All Ears

Life is an Open Blog

2008-10-12T23:56:00.001-04:00

For a busy clinician, I have done my share of writing. I have published more than a few hundred medical articles in lay and medical periodicals. I have written, edited, and published six books, including four medical textbooks. I edited a professional association newsletter for many years, was "Children's Health Editor" for a magazine, and still serve as an editorial advisor for a few more. As an educator, I have written hundreds of classes, lectures, and presentations, as well as many grant proposals. I have written poignant letters to the editor and a smattering of other rants and rages that still surface from time to time. I have written love letters and, of course, letters of apology to my wife. As a 12-year-old, I was a junior reporter for our local newspaper. Basically, I have written things since I learned to write.

When WebMD first approached me about doing a blog, I was not even sure what a blog was. Then, I was not sure I would have the time to do it, along with my busy clinic schedule and, of course, the ENT Board. I agreed to try it. Now, I am hooked.

I don't advertise my blog to my patients, but many have found it. Some will ask, "How's your daughter?" Or, "Did you kill those turkeys yet?" At first, I am amazed that they know these things. Then, I quickly realize they are reading my blog. It is a rare patient interaction when a patient knows that much about their medical provider.

I have shared personal stories with my patients for my entire career. They know I once smoked poison oak. Many know my father died of lung cancer at an early age. Many know about my klutzy son that broke his arm dancing at a wedding, and many will know that I nicknamed my new grandson, Elmo, and why.

There are few secrets when you grow up in a small town. Everyone knows everything about you. My life has always been an open book. Now, my life is an Open Blog. No difference.

Openly talking about your family or patients in a public blog can be tricky. You cannot disclose any confidential information about patients, although I do disclose a lot of family secrets. If I was running for Vice President, there would be little they could uncover. If I had written a personal diary for my entire life, there would be little left to uncover should someone find and read it.

Do I have secrets that I have not disclosed? You bet. We all have embarrassing secrets. We all have past events in our lives that we regret. Knowing that you cannot change the past, requires that we exercise a high degree of forgiveness - for others and for ourselves. We only have the ability to change the present, and the motivation to change certain aspects of our future.
Allowing people to know who you are as a person is more important than having your professional credentials on your office wall. Yes, people are interested in your educational background, but as humans - curious humans - people like to know your character. I am not afraid to share what makes me happy, or what makes me cry. I am still reluctant to discuss the two taboo subjects - politics and religion- with people I do not know. I feel that I know my blog readers well enough to give it a try.

My political beliefs are deeply personal. I cherish honesty and commitment. I will accept a President who exhibits both. I like to see things "get done", not just talked about. I would love to have a President that listens, and one who is articulate when he speaks on my behalf in front of the world. All Presidents have speech-writers, but some truly touch your heart. I grew up listening to John F. Kennedy. He was no angel, for sure, but people loved to hear him speak and he was trusted. I remember many wonderful speeches by Reagan. When I listen to Bush, I just listen for mistakes or errors. As a charismatic speaker, Obama is better than McCain, but I question his ability to lead a very troubled and damaged nation. If McCain is to be our next President, he needs to start working on his speaking ability. You are not supposed to judge a book by its cover, but crappy covers do not sell books. As a people, we often judge a leader by their ability to speak, and of course, their actions. Actions do speak louder than words, but I still like to her the words - the correct words; the reassuring words; the heart-felt words. I am proud of my imperfect country, and just want to love (and trust) a President again.

A physician colleague of mine (Jewish), moved to rural Ohio to practice. When the first words uttered by a patient are "Where do you go to church?" you know you are not in California anymore. People would not see this fine, wonderful man because he was Jewish. Disillusioned by the intolerance of the townsfolk, he eventually moved his family to a more ethnically and religiously-diverse college town in North Carolina. He and his family are so much happier. Ohio lost a good doctor.

I grew up Baptist in a tiny town with a dozen or more different churches. I went to a Baptist college (because they gave me a scholarship, not because of religion). My first wife was strict Catholic (Shi'ite Catholic!). My mentor was Jewish. I absorbed gifts from all of them. My Aunt Norine (now, 95) was my religious teacher. She took me to Church, taught me enough of the bible that I can still answer all of the Jeopardy questions when this category comes up. I took the required religion courses in college and got A's. My Catholic ex-wife introduced me to a community of people who are committed to their ancient faith. Many go to Mass every day, refuse to eat meat on Friday, and send their kids to Catholic schools. My children were raised Catholic. We used to say that the streets are empty in my town on Sunday because the Catholics are at Mass, and the Protestants are in bed sleeping. We didn't have any Jewish people in our town.

My first boss and dearest friend/mentor was Jewish. He invited me to Seder and shared with me the significance of the many Jewish holidays. I sat with his family at Passover. Until his death a few years ago, he was among the most important and influential people in my life. I would have converted to Judaism if he would have invited me.

One of my best friends is a Buddhist. My exchange student's family are Shinto. We had neighbors who were Muslim (and held services in their home) and many friends who are Mormon. I had one aunt who was Adventist. I have colleagues who are Hindu and patients who probably represent every religion on earth. They are all good people, but not because of their chosen religious. They are good people because they are... good people.

I consider myself deeply religious, but I am not a Baptist, a Catholic, or a Jew. I guess I am a combination of all that I have learned and all that I have experienced in my life so far - maybe I am a congregation of one. I do not attend an organized church anymore (I haven't really found one that "fits"), but I feel that I live a good life with the same morals and ideals that encompass all religions. I believe that this is really what a spiritual God intended.

Now, you know even more about me. I feel naked.

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Not a Good Week - Horrible, in Fact

2008-10-06T18:32:00.008-04:00

Photo Credit: Rod Moser

It was late Saturday night when I received the call. Late night calls are either bad news or someone does not understand time zones. It was my best friend, John, and it was bad news. I could tell that by his voice. If you read my blog post on Time Capsules posted a few weeks ago, you saw John's family. In the back of the photo, sitting next to him, is his 25-year-old son, Sam. He is the muscular one with the tattoo on his arm. John was calling to tell me that Sam had suddenly died a few hours prior.

Sam was preparing to watch a TV show with his mother when he seemed to be getting sleepy. When he stood up, he collapsed to the floor. He held on to the wall and went outside for some fresh air. A very short time later, he was found unconscious in the front yard. John tried desperately to resuscitate his son as Sam's mother called 911. So far an autopsy and toxicology report have not revealed the cause of his untimely passing. Sam was just 25 years old and he was just getting his life in order after a few set-backs. Tomorrow, I will give the eulogy at Sam's memorial service.

There is no pain greater than the loss of a child and my heart was literally bursting with sadness for our friends. Our five (adult) children are equally as saddened, since they were literally raised with John's sons. They swam together; played together; and ate together. We were family. Two of our grandchildren, Shelby and Dylan, were present when that Time Capsule was opened, so they remember Sam very well. He was the happy one; the one that talked to them and the one that laughed with them.

Yesterday, while returning early from a car trip to Southern California, we received a call that our grandson, Dylan, age 10, was rushed to the hospital and admitted to intensive care after collapsing after church. Dylan was playing basketball with some other children when he suddenly felt dizzy. He collapsed to the floor, striking his head, and remained unconscious for about twenty seconds. For unknown reasons, his pulse rate dropped to 40; he was vomiting and confused. Concerned that his unconsciousness was triggered by an unknown cardiac event, perhaps complicated by his head injury, he has been undergoing some extensive heart tests as I write this Blog. So far, all tests have been normal.

My PA wife is beside herself in worry. She did not sleep a wink last night. Dylan is her "boy". Of course we rushed directly to the hospital. This was the first time that my wife did not complain about me driving too fast. By the time we arrived, Dylan was complaining about being hungry. He had ordered some movies from the hospital library and was requesting someone to scratch his back (my wife's primary job when they are together). He is wearing a 24-hour heart (Holter) monitor and will be getting a stress test (treadmill) this evening. This event IS my wife's stress test.

Queen Elizabeth used to term Annus horribilis, referring to her horrible year. I am not a scholar of Latin, but I think these last seven days can be termed Septimanis horribilis, or horrible week.

Tomorrow, I must keep my composure long enough to give the eulogy that I have prepared for Sam. On the way home from the memorial service, we will visit Dylan. I suspect that he will be playing basketball again, like nothing has happened.

Life is so short and so precious. Why must it be so painful?

