When Ankles Go Bad

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

It’s the time of the year for leaves to change, pumpkin lattes to be served, and fall sports- and ankle injuries???  Yes! With sports comes consequences of inadequate summer conditioning, over-aggressive drills when the season starts, and new cleats with their fresh, turf-catching studs.  Ankle sprains are one of the most common injuries we see in the Pediatric Emergency Department, and not just in athletes.  With kids getting fatter and exercising thumbs more than legs, more non-athlete ankles are giving out too.

What are ankle sprains?  Ankle and foot bones are bound together with tough, fibrous bands called ligaments.  Sprain is when those bands get jerked so hard they begin to tear.  The “inversion” injury is most common, when the foot is wrenched inward so the victim ends up standing on the outside of the foot.  Then he goes “yowch” and hops around.

Ligament injuries come in three grades: Grade 1 is simple pulls, where ligaments are only bruised by the force.  Grade 2 is partial tears; Grade 3 is full tears, with complete joint instability.  Ankle bones can break too, with strong enough force, like when stepping in a hole while running, or landing wrong when jumping in basketball.  Also kids’ ligaments are often stronger than the bones they’re anchored on, making fractures even more possible.

When do children need x-rays?  If the ankle hurts when squeezed where fractures are most likely, or if the child cannot walk on it at all, then x-rays are necessary to look for breaks.  The degree of swelling doesn’t help decide.  Swelling happens with both ligament and bone injuries, so a more swollen ankle doesn’t mean fracture.

The best treatment for ankle injuries is, of course, prevention.  Athletes should have careful, supervised stretching before and after work-outs.  Conditioning should increase gradually, avoiding over-exertion, when fatigued muscles that support joints give out.  Kids with frequent ankle injuries should have velcro or lace-up braces, or be taped before practice and games.

Your 10 year-old Tim Tebow was throwing a pass when tackled.  Unable to walk on his ankle, he’s brought to us.  After the x-ray, parents often ask, “is it broken, or fractured?”  This question makes us pause and scratch our heads, since in medical terminology, fracture IS a broken bone.  We’re not sure what people think the difference might be.

If a bone’s broken, the child gets a cast, crutches, and a referral to Orthopedics, who  make sure the bone heals properly.  Occasionally, ankle fractures are so bad they need surgery.  Either way, that’s it for the season- it takes a month or two for fractures to heal.  We’ll write the child an excuse for PE and sports until the orthopedic doctor clears her.

If the ankle is sprained, the injured ligaments usually heal in a week or so.  Caring for sprains is actually more work for the parents and patient than fractures, because there’s more things for them to do, remembered by the acronym RICE.

R is for Rest.  Parents need to limit kid’s walking for the first days.  Occasionally rest means crutches, so the child can get around school and home without putting weight on the ankle.  Don’t leave the doctor’s without that PE excuse!  I is for Ice.  Wrap a bag of ice or a cold pack on the swollen part to decrease pain and swelling.

C is for Compression, with an ACE bandage or velcro brace, wrapped from toes to lower leg.  This minimizes swelling and gives ankles some support. E is for Elevation: sprained ankles swell and throb, so propping them up on pillows or footstools will decrease swelling and throbbing with gravity assistance. 

Finally, don’t forget pain medicine (maybe the acronym should include an M, like MR. ICE instead of RICE).  Sprains and fractures hurt, so don’t skimp on ibuprofen (AKA Motrin or Advil), which is better than acetaminophen (Tylenol).  Both ease pain, but ibuprofen also decreases inflammation in the injury, which eases swelling too.

Like we said above, prevention is the best treatment.  Get your kids off the couch and running around outside, so that they self-condition those legs.  Feed them less junk  they don’t get overweight and strain those ankles.  And don’t push the Tim Tebow thing- kids should condition in their own good time. 

Wheezing Through The Ages

Asthma has been with us for millenia.  The ancient Greek physician Hippocrates, inventor of the Hippocratic Oath, first used the term (from the Greek aazein, “to pant”). The Greeks had treatments- adding ephedra (an epinephrine-like drug) to red wine, and smoking stramonium, an atropine analog.  They weren’t entirely on the ball though, thinking that adding owl’s blood to the wine helped too.

