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Nature

I had a lot of babies in the nursery to examine this morning.  For those of you who haven't already figured it out, I am very pro-baby.  Babies make my days better.  Taking care of them is much more health care than the sick care that comprises a lot of my day.

One of the most interesting things to see in the nursery is the different personalities of the babies.  Yes, babies do have personalities.  Any parent of multiple children can attest to the fact that a large part of a child's demeanor is hard-wired in from the start.  Some babies cry continuously, some don't like to be messed with, while others are mellow and laid-back.  These personality traits do seem to carry over to childhood and even adulthood.  I have to say, though, that I haven't noticed much of a difference between boy and girl infants.  Either can be grumpy or mellow.

So what's a parent to do?  If your child is a whiney kid that doesn't want you to mess with them, are you doomed to a life of fighting with them?  Yes and no.  The personality is the foundation on which the child's character and personality are formed.  We certainly do have an effect on them through our efforts, but the basic nature of the child - the canvas on which they are painted - is difficult, if not impossible to change.  I am not sure you would want to change it anyhow.

This morning Mrs. Dr. Rob and I had a sense of de ja vu, as our 11 year-old daughter angrily declared that she didn't want to go to school.  She was very grumpy and saw the entire world as a conspiracy against her happiness.  Given that she's child #4, her mood did not have its intended effect.  We were not injured or angered by it.  We did not argue over the merits to going to school, or work to disprove her conspiracy theory.  We laughed to each other.  She is just like her older brother.  She has always been just like our child #1 in many ways, and this day had almost the identical script to mornings we had 7 years earlier.

It happens at this age, and it happens with certain personalities.  As parents, our job is not to shape the kids like a sculptor would shape a block of stone, it is to take what the child's personality gives us and direct it where we think it should go.  Even then, we can only expect limited success, but it's probably not wise to let the lunatics run the asylum (my kids might suggest the lunatics do run the asylum!).  When I first started parenting, I was all about being in control.  Kids don't know better and it is our job to make them do the right thing.  Now I see parenting more as acting as a guard.  Our main concern is their safety - both present and future - standing by them as they do their own journey.

One of the biggest mistakes I see nearly every parent make is to see their child as a "report card to the world" of their parenting skills.  Sure, parents who neglect or abuse their children will more likely turn out messed-up kids; but it is a huge pressure to put on your child to make them responsible for your parental reputation.  When we get mad at our kids, we need to ask ourselves if we are angry at them, or if we are angry that we didn't parent better.  That's unfair.  It's their journey, not ours.

What's the most important job of a parent?  Making kids believe they matter.  We need to give a damn about them.  It's got to be clear to them that it is about them, not us.  My selfishness is far more dangerous to them than their behavior.

So, to those parents of the babies I saw this morning, I say: you have incredible kids.  They are beautiful and unique.  They won't be like any other kids around, and that is a good thing.  They will make you feel like a bad parent, but don't get worked-up about it.  Parenting is a very wide road, not a treacherous path.  No matter what you do, you will screw your kid up in some way, so get over it early and just let them know they matter.

No matter their nature.

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Better Health Interviews - Fact or Fiction: Attention Deficit Disorder

Last Thursday (9/16/10) I had the pleasure of attending a conference on Attention Deficit Disorder.  The following are my two interviews.  They are both very interesting, and both apply greatly to my practice as a primary care physician. The first is Dr. Ari Tuckman, author of the book More Attention, Less Deficit, as well as the podcast with the same name:

The second interview is with Katherine Schantz, head of the Lab school, an innovative school for kids with ADHD and other learning problems.

I hope you enjoy watching these as much as I enjoyed doing the interviews.

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Podcast up: Breastfeeding

My latest podcast on breastfeeding is up at http://housecalldoctor.quickanddirtytips.com and in iTunes.  My bottom line is that breastfeeding is the best way for babies to be fed. When I was discussing this with Dr. Gwen, we got into an interesting discussion.  The dilemma pediatricians face is that if we strongly push nursing, we are criticizing anyone who chooses otherwise.  How strongly do we push breastfeeding when a large number of parents in our practice choose to nurse.  Beyond that, the advances in the quality of the formulas available have been great.  We have lots of bottle-fed babies in our practices and very few of them seem to suffer from it.