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Names and Nicknames

2008-09-29T07:22:00.003-04:00

Growing up, we all had nicknames. There was Bird, Thumpus, Special, Getchaoutside, just to name a few. In college, nicknames were mandatory, like Alf, Hally, Charlie Trombone, Quickdraw, and Irwin. Of course, I had a nickname, too. It was a legacy, since my brother (Larry) had it first. Our nickname is Moe. My brother has a son that took over the nickname, but my son, Ryan, never fully adopted it. I even gave him my gold ring with the raised letters, MOE, on it. A few people refer to him "Mo" (without the "e").

I grew up with the Three Stooges and my favorite Stooge (if you had to pick) was Moe, the self-appointed leader. My brother's real name was Larry (Well, Rupert actually), so that seemed to be a good fit for a nickname. We didn't have a Curly, but my step-father was a spitting image of him.

In Japanese, Moe is pronounced "Moe-eh" which means "love of characters". One of our Japanese exchange students has a niece (Yes, a girl) name Moe. I was honored.

I have a grandson named Dylan, which is a nickname cornucopia. From time to time, he gets Dilly, Dill Pickle, Dilbert, or simply, Dill. The guys on his Little League team call him Dee. When he starts Junior High, I am sure there will be other names less cute or flattering.

I am pretty good at creating nicknames. I have taken my share of punches during my formative years when the nicknamed person was not as enthusiastic. I recently won the "Name the Skeleton" contest at our new Medical Museum. It immediately came to me. Her (a female skeleton) is Anna Rexia. I have such a gift.

Yesterday, I was informed that my youngest son and his wife will be having a little boy. We knew she was pregnant for several weeks now, but yesterday was the ultrasound, or as I like to call it, "The Wiener Hunt". My daughter-in-law desperately wanted a little girl, but Nature has a way of serving up surprises. They are going to have a little boy; my first biological grandson. I have three other grandchildren from my wife's lineage. My son is elated, of course. They had picked out a name well in advance of the ultrasound. Regardless of the sex, the baby will be named, Ellis. Ellis Moser.

Ellis? A very nice name; somewhat atypical, but that is what makes names unique. My son, an avid Oakland A's baseball fan, said this is the name of the second baseman, Mark Ellis. Ellis is also the name of a famous island, perhaps an entry point of some of the ancestors. The grandmother's family - intensely Catholic - emigrated from Czechoslovakia in the early 1900's, so perhaps they came through Ellis Island. My family emigrated from Germany in 1790, so we were already here; way before Ellis Island. We probably co-mingled with the Native Americans (No, not the Mo-hicans!) I do not know anything about my daughter-in-law's family ancestors, except that they are Jewish. Perhaps, they came through Ellis Island. My grandson, Ellis, of course, will be Jewish through this proud, matriarchal line.

So, it is either Mark Ellis, Ellis Island, or they just liked the name, Ellis. Either way, we are going to welcome Ellis Moser with loving arms. Is he going to have a nickname? I have no doubt whatsoever.

It can't be Elly - much too feminine. It might be Moe, but Moe is a very unusual nickname for a baby. Moe Howard of the Three Stooges was Jewish (so was Larry and Shemp), but no, that isn't going to fly. There is Moe Szyslak from the Simpson's, but he is not really a good role model for my grandson, even though he invented the Flaming Moe. There is the Pep Boys - Manny, Moe, and Jack. There is Moe-hammad? (Oops, sorry about that. Please don't issue a fatwa; it was joke.) Maybe, he can be nicknamed Elton? (Great singer and composer, but flamboyant lifestyle) Or, Elwood? (One of the Blue's Boys) How about El-beau? No, too anatomical; perhaps, too Middle Eastern. Then, it hit me! His nickname will be Elmo. In Spanish, it would be El-Moe! The Moe. I ran nickname scenarios with some of my new parents of little boys. The fathers immediately guessed "Elmo" as the most logical nickname. I would like to know what YOU think, too.

In my pediatric practice, many babies, even the unborn ones, get nicknames. An excited four-year old once told me that she was going to Scooter's doctor's visit tomorrow. Scooter was what she called the tummy-baby. That has been several years ago now. Scooter (real name, Scott) is now one my patients. The nickname stuck. Maybe that is how Scooter Libby got his name?

Elmo. Why not? My daughter-in-law is an elementary school teacher with a special education masters. Elmo the Muppet from Sesame Street is an educational icon (good dancer, too, if you tickle him). Elmo was the only Muppet to testify before the U.S. Congress, urging support for increased funding for music education.

I work in pediatrics, and we have Elmo stuff all over the place. One of the other pediatricians actually wears Elmo clothes. There was a St. Elmo (aka, St. Elmo's Fire), so this may please the Catholic side of the family. And, most of all, Elmo is a damn, cute nickname. I love it. I suspect my son will think it is funny (he shares some of my warped sense of humor) but Elmo's mother may not immediately embrace it. Every child needs a cute nickname, so I am getting my dibs in first. If I have to secretly call him Elmo, so as to not offend anyone, I will.

As I write this Blog, my nickname campaign has begun. My wife is heading for Toys R Us to get a talking Elmo doll. I asked her to make a Sesame Street quilt, with Elmo in the center, of course. I have no idea if the nickname, Elmo, is going to stick. My son hopes it will be just "E". Borrrring!

I just can't wait until February so I can tickle me a REAL Elmo.

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Spoiled Rotten Kids - Part Two

2008-09-26T07:00:00.003-04:00

Children that are from financially-privileged families, those that seem to have all of the best toys and the best opportunities were discussed in Part 1. I would now like to comment on the "other" spoiled rotten kids - the ones that lack discipline, respect for parents and other adults, and the one's that seem to get away with murder (hopefully, figuratively).

We all see them. They are the one's screaming in the cereal aisle at the grocery store; or the one's having a fit at the kid-height candy stand at the checkout. We see spoiled rotten kids in restaurants, school functions, and at the sports fields. Day-care and preschool providers live with them every day.

A pediatric office is a place to do an anthropological study and child-parent interactions. When children come for medical care; either when ill or for preventative services, they do not come alone. One or both parents are usually accompanying them. More often than never, a cadre of siblings will also be there - as interested observers or annoying distracters. Grandparents also tag along from time to time - a true family reunion. The smaller the examination room; the more people there are; trying to find places to sit among the automobile-sized strollers.

At least one child will be on my roller stool, spinning around or trying to stand on it. I took the liberty of posting some basic exam room etiquette "rules" such as don't play on the stool, don't take out all of the gloves from the drawers, don' t take out the pelvic exam stirrups, or play with the expensive instruments. We like to give out stickers and sugar-free lollipops to the little ones, but I have to remind parents every day not to do this until AFTER the visit. They may be sugar-free, but they are not sticky-free. And, there is nothing like seeing a child with a sore throat who has been eating a red lollipop or drinking red Hawaiian punch before I had a chance to examine him.

One day, while sitting in my office typing some notes, I heard one my rolling stools flying from one end of the exam room to the other. Clearly, some oblivious parent was allowing the child to play on it. Since I had one child that kick-launched himself into the corner of a cabinet a few weeks prior, cutting a big gash in his head (I had to put in 5 sutures), I knew I needed to intervene. When I opened the exam room door, I did not find a child on the stool, but rather a Dad happily lying on his abdomen; darting from side to side, using his legs to kick off. He was embarrassed. Good.

When you open the exam room door to enter, you are rarely surprised what you will find. It could be a mother happily talking on the cell phone ("Gotta go. Doctor just came in.") while the child has taken all the exam gloves out of the box and put them on the floor. Or, they are tearing the pages out of the children's books that I brought from home. Those books survived five of our kids, only to be destroyed by an unsupervised child.

I encourage them draw on the exam table paper to occupy their time while waiting. The older kids can play Hang Man or Tic-Tac-Toe; the younger one's can scribble or draw pictures (often very cute). Unsupervised, the younger ones go beyond the table and try to decorate the walls. I completely gave up on putting up anatomical and educational posters because they just get ripped up. My PA wife was smarter, she had hers laminated.

All of these breaches in common etiquette reflect directly on the parent's ability or inability to supervise or appropriately discipline their children. Parents who do not let their kids jump on their living room furniture will allow their children to jump on mine; even with muddy shoes. Parents who do not permit their children to eat crackers in the living room, will allow children to drop them all over the floor, only to leave without offering to clean it up. There are so many cheese goldfish on my floor some days that I could survive a famine.

