Peanut butter and Bamba snacks

This is a picture of my daughter when she was seven months old. I buckled her into her highchair with a pile of puffs in front of her and served my 3 year old a peanut butter sandwich.  Then I turned my back.  It was just enough time for my baby to grab the table cloth, pull her brother’s plate across the table, and get her hands and mouth on a piece of sticky, gooey, peanut butter sandwich. She was quite pleased with herself as you can see. I posted the picture to my facebook page with the comment, “What would the AAP say?” I was actually referring to the act of leaving her unattended long enough to get her hands on a food that was a little too advanced for her and posed a choking risk. However, the comments that my friends left centered on the risks and benefits of early peanut exposure and allergies.

The literature and the AAP recommendations have gone back and forth on early exposure of infants to allergenic foods. When I was in medical school, we recommended avoidance of foods like peanuts, tree nuts and eggs. When I was in residency, the AAP formally rescinded this recommendation citing too little evidence to support it. At this point, small observational studies started to appear showing decreased rates of severe allergy with early exposure to allergenic foods but none of them were strong enough to provide a clear answer. As a result, different pediatricians were giving different advice.

Last week the New England Journal of Medicine published one of the largest studies looking at the effects of early exposure to peanuts on the development of peanut allergy. 600 babies between the ages of 4 and 11 months were enrolled in the study.  All of the kids who participated in the study had either severe eczema (a skin condition associated with food allergy) or confirmed egg allergy or both, indicating a predilection for food allergies in these individuals. A small group of participants had mild hypersensitivity to peanuts at the beginning of the study. The babies were randomly assigned either to avoid peanuts entirely until they were five years old or to receive peanut products in their diets regularly until they were five years old. After five years, every child in the study was fed peanut butter and monitored for signs of allergic reaction. The results? The kids who were exposed to peanuts for the first five years of life had significantly lower rates of peanut allergy than the kids who avoided peanuts completely. This was also true for the kids who showed mild hypersensitivity to peanuts at the beginning of the study.

Like any good study, this paper has people asking a lot of questions. What does this mean for babies who are at high risk for peanut allergy? What does it mean for kids without eczema or food allergies? How in the world to you expose babies to peanut products that are not choking hazards?

This article has had a huge impact on the discussion of when to introduce peanuts but it is by no means the last word on the subject. The study only included kids at high risk for peanut allergy so it is difficult to say with certainty if kids at low risk would respond in a similar pattern. Kids with mild reaction to peanuts at the beginning of the study were included, but those with a severe reaction to peanuts did not participate. Moreover, the study only looked at peanut exposure and peanut allergy. It did not evaluate other highly allergenic foods like seafood, tree nuts and wheat. And while the study has good data, early introduction did not work for everyone. Nine of the kids assigned to the peanut eating group withdrew from the study because they began to develop allergy symptoms.

For kids with a history of food allergies, eczema or a concerning family history, decisions about allergenic food introduction need to be made in conjunction with a physician who knows them well.  In my family, we do not have a significant history of food allergies. I introduced peanut products to my two older children before they were a year old. After reading this study, I will still plan to introduce peanut products to my youngest before she turns one, perhaps with a little more confidence.

And how do you introduce peanuts to babies? The study used Bamba snacks, which are apparently quite popular in Israel. They are corn puffs that are coated in peanut butter and dried. Out of curiosity, I ordered some. They are crunchy and taste like peanut butter. For the purposes of the study, the snacks were softened into a paste for babies who could not tolerate the crunchy texture. I thought my youngest might get to try Bamba snacks in a month or two but with the way my big kids are scarfing them down, they may not give her a chance.

*Disclaimer: The people who make Bamba snacks do not know who I am. I am not endorsing their product and I am not getting paid to tell you that my kids think their snacks taste good.

Thoughts on the HPV vaccine

A friend of mine recently asked me about the safety of the Human Papilloma Virus (HPV) vaccine. She had heard some scary stories about the vaccine and did not want to subject her children to something that could be dangerous. As a mom, I completely understand the desire to protect your children and make the best decisions for their health and safety. This is why we use car seats, put our babies to sleep on their backs and fuss about eating enough vegetables. This is also why I vaccinate.

