Meth, Medicine and Jury Duty

In the old days, medical providers were often excused from jury duty because of the importance of their jobs, but no longer.

Not that I would have tried to get out of this important (and interesting) responsibility of being an American citizen, but I sure would have like to do it at another time. The fall and winter season is absolutely brutal in a pediatric practice and I tend to work 13-14 hour days. Missing a week of work will put me behind until next May.

However, I know that my job is no more essential than the other hundred people that crowded the jury room. No one seemed particularly excited about being there. I guess I could have petitioned for a postponement, but I am convinced it would have been six months from now when I planned a vacation. I could have told them I had diarrhea, but I didn't.

I rarely win anything, but I did win a seat on a criminal trial. The good news is that it promised to be a short one; only about three days. As we sat there with our impartial demeanors, the attorneys took turns interviewing and asking us question to see if we would be biased or sympathetic or problematic or whatever. I answered those questions truthfully (of course). Yes, I had friends in law enforcement. Yes, my son is an attorney. Yes, I have been a victim of crime (someone stole my wife's car...twice!). Yes, I have treated patients who were methamphetamine users. None of those answers apparently mattered, because both attorneys allowed me to sit for this trial.

My medical knowledge came back to haunt me, however, when I heard the "expert witnesses" on the stand giving out erroneous information about the neurological effects of stimulants. Apparently, they just make things up if they don't know the answer. I did learn a lot about what police officers have to endure to get a drug charge to stick. Later, in the jury room, they turned to me to explain lab results, and the significance of those DUI field tests.

My eleven fellow jurors were nice, local people - businessmen, real estate salesmen, dot.com people, housewives, an arborist - a nice mix. But, there is always ONE in a crowd that rubs you the wrong way. The know-it-all. The bizarre scenario creator. The Doubting Thomas. I now know why they took my little penknife at security. He caused all of us to deliberate for another day. Perhaps it was for the best, since no one should render a verdict when they are tired, frustrated, confused, or annoyed.

What seemed to be a slam-dunk conviction was really more complicated than it seemed, and it was heartening to hear all of those different views from people that I have never met before. Profound insight flooded our jury chamber as we struggled to make the right decision. Medical people seem to tolerate ambiguity a bit better than, say truck drivers, but slowly...and carefully, we came to a consensus with our verdicts. Medical people are used to making important, life-altering decisions within a 15-minute appointment, not something that most people can do and probably not something medical providers really should do.

POSTSCRIPT: The defendent was convicted on all four counts. The jury did the right thing. Subsequently, the judge informed us that this was his third strike.

Related Topics: Does America Have a Meth Problem?, Meth 101

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Head to Toes, Part 2: The Eyes in the Pink

Not wanting to hone in on Dr. Lloyd's eye board, but various eye complaints are commonplace on a primary care office and also frequent questions on the General Health Board. Since my blog description mentions that I will discuss pinkeye at some point, I might as well do it.

In pediatrics, conjunctivitis (pink eye) tops the list. The eyes are quite sensitive to a variety of biological and environmental insults, from colds and allergies to bacterial infections and plain 'ol smog. For parents, anything that makes the eyes red is cause for concern. Schools and day-care facilities seem to consider pink eye in the same serious category as Ebola virus or meningitis. No sooner than a red eye is spotted, the child is isolated and the parent is called...for good reason. Depending on the cause, conjunctivitis can spread like bad rumor.

Viral conjunctivitis is probably the most common cause of pink eye and is highly contagious. It can be very difficult to distinguish conjunctivitis caused by a virus, or one caused by bacteria. Typically, the discharge of bacterial conjunctivitis is more purulent (pus-like, green, yucky). Most of the time, people are prescribed antibiotic eye solutions or ointments, even though the exact cause may not be clear. If it is bacterial, the medication will help. If it is viral, the parents will have something to do while God gets them better.

Putting eye medication in children is often a challenge. In the past, we would routinely prescribe sulfacetamide which burn like Hell. Most of the eye medications we use now do not burn very much, but for an irritated eye even water burns. One helpful way to administer eye medication to reluctant children is to allow them to close their eyes. Put a drop or two of the antibiotic eye solution in the corner of each eye. As soon as that eye opens, the drops will slide home. If the child refuses to open the eyes, you can just pull down gently on the lower lid and the drops should fall in place. The eye does not store more than a drop, so if you have to use several drops to get one in there, you will not have an overdose. The extra eye drops will just run down the cheek or go into the nose.

Several years ago, my PA wife and I went on a one week sea kayaking trip on the Sea of Cortez. As the only medical people on the trip, we were responsible for providing the first aid supplies. My wife took this job quite seriously and put together enough medical supplies for an army unit. We had suture sets, splints, and virtually every drug you could name, including some sulfacetamide solution for pinkeye.

The kayak has very limited storage space, and I was more concerned with the amount of food we were packing, not the medication. As I started to whittle down her pharmacy, I spotted the eye medication. "We do not need pink eye medication. We are all adults. When was the last time you had pink eye?" Her response was that the bottle was small and we are taking it.