Asthma has become more common in children in recent decades.  This is because of changes in kids’ environments, and because of the Hygiene Theory.  Hygiene Theory posits that since children’s lives have become cleaner, more infection-free, their immune systems attack their own tissues, having nothing else to do.  Also, it seems that when kids had intestinal worms from contaminated food, the worms put out substances that kept the immune system quiet.  This protected the worms from immunity, while lessening immune aggravation of the kid’s lung tissue too.  Now, no one’s advocating giving children tapeworms to lessen their asthma.  Yet.

The environmental issues are more clear.  Modern housing emphasizes energy saving with better sealed doors and windows.  This means less fresh air circulates into the house through those leaky portals.  Thus kids breathe more house dust, which irritates lungs.  People also open their windows less and make air conditioners and heating systems, which accumulate and circulate dust and other irritants, do more work.  Kids also spend more time indoors than out with TVs, computers, games, and phones; thus breathing that dusty indoor air more.  Less exercise clearly worsens asthma- kids need exercise to prevent it.  This may seem counter-intuitive, since exercise can sometimes trigger or worsen individual asthma attacks.  However, in the long run, more active children have fewer attacks.

These are clues to prevent asthma in children, and prevention is the mainstay of treatment.  Once kids start having asthma it’s a lot of trouble- they visit Emergency Departments for attacks, and sometimes get hospitalized.  They miss school, and parents miss work.  Occasionally kids end up on life support in the Pediatric Intensive Care Unit, or die.  Makes tapeworms sound better and better.

Continuing our asthma history lesson from above, asthma theory took a weird turn in the early 20th century, with Sigmund Freud’s theories of the subconscious mind.  Since anxiety attacks were known to trigger asthma, some over-enthusiastic Freudians believed that all asthma was psychological; even when patients had audible wheezing, that high-pitched whistle from deep down the throat. They thought that whistling was generated subconsciously as a tiny scream for help from the patient’s buried anxiety. 

Fortunately, in the 1940s and ’50s, physiologic understanding of asthma prevailed.  That understanding holds today, that asthma comes from two glitches in the airway.  First, the muscles that control airway diameter overreact to noxious stimuli like dust, allergens, and viruses.  When those muscles contract, they narrow airways to keep out the irritants. But doing that keeps out the air too.  Second, after too much stimulation, the airways become inflamed, causing swelling into the passage, and excess mucus production.  With airways narrowed by muscle contraction and swelling, and clogged with mucus, no wonder it’s hard to breathe.

Asthma treatment is two-pronged.  First, we use medicines inhaled as a mist, like albuterol.  Albuterol breathed into the airways relaxes the muscles lining them, opening the passages up.  Second, we use steroids, which decrease inflammation and mucus production.  Steroids have minimal side effects.  Sometimes when people hear steroids they think “anabolic steroids,” the kind that some athletes take to build muscle mass.  These aren’t the kind we use for asthma- kids aren’t going to bulk up, grow beards, and have rage attacks.

The most important treatment for asthma is prevention.  Like we mentioned above, regular exercise prevents asthma.  As kids exercise less these days, asthma has become more common.  Since individual asthma attacks can be worsened by exercise, some parents restrict their asthmatic kids’ activity.  However, over the course of childhood, regular exercise actually lessens asthma.  Also, like we said above, kids should get outdoors more to breathe fresh air, instead of dust-laden indoor air. 

Children can take medicines to prevent asthma attacks as well, particularly for air-borne allergen sensitivities, like to molds and pollens. Those kids can play outdoors too.  Talk to your doctor about treatment plans, prevention medication, and exercise plans for your child.  Asthma’s another good excuse to get your kids away from their screens and into the real world.     

Going To The Dogs

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

Every case is different.  Sometimes it’s a puppy playing with a toddler, a lick-fest gone wrong.  Once it was a mother of a litter protecting her young from potential buyers.  We see lots of dog bites in the Pediatric Emergency Department, and they generally come in two flavors.  The first is toddlers getting too close, and geting bitten in the face or hand.  Older kids get bitten in the legs and butt as they run away from loose neighborhood dogs.  Almost a million people visit ERs per year for dog bites.  Sometimes dogs can kill. How can you keep your kids from being Rover’s next victim?

