Vaccine "Skepticism"

I am a vaccine skeptic.

Now before anyone blows a gasket or has an intracranial hemorrhage, let me explain. A skeptic is simply a person who does not accept things without evidence. Let me give you an example.

In the spring of 2020, I thought it was unlikely that we would get an effective vaccine for COVID-19. We did not have vaccines for other novel coronaviruses (SARS and MERS) so I assumed that we would not get an effective one for COVID (in retrospect, those other novel coronavirus outbreaks were more easily contained so we never really got to the point of vaccine development).

When the early data came out on the mRNA COVID vaccines, I was pleasantly surprised. And the more data we got, the more I became convinced of their efficacy. I was thankful to get my first dose right at the end of 2020 and have had multiple doses since then. After the vaccine was out, data continued to be collected from many different places and types of sources and it became clear that the vaccine significantly decreased the risk of serious disease and death. Other data came out showing that the adenovirus vector vaccines (not the mRNA vaccines) had a rare but serious clotting side effect (thrombotic thrombocytopenic purpura) so they were withdrawn from use. The mRNA viruses were found to have a potential side effect of myocarditis, though this happened less often with the vaccine than with COVID infection and tended to be much less serious if it was a result of the vaccine.

The vaccines aren’t 100% effective or 100% safe. Nothing is. If we required that level of certainty, no one would get out of bed in the morning. We need to know if the benefits outweigh the potential risks. For at least the first couple of years of COVID, the answer was that for the vast majority of people, the benefit of COVID vaccines definitely outweighed the risk. Or to put it another way, the risk from not getting the vaccine was higher than the risk from getting it.

Through the years I have applied that same approach to other vaccines, particularly the ones we give in our practice. At one point years ago, I compiled a notebook of vaccine safety studies for parents who expressed concerns about side effects and declined vaccines for their children. I assumed if folks had access to accurate information, they would act in ways consistent with the evidence.

But no one looked at my notebook of studies. It took me years and years and many frustrating conversations to conclude that some self-identified “skeptics” are not actually interested in evidence. That is, they are not really skeptics.

In the old days if we wanted to read a study, we would need to go to the medical library, look it up and find the volume of The New England Journal of Medicine or The Journal of Pediatrics or whatever other journal the study was in and sit in a cubby in the library to read it or pay to photocopy it to take it with us. Now all of that is readily accessible to anyone who wants it, yet we have folks (including policymakers) confidently making statements that are patently false and easily disproven.

If someone says “There are no studies comparing vaccines to placebo,” you can simply do a PubMed search (https://pubmed.ncbi.nlm.nih.gov/) and find 547 pages of results on the topic. Same for someone who says that the MMR vaccine has not been tested for safety (104 pages of results). A person who makes statements like that is not a “vaccine skeptic.” They are the opposite of a skeptic, a person who makes claims without regards to the evidence.

I have largely given up on trying to convince people to vaccinate. You can’t use evidence to convince someone who is not interested in evidence. I have spent far too much time and energy in the past trying to convince folks who confidently repeat demonstrably false talking points. I make my recommendations and explain why I am recommending what I do. And I am quite happy to answer questions and address any concerns. But if they persist in making claims not based on the evidence, I no longer try to persuade them because experience tells me it won’t work anyway. It feels like failure to not be able to provide the best evidence-based care to patients, but I can’t be responsible for the decisions of others.

When our children are young, we try to teach them. “You need to wear your coat. It is cold outside.” Sometimes they listen but sometimes you just need to let them go without a coat and get cold and let them learn the hard way. I think that is kind of where we are in the United States now with medical disinformation. We have to live with the consequences of our own collective choices. Hopefully it won’t take us too long to learn our lessons and the harm will not be too extensive, especially for those too young to make their own medical decisions. But I think the effects will outlast my time in practice.

And the people convincing folks not to vaccinate will not be there to help the baby who is blue and gasping for air from a Pertussis infection or the child in the ICU with measles encephalitis.

