 hours after not vomiting, you can try bland starchy foods- rice, toast, crackers, bananas; nothing heavy like burgers, fries, or nuggets.

Your doctor can also prescribe Zofran over the phone, a medicine which can stop nausea and vomiting before it gets too far.  Antibiotics don’t help, and may worsen diarrhea.  They’re used only when tests on the stool indicate.

But if your kid is walking, smiling, and peeing, he’s not dehydrated.  Soon his body will shut off the Water Works, and the mess will finally end! 

McDonaldland

When I was a kid, McDonaldland wasn’t a playground- it was a fictional place in Saturday morning TV ads. I was enthralled with those ads: the outrageous-looking puppets, the colorful sets, evoked a Disney-like magic. Unbeknown to 8 year-old me, McDonald’s was sued by the producers of another Saturday morning program, H.R. Pufnstuf, because McDonaldland looked a lot like their show. McDonald’s lost the suit, and its TV land disappeared.

Then, as now, kids were bombarded by advertisements for toys and food. Ad makers realized that kids are easily swayed and could use them to get to the parents, who had the money.  One of the earliest to realize this was Walt Disney himself, airing a TV show in 1954 called Disneyland.  Besides cartoons and live-action dramas, every episode had updates on Disneyland itself, then under construction.  The show built enthusiasm, and when Disneyland opened it was jam-packed, and remains so today.

Parents’ desire to have healthy kids, and the ad-created desire of kids to go to these colorful places to play and eat, creates a battleground at home.  Parents want good nutrition for their children; children want to eat the really yummy stuff.  Kids’ weapons- perserverance, pleading, and whining.  Parents’ defense against this- authority, and knowledge that too much of a good thing is bad for children.  However, this defense is undermined by the competing parental desire to please their kids and see smiles instead of frowns.

The key to winning the battle is two-fold.  First, know you’re in charge.  You can refuse to get caught arguing about where to go and what to eat.  I would say to my kids, literally, “this is not an argument,” shutting off discussion about eating out.  You also have control of the wallet and the car.

The second key is knowing the consequences of losing the battle.  You want your kids to grow up, not grow wide.  You don’t want high-fat, low fiber diets that cause cramps and constipation.  And the evidence is mounting that these diets in kids lead to premature high blood pressure, heart attacks, and strokes as adults.

Besides the McDonaldland advertising campaign discussed above, as a kid I liked the food too.  About once a year my parents would allow a quarter-pounder, fries, and a shake.  It was delicious, and every store offered the exact same food and flavor. Thanks to manufacturing and food science, wherever we went, McDonalds’ nationwide offered the same yummy menu.

For instance, why are all McDonald’s fries so tasty?  Until 1990, it was because they were fried in oil and beef tallow.  That year McDonald’s bowed to public pressure to reduce the saturated fat in its food and switched to pure vegetable oil.  To retain that beef flavor though, they added a manufactured, beef-flavored chemical.

Uniform deliciousness isn’t the only reason fast food has been so successful.  It’s also inexpensive.  In 1948, the McDonald brothers, Dick and Mac, invented their “Speedee Service System,” to make their California hamburger stand more profitable.  This kitchen automation, designed to be operated by minimum-wage workers, cut food prep costs.  Then under McDonald’s empire builder Ray Kroc, the hyper-efficient kitchen was supported by central manufacturing of food products, delivered by 18-wheeler.  “Dining out” was now an option affordable for every family, not just the rich, and not just once a year.

Finally, fast food is successful because…it’s fast.  No waiting a half hour for your entree; burgers and fries are in the sack in minutes.  These three advantages to fast food- speed, cost, and deliciousness, help explain why poverty and obesity go together.  Most impoverished families I see in the Emergency Department are headed by single moms who often work two jobs.  It’s harder for them to spend the time and money to shop for and prepare home-made, healthy meals.  Their kids love fast food, it’s affordable and quickly available- meal is done!

Obesity used to be a sign of wealth- only the wealthy could afford to eat too much.  Now, the poor can also be obese, with the high-fat and sugar content of manufactured food.  Their kids suffer the consequences- abdominal pain, constipation, diabetes, high blood pressure, and early risk of heart disease.  So it behooves parents to take control of their kids’ diets, to avoid ruining their bodies.  As a kid, I loved eating at McDonald’s, but only once a year.  That’s about the right amount! 