Data suggests that certain dog breeds make better family pets than others.  Poodles and retrievers tend to be safer than terriers, shepherds, and guard-dog breeds. When picking a dog, be sure it’s young, preferably under four months.  Puppies are easier to train, and to acclimate to your kids.  If they do bite, they do less damage.  Older dogs, particularly rescues, can be unpredictable towards kids, and cause worse wounds.  Spay/neuter new dogs- this makes them less aggressive.

“Humanizing” pets has become more prevalent with social media.  People love videos of dogs in costumes, seeming to “talk” to their owners.  And everyone loves seeing laughing babies flop around with a litter of tail-wagging puppies.  Unfortunately,  humanizing encourages dogs in a family to think they’re more important than they are.  Sleeping in bed with family members, feeding from the table, hugging and kissing, generally treating the dog as a child, doesn’t teach the dog it’s place- that the kids outrank it.  You should be the alpha, kids the beta, and dogs last in your family’s “pack” hierarchy.

Having dogs with little kids isn’t great either.  Young kids, instead of running around screaming with the dogs, hyping them up, should be more restrained.  They shouldn’t  pet or get face-to-face with new or unfamiliar dogs.  Trying to train little kids and new dogs simultaneously is just too much- it’s hard enough to get kids to behave by themselves!

The two-year old was best friends with the puppy.  They napped together, played together, watched cartoons together.  Then one second they were tugging on a rope, the next the boy came running to his parents screaming, his face covered in blood.

As we said above, toddlers typically get bitten in the face, since their faces are at dog level, and toddlers get too close while inspecting, hugging, or kissing the dog.  The other popular injury sites are limbs, in the hands when petting a wary pooch, or in the legs and butt while running from a neighborhood dog.

When kids come to the ER, we copiously wash out the wound to reduce the risk of infection, and assess it.  The first question: are stitches needed, like for disfiguring face bites, or gaping wounds elsewhere. Sometimes the wound is so bad that it will leave an ugly scar, no matter how skilled the ED doctor or plastic surgeon.  We don’t sew simple punctures- these heal with small scars, and suturing bites runs the risk of trapping infection inside.

Infection is the next determination.  Kids should be vaccinated, because dog bites can cause tetanus.  Dog mouths can also contaminate wounds with bacteria, so bites that break the skin need antibiotics.  We also worry about rabies.  Wounds through the skin warrant calling Animal Control. The Animal Control officer assesses the dog for rabies risk.  Even if pooch is vaccinated, or is mostly indoors, rabies is still possible.  When dogs go outside to potty, they can get bitten by rabid animals like bats or skunks, and you won’t know it.  And dog rabies vaccine isn’t 100% protective.

We don’t mess with rabies.  If there’s any risk to the child, like being bitten by a stray animal that can’t be found and assessed, we start the kid on rabies vaccine.  Because if a human contracts rabies, it’s 100% fatal. 

Yes, dogs are furry and cute.  Kids love them, and dogs and humans have been  companions for thousands of years.  But make an informed decision when getting a dog: choose the safest breed, and get it when your kids are older.  Aren’t baby humans more important than pooches?

He Fell Out Of Bed and Bumped His Head

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

Three year-olds sit on barstools.  Three year-olds get the wiggles.  And when you’re in the kitchen making dinner, she does both at the same time.  Then she drops out of sight and you hear a smack and a scream.  You abandon the spaghetti and rush around to find her flat on her back, shrieking at the top of her lungs.

All parents have had this nightmare.  Your child hits his head, screams bloody murder or acts odd in some other way, and you think “do I need to call 911?”  Parents often feel that an immediate assessment is a must.  However, most head injuries don’t require an Emergency Department visit.  Knowing the signs and symptoms of severe head injuries, versus those that can stay home, can save you lots of anxiety, and moolah, on medical bills.

You can simply ask yourself three main questions: What was the mechanism of injury, how was the child immediately after, and how is the child now?  The bad mechanisms- high speed car crashes, getting hit by baseball bats- they’re easy. Get seen!  Likewise, the toddler bonks his head on the coffee table, the car’s rear-ended in a parking lot- stay home!  It’s those in-between patients, like the toddler on the barstool or the baby rolling off the bed, that require some thought.

