Pet peeves. It is near the anniversary of my father's death. I don't get maudlin but his grumpy man persona begins to enter my psyche. As a survivor of the Great Depression and years spent in the jungles of the Pacific theatre during WW2, my dad tended to be rather judgemental. Unfortunately, I absorbed his quick to condemn tendency. So in the spirit of crotchety old men everywhere, I wish to share with you a few of my pet peeves.
Noise. There is too much noise. I love music especially jazz and classical. I enjoy opera and ethnic music of many cultures. I am referring to noise. Cell phones are great contributors to the din around us. Loud and obnoxious ring tones and conversations that are "shared" with everyone in the speaker's vicinity. If you are wearing headphones or ear buds and I can clearly hear the music, it is too loud. Concerts produce noise levels that can cause permanent hearing loss to the attendees. The human ear is a remarkable organ. It is also fragile. Excessively loud noise in short bursts, or moderately loud noise over time will cause deafness. Sotto voce, speak softly. Indoor voices please.
Tanning. As we are in the throes of prom season, I wish to add my warning to the many advocates for avoiding ultraviolet radiation exposure. Tanning booths and sun exposure have two very injurious consequences, cancer and wrinkles. UV radiation damages the DNA of skin cells and the connective tissues of the skin. Squamous cell, basal cell and melanoma are becoming more prevalent in the users of tanning salons. Looking like a prune when you are in your thirties is the price for that glowing tan in your teens.
Binging. As I have reported in a previous blog, I enjoy alcoholic beverages. What I find distressing is the imbibing of large quantities of alcohol in a short period of time. This practice is rife on college campuses and increasingly at parties of high school students. The side effects may be tragic. Drinking responsibly is difficult in the face of peer pressure. Talk to your children and set a good example in your own intake of alcohol.
Protection. Sex comes later, this is about protective equipment and practices. Wear seatbelts. No exceptions ("I was just driving to the store"). If you are on a bicycle, motorcycle, or moped, wear a helmet. Use protective eyewear. Sunglasses that block UV rays will decrease the formation of cataracts. Safety glasses should be worn when using any type of tool, when using a lawn mower, and when riding any form of open transport. Boarders on the street or on the snow should wear appropriate padding and head protection. All skiers should use helmets. Walkers and runners should be on the left side of the road facing oncoming traffic.
Driving is a complex activity. It requires hearing, vision, coordination and attention. The state should not have to pass a law banning hands on cell phone use or texting while driving. Common sense should be used to avoid distraction while piloting a 1-2 kiloton vehicle in traffic. Avoid eating, shaving, applying makeup and tailgating.
Body art. The world's oldest ER doc has several tattoos. A t-shirt is enough to cover all my tats. Using your entire body surface area as a canvas may be a detriment when one is applying for a job. There is also the risk of transmission of HIV and hepatitis B and C from contaminated needles, inks, and even ink cups at the tattoo parlor or piercing salon. I would also advice my readers, that some parts of the human anatomy should not be pierced. Infection and scarring in these areas may be problematic.
Sex. Enjoy. Protection part II. Having sex is necessary for survival of the species. Only a few other animals seem to derive as much pleasure from intercourse as humans. Sex should never be coercive. Mutually pleasurable practices between consenting people is natural and very human. Two issues must be addressed by this cranky old man. Use birth control. I have seen too many "children having children". Sexually transmitted diseases are the other unfortunate side effect of a lack of protection.
That about covers this ER doc's pet peeves. Notice that they all involve things that are enjoyable. The problem is that my aged and well developed frontal lobes are immune from youthful indiscretions. The immature frontal lobes of young people make them "deaf" to my warnings. Wisdom comes at a price. Dad would tell me that I should listen to and heed his teachings.
Saturday, May 8, 2010
Thursday, May 6, 2010
Baby,Baby
The vast majority of infants and toddlers seen in the ER have some combination of fever, cough, stuffy nose, rash, vomiting and diarrhea. When some variation of this cluster of symptoms occur in the late afternoon, evening or night, the pediatricians' offices give the same advice: "Go to the ER".
Preschool children are divided into 4 groups by age: 0-28 days, 1-3 months, 3 months to 2 years and 2-5 years. Specific diseases predominate in each group with special attention in the early groups.
