Wednesday, November 21, 2012

school lunch

JAMA, November 14, 2012, - vol. 308, no. 18, pg 1849.

Meal programs questioned:
The ranking member of the Senate Committee on Agriculture, Nutrition, and Forestry, Sen. Pat Roberts (R Kansas) has asked the USDA for its justification of the new nutrition guideline for the National School Lunch and School Breakfast programs.
The above was the actual title and first paragraph of the short article. First, agriculture/nutrition/forestry? I can see the agriculture and nutrition link, but forestry? That’s gotta be political.
Second, the article’s premise is Sen. Roberts’ questioning of the new nutrition guidelines for the school lunch program above as required by the Healthy, Hunger-Free Kids Act of 2010, which increased the availability of fruits, vegetables, whole grains, and fat-free and low-fat milk in school meals. This was allegedly passed (this act, which took effect in March 2012) to meet the nutritional needs of schoolchildren. His concern is excessive ‘plate waste’ resulting from children not wanting to eat the new meals, especially the required servings of fruits and vegetables. OMG (that’s not a government office, nor is AYFKM, which is my wife’s personal favorite response to such BS –another nongovernment entity, though definitely something funded and encouraged by the government), if they were hungry, they’d be eating the food given to them. I strongly suspect/know that if these particular foods, however green and vegetable-y and whole grainy they were, were airlifted into Ethiopia or Sudan or (name your starving country), they would be fought over, and not by some fat and happy Kansas senator whose whiny baby constituents’ kids want corndogs and mac n cheese every day for breakfast and lunch…pass the mustard for my sausage biscuit.
This goes back to my 15 month checkup sheet where I specifically say, for the perusal and questioning of Senators and moms/dads/grandparents of the world, YOUR CHILD WON”T STARVE! If you offer good food and only good food (and that’s your choice, not the school’s or the government’s) and your child is truly needing to eat (not whining they’re hungry) then whatever you provide THEY WILL EAT.
Kids in the countries where there is truly hunger and starvation are eating out of the trash cans, licking cans, drinking rancid water from gutters, they’re not griping about having to eat veggies and fruit for lunch at school.
What’s next? ‘Transportation program questioned’ – Sen. Bla Bla reports that his constituents in Connecticut are appalled that children are forced to ride side by side in yellow (yellow? OMG!) public buses produced by some American company named Bluebird. The Senator recommends passage of the’Mercedes only’ school bus program. In this program, children are picked up in Mercedes limos and chauffeured to school while eating twinkies and ding dongs (oh wait, Hostess went belly up!). AYFKM?

parenting ceasefire

Time Nov 12, 2012 pg 18

In a piece about the ceasefire in Syria that was supposed to be for 4 days but lasted about 4 hours, a sentence caught my eye. ‘Having mediated in Lebanon and Afghanistan, the…diplomat knows that a civil war ends only when the parties want a solution as much as the mediator does.”
See ‘Siblings w/o Rivalry” by Adele Faber and Elaine Mazlish, ca 1980. ‘don't get in siblings’ fights’. Also, my sheet on Child’s Problems on - the problem must bother the child (in this case the combatants) more than it bothers you (in this case the mediators, the rest of the world, etc.).
Nuff said.
Pg 27
The obituary of Jacques Barzun, cultural historian, who lived to be 104 (kudos to him for that!), whose most famous book was written in 2000 and was called From Dawn to Decadence. He warned of the decline of Western Culture (of which he had experienced 20% of the past 500 years), citing the glorification of rebellion and the postmodern assault on the idea of truth as the causes.
Wow, we are supposed to submit to authority and believe in God’s truth. Whoda thunk it? and this from a secular historian.
            I bought this book but it hasn’t arrived yet. Can’t wait to read it!

when to take your child to the doctor

When to take your child to the doctor.

