On Being a Father and a Doctor

Sometimes things that seem routine to medical professionals can cause a lot of anxiety for patients and their families.

Last summer one of our teenaged children had his wisdom teeth removed. From a medical standpoint, everything went smoothly and there were no complications. However, being the one who cared for him the rest of the day reminded me why parents worry. He was so helpless, drifting in and out of sleep and hallucinating about elephants on the drive home. I had this big surge of a paternal protection instinct. And when his local anesthesia took longer to wear off than I expected, I started imagining permanent nerve damage. From a medical perspective, he did great. But from a parental perspective, it was an anxious day.

I have also had the experience of almost fainting while watching a routine procedure on a family member. Something that I had seen many times had a completely different effect on me when it was being done to a loved one, much to the amusement of the nurses who were there and knew me professionally.

Our family has also dealt with a genetic, metabolic disorder. It is extra work, expensive, and a pain to have to deal with. But it has not caused any real medical problems and the treatment is a huge medical success story. But as a parent, one worries about all of the “what ifs.”

I even had some of that protective feeling when I recently took one of our beagles in for a procedure. Even though he often drives me crazy barking at night, I was surprised to find myself worrying about him.

Sometimes the best thing I can do for a patient and her family is remind myself what it is like to be on the patient side, what it is like to be a parent with a sick child who you love more than anything.

Lyme Disease

I enjoy outdoor activities and pulled the first tick of 2016 off of myself last week so I guess it is that time of year again. Removing ticks from myself is a normal part of my warm weather routine.

Lyme disease is a not uncommon concern leading to visits with us. It is an infection caused by the bacteria Borrelia burgdorferi acquired through the bite of a deer tick. Although it has increased in our area in recent years, it is still relatively uncommon. While it is important to be aware of Lyme disease and evaluate and treat appropriately, it is also important to remember that the vast majority of tick bites do not result in any type of illness and that there are many other illnesses that remain far more common than Lyme disease. Even in areas with high rates of Lyme disease, the chance of catching it from a confirmed deer tick bite is 1-3%. So a child’s illness is much more likely to be from something more mundane.

Lyme disease most often presents as a characteristic target-like rash. Less often it can present as a single, swollen, painful joint (usually a knee), or a facial droop, or some combination of these symptoms. In cases when the presentation is clear, we will usually treat without doing any further testing. If the diagnosis is not clear, we will often do a blood test for Lyme disease. When we order the test, the state of Virginia requires us to inform patients that the test is not always accurate. Of course, no test we do gives a correct answer 100% of the time and diagnosing an illness is always based on a combination of history, physical exam findings, and other studies if indicated. As we have all been taught, it is important to treat the patient not the lab result.

Lyme disease is generally easily-treated with a course of oral antibiotics. If it is at a more advanced stage, occasionally a course of IV antibiotics is needed.

So be aware of the signs of Lyme disease and check yourself and your children for ticks after outdoor activities. Get checked if you develop any of the potential signs of Lyme disease. But don’t let concern of Lyme disease prevent you from getting outside and being active!

 

The Benefits of Exercise (and a caution)

Around the time our daughter was born, we had blood pressure screening one day at church and mine was surprisingly high. I had been very fit as a youngster and played a lot of sports. But in my mid 30s, I had gained weight and was not exercising. I was working too much, sleeping too little, and generally not being very healthy. The juxtaposition of the birth of our second child and the high blood pressure reading made me consider my responsibilities and resolve to do something about it. So I took up running.

It has been said that if exercise were a medication, it would be the most-prescribed drug of all because it is good for almost everything. Regular exercise decreases the risk of heart disease, high blood pressure, diabetes, some types of cancer, strokes, and arthritis. It increases bone strength, elevates mood, and improves energy levels and sleep.

So I started running, a little at first, then more. I eventually ran some 5Ks, then 10Ks, and then 10 milers. I lost weight, my blood pressure returned to normal, and I felt great. This progressed to a few half marathons and then some marathons (PR 3:16:04 for the runners out there). My training often required getting up in the wee hours of the morning to run or running with a head lamp at night. When I was on call, I would sometimes run laps around the hospital at night because I had to be able to get there within minutes if there was an emergency. In the process, I started getting more tired again, and then my leg started hurting. An MRI revealed a stress reaction in my tibia, the main bone in the lower leg.

