Momwithastethoscope's Weblog

September 22, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Uncategorized — momwithastethoscope @ 3:02 pm
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Reason Number 22: Tricks of the trade. Let me define what I mean by tricks – skills gained by experience – not pranks or deceit. A great deal of rapport with children lies in the trust they instill in me as their doctor. So pulling a fast one on a three year old can do a lot to dismantle the sometimes fragile bridge between us. Being deliberate and truthful with all ages of patients goes a long way for me.
One of my favorite aspects of pediatrics is the first hospital visit after a baby is born. Often, relatives and friends gather in the room of the new parents. After introducing myself, I like to scoop up the newborn under the arms supporting the baby’s buttocks with my other hand and gently bounce the infant. Many times, the baby will open his or her eyes and regard the well-wishers. For some parents, this is the first opportunity to gaze into the eyes of their child. This same technique calms crying babies, too, so it is helpful on return visit when new parents feel sleep deprived and frazzled. The bounce helps me determine if a baby wants to be held – those babies quiet quickly when moved up and down – versus a hungry infant who needs to be fed. Bouncing babies also helps waken a sleepy baby as most are in the first 24 hours after delivery.
Mary Poppins sang about a spoonful of sugar helping the medicine go down. I’ve found that to be true. Prednisolone syrup tastes pretty bad – no matter how sophisticated the flavoring. All have a slick, oily aftertaste that makes me gag and many children vomit. Liquid amoxicillin-clavulenate and cefpodoxime are also poor in the taste category. Chocolate syrup is my go-to spoonful of sugar, but I have the occasional patient who doesn’t like sweet tastes or chocolate. For these I usually suggest chasing the medication with a teaspoon of barbeque sauce. To be a good “chaser” for medication – the flavor needs to be dense with a thick texture. I’ve suggested honey-mustard sauce and ketchup. Ranch dressing also gets a nod of approval.
Do you have a trick of the trade to make your job in medicine easier? E-mail me @ momwithastethoscope@gmail.com and I’ll devote a future post to your ideas.

September 21, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,Parenthood,pediatrics — momwithastethoscope @ 6:51 pm
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Nasal foreign body

Nasal foreign body

Reason Number 21:  foreign bodies

Once I had a patient who had been to several doctors over the period of two weeks.  His mother complained about the odor coming from his green, drippy nose.   Despite medication, the color and smell persisted.   In my office I noted something white in addition to ruby nasal mucosa, and purulent snot.  With a well placed tweezer, I located the white spot and pulled to reveal a sodden wad of foreign body – probably wadded up tissue, but hard to tell after a two week vacation in the nasal passages of a preschooler.  Viola!

Yes, I pick noses for a living – and that activity is personally satisfying.  Identify object.  Locate object.  Pull object out.  Problem solved. 

Not all objects are easily removed.  Play doh melts.  M & Ms melt.  Beads can be a challenge.  Foreign bodies in ears can be difficult, too.  Sometimes, those need to be referred down the street to the ENTs who can suction them out.  (There is a similar hint of glee in my ENT colleagues about foreign bodies.)  Splinters can be difficult.  Glass is a challenge, too. 

Picking pediatric noses is anything but glamorous.  Kids put objects in the darndest places including their nostrils.  However, I would take a whole day of picking noses for the instant gratification it beings me.

September 20, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Parenthood,pediatrics,positive medicine — momwithastethoscope @ 7:10 am
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google images

google images

Reason Number 20:  Concierge Medicine @ home

On more than one occasion, I have treated my own children.  The lines get a little blurry between when I doctor my children as a mom and when I work on them as a physician.  The afternoon that my then five year old discovered yellow jackets chase you  and stung him 13 times was a mom-treated incident.  Intuitively, I dunked my frightened son in a big tub of lukewarm water and baking soda while I whacked the straggling yellow jackets. 

On another occasion, I had my MD hat on firmly as I watched my youngest struggle with RSV (respiratory syncytial virus).  With his wheezing growing more and more audible from the rotten virus, Harry got more and more still as he worked harder to breathe.  I suspected this fourth night into his illness that we were in for a rough night,  and I borrowed the pulse oximeter from the office to watch his oxygen levels.  He hovered in the low 90% range for most of the night while his chest retracted around his ribcage.  I pulled out my mom care, too, with lots of humidity and pushing him to drink enough electrolyte solution so that he wouldn’t get dehydrated.  The next two nights were equally tough as I watched his oxygen level bounce close to the point where I thought we needed to go to the hospital for oxygen and further treatment. I kept my partners up to date on his progress since we knew he was on the bubble for admission.  Tired and second guessing myself , I noticed a pretty good improvement on the seventh night, and knew we were pulling through. 