Two days into the trip, I had to eat my words (instead of all of the food I packed), for all eight of us had red, oozing eyes. Apparently, after a few days of camping in Mexico, adults take on the hygiene levels of a two-year-old. We had to share that one bottle of sulfacetamide...the only first aid item that we used for the entire trip. And, yes, it burned like Hell. I stopped using it in kids from that moment on. However, I still use it from time to time for very annoying adult patients.

Most of the time, children can return to school or day-care a day or so after treatment, assuming they are improving. It is better if the facilities will allow the medication to be administered during the day.

Hand-washing is the most important preventative method in preventing the spread of infectious conjunctivitis. If the child does not touch or rub the eyes (difficult to prevent), the microorganisms will not jump off of one person's eye onto another. The spread is primarily by hands, or hands to objects, such as towels.

Medical providers certainly have the opportunity, but do not have the time to experience all the diseases that they treat. In spite of our challenged immune systems, we do get sick occasionally. All of us learn from those experiences.

Related Topics: Eye Health, Which Hand Washing Cleansers Fight Germs Best?

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How OLD is your son?

When you give medical advice on the phone, or over the Internet on WebMD, one of the most important bits of information is the age of the patient.

Many years ago, I responded to a phone message from a worried mother. "I think my son has pinworms", she said. Pinworms are relatively common pediatric infestations, the predominant symptom being a very, very itchy butt. Pinworms live in the lower intestinal tract and have a nasty habit of emerging at night to lay eggs along the anal ring and socialize with other worms. I was once asked by a student, "How do pinworms know it is night?" --- an unanswerable question to this day. Pinworms are harmless, but very socially undesirable.

There are three ways to diagnose pinworms: 1. Send a stool specimen to the lab and have the lab tech dig through the poop and physically look for them. 2. Use a "Scotch Tape" test where a sticky plastic paddle is tapped around the anal ring hoping to find some microscopic eggs. 3. Having the parent physically LOOK for the live pinworms crawling around the anus...a task that must be done at night (when pinworms emerge).

I told the parent that she would have to go into her son's dark bedroom at night while he is sleeping. She would carefully pull down his underwear, spread his butt cheeks, and use a flashlight to search for these tiny, white, thread-like worms around his anus. Our phone call became a period of uncomfortable silence.

"He is 16 years old!"

It is very important to always ask the AGE of your patient before answering phone questions.

Related Links: Contagious Creepy Crawlies, Pinworms: Symptoms

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Head to Toes, Part 1: The Problematic Head

The head is the first thing to emerge in the world; assuming the baby is not breech and comes out butt-first trying to make a statement. Throughout the childhood years, the head is often a source of many concerns.

One of the first concerns that a new parent has is head size and shape. Squeezing a head through the birth canal can cause some interesting shapes, sort of like a cone-head. Baby heads often become flat on one side, if they develop a preference for position. Heads can be small; and they can be huge. Assuming that the child is not hydrocephalic, big heads are usually genetic. I once had a father ask me why his child had such a big head, and when I looked at the Dad, he had a head like one of those Macy's balloons. I always tell parents that big brains require big heads, and that their child will more likely become a surgeon or attorney (although some attorneys have pin-heads).

I love baby hair, but parents are absolutely shocked when they see their little daughter with a hairy back or butt. Babies also have very hairy ears, making a routine ear exam quite challenging. Thick beautiful, curly baby hair is a symbol of pride. Bald babies are also pretty cute, even though they look a bit like Uncle Fester. Bald little girls often get pierced earrings or wear some taped-on hair ribbons so as to not be confused with boys. Parents are also concerned when a bald spot emerges on the back of their heads, obviously worn away by head movements. Now looking like a monk, this hair will grow back in time.

Every parent is worried about the fontanelles -- the soft spots. They are afraid to touch it. When my youngest brother was born, I was sternly warned as an 8 year old NOT to touch his soft spot for fear of causing irreversible brain damage. Of course, I did poke him a few times just to see if it would affect his IQ, but alas, he turned out relatively normal (for my family, at least).

Head injuries are another common problem that I see in my clinic. Kids in motion lead with their heads, so this is usually the first thing that meets that pavement. Sometime, they just get a huge goose-egg; sometimes they can a laceration. The scalp has a very rich blood supply, so it does not take much of a hole to cause significant bleeding. New parents panic at the site of blood. Rather than simply put pressure on the bleeding site until it stops, they tend to call 911 or rush them in to my clinic. I saw a child last week completely covered in blood. It took me a good ten minutes to find the tiny hole that caused it. He didn't even need stitches.

Each week, I suture up three or four little heads. Sometimes, I will use surgical staples, but most times, I just use the standard nylon sutures. I even repaired a scalp laceration one time by tying and braiding the hair across the wound. Kids (and parents) freak out about stitches, so if a child does not want stitches, I tell them that I will only use sutures (they are the same thing).

I also tell them, that if it hurts, I will stop, but most of the time, sutures will tickle. They have to promise me they will not laugh. By preparing a child in advance that something may tickle, this is what they will expect. I can count on one hand the number of times that I had to restrain a child in a papoose board (probably not a politically-correct name to use). Emergency Rooms tend to always strap down kids, and it scares the crap out of them (literally, sometimes).