What had started as an attempt to get healthy by exercising resulted in me exercising so much I harmed myself. My leg healed with rest and I started running again, now in smaller amounts. There is nothing wrong with running marathons, but in my particular situation, running had led to a different kind of unhealthy. I haven’t raced since that injury but try to run a few times a week. My blood pressure remains fine (110/74 earlier this week) and I think I am in pretty good shape for a guy my age (though I certainly can't keep up with my teenage children). Sometimes my exercise for the day is simply walking the mile to and from our mailbox to get the mail. Even that little bit makes me feel better. Or if I have had a stressful day, a quick five mile run is the best way to burn that stress away.

You don’t have to be an athlete or compete in things to benefit from exercise. Find something you enjoy – walking, hiking, riding bike, working in the garden, playing basketball or soccer, kayaking, chopping wood, etc. and do it regularly. Or better yet, do some combination of several different activities. You will feel better and decrease your risk of a variety of health problems.

Whatever Happened to Rotavirus?

We are in the midst of what used to be Rotavirus season. Rotavirus is a viral intestinal infection which causes fever, vomiting, and diarrhea and generally lasts 3-8 days. In some cases, it can lead to dehydration and hospitalization, particularly in infants.

In the “old days,” meaning before 2006, it was not unusual for us to have several infants with Rotavirus admitted to the hospital at the same time at this time of year. Rotavirus was part of the reason that our pediatric ward was often full in the winter, sometimes causing our patients to overflow onto the adjacent adult ward. We dealt with Rotavirus so often that the nurses on the pediatric ward could usually predict a positive test for it before we had the results based on the smell of the stool. In contrast, that same pediatric ward now rarely houses more than a couple of patients at a time, though the decrease is certainly not due only to fewer cases of Rotavirus.

The difference is that we now have an oral vaccine for Rotavirus that is given at two, four, and six months of age. Just two years after introduction of this vaccine, there was an 85% reduction in ER visits and hospitalizations due to Rotavirus nationwide.

Prior to the currently available vaccines, there was another Rotavirus vaccine on the market. It was quickly discovered that there was a small increase in cases of intussusception, a type of intestinal obstruction, in children who had received the vaccine and it was quickly withdrawn from the market.

The currently available vaccines have been watched closely for this same association and no increased risk of intussusception has been found. The successful reduction of Rotavirus infections is evidence for the efficacy of the vaccine as well as the mechanisms in place for detecting adverse reactions to immunizations.

Effects of Too Much Screen Time

Sometimes when there is a big weekend of sports on TV, I find myself watching for far too long. Not infrequently, this leads to a headache and general grumpiness. The same thing happens when I spend too much time on-line, whether I am just reading the news or watching something mindless. I do not think I am alone in this and there is plenty of evidence that TV and other screen time has deleterious effects on other people as well, including children.

Television watching in young children has been linked to an increased risk of ADHD and watching TV is associated with obesity and sleep problems in children as well. Think about what children are not doing while watching TV. Children need to be interacting with others, playing outside, solving problems while building forts with things they find, playing games, etc. Play is how children learn about the world and learn to interact with others. Some of my best childhood memories are of building dams in a pasture stream, exploring the woods, and baseball games in the back yard that lasted for hours. Debating a close call at first base and coming to a conclusion together is practicing for real life.

TV also exposes children to scenes of violence, advertisements for unhealthy foods, lots of advertisements for alcohol (especially if you like to watch sports), and sex without consequences. The amount of sex that is implied on TV comes with remarkably low incidences of sexually transmitted diseases and unwanted pregnancies. In real life, people actually do get pregnant and pick up diseases. I remember once while watching TV with one of my children I was asked during a beer commercial “Why is she out in the snow in her bathing suit?” A reasonable question for which I had no reasonable answer.

The American Academy of Pediatrics recommends no screen time for children younger than two and a maximum of 1-2 hours per day for children older than that. With the ubiquity of TVs, computers, tablets, smart phones, etc., it is easy to exceed that without even noticing.

