Changes

Sometimes something sparks a memory and I am reminded how much has changed since I started in practice.

For example, consider an 18 month old who comes into the office with a fever of 104 and lethargy. She has some mild cold symptoms. She acts really sleepy and doesn’t react much when I examine her (it’s her nap time but mother also says she has been sleeping more than usual today). Her ears and throat look normal, her lungs are clear, she has no rash, and everything else looks and sounds normal other than just looking sick.

Here is my possible thought process in the late 20^th century:

• There is a good chance this is influenza but I don’t have any way to be sure
• Could be an early pneumococcal pneumonia (physical exam findings often do not show up right away so having clear lungs on exam does not necessarily exclude pneumonia)
• Could be another invasive bacterial infection such as a blood stream infection or meningitis which can not be ruled out on exam, especially in a young child
• Could be a kidney infection (a toddler is not going to complain of painful urination and you can’t really judge frequent urination in a child in a diaper)

What I might have done:

• Get some bloodwork to check for an elevated white blood cell count (particularly a type of white blood cells called bands) which could be a sign of a serious bacterial infection
• Get a chest X-ray to see if there is a pneumonia that I could not hear on exam
• Catheterize her to get a urine sample to check for signs of infection (she’s too young to pee in a cup and a bagged urine specimen is not reliable to rule out infection)
• If all other testing is unrevealing, potentially do a spinal tap to rule out meningitis
• Possibly admit her to the hospital for observation or for presumptive treatment of one of the above until further results are available.
• If I send the patient home, lie awake at night worrying that I may have missed something

Same patient in 2026:

• Since we now have the ability to test for influenza in the office, swab her nose
• If positive, discuss the expected course of the illness and symptomatic care and consider treating with Tamiflu.
• Discuss worrisome signs that would indicate a need to be rechecked.
• If negative for flu and other viruses that we can test for easily, maybe get a urine sample (but would probably wait to see if things resolve over a couple days before doing so because catheterizing an 18 month old is no fun for anyone involved)
• The other worrisome scenarios are vanishingly rare in a fully-vaccinated toddler in 2026 so can probably sit tight for now and treat symptoms unless she gets worse or something new develops.

In this scenario, I prefer 2026 and the patients and parents do as well.

·

Mole crabs and lightning bugs

This is not directly related to pediatrics, but it is in a roundabout way because it is about the world our children are growing up in and inheriting from us.

My friend Eric gave me a book called Solastalgia: An Anthology of Emotion in a Disappearing World.  Solastalgia is variously defined as “the lived experience of the desolation of a much-loved landscape” and “missing a loved place that still exists but to which the old birds and plants and animals no longer come.”

As I read through this collection of essays, I thought a lot about how I do not experience this much. We live in the Blue Ridge Mountains and often see white tailed deer, turkeys, and the occasional black bear outside our windows. We have skinks, lizards, and snakes. We have hummingbirds, goldfinches, pileated woodpeckers, and lots of other birds and at night we can lie in bed and listen to the whip-poor-wills sing. I fish for native brook trout in streams which emanate from mountain hollows with nothing upstream to spoil the water.

But several small things have gnawed at me. I love the beach and, in the past, whenever we would dig in the sand, we would uncover mole crabs which would quickly try to burrow back down into the sand as fast as we were digging them up. I don’t remember seeing any the last time we were at the beach just over a year ago. And while ghost crabs are still around, there don’t seem to be as many scampering around on the sand as there used to be. Or maybe it is just that we have happened to be at the wrong place on recent beach visits.

But I spend most of my time not at the beach and have always loved lightning bugs. I have fond memories of chasing them around at dusk and right after dark with our bare feet getting a little wet from the beginning of what would become the morning dew. A few years ago, I introduced our oldest grandchild to lightning bugs and loved watching her excitement as she spotted them. But for the past few years there have not been as many around. Maybe it is because the only significant patch of open grass was around the water tower adjacent to our wooded land and it was covered as part of a project to make the water tower more secure. Maybe if I lived among fields and grass there would be more?

This was in the back of my mind as I read these essays until I got to the final one entitled “Fireflies.” This essay confirmed my suspicion that there just aren’t as many lightning bugs (aka fireflies) around as there used to be. And it makes me sad to think that children are missing out on that experience.

Maybe future generations won’t miss mole crabs and lightning bugs just like I don’t miss passenger pigeons and American chestnut trees. How can you miss something you never knew? But I think our lives are poorer for not having had those experiences.

How old is your pediatrician?

Much like different types of scientists use different methods for dating natural phenomena, artifacts, fossils, etc., I have developed a way of figuring out how old a pediatrician is. Unlike the aforementioned scientific pursuits, my method is purely anecdotal and decidedly unscientific, though I do think it has merit (and is consistent with the data).