Doing the research for this podcast has swayed me back toward pushing breast milk more.  The studies I cite are fairly convincing to me that babies who are breastfed are at an advantage over those who are not.  At the very least, breastfeeding early in the baby's life is a very good idea.

This underlines one of the basic things I have learned about being a parent: you can't always do what is best.  There are lots of choices we make when raising kids: whether they should participate in sports or take music lessons, public or private schools, spending more time working to support them or spending more time at home.  It is rarely black and white.  Parenthood is full of second-guessing and can be burdened with lots of "if I had only done x" in retrospect.  Adding more guilt trips to an already self-conscious group may not be constructive.

I just think that telling parents the facts - in this case that breastfeeding is more advantageous than bottle-feeding - is the best I can do.  The choice is not always straightforward, so I won't criticize parents who do otherwise.  I do think, however, that some parents don't really know the facts.  I didn't even know all of the facts before researching this podcast.  As long as we give good information and communicate it clearly, the parents are the one who need to make the decision in the end.  I need to state the case for breastfeeding and then back off.

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Trust Me

I have never seen a case of epiglottitis.  I remember the stories I heard as a medical student: a young child comes to the ER with fever, drooling, and muffled voice - not just sick; a ticking time bomb.  I was told that if the child was disturbed - even something as small as putting a tongue depressor in their mouth - the airway could suddenly close and the child could die in minutes. It scared me then.

Now, thanks to the fear-mongers for immunizations, I may get to see it.  Today I got the following from the American Academy of Pediatrics:

Hib Alert: 5 Cases, 1 Death

The U.S. Centers for Disease Control and Prevention (CDC) today announced that five cases of Haemophilus influenzae, type b (Hib), invasive disease (meningitis, pneumonia and epiglottitis) were confirmed in 2008 in Minnesota. This is the highest number of cases of this vaccine-preventable disease in children under 5 years of age that Minnesota has seen since 1991.

Three patients had received no vaccinations due to parent or guardian deferral or refusal of vaccinations. One of the unimmunized patients, a 7-month-old infant, died of Hib disease. Two of the remaining children received age-appropriate immunizations. One child, a 5-month-old, had received two Hib immunizations. The other child was 15 months old and was fully vaccinated for age but, subsequent to Hib infection, was diagnosed with an immune deficiency (hypogammaglobulinemia).

Even in the conservative south I am having more parents falling prey to the immunization fear-mongers.  People are questioning them - even ones that don't have the feared autism association.  To my knowledge, HIB has never been a specific target of the anti-vaccination crowd (if you know otherwise, please tell me).

These parents probably thought "what's the harm?  Why can't we just wait to do the immunizations until the risk is less?"  A 7-month-old infant died from this logic.

As a pediatrician I work to keep children from unnecessary harm.  I am expected to pick out the very sick child - the child with life-threatening disease - from the routine illnesses.  It can be extremely difficult sometimes.  Catching disease early can save the life of the child.  Parents trust me to recognize this.  They expect me to have the training and wisdom to know what to do to keep their child from harm.

But there are some who would suggest that I am deluded.  I am brainwashed by the vaccine manufacturers, drug reps, or narrow-minded training.  Yes, I can be trusted to rescue their child from the brink of death, but can I be counted on when I recommend vaccines?  They trust me with the life of their baby when death is stalking, but what about when it is only a threat?

Horrible diseases have been prevented by immunizing children.  Is it worth the "risk?"

Ask the parents of this 7-month-old baby.

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Credit

Trust me.

I don't regret the fact that I have never seen epiglottitis.  I don't want to.  Trust me.

Please, trust me.

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Getting in a good word

Note: The Caption Contest is still going on…I am in the process of increasing the allowance of securing the judges.