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.

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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.

Thoughts on Ivermectin, masks, etc.

We are all sick of dealing with Covid and wish there was some kind of easy, fool-proof way to prevent or treat it. Unfortunately, as with most things in life, Covid does not work that way. Early on in the pandemic, hydroxychloroquine gained traction in some quarters as the answer and was ultimately shown to not be beneficial for Covid (and possibly made things worse). The new silver bullet being promoted by some which I have been asked about is Ivermectin.

Ivermectin is a drug I learned about in medical school but I do not have much experience with it because the human diseases it is typically used to treat are not common in the Shenandoah Valley. Ivermectin initially gained attention for Covid because it was shown to kill coronaviruses when used in high concentrations in a lab setting. Unfortunately, that does not necessarily mean it will work in a human being.

There are several studies which have been used to promote the use of Ivermectin for Covid which showed results that seem too good to be true. There are a lot of red flags with these studies which have been noted by epidemiologists who have reviewed them. One study included patients who died before the study even started, listed a hospital as part of the study as a participating institution even though the hospital denies any involvement, and listed an author who states he was never allowed to review the data. Other population studies do not account for the effects of concomitant policy changes such as lockdowns and one study appears to have sections directly cut and pasted from an earlier document.

It would be great if Ivermectin was effective. Imagine if it was really 100% effective as one study claimed. I could prescribe it for everyone and make it home in time for dinner with my wife. Unfortunately, the preponderance of the evidence for Ivermectin use in Covid is underwhelming (https://www.covid19treatmentguidelines.nih.gov/tables/table-2c/).

There are some things that we know help lessen the spread and effect of Covid. Masks have been shown to slow the spread of Covid. Vaccinations have been shown to significantly decrease one’s chance of catching Covid and to greatly decrease one’s chance of having a severe case of Covid. Being vaccinated also appears to decrease the amount and duration of viral shedding after a Covid infection, thus decreasing the chance of spreading it to someone else.

One of the most disheartening things for me about Covid is how much of the public discourse is about laws, mandates, court decisions, rights, and yelling at school board meetings. Wouldn’t it be nice if it was more about how we can voluntarily protect ourselves and those around us? Wouldn’t it be nice if there was more “What can I do to help?” and less “You can’t make me!”?

As of yesterday, our community hospital has 53 people hospitalized with Covid and has once again stopped doing elective surgeries. Several urgent cares have closed to reroute staff to where they are needed to help care for Covid patients. Recently, our days in the office are dominated by seeing patients with Covid, possible Covid, or exposure to Covid.

So please just wear a mask when you are indoors with folks outside your family and get vaccinated if you have not already. Ivermectin is not a panacea and we are unlikely to find anything else that is. The best way to get closer to our pre-Covid normal as soon as possible is for all of us to consistently do the things which we know work.

 

Warm weather and poison ivy

As the weather warms and people are spending more time outside, I have started seeing some children with poison ivy or poison oak.

It is important to note that even before the plants have leaves, contact with them can still result in a very unpleasant reaction. In fact, these photos are of a case of poison ivy contracted during the winter while cutting up some downed trees. Because there were no leaves, it was not clear until it was too late that there was poison ivy all around. Be especially wary of fuzzy vines on tree trunks.

The rash is a reaction to the oil from the plants. There can be secondary transmission from clothing or pets which have the oil on them. But once the oil is washed away, the rash itself is not contagious. If you know you have been exposed, washing as soon as possible with soap and water and washing your clothes immediately can help prevent any reaction. 

The rash is very itchy and can turn into weepy blisters as well. Treatment includes topical anti-itch creams, compresses and baths, oral antihistamines such as Benadryl, Zyrtec, or Claritin, and in severe cases a course of oral steroids.

So get outside and enjoy nature. Just be careful what you are touching.

I don't like masks

I don’t like wearing a mask.