The method is to ask which infectious diseases kept the pediatrician in question up at night. This could be awake at night worried about having missed something or up at night actively caring for a sick patient in the hospital.

One of the infections that kept pediatricians a bit older than me up at night was Haemophilus influenzae type b (Hib). A vaccine for Hib was introduced in the mid 1980s and by the time I graduated from medical school in 1993, Hib was no longer something we saw. But my older colleagues had many stories to tell about children with Hib meningitis and other Hib infections. We had “airway drills” so we knew what to do if a child came in with epiglottitis, a condition caused by Hib which caused the upper airway to swell shut and basically strangle the child. I remember when taking my board exams the first time there were a bunch of questions about Hib infections and I chuckled to myself about why the old folks who wrote the exam questions were so obsessed with infections that no longer existed.

For pediatricians my age, pneumococcus was a common, scary infection. Especially in infants, it was difficult to tell if they had a viral infection or potentially a blood stream infection or meningitis with pneumococcus so we did a lot of blood work and spinal taps on sick babies to rule out the scary things. And pneumococcus was also a frequent cause of pneumonia, sometimes causing large collections of pus in the chest requiring drainage with a chest tube which was inserted between the ribs into the chest cavity. Pneumococcal conjugate vaccines were introduced in the early 2000s and newer formulations have covered for more and more strains of pneumococcus and I have not seen an invasive pneumococcal infection in years. Once a colleague was waxing nostalgic about pneumococcus, a once familiar formidable foe. It was like talking about what one does on rivalry weekend if your arch-rival has dropped their football program.

Rotavirus and chicken pox were less scary but common infections early in my career and they pretty much vanished after the introduction of vaccines for them. Both of these infections could lead to complications requiring hospitalization. Our community hospital used to have an 8-bed pediatric ward which was often full in the winter. Occasionally pediatric patients spilled over into the adjoining adult ward because there wasn’t space for everyone on the peds ward. Now our hospital doesn’t even have an inpatient peds ward and the closest hospitals to our north and south also do not. In the infrequent event that one of our patients does need to be admitted to the hospital, they go across the mountain to the university hospital.

I’m not sure what keeps the doctors younger than me awake at night. They must just sleep soundly (except for when their children wake them).

It is pretty amazing to think back about the changes I have personally witnessed over the past 30 years. It is also concerning to see some of these illnesses making a comeback. There have been multiple outbreaks of measles in various parts of the country (almost all in unvaccinated patients) and we have recently seen both whooping cough and chicken pox in our office in unvaccinated patients. I really hope I do not need to practice my spinal tap skills and that we do not need to reinstate airway drills.

Is Natural Always Better?

I love nature. I love watching the animals in our woods – hummingbirds, lizards, skinks, skunks, raccoons, deer, woodpeckers, bears, snakes, etc. I am the guy who catches spiders and takes them outside instead of killing them. I love wading in the nearby river fishing. I think it is kind of the adult version of “playing in the creek.” In addition to the fish, there is usually a Great Blue Heron around as well as the occasional crayfish, turtle or water snake. I am intrigued by the little shells from fresh water mussels on the river bed and the assorted wildflowers growing on the bank.

A few years ago my father gave us some wild berries he had picked. Instead of eating them all, I saved a few and planted them along our road and now we have a robust wineberry patch. I have been known to eat insects, acorns, and the fungus known as sulphur shelf (aka “chicken of the woods”) which grows on trees. When our children were young we often made huckleberry pancakes using the berries from the wild huckleberry bushes in our woods. I have enjoyed watching the progress of the building of the hornet’s nest on our back porch this summer and I recently spent part of a morning watching a cricket with my grandchildren.

In general, I think nature is really good for us. It is much healthier to take a walk in the woods and listen to the birds than to sit and watch TV or scroll on one’s phone. And it is certainly healthier to eat some fresh produce rather than processed foods. But does that mean that “natural” is always better?

It is tempting to romanticize a time when everyone lived off the land and everything was natural. But the reality is that in the United States in 1900, when most people lived that way, life expectancy for white men (guys like me) was 46 years. Maybe other folks would be fine with that now. But as a healthy 55 year old, that seems suboptimal to me.

It is easy to come up with a list of things from nature that clearly are not good for us – poison ivy, prolonged sun exposure, radon gas, rattlesnake venom, arsenic, the gases emitted by volcanoes, plants and mushrooms which are poisonous if ingested, poison dart frogs, botulism, smallpox, diphtheria, polio, cholera, plague, malaria, assorted worms and other parasites, and every other infectious disease one could think of. I could go on and on but lists are boring. Obviously not everything in nature is safe and harmless. As I heard someone recently say “Nature has been trying to kill us for thousands of years.”