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holding_hands It’s a hard world for kids; they come into the world completely helpless to parents who don’t know much about how to raise them.  Some parents have a better idea than others, but as a parent of four children I can say that the mystery far outweighs the understood.  As a parent you are in constant fear that somehow what you are doing is going to cause some unexpected harm for you children down the road.  I have no doubt that many of the things I have done will cause such harm.

But as many know, the world is far harder for some kids than the rest.  These kids don’t simply have frail and fallible parents, they have parents who don’t care or are even emotionally antagonistic toward them.  Perhaps these parents had similar examples when they were kids – I can’t compare my relatively good childhood experience to theirs – but regardless of the reason, many parents’ attitudes cause significant harm.  I see it regularly.

Since my job is to maximize the overall health of children, I see somehow helping this situation as of high priority.  But how do you communicate this?  How do you get people to see that they are harming their child with their attitude?  How do you avoid coming across as judgmental or patronizing?  My goal is not to preach a sermon and feel better myself, but to actually affect change.

Treasure My current approach to this problem is simple: I say nice things.  From the very start of a child’s life I do whatever I can to get the parents thinking as highly of the child as possible.  Whenever they come in for a visit I comment on how cute, advanced, or smart the child is.  I use words like “perfect,” “wonderful,” and “beautiful.”  I want the parents to know what a great gift they have as a child – and perhaps that feeling of pride they get will cause them to pay more positive attention.  You take better care of treasure than trash, and part of my job is to convince parents that they have a treasure.  I believe they all do.

This does not stop when kids get older.  Much of a child’s success depends on what the child thinks about him/herself.  A sense of helplessness, hopelessness, or predictable failure will cause them to seek comfort in drugs, sex, or overachievement; or worse, it will cause them to be full of bitterness and anger toward the world.  It is my job to be a positive voice in their life.  I do what I can to emphasize their success, using words like “smart,” “successful,” and “terrific.”  I want the child to believe that they are valuable in who they are – not in what they need to become.

Now, I don’t buy into the modern mantra of “you can accomplish anything you want as long as you believe in it.”  That is simply not true.  I could have never been a professional baseball player (too klutzy), or a neurosurgeon (too distractible).  That type of mindset sets kids up for shame – a lack of success in what they do will simply be evidence that they didn’t try hard or believe enough.  You are who you are – with unique strengths and weaknesses.  I think it is the job of us adults to encourage children to be themselves and embrace who they are.

Belief in yourself should focus more on yourself, and less on belief.  It is not the strength of the belief, but the object of it.  Believe in who you are and not who you would be better off being.  I think one of the keys to both happiness and success is to like the person who wears your skin.  Self-contempt does not push people toward improving themselves, it stifles ambition.  Self-belief – the realization that you as a person have value as you are – is, in my opinion, the best predictor of a truly successful and happy person.

I can’t change the world; but it is nice to be able to put in a few good words and perhaps make a parent believe in a child, and a child believe that they are truly worth having in this world.

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Pot, Meet Kettle

At the start of next year, the drug companies will no longer be giving pens and pads of paper to doctors.  The rules regarding pharmaceutical sales practices have grown progressively more stringent over the past few years.  The FDA already regulates what the reps say to physicians (they may only assert what is in the PI, or package insert).  Now they will be very limited on other contact with physicians. Thank goodness.  Those pens and pads of paper were sending subliminal messages to me.  I hear them talking to me in my sleep.  I just have an insatiable need to prescribe unnecessary medications because of a ballpoint.  It will be good to get out of this marketing hell these reps have put me in.

PE-PenAd

Citizens are worried about the influence these companies are having over us physicians, wondering if their efforts to influence are driving up the cost of care.  One online petition site states:

Drug marketing is out of control. Help send a message to Congress. Support the Physician Payments Sunshine Act, which will require drug companies to publicly report their gifts and payments to doctors. Drug companies spend at least $25 billion each year marketing to doctors. We pay for that with every drug we buy. And studies prove that marketing causes doctors to prescribe higher-cost drugs. Some new drugs also have safety risks (like Vioxx). By increasing transparency, the Sunshine Act will help protect patients and help counter the skyrocketing costs of drugs.

