Sleep is for the birds and (fingers crossed) teenagers

Have you ever had one of those nights where you were woken up so many times that, at one point of wakefulness, you could not believe it was still nighttime?  And despite your fatigue, you almost did not want to go back to sleep because you knew that another premature awakening was waiting for you?  That was my night last night.

My daughter is an amazing sleeper.  Since six weeks of age, she has slept 7 to 9 hours almost every night.  I credit my pediatrician and her excellent coaching (Of me, not the kid).  Last night was one of the exceptions.  At 1 am, she was upset about being awake but later decided it was fantastic.  Normally, I love the sounds of a cooing baby practicing baby aerobics.  At two in the morning, it is actually quite difficult to sleep when the person in the bassinet next to you is having a raucous, one girl party.  Apparently, violating city noise ordinances is the natural next step after breaking out of your swaddle and spitting out your binkie.

When my son started sleeping through the night around 13 months, my husband and I were thrilled.  After one solid night of sleep, we said to each other, "I feel amazing!  Let's have more kids!"  We did not realize that a one year old sleeping all night was a short-lived accomplishment.  Potty training and nightmares lay just around the corner.

It is unfair that these two developmental hurdles overlap.  It gives my son two reasons to be up at night and two reasons to crawl into our bed.  It has, on more than one occasion, left me thinking how ineffective a mattress protector is when the person it was purchased for is in my bed.  Also, do they sell waterproof pajamas for moms? 

While the urine is inconvenient, the nightmares break my heart.  At 3am, my son arrived in our room demanding assistance with wet pjs.  We groaned.  At 4am, he cried out in his sleep, "I'm afraid!"  My heart ached.  It was nice to be able to hug him immediately but how dare scary lions and bad guys enter my son's dreams?  

We reassure him that he is always safe with us.  We try to empower him by encouraging him to put bad guys in time-out for inappropriate behavior.  We cheer for him when his play involves chasing scary lions from our house.  We try to maintain some control by limiting what he is exposed to on tv. As much as we do to protect him, it is hard to know that we cannot protect him from fear and his own imagination.  Harder still is realizing that someday he will be independent in a world with real bad guys. I think we are handling it ok.  This morning he picked up an imaginary creature and handed it to me, "Here, Mommy.  It's a nice, little, baby bad guy. Awwww."

If bladders can be controlled and imaginary bad guys can be tamed, maybe small humans can learn to sleep through the night every night. Until then, I will be thankful for strong coffee and good concealer.

Fact: I have never checked my kids’ temperature

It is true.  Never.  Once I tried.  My son was 18 months old and had Hand Foot and Mouth Virus.  He had been out of school (and I had been home from work) for a solid 2.5 days due to fever.  I was trying to convince myself that he really did not have a fever and I could go back to work.  I tried to use an ear thermometer.  For the record, I own a digital rectal thermometer but I could not find it at the time.  I do not know what I was thinking.  Everyone knows that 18 month olds hate having medical instruments in their ears and ear thermometers are notoriously inaccurate.   It was a fruitless endeavor.  My usually joyful toddler squirmed to the floor in tears before the required five seconds were up and I realized that, fever or no fever, a kid this miserable did not belong at school.

When I was a medical student, I used to document "tactile temperature" with a sense of serious doubt.  Then one of my attendings drew my attention to an article published in Pediatric Emergency Care in 1996.  The article showed that moms are pretty great at telling if their kids were febrile or not with about 80% accuracy.  When you compare that with ear thermometers, forehead strips and other devices, 80% is pretty respectable.  Now that I am a parent, I do not need a study to tell me that moms know what they are talking about.  It is painfully obvious when my son has a fever.  My house turns into Meltdown City as he loses all abilities to cope with frustration.  He feels incredibly hot.  This is usually topped off with a running nose or some other lovely sign that his body has been turned into a virus breeding ground.  (I use my son as the example because he has had many, many fevers.  Thankfully, my daughter has only felt warm once and this was accompanied by a runny nose and happy baby smiles.)

