Friday, April 26, 2019

Tick Bites 2019

Tick Season 2019
Ah, the twisted thinking of an advice nurse. For most folks, spring brings to mind warmer weather, longer days, lovely flowers...etc. Me? I think, "Here comes tick season." Indeed the calls are already coming in and I have spoken to a half dozen patients about tick bites just this week. It makes sense. With the nicer weather more of my patients are out there taking walks, hiking, and enjoying the beautiful area that we live in. The extra rain this season is contributing to one of the largest tick seasons that we have seen in a few years. Ticks can be an issue all year long, but the nymphs are born in the spring. These tiny little ticks are the ones most likely to transmit diseases. Of the many varieties of ticks out there, the ones responsible for the majority of disease transmission are the deer ticks. If you want to impress folks at your next cocktail party, our local deer tick is officially identified as the ixodes pacificus.
Although only a small percentage of tick bites are harmful, the diseases can have a major health impact, so we need to pay attention. There are multiple types of bacteria responsible for tick borne illnesses. Ticks here in California are known to transmit several different diseases, including Lyme. There are many conflicting reports, but recent studies coming out the past couple of years suggest that the rates for tick borne diseases are higher in California than previously thought.

The key is prevention.

Spray the clothing with the bug repellent Permethrin. This is okay for anyone over 2 months of age. Use Deet on exposed skin, avoiding hands, eyes, and mouth. If you are looking for more natural remedies, try some of these essential oils:

  • Lavender - This smells sweet to us but bugs tend to hate it. It can repel mosquitoes, flies and other insects.

  • PennyRoyal - this is a member of the mint family and it is toxic to insects (pregnant women need to avoid handling this essential oil, it has been linked to miscarriage)

  • Lemongrass - this essential oil comes from tropical lemongrass and has a citrusy scent. It is a natural flea and tick repellent that can be sprayed directly on the skin.

  • Eucalyptus - use this alone or along with citronella oil to keep bugs away. According to the Journal of Medical Entomology, eucalyptus extract can reduce tick bites.

  • Lemon - Some lemon essential oil can work against fleas and other bugs. Slightly dilute it and spray it on your clothing and and skin.

Sorry to say that none of the above are going to work as well as the DEET.

If you are going to be walking or hiking in densely wooded areas try to stay in the middle of the path. Avoid wood piles and logs. Light colored long sleeves and long pants are recommended.But let's face it, on a hot day we are not going to have our bodies covered completely, so here is the deal....

Everyone needs to get a naked head-to-toe body check after a walk in the woods.

If you are camping, do a full body check daily. Ticks can hide in out of the way places on your body. Don't forget to check the scalp. If you are dealing with thick darker hair, you can rub your fingertips along the scalp and feel for any bumps. Check in between the fingers,toes and behind the ears. Check armpits and belly buttons as well. You really need to be very thorough. Many of the ticks are very tiny and hard to see. Be familiar with little moles and freckles so you can recognize a new spot which might be a little tick.

If you are returning to your home after a hike, use a lint roller to do a quick pass over your clothes. You may be shocked at what you collect from that. Then carefully take off all clothing (try not to shake things out) and put everything in a hot dryer for 60 minutes to kill any wandering ticks. Don’t forget to check the car seat!

If you find a tick, it is very important to remove the tick as quickly as possible. If a tick is removed within 4 hours of the bite, the chances of any disease transmission are SIGNIFICANTLY decreased. For Lyme disease, the tick generally needs to be attached for more than 24 hours to be a concern. In fact, according to an infectious disease expert at UCSF, the tick typically needs to be on you, basically sucking your blood and attached to you for 36 to 48 hours, during which the Borrelia burgdorferi (the bacterium in the tick that causes Lyme diseasemigrates from the tick gut to its salivary glands, before it can transmit the Lyme pathogen.

If you find a tick, please stay calm. I can still remember vividly, years ago, a mom carrying her toddler into the office screaming (the mom, not the kid) "HELP ME GET THIS THING OUT OF MY BABY!" Hey, arachnophobia is appropriate in this case, because ticks are indeed arachnids (the spider family), but put on a brave face for your child.

The best way to remove a tick is with tweezers or a special tick removing tool. Grasp the tick as close to the skin as you can and firmly pull up and away. Do not twist. The Public Health department councils that you should not try any of the folk remedies such as Vaseline, burning match, etc., If you own a dog or go hiking frequently, do yourself a favor and get one of the tick removing tools. You can get them pretty cheaply from any sporting good or pet store. Amazon has a ton of different brands. My extra daughter Rachel just used the tick tornado to get a tick off her little one and was really pleased at how easy it was: Tick Tornado

Once the tick is out, clean the area with an antiseptic soap, apply a dab of Neosporin and then keep watch on the area to make sure there is no infection.

