Be There

So it's been 9 month since my last post. I can't believe how fast the kids are getting bigger. My Giselle is turning into a woman in front of my eyes. Sometimes when I look at her I have a hard time remembering her as a baby and then other times I'm not really sure who she is, because I still remember her as that little girl. I think I savored the young childhood more of Giselle because she was my only one child at the time.

I was pretty sure when we colored Easter eggs last month, that it had only been about a month since we last did it, but in fact a year has passed. I have to remind myself how important these traditions are and that we'll talk about the seemingly small things for years to come. I'm doing my best to "be there". What ever is going on around me with the kids to "be there". If the kids are playing "be there". If I'm cooking to "be there" and let them help me instead of being in a hurry to finish. I'm so afraid the time will have past and I will have missed it because I was trying to hurry through.

I would also recommend when children are vulnerable or ill to "be there". Especially as they get older these moments they need us to nurture them will happen less often. Be less irritated that they are ill and routine is disrupted and take advantage of the opportunity to hold that child that doesn't want to be held usually. Take advantage of the very active child being less active while they are sick and "be there". It might turn into one your best moments.

Injuries and x-rays

Summer has a lot of injuries, which makes a nice change from cold and flu season, except of coarse for the patient. When should you take your kid to get an x-ray of their injury? General speaking; pin point pain is more likely a fracture whereas pain over an area is most likely not. Wrists are much more likely to be fractured then ankles. Twisted ankles nine times out of ten are not fractured, but pin point wrist pain 9 times out of ten is a fracture. If your child can walk on their twisted ankle it is most likely not broken. Twisted ankles hurt below the lateral malleolous, the bone on the outside of the ankle. Pain over the bone or further up the leg is more concerning for a fracture. Most sprains should be improving in 2-3 days, if they are not please come get an x-ray. I have seen recently dislocations and fractures that are 2 weeks old. It's much easier to treat those early on and cheaper to boot.

We treat fractures in the acute setting most of the time with a splint. We don't cast right away. Most of the time there is swelling within the first few days of the injury. The swelling needs to subside before a cast is placed.
The initial treatment for any injury should be ice and ibuprofen and compression if available. A fracture has to heel on its own, the cast is simply there to hold the bone in place while it repairs.

Thoughts, doctors and patients

I was encourage by a friend today to blog about my current situation. I was diagnosed on pathology, meaning on examination of the tissue, after my thyroglossal duct cyst removal with papillary carcinoma. Thyroid cancer. I have since had a partial neck dissection and removal of my thyroid. I had 2 lymph nodes with cancer involvement.

People ask me if it is better or worse to be a doctor and go through this; my answer is both. I see a lot of bad things happen to people, it's just the nature of the job. I figure, pessimistically of coarse, that bad things happen to everyone. So when the call came my first thought was "well this is my bad thing", but then my next thought is "wait, that's cancer!". When I went to have an ultrasound of my neck to see if there was anything more involvement then the tissue already removed, the instant I saw the big lymph node on the screen, I started to get scared. When the endocrinologist who did the procedure looked at tissue from the lymph node and declared it thyroid tissue, everyone in the room knew that it was cancer, she didn't have to say it, there is no other reason for thyroid tissue to be in a lymph node other then cancer. My family kept saying "so when you get the results back you'll know" While it's true that we were waiting for official results from the pathologist, I knew it wasn't going to change anything. That's the problem with being a doctor, you can't shield the patient.

The good part is while it still is scary that I have thyroid cancer, it could be a lot worse. Not all cancers are created equal, some are a lllllooooottttt worse then others. Papillary carcinoma, as far as things go, is really on the good side of things. It's hard to explain to those around me that "I'm going to be fine" really means "I'm going to be fine". I say that with all of the medical statistics behind me. Papillary carcinoma has a 99% 20 year survival rate. That is fantastic. I will still have to constantly be checked to see if it is recurring, but really I'm going to be fine. I know that but those around me don't necessarily understand it and look at me like I'm dying.

Still it was very helpful when a college shared his personal experience with a different type of cancer, he didn't offer any advise, just shared. It's hard not to know what I want people to say and I'm sure it's hard to not know what to say.