It’s an age old question, answered many ways by many people, but forever the quandary is ‘I don’t want to wait too long’ or ‘I don’t want to go too early’.
For years my smart aleck answer to the ‘ideal patient’ was one who had a $35 copay or a 35 mile drive. They wouldn’t come in too often but they weren’t prohibited from being seen if necessary. But they wouldn’t just ‘pop in’ ‘because it was worth the 10 bucks and I was just around the corner’.
Different illnesses have different thresholds of concern. For instance, a cold can go on for several days before a mom gets concerned enough to be seen. However, fever and a rash might be cause for concern sooner.
The difference in even 20 years ago and now is amazing. The fear of meningitis and epiglottitis is pretty much gone. Scarlet fever, whooping cough, measles, mumps, rubella, all are things of the past…for the most part.
While grandmothers are helpful in advising moms in areas of concern, we in the grandparent age group have had different experiences and live different realities as parents. Another smart aleck response I have for grandmothers is that ‘if you act concerned, she will tell you why you’re being silly and overcautious, but if you act less than worried, she will say you should rush the child to the ER’. Selective memory is a joke for the most part, but it can be difficult if grandma is remembering serious illnesses that are gone now, or if she is chiding her daughter/daughter in law about illnesses that are relatively new and concerning in this new world. Funny how grandmothers remember (or misremember) the day you peed in the potty the first time (always earlier than the actual event) but they seem to have forgotten what it was like to have a baby keep you up at night crying.
So…some basic tenets: fever for 3 or more days should be looked at. If the child is under 2 months, the fever is over 102-103, the child is acting sick (won’t eat, won’t stop crying, won’t wake up), that’s a different story.
Vomiting is usually self limited and doesn’t cause dehydration by itself. Give clear liquids and 12 hours and most vomiting will be gone. Same story as above – age, severity, sickness level, these mean different things.
Diarrhea is usually not a big deal either. Give it a few days unless it’s associated with vomiting at the same time and the child is unable to hold down liquids.
I usually give a cough 2 weeks if it’s not too bad, but after 2 weeks, if the cough has been consistent and not responding to time and humidity and OTC medicines as needed, it’s generally bronchitis until proven otherwise. Wheezing, trouble breathing, coughing til she vomits, stridor (noisy breathing in), those mean different things.
Rashes are usually not serious. Unless they are. It’s a hard call with rashes, but in the absence of fever or other illness symptoms, it’s generally ok to give them a few days or weeks if they aren’t progressing/spreading quickly or bothering the child.
Bleeding is generally not a good thing for a child to do. Vomiting with blood, coughing with blood, diarrhea with blood…these would hopefully alarm most parents and prompt at least a call to the pediatrician. As far as cuts and scrapes, bleeding is to be expected, and one of my (many, apparently) smart aleck phrases, shared by many in the health care field is…all bleeding stops. Well, it does. It’s just at what point it stops that matters. Head and face wounds bleed more than other areas. Firm pressure on a wound will usually stop bleeding, and if as the pressure is removed the bleeding begins again, your child might need medical attention.
Injuries are a subject all to themselves, but I’ll give an overview.
            If the bone is sticking out, if the child is unconscious, if a joint is swollen and getting bigger, if your child is making no sense after being hit in the head or falling, if your child can’t walk (once able to walk) or use an extremity, those are reasons to seek medical attention.
Unfortunately, emergency rooms have become a place for people to go when they have nothing better to do.  People with colds, mild fevers, obviously mild problems, come to the ER because..because..well, because it’s there. ‘Build it and they will come’. And they do. If only emergencies went to the emergency room, I’d tell everyone with an emergency to go there, but that’s not the case. Now there are urgent care centers on every street corner, but there is no sign of that slowing the tide of bored people with mild vague complaints on Saturday night to show up in the ER demanding to be seen, and taking up the room of someone who is really in need of the level of care available in the ER.
That said, the ER is sometimes the place to go. Sometimes you even have to call 911. Unconscious children (after a fall, an ingestion of something, with a fever…unconscious is on the level of bleeding as something that is generally not good) and massive unstoppable bleeding and total unresponsiveness need 911. Unfortunately, like the ER, 911 is abused. If only people in real trouble called the ambulance, we wouldn’t need so many ambulances.
But that’s sort of the point of this article, right? When is it an emergency? When should I worry? What do I look for?
The internet is a treasure trove of paranoia. The second year of medical school is the year we learn pathology, the science of disease. All the diseases known to man are in one big book and every day you learn about a few more and you go home with the same headache and fatigue and insomnia and anxiety and nausea and stomach pain and each day you interpret those symptoms in a different way based on the disease you just learned about. One day you have African sleeping sickness, the next a brain tumor, and one day you have some illness like Chaga’s disease seen only in South America, to which you’ve never traveled.
The point is, the internet and Google have made that big old pathology textbook available to everyone and so everyone interprets their headache as a brain tumor, their child’s stomachache as appendicitis, their rash as measles, and their fever and stiff neck as meningitis. Thankfully, rarely are they right.
Finally, and in summation, use common sense and as much of a rational brain as you have left at the end of a sleepless night/week and interpret your child’s symptoms in light of the time, severity, appetite, sleep, likelihood, exposure,  of the illnesses you’re considering in the list of possibles (what we doctors call a differential diagnosis) and act accordingly, ruling out the Chaga’s disease early. New parents are given a pass for the first year or so, but after kid #3 you probably know about as much as your pediatrician, so we expect you to do most of the ‘ruling out’ job for us. 