Most children will simply sit still and cooperate if you quietly work with them and tell them exactly what you are doing and why. When I inject the lidocaine to numb the area, I simply tell them I am cleaning the wound. Before they know it, I have a half a dozen sutures in place, they got their sugar-free lollipop, and they are on their way home. Suture removal day is fun, since I always give the sutures back to the kids to put under their pillow for the Stitch Fairy.

Heads also can get head lice (also called the California Scalp Cricket in my office). There is nothing more harmless and more devastating than hearing that your child has head lice. Only one of my five kids (my only daughter) came home with head lice. Her long braided hair probably acted like she was trolling for them. Head lice treatment is relatively easy anymore using an insecticide made from the chrysanthemum plant. This stuff will kill lice and the eggs (nits), but you still have to hand-remove the dead nits. This is where the term nit-picking originated. The best way is to simply pull them out, one at a time. Some people have used mayonnaise, Vaseline, and other egg-removal products, but in the end, parents are always nit-picking. Most schools have a firm no-nit policy before the kids can come back. Regardless of urban legends, head lice do not fly, jump, or come from dogs. Head lice are human parasites. You can blame the dog for random flatus, but not head lice.

Related Topics: Parenting, Got Lice?

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More on Dumping Kids in Day Care

Rather than make individual responses to the many comments on the 4th Trimester post, I thought I would respond in blog form. When I used the word DUMPING, I clearly pushed some very sensitive buttons.

Hold on, I am going to push that button again.

If you were able to ask infants their preference of (a) stay home with Mom or Dad, or (b) go to day-care, what do you think they would say? Infants need to bond with their parents, and more importantly, parents need to bond with their baby.

Each day with a baby is a miracle. Do you want your baby's first laugh to be heard by a stranger? Or, have someone see their first attempts at sitting up or crawling, or take that monumental first step? It breaks my heart to see infants, barely dry from their delivery, heading off to be cared for by others. Every day in my pediatric clinic, I see the angst on the faces of young mothers when they tell me they are going back to work and their child is going to Kid World or the International House of Infants.

Yes, I am very sensitive that it may require two incomes to run many households. I know that single parents have few choices other than working. However, I do know that some working couples are working because they are paying for their own toys: a new car, a swimming pool, new furniture, or whatever. They have some mismatched priorities in my opinion.

Some parents (not all) literally dump their kids in daycare so they can work to pay for toys they really do not need. My issue is with them. They have the ultimate choice and they did not choose their own baby.

For nearly two decades, I taught a seminar exclusively for day-care providers called Pediatrics for Child Care Providers. It was a required class for day-care licensing in our county. I helped child care providers to recognize infectious diseases, how to develop reasonable exclusionary policies, and how to meet the health and emotional needs of the children in their care. Childcare providers are among the most dedicated people on this planet. It is an awesome responsibility to care for children that are not your own.

Kids in day-care get sick more often than children cared for at home. The simple answer is exposure. Before that umbilical cord is cut, powerful protective immunities are transferred to the baby so that they can exist in our germ-laden world.

Breast-feeding augments this maternal immunity, which will last six months or more. Almost like magic, children begin getting sick about age six months. This is when we really start seeing colds, ear infections, pinkeye, rotavirus diarrhea, and more. Babies quickly adapt to the resident germs carried by their parents and siblings, but they are very slow to adapt to the germs of others.

Even the cleanest and most sanitary day-care facility is a hotbed of contagion. Although we dearly love children, their levels of personal hygiene are worse than you can imagine. Kids are nose-pickers, free-sneezers, snot-wipers, and butt-diggers. When you put a group of kids together, the only thing they will freely-share is their microorganisms.

When you put your child or baby in day-care, you can count the days until the first viral infection. Now granted, viral infections help build the child's own immunity, not unlike immunizations, but many children are not ready for this Battle of the Germs. Day-care providers do not charge for this extra immune-building service.

So, your child will get sick. When your child gets sick, you will need to miss work to bring them to a medical office. Many day-care providers will require a note from the medical provider before they can come back, so it could be days before you go back to work. Not only do you lose money by not working, medical care and medications are expensive. Miss enough days of work and you may not have a job.

Perhaps this is the clandestine plan of day-care children. Let's get Mom fired so she will stay home with us.

Day-care is big business. It is expensive, and it should be. Some day-care providers in our county were making less than the guy that cleans the dog cages at the pound, but someone is making a profit. As much as day-care costs, the people that actually diaper and feed your baby are terribly underpaid. Many are day-care providers are mothers who are working in order to get a discount for their own kids in day-care! Do not miss the irony here.

When you add up the cost of full-time day care, the cost of missed days from work, the costs of medical expenses, the cost of gasoline to transport kids to and from the day-care, you better be making a high salary.

Second-income people get hit with higher tax brackets and higher peripheral expenses (like fast-food meals since you are not home to cook). Add it up some day. Subtract it from your take-home pay and divide it by the number of hours that you work and commute, and you will be shocked by how little you actually make. Some parent actually SAVE money by staying home with their kids. Don't just automatically assume you need two incomes. Do the math. I think you will be surprised.