Here’s the mechanism rules, plain and simple.  If your kid is over two year’s old, it takes a fall from 5 feet or more to generate enough energy for bad head injuries.  Under two years-old: a 3 foot fall.  Use a measuring tape; sometimes we do, to show a parent what three feet looks like.  Is that how high your bed is, we ask?

High energy impacts, like thrown baseballs, swinging bats and golf clubs, also need checking.  Getting hit by a car, whether your kid’s walking or on a bike without a helmet, warrants an ER visit.  Getting hit by a thrown plastic toy- not so much.

Children jump from one couch to another- it’s what they do.  We all, you and me, did it as kids.  Who needs trampoline parks when we all have one at home, whether it’s couches or a room with two beds?  But then the inevitable- young Mary Lou Retton doesn’t stick the landing, stopping the fall with her scalp instead of her feet.

Let’s answer that second question from above: immediately after a head injury, how’s your kid acting?  There’s red flags at this stage that tell us a kid needs medical attention.  Of course, if the child is unconscious, he needs to be seen.  If the child isn’t knocked out, but is acting dazed and talking in a confused manner, that’s worrisome too.  This is the scenario with many football players- they aren’t knocked out, but are staggering around after the blow, can’t remember their plays or what just happened, or  even where they are.

For babies and toddlers, the immediate assessment is more vague.  Of course if after stopping crying, they go back to themselves, walking about and smiling and babbling, you can stay home.  But if they’re acting sleepy, seem more unsteady than usual, or are “just not acting right,” then you should call your doctor, or get seen.

The third question is: how is your child acting now, some time after the injury.  Of course if he goes back to playing and running,it’s cool.  But what if he goes to sleep?  Many kids tend to want to lie down and nap after a traumatic experience and some hard crying, but what’s the line between a normal nap and somnolence from head injury?  If it’s the child’s normal nap time, she takes her usual 30 minute nap and then wakes up, then cool.  But if after a half hour she’s harder-than-usual to wake up, it’s check time.

Other red flags are vomiting after a head injury, or severe headaches.  Children who are squinting and holding their heads hours after a head injury need to get seen.  What about lumps?  Many kids get them, just like characters on Bugs Bunny cartoons, rising from their scalps.  We only worry about lumps on kids under two years-old.  And even then, lumps on foreheads are okay.  Lumps on the sides or back of the head- come on in! 

Back To School- Get It Right!

Schoolteacher Jane Anderson Lemoine has lots of back-to-school stories- kids falling asleep in class and drooling all over their desks, a boy accidentally going to two social studies classes per day for a whole week and not telling anyone, and one five year-old who was so scared it took three adults to coax him into his first day of class.  Yes, getting back to school can be exciting, but given the swarm of deer-in-the-headlights kids (and teachers and parents), there’s goof-ups too.

August 8 is the first day in Lafayette parish, so when reading this you’re already behind!  First things first- get your children into their doctor.  They’ll need physicals for school and sports, and maybe vaccines.  Some need medications for school, like asthma inhalers or ADHD meds.  Many kids must have these things, so appointments are tight.  Make that call now!  Some walk-in clinics provide some of these services, but NOT the Emergency Department.

Your child may also need a new backpack.  If so, this isn’t something to skimp on.  Though the jury’s out on whether they contribute to kids’ back pain, you’ll want a comfortable one.  It should have wide, padded shoulders, and a waist strap.  The waist strap is very important, because weight is best carried on the hips, not the shoulders.  Whatever the current school fashion, heavily-loaded kids should have both shoulder straps on, and the waist strap buckled and cinched.

As the 8th approaches, it’s also time to get children back on a school sleep schedule.  Start walking those bedtimes back from midnight to something more appropriate- 8 or 9 pm for elementary kids (at the very latest!), 10 pm for teens.  They also need to start waking up sooner.  A week before school starts, wake them at 10 am instead of noon, then 9, then 8, and so on.  Bedtime also means phones and other screens off!  Leave enough time for breakfast before school. Kids don’t learn or behave well on an empty stomach!  Finally, you should always be reading books with your young children at bedtime.  They learn to read, acquire more words, have family time, and wind down for sleep.