Congress is also getting involved:

While it's no secret that pharmaceutical companies lavish gifts on doctors -- everything from free notepads and pens to meals to the more extravagant paid trips or seminars -- most patients are in the dark about who, exactly, is courting their physicians. But Congress may be finally acknowledging this relationship, one important step toward creating a national gift registry so patients can track the perks Big Pharma is giving to their doctors.

In June, the nonprofit government watchdog Public Citizen testified before the Senate Special Committee on Aging in favor of federal legislation that would require drug companies to disclose payments to doctors. But the group urged lawmakers, before jumping on the proposal, to examine a Petri dish of existing disclosure laws. Although four states and the District of Columbia already have disclosure laws on the books, the group says they are "inadequate" and do not give patients a clear picture of how money is changing hands.

GoEnglish_com_ThePotCallingTheKettleBlack

I do understand this concern.  Advertising works, and there are definite financial reasons for the drug industry's aggressive marketing to doctors.  The pressure seems to be working, as witnessed by the pen and paper ban.

I guess it is appropriate congress is getting involved, since they are very familiar with the influence the drug companies can have over people and their behavior.  From the Wall Street Journal:

Health Industry Pours Money Into Democratic Convention

The health-care industry has a lot at stake in Washington these days. Maybe that’s why the list of the Democratic convention’s host-committee sponsors is so full of big players from the health sector.

Among them: Merck, Amgen, Pfizer, AstraZeneca, Novartis, Mylan, Medtronic — (pause for breath) — Abbott, Walgreen, UnitedHealth, Eli Lilly and Anthem Blue Cross Blue Shield.

Nor are the companies letting the money do the talking. The CEOs of Pfizer, AstraZeneca, Eli Lilly, Amgen and Merck are all making appearances in Denver this week, reports FDA Legislative Watch.

And Pfizer was among the million-dollar donors that landed skyboxes at Invesco Field for Obama’s big speech Thursday, the Dallas Morning News reports.

As we noted earlier this year, the sector has shifted to favor Democrats over Republicans recently. But that doesn’t mean the Democrats are getting everything: There will be plenty of industry money sloshing around Minneapolis - St. Paul next week for the Republican convention.

bribe Hmm....  I smell hypocrisy here.  Isn't this problem of at least equal importance to the short-skirted drug reps and gawking doctors?  Is the lack of pens and paper in my office (which will boost the local economy as we go to Staples to buy it for ourselves) such a great accomplishment when Pharma (and every other industry) is buying influence with our government?

I don't really care about the pens, but it seems a much bigger issue to me that corporate America has bought our legislators and are trying to influence our President.  These are the people who are going to reform healthcare?  These are the people who have a vision of how things need to be?

I've got an idea: let's start a petition to prohibit them from giving pens and pads of paper to politicians.

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Self-Assured Destruction

CYS020 OK, it is time to put on your nostalgia caps and remember back to the cold war.  Those were the days, weren't they?  "Nuclear Winter" was being thrown around like "Global Warming" is now.  Life went on like normal, but life was always lived with an underlying dis-ease that the end of everything was just a button-push away. One term frequently used at that time was "Mutually-Assured Destruction" (MAD) which described the stalemate of two huge stockpiles of nuclear weapons that could destroy the world many times over.   The thing that kept the fingers off of the button was the surety that the destruction of one side would result in the end of life for both sides.  It wasn't a comforting thing to have to trust the rationality of two sides that had created the stockpiles in the first place, but perhaps there was some truth to the idea of MAD causing restraint to occur even in the least rational of all people: our leaders.  Who knows?  We're not really out of those woods yet.

But this is not a post about nuclear weapons.

I was listening to the NPR Science Friday podcast, and there was a very interesting story about a journalist who had studied and befriended people with Lesch-Nyhan syndrome, a condition where people have a single nucleotide substituted in their DNA that causes them to engage in grotesque self-mutilation.  The degree to which people with this disease harm themselves is quite disturbing (don't look at pictures of it unless you are prepared), even resulting in these patients chewing off their fingers.  Very disturbing.