There is a lot of misinformation about vaccines in general and Gardasil especially. Just last week the Toronto Star – the biggest newspaper in Canada – published an “investigation” about side effects rumored to be associated with Gardasil. For this article, the author failed to interview anyone in the medical community or cite any of the studies formally evaluating the safety of the vaccine. The article has since been retracted and while it was embarrassing for the newspaper, I think it is also a reflection of how pervasive vaccine rumors are in our society.

The HPV vaccine (available in the US as Gardasil or Cervarix) has a lot of the same side effects as other vaccines – pain, local reaction, allergic reaction in some people, etc. Its unique side effect is syncope, or fainting. I think every pediatrician I know has seen at least one kid get the Gardasil shot and get a little light headed afterwards. This is in part because it is a painful shot. The other part of it is that teenagers faint more frequently than little kids and adults (for all kinds of reasons).

The other stories about bad things happening after receiving the vaccine are just stories with no data to support causality. There is a database called the Vaccine Adverse Event Reporting System where anything bad that could possibly be related to a vaccine is reported. Anyone can contribute. If you search the database, you will see there are three children under the age of 12 who were in car accidents some time after receiving vaccines. The vaccines probably did not cause the accidents. There are 40 reported cases of acne after receiving Gardasil. Did Gardasil cause the acne or did acne develop because the teenaged patients were already predisposed to developing acne, with or without the vaccine? The purpose of VAERS is to continue to monitor the vaccines for safety. It is good to have this system in place. It is not reasonable to do a scientific study for every story but if enough accumulate (there are over 3,000 reports of syncope after Gardasil injection) then it is reasonable to structure a formal evaluation to determine if there is a true association or just coincidence. One side effect of this effort is that it seems to give some credibility to stories that probably are not related to the vaccine.

Everything we do has risk. Gardasil does have an increased risk of fainting immediately after injection. There is no scientific evidence substantiating other scary rumors. There is good, solid evidence that it protects against the two strains of HPV that cause 70% of cervical cancer. And HPV infection is incredibly common. 50% of sexually active adults carry HPV. In 2008 there were 20 million new HPV infections in the United States. Cervical cancer is the only cancer we test for in healthy people under the age of 40. I never want my daughters or anyone I care about to have to worry about a positive pap smear. I absolutely will vaccinate my kids against HPV.

The only thing to fear is fear itself: A breakdown of vaccine ingredients

Let’s talk about vaccine ingredients. I am reading less about vaccines causing autism (we all know that theory is utter nonsense, right?) and more about vague concerns regarding the chemicals in vaccines. To begin with, we are surrounded by chemicals. Water (H2O), caffeine (C8H10N4O2), sugar (C12H22O11) are all chemicals.  But perhaps it is the unfamiliar ingredients that people find intimidating. 

Let’s tackle the ingredients in the Measles,Mumps, Rubella and Varicella (MMRV) vaccine and see what there is to fear:

sucrose, hydrolyzed gelatin, sorbitol, monosodium L-glutamate, sodium phosphate, albumin, sodium bicarbonate, potassium phosphate monobasic, potassium chloride, potassium phosphate dibasic, neomycin, bovine calf serum, chick embryo cell culture, WI-38 human diploid lung fibroblasts, MRC-5 cells.

That is 15 ingredients in one 0.5mL injection. Grab a cup of C8H10N4O2 because we are going to cover each one. The last four, bovine calf serum, chick embryo cell culture, WI-38 human diploid lung fibroblasts, and MRC-5 cells, are the ingredients used to make the attenuated live viruses used in the vaccine.  They also sound the most foreign, so I will start there.