Okay, We got a tick bite. We removed it, but now what???  

I am going to have you keep your antenna up for at least 30 days. If there is any odd rash, flu like illness, aches, or fever it is important to notify your doctor. We will want to know the date of the bite, and if possible the region where the tick came from. Any recent travels could provide important data.

Unfortunately the blood tests for tick borne diseases such as Lyme are initially not all that helpful. To start off with, you can get both false positive and false negative results (making it pretty useless.) It turns out that once you have symptoms several weeks after the bite, the tests for Lyme are apt to be more accurate, but that isn't all that useful right after the tick encounter when we are trying to decide whether or not to treat.

Rather than testing the patient, I would focus on the tick. If you do a lot of hiking, keep a little baggy in a pocket of a backpack or diaper bag so that you have a place to stick any ticks that you remove. 
The Sonoma County Health Department will identify the tick for free to see if it is the type you need to be worried about. They will also take it a step further and test it for Lyme disease. They charge a fee of $33 (such a deal.) They don't test the ticks for other illnesses. They do the testing every Thursday and they will have the results by Friday. They say that about 1-3% of the ticks test positive.

In Marin they will also test the ticks:

Read the instructions on their website for how to send the tick.

As many of you have heard me say time and time again, ask a question and get multiple opinions and answers. Kerry Padgett at the California Department of Public Health in Richmond, California has been identifying ticks for our patients for many years. The folks over there are happy to tell you if it is a tick that you need to be on alert for, but don’t bother to test the tick. Her reasoning makes a good deal of sense:

  • A tick testing positive doesn’t necessarily mean that it was on long enough to transmit a disease.

  • A tick testing negative for Lyme may be infected with the Lyme-like illness that we can’t test for yet.

You can send the tick for identification purposes only, to:

Kerry A. Padgett, Ph.D.
Supervising Public Health Biologist
California Department of Public Health
Division of Communicable Disease Control
Vector Borne Disease Section
850 Marina Bay Parkway
Richmond, CA 94804

There is currently no fee for this.

Here is the bottom line. Regardless of whether or not you get the tick tested....

Watch the person who has been bitten very carefully for the next 4-5 weeks. If there are any suspicious symptoms within the month following a tick bite you absolutely want to speak to your doctor about doing a course of antibiotics. Reactions that are a cause for concern would be a bulls-eye rash around the tick bite site and/or any type of flu symptoms. Some of the less frequent tick borne illnesses might have a more diffuse rash. Not everyone gets all symptoms.

We don't want to treat every tick bite with antibiotics for obvious reasons. As with everything, we need to strive for balance. We can't keep our kids in a box. Go out there and enjoy the hike, but then do that thorough body check and you should be fine. If you are a pet owner and you treat your pet with one of the flea and tick treatments, keep in mind that those ticks may leave the pet and go find someplace else to hang out!
 August 2019
New information
In areas that are highly endemic for Lyme disease, a single prophylactic dose of doxycycline (200 mg for adults or 4.4 mg/kg for children of any age weighing less than 45 kg) may be used to reduce the risk of acquiring Lyme disease after the bite of a high risk tick bite. Benefits of prophylaxis may outweigh risks when all of the following circumstances are present:
  1. Doxycycline is not contraindicated.
  2. The attached tick can be identified as an adult or nymphal I. scapularis tick.
  3. The estimated time of attachment is ≥36 h based on the degree of tick engorgement with blood or likely time of exposure to the tick.
  4. Prophylaxis can be started within 72 h of tick removal.
  5. Lyme disease is common in the county or state where the tick bite occurred (i.e., CT, DE, DC, MA, MD, ME, MN, NH, NJ, NY, PA, RI, VA, VT, WI, WV).

Friday, April 19, 2019

Keep your kids safe from toxic plants

Poisonous Plants
There have been warnings on the news lately about the dangers of Easter Lilies being toxic to cats. Lilies can be toxic for young kids as well.

It is not uncommon for me to get calls from parents whose young kids decided to nibble on some house plants, so those news stories are a good reminder for all of us that we need to be in the know about plants that our kids come into contact with.