It is good that parents do not hit their children anymore, but that does not mean a parent should allow a child to hit them (or me). I see toddlers punching their mothers in the face, and I have had several toddlers try to take a bit out of my leg. Granted, toddlers are not a good example, because most are inherently mean. The Terrible Twos tend to start at age 15 months with stranger anxiety, and supposed to end before age three. Some children will carry whining and tantrums well into their teen years and beyond.

Thankfully, undisciplined children are not the majority. Most of my little patients are delightful and respectful - this is why I love pediatrics. Most parents are wonderful; especially the Moms (Some Dads are clueless, I have to say). I am heartened when I find a sulking child sitting in the corner in "time out", or the peripheral entourage of kids quietly reading, listening to music (with headphones), or doing their homework. I am delighted when I see a parent reading to a child, instead of talking on the phone while their child destroys the books.

I love it when I see a parent stick to their guns. No means no. It is not negotiable. If you don't behave, you will not get a lollipop. Twenty minutes later, I will see that same child decompensating down the hall, screaming that he wants a lollipop. I told you. You wouldn't listen. Maybe next time you will get one.

I think I can handle undisciplined children (and their parents) quite well. After thirty plus years in this medical business, I don't hold my tongue anymore. I will intervene if I see a parent being abused by a toddler, or a teenager being verbally disrespectful to parent. I will also proudly comment on excellent behavior when I see it; both to the child and the excellent parent.

Positive discipline goes a long way. Children need boundaries and limits. They need to experience disappointment and logical consequences; as well as receive rewards and accolades for positive acts. They need to see examples of acceptable public behavior from their parents. The "Don't do as I do, do as I tell you" approach to parenting just doesn't work.

Lastly, children need attention and they need love. When they seek out parental approval, they should get it. When they try to please, it should be noticed and acknowledged. And, when their behavior is inappropriate, regardless of the setting, they should not get away with it.

All children are good. Good children occasionally do bad things. Bad things have consequences. Good parents have the ability to discipline with love.

Spoiled Rotten Kids - Part One

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Spoiled Rotten Kids - Part One

2008-09-24T14:00:00.005-04:00

There is nothing like a pediatric practice to demonstrate a wide variety of parenting (or lack of) styles. I see 'em all. Can you really have children who are considered spoiled rotten?

A well-cared for and loved child may be viewed as spoiled rotten, but these are not the kids I am talking about. I am talking about the kids that have the best of toys, the finest designer clothes, and devoted parents who make sure the get the best of everything. I see kids with expensive iPods, their own, high-tech cell phones, and some pretty impressive toys. I have teenage patients who drive better cars than I drive (I actually have issues with that one). If people have the financial ability to provide their children with those things, then who are we to judge?
We helped all of our kids (all five of them) buy used cars when circumstances dictated that they needed them, such as sports practices, college, or after-school jobs. Most of our kids were grateful; some were miffed that we didn't lease them a BMW, like Kim's dad.

I said, "Why don't you call Kim's dad and see if he will get you one, too."

Some of my older patients are heading off to the universities - Stanford, UC Berkeley, Cal Poly, Yale, and Harvard. Their parents are forking out a King's Ransom in tuition. Of course, I had to work my way through school by dumping bedpans and feeding old geezers, but I am not jealous. I am not jealous because I couldn't have been ACCEPTED to those schools, let alone afford to go there. I am justifiably humbled by their accomplishments and tell them so. From a financial point of view, I am glad that my kids attended state schools. It was hard enough with four of them in college at the same time. Thank God for student loans to postpone some of those costs. We only have one more left in college, which is good since I would like to retire some day.

I have one father who built an Olympic-class pole vaulting run in his backyard so that his son could train. Parents travel the country with their kids who are in competitive soccer leagues. We have several friends who sent their kids to Europe (for fun), and one who sent their son to Japan to study the violin (he does not play the violin anymore). My heart goes out to the families that support their children in sports or other pursuits. Special kudos to Michael Phelps's mother and all those like her. I was not a promising athlete or musician, so my parents didn't have to shell out squat. My parents chose not pay a dime toward my college education, either.

A large number of my little patients attend preschool - some of the more prestigious (and expensive ones). My kids went to Montessori School - about thirty years ago now - and I was shocked by the costs then. I was amazed that it cost more for my daughter to go to Montessori for one year than it did for me to get a graduate degree at UC Davis. She even had more fun that I did. Nowadays, I have no idea how parents can afford to send their kids to private preschools and schools. I guess you can't put a price on good education. Wait! Yes, you can.

My wife did attend a snooty private school outside of Boston when she was in high school. It was the same school that her mother attended, so it was sort of expected that she would go there some day as well. She even had classmates named Muffy and Winky (I am not kidding!). In Appalachia, I had classmates named Cletus and Buck. She went to school with crowned African princes, movie star and politician's kids. Many of my classmates went to jail, or quit school in junior high to work in the coal mines. My wife and I both work in the same clinic and get the same salary. We are equal in every respect. She just has better class reunions that I do. I tease her about her private, finishing school, but I would have given my right arm to go there. Her tuition was a subsidized $6,000 a year in the mid-1960s - a lot of money in those days. It is $43,600 a year now. Even adjusted for inflation, that is still a huge tuition.

Do children appreciate things more if they have to work for them? Perhaps, but if they have a choice, they would prefer that you gave it to them Scott-free. The first car that we gave our kids was a very used Olds Vista Cruiser station wagon with faded wood grain on the sides; like the one Chevy Chase drove to Wally World - not what you would call a Babe Mobile. We found out that they parked it a few blocks from school so that the other kids would not see them in it. Very few of our kids dated seriously while in high school; perhaps, due in part to this car - our BCV (Birth Control Vehicle).

We didn't pamper (actually we did use Pampers) our children; and they seemed to turn out just fine - an attorney, two engineers, a registered nurse, and hopefully, an MBA in marketing. They don't drive fancy cars; they go to work everyday, pay their mortgages, and the ones who have children do not pamper them. Our grandchildren go to public school (those that are old enough). If anyone spoils them with toys and gifts, it is us; my wife, actually - 'Ol Giftin' Grammy.

Spoiled Rotten Kids - Part Two

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Ear Infections: Why Every Parent Should Own an Otoscope

2008-09-04T09:00:00.001-04:00

When you buy a new lawnmower or washing machine, you get a huge instruction manual or even a tool. When you get a new baby, you really get zilch, unless you go out and by a few books to read up on children's illnesses, and collect your own, home "black bag". I have always felt that education is much better than medications. Education also lasts longer, is less expensive, and has little or no side effects. And, speaking of medical tools... for ear infections, you just need a good home otoscope and some dedicated practice.

A large percentage of my day is dedicated to dealing with suspected (or real) ear infections, so I spend a considerable amount of time with parents - especially NEW parents - on how do deal with simple ear infections. These are TEN educational EAR points that I like to make:

Not every fussy and feverish baby has an ear infection.

Just because a child pulls on his ears, it in no way means they have an ear infection.

Just because they had one ear infection in the past, does not mean they will be getting another one soon.

Ear wax is not dirt and should not be removed (unless you can see it at the ear opening). Q-tips have no place inside the ear canal.

The amount and consistency of ear wax is genetically-determined. There is really nothing you can do to prevent it, but you can blame your parents.

Nearly all ear infections are painful. Some are simply annoying due to the stuffiness. Painful ear infections should be treated with pain medications, too. Every ear infection does NOT need an antibiotic.

Getting water in the ear from bathing or swimming does not cause MIDDLE ear infections. It can cause otitis externa (swimmer's ear); an entirely different issue.

Children who have tubes can still get middle ear infections. Tubes last about a year if you are lucky; and will fall out when they want - no matter how much you paid to get them put in.

Adults can get ear infections, too. Adults occasionally need tubes, just like kids.

Parents with children who have ear infections or who are prone to wax impactions should own a good otoscope and learn how to properly use it.

Some children are more prone to ear infections, either genetically (narrowed eustachian tubes), short/stocky neck, or by other risk factors. Some of the risk factors for middle ear infection in children are:

Colds: Children get 6-9 colds per year, any of which can set the stage for a middle ear infection. Preventing the colds would prevent ear infections, but preventing all colds is really impossible. Children in day care get many more colds than those cared for at home.

Day-care Attendance: Children who attend day-care, especially as an infant, are just asking for ear infections. The smaller the day-care, the less biological exposure a child is likely to get.

