Our Culture, Ourselves
Two tidbits from my Pediatric Urgent Care Clinic:
- Mom comes in with sick baby who has been vomitting after breast feeding. We see the child, he looks okay, and pediatrician reassures mom that baby will be getting better soon. Main thing to do is keep the baby hydrated. Perhaps smaller, more frequent feeding will help; Pedialyte might work as well. Instantly, mom wants Pedialyte. Pediatrician again reassures mom: mother’s breast milk is fine. Mom again, “No, I want the Pedialyte.” Me: How did we get to the point that we trust Pedialyte (which actually has too much sugar to be of the right concentrations) over evolution? Have we made the human body and breast so potentially pathologic that we’d rather use some man-made concoction?
- The effect of the nuclear family: my attending today said one of the biggest reasons she hated private pediatric practice was “4am calls for Tylenol dosing from rich parents. They don’t have close ties to grandparents or aunts or uncles, so they rely on the pediatrician for common ‘raising your child basics’ information.” I’ve often thought this is also why all the “X for Dummies” and “Idiot’s Guide to Y” have become so popular: often these are subjects that used to be passed down through generations and oral tradition. Now we opt to pay for the same advice from strangers, albeit experts in their field. (On one hand, maybe this nips some bad parenting styles in the bud. On the other, seems like an awful waste of often good, comforting information.)
I had an amazing day of family practice on Tuesday (cross-posted from elsewhere)
Pre-natal exams
First up, a pre-natal exam for a woman who was 14 weeks along with her second child. She’d had complications at the end of her last pregnancy [the HELLP syndrome] so we added some extra tests to monitor that stuff and referred her to a gynecologist. We took BP readings and asked about weight gain and any fetal movement, bleeding, or other important things. In each case, I got to palpate the woman’s abdomen and feel for the distended uterus.
Here’s the ‘Wow’ (for me, anyway):
Using the doppler ultrasound (an audio tool), we searched for the fetus. We could hear the ‘whoosh whoosh’ of the uterine arteries and the crackling of the doppler when it lost contact as we swept it across the abdomen, until finally it landed where we wanted it. At 146 bpm, the fetal heart clicked away. I’ve never heard anything so exceptionally beautiful as the music that was the closing of two microscopic cardiac ventricles.
Testing for chromosomal abnormalities:
We discussed the triple screen test; for those of you not familiar with it, it is a blood test available to all BC women in order to assess their risk for carrying a child with some specific chromosomal abnormalities, namely Downs Syndrome. Because it has huge decision-making implications down the road (i.e. “if positive, should we follow up with amniocentesis to verify it, even though the amnio procedure makes spontaneous miscarriage more likely?” and “if positive, will we terminate the pregnancy or keep the child that probably will have severe defects?”). It was really great to see the ‘informed consent’ discussion about this topic, as I’d written a bioethics essay on it back in undergrad. Real doctors do perform informed consent!
Concussion – psychosomatic symptoms?:
A girl in her early teens experienced a severe concussion 7 months ago. The dizziness and headaches lasted for a while, but she got better and was cleared as “fit enough” again. Two months ago, she had another small concussion and the symptoms returned. They worsened at resolved at times, adhering to no specific pattern of presence. Things got to the point where she had difficulty standing and walking. Neurological consult and relevant imaging (CT) showed no identifiable abnormalities in her brain at the initial injury or at present. No bruising or bleeding in there. Review of her presentation proved interesting.
She described her dizziness as feeling that she was spinning and the room was not. My preceptor says that he has never heard of this. Likewise, the analysis of her gait proved it to be abnormal – the way she walked was not a pattern that was associated with any neurological phenomenon the neurologist could describe. We asked her to stand up (and held her weight) while we watched her knees wobble; it was as if they were buckling under the stress. Theoretically, the doc pointed out, anyone who is attempting to stand will lock their knees. If it’s just a question of balance, a person might fall, but not when others are holding them up. The patient had a history of some other poorly defined illnesses and lasting symptoms that could be attributed to no physical cause.