Yes, you may have to cut some expenses and carefully budget, but isn't it worth it to your kids?

What about your career? Put it on hold for a few years, or at least until the kids go to school. Work from home. Work part-time. Find other creative ways of stretching your family budget. Even the pediatricians in my office have reduced their work hours to care for their kids at home. They help out in the classroom, help their children with the piles of homework they get, and they are now able to go on field trips and attend recitals. Your children will only be children ONCE. Don't miss it.

We raised five kids and I am personally ashamed by how little I was home during those most important years. I could cry when I think of what I missed. I made many of these same mistakes that I am harping about now. With age and experience comes wisdom. I was stupid then.

Although it may be a bit too late, I am proud to be a Born-Again Parent. If only I could do it over again.

Related Topics: 5 Tips For Better Work-Life Balance, Are Kids' Diets Harmed if Mom Works?

Technorati Tags: parenting, infants, childcare, daycare

Stomach Flu or My Worst Day in the Clinic...

About a day or so after the first day of school, we start seeing vomiting and diarrhea in the clinic. Typically, these are self-limiting viral infections, such as rotavirus, but troubling nonetheless. As soon as toddlers poop up their backs in day-care, they are excluded. When the 3rd grader barfs in his desk, they are sent home. And, working parents who have used all of their sick days for the next ten years already, will need to stay home and take care of them until they are better.

Like most viruses, the symptoms will last a week if you agressively treat them, and seven days if just leave it alone. The first three days of this "stomach flu" as it is often called (even though it is unrelated to the feared influenza) are the worst. Now, that gets me to my Worst Day in the Clinic story.

As I entered the examination room, I saw a very concerned Hispanic mother clinging to her obviously-ill two year old lying on her lap. This kid immediately failed the "eyeball test" -- if they LOOK sick, they are more likely to be sick. Vomiting is always the biggest concern since dehydration can occur rapidly in these little people. When you are losing fluid from both ends, as well as perspiration from a fever, a child can become seriously dehydrated in a matter of hours.

After my examination, I informed the worried mother that her child would need some medication to control the vomiting; and that this medication will need to be administered in the form of a rectal suppository (If you give medication by mouth, they will usually just vomit it back up). She stared and horror at the thought of inserting something up her little boy's butt. I carefully explained the procedure, but her "deer in a headlight" facial expression did not change. "Would you like me to show you how to do it?" She smiled and said, "Yes, please."

No problem. I went to our medication refrigerator and got a Tigan pediatric suppository and some K-Y Jelly. I greased up the suppository, told the mother to lay the child across her lap. We pulled down his Pamper and I started to explain the procedure in detail.

"First, you lubricate the suppository in your gloved hand". "Next, you spread their little butt cheeks............................

Apparently, the words "Spread those little butt cheeks" was the secret body signal for an explosive release of diarrhea. That innocent little butt absolutely erupted like Mt. St Helen's, covering me, the walls, the floors, and Mom with the most disgusting diarrhea you can imagine. I sat their for a moment in shock, as watery poop dripped from my glasses, and my formerly-white beard. In a malordorous stupor, I emerged from the examining room and called for some help. The nurses ran to my assistance, only to be startled by what they saw. Instead of help, I was greated by laughter...laughter that attracted more nurses. Once they had their fill of amusement at my expense, I was offer a pair of scrub pants...a size that would have been more appropriate for the sick two year old.

So, Rod Moser, PA, PhD, respected clinician, walked to his car, clad in one of those white paper gowns with the open back. Destination: Home to a shower and thorough decontamination.

Related Links: Child too sick for school, Germs in the classroom

Technorati Tags: stomachflu, diarrhea, pediatrics

The Wiener Dance

Those of us who are blessed with grandchildren often revel in their accomplishments. However, as we raised our own challenging children, we often hoped that someday they will have kids that will test their parenting skills. As grandparents, we will sit back, listen to those stories, and just say...YES!

My wife and I raised five very different children. The oldest one, the self-declared leader, was the first to generate those notes that came home from school. There was the incident on the bus where a Coke can was thrown out of a window. Or, the car accident in front of the high school that revealed several cans of well-hidden beer to the police. We had a little shoplifting of gum from a convenience store, some dabbling in mind-altering substances (not that a teenage mind needs altering), but slowly but surely we lead them down a safe, albeit rocky, path to adulthood and the responsibilities thereto.

Out of five adult children, we only have three grandchildren so far: a 12-year old girl going on twenty, a redheaded 8-year old boy that stands out like a lighthouse in his multi-ethnic classroom, and of course, the new baby (another redhead little boy). Other than peeing on people who are changing his diaper, he is much too young for serious entertainment value.

Our granddaughter is really a sweetheart; a good student, voracious reader, and with the minor exception of some annoying eye-rolling, she has been trouble-free (so far). However, we do know that something happens when girl turns 13. Apparently, the tooth fairy, not having any more teeth to process, begins to remove significant portions of their brain. This results in back-talking, lying, sneaking around, and other attributes that we have all experienced or done ourselves at this age. We estimate that we have another year before hormones surge, tempers rise, and home tension escalates to the point we may have another teenager living in our house again. Hopefully not, but we will keep the spare room ready.