Allergies: Just like colds, allergies can help set the stage for middle ear infection by contributing to stagnant fluid in the middle ear space, or by clogging eustachian tubes. Identifying the allergen may not be particularly helpful.

Smoke: Exposure to secondary smoke from cigarettes (or even wood-burning fireplaces in the colder climates) can make a child more prone.

Night time bottles: Bottle fed babies get more ear infections than breast-fed babies. Breast milk is loaded with disease-preventing immunoglobulins. Babies that are handed a bottle to hold at night (and drink while lying down) are definitely at risk.

Pacifiers: Sucking on pacifier all day helps create negative ear pressure (ear pressure is supposed to be equalized to the outside atmosphere) and is a contributing factor. Using a pacifier for a short time at naps or bedtime may not be that problematic.

Poor hygiene: Most respiratory viruses enter the body through the nose or when a child rubs the eyes with unwashed hands. Efforts to promote hand-washing, discourage nose-picking, or nose/eye rubbing would reduce viral exposure.

Adenoids: Children with large, obstructive adenoids - the ones with a nasal quality voice - and the ones who snore like lumberjacks, are more prone to ear infections. Children with just big tonsils are not considered at risk.

Family History: If both parents had middle ear infections (or tubes) as a child, then the apple does not fall far from the tree - they may have children who are equally as ear infection-prone.

Over-treatment: Middle ear infections in children are definitely over-diagnosed and over-treated. Antibiotics are often inappropriately prescribed; too often and too soon. Allowing the immune system to naturally fight off these common infections for several days can go a long way in preventing recurrent middle ear infections. Just because an eardrum is pink or even red, is not a definitive sign of an ear infection - it is only a presumptive sign. The vast majority of ear infections in children over six months of age will go away...on their own...without antibiotics...IF you give the body a chance.

Making a decision to take a more active role in your child's ear infections is a huge decision. You have to do your homework and read as much as you can - in books and online - about ear infections. You have to avoid those non-medical sites that promote scientifically unproven "miracle" cures like herbal drops, chiropractic adjustments, ear candles, etc. Most are a waste of money; some are potentially dangerous. And, you MUST have a good otoscope and know how to use it.

It takes your doctor years to get good at using an otoscope, and I have to say that many well-trained medical professionals are STILL not very good at it. At the home level, all you can do is observe the appearance of the eardrum. Since home otoscopes do not have pneumatic attachments (that little bulb syringe that is attached to the professional models), novice home-otoscopers will not be able to observe eardrum movement/mobility - perhaps the MOST IMPORTANT component of a comprehensive medical assessment of the ears, and unfortunately, the component most likely skipped by your medical provider. Don't ask me why they gave it up.

I was searching eBay and found dozens of otoscopes, including some ancient ones that you should avoid, and some professional models that parents really do not need. There are several really good NEW home otoscopes ranging from $20 or so to a $100 at various Internet sites. You definitely need one with a good light source, and one with fresh batteries, but you don't have to spend a lot of money.

Parents who practice using a home otoscope can get darn good at it. The more ears they see, the better they get (just like your doctor). By examining children (and adults) when they are well, you will get a good idea what normal is; and you may be able to avoid many of those medical "false-alarms", high insurance co-payments, and time off from work.

You will still need a cooperative, trusting partner - namely, your medical provider. Most will require medical confirmation of an infection before blindly issuing an antibiotic (should they be needed). You also need a supportive medical provider that is not going to pooh-pooh your newly-acquired otoscopic skills. Most medical providers will be happy with any effort to reduce unnecessary antibiotic use, including offering WASP prescriptions (means "Wait and See Prescriptions").

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Life Lessons from Dr. Moser

2008-08-22T16:50:00.001-04:00

Lesson 1: When you need help moving, your friends and family have other plans.

My adult daughter needed some help moving to a new apartment. Her father (me) just happens to own a truck and trailer. I offered to help as long as she could line up some of her buff brothers and their friends to carry the big stuff. One brother (who also has a truck) was out. He had knee surgery for a meniscus tear earlier in the week. The injury occurred from coaching Little League baseball (don't ask). Two other brothers live out of town. And the last brother suspiciously wouldn't answer his cell phone.

Of course, her new apartment is on the second floor requiring a tricky navigation of wooden steps, turns, and other hazards. My daughter did find two friends to help on day one, but day two was all my wife and me. There is nothing I love to do more than lug a big couch, heavy shelves, and mattresses up a few flights of stairs.

My daughter has agreed to provide a home for my parrot, Dorian. Dorian is an African Grey and is about 30 years old. Besides myself, my daughter is really the only person that can handle her. Dorian was a male (presumably) for nearly 16 years, until he/she decided to start laying eggs on a regular basis. Of course, she does not have a mate (other than me), so the eggs are just for practice. Dorian does not like my wife, or cats. I have both, so she is going to live with my daughter, at least for now.

Lesson 2: When someone hits your vehicle, they develop memory loss.

I had an interesting weekend, highlighted by being involved in a four car accident on the freeway. I not exactly sure what went on behind me, but there was a lot of screeching of tires and swerving, quickly followed by the thud of a large object hitting the side of my trailer. This, of course, caused a little butt-tightening fish-tailing, but I was able to control it and pull to the side.

A young boy stopped behind me. He said that he didn't remember hitting my car, but the paint on my trailer did match the paint on his passenger side door and I did have a bit of his green paint on my trailer - an odd coincidence. And I thought I had a short-term memory! As much as I can piece together based on witnesses who stopped, two other vehicles tried to occupy the same lane, causing them to hit each other, and so forth. I was just an innocent bystander, traveling along minding my own business. Now, I will need to get my trailer fixed...

Lesson 3: Heavy books should be packed in little boxes.

Several of my daughter's heavily-packed boxes contained books. One cardboard box must have weighed three thousand pounds (perhaps, I exaggerate). Some smaller boxes seemed to contain helium balloons or cotton. Being the only male in the Sunday moving crew, I was assigned the heavy boxes, of course. So, instead of lugging a huge box of books up the stairs, risking a hernia, I had to repack the boxes at the bottom of the stairs, or carry up a stack at a time.

Lesson 4: Turkeys do not respect landscaping.

Large amounts of bark have been appearing in my lawn along the edges of the planters. I rake it back, but the next day it appears again. This weekend, I caught the culprits - a family of wild turkeys; Mom and her seven juvenile (delinquent) turkeyettes. My dog happily chased them away, but they simply walked back in a few minutes and continued their ongoing destruction of my landscaping. I don't mind them eating the bugs, but I do mind the excavation. This morning, the devastation was even worse.

Ever since we seriously reduced the family of coyotes living on our hill, we have been up to our butts in turkeys. When the coyotes finished eating the turkeys and rabbits, they ate my favorite cat, George. It is just one ecological disaster after another in the Sierra Foothills.

I guess I could lay out some feed and fatten them up for Thanksgiving. The last time I killed and ate a wild turkey was when I was a high school teenager in Pennsylvania. It tasted pretty bad; very stringy - certainly not as good as those hormone-injected and artificially-fattened store birds.

I spent some time on the Internet researching turkey repellents; and yes, there are such things. I have not decided if I am going to spend the money and buy one though. Maybe I will see if I can get the coyotes to come back.

Lesson 5: If you don't want to tramp in dog poop, walk in the grass.

I take a lot of pride in my lawns. They are green and lush and I water them regularly when our irrigation system is functioning. We have two dogs and about three acres for them to roam and poop wherever and whenever they want - sort of a Poop Heaven. Do they poop in the lawn like most dogs? No, they poop in the sidewalk; right in the middle where a human walks. Perhaps they do not want to be eaten by a rogue coyote during their morning constitution; or perhaps they do not want to get grass on their feet. Regardless of the reason, my sandals seemed to have some sort of poop magnet.

Lesson 6: You can't spend $20 at Costco.

I needed a box of copy paper. It was cheaper at Costco than the local stationary store, so I stopped on the way home. I ended up spending over $200 on stuff that I really didn't need, and they didn't even have the proper copy paper. I had to buy it at the local stationary store.

Lesson 7: Always look in the mirror before you leave the house.

