Trusting Science, When It’s Convenient

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

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

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

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

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

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

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

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

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

And They All Came Tumbling Down

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

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

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

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

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

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

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

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

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

How Doctors, And Parents, Talk

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

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

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

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

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

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

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

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

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

Scary New Babies

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

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

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

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

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

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

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

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

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

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

A Wet End for Scott?

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

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

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

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

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

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

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

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

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

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

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

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

Pills and Detergents and Outlets..Oh My!

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

It’s a classic medical board question: “A two-year old visiting her grandparents’ is found with some blood pressure pills.  What is the best first step managing this patient?” Though I’ve answered this questions many times on tests, I was still at a loss when it really happened!  My two year-old had discovered some luggage with unsecured medication inside, and was mouthing one when we came upon her. So I called Poison Control (stop reading now and write down this number: 1-800-222-1222). They advised a trip to the Emergency Department, where our girl drank an activated charcoal mix, was watched for some hours, and we went home.

Although we thought we had meticulously placed all medications out of reach, in locked containers, accidents still happen.  So when your child begins crawling (or even after!), it’s a good time to think about child-proofing.  From button batteries to cosmetics and talcum powder, a young adult’s first “grown-up” house, when they have kids, can be a house-of-horrors for youngsters.  The newest hazard is laundry-detergent pods. Designed for ease of use by adults, these tasty-looking, colorful gems can burn mouths and throats and eyes, causing vomiting and breathing difficulty. Do they have to make them look so good to eat?

The best way to toddler-proof your house is to be a toddler.  Get down on your hands and knees and crawl through every square-inch of your house.  Open every cabinet and drawer you can reach, and put every single thing you find in your mouth.  If you don’t dare eat what you grab, it needs to be somewhere safer.  Then from your hands and knees, look up.

What’s above you that looks attractive, or even just mildly fun to play with? Find something to climb on- a kitchen step-stool, chair, or ottoman.  Can you push it over and crawl up within reach of what you see?  Grab the boiling pot.  Eat the medication sitting on the counter.  Absurd as this sounds, if it can be done, a toddler has already done so in the past, and will in the future.  Make sure it’s not your’s.

Now that you’ve done a decent job of making home safe for your little one, you may feel adventurous and head out for vacation, or maybe just Wal-Mart.  One such trip to the store nearly ended in tragedy for me.  My child launched herself out of the shopping cart in the one second it took to reach for some salad dressing.  Luckily my husband was right there and grabbed her as she tumbled out head-first!  From then on she was seated and belted in the cart. While that’s not as fun as shopping cart surfing, it may save a trip to the the ER.

Going out with toddlers poses a new set of risks than your home.  Perhaps most important when you are out is safety around cars, moving or parked. Every week in the U.S., at least 50 children are backed over in driveways and parking lots. LIttle ones who dart outside to say goodbye often go unseen by a driver when the vehicle is set in motion. Many times the driver is a parent, relative, or neighbor.  

Following a few simple tips can protect your family from this tragedy.  Teach children that parked cars may move at any time.  Let them know that even if they see the vehicle, the driver may not see them.  Always hold a child’s hand in the parking lot. Teach them never to play in, around, or especially behind any vehicle.  Be especially vigilant when someone else is leaving the house and driving away.  Outside house doors should be toddler-proofed.

The world of baby safety can be overwhelming.  And now manufacturers prey on your fears, offering lots of products- toilet bowl locks, outlet plugs, stove knob covers, baby gates, etc.  While some of these items may be helpful, doing the simple things we’ve discussed above goes a long way.  The last thing to do is be prepared for an emergency: post or put in your phone the Poison Control number (again, 1-800-222-1222).  Take a CPR/Heimlich class.  Read the books.  Know the location of your nearest child-capable ER.  And for goodness sake don’t buy those stupid detergent pods.

Hospitals Are Cool

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

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

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

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

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

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

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

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

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

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

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

Real Animals Are Not Cartoons

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

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

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

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

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

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

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

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

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

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

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

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

Drama In Real Life

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

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

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

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

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

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

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

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

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

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

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

Explosive Babies

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

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

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

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

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

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

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

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

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

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

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

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

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