On the podcast (I highly recommend it), the journalist makes the statement: "There's a little of Lesch-Nyhan in all of us."  Some people chew their fingernails and others bite their cuticles, even when they know they shouldn't.  Lesch-Nyhan is just the extreme of this type of behavior.

smoking Yes, there is a little of Lesch-Nyhan in all of us.  Smokers smoke despite their emphysema, alcoholics would do anything to get away from the destruction of drinking but keep drinking to their own harm, compulsive gamblers gamble away all of their money, and people with credit cards spent to the limit somehow find a way to keep spending.  Last week I picked at a callus on my foot so much that it hurt to walk.  I kept telling myself to stop, but my hand would somehow end up on my heel without before I could think to pull it away.

My job depends on this irrationality.  I once posed the question: what impacts my income more, human frailty or human stupidity?  Self-destructive behavior causes a significant percentage of my visits - whether it be subtle: noncompliance with medications or tests ordered; obvious: alcohol, smoking, or overeating; or overt; anorexia nervosa, people staying in abusive relationships, or people "cutting" themselves.  Is this stupidity?  It certainly is irrational - people feel like they can't stop themselves in this kind of behavior and sometimes even feel a pleasure in the self-harm.  Yet there is also a degree of rationality to it, as it puts pain in our own control rather than in the hands of others.  The draw to it is moth/flame-like.  The more irrational the behavior seems, the stronger the gravity of the need it is filling.

Credit.

This is a mystery to me.  I see it every day in my patients and I see it in myself.  I sometimes tell my patients that one of the best parts of being a doctor is that you get to see that everyone is as screwed up as you are.  If I could push a button or prescribe a drug to help with this behavior, I would.  I doubt there will be a button or drug to fix this, however, as history tells us that this kind of self-assured destruction (SAD) is not new to our time and culture.

This is probably the main reason I don't feel I can judge my patients for their self-destructive behavior.  It is too common.  I see it in the mirror every morning.  That is not to say that the behavior itself is not wrong or bad, but to make the jump to say that I wouldn't do the same in their shoes belies the fact that I engage in my own form of SAD.

Too many people see SAD as inevitable and too many physicians just treat the consequences of this behavior.  My hope for both myself and my patients is that somehow this cycle can be broken and the legacy of self-destruction can be interrupted.  As any recovering alcoholic can tell you, this is not easy at all.  But life would be a lot happier for all of us without that dis-ease of the finger close to the button.

As one of my favorite musicians once put it:

The man who twirled with rose in teeth Has his tongue tied up in thorns His once expanded sense of time and Space all shot and torn See him wander hat in hand - "Look at me, I'm so forlorn - Ask anyone who can recall It's horrible to be born!"

Life is hard.  But it is far harder when we forget that, despite the appearances, we are all human.

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"My Baby Turned Blue"

98292 Being a parent is scary.

I remember when my first son was born I looked at him and was overwhelmed.  This person was my responsibility.  Even as a pediatrician, I felt a sense of being lost in the sea.  Remembering this feeling makes me have much more compassion on my patients.

The incredible fear the can carry into the office is palpable.  I think you have to be a parent to understand.  Most of the time I can find ways to diffuse the fear - through reassurance, diagnosis, or making a plan to come to a diagnosis.  This is true in about 99% of the pediatric cases I see.  Most kids aren't really that sick, and those who are can be treated easily.

There is one type of visit, however, that stops me in my tracks.  It is called an Apparent life-threatening event or ALTE.  UpToDate defines an ALTE as:

ALTE is the abbreviation for "apparent life-threatening event", a poorly defined term to describe an acute, unexpected change in an infant's breathing behavior that was frightening to the infant's caretaker and that included some combination of the following features:

  • Apnea — usually no respiratory effort (central) or sometimes effort with difficulty (obstructive)
  • Color change — usually cyanotic or pallid, but occasionally erythematous or plethoric
  • Marked change in muscle tone (usually limpness or rarely rigidity)
  • Choking or gagging

Unfortunately, an ALTE is only observed by the parent at the time of the event.  They present either to the office or the Emergency room understandably panicked.  Their baby has stopped breathing, turned blue, went limp, or choked.  If a parent is not upset, I get really worried.