I wake up about 5:30 AM, partly due to the dogs and partly due to my own bladder. I tend to have plenty of time to have a leisurely cup of coffee, watch the news, take a shower, and get dressed for work. I have never been late for work in my life. This morning (Monday), I was a mile from home when I noticed that I had not dried or combed my hair after my shower. It had that same, spiky look when you towel dry it. I had to go back home and finish my grooming. I still made it to work on time and did not spend the day looking like a derelict.

Life truly is a on-going series of lessons.

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Dealing with Swimmer's Ear - Even If You Don't Swim

2008-08-19T07:35:00.004-04:00

Summertime is the season for swimmer's ear, medically known as otitis externa (OE). Basically, OE is a skin infection that just happens to be in the ear canal. Ninety percent of the time, the opportunistic organism that causes OE is a bacterial. About 10% of the time, it is fungal.

The ear canal is a warm, dark, most tunnel about 2.5 cm long, lined with sebaceous (oil) and ceruminous (wax) glands. A healthy ear canal is lined with a thin layer of acidic wax, protecting this sensitive skin from water and moisture, as well as inhibiting bacterial and fungal growth. The shape and angle of the ear canal allows for natural drainage of excess wax and debris. When these natural, protective measures fail, otitis externa can result.

In the summer months, people love to swim. Combined with the warmer (wax-melting) temperatures, moist perspiration, and excess water exposure, it doesn't take long for this protective wax coating to be depleted. Showers and bathing can also be factors. Year-round, we often have another underlying culprit - the frequent use of cotton-tipped applicators (Q-tips), or other instruments (paper clips, bobby pins, fingernails, etc.). If you happen to have a dry, itchy skin condition like eczema (atopic dermatitis) or psoriasis, this can occur in the ear canal as well.

Because the ear canal is rich in sensory nerves, OE is considered one of the more painful ear conditions. It can come on slow over a week or so, often starting as an annoying itch; or it can come on painfully fast with profound pain, swelling, or even drainage from the ear canal. It can become so painful, in fact, that people often cannot even touch their ears. OE is one of the many causes of ear pain that does not require an otoscope to diagnose.

The classic MIDDLE EAR infection, common in children, does not cause pain when the outer ear is moved or the tragus (the little flap of skin directly in front of the ear canal opening) is compressed. More often than never, if it hurts to move the outer ear or push on the tragus, you most likely have OE.

OE can be somewhat challenging to diagnose and treat. If the ear canal is painful and swollen, it can be nearly impossible for your medical provider to completely examine your ear. If there is considerable swelling, getting those eardrops in will also be a challenge. In severe cases, medical providers often insert little wicks made of compressed seaweed. These wicks gradually and painlessly expand and allow the penetration of antibiotic and antibiotic/steroid eardrops. It is rarely necessary to take oral antibiotics for OE, but some practitioners still give them anyway.

There are many different types of eardrops; some containing just an antibiotic and others containing a combination of an antibiotic (or two) plus a steroid. Why steroids? First, they are not the "bad steroids", so don't expect muscles to grow and foreheads to widen. These safe, topical steroids are used to help reduce the often-severe swelling and inflammation so that the topical antibiotics can do their job.

I am constantly puzzled why these eardrops are so darn expensive. Some of the older ones that we use have been around for decades. They should be dirt-cheap, but they are not. The newer ones, like Floxin or Ciprodex, can retail for nearly a hundred dollars, sometimes more. And, people complain about the price of gasoline! If eardrops sold be the gallon, they would be cost over ten thousand dollars. Of course, no one really needs a gallon of this stuff.

OE eardrops should always be instilled at body temperature. Why? The ear is extremely sensitive to temperature. If you put ice cold drops (some people mistakenly put these eardrops in the refrigerator) or even room temperature drops of anything in the ear, you could experience a caloric response. Your eyes will rapidly twitch from side to side (nystagmus), and you may get profoundly dizzy and nauseated; could even vomit. So, warm up those drops up in your hand or under your arm before putting them in your ear.

Do earplugs help? Sometimes; basically anything that keeps the water out of the ear canal may help. The trick is keeping the earplugs in place unless you are also wearing a bathing cap - not a fashion statement that kids are fond of making. Children, in particular, tend to lose earplugs relatively fast; so if you do use them, but the cheaper wax or silicon ones. Kids will also scream louder during water play when they using ear plugs and parents find it more difficult to yell at them for doing something wrong. For this reason, I rarely recommend them routinely, unless the child has surgical tubes in place.

Part of reason why earwax is so protective against infection is that it is acidic. Bacteria and fungus does not do well in an acidic environment. So what can we do to make sure the ear canal is more acidic? The answer is in your kitchen cabinets - vinegar. If you are particularly prone to getting OE, a 50/50 solution of white vinegar (acetic acid) and water is a cheap and very effective preventative. Just instill a few drops (at body temperature!) of this solution after swimming or showering will help prevent OE. Many of the over-the-counter swimmer's ear drops are primarily acetic acid mixed with rubbing alcohol.

Alcohol-based eardrops are safe as long as you do not have tubes, a ruptured eardrum, or a break in the skin lining. If you do, expect that those drops are going to burn...burn a lot! For this reason, I tend to prefer the homemade vinegar-only eardrops over products containing alcohol.

A final word about fungus: About 10% of OE will be fungal; often yeast. Unless properly diagnosed, fungal infections can last a long time and be an itching nightmare. Guess what? Many fungal infections in the ear canal will respond to the vinegar (acetic acid) solution. Some will require anti-fungal therapy, however, so it is important to consult your medical provider when home and/or prescription medications seem to be failing.

Now, go swimming and have a good time.

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Dolphin Encounters - Therapeutic or Not?

2008-08-14T07:00:00.001-04:00

As a child, I watched a show called Flipper. It was about a bottle-nose dolphin that lived in Florida and apparently had a PhD in psychology. Each week, Flipper would happily save someone's life or solve some puzzling criminal investigation. He would follow his triumphs with a happy dance and that voice of his. I once saw a cartoon that showed Flipper removing his outer skin (there was a zipper in the back), only to reveal that Lassie was inside. Lassie was always getting Timmy out of a well; his Flipper persona could have just dove in and saved him.

I would read stories about clandestine military dolphins trained to detect underwater explosives and help recover accidentally-dropped hydrogen bombs. I would go to Sea World and see captive dolphins jumping through flaming hoops (something they often encounter in the wild, apparently), playing beach ball, or catching thrown rings. Their reward was a few dead fish, a clean tank, and top-notch veterinarian care.

I think that dolphins are fascinating creatures and I am glad that we share our world with them. I am also pleased that humans have not developed a taste for bottle-nose dolphins and eat them. Of course, bottle-nose dolphins do not eat us, either - a nice trade-off in my opinion.

About 15 years ago, I was in Florida for a medical conference with several of my professional colleagues. They decided to head to the Florida Keys and swim with the dolphins. A group of entrepreneurial people had made an inlet to the ocean and lured some wild dolphins into some swimming pool-like pens. According to the trainers, the dolphins were free to come and go as they pleased, but many simply chose to hang around and eat the free fish. In exchange for these handouts, the dolphins would have to tolerate paying people bobbing around in their pool.

This dolphin research facility also allows for developmentally-disabled children, especially those with autism, to have these therapeutic encounters for free.

We arrived at the Dolphin Encounter, paid our fee, and entered the water. There were about four "wild" dolphins swimming around. We were told to stick our heads underwater and make dolphin noises. Dolphins are apparently tricked in to believing our very strange, underwater whistles, shouts, and clicks were somehow other dolphins.

The dolphins were swimming around looking at us. Once they determined that we were not packing fish, they would swim on. One particularly amorous dolphin took a liking to a young woman in a bikini. He would not leave her alone, perhaps attempting to have a little inter-species love making (Once you go human, you don't go back). A bit intimidated by this unwelcome attention, she left the water. So, instead of a sleek, thin young woman to cuddle-up with, the dolphins were left with a handful of hairy men treading water, and a few ample women bobbing around like manatees. They were not impressed. During my hour in the murky, dolphin-poop pool, I was only able to briefly touch one as he (she?) went quickly by. I guess that was worth eighty bucks at that time.

Photo Credit: Rod Moser

For the last two years, we have been driving about 1500 miles south to Loreto, Baja Mexico. Kayaking or boating in the clear waters of the Sea of Cortez is a real dolphin experience. It is not unusual to see hundreds of dolphins playing in the boat's wake, or feeding on the abundance of fish in this area. Loreto Bay is a protected marine sanctuary, so it is prohibited to chase or molest any marine mammals.