Besides the physical preparations for school we discussed above, you’ll want to prepare your child psychologically too.  Kids are nervous- is my new teacher nice?  Can I handle the workload?  Who’ll be in my class?  Some kids are also terrified of being bullied.  Worse than hard homework or frowning teachers, is the prospect of public humiliation and violence.  No wonder some kids stay home with “stomachaches.”

Bullying takes a toll.  Many ruminate on their victimization for years after.  A significant percentage of school shooters were loners, outcasts from school cliques, picked on for being different.  Prepare your child to not be victimized. Shy kids need to rehearse what they’ll say and do if bullied, so that they confidently deflect attempts at humiliation; practice where to go, where not to go, which friends and school personnel will help.

Besides victims, bullying also requires bullies, and passive bystanders.  Don’t let your kid be either one!  Teach them that bullies are the bad guys.  Before school, be clear that there’s firm consequences if they bully- grounding, detention, phones and video games revoked.  Don’t threaten them with violence, since this begats violence in them.  Also talk about how bystanders who intervene on behalf of victims are the brave ones,the good guys. Encourage them to sway crowds to protect victims- there’s safety in numbers for victims and bystanders.

Fortunately, most kids only have the usual nerves- new teachers, new classes, new classmates.  The best preparation for this- meet your teacher!  Jane Anderson Lemoine, our schoolteacher from above, tells of a kid who went a whole week going to two social studies classes, wandering from one to the other, hearing the same lesson twice.  When she discovered this, he hadn’t said anything to anyone about it, and the parents were clueless. If only someone had double-checked his schedule.

Meet the teachers, so you become allies in your child’s school experience.  It’s better to get to know each other in the beginning, instead of later when you’re irate about bad grades or conduct notices.  Know how they communicate, with students and parents.  Email, text, school website, phone?  If your kid takes the bus, meet the driver too.  The driver is a VIP, taking your child through traffic, twice daily, for all year!

Who Do You Trust?

Sometimes when seeing a patient in the Emergency Department, I discover the kid isn’t vaccinated.  The parents often say “I researched it” when explaining why they don’t vaccinate.  When I hear the word ”research,” I picture protocols, test subjects, and data assessment.  Which makes me want to say something snarky to the parents, like “Oh, by ‘research’ you mean you pulled the original data, did your own statistical analysis, and found their study design wanting?  Or you just read some crank on the internet?”  But of course I don’t.

Where can you go these days for good medical advice?  The internet, when it came out, was meant to be an “information highway,” where everyone could get knowledge fast.  However, it’s now sometimes the “misinformation highway,” where non-facts spread quickly.  Like when “anti-vaccers” use wrong material to scare people from vaccinating their kids.

People used to get their medical information from TV, magazines, newspapers, and books.  However, who buys books and magazines anymore, or watches TV news?  Newspaper circulation is way down too, and papers are getting thinner and go less in-depth with their articles.  People often go to friends for advice, but like the internet, friends’ information is only as good as their own sources.  Some people listen to celebrities for advice.  We always hear from celebrities, either on old platforms (TV and magazines), or new ones (Twitter, Facebook, TMZ).  Since interviewers cling to celebrities’ every word, sometimes those celebrities use their media soapboxes to expound on subjects where they have no expertise.

There’s also a trend where institutions like medicine, news media, or government aren’t as trusted as they used to be.  In the twentieth century, when medicine was making great strides with inventions like antibiotics, vaccines, and cancer treatments, lives were obviously being saved, and people listened.  Government was also showing its competence, winning World Wars, putting men on the moon, and establishing social safety nets for the poor and elderly.  Now the pace of medical breakthroughs has decelerated, and we find it harder to trust medical science, especially when one month the news reports that coffee, eggs, or butter are bad for you; then the next month they’re healthy again.  And since the Vietnam war and Watergate, government has become suspect as well.

