Friday, November 24, 2017

The impact of a single sentence

Social media in general and Facebook in particular have their benefits and drawbacks There is no doubt that it is way easier to reconnect with long lost friends than it used to be.

Recently my husband got tagged in a 6th grade class photo from his good old PS 32 in New York City. This started a flurry of conversation between people who hadn’t been in touch for many many (many) years. There is really nothing quite like an old friend who knew you when. I believe he may actually stay reconnected with some of these folks.

With all the catching up that was going on, there was a comment from a girl in his class that caught my attention. She wanted to let Sandy know that after all this time, she still thought about his mother.

It turns out that way back when, after a school performance, my mother-in-law had made a bee-line straight over to this girl just to tell her what a wonderful job she had done. It wasn’t the simple “good for you”; mom had told her how moved she had been and that this young lady should be very proud of the performance. Fortyeight years later, this woman says that she still remembers how impacted she was by the interaction. Wow!

There are more people out there than we can count for whom a crumb of positive feedback is rare and important. Words, either kind ones or mean ones, are often put out there without much thought and the speaker moves on. This story illustrates how much a message can sometimes stick and make a profound impact.

Go out there on this Thanksgiving weekend and make a lasting positive impact with your conversations!

Friday, November 17, 2017

Carbon Monoxide 2017

Carbon Monoxide

Carbon monoxide (hereafter referred by its chemical symbol CO)
This post could save your life. How many of you own a carbon monoxide alarm? If you do, good for you. Make sure that it is in good working order. The units do not last forever. IN some of the older units, batteries need to be changed annually (at least) and some units suggest that you vacuum the cover monthly to remove accumulated dust. If you are one of the many who do not yet own one, please remedy that immediately. It has been the law since January, 2013, with few exceptions.

Homes with a fireplace, attached, garage, or any gas appliances are at higher risk, but there are many different factors that can cause an elevated level. A friend of mine is a lawyer who was involved in a heartbreaking case where a guest at a Bay Area hotel sustained long term health impairment from an exposure. The victim’s room was above the hotel pool and a faulty boiler used to heat the pool vented carbon monoxide into his room. When he didn't show up for dinner, his friends found him unresponsive. It was a very alert physician in the emergency room who figured out the cause. It was only at that point that the hotel was evacuated. This is not an isolated incident. As a result, my lawyer friend takes a portable detector along with him on all of his travels!

Because heaters and fireplaces are often involved, exposure is usually higher during the winter months.

Carbon monoxide is a colorless, odorless and tasteless poison gas that can be fatal when inhaled. CO binds to hemoglobin with much greater affinity than oxygen, forming carboxyhemoglobin (COHb). It is hundreds of times more efficient than oxygen at attaching to the cells, so even small amounts can deprive our bodies of vital oxygen. In severe cases, for folks who survive an exposure, it can cause irreversible brain damage by starving the brain of oxygen.

Normally if someone is deprived of oxygen they may look pale or cyanotic (bluish); in the case of CO poisoning, the color will remain nice and pink. A standard pulse oximeter may not be an accurate indicator of where or not there is a problem. If carbon monoxide exposure is suspected a blood test can be done to check the carboxyhemoglobin level.

One of our local ER docs who allowed me to pick his brain added that one of the tricky things about CO poisoning is that the symptoms are very vague and nonspecific. A faster than normal heart rate (tachycardia) is the only really reliable physical exam finding.

Mild exposure might cause slight headache, nausea, vomiting and fatigue. This can easily be mistaken for flu or viral syndrome. Medium exposure symptoms would be a throbbing headache, drowsiness, confusion and a rapid heart rate. Extreme exposure will lead to unconsciousness, seizures, and cardio-respiratory failure that usually is fatal.

The effects of exposure can vary greatly from person to person depending on age, overall health, and the concentration and length of exposure. Young children and pets are thought to be especially vulnerable. Pregnant women should also be especially careful because the fetus can be seriously impacted.