the drive across town/surfing

The drive across town, and the lessons for parenting/life it brings.

During a remodel of our house, we moved into a rental house in another neighborhood to be out of the dust. This house is not far away, but to get there (traveling east and west) on the straightest path, one must cross the railroad tracks. And sometimes there is a train.
Yes, there are other ways to get to there from here or vice versa, but the easiest way involves the railroad tracks. Oh, there are 2 school zones, too.
There is one alternative route that involves some construction zones and only one school zone and it has a railroad bridge over it, taking the train out of the equation.
Another alternate route is closer into town and there are many more traffic lights and I’m pretty sure no school zones, and another railroad bridge that similarly makes the train not an issue.
I could go north or south between these routes and sometimes do depending on the lights, etc., and I so remember my dad when I was a kid riding with him to the hospital or office. He had a system. If a certain light was green way up ahead he knew (or at least he said he knew) that he could hit all the lights and make it to the office quicker by turning down one route, but if that light in the distance was red we went another route.
I haven’t come up with a system. Maybe I haven’t tried. Maybe I’m telling myself that there is no system and to try to come up with one is a waste of time. I sort of wing it on a day to day basis, trying to make the best decisions based on time of day and level of traffic and likelihood of trains and schoolchildren. Sometimes it works out great. Sometimes it doesn’t.
What does any of this have to do with you as a parent? It means that sometimes you can’t get from point A to point B without encountering some obstacles. It means that some days there are the ‘trains’ of temper tantrums and the ‘school zones’ of kids learning to tie their shoes or eat by themselves. There’s the ‘construction zone’ of picking up the messes left behind from your previous trip to point B before piling in the van for yet another adventure. And this may not even be a car ride. It may just be getting a lesson taught or a room cleaned or a chore done or just trying to navigate a normal day of picking up/bathing/laundry/groceries/daycare dropoff and pickup/dinner/naps/birthday party planning/ad infinitum. The point is, each day is a trip across town, at least figuratively.
One of my favorite sayings is “Leave wide margins in your day”. If you’ve written from margin to margin in your day planner from top to bottom with no wiggle room for the ‘train’, you’re going to be very frustrated when those barriers start coming down right after you missed your chance to use another route. I see this in the office when parents schedule appointments at times close to when they need to pick up a child from school. Perhaps it’s our fault in scheduling, and I’m working on that, but in general, in my world, 2:30 means sometime before 3:00 hopefully. I won’t bore you with the reasons for this, but many of them start with ‘oh by the way’ or ‘would you mind’ or ‘since we’re here’.
A variation/improvement/addition to ‘wide margins’ is ‘surfing’ which I took from a marvelous old Christian writer Oswald Chambers: “The surf that distresses the ordinary swimmer produces in the surf-rider the super-joy of going clean through it. Apply that to our own circumstances, these very things – tribulation, distress, persecution, produce in us the super-joy; they are not things to fight. We are more than conquerors through Him in all these things, not in spite of them, but in the midst of them. The saint never knows the joy of the Lord in spite of tribulation, but because of it…”.
My wife exhibited this just yesterday. As aforementioned, we have moved out of our house to remodel it, but we were able to just sort of move furniture into other rooms and not have to put stuff in storage or anything…until now. She texted me yesterday with the news that we need to get PODS in the drive for our furniture. But instead of griping or a grumpy face on the text, she put a great quote from one of our favorite Christmas movies, Christmas Vacation, by Randy Quaid made while he is emptying the contents of the RV’s septic system into the storm drain. And then she suggested we could put Christmas lights on the PODS! What a great lady!
So…there are two lessons (at least) I want to get across from this ranting/rambling piece.
1)    Leave wide margins in your day. Don’t overschedule and make things difficult. When it’s possible, leave enough time that (gasp!) you might have nothing to do for a few minutes or hours vs. having things timed down to the minute where a train will just wreck the whole day. Let a 3 year old pick out her own clothes, ask him if he’d like to shut the door or turn off the light or would he like you to do it..avoid the obvious areas of confrontation and problems. You know your kid. You know where their traffic lights and school zones are, and you know that sometimes there’s a train. Plan for it.
2)    Learn to surf. So not only do you plan your day to have some downtime or train time, you learn to make the most of it. One commercial (which is advertising I don’t know what, but isn’t that true of the best commercials?) is the mom in the SUV/van with the kids in the automatic carwash as they all imagine monsoon rains and the brushes and pads come at them and they squeal with glee. She’s surfing. So maybe, when you have your kids with you and the train comes, or the school zone light is flashing, or someone pulls out in front of you, you can learn and teach from the situation. Counting railroad cars is interesting business for a while. Looking at the graffiti is sometimes fun. Guessing how long the train is, guessing where it’s going and what is being shipped. Discuss how school zones are there to keep kids safe if they something stupid like run out in the street in their exhilarated stated when they get out of school (since you all homeschool, you can discuss the evils of modern public education and how it’s nice that they don't have to be confined all day in a classroom learning revisionist history and new math and all sorts of subversive brainwash type stuff).
3)    Above all, (that’s why I said ‘at least 2), enjoy life with children. You get in big trouble if you try to dump them on the side of the road, so you’re pretty much stuck with them and really, I know you wanted them sometime in the past. So enjoy them, it beats the alternative. 