A virus is a parasitic microorganism. It has to invade a cell and use the cell’s resources to survive and replicate. In order to make viruses for use in vaccines, scientists must first grow cells to host the virus. Bovine calf serum is used to provide nutrients to the cells. The types of cells used are named in the list of ingredients. Chick embryo cells are able to grow measles and mumps. A human cell line of fibroblasts (a fibroblast is a type of cell) called WI-38 grows rubella virus. A second human cell line called MRC-5 grows varicella.

Making these viruses attenuated, or weak, and suitable for vaccines involves gradually decreasing the temperature the cells are grown in over generations of viral replication. Normal measles virus prefers to replicate at human body temperature. With the decrease in temperature, the laboratory virus population adapts. Subsequent generations become proficient at replicating at 83 to 93 degrees Farenheit (instead of 98.6 degrees). When this weakened virus is injected into your body and subjected to normal body temperature, it is sluggish and slow and your immune system is able to kill it off before it is able to establish infection.

When the generations of attenuated virus have developed, the infected cells are put in a centrifuge. This machine rapidly spins the cells, rupturing the walls and allowing the virus to separate away from the other cell contents. The virus is then available to be placed in the vaccine. The cells and the serum that helped grow them are listed as ingredients, but in reality there is only a possibility of trace remnants present in the actual vaccine.

Neomycin is an antibiotic to keep bacteria from contaminating the vaccine. Neomycin is the same antibiotic present in Neosporin and triple antibiotic ointment. There are 5 micrograms in the vaccine injection. This is approximately 1/500th of the amount of neomycin present in the amount of neosporin that you would apply to a small cut.

The rest of the ingredients are used to maintain the pH and the stability of the virus so that it is still alive and potent enough to allow you to develop immunity when you get your shot.

Sucrose is table sugar. 20 milligrams of sugar, or 1/200^th of a teaspoon, are present in the vaccine.

Sodium bicarbonate is baking soda.

Hydrolyzed gelatin can also be found in Jello.

Sorbitol is also used as an artificial sweetener in chewing gum and Vitamin C tablets.  Your body makes sorbitol during the sugar break-down process.

Monosodium glutamate aka MSG, is an amino acid known for giving umami flavor to many Chinese dishes. It is also found in mushrooms and breast milk. There is more MSG in a fresh tomato than there is in the MMRV vaccine.

Albumin is a protein. In fact, it is the most abundant protein in your blood plasma. Every day your liver makes about 40,000 times more albumin than the amount present in the MMRV vaccine.

The rest of the ingredients: sodium, potassium, phosphate and chloride are electrolytes that your body uses every day. 

To sum up, we have three kinds of cells that are not actually present in the vaccine. Cell food, which is also not in the vaccine. An antibiotic to keep the vaccine free of bacteria. 2 ingredients that your body makes naturally. 4 ingredients that are in my kitchen cupboard right now, except in vastly greater quantities. And electrolytes that our bodies take in and use and excrete on a daily basis. I do not think these chemicals sound scary. In fact, I think the chemicals that we use to prevent people from dying of dehydration, respiratory distress and bacterial super infections (all of which can happen as a result of measles infection) are more complex and bring with them more potential for side effects than any of the chemicals found in the MMRV vaccine.

If you still find the chemicals that make up the MMRV vaccine intimidating, please leave a question in the comments below.

Kids, Germs and the Flu Vaccine

Last week I was at a public play area with my eleven month old daughter.  Most of the other kids were older and she found them fascinating.  One 22 month old knelt in front of her, excitedly calling to his mother about the baby he had discovered.  After a few moments, he suddenly leaned over and licked her face, cheek to eyebrow.  His mother swooped in with impressive speed and my daughter looked a little forlorn as her new friend was carted away.

The concepts of germs and infection are not something we are born understanding.  The germ theory of disease was not popularized until the late nineteenth century.  For the under five crowd, the entire relationship is fairly abstract.  I have recently started introducing the idea to my three year old.  Our conversations usually go something like this:

"Honey, don't put that in your mouth.  That's yucky."

"Why is it yucky?"

"Because there might be germs on it that could make you sick."

"Oh... No, I don't see any germs."