In the first 4 weeks of life any fever above 100.4 F triggers an examination and tests to look for infections that are potentially life threatening. Blood, urine, cerebrospinal fluid from a lumbar puncture (spinal tap) and a chest x-ray are performed on the neonate. Antibiotics are given pending the results of cultures of these body fluids. Unfortunately the tests are painful to the infant and disturbing to the parents. Sedation may be given to the baby but the parents are left to pray and fret.
The second and third month of an infants life is also a time for concern if high fevers develop. The ER doctor has some discretion as to the extent of the fever work up. Up to age 2, a temperature of 40 degrees C or 103.8 F or above raises the suspicion of occult bacterium. This is when a source of bacteria on the skin, in the ears, mouth or throat, the lungs or in the urinary or digestive track gains access to the blood stream. Tests may include blood counts and cultures, catheterization of the bladder to obtain urine, a chest x-ray and a lumbar puncture. Sedation may be given to the child to relieve discomfort and expedite the procedures. Appropriate antibiotics are given while awaiting the culture results.
Toddlers have better developed immune systems and have received a full complement of vital immunizations. The fever work up is guided by the specific symptoms and the results of the physical exam. A recent practice in treating children with ear infection is gaining greater acceptance. A child with an inflamed ear drum and a low to moderate fever may be treated with watchful waiting. A prescription for an antibiotic is given but the parents are instructed to wait 48 hours before filling and starting to dose the child. If the symptoms of the ear infection cease, the antibiotics are not given. Studies have shown that 80% of ear infections in children are caused by viruses, not bacteria. This 48 hour waiting period may significant reduce the use of unnecessary antibiotics.
Febrile seizures are frightening to parents. The height of the fever is not predictive of which child will suffer a febrile seizure. Simple febrile seizures involve a generalized convulsion in a febrile child. The period of the convulsion should last less than 5 minutes. Only one child in five who has a febrile seizure will have a subsequent episode. Parents should be instructed in the correct dosages of acetaminophen (tylenol) and ibuprofen (motrin). The weight derived dose must be stressed. The overwhelming number of children that I see in the ER have been underdosed with antipyretics. It is also important to make the parents aware that fever is not a bad thing. An elevated body temperature occurs during an infectious illness as a response and an aid to the immune system fighting off the infection.
Vomiting and diarrhea are frequent causes of pediatric ER visits. If the only symptom is vomiting, the parents should not try to force fluids. After a few hours of stomach rest, an attempt should be made to offer small amounts of clear fluids. Diarrhea is significant if 10 or more watery stools occur in a 24 hour period. Oral rehydration with Pedialyte or some other oral rehydration formula should be attempted. Breast fed infants should continue to be offered breast milk. Dry mouth, decreased urine output, lethargy, and a depressed fontanel (soft spot in the middle of a baby's head) are all signs of dehydration.
Rashes in children are common and usually benign. Eczema, fungal infections and variations of heat or diaper rash are easily diagnosed. Swelling or crusting of a rash may indicate a bacterial skin infection. Many viruses trigger a nonspecific skin reaction. Rashes that occur while the child is taking antibiotics may represent an allergic reaction. Any rash that looks like purple spots or bumps should be evaluated quickly. Blood blisters also fall into this group of rashes that are likely to be a serious infection or disorder of the blood cells.
At the age of 4, I announced to anyone foolish enough to listen, that I wanted to be a doctor when I grew up. I was adamant that I would be a pediatrician. My own pediatrician was Dr Charles Berson. He was handsome, smart, dressed immaculately and actually spoke directly to me. In the days before routine immunizations for most of serious childhood diseases, the family doctor or pediatrician was the source of all medical knowledge. ER's were rudimentary at best. If you were a sick child, you saw your pediatrician. Now I am the off (and sometimes on) hour pediatrician. Despite the virtual elimination of measles, mumps, chicken pox, rubella, H influenza bacterial infections, whooping cough(pertussis) and diphtheria, parents seem less able to cope with the innumerable minor illness that afflict their children. My role as educator in addition to physician has become more important.
One of the reasons that I chose emergency medicine instead of pediatrics was that I easily relate to children but not to working in an office. Helping an ill or traumatized child, is very satisfying. I also get to play with some really cool equipment in the ER. Advances in sedation allow me to make it less traumatic for the child to undergo painful and frightening procedures in the ER. I guess I made the correct choice.
Preschool children are divided into 4 groups by age: 0-28 days, 1-3 months, 3 months to 2 years and 2-5 years. Specific diseases predominate in each group with special attention in the early groups.