Harry’s older brother, Will,  got a taste of mom in MD mode as a vacation at the beach was ending.  In a game of beat-the-clock, my husband and I were trying to get us packed up and checked out when we discovered that young Will had shoved one of my broken earrings up his nose.  Why he chose that moment we’ll never know, but I immediately went into action to avoid an ED visit and still check-out on time.  Will knew I meant business as I came after him with eyebrow tweezers and a headlock.  In retrospect, his cooperation was the key to the success of the earring-ectomy. We pulled away from our beach rental with minutes to spare as I gripped the pearl – a souvenir from the trip that I hadn’t anticipated.

The knack of concierge medicine at home is having second opinions close by.  My husband is an integral part of that equation as are my partners.  Even if I think I know the answer, I lean on this support system to validate my thoughts.  Occasionally I feel silly when I ask for back-up but it’s a small price to pay to do the right thing for my most important patients.

September 19, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:32 am
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Reason Number 19:  Specialty in a specialty

At one point in my career, I wondered if I had taken a wrong turn by choosing general pediatrics.  As a resident, my neonatology attending encouraged me to subspecialize – preferably in neonatology.  While I really enjoyed the NICU – the rotation allowed me to do procedures, attend deliveries, care for really sick patients, and care for unusual problems – the ethical dilemas I encountered took their toll on my young interests.  This attending told me I would be bored in general pediatrics taking care of runny nose after runny nose. 

I have never been bored in general pediatrics. Quite the opposite.  Just when I think that my practice is humdrum, a patient will arrive with a zebra – a problem seen mostly in textbooks and on board exams.  My medical curiosity will smack me between the eyes as I dig in annals and journals and zebra websites.  So that time I was pondering the value of general pediatrics was not from the mundane.  Instead and because of the amount of information I am expected to keep in my cranium, I pondered fine tuning my specialty choice. 

I applied for fellowship in a very competitive specialty, dermatology, and as no surprise to anyone but me, I was not chosen for the extra training despite a shortage of pediatric dermatologists in the area.  No regrets about the experience.  I am meant to be in general pediatrics. 

Now with partners and the prowess of mentors, I see myself able to specialize in an informal way.  Already, my nurses will say to my younger partners, “Ask Dr. MWAS about that – she likes rashes.” Fellow pediatricans in my town have marketed themselves as “specialists” in ADD or autism.  I’m not ready to market myself, but I do see that I can develop a niche in my own practice.  It’s nice to be able to refer to my own partners because of special interests they have in areas of pediatrics.

So I may never hang the shingle for pediatric derm at my office, but my scheduling staff steers dermatological concerns my way.  And I’ll keep working on that knowledge base so that maybe one day I can trade a day of general pediatrics for pediatric dermatology.

September 18, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:51 am
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Reason Number 18:  The specialty of pediatrics

In a typical week, I refer patients to lots of different specialists – ophthalmology, cardiology, pediatric surgery and ENT to name a few.  Some patients need more specialized examinations than I am trained to do, some need surgery, some need studies or lab work that is best ordered from the office of a specialist.  It is easy to be lulled into a triage mentality when some visits feel like your purpose is to identify and send to the appropriate next step.

Every so often, another physician will consult me, the primary care pediatrician.  At that moment, I realize pediatrics is indeed a specialty with specific knowledge and skills.  Part of my job is to put together pieces of a problem, and to see them as a whole.  So that the patient with juvenile rheumatoid arthritis needs an influenza vaccine when he is on medication that treats his JRA but also compromises his immune system. 

In my 120 bed local hospital, my colleagues look to me and my fellow pediatricians to make recommendations about care of children that effects the entire hospital.  When the call comes in at 2 AM for my opinion, my brain sometimes wants to say “duh, who doesn’t know that?”  By grace and experience, I don’t blurt that out.  Instead, I try to give information that is appropriate, and specialized.  In return, I’m reminded that caring for children takes expertise that I have earned and should use judiciously.

September 17, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine,Uncategorized — momwithastethoscope @ 1:23 pm
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photo from NatGeo

Sea otters hold the world's record for densest coat with 650,000 hairs per square inch. They are a protected species after being hunted for their pelts in the 18th and 19th centuries.

 

Reason Number 17:  Hair. 

“He had more hair than you would think a single skull could hold.  His hair – blue-black, thick and straight – it did not have the hard sheen of the hair of the Chinese or Japanese but had the soft look of fabric.”

About Julian Singh in E.L. Konigsburg’s The View From Saturday

“Hair is vitally personal to children.  They weep vigorously when it is cut for the first time;  no matter how it grows, bushy, straight, or curly, they feel they are being shorn of part of their personality.”

Charles Chaplin, My Autobiography. 1964

“And forget not that the earth delights to feel your bare feet and the winds long to play with your hair.”