My most recent blog post featured a little girl with influenza whose mother wanted to know if it was too late for her other children to get the flu vaccine.  My dad was not impressed that I did not answer the question.  So here goes.  The short answer is yes and no.

Influenza virus is primarily spread through respiratory droplets.  These are the particles of mucous or saliva ejected when someone coughs or sneezes.  They are fairly heavy and usually do not travel more then three feet.  Influenza virus can also survive on a hard surface for up to eight hours.  People can be contagious one to two days before they start showing symptoms and are most contagious for the first three to five days of illness.

Based solely on my observations (and not data) it is my impression that small children are just as likely to use their hands and sleeves as they are to use a tissue to wipe their noses.  Their hand washing skills leave something to be desired (like soap). Siblings hug and spit and snuggle and fight.  They play with the same toys, read the same books, and color with the same markers.  Small children are known to use someone else's spoon or straw or toothbrush without a second thought.  They lick other people's faces and they do not see any germs.  In a family where one child has been contagious for over two days, there is a good chance that the other children are already infected.   

The flu vaccine takes up to two weeks to take effect. Meaning, after receiving the influenza vaccine, it takes your body about two weeks to develop the antibodies that will protect against the actual influenza virus.  If you have not gotten your flu vaccine and your body is invaded by the influenza virus, getting the vaccine at that point will not protect you from getting sick.

That being said, each flu season features multiple strains of influenza.  The influenza vaccine usually protects against 3 or 4 different kinds of influenza virus.  If you have the flu, you will develop antibodies to the strain of virus you were infected with, not the other kinds that are out there.  Getting the flu vaccine, even after you have had the flu, can protect you against the other strains of flu virus.

It is never too late to get the flu vaccine but it is most beneficial if given prior to actual infection.

Is It Too Late To Get the Flu Shot?

February of my intern year in residency I was assigned to the Emergency Department.  The season of respiratory illnesses was in full swing.  Before each shift, I would wade through a packed waiting room.  The air in the ER was buzzing, the rooms were full, and a rack of charts belonging to patients yet to be seen greeted me.  Influenza, respiratory syncytial virus and flu-like illness were diagnoses I made daily.

On a bed in the hallway, a five year old girl sat with her mother.  She had a fever, a runny nose and was generally feeling miserable.  I ran through the usual history taking, narrowing the diagnosis and checking for red flags.  “Did she get her flu shot this year?”  I asked. 

“Oh, we never get a flu shot,” the mother stated, proudly.

“We recommend that all kids get one every year,” the words came out automatically at this point in the month.  I felt like a recording.  “It is the best way to prevent the flu.”  She did not respond so I finished the history and examined the child.  She had no signs of a bacterial infection and was well hydrated.  I explained that it was most likely a virus and that I recommended checking for the flu.  She had been ill for less than 48 hours so treatment with antiviral medication was a possibility.

The test was positive for influenza A.

I wrote a prescription for tamiflu and explained that antivirals are different than antibiotics.  With antibiotics for an ear infection of strep pharyngitis, you expect to be feeling significantly better in 1 to 2 days.  The antivirals just helped make influenza a little less severe, a little shorter in duration.  “Also,” I told her, “Recent reports have indicated that this year’s strain of influenza A do not seem all that susceptible to tamiflu.  The medicine may only help a little bit.”

“Is she contagious?”  

“Well, yes,” I explained.  “The flu is very contagious.  I would keep her home from school until she has not had a fever for a full 24 hours.  Even then, she may still feel pretty crummy.  She will probably be out of school for the rest of the week.”

“Is it too late to get the flu shot?”

“I’m sorry?”  I was a little confused by the question.

“I have three other kids at home.  I don’t want them to get sick too.”

 

Video Games Might Not Be the Worst Ever

Last Sunday I listened to a talk given by Debra Lieberman, a PhD and communications researcher at University of California, Santa Barbara, whose area of interest is video games.  This is also my husband’s area of interest, but she gets paid for it.  She presented some incredible data and an opinion of video games that is not frequently championed among pediatricians.  Before I get into what she spoke about, I want to give you a little background on my traumatic perspective with regard to Nintendo.