Back to our non-vaccinating parents from above.  Instead of saying what I really want (“So when you did your ‘research’ on vaccine safety, that means you read some yahoos on the internet?”), I go more constructive.  I ask about their specific fears- what exactly worries you about vaccines?  Then I address those worries with facts, and stories from my own practice.  People appreciate education when it’s presented in a positive, non-judgemental manner.

Data on patient-doctor encounters shows that people still generally trust their own doctor, more than the medical establishment as a whole.  As we discussed above, public confidence in medicine, government, and the press has declined over past decades.  So like your local doctor, trust me when I say that these institutions are trust-worthy themselves.  I worked at a pillar of medicine- Johns Hopkins Hospital- and knew medical researchers, there and at the CDC and NIH.  These are earnest guys whose ambition is to serve people and do good science.  There’s no conspiracy between these doctors, government, or drug companies to line pockets and hide good data from the public.

I also have friends in media, from  local TV stations and newspapers, to the New York Times.  Again, they’re hard-working professionals who get facts straight and provide good information.  Allegations that they make “fake news” is the fake news itself.  Bottom line: you can trust institutions as sources for good information.

So where can you go for clearly written, fact-based medical information for your decision making?  First, if you’re reading this column on-line, you’re already there!  Go to the tabs at the right of this paragraph to read more on each subject.  If you’re reading this in the newspaper, go to parentsdontfret.net for the blog version.  Other good websites are at major university-based children’s hospitals, the NIH, or the CDC.  Also, there’s good ol’ books.  Barton Schmitt is a pediatrician who’s written some of the best books on caring for sick children.  The “What To Expect” series is also very good.

If it’s vaccines, rashes, emergencies, or what-the-heck-is-my-baby-doing-now-is-this normal, go to these places for help.  They’re tried, true, and fake news free.

Scary Nuts

This week’s guest columnists are Drs. Crystal Davis and Danielle Fuselier, Family Practice residents at the University Hospital and Clinics here in Lafayette.

She was hungry after softball practice, and took the snack bar her friend offered.  It looked like a bar she had eaten before, so she didn’t think twice.  A few minutes later, though, her throat began to feel scratchy and tight.  She got scared and called her father.  When he arrived, he saw she was pale, had a swollen face, and was breathing hard.  He gave her benadryl and called 911.  Later, the girl told us that when she looked at the snack bar package again, she saw it contained cashews.  She had an allergy to tree nuts.

Severe allergic reactions can be very frightening for parents, and kids!  Everyone knows a horror story of allergies that end tragically.  Knowing the proper steps to take can save your child’s life.  First, its important to identify the symptoms.  These include hives, itching, and flushing or pallor.  More severe symptoms include swelling of the lips and tongue, shortness of breath, wheezing, vomiting, and worsening lethargy.

We call severe allergic reactions anaphylaxis- when the allergy affects two or more organ systems (cardiovascular system, respiratory system, skin, GI tract, etc).  Anaphylaxis can be deadly and requires quick action.  If your child has an epipen, use it!  Then call 911.  Studies show that many parents, and even doctors, don’t give epinephrine often enough.  Don’t be afraid to use it- it doesn’t hurt kids to give (except for the shot sting itself), and can be lifesaving.  There are videos and dummy epipens for training, so parents and patients can practice for when it’s needed.

Your job’s not over yet.  Take your child to the ER for further evaluation.  Best to call 911- paramedics carry epinephrine, steroids, benadryl, and other important anti-allergy medicines. Then at the hospital, your child will be observed in the ER and maybe admitted overnight.  Even after initial treatment, the body continues to release inflammatory cells and chemicals to attack the substance it recognizes as foreign.  Thus kids need monitoring and may require further medication.

Our girl above, who had nut allergies and ate a cashew-containing snack bar, had low blood pressure, shortness of breath, and was lethargic and pale when the paramedics arrived.  They gave her an epinephrine shot, steroids, and IV fluids.  She still looked sick when the medics brought her in- pale and fatigued.  But she gave us a weak smile and insisted she felt better!  We admitted her to the ICU, and she recovered.

When kids have severe allergic reactions, or lesser but still bothersome symptoms, it’s important to find the culprit.  There’s no single way to identify allergens.  Some types are best identified with skin tests, like inhaled allergens.  Blood tests are better to identify food allergies, or causes of eczema.