Khalil Gibran

Toddler curls that cascade and rebound when tugged.  The brushy feel of a new summer buzz cut.  Silky, inky braids. A shock of  dense hair on a newborn.  I love the endless variety of color, texture, and length of hair on children.  I make it my professional responsibility to examine  a patient’s hair during a physical, but secretly, playing with all the different strands is a marvel.

One patient in my practice is recovering from Alopecia universalis.  At the onset of the diagnosis, I felt I was in mourning  and panic each time she presented to my office.  Her pre-diagnosis hair was lovely shoulder length blonde.  It was the type of blonde that we adults strive for – bright strands intermixed with tawny like the sun knew what it was doing each time it touched her head.  I referred her to three different dermatologists in hopes that one would have a new protocol for stemming the loss of this patient’s eyebrow, scalp, and even nostril hair.  Despite the collective efforts of her mother, myself, and the dermatologists, my patient lost all of her hair.  She has handled the course in the face of uncertain prognosis with grace and a great wig.  Eight months later, small tufts are beginning to come back.  

Once a mom came to my office with her preschooler, and she told me that she knew the child was sick because her hair wasn’t right.  It turns out she was right, so maybe I’m on to something by examining the ringlets of infants and the swath of hair covering the eyes of the young teen.  Maybe it’s not just curious fascination, but yet another clue to the inner workings of my patients.

September 16, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:22 am
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Reason Number 16:  Ah Ha! Moments.  This was a piece that I intended to submit for a recent Grand Rounds, but didn’t get it finished on time. 

A mother of a three year old called my office one afternoon with a rash.  She described her daughter’s skin as blue bordering on purple and appearing suddenly on the arms and legs.  Several thoughts went through my head as I cued Colleen, my nurse, to bring this patient in for an appointment at 2:15.  Colleen assured me that the child was in no distress other than her mother’s angst.

Is this cyanosis?  Was there occult congenital heart disease?  Is this poisoning or methehemoglobinemia?  My mind raced to make a differential.  I googled cyanosis. I searched for pictures of children with acute purple extremitites.

Jennifer, my young patient, hopped onto the papered exam table with her usual vim and vigor.  She didn’t appear to be in any acute distress of pain.  Her mother pulled off her coat, and continued pull the layers of socks and leggings and tops. 

I reached out to touch her legs. No texture.  No signs of trauma or bruising.  Not tender or sensitive.  Just blue as a blueberry.

“Any fever?”

“No.”  Her mother answered.

“Sore throat?”

“No.”

“Does it itch?”

“No.”  mother and daughter offered.

For a full five minutes, I touched, I examined, and pondered.

“Hmm.” I mindlessly reached into the drawer of the exam table and pulled out an alcohol wipe.  It could have been a throat culture had I touch that first. I was just looking for a way to solve the mystery.  I ripped open the package and wiped it over Jennifer’s leg.  A streak of normal skin appeared where I swiped.  The pad turned more and more blue with successive swipes.

“You’re kidding me!”  Jennifer’s mom gasped.  “It’s just some kind of dye?”

“Yea.  That’s all it is. Has she worn anything new and blue?”  Jennifer’s mom couldn’t recall any exposure to blue anywhere. No blue bubble bath.  No blue markers.  No blue bath crayons.  No new blue jeans.

“How did you know to try to wipe it off?”  Colleen asked me afterward.

“I don’t know.  It just felt like the right, least invasive thing to try first.”

Still trying to figure out how to ICD code that visit…

September 15, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:21 am
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Reason Number 15: Books 2.  Books for Doctors by (mostly) Doctors

How Doctors Think  by Jerome Groopman, MD  This 2007 publication by Hematologist-Oncologist Groopman was billed as the layperson’s guide to a physician’s thought process.  Some of the mechanics of MD thinking can be found in heuristics which are not necessarily evidence based.  For me, Groopman points to potential pitfalls in medical decision making that I now apply to everyday care.  Loaded with examples including pediatric cases, Groopman navigates with curiosity and doesn’t condescend.

Complications:  A Surgeon’s Notes on an Imperfect Science by Atul Gawande, MD. The son of a pediatrician and urologist, Dr. Gawande published his first book, a collection of essays,in 2002.  Few books existed prior to Complicationsthat addressed mistakes in medicine with Gawande’s candor.  In my own medical education, I received little training about how to handle mistakes.  Most were dealt with from a liability/risk standpoint with as scant information as possible shared  with family or patient.   It is Gawande’s thirst for a better way that has taught me that more communication between doctor & family/patient/parent  is needed, not less.