A carbon monoxide alarm is similar to a smoke detector because it monitors the air in your home and sounds a loud alarm to alert you of trouble. However, the way you respond to a CO alarm is very different than a smoke detector. When a smoke detector goes off, it is pretty easy to to judge the level of danger. You can see or smell the smoke. On the other hand, because CO is completely undetectable to your senses, you are dependent on the alarm to let you know there is a problem. If the alarm sounds:

  • Operate the test/reset button
  • Call 911
  • Immediately move to fresh air (make sure that everyone in the household is accounted for.)
  • Do not go back in until you have the all clear from the emergency responders.

Concentrations of CO between 1 and 30 ppm can often occur in normal, everyday conditions. See the chart below for CO levels and corresponding symptoms.

If your unit is coming to the end of it’s life it may give off multiple chirps to notify you that you need to replace the device or change the batteries. Newer alarms might be good for as long as 10 years. Ours has a digital display that will signal when it is time to replace it.

Last year my daughter Alana had her CO alarm go off in her apartment in Michigan. She knew enough to get outside and call 911 immediately. After the fact she recounted her conversation with the fireman who had responded:

“I am worried about my cats, can you help get them out?”
“What do they look like?
“They are CATS, they are furry, have 4 feet and tails!”

Happily the kitties were all safely brought out of the apartment.

The best guess for what set off the alarm was something faulty with the air conditioning system. It went off several times with no clear source identified, which prompted her to move.

You may not think that your home is at risk, but there is NO downside for investing in an alarm (plus you are complying with the law.) They are inexpensive. If you are renting and there is not a unit in your apartment, call your landlord immediately and get that remedied. in January of 2017, in the Bay area, there was the tragic instance of a young couple and their pets all found dead with no obvious cause. It turned out that it was CO exposure from a malfunctioning 3D printer. A functioning alarm would have saved their lives. Don’t mess around with this. Please make sure you are protected.

Saturday, November 11, 2017

RSV 2017

November is often considered the start of RSV season. It has yet to arrive with a vengeance, but I know it is coming. The local emergency rooms may have started to see some cases. Here is the RSV post, updated for the 2017/18 season.

What is severe RSV disease?
Respiratory syncytial (sin-SI-shul) virus, or RSV, is a common, seasonal, and easily spread virus. In fact, nearly all children will get their first RSV infection by age 2. Like most viruses it ranges in its severity from case to case.

Severe RSV disease is the number one reason babies under 12 months old have to be admitted to hospitals in the US. You know the wretched colds that knock you flat and stand out in your memory? These are the colds that come with runny noses, sniffling and sneezing, harsh cough and fever. That illness might well be RSV. I actually can almost diagnose it over the phone when I hear the patients coughing. The cough sounds like it hurts. Generally the first signs are runny nose and decreased appetite. The cough follows a few days later.

There is a test that we can do in the office (a swab to the nose) to see if it is RSV or not, but unless your child is looking really sick we might not bother. It doesn't necessarily change the approach. We often do nebulizer treatments for our wheezers, but with RSV they don't always help all that much. This is a virus and antibiotics would not be appropriate.

Time usually fixes this and all that we can offer is often the same symptomatic treatment and supportive care that we would do for any bad cold and cough. Treat the fever as needed  
To clear the nose, squirt some saline or breast milk in each nostril and then suck it back out with either a Nose Frida/ aspirator or theNeil Med Naspira. I think those are much easier to use than the standard bulb aspirators.
Another available product that some parents like is the Oogie bear.This is a safe little scoop that can safely get into the nostril and removed the more stubborn boogies.

If your child is having trouble eating because of all the congestion, try doing some clearing about ten minutes before a feeding. It is also helpful to keep their heads elevated. They may need to spend the night in a safe infant seat or you can try to raise the mattress a bit. For older kids, add an extra pillow. Let them sit in a steamy bathroom, and use a humidifier at night. Increase fluids during the day.