My focus is more on the amusing antics of the redheaded 8-year old. At two, he spent a considerable amount of his day in the time-out chair at this day-care for a variety of infractions, mostly biting. One day, my PA wife who works in family medicine saw a child who was bitten by another child at day-care. Apparently some red-haired kid bit him over a toy struggle. A week later, our grandson became the patient, having been bitten back.

When he started Kindergarten, there were two incidents that just cracked us up. First was the incident where he decided to stand up in the aisle of the bus and demonstrate a line dance, holding his two hands near his belt buckle in the traditional cowboy style. Apparently, another sensitive child unfamiliar with this type of dancing thought he was holding his penis, Michael Jackson-style. The school does not take alleged sexual matters lightly and blew this totally out of proportion. At the end of the inquisition, it was determined that no penis actually emerged, and he was exonerated. He was chastised for standing, however. We now refer to this incident as the Wiener Dance.

The seriousness of the Columbine incident should not be taken lightly, but it has sensitized schools considerably. One day (again on the bus), he brandished a weapon from his backpack - a menacing-looking green squirt gun. The bus driver, clearly having a myopic eye out for him since the Wiener Dance, immediately stopped the bus and shouted for him to put down the weapon. Kids screamed and dove for cover under the bus seats. Quickly disarmed of his squirt gun, he again was called before the Principal.

The latest incident occurred in his second-grade classroom during a book report. After his presentation in front of the room, the teacher inquired if he liked the book. In his true and amusing style, he rubbed the book on his butt and said...Oh, baby, baby. Again, with sexual overtones blown out of portion, a note came home. It is things like this that discourage little boys to read. He really liked that book!

I love being a grandparent because I can now sit back and be tickled by these little childhood pranks. Our son (his father) is not quite as amused, but we don't care. I love it and I am not ashamed to admit it. It is the Circle of Life. What goes around; comes around.

Kids are kids. As adults we have to remember that we did many of the same things. Maybe not a Wiener Dance on the school bus, but we were right in there with the rest of the crowd. Before judging the odd behaviors of your children, try and remember that you are responsible for half of their gene pool. Genetically, they may not be able to control some of those things. Schools and bus drives can blow things out of proportion, but loving parents need to have some serious understanding. When it comes to parental discipline, it is best to speak firmly, dish out reasonable consequences, and always carry a soft and understanding stick.

Related Topics: Distant Dads? Not Us, Many Say, How Parents Can Stop Kids' Fighting

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What about that 4th Trimester?

Nearly every day, I see terrified new parents faced with the reality that they now have this little baby....and they don't have a clue how to take care of it. They spent months in Lamaze classes learning how to breathe...relax....and to have an uneventful, natural delivery. But, as soon as that baby enters the world....the parents lose it. The 4th trimester starts at birth and basically ends at age 18 (or so).

I feel really sorry for these frightened new parents. We buy a lawn mower and it is accompanied by a 57 page manual (in three languages) on how to take care of it. But, when we get a new baby...nothing! Parents need classes...raising children is not an easy job. There are lots of books out there for new parents, but parents don't even know which one to buy anymore. It used to be just Dr. Spock (not the one from Star Trek)....or just Grandma.

Thank goodness for maternal immunity, since most new babies rarely get sick until they are about six months old (unless they are dumped off in day-care as soon as they dry). However, those first six months are filled with lots of concerns....pooping too much, not pooping enough, green poop, crying for no particular reason (the child, not the parents), spitting up, not sleeping, etc. etc. When the child reaches six months, sometimes sooner, the illness train begins. Most new parents do not know that the children average about 6-9 viral infections per year for the first 5-6 years of life. That adds up to a whopping 50-60 illnesses before first grade.

Parents are deathly afraid of fever...any fever. They think that the higher the fever, the more serious the illness, and that any temperature in the 103 plus range is surely going to cause permanent brain damage. Medical providers need to sit down with ALL new parents and explain that fevers are really not bad, and actually very therapeutic. Fevers do not need to be treated in most children, although ibuprofen and acetaminophen can really help children that are uncomfortable.

So, children get colds....LOTS of colds. Why? Their immune systems are unchallenged and not a strong as adults. Their levels of personal hygiene are similar to third-world countries. They are lousy handwashers and good nose-pickers. And, they hang around other kids that are equally as hygiene-challenged. But, colds are not all bad. Colds help jump-start the immune system (much like immunizations, but only colds are free) and make us more resilient to other, more serious illnesses.

Oh, and then there are rashes. Grandparents often think that any non-diaper rash is measles...or chicken pox....or Ebola....or something horrible. Most of the time, rashes are just due to our frequent visitor....one of those pesky, self-limiting viruses.

The 4th trimester lasts a long, long time. If you are going to have children, you got to expect to see some illnesses. As this Fall/Winter season begins, my heart goes out to all of the new parents.