It makes my face hot and gets snagged on my whiskers. It tickles my nose. My glasses get fogged up when I wear them. I can’t see the facial expressions of others who are wearing masks. I really enjoyed my surgery rotation in medical school except for having to wear a mask for hours at a time in the operating room.

But here’s the thing – it is one of the few effective measures we currently have to help keep from spreading a potentially deadly virus to each other. Masks aren’t perfect, but the mounting evidence shows that they decrease the spread of SARS-CoV-2.

We have all been wearing masks all day in our office for months now. I wear one whenever I am indoors in a public building, except occasionally when I am in a room by myself. I don’t wear it when I am outside unless I am in a crowd of some sort or visiting outside with particularly high risk people. So if I am working outside, or running or hiking or fishing, I don’t have one on but I stay away from other people.

Since we know that it is possible to have the novel coronavirus and not know it, wearing a mask not only protects me but those around me. In fact, the evidence suggests it protects others even more than it protects me. The person I walk by in the grocery store could have a medical problem that I can’t know about by just looking at them. Wearing a mask is an act of compassion. It is a tangible way to love your neighbor as yourself.

For 99% of us, wearing a mask is a minor inconvenience. If masks work, I can potentially help save lives by wearing one. An itchy nose seems like a small price to pay. If it turns out we were wrong and masks didn’t really help, is it really so bad to have inconvenienced myself a little bit in an effort to protect my fellow human beings?

Running Red Lights

There is a Subway just up the main road from our office and one day last summer I went there to get a sandwich for lunch. There is a traffic light almost immediately after turning left out of the Subway parking lot to head back towards the office. Sometimes I am a bit absent-minded and thinking about other things and I was most of the way through a red light when I realized what I was doing. Since the intersection was empty I proceeded on through instead of stopping in the middle of it.


Almost immediately I saw blue lights flashing behind me. My first thought was “Well that was really dumb of me. I hope I can just pay a fine and not have to go to court.” I pulled over and the officer came up. I handed him my license and told him I needed to find the registration.


As I rummaged around in the glove box, he asked me why I ran a red light. I told him I didn’t know, that I had just screwed up. He asked where I was going, what my job was, etc. After I found my registration, he looked at it and my license for a while. He handed them back to me and told me to be more careful. And that was it.


I had clearly violated the law and was expecting a ticket and a fine. And there was nothing.


This morning I read a story from an African-American professor who had not done anything wrong but was still detained because he “matched the description.” He spoke of his fear and how the incident left him rattled afterwards. His experience and mine bore little resemblance to each other. I was actually guilty and he wasn’t. But I was never frightened.


I know some police officers and I think the ones I know are good people. And I think I am a basically decent human being as well. But years ago I read some data about the differences in medical treatment of white children and African-American children with respect to pain control, etc. It was jarring and I began to examine myself. And one day in the office, I realized I had a white patient and a black patient with pretty much the same issue, and I had provided a more aggressive evaluation for the white child. I could rationalize why I did that. But there isn’t a good reason.


I hope that doesn’t make me a bad person. Both of the children were fine and the white child got more evaluation than was needed. But I think it does show that I am (was?) a biased person. Both mothers were worried about their children and I did more to allay the fears of one than the other. And only by knowing and admitting that about myself can I do anything to correct it.

Is this Covid Information Reliable?

It seems like every day there is a new video from a doctor claiming some special insight into Covid-19. I have a few thoughts about how to approach these.


I think it is important to remember that being a doctor can mean a lot of different things. If you have a sick three year old, I am your man. That is why I am here. That is what I do. But you should worry if you are sixty years old and possibly having a heart attack and I show up to take care of you. That is not what I am trained to do. I could maybe muddle my way through and help some, but you would have a much better chance with an ER doctor or cardiologist caring for you. For information on Covid-19, I want to hear from virologists, epidemiologists, and the ER physicians, intensivists, and hospitalists caring for patients with the disease.