RSV can cause ear infections and pneumonia. In fact some studies show that somewhere between 25-40% of young infants with the RSV virus will have bronchiolitis or pneumonia. Severe RSV disease symptoms include:

Coughing or wheezing that does not stop
Fast or troubled breathing
A bluish color around the mouth or fingernails
Spread-out nostrils and/or a caved-in chest when trying to breathe
Gasping for breath

If your child is having trouble breathing, or significant trouble feeding, they may need to be hospitalized for a night or two for fluids, oxygen and observation. I would say that we have several kids routinely hospitalized for this every year (not just young babies.) There is no other real treatment for RSV other that close observation, but for certain high risk patients, there is a medication that is given monthly that significantly protects them. This medication is called Synagis.

If your child was premature, or has cardiac or pulmonary issues, they may qualify. Talk to your doctor's office ASAP to find out if your child fits into the guidelines. Alas the guidelines are quite restrictive. Much to the dismay of most sensible practitioners, they became even tougher last year. We used to be able to get it for preemies who were born before 35 weeks. The new rules moved that to 30 weeks. So far I don’t have any candidates this season. I hope it stays that way. In California the official RSV season starts on November 1st. (I don't think that RSV knows that it has a season, but that is when the insurance companies will start shipping the medication.)

Since most of our children can not get protected with Synagis, please take precautions to prevent the spread of this nasty virus, especially for the youngest most vulnerable babies.

Wash your hands before touching your child. Make sure others wash up, too. Clean toys, crib rails, and any other surfaces your baby might touch. Try to keep your baby away from crowds. Avoid anyone with a cold or fever. Don't let anyone smoke near your baby. Tobacco smoke exposure can increase the risk of severe RSV disease.

Sadly it takes multiple exposures before you develop immunity. Most folks get RSV about 8 times until they finally seem to be not as vulnerable! It spikes again in older folks when the immunity tends to wane and it can sweep through retirement communities, so be cautious for the older adults in your life as well.

If your child is unfortunate enough to get a nasty case of RSV during the season it takes a long time for the lungs to calm down. In my experience it is not uncommon for these kids to have a tough winter. Every new cold seems to re-trigger the wheeze. This does NOT necessarily mean they have asthma. For repeat wheezers, if the nebulized medications bring relief it might be worth owning a machine. We rent them out of the office for $5/ day, but you can purchase them for less than $100 from Walgreen's. Having a nebulizer safely tucked away in the bottom of the closet may save you from a nighttime or weekend trip to the emergency room.

Halloween Safety tips 2017

Halloween Safety tips 2017

Halloween can be such a fun holiday, but as you can imagine, as advice nurses we tend to hear about some of the misfortunes that can along as part of the festivities.

Carving a pumpkin can be a very fun tradition. Please make sure that your child's level of participation is consistent with their age and ability. Watch out for the sharp implements and make sure you assign your younger child to the safer tasks (young kids can draw on the pumpkin rather than carving.)
Clean up the mess. Pumpkin flesh is slippery and can cause falls and injuries when dropped on the floor. Layer newspaper or old cloths under your carving work space and clean up spills right away so no one slips or trips. Skip the candles, which may cause fires. A burning candle in a pumpkin may become a blazing fire if left unattended. Instead, use a glow stick (available in many colors) or flame-less candle to safely illuminate your jack-o'-lantern.

Choosing a costume
Children are more than twice as likely to be hit by a car on Halloween than on any other day of the year!