So the reaction of the parent is extreme.  But what really happened?  Nobody knows.  Did the child really stop breathing, or is it an over-reaction to something that was a little scary?  How do you reassure a mom when you don't know what really happened?

The good news is that there is no clear relationship of ALTE and SIDS (Sudden Infant Death Syndrome).  The bad news is that it is very difficult to figure out what to do.  Studies show that about 50% of the time, a diagnosis can be reached through exam and a careful history.  The most common cause of apnea-like symptoms is reflux (that happens in nearly 75% of babies).

Even with a child who refluxes, however, there is often doubt in the back of your mind as a doctor that you are taking a risk at calling it "just reflux."  So more studies are usually ordered.  Here is a list of possible tests from UpToDate:

In one review of test results from a consecutive series of 243 infants admitted to a tertiary center with ALTE, 3776 tests were ordered, of which 18 percent were positive and only 6 percent contributed to the diagnosis

In the consecutive series of 243 infants with ALTE described above, among 171 infants in whom a particlar diagnosis was suggested by the history and examination, the following tests contributed to establishing the diagnosis:

  • Blood counts, chemistries, and cultures
  • CSF fluid analysis and cultures
  • Metabolic screening
  • Screening for respiratory pathogens
  • Screening for gastroesophageal reflux
  • Chest radiograph
  • Brain neuroimaging
  • Skeletal survey
  • Electroencephalogram
  • Echocardiogram
  • Polysomnography

Among the 72 infants in whom the history and examination were noncontributory, only the following tests contributed to establishing the diagnosis:

  • White blood cell count
  • Screening for gastroesophageal reflux
  • Urine analysis and culture
  • Brain neuroimaging
  • Chest radiograph
  • Polysomnography

This means that there is an average of more than 10 tests ordered per child, with only 6% of them actually helping.  Great.

Most of the time, the kids do great.  Sometimes you put the baby on an apnea monitor - a device that lets out a shrill sound when the breathing rate goes down or the heart rate goes too high or low.  The vast majority of alarms on these devices are false-alarms and can make an already anxious parent become even more anxious.  But what else can you do?

I have never had a bad outcome with an ALTE.  Most of the time the child does just fine.  So when will the good luck end?  It just puts a bad feeling in the pit of your stomach.

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Baby Therapy

218301wcEB_w Today was nuts. It was absolutely nuts. My auto repair shop had called last week telling me the parts they ordered to fix my windows were in. Today was my first chance in a week to get my car fixed.

After dropping my daughter off at school, I drove over to the auto shop. I was greeted by a delightful elderly man there who asked me if I needed a ride home. I told him I did, and he directed me to where the Courtesy Van was parked. I climbed in and we headed toward my home.

We had a pleasant conversation about our city and all the history he had experienced over the many years he lived there. At his request, I punched my address on the GPS device so he could know exactly how to get to my house. I am not sure why he wanted me to do this, because he totally ignored anything it said. He had a better way.

GPS-500 Each time he went off of the prescribed course, the GPS would state it was "recalculating directions" and then try to get us back on the way it knew to be the quickest route. GPS devices are great inventions, although they do have their quirks. I was in Oregon once in a rental car and asked for directions to the nearest Wal-Mart. It gave me directions to a Wal-Mart in Las Vegas, over 1000 miles away. Perhaps my driver knew better. I gave him the benefit of the doubt.

By about the fifth time the GPS announced it was "recalculating directions," my driver was getting annoyed. He grabbed the GPS and started trying to reprogram it. Why he did not just push the little "off" button, I was not certain. Perhaps he felt that if he pressed enough buttons, the device would realize that his directions were superior and stop "recalculating directions". With his attention fixed on the task of educating this new-fangled device, he neglected the fact that we were driving through a residential neighborhood. We were headed us directly at a car parked on the right side of the street.