YOUR CHILD IN THE WILD WEST?

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

The wild west was plenty dangerous: prostitution, stage coach robbery, gunfights.  No place to send your child, even with a six-shooter strapped on the hip. Yet every day kids as young as 2 years are allowed to wander into similarly threatening territory- the internet.

For small children, the internet can be a welcome distraction while you wait in line.  Then a fun song on the phone leads to a Youtube video, which leads to a game, and ends with a $1000 data bill.  Stage coach robbery indeed!  Fortunately, this scenario has an easy solution: don’t link financial access to your phone, or password or pin-code it.

Some kids are allowed to spend all day on a screen.  While there’s no obvious immediate harm, it’s an activity that’s been engineered to be addictive.  The longer developers can keep your child engaged, the more money they earn from advertisers.  If you think it’s not addictive, try taking the phone away.  Children can act just like addicts who can’t get a fix- whining, aggressive, foul-mouthed; not the nice kids they used to be!

Sites like Youtube are also designed for children as young as 2 years to operate, surfing whatever videos they like.  More disconcerting, some producers have posted questionable content aimed at younger children, often optimized so you won’t find it until you’ve gone through 9 or 10 videos first.  One parent warned us this past week of corrupted Peppa Pig videos, the characters talking about marijuana.

Policing content is a problem without a simple answer.  The multitude of platforms for internet access means a multitude of solutions.  Fortunately, most phones and browsers have methods for filtering what can be seen.  Search how to “blacklist” (block sites), or “whitelist” (allow sites) on your device or browser.

Fortunately for parents, you can do what large corporate IT departments can’t- discuss internet content and safe-surfing directly with your kids.  Watch over their shoulders.  Failing that, you can pull the plug on power, or internet service.

Back to our wild west analogy from above- the dare.  Quick-draw gunfights often involved one assailant goading the other into combat.  Afraid of being seen as cowardly, the reluctant fighter was drawn in, and one or both would end up wounded or dead.  The modern internet version of this: the Tide-Pod Challenge.

If you haven’t seen the news recently, this involved videos daring teens to eat Tide-Pod dishwashing detergent packets.  Then Emergency Departments around the country began to see these potentially lethal cases, and most videos became blocked.  Other harmful video-generated pranks: children creating and inhaling chlorine gas, drinking antifreeze, and running cars in enclosed spaces.  Parents must teach children that following instructions from strangers on the internet is just as dangerous as with strangers on the street.

Despite blacklists, history searches, and firewalls to limit your internet content, teens can be a special worry.  Most teenagers can find work-arounds, on the net or from friends, that you might not know.  After all, unlike most parents, they’ve grown up with the net; they’ve used it their whole lives.  In the end, there’s no better solution to knowing what your teen is watching, than talking about it with them.

Another internet problem for teens is social media bullying.  The net offers the ability to bully away from school or other social activities, where the bully might be caught.  Also, social media can magnify bullying.  Instead of the bully egging on a jeering handful of lackeys, the lackeys on-line can number in the hundreds.  Imagine your kid being laughed at by a crowded auditorium- a nightmare often depicted on film and TV.  Social media easily creates a real-life equivalent.  An even worse nightmare: in 2014, a 17 year-old girl boasted affiliation with a Chicago gang, and revealed her address, on social media.  Affiliation true or not, rival gang members killed her 3 blocks from her home.

Today’s children are the first generation with these internet worries; parents aren’t equipped to deal with them from their own childhood experience.  Social media, while being a great new way to communicate, also begats new problems.  Parents need to learn the new solutions.  And the old solution too- talking these things through with their kids.  

IT’S NOT THE HEART!

I had funny feelings in my chest.  Because both my brothers had cardiac issues in their 50s, and I was about to go on a hiking vacation, I was a little concerned. So while at work, I asked one of the nurses to check my EKG.  Her eyes bugged out, and I could see her thinking “Dr. Hamilton’s having a heart attack??”  Her hands shook as she stuck the leads on, apparently more worried about me than I was. Fortunately the EKG was normal and vacation went fine.  And I lamely apologized to the nurse for scaring her with my apparent muscle pain.