Decorate costumes and bags with reflective tape or stickers and, if possible, choose light colors.
Have kids use glow sticks or flashlights to help them see and be seen by drivers. Is your dog going along with the trick or treaters? Have them wear a glow in the dark collar!
When selecting a costume make sure it is the right size to prevent trips and falls.
Be sure to wear flame-resistant costumes. Remind your child that they need to pay very close attention to their surroundings and avoid walking near any candles or flames, especially if they have loose flowy costumes.
If a sword, cane, or stick is a part of the costume, make sure it is not sharp or too long. A child may be easily hurt by these accessories if he or she stumbles or trips.
make sure that no part of the costume is covering their ears solidly enough that their hearing might be impacted.
Since masks can sometimes obstruct a child's vision, try non-toxic face paint and makeup as another option. Face paints have been in the news lately. Some of them have some toxic ingredients like lead. Be familiar with the ingredients before you apply anything to your child’s skin.
Always test the makeup in a small area first. Always completely remove it before bedtime to prevent possible skin and eye irritation.
Make sure that your child doesn't have any latex sensitivity before you do too heavy of an exposure. Many masks are made of latex. We actually had a patient who had an allergic reaction to the hair tinsel. You may want to do a test run of the costume and make up a couple of days ahead of time to rule out any allergies.

Trick or treat rules
Children under the age of 12 should not be alone at night without adult supervision. If kids are mature enough to be out without supervision, remind them to stick to familiar areas that are well lit and trick-or-treat in groups. Never go into a strangers house without supervision.

Popular trick-or-treating hours are 5:30 p.m. to 9:30 p.m. so be especially alert for kids during that time if you are out driving.

A good meal prior to parties and trick-or-treating may discourage youngsters from filling up on Halloween treats.

Bring plenty of water along when you go trick or treating. Just trust me on this one.

Make sure that your children know that after trick or treating, the grown up needs to pick through trick or treat bag and toss anything that looks suspicious. There is a warning out in Colorado this year about "pot laced" treats. That could happen here just as easily. Anything that looks like it has been tampered with should get tossed. Some candies are real choking hazards. If you have a younger child in the house, make sure they don't have access to the stash.
If you have a child with nut allergies (I am sure this is NOT your favorite holiday) make sure that they turn over ALL the candy so that you can separate out anything that might cause trouble. My favorite allergist adds another piece of advice. Most of the time nuts may be just one of the ingredients, but as a general rule, kids who are allergic to nuts should also be able to identify the nuts that they are allergic to. If it is peanuts, make sure they know what an actual peanut looks like.

Expecting trick-or-treaters or party guests?
Consider purchasing non-food treats for those who visit your home, such as coloring books, stickers or tattoos. Provide healthier treats for trick-or-treaters such as low-calorie treats and drinks.(Okay, fine...maybe you don't want to be "that" house, but I had to put it on the list.) Be sure walking areas and stairs are well-lit and free of obstacles that could result in falls. Keep candle-lit jack o'lanterns and luminaries away from doorsteps, walkways, landings, and curtains. Place them on sturdy tables, keep them out of the reach of pets and small children, and never leave them unattended.

Now what do we do with all this candy!!!
Make a plan about how much candy they can eat at one time. It is okay to be a little more liberal than usual for a day or two, but come to an agreement about a reasonable candy intake over the next few weeks. Some dentists and orthodontists have buy back programs, where they will give your child a reward for turning in their candy. Check with your dentist to see if they participate

Bibi, one of our mom's, doesn't bother with the dentist and has instituted her own buyback program. Her kids can exchange candy of new lego pieces.

You may need to be extra vigilant with teeth brushing this season.

Remember that candy freezes (and some of it is actually better that way; frozen snickers bars, yum!) My daughter Lauren was about 6 when she caught on that mom and dad were pilfering through her trick or trick bag and stealing all the good stuff. After that she guarded her stash more carefully.

Here are some tips that some wise mamas have added to this post over the years:

"Once Cleo was out of the stroller and walking, we put glow stick bracelets and necklaces on her so we could see her more easily when out and about in crowded spaces in the dark (we do this at things like the Dia de Los Muertos parade, too.) Cliff's sells them in a big 100-stick bulk container. Not terribly eco, but gives a little extra "eyes on" help when navigating the crowds."

My little patient Franny, bent a glow stick in order to activate it and it broke.
Some squirted in her mouth. While, you do want to avoid unnecessary contact with the insides of a Glow sticks, they are non toxic

Here are some Halloween activities