Baby Doctorby Perri Klass, MD.  Passed from fellow student to fellow student, this book was mandatory reading for all of the first year medical students who declared pediatrics as their specialty of choice.  Wishy-washy and leaning to a more surgical specialty (as much as a first year, twenty-something can lean) I attended Dr. Klass’s book signing at my school on a whim.  Pediatrician.  Nah. Not me.  Writer. Nah. Not Me, either.  Fast forward 20 years and Dr. Klass has been by long-distance mentor.  She changed diapers when no-one else would on rounds.  She knits during (otherwise boring) meetings.  She writes across the genres.  Trying to link to this book, I find that it is now out of print.  For wannabe pediatricians – this one is a must-read!

Dr. Spock’s Baby and Child Care, 8th Editionby Benjamin Spock, MD A tried and true favorite.  “You know more than you think you do.” is a Spock mantra I’ve uttered on more than one middle of the night run to hospital and my own son’s nursery.

Touchpoints The Essential Reference:  Your Child’s Emotional and Behavioral Developmentby T. Berry Brazelton, MD  Truly an essential reference.  Touchpoints taught me children are never too young to have emotions – that issues like night waking or biting can stem from these emotions and transitions to new stages – and to interpret for parents what’s going on in the mind of a young child. 

In the Blink of an Eye:  Inside a Children’s Trauma Centerby Alan Doelp  This book cemented my committment to the powers of prevention – especially as they apply to pediatrics.  If I can prevent one of these traumatic events from happening to a child, I’ve done my job.

How to Say No to Your Toddler: Creating a Safe, Rational, and Effective Discipline Program for Your 9-month to 3 year Old by William  G. Wilkoff, MD  True confession time:  I have not read this book…BUT… I have faithfully read Dr. Wilkoff’s column written from his pediatric practice in Maine for 8 years.  As I searched his name on Amazon – I realize he’s written 4 books, but his columns are still what I look forward to each month. 

Selected Poems (William Carols Williams) by William Carols Williams, MD  Dr. Williams was a pediatrician who composed some of his poetry on the insides of his prescription pads. 

  “By the road to the contagious hospital
under the surge of the blue
mottled clouds driven from the
northwest—a cold wind.”
William Carlos Williams (1883-1963), U.S. poet. Spring and All (l. 1-4). . . The Collected Poems of William Carlos Williams; Vol. 1, 1909-1939. A. Walton Litz and Christopher MacGowan, eds. (1986) New Directions.

September 14, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:02 am
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One of my favorite recommendations

One of my favorite recommendations

Reason Number 14:  Books, Part 1

 

As our practice’s resident bibliophile, I could write a month’s worth of posts on books for kids, parents, and pediatricians.  Books are a great fodder for The Drawer.  The Drawer is my method of occupying hands and minds of my patients of all sizes.  Sometimes it can provide two minutes of distraction while I convey advice to a parent.  Sometimes it showcases a new toy, and some stealthy educational material. 

Books for my profession fall into a few categories:

Body – educational (again on the sly) about various functions of our bodies. This category started with the need for a puberty book, but has morphed into any book with clever illustrations that explains the inner workings of humans. Some topics for parents need follow-up support – and books are a nonthreatening way to approach some touchy topics.

Mental Health – another topic I have a tough time watering down into a 15 minute appointment.  Stress. anger management, behavior issues are well augmented with a good reference.

Life Changes:  Death and divorce are all too common issues for my patients.  I have several favorites in both categories because toddlers need different explanations than teens.

Art:  My soft spot.  It is a joy to share my passion for creativity with children.

Entertainment:  Sometimes a favorite joins my library just because the book is well illustrated or written from a clever stance. 

 

 

Don’t Pop Your Cork on Mondays!: The Children’s Anti-Stress Book by Adolph Moser

Food Play by Joost Elffers

Peaceful Piggy Meditation by Kerry Lee Maclean

The Care and Keeping of You:  The Body Book for Girls by Valorie Schaefer (author) and Norm  Bendell(illustrator)

The Berstein Bears by Jan and Mike Berstein

Relax Kids:  The Wishing Star by Marneta Viegas

Helping Me Say Goodbye by Janis Silverman

Zen Shorts by Jon J. Muth

American Medical Association  Boy’s Guide to Becoming a Teen by Kate Gruewald Pfeifer

September 13, 2009

Loving Pediatric Medicine – the anti-rant

Filed under: Office,pediatrics,positive medicine — momwithastethoscope @ 7:39 am
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Reason Number 13:  Partners.  My practice started as a solo effort, but I never intended to stay in practice by myself.  Well-trained, compassionate pediatric partners who value family time  were part of my agenda from the beginning. I’ve heard some physicians describe their partnerships as marriages of sorts.  I see the committment we all have to a common goal like a marriage, but we seem to behave more as cohesive siblings than spouses. 

Through well, choreographed scheduling, we have a nice give and take between the four of us.  And while our ages are staggered, I consider all three to be my peers.  We vary in our interests within our profession, but the variances compliment each other.  Moreover, I trust these people with not only my practice and patients, but my own children.

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