We older adults are continually warned to take chest pain seriously. With bad pain, we’re to call 911.  Paramedics carry medicines for heart attacks, and can send EKGs to  the ER to warn that a cardiac patient is imminent.  Also, sometimes adults pass out from heart attacks while driving themselves to the hospital, endangering others as well as themselves- let the medics drive!

You may be surprised, but kids get chest pain too, and when they do, sometimes parents panic.  Is my child having a heart attack like Uncle Frim did? The good news: rarely is chest pain something bad in kids.  The majority of their chest pain is in the chest wall: muscles, ligaments, and ribs.  The rib cage is not rigid like a bird cage; it has joints, expanding to suck air into the lungs, and contracting to squeeze air back out.  Like any joints, whether in the chest wall, knees, or knuckles, they can hurt.  Furthermore, the rib cage often hurts in kids for no apparent reason.  Sometimes the joints are strained by coughing, or lifting weights, sometimes they just hurt randomly.

The treatment for “costochondritis” (latin for rib and cartilage inflammation) is the same as for any sore joint.  Medicines like ibuprofen (brand names Motrin, Advil) decrease pain and inflammation- kids can take them three time daily for four days to settle things down.  Rest is important too- no PE, running, or other exercise that will get kids breathing hard and stress those sore rib joints.

Red flags for pediatric heart conditions below.

A teenager was in the chair at the hair salon, getting her hair done.  As the stylist worked, the girl started to feel weak, her vision closed in, and she slumped in the chair, unconscious.  Everyone began shouting, someone called 911, and they lowered her to the floor.  When the paramedics arrived, she was awake and feeling normal.

“Hair-Grooming Syncope” is the medical term for this phenomenon, where hair braiding, drying, or brushing leads to fainting spells.  It can happen in boys as well as girls, and isn’t from seizures or heart conditions.  It’s another case where teenagers can have an exaggerated tendency to faint.

Teens faint more easily than adults.  About 15% of kids have “syncope” before adulthood.  Kids have more pliant blood vessels in their extremities, and blood can pool there when they stand, sit, or lie down for long periods.  Then when they get up, it takes some seconds for the leg muscles to pump that blood back up into the central circulation to feed the brain.  When the brain lacks blood, kids faint. They fall down flat, blood gets back to the brain, and they wake up.

Other things besides hair grooming and sudden standing can make kids faint, like stress or anxiety. The site of blood itself can bring on syncope- we always have parents sit down when we stitch their kids’ lacerations, because sometimes the sight of blood gets them woozy and they collapse before we can catch them.  Illnesses like stomach or flu viruses, or certain smells can also cause syncope.

Like with chest pain, fainting is rarely due to heart conditions in kids.  However, there’s some red flags for the heart when kids faint or have chest pain.  If the child or teen has pain or faint-feeling while exercising, that needs checking. Kids who have chest pain or palpitations with fainting are concerning.  We also worry if there’s family members who suddenly died at an early age.  Rare-but-lethal heart rhythm conditions can run in families: these are the kids at risk for collapsing on the basketball court.  But if your kid feels woozy in the salon chair, don’t panic- it’s the hair, not the heart.

It’s My Head, It’s my Belly!

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

Every parent dreads: “Mommy..Daddy…my tummy hurts…”  Sometimes they whisper this in the middle of the night, sometimes they holler it at the bus stop.  Then often when they come to the Emergency Department, we walk in the room and the kid is leaping off the stretcher, smiling and giggling.  “I swear he was in terrible pain!” mom says.

Stomachaches are a common pediatric complaint.  Sometimes it’s serious, sometimes not.  Questions many parents ask: When was the last bowel movement?  How much junk food did he eat today? How’s she drinking?

Constipation is the most common reason for belly pain in the ER.  This is because the pain can look terrible, the child crying, doubled over with cramps.  This freaks parents out. They worry about bad things like appendicitis.  Then the pain relents, and the kid looks fine upon arrival.  Signs of constipation include skipping days of pooping, or passing hard painful stools, or only passing small pebbles.  Often parents don’t know their kids’ stooling patterns- who investigates what’s happening in the bathroom?  Sometimes kids go in, sit for awhile, produce nothing, and then leave.  But mom assumes they stooled.

If it’s constipation causing pain, the fix is usually dietary.  Kids don’t get enough fiber, especially when they eat lots of prepared foods like hot pockets, pop-tarts, McDonald’s, and other junk.  Kids should eat fruit with every meal, vegetables with lunch and dinner, and eat more fiber.  Sometimes they need medicine from their doctor to help.