Sunday, March 4, 2012

white space

in reading malcolm gladwell's book, Blink, i came across a phrase, a concept, that i find interesting. in a part of the book dealing with decisions made in a hurry that turned out wrong, such as police officers shooting someone because they thought he had a gun when in fact it was his wallet, he mentions that the situation set them up to assume he had a gun and that the circumstances were not such that they had any 'white space' to consider their actions more rationally...they were acting on instinct, in this case, wrongly. the whole book is really a wonderful read and sort of reinforces my notion of balance, in this case between acting quickly and decisively on gut feelings vs. considering/thinking long and hard about a decision. gladwell explores the goods and bads of both. i recommend the book.
now to my point...i find myself providing 'white space' more and more. in my capacity as a pediatrician, i am faced with emails, texts, phone calls regularly that are from people facing a problem and they are wanting advice on what to do. usually it's at night or on the weekend when the 'white space' provision comes up. 'do i need to take him/her to the ER or urgent care for this fever/cough/earache/belly pain/acting weird/possible ingestion of poison/bonk on the head or can i wait and see how he/she does?
this wasn't an issue in the not so distant past when there wasn't an urgent care center on every corner. i'm waiting for starbuck's to add a clinic. even my employer has sided with the devil and has clinics in walmarts. and this wasn't an issue before the news started getting bored with just what was happening in the city/state/nation/world and started running stories on the weird stuff that very occasionally happens to people in otherwise seemingly normal situations. 'he was fine until his shots, hit his head, got a fever, started coughing' name it, 'and then he 'had a seizure, stopped breathing, started bleeding, went unconscious, has never been the same'. mind you, these things sometimes happen. but way more often, they don't. and often the talking heads have to go far and wide to find the story. and of course they wouldn't run a story on a kid who fell off the counter and landed on his head after having a fever of 105 and drinking a bottle of tylenol and eating honey and peanuts together in infancy and lived and was normal. that's boring. but that's normal. but it's not normal if you aren't afforded any 'white space'. if you've just watched the story of the kid who got brain damage and died from a seemingly innocent fall and you hear that sickening thud in the next room and realize it's your baby who just learned to roll over when you thought he was safe on the bed...his dad was watching him while he was folding laundry and just stepped away for a second to shut the lid of the washer so it would start...and you rush in all scared and panicked and set up for an adrenaline-charged reaction (with a heavy dose of guilt because you were watching the news or getting stupid updates on facebook and following rabbit trails on the computer looking for things to worry about so you could avoid all pitfalls in the life of your child when you should have been either the laundry or the baby-watching - send your comments, i'm ready) and you rush to the ER and the goose egg on the kid's head hasn't even gotten a chance to grow. there you run into a doctor who just read an article on 'the effects of traumatic brain injury on otherwise normal children falling from beds at home while supposedly supervised by their parent and who look completely normal and way better than their parents' who is similarly set up to see helicopters landing outside to take your child away if he doesn't act quickly (or he sees lawsuits being delivered on said helicopters because he missed