"Car!" I said forcefully, digging my fingers deep into the fabric on my seat. He looked up in time and redirected his course, dropping the GPS, which once again tried to recalculate our course (I was hoping it was trying to find a very wide road).

We wound around the back roads of our town and my driver decided to show me some sites of historic interest. "This is the oldest cemetery in the city," he said, pointing to the right. I let off a little prayer that we would not be in need of a cemetery any time soon.

do-not-enter"Turn Left" said the GPS in a voice that was sounding a bit perturbed at this point. We went straight, turning left at the next intersection. I noticed a "do not enter" sign that we drove quickly past.

"I think this is a one-way street" I offered, as the GPS once again recalculated our course. The drivers coming at us scowled and shook their heads. We passed another cemetery, and my driver again pointed it out. Was he trying to tell me something?

Cemetery

The rest of the trip was uneventful (aside from the refrain of "Nearer Oh God to Thee" that ran through my head). I thanked my chauffeur for the ride as I stepped quickly out of the car. There were deep indentations on the seat where my fingers had embedded themselves. He told me to call him if I needed another ride, and I smiled graciously to hide my abject horror at the thought. I think he wants to show me all the funeral homes in town. As he drove away I fell on my knees and kissed the ground.

After talking myself out of a stiff drink and filling my wife in on my near-death ride of horrors, I drove with her to work. I did the driving - not that I don't trust her, but I thought another ride in the passenger's seat would only lengthen my emotional recovery. When we got to my office, she drove home, leaving me there without a means of transportation. She would either pick me up after work, or I would mooch a ride from my partner.

The day seemed to be settling down and I saw my first two patients. As I wrapped up with the second, there was a hard knock on the door. "Labor and Delivery is on the phone. There is an emergency C-Section at the hospital."

As pediatricians, we have to attend C-Sections or complicated deliveries at one of our local hospitals. My training in newborn resuscitation was 14 years ago, and the number of times there are truly sick babies at these deliveries is quite low. I can go years between having to intubate or resuscitate a child - which is fine with me. But this always makes these deliveries a somewhat tense affair. The problem of our rusty skills is balanced with the high level of experience of the Nursery nurses who are there to "help us." The truth is, they could probably do it just as well without us.

2 So here I was in my office without a car, needing to get to the hospital quickly. The other pediatrician in our group is in Siberia right now (really, he is on a mission trip - he did not get sent there for being behind on medical records). I was the only one who could attend this delivery. I begged a car off of my other partner, who explained that the Air Conditioning was not working. I didn't care; I had to hurry to the hospital and be at this C-Section. So I drove the hot car through mid-day traffic to our hospital, which is about 7 miles from our office. Luckily, I don't have to drive by any cemeteries on the way.

By the time I arrived at Labor and Delivery, the baby was already born and was thankfully crying. I did my doctorly act and declared the baby born, grabbed a bite to eat, and headed back to work. The other physicians in my office saw the rest of my morning patients, and my afternoon schedule was fast approaching.

I was trying to catch up on charts in my office when my pager blasted an angry beep at me. I looked, and it told me to call Labor and Delivery for a C-Section. "You're popular today, Dr. Rob" the nurse told me on the phone. I guess I had done such a fine job declaring the last baby born that they needed an encore performance. Flustered, I grabbed the keys - still warm from my last use - off of my partner's desk.

sauna I once again maneuvered the sauna-mobile through mid-day traffic and ran up to Labor and Delivery. The Operating Room where the C-Section was to take place was empty. The nurse informed me that Anesthesia was taking a long time to get the epidural in. The C-Section, it turns out, was happening because the baby decided to stick his hand out first. Perhaps that is what his GPS told him to do. Unfortunately, the OB would have to recalculate his course and bring him out through another route.

After a 45 minute wait, the C-Section was on. It went fine, and I once again declared the baby born (to the jubilant cheers of the nurses and obstetricians in the OR), and I left go back to my office.