“Stomach bugs” are another common cause of abdominal pain.  Usually these are associated with vomiting, diarrhea, and fever, but not always!  They usually last 1-2 days, and the goal is to keep the child hydrated.  Give clear liquids like sports drinks or Pedialyte.  They’re easy on the stomach and well absorbed for hydration.  Other viruses, like the common cold, can cause stomach aches too.  If your child vomits more than 4-5 times, has worsening belly pain, or has worsening fatigue, get seen.

Headaches are another common complaint that brings children to the Emergency Department.  Like our stomachache from above, kids can cry in pain.  Then often when they get to the ER, they’re going through all the cabinets and running into other patient’s rooms..  What kids do to entertain themselves while waiting for the doctor! They’re not miserable like they were earlier, to the parents’ embarrassment.

The majority of headaches aren’t serious.  Usually they’re brief pain episodes, called “tension headaches,” or are due to illnesses like viruses or allergies.  Sometimes, the “tension” is because kids don’t want to go to school.  Infections like stomach viruses, influenza, and strep throat are notorious for causing headaches.  Kids, like adults, sometimes get migraines too.

When children cry with head pain, parents go to their worst fears.  Is it meningitis?  A brain tumor?  Meningitis is an infection of a lining of the brain called the meninges, a saran-wrap-like membrane, which can get infected.  When this happens, the inflammation from meningitis presses on and poisons the brain.  It can be life-threatening, and cause permanent brain injuries like hearing loss or cerebral palsy.  Brain tumors are lumps that grow in the brain, compressing it, causing headaches and vomiting.  Sometimes the tumor is cancer, sometimes not.

How do you tell if the headache is serious, or just school avoidance?  If a dose of Tylenol or ibuprofen fixes it, no problem.  It’s also easy to try a cold compress on the forehead.  Questions to ask: Is there vomiting or nausea?  Is there a stiff neck?  Was she awakened at night by the pain?  Does he look excessively tired?  Yes answers to these mean your child should get seen.

As we mentioned, kids can get migraines.  These are recurrent headaches, often accompanied by nausea and vomiting.  They can be worsened by bright light and loud sounds, and can be debilitating.  Sometimes kids need brain scans to tell the difference between migraines and more serious things.  Fortunately, once brain tumors or meningitis are ruled out, migraines can be treated.  Usually a healthy dose of ibuprofen and napping in a dark, quiet room are all that’s needed.  And they’re prevented by basic good health- three healthy meals a day, reduced phone and computer time, and  reasonable bed times!

Guns Or Mental Health?

On February 9, Acadiana’s regional EMS Council had it’s latest meeting, representing local ambulance services, Emergency Departments, and disaster coordinators.  First we congratulated ourselves on providing tourniquet training to 105 Sheriff’s deputies, to stop life threatening bleeding from gunshot wounds. Our next consideration was to provide this training to schools.  We all shook our heads: the world’s come to this, that schools need tourniquet training?  Five days later, another school shooting, this time in Parkland, Florida.

This latest shooting reignited national debate on preventing these tragedies.  Is it a lapse in mental health care; or is access to assault rifles, designed to kill large amounts of people, too easy?  I see lots of kids in the ER with suicidal and violent tendencies. Occasionally they threaten to shoot up their school, and can get a gun.  When we hear that, we admit them to a psychiatric facility for evaluation.

However, there’s limited treatment options for these kids.  There’s not enough mental health beds or outpatient services for all the teens who need help. When it comes to pre-teens, it sometimes takes days to get them into an appropriate hospital- there’s not that many beds for that age in Louisiana.  The closed option for younger kids from our area is Alexandria.  If that hospital’s full, it’s Shreveport or New Orleans.  That’s far for impoverished, working families to visit, and far for those hospitals to coordinate outpatient care for patients returning home.

Obviously, mental health needs more money for doctors, therapists, and beds.  Like roads and schools, when it comes to quality, you get what you pay for.  There’s also a need for finding lonely, bullied kids and support them before they become risks.  The Huffington Post recently reported on a teacher who uses surveys in her fifth grade classes, asking who wants to sit with whom for the following week, and asking for nominations for the week’s exceptional class citizen.  But instead of using those surveys to see where kids want to sit and their nominations, she’s finding out who’s not getting requests to be sat with, or nominated.  She’s looking for lonely kids who needs friends.