When I was 8 years old, Santa Claus left a Nintendo Entertainment System under the Christmas tree.  My brothers were five and three.  We could not believe our good fortune.  This was a gift so amazing that none of us had even thought to ask Santa for it!  We took turns, making a rule that you could play until Mario died.  This was a mistake.  It turned out that middle brother could play for an eternity and never die.  Meanwhile, youngest brother and I were upended by shells, burned by lava, or smashed by giant flying bullets mere seconds after starting to play.  Crying, fighting, and an inordinate number of time outs ensued. Three years later, my parents sold the NES at a garage sale for $20.  My brothers and I were appalled.  (Seriously, I am writing about it 22 years later.)  How could they let this priceless source of joy go for such a paltry sum?  For the next decade, video games were banned from our house completely. 

As an adult, I have a little more understanding of things from my parents’ perspective.  I told my husband years ago that I wanted to raise our children without video games.  The man who can play FIFA Soccer (the most boring game with the worst soundtrack) for hours on end, protested.  “How will our kids become great laparoscopic surgeons?”  He cited one of his favorite studies in which video game skill was found to correlate with laparoscopic surgery skill.  I pointed to the addictive nature of gaming, the incessant screen time that I witness with portable video game devices and the way that video games can encroach on more enriching activities, like creative play, reading and family time.

Enter Dr. Lieberman.  She showed pictures of parents, children, and grandparents engaged in video game play and discussed the ways in which these games can be social, intergenerational and confidence building.  We often focus on the educational aspect of games but she stressed behavior modification.  Qualities of video game play that many of us see as negatives – how one can become completely engrossed in a game, the “just one more try” phenomenon – could actually be positives.  Dr.  Lieberman did talk about the physical games that can be used for rehabilitation, physical therapy and physical activity.  But the really astounding data, to me, came from games designed to improve chronic disease management in kids.

The first video game features Bronkie, a “bronchiasaurus” who has asthma.  In addition to fighting adversaries and collecting points and exploring a prehistoric city, Bronkie must also take his daily medications, avoid asthma triggers and answer basic questions about asthma.  Skeptical?  Kids with asthma who played Bronkie on a regular basis had a 40% decrease in sick visits compared to those who did not.  Forty percent!  In 2010 there were 1.8 million emergency room visits with asthma as the primary complaint, costing the US over $50 billion.   

The second game, Packy and Marlon, follows a similar formula.  Two elephants with diabetes must fight of horrific flying rats that have invaded their camp all while taking insulin properly, eating healthy food and answering questions about diabetes.  With this game, Leiberman reported at 77% decrease in urgent and emergent visits.

Thanks to Dr. Leiberman, I now think that video games may have some redeeming properties.  There is a possibility that someday we might have them in our house.  But there will be rules!  They will be used in moderation.  With parental supervision.  And if things spiral out of control I will not hesitate to sell a game console for $20 at a garage sale.

Anne

When, at your 18 week pregnancy check-up, you are told, “I’m so sorry, but there is no heartbeat,” you have to make a lot of decisions that you never knew you would make.

How will you deliver your baby who has died? And when?  Will you have an amniocentesis?  Do you want an autopsy?  Will you want to see her after she is born?  Will you hold her?  Do you want pictures?  What will you name her?   Will you name her?

My dad called me in the days after the appointment and before the delivery. 

You are still in shock.  Grief has not even set in.  Real grief takes a long time.  What is her name?

We haven’t talked about it.

You have to name her.

My dad knows me and he knows grief.  My brother Mike died at 2 months old.  Deep down, I knew I wanted to name her but I was scared.

When my husband and I had our first child, our son, we spent nine months mulling over names.  We laughed and argued and pondered and teased.  His name was finally settled after he was born.  With our rainbow*, the name selection was a little more serious but just as thoughtful.  We had two names picked before the first trimester was over. 