Knowing from past experiences that dolphins do not like hairy men, I did not attempt to enter the water with them. They were free to jump up and enter mine, but that was as close as I was going to get. I got this one in the air trying to have his "human encounter". I wonder how much he paid?

The Mexican people love dolphins and consider them lucky. Of course, feeding dolphins also help locate fish for the fisherman. The dolphins do not seem to mind sharing their fish.

Photo Credit: Rod Moser

My teenage granddaughter wants to be a marine biologist , so for her birthday, my wife and I arranged a dolphin encounter for her at Six Flags Marine World in Vallejo, CA. For about two hundred dollars, she could actually enter the training tank, one on one with an instructor/trainer, and commune with those fascinating mammals. It was an overcast, rainy day; a bit cold to be plunging into a tank of sea water in my opinion. She ended up being the only person who showed up for the Dolphin Encounter that day. After a brief class and some instruction, she donned her wet suit and headed to the tank. There were two or three dolphins waiting for her. She stood on an underwater platform with a dolphin trainer and had the time of her life.

Apparently, the animal rights activists are not happy about these encounters and other dolphin encounters that have appeared all over the world, including Disney World. They consider any dolphin encounters a type of animal abuse. Capturing dolphins in the wild and forcing them to swim with humans is not a good idea, but for dolphins born in captivity, this appears to be fun (and therapeutic) for them, too. The picture is my granddaughter, Shelby, communing with a dolphin. Doesn't seem a bit abusive to me at all. I thought the two hundred bucks was a bit abusive, but I was assured that part of this money goes toward ongoing dolphin research, and of course, the care and feeding of them.

Being in California, these dolphins appeared to have a much better disposition then those delinquent ones in Florida. (Of course, the ones in Florida were wild.) She could freely touch and hug them and the dolphins did not seem to consider it harassment (or even foreplay). These were "nice" dolphins; mellow in fact. This behavior was certainly due to their constant socialization with humans.

Personally, I wouldn't mind trying to swim with the dolphins again. Maybe these California dolphins will be a bit more tolerant of a hairy man; maybe even like them. On second thought, I think I will just take pictures of them from the dry land.

If I were somehow reincarnated as a dolphin, I would prefer to be one of those Mexican ones frolicking free in the Sea of Cortez. However, I wouldn't mind retiring at Six Flags. Just kick back, eat some fish, and play with the kids.

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Creating a Time Capsule

2008-08-11T12:47:00.002-04:00

Photo Credit: Rod Moser

Lucas was born twenty-one years ago, the son of one of my best friends. As a gift to the family, my wife and I decided to create a time capsule in a big PVC pipe; one to be opened on his 21st birthday. Since this first capsule, we have created them for all of our grandchildren, and I have launched a few hundred with my patients. I tell all new parents about creating time capsules.

So, what has changed in the last 21 years?
January, 1987: the Dow Jones closed for the first time over 2000.
February, 1987: The Unabomber was up to his antics.
In April that year, Mike Schmidt joined the 500 Home Run club.
Iran and Iraq were fighting each other; and there was the Iran-Contra Affair going on in Washington

Much has changed in the Smiley family since Lucas was born. For instance, they now have two grandchildren. One of the sons, Judson, could not be present for the picture. Some things have not changed in 21 years - Lucas is still living at home, but in a bigger bed.

Photo Credit: Rod Moser

What we put in Lucas' time capsule (some of the things):

A nice bottle of wine to celebrate

A pack of condoms

Firecrackers (for the celebration, of course)

Party hats, balloons, etc.

We picked out an outfit for Lucas to wear on this 21st birthday: a pair of surfer shorts and a t-shirt with the California Raisins ("I heard it through the grapevine"). I even included the receipt and encouraged him to try and return it (21 years later) if it didn’t fit! But it did fit - see photo.

A collection of magazines published the month of his birth, including a Playboy.*

A video of shows that were on television, including the news and a lot of commercials. The video also had precious interviews by his older brothers, aged 5 and 7.
Birthday cards: Written 21 years ago.

An autographed blow-up dog (with signatures of everyone)

Stamps

Mementos: Collectible baseball cards, two antique medical bottles (from me), Canadian money (now worth more)

A funky, cheap digital watch (it had stopped)
Stickers and Disney memorabilia

A Baby's First Christmas Hallmark ornament

Photo Credit: Rod Moser

*Strangely, we included a Sports Illustrated magazine that had a vicious-looking pit bull on the cover. For the last ten years or so, they own a near identical dog (not vicious, of course) now. See photo.

Every Time Capsule should be unique to the person or family. For our grandchildren, they included some of the following; some are suggestions:

Clothes - we really spent time predicting sizes and tried to pick contemporary styles of the day; the more-weird, the better, like a bathing suit. Sports clothing items are a plus. Include some interesting underwear if you want, or one of Dad's shirts or Mom's bra!

As many magazines, newspapers, etc. from the day or month of the birth as we can stuff into the box (fits well on the top).

An expensive, collectible Barbie doll or Star War or GI Joe figures

McDonald give-away toys from those Happy Meals

Collectible comic books
Small, interesting toys, trinkets, and (little) stuffed animals

Sports memorabilia, like a signed baseball

Birthday cards from grandparents and great-grandparents who may not be present when the capsule is opened 21 years in the future

Hand-written, stamped, and sealed letters and life-stories from relatives (especially the grandparents and great-grandparents)
Collectible coin sets

Future predictions (We made a list of 20 questions for people to fill out, trying to guess the weight, height, occupation, etc. of the child at age 21).

Stock certificate (Yes, that worked out)

Jewelry from grandparents, etc.

Other family heirlooms

Local tourist collectibles like banners, flags, post-cards, etc.

Video tapes (DVDs or CDs), pictures, and a few baby items.

A "packing list", including an explanation of some of the more confusing items. Delete this list from your computer files, so you will be surprised.

Don't leave any room in the time capsule box - stuff it!

What you should NOT include:

Don't use a PVC pipe! Too small and too difficult to open.

Wine – not only did the sealed time capsule not protect the wine, it leaked on some of the other stuff. Perhaps, anything in liquid is not a good idea

Things that a heat sensitive; stuff that could melt. Balloons and other latex items, like condoms, are not reliable and should only be included for the humor element.

Things not sealed in proper protective packaging. You don't want a Mickey Mantle rookie card getting ruined.

Anything edible

Large amounts of money – you don’t want the kids breaking in to it.

Anything that you might need in the next 21 years.

How to get started: Buy a big, opaque-plastic file box or other suitable container that can be permanently sealed. Don't get them too big or they will become annoying over the next 21 years moving them around; or too small that you cannot include everything that is collected. Buy a big tube of silicon to seal the box. Write the date this capsule will be opened, who owns it, etc. with a permanent marker. Have a safe, cool place to store it, like a bedroom closet. Start collecting some things BEFORE the baby is born, or at least shortly thereafter. It would be great to have letters and cards mailed and postmarked on the day of the birth. You can seal the box anytime, but it must be sealed by the first birthday.

Photo Credit: Rod Moser

In 21 years, you can invite people that contributed to the time capsule for the Grand Opening party or get-together. Some items will have significantly increased in value; others will have questionable significance. The personal letters may need to be read in private, especially letters from relatives or family members that are no longer with us. Technology rapidly changes - make sure to retain a device to play any electronic items (We had to hold back a VCR player).

You are preparing for a celebration in the future. Let your mind go wild and have fun.

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Diagnosis by Photograph? It's NOT Worth A Thousand Words

2008-07-29T12:30:00.004-04:00

It is rare that a medical condition can be diagnosed solely by a photograph. Without the corresponding medical history and other detailed information about the person, a picture is not worth those proverbial "thousand words". The medical magazines must plenty of photographs to test the diagnostic acumen of clinicians, but these are often accompanied by a long medical explanation, and have at least two or three diagnostic considerations (clinical possibilities).

I love my new digital camera. I had always prided myself as being a good medical photographer using my collection of 35mm lens, but my digital one trumps them all. Lighting is always a consideration when doing medical photography. The best medical pictures use a circular flash the surrounds the lens; eliminating much of the shadows that accompany a flash located above the lens. The light has to be perfect to get a perfect picture. I have been taking medical photographs for over three decades but I would never expect another clinician to be able to consult on a case with me, based solely on a photograph.