In the first 4 weeks of life any fever above 100.4 F triggers an examination and tests to look for infections that are potentially life threatening. Blood, urine, cerebrospinal fluid from a lumbar puncture (spinal tap) and a chest x-ray are performed on the neonate. Antibiotics are given pending the results of cultures of these body fluids. Unfortunately the tests are painful to the infant and disturbing to the parents. Sedation may be given to the baby but the parents are left to pray and fret.
The second and third month of an infants life is also a time for concern if high fevers develop. The ER doctor has some discretion as to the extent of the fever work up. Up to age 2, a temperature of 40 degrees C or 103.8 F or above raises the suspicion of occult bacterium. This is when a source of bacteria on the skin, in the ears, mouth or throat, the lungs or in the urinary or digestive track gains access to the blood stream. Tests may include blood counts and cultures, catheterization of the bladder to obtain urine, a chest x-ray and a lumbar puncture. Sedation may be given to the child to relieve discomfort and expedite the procedures. Appropriate antibiotics are given while awaiting the culture results.
Toddlers have better developed immune systems and have received a full complement of vital immunizations. The fever work up is guided by the specific symptoms and the results of the physical exam. A recent practice in treating children with ear infection is gaining greater acceptance. A child with an inflamed ear drum and a low to moderate fever may be treated with watchful waiting. A prescription for an antibiotic is given but the parents are instructed to wait 48 hours before filling and starting to dose the child. If the symptoms of the ear infection cease, the antibiotics are not given. Studies have shown that 80% of ear infections in children are caused by viruses, not bacteria. This 48 hour waiting period may significant reduce the use of unnecessary antibiotics.
Febrile seizures are frightening to parents. The height of the fever is not predictive of which child will suffer a febrile seizure. Simple febrile seizures involve a generalized convulsion in a febrile child. The period of the convulsion should last less than 5 minutes. Only one child in five who has a febrile seizure will have a subsequent episode. Parents should be instructed in the correct dosages of acetaminophen (tylenol) and ibuprofen (motrin). The weight derived dose must be stressed. The overwhelming number of children that I see in the ER have been underdosed with antipyretics. It is also important to make the parents aware that fever is not a bad thing. An elevated body temperature occurs during an infectious illness as a response and an aid to the immune system fighting off the infection.
Vomiting and diarrhea are frequent causes of pediatric ER visits. If the only symptom is vomiting, the parents should not try to force fluids. After a few hours of stomach rest, an attempt should be made to offer small amounts of clear fluids. Diarrhea is significant if 10 or more watery stools occur in a 24 hour period. Oral rehydration with Pedialyte or some other oral rehydration formula should be attempted. Breast fed infants should continue to be offered breast milk. Dry mouth, decreased urine output, lethargy, and a depressed fontanel (soft spot in the middle of a baby's head) are all signs of dehydration.
Rashes in children are common and usually benign. Eczema, fungal infections and variations of heat or diaper rash are easily diagnosed. Swelling or crusting of a rash may indicate a bacterial skin infection. Many viruses trigger a nonspecific skin reaction. Rashes that occur while the child is taking antibiotics may represent an allergic reaction. Any rash that looks like purple spots or bumps should be evaluated quickly. Blood blisters also fall into this group of rashes that are likely to be a serious infection or disorder of the blood cells.
At the age of 4, I announced to anyone foolish enough to listen, that I wanted to be a doctor when I grew up. I was adamant that I would be a pediatrician. My own pediatrician was Dr Charles Berson. He was handsome, smart, dressed immaculately and actually spoke directly to me. In the days before routine immunizations for most of serious childhood diseases, the family doctor or pediatrician was the source of all medical knowledge. ER's were rudimentary at best. If you were a sick child, you saw your pediatrician. Now I am the off (and sometimes on) hour pediatrician. Despite the virtual elimination of measles, mumps, chicken pox, rubella, H influenza bacterial infections, whooping cough(pertussis) and diphtheria, parents seem less able to cope with the innumerable minor illness that afflict their children. My role as educator in addition to physician has become more important.
One of the reasons that I chose emergency medicine instead of pediatrics was that I easily relate to children but not to working in an office. Helping an ill or traumatized child, is very satisfying. I also get to play with some really cool equipment in the ER. Advances in sedation allow me to make it less traumatic for the child to undergo painful and frightening procedures in the ER. I guess I made the correct choice.
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