In contrast, Anne’s name was selected on the interstate as we were on our way to the second appointment with the specialist.  We had just established that we strongly disagreed on method of delivery.  I struggled to broach the subject.  The clock was ticking.  Decisions had to be made.  We had not talked about names at all this pregnancy.

I want to name her.

I don’t.

Silence.  Was it worth it?  All of this conflict when we really needed each other?  In four years of marriage our disagreements had never felt so heavy.

What names have you thought about?

I threw out a couple.  He hated them.

What about Anne?

I love Anne.  Let’s name her Anne.

Anne is my middle name.   Whenever I fill out a form that asks for my middle name now, I think of her.  My name tags, drivers license, and lab coat all bear the letter A.  For Anne.  Anne’s mom.  It makes me happy every time.

On the Still Standing Magazine website, there was recently an article talking about the meaning of the author’s daughter’s name.  With all of the research that went into the names of my other two children, I never thought to look into the meaning of Anne.  I finally did.

Favor.  Grace.  God has favored me.

That she is and that he has.

This grief journey has involved a lot of darkness and tears but there are little joys and blessings along the way as well.  I love Anne.

*Rainbow is a term in the loss community that refers to a child born after a son or daughter who died.  Our Rainbow was born healthy and happy in December 2012.

Pregnancy and Infant Loss Awareness Month

October is Pregnancy and Infant Loss Awareness month.  This is an issue that is dear to my heart.  On January 6, 2012 my daughter Anne was born still.

There are two things that I hope more people can be aware of:

1. That even in 2013 miscarriage and still birth are not uncommon.  1 in 4 women will experience this kind of loss.
2. That this is not something to be brushed aside.  For many, no matter when the loss occurs, this is a son or daughter who is treasured and deeply loved.  The loss is devastating and there is a grief that must be observed.

From awareness, I hope to see the following changes:

1. That the families who experience this kind of loss are better supported.  We were blessed to have a strong support system.  Prior to my own experience, I did not know how to support my friends who suffered similar losses. I wish I could have been a better friend. I do not believe that I am alone in wanting to support those I care about in difficult times.
2. That through awareness there is more support for research.  We had an autopsy, a chromosome analysis and spoke with multiple experts.  To this day we do not know why our daughter died.  Sadly, this is the case for many families.  It is my great hope that there will be more research in this field.

Last year, I participated in the CarlyMarie Project Heal 31 day photo challenge in honor of my daughter.  It was simply amazing.  The process itself was therapeutic.  There were aspects of my own grief that I was able to face and work through.  I shared the process on my Facebook page and was able to connect with a number of amazing friends who had traveled similar paths.  Moreover, 2,000 other people from around the world participated.  Seeing so many stories of love was absolutely incredible.

Project Heal is sponsoring the photo challenge again this year. I will be participating in a few days.  For multiple reasons, I have chosen not to do all 31.  Keep an eye on my blog for updates this month.  For truly beautiful photography and an uplifting perspective on grief, visit CarlyMarie Project Heal.

Day 1 Sunrise

Parenting Expert

I went to bed at 8:30 last night.  I know.  Foolish.  That is how I found myself awake at 2 am, reading the Twitter profiles of people I have never met.  Do you know how many parenting experts there are out there?  Many.  More than I would expect.  Go search “parenting expert” on Twitter and then come back and finish reading this.

It’s not that I don't think it’s possible to be a parenting expert.  I am just astounded that so many individuals have achieved the status.  And here I am, with my doctorate and my pediatric training and my two kids and my kindle full of parenting books and I am definitely not an expert. 

Example 1:

I have spent the past two months trying to get my three-year-old to stay in his bed at bedtime.  Instead he spends two hours needing one more hug and one more drink and one more potty run and one more stuffed animal to cuddle and one more standing in the doorway of the living room looking lost.  Our pediatrician recommended a sticker chart with prizes.  I will admit I am skeptical.  The only sticker chart I remember from childhood was the reading chart in fourth grade.  And I did not care about the stickers or prizes.  I just cared about reading more than Jenny, who lived two blocks away and routinely out-read me.  But I am desperate for a solution so I will try it.  I wonder if Jenny has read more parenting books than I have.