Clinicians who practice in very remote areas, often use high-resolution photographs or videos for medical consultation. The military has been experimenting with this for years. Live feeds can be sent across the world to specialists for consultative advice. There are even cases where doctors have remotely operated on patients by telemetry and robotics. Who really knows where this technology will end, but don't expect to find this equipment in your local computer store.

On the WebMD Ear, Nose, and Throat message board, I am getting an increasing number of links to photographs that the posters would like me to view. This is not really helpful. In most cases, the photographs are of poor quality (sorry, but we clinicians are picky), and do not reveal the three dimensional view that we really need. A photograph is not even close to seeing the actual picture. I know that people are just trying to be helpful and thorough, but photographs are not really helpful.

Making a diagnosis is much more than visual. For instance, when I look in the throat at some inflamed tonsils, I don't just take a quick glance; I examine the throat. I look around that tonsil from all sides, I smell the breath (mostly inadvertently), I look at the surrounding tissue above and below that tonsil; I look at the teeth and gums, the sides of the mouth, and I feel the neck carefully for suspicious lymph nodes or lumps. I can look for rashes, feel the skin for fever, and listen to the heart for murmurs that may accompany strep throats. If the person is a smoker, I take that exam up another notch, adding cancer to my diagnostic considerations. I can perform certain diagnostic studies, like a rapid strep, culture, blood count, or mono test. And, I can see and talk to the patient. The medical history is the probably the most important part of any medical encounter.

When someone posts a brief posting and even a picture on WebMD hoping to get both a diagnosis and a treatment plan, it is not happen. A diagnosis is not made this way. Not only are WebMD health experts prohibited from diagnosing someone; how in the world are we going to treat them? Yes, we give suggestions/advice; many times pointing the person in the right direction. We can make suggestions on what they can do to help symptoms, such as pain. However, this is not a true, medical encounter and should never be viewed as such.

Everyone is taking digital photos now. I sutured a child the other day in the clinic, and the mother clicked away on her cell phone. Sometimes, a teen patient will take pictures of me doing a surgical procedure on them. Some medical providers absolutely forbid this practice; I really don't care. However, I would hate for those photographs and videos to appear on You Tube or shared on medical web sites from someone seeking a "second opinion".

"Look at this mole. Do you think it is cancer? Should it be biopsied or removed?"

In recent months, I had one person attempt to post dozens of pictures, including microscopic slides of something he removed from a part of his body, asking for my opinion. People request to send x-rays and MRIs, and well as complete medical records. A few years ago, I looked at a few of those photos, but not anymore. Sometimes, that is way too much information, if you know what I mean.

I run the ENT board. I really feel sorry for someone addressing questions about hemorrhoids or sexually-transmitted diseases. Can you imagine those pictures being posted? Don't get me wrong; photographs can be helpful in some cases, but usually not in the context of providing an educational service on WebMD member boards.

On the Boards, I do miss not looking at the face asking the question. Is she crying? Is she young or old? Is she a she? During a medical encounter, I watch the eyes more than any other part of the body. The eyes are truly the window to the medical soul, and reveal so much about a person. No offense to the visually impaired who have adjusted to a life without seeing those eyes. In my clinic, I will try not to converse with anyone wearing sunglasses (unless they are blind or prescription ones). I want to see those eyes, those reactive emotions, even if they have a sore toe.

The Internet is progressing rapidly, but it will always have its limitations. With advanced telemetry, it will be possible to monitor and even accurately diagnose patients from remote areas, and perhaps, even perform certain endoscopic surgeries. This will never be like having a live, breathing, talking, complaining, crying, moving patient in the room with you. The art and practice of medicine requires that you reach out and hold a hand, or even give a hug to a grieving patient. A robotic arm is not going to do that. A two-dimensional picture, often out of focus and frozen in time, will never be a substitute for seeing something "first-hand".

Want to see how easy it is? What would be your diagnosis for these three pictures? These are some EASY ones. If you do well, I will post give you some more difficult ones. Post your guesses and I will post the answers in about a week.

Picture A: What is this rash on my son's legs?

Picture B: My daughter has a fever, rash, and sore throat. What is it? Is it serious?

Picture C: What is this skin lesion on my son's upper arm?

Security Blankets and Blankies

2008-07-24T13:08:00.001-04:00

Photo Credit: Mahalie

Charles Schulz's Linus had one; my daughter had one, and in my clinic, I see lots of children dragging around favorite blankets, many reminiscent of the grease rags used by auto mechanics. Children are given a lot of gifts in their young lives, but why they pick a favorite blanket or toy has always been a mystery to me. And, for some reason, parents are always trying to get rid of those nasty-looking blankets. Children really have such few treasures, that I often have to intervene and support the child's God-given rights to keep it, no matter what they look like.

I can't stand older kids addicted to pacifiers. This is just wrong. A baby needs to suck and breast-feeding moms need a break, so it is fine when they are babies...but NOT when they are six years old! Pacifiers are one of the predisposing factors in children who have recurrent ear infections, so I have always been down on them. There are virtually no health consequences of security blankets.

Not only did my daughter have one security blanket, she had two nearly identical ones. From time to time, you need to clandestinely swipe the "real" blanket with an impostor, mostly so you can wash it. She also have a frightening-looking doll - a skank, really - that she loved, that we named Phyllis. Phyllis had hair like Phyllis Diller; hence the name. She still has Phyllis, and believe it or not, she still has BOTH of those blankets. Just recently, my 31 year old daughter had a discussion about that very blanket. She thinks she has the real one, but little does she know...I have it.

I have also squirreled-away another treasure from her childhood. When my daughter was three or four, one of my patients at that time, a now-famous artist from Carmel by the name of Lynn Lupetti, offered to paint her portrait. Lynn sent us shopping for a nightie and Kristin picked out a pretty blue one. It was a bit pricey, but she loved it. So, Lynn painted her picture in that little nightie. As a matter of fact, she painted a few more and sold them in her gallery. It was a real thrill when one was struck as a limited-edition lithograph. Not only did we buy the original painting, but now were buying up those lithographs to distribute to family and friends. This was about 28 or 29 years ago. At least three times, one of those lithos appeared on eBay. I lost one to a clever bidder who snatched it up in the last second. Damn my slow Internet! Another one sold for more than I was willing to pay, but I did buy the third. Now, I own three, and of course, I have the "original". I am referring to my daughter, of course. Carefully matted and sealed behind one of those lithographs is that blue nightie - a hidden treasure, perhaps to be uncovered a hundred years from now.

Kristin definitely inherited collection genes. She saved all of her (original) Strawberry Shortcakes and Barbie dolls. One Barbie doll (an older, more valuable one) met a tragic end during sixth grade. Kristin had me construct a working guillotine for some school project about Marie Antoinette. The Barbie met the same fate in front of a class of screaming 12-year-olds. And then, they ate cake.

One more story: One of my patients, about six years old at the time, would always come in with a ratty-looking, washcloth-sized blanket at every visit. Once the size of a normal blanket, this "thing", as the mother called it, had been systematically decomposing over the years. The mother would periodically snip away pieces of it, clandestinely accelerating the deterioration process. Over a year or so, I watched that blanket shrink to the size of a postage stamp, I kid you not. Where did he keep it? In his pocket? No. He would put it in his nostril! This was clearly the most extreme case of blanket addiction that I had ever witnessed. When a kid has to resort to snorting a fragment of his security blanket, perhaps we should just let him have it when it was too big to fit in his nose. Removing a blanket fragment from a lung or the nasal airway is not something that I would enjoy doing.

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No More Cell Phones While Driving

2008-07-17T15:31:00.005-04:00

But What About Those OTHER Distractions?

When you are on the freeway, and suddenly see a car slow down (even if they are in the fast lane), you can rest assure the person is talking on the phone. On July 1st, California joined several other states that have banned the use of cell phones while driving. Drivers can use hands-free devices, but if you are under 18 years old, you can't use those either. This was bound to happen, but telephone use is just one of the distractions that cause accidents.

A few years ago, the mother of one of my patients was stuck while crossing the street in a cross-walk by a person driving too fast and talking on a cell phone. According to witnesses, he continued to talk on the cell phone as she was lying in the street. Someone else had to call 911.

Kids are a big distraction for drivers. I have seen parents feeding a child who was unrestrained in the front seat. She would use her right hand to try and find his mouth with the spoon, as she drove 65 miles an hour down the freeway. Another time, I followed a weaving vehicle where the male driver was physically beating a kid in the backseat with his belt. The kid was jumping from side to side trying to avoid the flaying belt.