When we say “skin tests,” there’s different kinds of that.  One is the prick test, where drops of fluid with allergens are put on the back, and then pricked into the skin with a  needle.  If the child is allergic, the skin swells and reddens around the prick, like a mosquito bite.  Up to 40 different allergens can be tested at once this way, depending on the allergist’s suspicions, the size of the child’s back, and what the kid will tolerate!

Other skin tests are “intradermal,” where allergen is injected within layers of the skin.  In cases of possible anaphylaxis, like our girl with the tree nut allergy, “challenge” allergy testing like this may not be safe- no one wants anaphylaxis in the office!  Blood testing is safer.

The point of allergy testing is to find out what to avoid.- bee stings, spring pollen, kiwi.  Avoidance can be used as as an allergy test itself, particularly for foods.  Say a kid has a chronic allergy like eczema.  You start the “elimination diet,” where you subtract suspected foods from the child’s diet, one food per week.  If in one of those weeks the eczema suddenly improves- voila, you have the culprit!

Testing can help you choose appropriate treatment: avoidance, medicines for when your kid can’t avoid the air he breathes, allergy shots, or epipens.  For the potentially severe reactions, as we said above, don’t be afraid to use that epipen!  It could save a life gone nuts.

Is This Really “That”?

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

I recently saw a 4 year-old named Mary in the Emergency Department.  She vomited once while eating lunch, and was brought in by both parents for evaluation.  Mother appeared more concerned about the episode, and said “Mary is always happy and active, but she’s acting tired since she vomited.  I’m always with her, she’s not herself.”  However, the father said “Mary only vomited because she doesn’t like pickles, so she spit them out.  Then she ate some of my fries and finished her lemonade.”  At this point mom looked at me and said, “I’m worried about food poisoning.”

Most visits to the ER are not emergencies.  However, it’s reasonable for parents to be concerned about a symptom like vomiting.  Parenting isn’t easy, and when folks see their child in distress, it often sticks them right in the heart.  So how do we decide that this is a benign problem, which only needs us to reassure the parent; or decide that this could be a serious problem that requires more attention?

FIrst of course, we listen to the story of what happened.  This story is the “medical history,” which also includes asking about related symptoms, and the child’s past illnesses.  Then we examine the child, to match the story with what’s happening in the kid herself.

In Mary’s case, we have a girl who vomited only one time, which typically isn’t severe enough to worry about bad things like dehydration or appendicitis.  When I examined her, I saw a child who was active and playful, with plenty of moisture in her mouth, good circulation, and normal vital signs.  This confirmed that Mary was doing well.  I reassured mom that Mary’s condition was mild, that she was going to be okay, and mom was relieved.

Parents can do this exercise at home, and avoid a costly and time-consuming ER visit.  If your child is eating and drinking well, breathing normally, and active, they are probably not having an emergency.  However, if they are acting excessively tired, vomiting for several hours in a row, in severe pain, or having trouble breathing, then it’s time to see a doctor; if not your own, then in the ER.

Omar is a 9 year-old boy whose mother is concerned about a rash that appeared on his arm. It first appeared last week, and then went away a few days later.  It looked like a sunburn, according to mom, but she was worried that it was something else bad.

Mother had not discussed the rash with Omar’s pediatrician since “every time I call the office, they give me an appointment for the next 2 or 3 days.”  Like with Mary above, the first thing is to take a history: was the rash itchy, did it hurt, were there any accompanying symptoms like fever, cough, or diarrhea?  Mother thought it might be the sunscreen she applied, though she said “it’s not a new brand, he’s used this before.”

Next is the physical exam.  I checked Omar’s skin for lingering signs of the rash, and also did the basics- listened to his lungs and heart, felt his belly, looked in his mouth and throat.  There was no rash, and he otherwise was well, an active and polite 9 year-old boy.  Mom was happy to hear that Omar was fine, we discussed the possibilities of what caused his rash (sunscreen irritation versus sunburn on a patch she missed with the screen), and they went on their way.

Many parents come to the Emergency Department for questions that worry them, and often because they can’t get into their child’s doctor.  These worries can be profound- is this cancer, or in Omar’s case, is this a sign of a potentially bad allergic reaction in the future?  When parents have these questions that keep them up at night, they come to the ER.