Example 2:

My nine-month-old has taken to shrieking as her preferred form of communication.  Especially when there is food involved.  The three-year-old thinks it is hilarious and copies her.  She thinks he is amazing and echoes back.  And now it is something like a shriek conversation.  They are screaming in unison with every bit of air that can fit in their lungs.  Meanwhile, I use my calm, stern Mom Voice and say “No shrieking,” “No shrieking,” “No shr-,” “Do you need to leave?” “Stop.” “No shrieking.”  Before you know it, I am screaming, “No screaming at the dinner table!” at the dinner table.  It works but I cannot imagine that I am modeling the right behavior.

If you read Malcolm Gladwell’s Outliers, you will recall that it takes 10,000 hours to become an expert at a given activity.  There are 8,765 hours in a year.  If one has a kid who is literally “up all night” for the first year of life, that person could become an expert in about a year and a half.  Although, I might wait and see how he or she does with kid #2’s sleep habits before I listen to any advice.  Alternatively, Gladwell says, it can take ten years to become an expert.  So maybe any parent of a ten-year-old is an expert?  In just the past month, I have had the mother of a nine-year-old and the grandmother of an 11-year-old request prescriptions for prn sedatives for their children.  My gut reaction is that there may be exceptions to that rule. 

There is a writer named Eric Barker, who blogs here, and points out that these 10,000 hours or ten years leading to expertise must involve actual dedicated practice.  In fact, some studies suggest that after ten years some experts may see their skills worsen.  Experts need “countless drills” to improve mastery.  I am not exactly sure what parenting drills would look like.  As a physician, I have practiced suturing on pig feet bought at the grocery store.  I have rehearsed physician-patient interaction with paid actors.  I have resuscitated plastic mannequins time and time again.  I wonder what a third-party would think of my Mom Voice.  A plastic mannequin would certainly prove even more steadfast than my three year old in response to my verbal commands, although the "picking up and placing in bed" strategy would probably be very effective.

I guess seven years from now I will be an expert, too.  I will either be very good or even worse than I am now.  Just in time to start parenting teenagers.  Either way, I will be sure to add Parenting Expert to my Twitter profile.

Spotting measles

There is a sort of game I like to play at work.  Based only on what the triage nurse writes as the chief complaint, I try to guess the final diagnosis. The game is especially fun when the chief complaint is something like "Eats shirts,” but that is a story for another time.  A few weeks ago, a little girl came into the Emergency Department.  The triage note read, "Fever, drooling, mouth sores."  I narrowed my guess to two common viral illnesses.  A good history and exam and the diagnosis would be in the bag. 

My resident saw the patient first.  He came out of the room and described to me a previously healthy, unvaccinated girl with fever, drooling and mouth sores.  Suddenly everything changed. Sure, this child was still most likely to have a common virus, but now I had to consider a list of diseases that I almost never seriously entertain.  Diseases I have never seen because we live in the post vaccine era.

We live in the post vaccine era.  Isn't that amazing?  Vaccines have so changed the landscape of modern medicine that they have earned their own era.  We often talk about how vaccines mean that children are protected against death and morbidity from diseases like tetanus, polio and diphtheria.  While this is true, vaccines have also revolutionized the way that doctors manage infection.  Because of vaccines, I can view fever as nothing more than the normal response of a healthy immune system.  I can confidently tell more parents after a simple, painless examination that their child has an illness he can fight off on his own.  No irradiating him with x-rays or cat scans, no painful blood draws, no tubes shoved into orifices.  It is a great time to be a pediatrician.

As a physician who has only ever known medicine in the post vaccine era, there are some drawbacks.  The most valuable teaching in medical school and residency came from patients and the experienced physicians instructing me.  This is what pneumonia sounds like.  This is what a surgical abdomen feels like.  This is what leukemia looks like.  This.  Right here.  Don't forget this.  Even the best textbook pales in comparison to the real thing.  My knowledge of these vaccine-preventable infections is exclusively from textbooks.