It is also important to remember that even doctors in the same field can have varying levels of expertise. This can vary based on intrinsic abilities, where someone went to school, where they did their residency (or if they even completed one), whether they are board certified, how much experience they have, if they did fellowship training after residency, etc.


Some mechanics are better at fixing engines than others. There are some basketball players who are more likely to make a clutch shot on the last possession in the championship game. Some carpenters build a more solid house than others. Some people make tastier, more nutritious food than others. No matter what field you are in, I am sure there are people who you recognize as being more competent and trustworthy than others. In the same way, some doctors are better positioned to speak about Covid-19 than others. Being a doctor does not magically imbue one with wisdom on all things medical.


Medical progress is plodding. It is based on rigorous evaluation of data and attention to detail. I am not aware of any significant medical insights to ever first be released via You Tube or Facebook. They are much more likely to be on page 38 of The New England Journal of Medicine. Some of the videos I have seen in the past few weeks have some basic errors that are easy for other doctors to spot. So just be cautious about jumping on bandwagons, unless you are fine with me treating your heart attack.

Covid-19 and the General Pediatrician

I am not an infectious disease specialist, epidemiologist, or someone who works in the ER or ICU but I am certainly paying attention to what they are saying about the novel coronavirus (SARS-CoV-2) and the disease it causes, Covid-19. I have seen some folks making comparisons between this and the H1N1 pandemic in 2009. I remember the H1N1 pandemic as being a busy time with a lot of sick patients and one child who was hospitalized with it but did fine. From my perspective, the H1N1 pandemic was busy but it wasn’t scary.


As a general pediatrician, my interactions with patients not infrequently involve flying saliva and mucous from uncovered coughs or sneezes or resistance to a strep test or flu swab. And there is always a toddler who grabs the otoscope right after smearing snot all over his or her face with the same hand. That’s just the way kids are and their innocence about these things is part of what makes it entertaining to be their doctor.


Sometimes after a child sneezes all over me, a parent will ask “How do you not stay sick?” My half-joking answer is that “I wash my hands a lot and get a flu shot every year. And I have already been exposed to everything.” During flu season, I am exposed to influenza multiple times each day and have not historically been wearing any protective equipment during those visits. And I have never had the flu or, if I have, it was never bad enough to recognize it as such.


But to the best of my knowledge, I have not yet been exposed to SARS-CoV-2. If I do get it, am I going to be one of those folks who doesn’t even realize they have it while potentially spreading it to others? Or am I going to get really sick and possibly die like over 60 doctors in Italy already have? Like I tell 13 year old boys who want to know how tall they are going to be, “Come back when you’re 22 and I will tell you.”


Fortunately, children seemed to be mostly spared from the worst of this disease and for that we are thankful. And I am thankful that Augusta Health has been working hard to prepare for what may come and that across the mountain at UVA they have already been able to develop their own test which they are providing to other hospitals.


But I worry about my parents and my in-laws and everyone I know with medical issues or those with the highest risk of exposure from their jobs. And I worry about people who are losing their livelihoods and the folks I know here and in other parts of the world who are wondering how they are going to feed their families if they can’t work.


So we prepare for the worst while we hope for the best. We take a walk, exercise, or pray to alleviate our anxiety while still maintaining vigilance. We don’t hug our loved ones or even see them face-to-face just in case, but we stay connected as best we can. We recognize the value in each person we meet and do our best not to put them at risk. And we continue to care for each other’s needs – physical, emotional, medical, and spiritual. And I think that is all we can do.

In praise of car seats and helmets (but not kneepads)

Over the past few years, I have become a fan of Jonathan Haidt’s books. I have read The Happiness Hypothesis and The Righteous Mind (twice) and they have helped me understand myself and others better. Last night I finished reading The Coddling of the American Mind which he co-wrote with Greg Lukianoff.