So turn off the electronics and get kids outside playing or building a house in the living room with chairs and a blanket or just exploring the world around them. I know for myself, getting away from the TV or computer and going for a run, walking the ½ mile to get the mail from our mailbox, shooting baskets in the driveway, or even just sitting on the porch and watching and listening to birds and lizards can really improve the way I feel both mentally and physically. And it probably makes me more pleasant to be around as well.

Just Because Something Sounds True Doesn't Mean It Is

I have been thinking a lot about how easily medical misunderstandings happen and how easily misinformation can be propagated. Specifically, I have heard concerns from some patients that the commonly-used laxative, Miralax, contains antifreeze. Fortunately this is not the case. I helped take care of a child who had ingested antifreeze during my time in the Pediatric Intensive Care Unit as a resident at UVa. That is not something we would want any child to go through.

The confusion comes from the similar-sounding ingredients. The main ingredient in Miralax is polyethylene glycol and many brands of antifreeze contain ethylene glycol. It sure sounds like they are almost the same thing and would probably have the same effects, right? But they aren’t and they don’t.

Consider this. Regular table salt is sodium chloride. It tastes good and we need a certain amount of it to maintain proper electrolyte levels in our bodies. Using too much can increase blood pressure but we all use it and it is not acutely dangerous. One may then think that plain old sodium would react similarly, but it doesn’t. When placed in water, pure sodium reacts violently, bursting into flames. Obviously that would cause a very concerning reaction if it was on your French fries.

So even though the names are similar and both contain sodium, sodium chloride and sodium metal are completely different chemicals with completely different properties and effects. The same is true of polyethylene glycol and ethylene glycol.

So just because two things sound similar and it sounds true that they are the same, that is often not the case. Come to think of it, that applies to a lot more in life than just medicine and chemistry.

The Importance of Strep Tests

One of the most common reasons for patients to come see us is for a sore throat. Except in extremely unusual circumstances, the only bacterial cause of throat infections in children is strep throat. That means that strep throat is the only cause of a sore throat which will be helped by treatment with antibiotics. Furthermore, strep is less common than viruses as a cause of sore throats.

There is a quick, easy test to check for strep throat that involves swabbing the throat and testing for streptococcal antigens (essentially tiny pieces of the strep bacteria). These tests catch a very high percentage of cases of strep throat. If the strep test is negative, generally a back-up throat culture is performed to pick up the ones that sneak through unidentified.

Why is this important? Because doctors are not very good at diagnosing strep throat without the test. When I was in the first year of my pediatric residency at UVa, we had a contest to see who could best predict the results of strep tests on their patients. We wrote down our predictions prior to having the tests run and then calculated who had the highest percentage correct for the year. I was the “Golden Loop” winner for my year (named for the loop used to streak a sample on a blood agar plate for growing bacteria). Even so, I think my percentage of correct predictions was only around 70%. And after 18 years of practicing pediatrics and thousands of visits in which I have done strep tests, it is still not unusual for me to be surprised by the result of a strep test.

Some providers diagnose strep throat using the Centor criteria. These criteria were developed for adults. If a patient meets all of the criteria, their chance of having strep throat is around 50%. So if adults are treated based on these criteria alone, about half of them will receive antibiotics for a condition which they do not have. When applied to children, the predictive value of these criteria is even lower.

It is not unusual for us to see patients who were seen elsewhere for a sore throat, placed on antibiotics without a strep test, and are no better a couple days later. It is understandably frustrating for them to have a second visit for the same problem only to learn they have an illness for which the treatment they were prescribed would not be expected to be helpful.

Strep tests are quick, easy, and reliable. So the next time someone wants to treat your child’s sore throat with antibiotics without first testing for strep, request a strep test. There is a good chance it could save him from taking 10 days of antibiotics which will not help and could cause side effects. In addition, you will be doing society a favor. Overuse of antibiotics leads to antibiotic resistance and, according to one recent estimate, infections with antibiotic-resistant bacteria cost the United States $20 billion annually. The first, obvious step to combating antibiotic resistance and doing what’s best for patients, is to not use antibiotics for conditions they will not help.