So on the night that I see this little girl with fever and drooling and oral lesions, things go a little differently than usual.  I still think she has a common virus.  But could it be epiglottitis?  I don't know; I've never seen it.  It is probably best to get an x-ray to be on the safe side.  And maybe some labs.  And if we are drawing blood, we better try for an IV.  Could it be measles?  I don't know; I've never seen it.  My resident and I pore over pictures of Koplik's spots.  The textbook says they should have a blue or gray hue, and I don't think that hers do.  It is hard to be confident.  The ramifications of being wrong play out in the back of my mind.

I discharge her.  In my note, I document no cough, no coryza, no conjunctivitis, no rash... no evidence of measles.  Because, according to articles like this US Measles Cases in 2013 May Be Worst in 17 Years, that is a real concern and there may come a day when I no longer have the privilege of saying, "I've never seen that." 

The Patient Needs A Doctor

July always makes me think of my intern year. Every July, my Facebook feed is peppered with commentary on the newness of the interns, the naivete of the medical students, and the challenges of advancement to senior roles.

I look back on my intern year fondly. It was hard. And exhausting. But there is such an incredible feeling of satisfaction not only in accomplishing something that is difficult but also in knowing that you are improving. My husband and I were newlyweds. He was a surgical intern and we supported each other up the learning curve of hospital life. Post-call, over dinners of take-out and three dollar wine, we shared our experiences.

One evening my husband told me about rounding with his attending the morning after an especially busy call night. While making their way down the hall, seeing each newly admitted patient, the attending surgeon paused at the room of a patient who was not on the team list. The man looked terrible -- roughly 60 years old, jaundiced and somnolent. As my husband frantically shuffled through notes and lists wondering how he had forgotten an admission, the attending introduced himself and did a brief exam. Upon exiting the patient's room, he asked the team to add the patient to the list. My husband was certain that he had not forgotten any of the night's admissions and consults. "Sir," he asked, confused. "Is this our patient? I don't remember admitting him."

"This man needs a doctor," the attending responded simply and continued with rounds.**

That night, we laughed at the statement and attributed it to the quirkiness of a dear mentor. The year progressed and the phrase stuck with us. It came in handy as we retold the frustrations and challenges of new services, perceived injustices, and work left undone by other services or other residents. "Oh!" the listener would interject lightheartedly. "You're saying the patient needed a doctor!"

Later in our training, our use of the phrase reflected a more seasoned perspective. While supervising admissions, teaching and managing the very sick, we would also find ourselves caring for people who might traditionally be admitted to different services or were, perhaps, admitted for conservative reasons. As interns we might have complained but as seniors we would merely shrug and say, "I guess the patient needed a doctor." (Of note, this is easier when you are not the one doing the grunt work of an intern.)

I work in the pediatric emergency department now. There is a lot of discussion both during my shifts and in the global medical community about misuse of emergency services by patients. I hear the comments regularly.

"My parents would never have brought me to the ER for that."
"Didn't they call their PCP? It's the middle of the day."
"It's 2 am. This couldn't wait until the morning?"

On Twitter, other blogs and in medical journals, there is discussion as to how we can encourage proper home triage. I used to ask the patients themselves but have stopped unless it seems useful to my clinical decision making. The answers are always the same. The pediatrician's schedule was full. The parents could not take time off from work. They did not have a car. It seemed like it was getting worse. Someone was hurting. Someone was worried.

In all of these situations, whether expressed out of frustration or resignation, the statement "This patient needs a doctor" repaints the picture. What was once an injustice becomes a call to duty. Sometimes our job is not fair. Politics, fatigue, electronic medical records, work hours and someone else's bad day can all compete to cloud our outlook. While many of these things do need improvement, it helps to remember that at the bottom of this, there is a patient who needs a doctor.


**For my mom and others not in the medical field, a patient does not get admitted to the hospital without a specific doctor agreeing to care for him or her. The patient in this story was admitted to another hospital service but the surgeon identified him as potentially in need of surgical care.