the traumatic brain injury and your child was that rare exception he just read about and you just watched on TV). nobody looks at the child. they do a CT scan. why? because they can. because you want them to. because they think they are supposed to and are justified in doing one. because the hospital owns the CT scan machine and they didn't buy it to toast bagels, they've got to pay for the crazy thing so you'd better use it when you can or your job might be in jeopardy and besides, once you do it you're off the hook and now the radiologist who reads the scan has to interpret it and make the right diagnosis (at least the radiologist isn't supposed to have seen and examined the child first).
nobody considers that the radiation from the XRay or CT scan will add up over time with other 'necessary' tests involving radiation and when the 40 year old kid who somehow survived all those falls off the bed and those jumps out of the swing and stitches and casts now has a weird cancer and that maybe it had something to do with the cumulative radiation exposure from said tests. we're just concerned with the immediate problem.
back to 'white space'. in allowing patients to email me (or text/call if they have found my cell number) perhaps i (and cathy, too, don't forget the cutest little curly headed provider of 'white space' to good Catholics and friends of her daughters everywhere) provide the time needed to slow down and think a little,  the shoulder/s on which to unload at least some of the responsibility, so that all minds can get back to the common sense that says 'he's running around playing, he just ate a crayon and didn't throw up, he's opened my iPhone and is accessing his own apps...wait, he's downloading new apps, who gave him the iTunes password?' and i guess he's fine and i'll stay home and not go to starbucks where they have a caffeine addiction clinic that also sees children and they have a drive thru CT scanner that is begging me to pay for it.
ok. i'm happy to provide 'white space'.
most problems don't need an evaluation right away, if at all.
the reason that 'ER' and all those hospital shows get weird really quick is that the exciting stuff...well, it just isn't that common. it's mostly patients set up to worry about the miniscule chance of a fever and headache being meningitis or a stomachache being appendicitis or a head bonk being an epidural hematoma colliding with a room full of people who are primed for an emergency and whose assumption is that your child has all those things and more until we do enough tests to rule them out.
there's an old medical joke that goes 'an internist, a radiologist, a surgeon, and a pathologist go duck hunting. some birds fly over. the internist looks and looks and says they may be ducks but they might be geese and i'm going to need to run some tests before i decide. the birds fly away. next flock of birds flies over. the radiologist says these birds look to be consistent with the appearance of ducks but are not absolutely diagnostic of ducks unless coupled with clinical evidence to support the presence of ducks. the birds fly away. the next flock of birds come by. the surgeons stands up, starts shooting every bird he can see, then he turns to the pathologist and says - 'find me a duck'.'
we have a lot of information and a lot of ways to act on that information and unfortunately no guaranteed filter through which to sift that information. we're going to miss shooting a duck sometimes, and sometimes something other than a duck might get shot. but in the end, 'white space' allows people to look a little closer at the flock of information and act correctly most of the time instead of jumping to the worst case scenario conclusion quickly and acting on it.
so, maybe 'primary care provider' isn't the best name for us. it's not PCP now, it's WSP.