Chicken Little Flu

H1N1 is everywhere. About 50% of what I am currently seeing in clinic is most likely swine flu. It amazes me how freaked out people are about this pandemic. I've started calling it the chicken little flu because evidently the sky is falling. Most people are no more sick than from the normal flu. It's just at an odd time of year. H1N1 is so prevalent now that we no longer test for it. If it looks like a duck, quacks like a duck or is it a pig in this case? The best way to prevent flu is lots of good hand washing and basically not letting people cough or sneeze on you. If you are sick you don't necessarily need to go to the doctor unless you are getting worse or not improving. Secondary infections from the flu are not unusual following flu the most common being ear infections and pneumonia. Every year people die from flu. This is really not any different. Most otherwise healthy people are not at risk from dying from H1N1. Tamiflu, which is an antiviral, mostly helps you not be contagious to other people. Mostly we are using it in high risk groups or hospitalized patients. Try not to freak out about swine flu, just wash your hands and stay away from sick people, I personally have a hard time with that last one.

My Adventures as a Patient

Recently I had my thyroglossal duct cyst removed. It is an embryological remnent of head and neck developement that should have closed off but in some people like me persisted as a potential space. I first noticed a lump on my neck about 4 years ago, but when I look at pictures it has been there longer then that. I'm sure I made the ENT's day when I walked into his clinic and said I wanted it out and had already done all the workup.

That being said, doctors make horrible patients. I told the aide taking my tempurature that she had done it wrong and had bounced off the wall instead of the tympanic membrane. My husband says "Stop being a doctor." I didn't tell them again when they were doing it wrong, but I did argue with the anesthesiologist about breastfeeding and general anesthesia. I had researched it and post-op pain control. He did put me to sleep kinda fast. After the surgery when I asked for pain and there was no order for what I wanted I made the nursing staff call and get it ordered. I kept dumping the output(urine) after noting how much and then would just tell the nursing staff, finally they brought me the sheet to chart input and output. The computure in the room to track medication kept spinning up and down so I put it on standby. I made them turn down my IV without an order because I was having some much output. I stripped my own JP drain. I made them take out my IV without an order and told them how to bandage my wounds. I am sure the nursing staff was very happy to have me go home.

Ear infections-- drugs

Sorry for infrequent blogging, evidently when I say tomorrow, I actually mean next week. I blog at work if not too busy, and lately it's been so busy I don't eat. Trying to blog at home is too much of a headache for me with children, hats off to all of you who accomplish that feat. On to ear infectons.

There are three major organisms that can cause ear infection. We usually start with high dose Amoxicillin for ear infections. Sometimes the bacteria have mechanisms in place to defend against the antibiotics we give. Augmentin, which is usually the next step, is amoxicillin plus a drug to fight the bacteria's defense mechanism. Omnicef, which is often the third choice, is a broad spectrum antibiotic. It's like a big missile that wipes out everything in its path. Amoxicillin is not a weak antibiotic anymore then Omnicef is a strong antibiotic. Amoxicillin is a great drug, but more specific like a precision missile that only wipes out a few buildings instead of a whole block. Any antibiotic can cause diarrhea and these often do. Taking some probiotics like lactobacillus when on antibiotics can help. Usually if your child has not been on any antibiotics for at least 2 months we start with amoxicillin again. The bacteria usually have to be exposed to the drug to be resistant to it. We want to use the antibiotic with the most narrow spectrum to cover the infection, because if we keep giving the broad spectrum drugs and your child's infection become resistant to that drug, there are fewer antibiotic choices left and a higher likelihood that your child could have complications with other resistant bacteria. Some children do seem to be colonized with resistant bacteria for whom amoxicillin no longer is effective, but for the most part always start with amoxicillin, excepting of course those who are penicillin allergic.

Ear infection

Ear infections are a secondary infection that usually occur after an upper respiratory tract infection ( runny nose, congestion and cough). Most often your child has been sick for a bit, starts to get better and then develops fever and stops eating or sleeping much. Fluid that has built up in the Eustachian tube gets secondarily infected. Recently there have been a lot of studies in Europe where they actually tap the infected ear and grow them out and they have found that especially in older children, the vast majority of unilateral ear infection without fever are viral. In the realm of 75-80% of them. In children older then 2 without fever and a one sided ear infection I give the parents a script for an antibiotic and tell them to wait a couple of days to see what happens. I recommend the parents continue to treat their child's pain with Tylenol and ibuprofen and I really like the benzacaine numbing drops. I even do this with my own children. I have looked in their ears and they have bad infection I given them pain meds and send them to bed and then they never complain about it again.

In children less then 2 I treat all infections.
More about ear infections tomorrow.