In most of the cases of these plant eaters, the kids aren’t showing any obvious signs that there was an issue. Typically if someone eats something that is toxic, and there is cause for concern, you would expect vomiting, diarrhea, a rash or fussing. To be on the safe side, the best course of action if you know your child has eaten something you aren’t sure about is to check in with the poison control center. In California that number is 1-800-222-1222

The Poison Control Centers here in the United States report that they get over 100,000 annual calls about plant or mushroom exposure annually. Knowing what plant your child actually came in contact with is very helpful to them. Unfortunately most of the time all we know is that it has leaves and is green. I would place a bet that many of us can't actually identify the plants we have in our homes and yards, and therefore have no idea about whether or not they are a potential hazard.

It is a good idea to become familiar with the plants you have in and around your house and garden. Different plants will cause a variety of symptoms. Just like a sensitivity to food, not all kids will be equally reactive to an exposure. Reactions can range from mild vomiting and stomach cramps to more severe seizures and heart irregularities.Some plants can be deadly. Mushrooms are the biggest culprits

Some plants will cause irritation just by coming in contact with them. Locally the most common culprit for that is poison oak. Some succulents and cacti aren’t poisonous but can cause a wicked scratch from getting too close to their spikes

Step one is to teach your children not to put any part of a plant in the mouth (yeah, good luck with that…..) This means leaves, stems, bark, seeds, nuts, berries, and bulbs. Do not allow children to suck nectar from flowers or make "tea" from the leaves. Never chew, or let children chew on jewelry made from seeds or beans. Unfortunately kids will chew or eat things regardless of how they taste or the level of disgustingness. Depending on the plant, eating a tiny amount might not be an issue, but large or repeated doses can be harmful. I know it just about impossible to watch them every second, so it is important for you to be able to recognize plants that are more hazardous.

If you have small children or curious pets, consider removing toxic plants. If you are attached to a plant that is on the list, perhaps lend it to a friend or neighbor until your little one is out of the "everything in the mouth" stage.
In general, toxic or not, house plants should be placed out of reach of the very young. You also need to pay attention to falling leaves. If there are other houses or places that you frequent with your kids, make sure those plants are safe as well.

If you are a gardener, make sure you store labeled bulbs and seeds in a safe place where your kids and pets don’t have access to them.

Below is a list of some of the common house and garden plants with poisonous parts.

Plants causing severe or fatal poisoning are marked *. Plants causing rashes are marked with°.

Plants                                    Poisonous Parts
African violet                                      Leaves
Amaryllis-garden                                 Bulbs
Azalea *                                              Leaves
Castor bean                                        All parts
Cherries *                                          Seeds and leaves
Citrus fruits                                          Leaves
Crown of thorns°                                 Milky sap
Cyclamen*                                         Tuber
Daffodil*                                            Bulbs
Delphinium                                         Young plant, seeds
Elephant ear*                                     All parts
Figs°                                                  Milky sap
Four o'clock*                                    Root, seeds
Foxglove*                                         Leaves
Holly-English                                     Berries
Hyacinth*                                          Bulbs
Hydrangea                                         Leaves
Impatiens                                         Young stems, leaves
Iris°                                                 Rhizomes
Ivy-English, German, ground         Leaves, stems, berries
Larkspur*                                         Young plants, seeds
Laurel-Australian mountain                 All leaves
Lily-of-the-Valley                                Leaves, flowers
Lilies                                                  Bulbs
Lupines                                             Leaves, pods, seeds
Mistletoe*                                          Berries
Narcissus*                                          Bulbs
Oaks                                                  Acorns, foliage
Oleander*                                         All parts
Peaches                                             Seeds, leaves
Philodendron                                     Stems, leaves
Plums                                               Seeds, leaves
Poinsettia*                                        Milky sap
Potato-Irish                                     Green skin on tubers
Primrose                                         Leaves, stem
Rhododendron*                               Leaves
Rhubarb*°                                       Leaves
Sweet peas                                      Stem
Tomato                                           Green foliage
Tulip*                                             Bulbs
Wisteria                                          Pods and seed
Yew*                                              Foliage, bark, seeds

Here is a list of : Safe and Poisonous Garden Plants

Pets can also have different reactions to certain plants. The link below provides a list of plants that are toxic for your pets:

I just inherited some lovely plants from my daughter since she has kitties.

Be Safe!!

Friday, April 12, 2019

There is no such thing as a silly question!

Let me tell you a story...

I was a nurse with a few years of experience under my belt when I moved to San Francisco. I was promptly hired at UCSF, which was, and remains in my experience, an excellent hospital. UC, because of its excellence, is a center where patients with many of the more exotic and hard to treat conditions are sent for care.

On one of my first days on the job I was getting report from a nurse; I don’t remember much about her and don’t know that I ever interacted with her again. She was passing along information about a patient who would be under my care for the upcoming shift. This little guy had an unusual illness with a long complicated name, no doubt named after the folks who discovered it. For the purposes of this post, and since I have long forgotten what it was, I will call it Hughie, Dewie and Louis disease. Here is the thing - this wasn’t something that I once knew and had forgotten. I had never, ever heard of it. Not even a glimmer of an idea.