I see a lot of kids whose parents have kept a detailed record of the ups and downs of the thermometer readings.  Some of these parents are checking temperatures every two hours.  To begin with, I am super impressed by their dedication and ability to get the readings.  You see how well my one and only attempt went.  How do you get a kid who feels terrible to hold still that long?  That many times in a day?  It cannot not be easy.  To be completely honest, though, as a pediatrician, I do not care about fevers in that detail.  For the most part, I do not care about the numbers at all.  If you are his primary caregiver and you tell me he had a fever, I believe you.   I actually kind of prefer the tactile temperature.  Anecdotally, actual numbers can make things more confusing.  I spend quite a bit of time sorting out and discussing home readings of 108, 99.7, 19 and Lo.  The findings of a study done at Stanford University indicate that most people (as in, every person surveyed) have a hard time remembering what temperature readings dictate a true fever.   Hands, on the other hand, seem to have a pretty great memory for the difference between warm and hot.

I have never checked my kids’ temperature because the actual number does not make much of a difference to me.  I know he (or she) is sick.  I know he has a fever.  And on day one, two and three of illness, I know that it is most likely a virus.  So if he does the other things he is supposed to do - breathe, drink, pee and throw impressive fits when I approach him with the blue nasal suction bulb - the height of his fever is not going to change much of what his pediatrician or I will do for him. 

Now, a caveat - there is always a caveat - neither of my kids has ever been lethargic.  Neither of them has ever had a fever under the age of 3 months.  If I was ever faced with either of these situations, I do not know that I would waste time rummaging through the linen closet looking for my digital thermometer.  I think I would be bee-lining it to the nearest medical center.  The only situation that I can imagine myself wanting to know a real number at home would be if I really thought my child had a fever but could not figure out why.  As in, no runny nose, cough, upset tummy, etc.  But even in that case, I would probably be seeking out an objective medical opinion fairly soon afterwards.  A temperature reading greater than 100.4 F would only speed my decision along.

References:

Dodd, SR, et al.  “In a systematic review, infrared ear thermometry for fever diagnosis in children finds poor sensitivity.”  Journal of Clinical Epidemiology. 2006 Apr;59(4):354-7. Epub 2006 Feb 20.

Graneto JW and Soglin DF.  “Maternal screening of childhood fever by palpation.”  Pediatric Emergency Care. 1996 Jun;12(3):183-4.

Wallenstein MB, et al.  “Fever Literacy and Fever Phobia.”  Clinical Pediatrics. 2013 Mar;52(3):254-9. Epub 2013 Jan 24.

Awesome product & follow-up on kid-friendly bathroom facilities

One of my former co-chiefs just saw this in the Atlanta airport. It is called a Step 'n Wash.  It folds out and serves as a step to help kids reach sinks and wash their hands. I would also like to draw your attention to the motion activated faucet and soap dispenser in the picture. I have yet to embark on Air Travel with Toddler but I would be so happy to help my son wash his hands here!

The company's website is http://www.stepnwash.com and they list a bunch of their customers online. These include children's hospitals, amusement parks and other places that are frequented by families with small children, like Costco.

This clever innovation makes me so happy!

Kid-friendly should not stop at the bathrooms

As a completely biased mother of a potty-training toddler, I am willing to argue that it should start at the bathrooms. 

I had the opportunity to visit a big, newly constructed children's hospital recently. I love children’s hospitals, especially the more recently built. Everything is designed with kids in mind. The entrance is colorful and light-filled. The rooms have accommodations for parents, home work and play. There are novel design features like a giant Rube-Goldberg machine, a movie screen that can be seen from every inpatient room or a hallway that feels like a space-themed maze.  In this particular children’s hospital, the details were just as complete and amusing. 

During my visit, I stepped into the bathroom where I got a visual of what I look like when I visit public bathrooms with my son. A mother stood at the sink with a huge diaper bag over her shoulder and a squirming toddler under her arm. With her free hand she was attempting to apply soap and water to the child's hands while at the same time trying to keep the cuffs of his winter coat dry.  It was not going well. Toddlers and public restrooms are not a good combination. 

Upon entering a public restroom with my son, the first words out of my mouth are, "Don't touch anything."   I see germs everywhere, especially in public restrooms. Maybe it is the amount of gastroenteritis I see at work; maybe I am just a little obsessive. Either way, I impulse-buy hand sanitizer every time I see it in the check-out aisle. 

My son generally responds to my command by double palming the commode. It has been a while since I came into contact with a toilet that came up to my ribs, but I am starting to wonder if that is just the body's natural reaction when faced with a potty of such astounding height.  On a good day, the bathroom exploring ends there. On a bad day, he grabs the handrail, crawls on the floor and tries to pick up the cleaner contraption under the rim. Oh, the germs…

As we wrap up our potty trip with him under my arm, trying to wash four hands without injury or recontamination, I am frequently uncertain how much, if any, soap comes into contact with his fingers.  Hand sanitizer usually follows for good measure but it does not kill all fecal-orally transmitted organisms. 