Related Topics: Parenting, Childhood Immunizations

My Battery-Powered World

Not wanting to sound like Andy Rooney today, but have you ever stopped and wondered how much of our world depends on batteries? As a child, I only thought of batteries in flashlights, or when the battery was dead in our car. Last night, as I was filling my gas tank for the second time this week, my neighbor drove by in her hybrid-electric car. She smiled and waved. Like the Energizer Bunny, I got the subtle message.

I have a drawer in my office filled with a variety of batteries that makes my world function easier. About twice a year, I replenish my supply from Costco.

Here is my typical day. I wake up about 5:30 AM from a battery-powered alarm clock. Our electricity goes out quite often in our rural area, so I cannot be late for work. I double-check the time with my watch (not a wind-up, of course) and of course, I check the outside temperature with my digital thermometer. I turn on the news with the remote.

After trimming my beard with my battery-powered razor and brush my teeth with my electric toothbrush, I take my shower and head off to work. I don't even think about it when my car starts easily. I arrive at work and push the button to turn on my car alarm and lock the doors. I have a battery-powered calculator and another clock on my desk. I check my schedule on my PDA.

Even my new stethoscope is electronic. As I examine my first patient, I use a battery-powered otoscope, ophthalmoscope, and penlight. If I need a specialized test, there is always the portable pulse oxygen monitor, the tympanogram. And, I never go anywhere without my digital camera and medical flash unit. As a gadget nut, I even have a few ink pens that light up like a neon sign. Kids love them.

I will see at least a few patients today that have hearing aids or a cochlear implant. The rest will have cell phones, IPods, portable video players, or electronic games. I was absolutely amazed when I added the batteries that I depend on EVERY day, and I know I missed a lot of them, since many batteries are stealth.

I love Star Trek, but I am not one of those guys that would go to a convention dressed like Worf. I have always wondered what powers Data, the android, in the 25th century. A dilithium crystal? A tiny nuclear reactor? Or, a 9-volt Eveready that is still working?

Medicine is on the threshold of unbelievable electronic advances, and I am sure we will all have embedded batteries some day, and not just pacemakers or our digital hearing aids. I will be 55 years old this year and I am counting on it.

Related Topics: Baby Boomer Noise-Protection Guidelines (Sponsored), Backpack Creates Electric Power as You Walk

Technorati Tags: batteries, medical devices

The Injured Ear - Ouch!

The injured ear is always accompanied by a story...

One of my medical assistants has a very challenging teenager. He mouths-off, swears, and is very disrespectful to his hard-working mother. Recently, in a spontaneous act of frustration, she slapped him across the face and accidentally hit his ear, instead of the mouth that was emitting four-letter words. Instantly, his hearing changed (albeit, temporary).

Child abuse or not...you be the judge. Did he deserve it? In my opinion, he did not. No child should be hit or slapped, no matter what emotional buttons they push. Adults must have the wisdom and constraints not to strike out physically at their kids (unless they are defending themselves).

Blunt traumas of the ear are one of the most common types of ear injuries. The sudden application of air pressure in the ear canal can occur from soccer and basketballs, wrestling with friends, a blast (from a firework or gun), or an open hand slap. A ruptured eardrum can even occur from a poorly-placed kiss. Blow in my ear and I will follow you anywhere, including the ENT.

Several years ago, I had a 12-year-old girl present to my office with blood coming out of her right ear. She said that a man in a ski mask ran up to her at the bus stop and slapped her ear and ran away into the woods. Yes. That happened. Her shifty-eyed father was not very interested in me calling the police to find this masked perpetrator, reminiscent of OJ Simpson's exhaustive search for the killer.

The bottom line was that he slapped her across the ear and ruptured her eardrum. She did recover physically from this injury, but the emotional scars of being abused by her Dad can go deep. I did call Child Protective Services, as required by law, because I have no idea if this was an isolated incident.

Trauma to the outer ear can also cause lacerations and severe bruising that can result in a cauliflower ear. Most minor lacerations of the auricle can be repaired, usually with perfect cosmetic results. It is not uncommon to have earrings ripped from a pierced ear, accidentally caught on something, or even pulled during an altercation. These, too, can be repaired. Last week, I sutured another teenager that had the crap beat out of him at school, sustaining a cut above his eye, the back of his head, and his outer left ear was bruised. His eardrum was intact, but the appearance of the outer ear is always a cause for concern.

An accumulation of blood in the outer ear (called a hematoma) can result in a permanent cosmetic deformity called a cauliflower ear, unless it is treated promptly. Left alone, the accumulated blood in the ear will be replaced by fibrous tissue and perichondritis (a cartilage infection). We really do not want our kids looking like Mike Tyson or Leon Spinks. (Mike and Leon...this is just a joke. Please don't hurt me) I typically refer outer ear hematomas to a plastic surgeon or ENT specialist so that this blood can be definitively drained and irrigated.