The sun is about to come up, the woods quiet and dark.  My son, my brother-in-law, and I stand in knee-deep water, listening.  The birds start to chirp, the frogs croak, the sky lightens. Alas, no ducks show up, and when the dawn is over, we unload our shotguns and head home.  Another morning where, instead of “hunters,” we’re just “heavily-armed nature lovers.”

As mental health care has again become a national issue after the latest school shooting in Florida, as we discussed above, gun control has also resurfaced.  As many are vilifying the National Rifle Association for it’s gun access advocacy, we learn there’s actually two NRAs.  The historical NRA, and majority of members, are hunters like us, nature lovers with shotguns.  This NRA is about spending time outdoors with family, gun safety, and how to cook your deer or ducks.  For most of the 20th century the NRA actually helped write some gun control laws, including restrictions on “crime” weapons like submachine guns.  It’s only in recent history that there’s a political NRA, lobbying for access to all types of weapons.

Like them or not, the NRA has important safety advice for parents.  After all, most gun injuries and deaths happen in the home, from suicide, domestic violence, or accidents.  Keep guns unloaded and locked, and ammunition locked up separately.  When your kids get curious about guns, teach them gun safety, to take away the mystery and desire to “play with guns.”  If kids find an unsecure weapon, they should run from it and and report it to a responsible adult.  With little kids, or depressed teens, don’t have a gun in the house at all.

Finally, no one needs an assault rifle, especially the mentally ill.  They’re no good for hunting ducks.  The high energy, tumbling action of their bullets, designed to inflict maximal damage to soldiers, destroys deer meat.  Like I mentioned above, our regional EMS council was considering providing tourniquet training for our local schools, even before the latest school shooting.  But prevention, by regulating these weapons, or their ammunition, is way better than having to treat pediatric gunshot wounds.  The only animals that should be at risk are those that are good in gumbo. 

Beware of UFOs!

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

It’s Sunday afternoon, you’re prepping dinner and keeping an eye on the kids.  You catch a fleeting glimpse of your youngest casually shoving something up his nose.  Did that just happen?  What’s he put up there?  You grab his head to look, and see something- let’s call it an Unidentified Foreign Object, a pediatric UFO.

Besides the obvious question- what the heck did he stick up there- there’s others.  Is this dangerous?  Does he need to go to the Emergency Room?  Often, parents decide the answer is yes, I need a professional to remove and identify this thing.  But you don’t need the ER with every UFO sighting.

Most objects in the nose are benign, and since they irritate, eventually get sneezed out.  If it’s close to the nasal opening, you can often grab it with tweezers.  However, if it’s big, round, slippery, and far up there, you may need help getting it out.  Also, if it’s a disc battery, it needs removal now.  Mucus in the nose sets up a current between the battery’s terminals, heating it up and burning the inside of the nose.  UFOs that are far up there pose other risks.  If they clog a sinus passage, mucus and debris can accumulate in the sinus and cause infection.  Also, the back of the nose opens into the throat, and occasionally UFOs can fall back and be breathed into the lungs.

Ears are another popular place children hide things.  Dr. Hamilton once had a kid put orange seeds in each ear to block having to listen to his sister. Usually there’s less reason kids do this besides, that they can.  Ears are trickier for UFOs- it’s harder to get objects out of that skinny, sensitive canal.  Also, there’s the ear drum back there.  If you hit that while trying to get a UFO out, it really hurts!  And you might injure the drum and affect hearing.  Ear UFOs that aren’t tiny enough to fall out on their own require us, or an ENT specialist, to remove.

Back to our toddler from above, casually shoving random objects up his nose.  Let’s say he does another common toddler move- putting things in his mouth and swallowing them.  Again you panic, rush over to look, and wonder what was that Unidentified Foreign Object (UFO) he just scarfed?  Is this bad?  You see some coins lying around, was that it?  At this point, many families rush to the Emergency Room.