This whole day had conspired to turn me into a grump. I really had not wanted to be grumpy, but my course could not be recalculated and thus headed straight for Grumpville. My mind was jumbled. I had narrowly avoided death and then had then declared two babies born. I had been face to face with the beginning and end of life. Now there was work to do.

It is hard to reset your brain on a day like this and not wallow in your misery. You want everyone to know how bad your day had been, but as a doctor, you can't do that. The visits are not about you, they are about your patients. They are not there to hear your day was like, they want you to care for them. Taking mind off of yourself on this kind of day takes a whole lot of discipline (and perhaps some mild shock therapy).

And so this grumpy, self-pitying, GPS-hating, car-borrowing, birth-declaring doctor walked into his first patient's room and was greeted by a grin. A baby grin.

cutebabyblueeyes_01

Babies don't care who you are, they just smile. Between two and nine months of age, babies can't help but smile at everyone and everything. Even grumpy doctors; although this doctor had just been cured by a good dose of baby therapy.

Thanks baby.

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Attention Deficit and School

distractedI take care of a lot of patients with ADD/ADHD.  I cringe when I say it, but I have developed a fair amount of expertise in the area.

I also have ADD: hence the name of my blog.

There will always be some controversy swirling around the subject.  Some feel it is over-diagnosed and medications are given out to kids who simply need better parenting.  Others feel it should be treated as a disease and should always be treated with medication.  I don't agree with either of these.

To me, ADD is a personality type.  Everyone has areas in which they excel and others that pose big problems.  That is just part of being a human.  Most of the time, the strengths in our personality also have matching weaknesses.  For example, a person who is very emotional and empathic (which is a very positive trait when dealing with people who are hurting) have a tendency to not stand up to others when they should (because they don't want to hurt them).  Compulsive type A are great employees when they are put in a role where attention to detail, but they tend to be less flexible and imaginative.

The same is true with ADD/ADHD.  While the ADD personality may lend itself to a more social personality, better leadership skills, and a more vivid imagination, it also causes trouble at school.  Here is how I explain it to parents and kids:

f1060628914031Q:  What can you say about kids at school with straight A's?
They usually answer "They are smart."
A.  No, actually you can only say that they are very good at school.  They possess the skills it takes to get good grades in school.  Are they smart?  Maybe.  But more likely they are very compulsive, able to pay attention for long periods of time, desiring to please the teacher, and good rule-followers.  Some people with average intelligence possess these skills and can do quite well in school. 

On the other side, there are plenty of very smart people who are not good at all at "doing school."  They would rather mess with their friends, are easily bored, don't like to do assignments they think are "stupid," and don't follow rules well.  My goal in treating ADD is to make the square peg fit in the round hole - to make kids who are not good at school to be able to do school better.

Makes sense?  You probably aren't going to change school to fit the student, so you fit the student to school.  Sad, but necessary.

square-pegOn further contemplation of this, I realized that the skills that make a person successful leaders later in life: independent thinking, social-orientation, not accepting pat answers, and vivid imaginations, are actually a liability in school for many students.  Many teachers don't want a bunch of independent leaders in their classrooms, they want followers who do what they are told.  The exceptional teacher can engage the students who are not good at doing school.  It takes more work, so many teachers aren't willing to adapt.

I see this as a major problem in the schooling of our children.  We are not rewarding leaders and high imaginations.  Many very bright children come into school and have to slow down their learning from before they were students.  We have to keep all students at the same pace.  We don't let the fast-learners move ahead.  I know, because I have several of these kids.

phs_noenglish I don't know the answers.  I would rather not medicate the child and simply change the schooling setting; but I don't think the "no child left behind" fiasco will allow us to fall outside of the prescribed image by which success in education is defined.  Misguided laws like this make education an exercise in conformity, rather than an opportunity to nurse the strengths of each student so they can blossom when they have the chance to be on their own.

I was lucky.  My parents were very structured and my education didn't ask enough out of me for me to fail out at a younger age.  By the time that classes got demanding, I was taking courses that I wanted to take and that I felt were important.  Unfortunately, this is not the case with a lot of children.

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