Another type of outer ear injury is the thermal injury. Growing up in a cold climate and not wanting to wear a hat with those furry earmuffs that would mess up my hair, I had some close calls with frostbite. When that icy snowball hits your ear, it feels like it could just snap right off the side of your head. Snow-boarders and skiers tend to show up at ERs during the winter season with some painful, cold-damaged ears. I remember seeing the photos of the doctor who survived that terrible Mt. Everest attempt. His outer ears were nearly gone.

If you are foolish enough to snowboard without a hat (let alone a helmet!) then you better learn some rapid-warming techniques to prevent outer ear thermal injuries. The prompt application of moist, warm (100-104 degree) gauze can prevent permanent damage. Injuries caused by heat are also relatively common. Burns, including sunburns, should also be treated promptly to prevent cosmetic damage.

Q-tip injuries are a weekly posting on the WebMD Ear Disorders Board. For some reason, people feel that wax is dirt that must be thoroughly removed. The probe their ear canals with bobby pins, toothpicks, and cotton-tipped swabs. Granted, earwax is not the most appealing substance on this planet, and no one really likes to see it dripping out of your ear, it is NOT dirty. Short of a public relations campaign to restore the damaged image of earwax, they only thing I can do is continue my personal campaign against people using Q-tips for this purpose. Q-tips do perforate eardrums from time to time -- a very painful experience.

A teen was cleaning her ear a month ago when the bathroom door was suddenly opened by an impatient sibling needing to urinate. The door struck her elbow and the Q-tip plunged deep in her ear canal, resulting in a very impressive rupture that took over a month to heal. Fortunately, there was not permanent damage.

Children do other stupid things. I had the class clown in my trauma room one day with blood pouring out of his ears. Apparently, as the story went, he had a sharpened pencil in each ear, dancing around in an effort to impress one of the girls in his class. Not amused by this display, the girl slapped one of those protruding pencils and jammed it through the eardrum into the middle ear, damaging those tiny ear bones. Had there been a bit more force, the pencil may have killed him. This even makes MY ear hurt telling you about it, but a skillful ENT repaired the damage.

So, the outer ears are more important than just holding up our glasses, or providing a place to hand earrings. It is okay to nibble on them from time to time, but otherwise, treat them with respect.

Where There Is No Doctor

Back in the mid-1970s, I read a book by David Werner called WHERE THERE IS NO DOCTOR - A Village Health Care Handbook, published by the Hesperian Foundation in Berkeley. This book was written primarily for people who live far from the ivory halls of modern medicine, in areas where you have to depend on common sense and common resources to deal with common and even complex medical problems. Published in numerous languages, it is one of the most widely-used community health books in the world. This book did more to influence the way that I practice medicine than any medical textbook, because it helped me form a philosophy of healing.

I have a copy of David Werner's credo on my wall that I will reprint here with implied permission:

1. Health care is not only everyone's RIGHT, but everyone's RESPONSIBILITY.
2. Informed self-care should be the main goal of any health program or activity.
3. Ordinary people provided with clear, simple information can prevent and treat most common health problems in their own homes - earlier, cheaper, and often better than doctors.
4. Medical knowledge should not be the guarded secret of a select few, but should be freely shared by everyone.
5. People with little formal education can be trusted as much as those with a lot. And they are just as smart.
6. Basic health care should not be delivered, but encouraged.

The 1970s and the 1980s were the golden years for the SELFCARE MOVEMENT, the idea that people can and should take more responsibility for their own medical care. I published my first article ever in Medical Self-Care Magazine (which, unfortunately, is no longer published.) I had the opportunity to meet some of the movers and shakers in this growing movement, like Tom Ferguson, MD, who devoted his life and career to education, not just medication, and best-selling author (and friend), Michael Castleman.

I can't help but see WebMD as an extension of this heartening self-care movement. WebMD not only encourages people to become more involved in their own health, they provide instant resources a mouse-click away and the opportunity to have a person-to-person dialogue on Member Boards. Millions of ordinary people everyday log on to WebMDs library of resources every month, and that number is growing exponentially. Ordinary people share their experiences, their fears, their pains, with other ordinary people. We are truly becoming a village that takes care of ourselves.

Most of the world does not have the ability to see a doctor today. They do not have the financial resources, trained medical personnel, modern medicines, or high-tech imaging facilities. But, yet, they survive. We who are blessed with insurance and access to medical care should take a lesson from those who do not.

Something has happened to the consumers of health care today. Insurance makes them feel entitled, and they prefer to relinquish the responsibility of their health to strangers. Waiting rooms are filled with mildly-ill people taking up space and time that could better be served by caring for the more urgent or acutely ill.

Many people are clueless about their hypertension or diabetes or even their cold. Some are so afraid to make responsible health decisions that they don't make decisions at all. Some will experience an earlier death because of they have not taken the reins of their own health.

Tom Ferguson often referred to this as the PILL FAIRY MODEL of medicine. Imagine the doctor as a winged creature hovering above the subservient patient, dropping a capsule of medicine into their eager hands. Not only is this model demeaning to the consumer, it implies that doctors are a different species than their patients. They are not.

Medical providers are not unlike travel agents. The trip you are taking is your own life and you invite a medical professional to help plan that trip. We can help you find the best route to stay well, provide the resources to combat some of life's illnesses, perform the surgeries, but it is YOU are the one taking this trip.