This book has a lot of information which is pertinent for folks raising children as well as those of us advising folks who are and much of it resonates with me. But I want to focus here on what they refer to as “safetyism.” That is, the normal impulse to try and protect our kids, but taken to extremes. They point out that children need to have free, unsupervised play, take risks, and to experience disappointment, injury, losing, conflicts, etc. in order to be able to navigate those things as they get older. If we always rush to protect them, they will never develop the skills needed to navigate the world as adults. Children who never experience adversity lack resilience and are prone to anxiety when faced with the real world.

Some people in my generation are fond of saying things like “We never used seat belts and bike helmets and we survived.” That is not what Haidt and Lukianoff are saying. The reason some of us can make statements like that is that the folks who didn’t survive aren’t around to disagree. The book points out that “from 1960 to 1990, there was a 48% reduction in deaths from unintended injuries and accidents among kids between five and fourteen years of age, and a 57% drop in deaths of younger kids (ages one to four)” due to more safety measures for children. We obviously want fewer children to die so they are not advocating going back to no seat belts, car seats, or bike helmets.

Some risk is good and builds resilience but too much can be dangerous. So how do we navigate this as parents, grandparents, teachers, pediatricians, lawmakers, etc.? Everyone has different tolerance of risk and some people’s environments are more risky than others.

One way I approach this with my patients is to say something like this when I recommend helmets for bicycles, skateboards, etc.: “If you fall off your bike and break your arm, it will hurt but it will heal up and you will be OK. But if you fall and hit your head and damage your brain, it could cause trouble the rest of your life because brains don’t heal very well.”

I think a healthy childhood includes bruised shins, bike helmets, scraped knees, seat belts, and the occasional minor fracture.

This is how I make sense of it but I welcome other perspectives.

The Little Things

“This is a wonderful day. I’ve never seen this one before.”

-Maya Angelou

 

Every job, vocation, profession, and calling has its challenges, headaches, and days that make one wonder what they were thinking when they pursued the career path in question. Pediatrics is no exception. But among the occasional frustrations, there is much for which to be grateful:

·         Finding the perfect sticker for the child who loves trains or kittens or Paw Patrol

·         Celebrating with the big, but scared teenager after he was able to receive his shots without incident

·         The intellectual satisfaction of a diagnosis made and effective treatment given, especially if the condition is a bit obscure

·         Hugs from children in the office hallway, grocery store, or post office

·         Seeing the child of a former patient and reminiscing with the (now) mother and grandmother about something that happened twenty years ago

·         Babies who smile and coo at you or determinedly try to grab your stethoscope

·         A child who is comfortable enough to tell you what is bothering her

·         Being able to reassure a worried parent

·         The fact that some diseases which were common when I started in practice have all but disappeared.

·         Discussing books, drama, baseball games, and fishing spots with patients

·         The child who says “Siri, where is Dr. Sauder?” while waiting in the exam room

·         A parent or grandparent telling a story of an event you shared that had a lasting impact

·         Connecting with a child with gestures and stickers when you don’t speak the same language

·         The satisfaction of popping a dislocated elbow back into place or retrieving a bead or rock from a nose or an ear

·         Discussing an interesting case with colleagues

·         Congratulating a patient who has made a healthy lifestyle change

·         Hearing that a patient uses their doctor kit at home to pretend to be me

·         Seeing someone walking down the street who you know could have easily died in the past

·         Dedicated parents, grandparents, foster parents, and others who do their best to help children with difficult medical and psychosocial needs

·         The moment a patient realizes my wife is his math teacher or the former student of hers who asks “So how’s Mrs. Sauder doing?”

For these reasons and many other things, I am thankful to be able to do what I do. Thank you for letting us (me) participate in the care of your children.

Dangerous Stories

Stories can be inspiring and entertaining and help us understand the world around us. But if simply accepted uncritically, anecdotes can also mislead is in major ways. Medical information is not exempt from this type of misdirection.

One reason stories can mislead us is they may simply be false from the outset. Some of the more outlandish stories I have heard from patients are “The HPV vaccine makes you walk backwards” and “The flu shot contains microchips so the government can track you.” These are obviously false on so many levels that they are almost comical. But they are also real concerns that people have based on false information being spread on social media and elsewhere.