This led us to believe that perhaps there was no underlying physical phenomenon responsible for her condition. So I had my first (probable) psychosomatic patient! She could also be faking it but it’s hard to tell because she may unconsciously be causing these unusual symptoms to achieve some benefit, like missing school or getting more attention at home. I am sympathetic to her in any way, but when I interviewed her, I didn’t get a sense of frustration or fear of long term morbidity from her, as you might expect would occur in a patient who has lost the ability to walk and might be forever confined to a wheelchair. It’s very difficult to judge these sorts of things and I’m certainly no expert.
Maybe it isn’t that exciting for you to read about, but I’d imagine you were also this eager when you first started out. I’m working on my cynicism. Just wait until I’m on the wards; typing at this rate, I’ll have to write a book! But I might want to read up on breeching confidentiality first…
Cheers,
Jessica
FWIW, All the 4 AM calls I ever got re: Tylenol dosing came from folks who were not rich.
Can’t say I understand what being rich has to do with it. I have no problem in principle with rich-bashing, so long as it makes sense.
Also FWIW, the social isolation you speak of occurs in my immigrant families as well, only it’s much much worse, exacerbated by distance and language.
Finally, I no longer get 4 AM calls for Tylenol dosing because I educate my families about it at every well visit. I give refrigerator magnets with the child’s APAP and Ibuprofen dose.
90% of the emergency phone calls you get could have been forestalled with good education (in the medical sense, not the academic sense)
best,
Flea
The mother may have had her *own* reasons for wanting to go to a bottle, once learning that it was at least a second choice….
Another reason to encourage breastfeeding during the vomiting, is because the breastmilk now has antibodies that the mother’s producing to fight off the virus. It’s also digested rapidly, which means the baby is still getting some kind of nutrition, even if s/he continues to vomit.
As for the tylenol, you’ll notice that on most packaging it says ask your dr for the proper dosage because it’s not given. My ped always rights down the proper dosage at WBCs. I doubt that my mom would even know the dosage because I just remember baby aspirin (1970s). She doesn’t know about alot of other things, too – carseats, back to sleep, starting solids, etc. Things have changed quite a bit since I was growing up, and my mom is the first one to admit it.
I’m nursing my fourth child, and, even though othere see how healthy my children have been, there are those who insist that breast milk is not satisfying or “good” for my babies! I think the choosing of “man-made concoctions” over natural breast milk comes from so many medical advances through the years, and people simply having a doctor-knows-best attitude.
Re: Raising Children for Dummies–I’ve consulted reputable websites before when I didn’t know how much medicine to give my kids. I loved the fridge magnets idea. I would ask a parent from my generation before I asked someone older for advice, anyway– those older parents are the same ones that are telling me to fill my two-week-old with some water, apple juice and cereal in their milk…
“Have we made the human body and breast so potentially pathologic that we’d rather use some man-made concoction?”
If by “we” you mean the medical profession, yes. Docs have been working hard to convince mothers that formula is just as good as breastmilk and now that they’ve been successful, it looks like you’re blaming the moms for just having this attitude without a couple generations of input from docs.
As recently as 1997, I had a 2 yr old nursling with gastroenteritis and severe dehydration. The pedi — whom I trusted, as he was the first in the area to employ a lactation consultant, so I figured he knew what was best — insisted I put my child on pedialyte for 24 hours, then come back and he’d decide if hospitalization was necessary. I bought the pedialyte and my child was smart enough to refuse it. I followed my child’s cues and nursed almost non-stop until our appt. the next day. The doc was pleased with the outcome and told the med student who was present, “Pedialyte works every time!” I told him that my son had refused the pedialyte, and I’d nursed him non-stop instead, and the doc and the student rolled their eyes at each other.
Moms aren’t coming up with these ideas on their own.