It has been said that if you give a man a fish, he will eat for a day. But, if you teach him to fish, he will eat for a lifetime. As David Werner and so many others have shared, it is YOUR responsibility to take charge of your own health. As you fish for information on WebMD, know that you are among beginning to take charge. When you fail to just swallow what your doctor feeds you, you are taking charge. When you realize that your medical provider is merely a consultant and not the leader of your health care team, then you are taking charge.

The ability to change starts with one simple decision. Isn't it time that we ALL take a more responsibility for our health and stopped blaming everything on your doctor or the system? Remember, we all had a hand in the creation of this system that we now abhor. It doesn't have to be this way.

Related Topics: How Healthy is Your Lifestyle?, 5 Tips to Improve Your Nutrition

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Drug Reps - Helpful or a Pain?

In my Blog about Chaos in the Medical Office, I received a few comments about pharmaceutical representatives that may have an impact on both the daily life of medical providers and patient flow.

Pharmaceutical representatives (hereto called drug reps) have a job. They are required to inform busy medical providers about new medications, new indications for old medications, and provide other educational services.

Yes, they are hocking their wares, but that is their business. Use my drug, not theirs. Mine is better. Mine is less expensive. Their drug causes explosive diarrhea and hair loss. Although they are trained to be respectful of our time, they are also judged by their bosses on how many practices they visit, and how this expensive market effort is working (based on the number of prescriptions that are filled in your local area).

Believe it or not, drug reps do provide some good information, and some excellent patient educational materials. I have some wonderful anatomical posters on my exam room walls, and some great handouts that the patients love. And, I do readily accept samples of my favorite medications. Samples, when properly used, are wonderful. I can give a patient a few days of medications to try it, or give them a day of samples when the pharmacies are closed.

Or, I can provide a full-course of therapy for a struggling family that does not have the resources to pay for their prescriptions. We have a store room filled with expensive infant formula, which I love to give out to needy parents during a well child visit. A can of formula will often save them the cost of their co-pay. Additionally, one pharmaceutical company even provides cases of a wonderful book called Caring for Your Baby - Birth to Year One that we distribute to all new parents, whether they use their formula or not. This is good stuff.

In the old days,drug reps wooed us with many more perks and giveaways that we now receive. Would I prefer an all-expense trip to a resort for a weekend seminar on hypertension, or some more ink pens?

Because of new pharmaceutical guidelines, those trips are now a thing of the past. I have drawers filled with HUNDREDS of ink pens that I do not use - including some cool ones that light up. I have note pads with every drug known to mankind, but yet I write phone numbers down on tongue depressors and paper towels. I have stuffed animals with Zithromax written on them that I give away to kids who have to have a painful procedure. I have a Viagra flower pot with a big 'ol penis-looking cactus poking up out of the soil (I love that). I have worthless paperweights, wind up noses, three-dimensional rectums, and stacks of literature that I do not read. I take some of those things to be nice. I was embarrassed one time when I was caught throwing some things the trash can when the rep returned to give me something else.

I used to work with a family Doc called Dean who absolutely was addicted to ANY pharmaceutical giveaway. Over the years, he collected thousands of eclectic drug rep toys, proudly displayed on his shelf (and now in his home, much to the horror of his wife). One day, I went out over lunch and bought a new blender. I took it out of the box to see if it was made of real stainless steel or not, testing it with one of the many drug advertising magnets that I had lying around. I was pleased to discover that the Augmentin magnet stuck to it.

When Dean returned from lunch, he immediately noticed the blender sitting on my desk WITH the Augmentin magnet. "Where did you get the blender?" Seeing a rare opportunity to jerk him around, I told him that the Augmentin Rep came by and gave us all blenders. Ticked that I didn't get him one, I relished in his efforts the rest of the afternoon trying to call the Rep to get his blender, too.

I can't tell you how difficult it was holding back the laughter when I overheard, "What do you mean you don't what I am talking about. The blenders that you gave the rest of the people!"

I will admit it here. I am a Sushi Whore. Regardless of the topic, I will attend ANY pharmaceutical-sponsored lecture held at my favorite Japanese Restaurant. I can wolf down hundreds of dollars of sashimi, specialty rolls, and sushi without hearing a word. I even sat through an erectile dysfunction lecture - a very important problem that I see in my pediatric practice (right!). I am not happy with myself about doing this, but I do love sushi, and my favorite kind is FREE sushi.

So, I accept nice posters, toys that I can give away to kids, pharmaceutical samples, a few selected ink pens, and yes...sushi, but I do not feel that I am influenced to change my practice style or pharmaceutical choices. If I like a drug, I prescribe it. If I don't, I won't. Simple as that. If I have a busy day with patients waiting, I do not devote even a minute, to spend time with the Reps. They see charts sticking in the doors and on my desk and they see me darting from room to room, and most (not all) while just say hello, and try and catch me next time. And, I will try and talk with them next time, if only for a few minutes. I may learn something.

Related Topics: Drug Industry Pledges New Openness, Heart Drug For Free Could Save Lives, Money

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