Most ingested objects are benign. They simply pass through the gastrointestinal tract and out the other end.  If the UFO landed somewhere more concerning, like in the airway, or in the esophagus on the way to the stomach, your child lets you know.  UFOs in the upper airway or lungs irritate, causing coughing and obvious distress.  If stuck in the esophagus, kids feel that too, and will gag and squirm and have trouble swallowing.  These kids certainly need the ER.

Another emergency situation is if your child swallows toy magnets.  Even though these go down easily and he toddles off to get into more mischief, magnets can cause serious internal injuries.  Two magnets can cling together, trapping intestinal lining between them.  When that lining is compressed, it’s blood supply is squeezed out, it perforates, and gut contents can leak out and cause life-threatening abdominal infections.

Another stat scenario is disc or button batteries stuck in the esophagus.  Like the battery in the nose from above, the esophageal mucus makes a current between the battery’s + and – sides, heating it up, and causing burns.  If the esophagus burns through, it’s a risk for another life-threatening internal infection, inside the chest.

Understandably, having a UFO in your child’s ear, nose, or throat is alarming.  But stay calm.  Becoming upset also upsets your child, and when she’s crying, you can’t tell if it’s because you’re crying, or she’s in true distress.  No parent wants their child to become the next Area 51, but if he’s not coughing and choking, and you’re sure the UFO was something inert like a coin or lego, it’s cool.  If in doubt, call your doctor for advice.  A UFO is scariest because it’s unidentified, but really, they usually come in peace.

Too Many Tests, Too Many Meds

I remember that first time- a parent insisting on antibiotics despite my advice.  The girl clearly had a virus- cough and runny nose for two days.  I explained to the father that antibiotics don’t kill viruses, she’ll get better regardless.  “I still want the antibiotic,” he answered.  No doctor likes to disappoint, but I didn’t give in.  Better to anger a parent than prescribe unnecessary medications; as I explained to him, medications have risks.

In the past two decades, medicine has been touting “Antibiotic Stewardship.”  As more antibiotics are prescribed, bacteria develop resistance to them.  ”Super-bacteria” that resist all antibiotics sometimes infect patients.  Scientists worry that one day, bacteria will win the battle, they’ll all become resistant to all antibiotics.  The age of these miracle medicines will have passed, and a new medical dark age begun.

Antibiotics also are not entirely benign.  They can have side-effects.  Kids can get allergic reactions, sometimes just itchy hives, sometimes more severe.  Antibiotics can cause diarrhea and yeast infections.  Kids come to the Emergency Department for antibiotic reactions, and I sigh when the antibiotics were prescribed “for a cold.”  Unnecessary medications can lead to unnecessary ER visits.

Since the Antibiotic Stewardship campaign hasn’t really changed prescribing habits, there’s now a program called “Choosing Wisely.”  This new push is for doctors not only to prescribe medications carefully, but also stop unnecessary testing that can be potentially harmful, like unnecessary CT scans.  All the major medical academies, like the American Academy of Pediatrics, have Choosing Wisely goals for their specialties.

Why are campaigns like Choosing Wisely and Antibiotic Stewardship necessary?  Usage of medical testing and medication has skyrocketed, without improvement in health.  The most stark example is the opioid epidemic: more Americans are now dying of narcotic overdoses than from car accidents.  Part of the problem is consumer demand. We think that more is better, and that more tests, more medications, lead to better results.  Also, everyone knows a story of someone who suffered or died because the doctor didn’t order this test, or give that medication.  Then when their kid’s sick, they want it all.

Many people aren’t aware that tests can be harmful.  When I discuss the risks of CT scans, I sometimes talk about this experiment:  In August 1945, the Army Air Force dropped atomic bombs on two Japanese cities, Hiroshima and Nagasaki.  The physicists knew how much radiation the explosions would put out for each given distance from ground zero.  After the war, scientists followed the radiation effects in the victims.  From this data, we know from those that got a radiation dose equal to a CT scan, that dose increases your risk of cancer a small, but real, amount.

Besides radiation risk, CT scans can also cause other problems.  Often we need to give medical dye to “light up” inflammation for the scan, and that dye can cause allergic reactions.  Also, scans carry the risk of “too much information.”  Sometimes the scan shows not only what we’re interested in, like the appendix, but also shows other weird things we can’t explain.  Usually those weird things are normal, but sometimes we can’t be sure.  Then doctors are faced with a dilemma: do we spend more time and tests to prove that thing is cool, or do we just assume so and move on?