“ So, Your patient X has HDL disease...These are his orders”

“Hold on a moment, What is HDL? I am not familiar with it.”

There was a pause and maybe a sneer

“You haven’t ever heard of HDL?”

I imagine that this was my opportunity to get a bit shame faced and say, "Oh! HDL, of course" and continue to get the report, but I don’t work that way. One of the things I respect the most in a person is to be comfortable with what they don’t know. Now, it is easier than ever to get educated. This was long before the days where I could pull out a phone and simply google it. This was now a game of poker. Some of you may not know, but Nurse Judy plays poker in Vegas.

“I have never, ever heard of it. Can you please tell me a bit about it so that I can take better care of the patient?"

She doubled down, I think she had come too far to save face and was hoping I would cave first.

“How long have you been a nurse? Where have you worked before this”?

“Is there anyone here who can tell me a bit about HDL?”

There was a resident sitting there who was happy to tell me all about this very rare condition. EVERYONE in the break room was hanging onto every word. Is it possible that no one had dared to ask? That was an isolated case at UC, but I carried the lesson along with me.

If I am talking to a parent and they are confused about a dose, a diagnosis or anything, the LAST thing I want is for someone to be embarrassed that they aren’t “getting it” and accept the information without clear understanding.

No one knows everything. As parents this is a good lesson to pass along to our children. Being comfortable enough to acknowledge what we don’t know and learning how to find the information we seek are important skills.

Friday, April 5, 2019

Ear Infections/to treat or not to treat

As an advice nurse at a busy pediatricians office, talking about ear infections (medical lingo otitis) is among one of the more frequent calls I deal with. I feel a pang for the stressed out, busy parent who would love to throw some magic medicine at the issue without an office visit. I know it is hard to take off time from work. Alas, it isn’t so simple.

Ear infections come in different varieties and complexities. Not only is there is not one standard treatment, but many times no treatment is even needed. Some stoic kids don’t make a noise about a severe infection while others complain bitterly about a little fluid in the ear that is not actually infected. If we blindly treated every complaint about an earache, we would be wildly over prescribing antibiotics. A special instrument that looks in the ear is often needed to make a true diagnosis. Factors like lots of ear wax, or an uncooperative patient can add a level of complexity to the exam. If a patient is screaming bloody murder from the simple exam, that can make the eardrum appear redder than normal.

The most common ear issues that we see are:

Otitis media (a middle ear infection)
Severe cases are treated with antibiotics

Serous Otitis (fluid behind the eardrum)
This may be treated with decongestants or in chronic cases with ear tubes

Otitis externa (also known as swimmer's ear)
With otitis externa the outside of the ear is usually red and sore. The ears may be tender and will look inflamed. With summer coming, I usually see an increase in these cases, with more kids being in water or pools.

While the first two forms of otitis require a tool for diagnosis, otitis externa may be visible by just looking with the naked eye. This condition may be treated with ear drops rather than oral medications, depending on the severity.

Some kids make it obvious. If they are old enough, they may simply tell you that their ear hurts. If they are still young and nonverbal, they may be extra fussy (especially when put down) feverish, or tug at their ear. Many kids wake up more than usual at night. Most of the time kids are congested. Sometimes vomiting can be associated with ear infections.

Some kids seem like their balance is off. Others seem like they are having trouble hearing (I know I know, all of our kids can seem deaf when we are telling them something they don’t care to hear!)

A good number of kids don’t let you know at all. We have had patients in the office for a well child exam and have been caught by surprise when a routine ear check revealed a raging infection. I have also seen ear infections go from ‘zero to sixty’ in no time flat. A child with a perfectly normal ear exam one day can have a horrible ear infection the next.

Most of the time, an infection in the middle ear accompanies a common cold, the flu, or other types of respiratory infections. This is because the middle ear is connected to the upper respiratory tract by a tiny channel known as the eustachian tube. Germs that are growing in the nose or sinus cavities can climb up the eustachian tube and enter the middle ear. Children’s eustachian tubes are smaller and more level than those of an adult. This means it is harder for them to drain well and easier to get blocked up even with mild swelling. Because of these drainage issues, when kids are congested, they also may have fluid in their ear (serous otitis). This is why I am more suspicious about a possible ear infection in a child who has a cold. What may start out as a virus can turn into something bacterial. That fluid is the perfect medium for bacteria to grow. I compare it to a stagnant pond just waiting for the mosquitoes to breed.