Supplements are often marketed as being natural with the implication being that they therefore are safe. It is important to remember that supplements are not required to undergo the same kind of testing for safety and efficacy as medications are. Some supplements, when tested independently, have been found to contain harmful compounds and others have been found to contain actual prescription medications. Do you really want to use a “natural” supplement that actually contains a banned drug? There was a tragic death recently reported in California, apparently linked to an herbal supplement.

In contrast, we have all seen those almost comical commercials for medications that list a bunch of potential side effects. They list all of those because they are required by law to include that information in the advertising for a drug, as opposed to supplements which are not required to provide any of that information or to even test for potential side effects before marketing.

There are also other variables related to individual persons, locations, etc. that affect one’s response to nature. If a person who has an inborn error of metabolism were to eschew all “unnatural” products, it could lead to severe disability or death. If my grandson eats some dirt from his back yard, he will likely be fine. But in some parts of the world, that is an almost surefire way to contract parasites.

Is nature good? Yes. Is nature sometimes dangerous? Yes. Are “unnatural” things sometimes bad? Yes. Are unnatural things sometimes beneficial? Yes. When I am making a recommendation for a patient, whether or not a treatment is “natural” is immaterial. The questions that concern me are whether a treatment is safe, effective, and whether the benefits outweigh any potential risks.

So I will eat my wild berries, take walks in the woods, and sit on the porch listening to the birds sing. And I will also gratefully utilize any treatments which have been shown to be safe and beneficial.

25 Years of Changes

It was recently pointed out to me that this summer marked 25 years that I have been practicing pediatrics in the Staunton, Augusta, and Waynesboro area. A recent discussion with a younger colleague who has never seen a case of chicken pox got me thinking about the things that have changed in the past 25 years. Many of the changes are unquestionably positive while some of the others are not.

Chicken pox used to be common but I have not seen a case locally in years thanks to the vaccine which was introduced early in my career. In the past we sometimes had children hospitalized for complications of chicken pox and I once had a patient with a complication called acute cerebellar ataxia – a condition which has hopefully been relegated to the dustbin of diagnostic history forever.

The bacteria Streptococcus pneumoniae (also known as pneumococcus) was a formidable foe which often kept me up with worry at night. It caused bloodstream infections, meningitis and nasty pneumonias which could fill the chest cavity with pus. Early in my career there was robust debate about the proper timing for inserting a tube into a child’s chest to drain the fluid around the lung caused by pneumococcal pneumonia. And it wasn’t unusual to do a spinal tap in the office on a baby to rule out meningitis. But again, with the introduction of a pneumococcal vaccine, I have not done a spinal tap on a baby in years and have not needed to ponder the pros and cons of chest tube placement in a child with pneumonia for a very long time.

Rotavirus was a common wintertime intestinal infection which often led to dehydration needing hospital admission for IV fluids. It was common enough that our pediatric nurses in the hospital could often correctly diagnose it by the smell of a patient’s stool before we had lab results back. Again, after introduction of a vaccine for it, this disease has almost disappeared.

I have also not seen a case of meningococcal disease (an awful, often fatal illness) in years. You may have guessed by now that a vaccine for this was also introduced since I started practicing.

Of course, we did not have COVID when I started out and that has obviously been a huge change. In a way it was not too surprising because the folks who study these things have been warning us for a long time that it was not a matter of if, but when the next global pandemic would occur. However, I did not have a coronavirus on my Bingo card as the likely culprit, though SARS should have been a warning. And apparently, we now need to keep polio in mind as a possibility, even though it was almost entirely eradicated from the entire world not that long ago.

The number of anxious children and adolescents seems to have increased exponentially in the past 25 years. COVID and its downstream effects have clearly been a factor in this increase, but anxiety was already increasing before any of us had heard of COVID. There is evidence which points to the role of social media and ubiquitous smart phones as part of the cause of this increase.

On a positive note, many parents are now aware of the downsides to overuse of antibiotics and there is much less pressure to prescribe them when they are not indicated. I now occasionally find myself in the awkward position of thinking antibiotics are needed and having the mother not want to use them. I do not recall that ever happening 20-25 years ago.

The way pediatrics is practiced has also changed. Although it took longer to become the case here than in many more populated areas, pediatric practice is now largely divided between outpatient and inpatient practice. We used to do it all. I might have fielded a middle-of-the-night phone call about a patient, seen them in the office the following day and then admitted them to the hospital and provided their hospital care as well. Now those different functions would fall to different people. While it certainly makes life more livable for us to not be chronically exhausted, I think something is lost in the disconnect of not having the continuity of care from one’s own doctor. And I do miss providing inpatient care. On the other hand, sometimes a new set of eyes can pick up on something that may not have been noticed if the same doctor was providing all the care.