Contrast this with our last trip to Target and a visit the family restroom.  In addition to the traditional bathroom accommodations, there was a sink and a potty that came up to my knees. They were perfect for a potty trainer. Hand washing was not a breeze (he is only two and a half) but it was significantly better.  It was the easiest public bathroom trip ever. 

I do not think every bathroom should have toddler facilities.  But if you are trying to be kid friendly, little sinks, little potties and automatic soap, water and paper towel dispensers are details that should not be overlooked.  At the very least, maybe a little step stool to assist the under four feet crowd in accessing the facilities.  This is especially true if you are, say, maybe, a children's hospital and you are trying to promote effective hand washing. Providing user-friendly equipment is key. 

Also, Target, keep up the good work. You can count on me to keep shopping.  Keep your check-out aisles stocked.  I will be picking up a bottle of hand sanitizer with every trip. 

I am a doctor, I work part time and I am not sorry

This piece was posted on KevinMD.com on 3/20/2013: I'm a part time physician, and I'm not sorry

This is my reaction to "Doctors who work part time: I'm sorry that I'm ruining medicine."

http://www.kevinmd.com/blog/2013/03/doctors-work-part-time-ruining-medicine.html

I began the medical school application process 10 years ago.  I was 23, single and most of my role models worked full time.  I had no idea that a part-time medical career lay in my future.  Quite a bit has changed since the days of hoping and praying and crossing my fingers for a medical school acceptance letter.   In the past 10 years I have, at varying times, declared the following:

1. I will join a private practice in primary care immediately after residency and never move (as a former Navy brat, this would be quite the luxury).
2. I will not marry a doctor.
3. I will definitely not marry a surgeon.
4. I will not have kids until after residency.
5. Sparing you the details, I had an exact plan for when I would deliver all of my children such that they were born after residency and before I turned 36.
6. I will definitely not ever work a job that requires me to be awake at night on a regular basis.
7. Specifically, and most certainly, I will never go into Emergency Medicine.

 The reality? I married a surgeon, had a baby half way through residency, lost a child to stillbirth during my chief year and fell pregnant with my third child 2 months later.   I fell in love with Pediatric Emergency Medicine and, for many of the above reasons, I am awake at night on a regular basis.

So, yeah, I work part-time.  It is awesome and I am a great doctor to my patients.  I think the fact that my schedule is so symbiotic with my family life enhances my abilities as a physician.

In the big picture, when home life is good, it is easier to focus on others.

In the details, I had time to grieve the loss of my second child (something I had not allowed myself to adequately do during the demands of my chief year) and figure out how to navigate pregnancy after loss.

My schedule is flexible enough that I can trade shifts and cover for coworkers without difficulty.  I love being able to do this without sweating whether I am sacrificing time with my kids.

Finally (and perhaps most importantly) it helps with my patient interactions.  My son spent a year in full time day care.  I know the pain and stress of the incessant viral infections of the first year of day care.  After a particularly bad week home with the kids last month, I picked up and drove three hours to my parents' house.  Literally.  I left dishes in the sink, wet clothes in the washer and 2T Mickey Mouse underpants on the floor.  Being at home with kids is no cakewalk.  If a rough week of stay-at-home parenting is capped off with a trip to see me in the Emergency Department, I can totally empathize.

Some might argue that these benefits are unique to the world of pediatrics but I disagree.  We all care for parents and spouses.  We counsel people who are trying to lose weight, minimize stress and make ends meet.  Life is about balance.  Finding balance is a constant process and it is not easy.  By recognizing how we have found it (or not) we can better empathize with our patients and their families.

I understand that if there are x number of individuals accepted to a medical school, one might expect y number of hours of doctoring out of them when they graduate.  But these are people, not widgets.  People change.  As my high school English teacher used to say, "The exigencies of life impinge."  Moreover, the product of our labor is difficult to quantify.  Sure, my hospital is aware of how many people I see in a day and how many procedures I do, but the people I treat remember my ability to listen, to engage, and to understand.    I can tell you this:  My best patient care is delivered in 9 eight hour shifts a month.  Five years ago I could not have predicted this.  Five years from now, it may be different.