Another way that stories can mislead us that our recollection of events is notoriously inaccurate. I once saw a new patient for the first time and the father told me they had left his previous doctor because he had given them an MMR vaccine and caused his child to have autism. Fortunately, I had the records from his previous physician to review and it was obvious that the child had developmental problems long before receiving the MMR vaccine and that there was a different explanation for his difficulties. I don’t think the father lied to me. I think he believed the story he told me. It just didn’t match up with the evidence. But without having the other information available, one could have been easily misled by the story.

It is common for folks to have memories that diverge significantly from the written record. This has happened to me as a patient as well as I have misremembered things about my own medical history. And I have had patients tell me detailed stories about myself in certain situations, only to discover when I checked the record of the event that I wasn’t even there.

A final way that stories can mislead is that we tend to connect dots that aren’t necessarily connected. Many years ago I had an infant patient who did not show up for his check-up where he would have received multiple vaccines. Tragically, the night after his missed appointment, he died. Now imagine he had showed up, we had given him vaccines, and then he died later that same day. I think it is inevitable that someone would have reached the “obvious” conclusion that his vaccines killed him, even though we know that wasn’t the case.

Anecdotes can be the first step in uncovering important information. But accepting a story without digging into it and collecting data in a way that is as objective as possible can lead us astray and cause us to make decisions which have dangerous consequences down the road.

Can we please discuss this like adults?

I recently read an article in the journal Pediatrics entitled “Infant with Trisomy 18 and Hypoplastic Left Heart Syndrome.” It was about the decision-making process regarding how to treat a newborn with a complicated heart condition in addition to an incurable, genetic, life-limiting condition. The majority of children with Trisomy 18 die within the first year though some live longer, always with severe limitations cognitively and developmentally.

Hypoplastic left heart is a complex cardiac condition requiring multiple surgeries for repair. The survival rate five years after surgery is approximately 65%. Clearly having both Trisomy 18 and Hypoplastic Left Heart Syndrome presents a very complex set of questions and decisions for the parents and the doctors.

Should the baby have heart surgery? Is heart surgery futile in this instance? Would the baby be better off with comfort care rather than invasive procedures not likely to significantly prolong life? Are there mitigating circumstances which make this baby more or less likely to have a positive outcome? Who decides? The parents? The surgeon? The cardiologist? The neonatologist? The geneticist? The hospital ethics committee? The insurance company? Where do the hundreds of thousands of dollars (or more) for complex surgery and weeks or months of ICU care come from? These are the kind of discussions which take place when a baby has a serious condition with a limited life expectancy.

Reading this article reminded me how ridiculously simplistic our public debate often is about issues like this. When people throw around words like “infanticide” or “execute,” they are poisoning important conversations, either purposefully or because they don’t understand how these things actually work.

When a baby has a condition incompatible with long-term survival, keeping him comfortable while allowing him to die naturally is very different from “executing” someone. And people who engage in infanticide are prosecuted for murder. It is not something that is done or that people are in favor of. Reasonable people can disagree on the best way to handle these issues. But we need to make sure we are discussing the same thing and basing our discussions on facts, not misleading innuendo or outright falsehoods.

The baby in this case did undergo heart surgery and subsequently died at 14 weeks of age, clearly a difficult situation for all involved. I propose the most important first step in discussing these situations is to acknowledge how complex they can be and to provide a healthy dose of compassion for the parents and others involved in these difficult decisions.

Copperheads and Fear

I was recently using the weed eater to trim up some things around our house when I suddenly saw a small snake slithering under the swirling line. Almost as suddenly, I realized it was a copperhead and simultaneous to this realization, the line caught the snake and slung it back towards me. I frantically tried to see if it was on me somewhere, right at my feet, etc. Eventually I found the lifeless front half of it on the ground about ten feet away.