We had five kids and a dog, all stuffed in a mini-van. While on one of those Chevy Chase-type family vacations to Yellowstone, I nearly had a nervous breakdown. The only saving grace was that most of them fell asleep in the car, perhaps exhausted from all of that bickering. We would have to wake them up when we spotted a bison or geyser. I learned one of my most valuable lessons on that road trip. I learned that sugar-free candy can be hazardous to the driver.

Not wanting to zip them up anymore on sugar, I bought a huge bag of sugar-free Gummy Bears; nearly pure sorbitol - a sweetening substance with an odd side effect. Too much sorbitol causes flatulence (the medical name for farting). You have not lived until you try to drive in a van full of kids who are trying to out-fart each other. I can assure you that this was a major distraction to my driving. I am surprised that I even survived.

We all eat in the car; some of us more than others. The government has yet to ban eating or drinking in our own vehicles, but that, too, can be a driving hazard. Remember the guy that held a hot cup of McDonald's coffee between his legs while driving?

I used to spill so much crap on myself while driving, that I thought I would invent a commuter bib like that hard plastic one with a tray that we use on children. There are only a few foods that you can safely eat in a car without having the potential to ruin your clothing: Chicken tenders or McNuggets (without the sauce) and fries. I cleaned my car yesterday and found a few stray fries under the seat. You cannot safely eat a taco or any type of salad. Burgers with lots of sauce, slippery lettuce, and juicy tomatoes are among the worst distractors.

I love gadgets and my favorite gadget is a GPS. I love tracking my progress and punching in destinations of places I already know how to reach. A GPS on the dash is actually worse than a cell phone, especially if your near vision is not as good as it used to be. Someday, they'll have a voice-prompting GPS that tells you that you have just hit a truck.

Radios and stereos have gotten a bit better in cars now that some of the controls are on the steering wheel. More and more cars have video monitors to entertain the passengers, but you would be surprised how many people try to watch TV in their cars while they drive. It is illegal in most states for the driver to wear headphones that cover both ears, but I see this quite often. Those cars with huge speakers with the bass cranked up are definitely distracting to everyone other than the driver who seems to be enjoying his remaining days as a hearing person.

Watching other drivers - one of my admitted pastimes - is another hazard. Instead of watching the road 100% of the time, I find myself looking around at the other drivers. Many are picking their noses, singing, or looking at me to see if I am doing that as well. Occasionally, I am awarded by seeing a good-looking woman who doesn't see me looking at her.

For any male driver, an attractive female pedestrian is always a distraction. I was rear-ended once by a kid on a bicycle, distracted by some cheerleaders practicing. Perhaps I was at fault as well, since I was sort of looking at them, too.

If I spot a particularly bad or swerving driver, I tend to be curious as to their demographics: Is it a woman on a cell phone or putting on make-up? A guy reading a map? A teenager trying to text message a friend? An elderly woman with sunglasses? A guy beating his kids? A fat person eating a donut? Of course, he could also be a drunk. This can be a fun game on a long and boring trip, assuming they do not swerve into you.

Rubbernecking is a definite hazard to safe driving. Any car stopped at the side of the road automatically triggers the curious. Why has he stopped? Is it a flat tire? Was it an accident? If there is a police car involved, then the curiosity jumps to the highest level. We are so glad that he was caught speeding and not us, that we are actually happy. My wife became very excited one day with the driver was in handcuffs. That really peaked her womanly curiosity. I wonder what he did?

I have had a few flat tires in my time, reluctantly becoming the focus for rubberneckers. Many will slow down and see what I am doing; some will actually yell or laugh at me as they pass; and once, someone threw a cup of soda out of the window and tried to hit me. Nice. It is not bad enough that I have a flat tire. Apparently someone thinks I should be sticky, too.

Bumper stickers and vanity plates are distractions. I really enjoy clever bumper stickers, but it can be very dangerous to try and get close enough to read them. The same goes for vanity plates. It can be very distracting when you are trying to figure it out what they mean.

I can go on, but my point is that there are considerably more distractions out there than holding a cell phone in one of your hands. The first offense in California will cost you about $75; twice as much if you get caught a second (or third) time. I waited until the last minute to buy my hands-free adaptor, so they were out of them. I am too cheap to buy a Bluetooth device. I don't use my cell phone very often in the car, but sometimes it is important. I will try and be careful. I don't want the cell phone distracting me from my other distractions.

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Honey, I Healed the Wound

2008-07-15T16:31:00.002-04:00

With all due respects, Raye was a "big" woman. She topped the scales around 250 and stood well over six feet tall, appearing considerably ominous with her towering, beehive hairdo. She had a sweet disposition and a heart as big as her hair. She was about sixty years old when I first met her; I was in my thirties. What endeared me the most was that she called me, "Honey".

"Hi, Honey!" Raye said, with her deep, gravelly, former-smoker voice. "How the hell are 'ya?"

Although it is not very professional, I always submitted to her bear hug greeting, my face plunged deeply into her breasts, causing my glasses to be askew.

"I am just fine, Raye."

To this day, when I think of "honey", I think of Raye with that beehive. What a sweet lady.

Photo Credit: Nevena

Four thousand years ago, the Egyptians were routinely using honey for wound management, long before people knew that potentially-fatal microscopic bugs called bacteria even existed. We are not sure who slapped the first, sticky gob of honey on an infected wound, but it must have worked well. Honey became an integral component of the ancient pharmacopedia.

The first antibiotic (sulfa) was discovered in the 1930's. Penicillin was found in bread mold a few years later; both were just in time to save countless lives during World War II. Antibiotics were miracle drugs and everyone wanted a shot of penicillin, no matter what they had. For a while, it worked, but slowly but surely, the bacteria mutated and developed resistant strains. Prior to 1988, 99% of all bacterial infections caused by Strep pneumoniae were effectively treated with plain 'ol, cheap, penicillin. Due to antibiotics being misused, the level of resistant infections in California increased to 30% in 2000. It is even higher now, forcing medical providers to use the more-toxic and expensive "last resort" antibiotics.

Honey has naturally-occurring antibacterial and antioxidant properties and it resists bacterial resistance. It may be greatly useful in treating the dreaded MRSA - methicillin-resistant Staphylococcus aureus - the superbug that you have heard so much about. But don't go out and buy some raw or store-shelf honey and use it on Grandma's bed sores. Not all honey is the same.

A new honey-infused bandage called Medihoney was granted approval by the FDA in November. It is made with highly-absorbent seaweed soaked in a special, sterilized Manuka honey, produced from the oil of tea trees in Australia and New Zealand. Wound management experts are ecstatic. Not only has it closed some chronic wounds that have defied modern drugs, it acts as a protective barrier against secondary infections. I bought some Manuka honey many years ago when traveling in New Zealand, but I had no idea of its potency for wound healing. I used it on muffins (better than Vegemite) and it did heal my sweet tooth.

Photo Credit: Vicky Brock

In October last year, parents were alarmed when infant cough and cold drugs were withdrawn from the market, due to safety issues and misuse. Lo and behold, an old folk medicine for cough resurfaced - honey. Honey has been used for centuries to combat coughs, often combined with lemon or ginger. I worked with an old pediatrician during the 1970's that gave his parents a "prescription" for his homemade cough medicine containing honey, whiskey, and lemon. Many years later, I desperately tried to remember the recipe to give to my own coughing daughter. I sort of guessed at it, perhaps adding more whiskey -or more lemon - than the prescription required. One taste caused my three-year-old to run crying and spitting from the room, mistrusting me for months to come anytime that I offered her medicine.

Honey should not be used by children under the age of 12 months (some pediatricians say age 18-24), because honey may have traces of botulism spores that cannot be filtered out during processing. Since the baby's gastrointestinal and immune systems are immature, they may not be able to fight of a rare botulism-toxin case of food poisoning.

When compared to dextromethorphan (DM), honey was found to be better and controlling cough and promoting sleep in a controlled, university study. Incidentally, DM is also one of those over-the-counter drugs of abuse used by teenagers.

Honey has been also been promoted for hangovers, insomnia, weight loss, bad breath, sore throats, digestive problems, athlete's feet, facial scrubs, and dry skin, just to name a few. While honey may not be the miracle drug of the century, it does seem to have some proven beneficial effects. And, it is good on muffins.

So, here's to you, Raye. Love 'ya, Honey.

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