I remember early in my career feeling like I was in a good rhythm and that I would just do what I was doing for 35 or 40 years and then retire. I had no idea how much would change over the years but I guess that is how life works.

Thank you to all who have allowed me to be part of your lives for the past 25 years. Maybe I will be at it long enough to someday reminisce about how things were in 2022.

Of Snakes and Mistakes

I was recently summoned because there was a snake in a public area and there was concern that it may be a copperhead and I am known to have an interest in snakes. By the time I got there, a man was in the process of decapitating a harmless milk snake while invoking the need to protect people walking by.

This made me frustrated because the snake could have easily been removed alive and taken to a nearby field or patch of woods.

The following day, in the midst of my still smoldering righteous indignation, I remembered an incident from maybe 10 or 12 years ago. We had moved into the mountains where we see snakes fairly often, including copperheads and rattlesnakes. One day, one of our kids reported seeing some baby snakes and, sure enough, there were multiple little snakes poking their heads out of a large crack in the blocks surrounding a planting bed right next to the house.

Baby snakes often look different than their adult counterparts and I did not know what kind of snakes they were and was concerned because they were right beside the house. I was worried that they may be baby rattlesnakes. So I killed the ones I could get to and tried to flush the others out with a water hose. Only later did I realize that they were baby rat snakes, totally harmless and maybe even helpful in keeping the poisonous snakes away.

Now I know what baby rat snakes look like and would never kill them. If that happened today, I would take some pictures and leave them be. But the younger, less-experienced version of me didn’t know what I know now.

At that time, I was basically the same as the guy killing the milk snake a few days ago. Perhaps we are most frustrated by the actions of others that reflect poorly on our past selves? As humans, we often react violently to things we fear because we do not understand. Fear and ignorance are a dangerous combination.

The antidote is to seek to learn more about the things we do not understand. After I had killed the baby snakes, I posted some pictures to ask others what kind they were and quickly got responses from a couple of people who knew. I confirmed this by checking in my field guides as well. In retrospect, it would have been good to do this before killing them.

How much of what we do to “protect” ourselves and others are simply illogical actions borne out of fear and ignorance? And what are the ramifications of those actions?

Running, fishing, and the benefit of the doubt

Sunday afternoon felt like mid-July so I was trying not to move too much, sitting quietly and reading. Then a nice thunderstorm came through and cooled things down and I decided to go for a run. When I was younger, I enjoyed running on trails in the mountains but that is a lot harder than it used to be so I headed down to my usual spot to run along the river where it is flat.

Several weeks ago while I was running there, I came across a fisherman wading in the river close to the near bank. He was trying to use his phone to take a photo of a fish he had in his net which is no easy feat while also trying to hold onto a fishing rod and not drop anything in the river. I immediately understood his situation. I am still pained that I do not have photographic evidence of my two best freshwater catches ever – a big brown trout from this same river a few years ago and a monster smallmouth that I caught last summer on the James. So I scurried down to the bank and offered to take a photo of him with the fish. After a couple of nice, quick pictures of a happy fisherman with a beautiful rainbow trout, he gently slipped the fish back in the water and it swam away quickly to continue enjoying the cool water and perhaps make another fisherman’s day.

It was just as it should be. A man communing with and respecting nature and leaving it intact for another day.

On my run on Sunday, I spotted four people on the far bank of the river. They had a large red cooler which meant they were either fishing with live bait and/or planning to keep what they caught, both of which are forbidden on that stretch of the river. I could not see them very well without my glasses but I was immediately annoyed.

But as I continued my run, I thought of other possible scenarios. Maybe they needed the food so that’s why they were going to keep some fish. Or maybe they didn’t know it was a special regulation area. Or maybe they weren’t even planning to keep any fish. Maybe they had some sandwiches and drinks in the cooler. And then I wondered if they knew part of the reason for not keeping and eating fish from the river was that it is contaminated with mercury. Maybe I should warn them instead of being angry at them.

I also have enough generational memory to understand why it seems silly to catch something and then just let it go instead of eating it, even if it is a turtle that was caught accidentally (but that is a whole other story). Catch and release fishing is something that people who have plenty of food do and not something that would make any sense to much of the world’s population. For that matter, going for a run on a Sunday evening to get some exercise also wouldn’t make sense to a lot of folks.

So I try to give people the benefit of the doubt and not immediately jump to ascribing malevolent intent to their actions. Maybe that makes me a sucker sometimes. But I would rather be a sucker than to accuse someone unfairly.