As I continued working, I began thinking about this more. It all happened so fast. Had I killed it intentionally or did I accidentally snag it with the weed eater? If I had seen him lying in the middle of the trail while out hiking or in the middle of the road and been able to observe from a distance, I would have just waited until he left, or maybe tossed some sticks at him to make him leave so I could pass. This is a different calculation, however, right next to my house where my granddaughter may be toddling around in the grass not too many months from now.

If it had been a black snake or garter snake (which are not poisonous), I think my reflexive reaction would have been to move the weed eater away from him to make sure I didn’t hit him. I have recently escorted non-venomous snakes off a road and away from a sidewalk to make sure they weren’t harmed.

I think the answer to my question is that my unconscious brain decided to kill it before my conscious brain had time to make a decision. We know that much of what we do is determined by our unconscious brain before our conscious brain has time to intervene. Much of what we do consciously is simply developing rationales for what our unconscious brain has already done, even when we think we are making conscious decisions.

So why would I have reacted differently to a black snake? Over the years, my conscious brain has trained my unconscious to not fear black snakes because they are not dangerous. When I see a black snake I often just stand and watch until it slithers off somewhere. Often this means five or ten minutes of just observing it. And over time my unconscious brain has gotten the message that a snake that looks like that (in the United States) is not a reason to fear.

This same process in our brains occurs with other things. How do you get over a visceral fear of a place, a situation, or an object? You place yourself in the feared placed, by the feared object, in the feared situation and eventually recognize that it did not harm you. How do you make that fear worse? You avoid the situation, object, or place and continue to think how scary it is, thereby fortifying the corresponding fear pathways in your brain.

This applies to people as well. Are there certain people you fear based on their appearance, the way they talk, what they wear, or your assumptions about the way they act based on their politics? The best way to get over that fear is to get to know them. The best way to enhance your fear is to avoid them and keep telling yourself why you should fear them.

How do we help our children not develop fear of others who are different? We have them interact with folks from different races, ethnic groups, cultures, religions, etc. so they can learn that people are just people.

Sometimes it is rational to be afraid of certain people in certain situations. But I think much of the rampant fear and anxiety in our society is misplaced. In some cases, it is detrimental to our children. And when we make decisions based on misplaced fear, we are unlikely to choose wisely.

 

Just watch this while I...

More and more often when I walk into an exam room I find a child or children watching something on a phone or tablet. It is not unusual for them to be completely oblivious to what is going on around them and to get upset when asked to put it away. Sometimes children almost look like they are in a trance as they stare at a device. This makes me wonder about what effect these devices may be having on children’s development and behavior.

The evidence suggests that children younger than two generally do not learn from watching something on a screen because they are developmentally unable to transfer what is happening on the screen into their three dimensional reality. Children aged 3-5 may benefit from limited use of well-designed TV shows such as Sesame Street and this effect is enhanced if the child and parent watch together and discuss what they are watching. However, many shows and apps which claim to be educational have not been developed in a way which is supported by research and what is known about child development.

Skills which are important for later school success such as persistence, impulse control, emotional regulation, and creative thinking are learned best through unstructured and social play and interactions between a child and parent. So it is much better to get down on the floor and build something with your child out of blocks than watch a video about building something.

Increased use of digital media increases the risk of obesity and the use of media in the evening, especially in a child’s bedroom, decreases the amount of sleep obtained. The data suggests that excessive watching of television in early childhood can lead to delays in a child’s cognitive, language and emotional development. The effects are worse for younger children, more hours watched, and watching things other than PBS (an interesting finding).

When parents spend a lot of time on their phones or watching TV, this decreases the amount of interaction they have with their children which also can have adverse effects on the child.

As tempting as it can be to let the TV, phone, or tablet keep your child occupied, remember that they need to learn to live in the real world, not a virtual world. So play with them, talk to them, and turn them loose to play and explore on their own (in a safe environment). This will help them develop the skills they need in the real world.

 

Reference: https://pediatrics.aappublications.org/content/138/5/e20162591