When people want more tests, like we discussed above, they’re often unaware that tests usually don’t declare the diagnosis, but only provide more clues.  What’s not well known to the public (and some doctors!), is that most diagnosis, as much as 85%, is made from the medical history alone.  The medical history is the “story” of the illness that doctors elicit from the patient.  Taking a thorough history if far more important than tests.  A good history also helps point to the best tests to do, or can eliminate the need for tests.

When the family wants a test or medication that the doctor is wary to order, there should be a clear conversation.  The doctor needs to explain why the risks outweigh the benefits, that the test or medication may harm the child more than help.  If the parents still insist, then the doctor either cedes to the parent’s request, if the harm is minimal, or must stand firm for the good of the child.  Sometimes we make parents angry, in order to Do No Harm.

 

Two Peds In A Pod

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

We see lots of kids with abdominal pain in the Emergency Department.  They’ll maybe have cramps or sharp pains, sometimes diarrhea, or have hard stools that hurt.  We’ll ask “what did you have for dinner last night?”  A common answer: Taco Bell.  Or McDonald’s.  Or “rice and gravy.”  Few families make the link between their greasy, fatty diets and their kids’ grumpy guts.

It’s no secret that feeding kids can be challenging.  You may want them to eat a healthy diet, but when they get old enough, kids can be fussy about what they like.  They have more control over what they eat as well.  Toddlers can be stubborn and refuse what you make; meals become battles.  School-age kids just go to the kitchen and snack when they’re hungry.  Teens hop into cars and drive to fast food joints.

Eating well is important for all ages, but particularly for children, who require adequate nutrients for their growing bodies.  Lucky for parents, they really have a great deal of control over the evolution of their kids’ taste buds, and can steer food preferences to healthier choices.

Taste development actually begins in the womb.  Amniotic fluid contains flavors based on mom’s diet.  After delivery, breast-fed babies get flavors of mom’s food through her milk.  To illustrate, after someone eats garlic, their breath still smells the next morning, no matter how much they brushed their teeth.  That’s because garlic is suffused through their bodies, and the smell is exhaled out their lungs, not their mouths.  For pregnant and nursing moms, that includes the placenta and breast milk.

So to all pregnant and breast-feeding moms out there, a well-balanced, healthy diet is not only important for you, but for baby’s developing tastes.  These women need to be good about what they eat- low fat, high-fiber, lots of fruits and vegetables, and whole grains.  That way their bodies are the best incubators for babies, and so babies also prefer healthy foods for themselves.

I know of one toddler whose parents fed her a variety of foods, and she learned to eat lots of things.  She also liked to put each of those foods on top of her head while she ate.  She did it for fun, smiling and enjoying her parents’ reactions, as peach juice ran down her forehead.

When babies reach the age of 6 months, taste preferences start to flourish- that’s when they start solid foods.  Introducing pureed vegetables before fruits is a great way to acclimate your child’s taste buds to low-sugar foods.  Giving many different baby foods is crucial; as many pureed vegetables, fruits, meats, and grains as you can.  This will make transition to a toddler diet easier, as they will have already been exposed to almost all flavors and will therefore be less likely to react adversely to a taste.

It’s also important to remember to introduce only one new food at a time at that age.  That way, if baby has an allergic reaction, or doesn’t digest that food well (has vomiting or diarrhea), you’ll know it’s the new food that caused it.  If a particular food is tolerated after 4 days of eating it, move on to the next new thing.

Toddler-hood is when routines and healthy eating can be challenging.  These kids  vocalize food preferences, and can be stubborn refusers.  Stock your kitchen with a variety of healthy choices, with no junk food choices that he can focus on.  Avoid buying the 20-count pack of chips, no matter how cheap.  If your toddler sees that, good luck getting him to eat his peas!

It’s important to establish routines: the family should sit down together for meals, three times daily.  These meals should feature most food groups, and toddlers need to try each one, if only one bite.  It can sometimes take fifteen tries before a kid decides they like a food.  If they refuse a bite, no treats!  If a toddler refuses to eat anything at all, don’t give into the fear that they’ll starve and make them something else.  We’ve never seen a child starve from refusing food.  When they’re hungry, they’ll eat.  Parents who fix their children different foods than they’re eating, catering to the child’s preferences, are creating diet monsters.