Fortunately, the answer is most often benign.  And if the child looks fine in the basic ways- is eating and drinking, is breathing comfortably, is active, then the answer can wait until the next available appointment with your doctor.  If the child is truly sick, with persistent vomiting, shortness of breath, worsening fatigue, and you can’t get into your regular practice, then by all means, come in!

Screamin’ Down The Road- Part II

In 2014, I wrote about traveling with kids.  I had just read a book about disasters, and piled on stories of surviving plane crashes and hotel fires. Friends gave me more practical advice for this summer . Jane Anderson Lemoine of Lafayette told about while at Disney, her 3 year-old son was constipated.  One morning she gave him a laxative before heading out.  “Within an hour it started to take effect….in front of the Swiss Family Robinson tree house he’s pulling down his pants, in the middle of the Magic Kingdom, because when you gotta go, you gotta go.  I’ve never seen my husband run so fast…”

The moral of the story: prepare for bodily function disasters.  Pack medications, like for pain or fever, some bandaids and ointment- you decide on the laxative.  I’ve looked for pharmacies at night in unfamiliar cities- it’s no fun.

Besides meds, pack extra clothes for your kids, and you.  Jane always packed more for her kids, anticipating spills and vomit.  However, she didn’t pack for when her son barfed on her at the beginning of a plane flight.  While he had fresh clothes at hand, she wore his vomit for 5 hours, even down her back and into her pants.  Extra grocery bags to store those soiled clothes is a good idea too.

Speaking of airliners: tray tables, armrests, seatbelt buckles, and airvents are all touched by multiple people, and don’t get regularly cleaned between flights.  They can harbor more bacteria and viruses than the flush button in the airliner’s toilets- and at one toilet per 50 passengers, that’s saying something!  So pack disinfectant wipes and and hand sanitizer, and clean those surfaces as you settle in.  You and your kids don’t want more bodily explosions when you get to your destination.

Kids can be embarrassing on the road, especially sitting close to strangers in restaurants and airliners.  Jane’s son loved to chat up those around him.  Loudly.  At first she and her husband were mortified, until they realized that most strangers love kids, no matter how deafening.  Kids can be fun for other folks, distracting them from their own traveling woes.

Tina Kelley of Maplewood, New Jersey, wrote me about camping vacations.  Once she put her baby in the car for the night, in case of bears.  That didn’t stop a park ranger from yelling at her, though the evening was cool.  He’d probably seen too many kids left cooking in cars during the day.  Her story reminds us of traveling safety, though car crashes are way more likely than grizzly attacks.

Make sure everyone, even the backseat passengers, are buckled in carseats or seatbelts.  Identify your exits in planes and hotels, before you need them.  If you go to a waterpark, don’t drink the water!  Keep mouths closed and hands clean, and shower off before and after a visit.  Think about all those other bodies, and diapers, you’re sharing the water with.

Besides safety, plan entertainment for your kids.  Sure, phones and tablets are distracting, but there’s healthier options for childrens’ brains.  Books on tape work great, for parents and kids.  When mine were young, we listened to Harry Potter books on long drives.  Everyone was so enthralled that even after an 11 hour drive, we’d sit in the car, in the driveway, until the chapter finished. 

Books, board games, and coloring are fun too.  Save the screens for when kids are tired of those things.  Jane Anderson Lemoine, from above, only allowed screen time at night, after the non-electronic distractions.  This was a treat for her kids, since screens were limited at home.  

There’s generally two kinds of vacations.  One’s the relaxing trip, where otherwise busy parents get to lay on the beach or by the pool.  Then there’s Disney- dashing about miles of tarmac in the heat to get ahead in line, followed by standing in those lines.  Then a brief rest on the ride before heading back into the rush.

Often your kids will have opposite needs of yours.  If you want to relax, they’ll want to be busy. The things that work in car rides also work then- books, board games, saving screens for later.  If it’s a Disney-Death-March vacation, you’ll ALL need a rest.  Plan downtime in your schedule- an afternoon of napping and poolside rest in the middle of the park frenzy.  Have fun! 


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.