Kids with chronic serous otitis who get one infection after another will usually end up at the ENT doc who may put some tubes in the ear to help them drain. Melissa Wilson, Doctor of Audiology at Sound Speech and Hearing, adds that tubes are also put in to address the hearing loss that often accompanies middle ear fluid. Fluid build-up often causes a hearing loss on the order of 30-40 decibels. Average speech is about 60 decibels, so having fluid is like listening with your fingers plugging up your ears. Everything your child hears is muffled and over time, this can impact their speech and language development, and for the school-aged children this can cause issues with listening in the classroom and academics.

An important thing to note is that when kids have goopy eyes, many times they also have an otitis, which is why we may bring them in to check out the eyes and the ears rather than just giving eye drops over the phone.

Just because your child is tugging at their ear does not mean they have an infection. Some kids do it as a habit when they are tired, Others do it when they are teething (especially upper teeth.) Nevertheless, It can be a clue that is worth paying attention to, especially if it accompanies any other symptoms. I realized after the fact that I had ignored my daughter Lauren’s first ear infection for more than a week when she was fairly young. Looking back at videos you can see the poor kid simply grabbing at her ear constantly. This was a long time ago, prior to my Noe Valley Pediatrics job, when I was working at UCSF with complicated surgical cases and thoughts of an ear infection didn’t even cross my mind.

If your child is diagnosed with an ear infection, chances are you will get a prescription for antibiotics. No one likes to overuse antibiotics, but If your child is miserable and feverish, I would follow through with the treatment. If the eardrum is bulging and looks like the membrane may rupture, the doctor will advise you that you should absolutely go ahead with the medication regardless of how your child is acting. On the other hand, if it is not a severe infection and your child seems consolable, in our office we may suggest that it is perfectly fine to watch and see for a few days. Many ear infections can indeed clear up on their own and of course we all would like to avoid the use of antibiotics if we can. My main agenda, aside from making the kids more comfortable, is preventing an eardrum from rupturing. This does happen and we can’t always stop it but we avoid it when we can. An eardrum that ruptures frequently can become scarred and this can lead to hearing loss.

A miserable screaming child might actually seem more comfortable after the eardrum finally bursts. They will also likely have lots of yellow/orange stuff draining out of the ear. The good news is that the pain of the pressure in there is gone, but the tympanic membrane (an important protective barrier) is no longer intact. Therefore, if your child does have a ruptured membrane, they need to be seen and treated even though they are no longer quite as fussy. After a rupture (certainly if there is more than one) it is worthwhile getting the hearing tested to make sure there is no lingering hearing loss after the eardrum heals.

If the treatment plan includes a course of antibiotics, make sure that you finish the entire course of medication. Most pharmacists will take a moment when you pick up the prescription to go over the directions. Don’t treat them the way we do the flight attendants who are telling us how to buckle a seat belt. Pay attention and please make sure you are clear with the dosing instructions including whether or not the medicine should be taken with or without food. Some require refrigeration. Some might cause extra sensitivity to the sun. Make sure you are familiar with what you are giving your child. Please don’t forget to brush those teeth. Liquid antibiotics tend to be sticky and sweetened in order to make them more palatable.

Some pharmacies can add flavors that might help with compliance:

It may take the medication at least a couple of days before you notice a significant improvement. If your child is still super fussy or feverish after a full three days, have your doctor take another look in there to make sure the meds are working. Some kids who are having a really difficult time may end up getting an antibiotic injection. These hurt a bit, but they are usually quite effective.

With or without the use of antibiotics there are several things you can do to ease the discomfort of a painful ear. Tylenol and/ or Ibuprofen are useful. There are some prescription ear drops that can numb the ear, but they have some possible negative side effects, so most doctors no longer prescribe them. Warmth usually feels good. Try a warm wet washcloth against the ear. You also can put some rice in a sock or pour water into a clean diaper, heat either of those up in a microwave for a quick heat pad that will stay warm for a while (heat in 30 second increments to make sure they don’t get too hot.) Some folks swear by a warm hair dryer held about a foot away from the ear. Believe it or not though, my favorite remedy is garlic oil. Check the ear to make sure there is no reason to suspect a rupture; I don’t like to add any drops if I have any suspicion that the eardrum may not be intact. If there is no odor or drainage (a little wax doesn’t count) garlic oil may be a good option. Saute some cloves of garlic in some olive oil. Let the oil cool until it is warm/not hot. Take a cosmetic square (these are the round or square cotton pads that often come in a stack. I like them better than cotton balls for this.) Dip one half of the pad into the oil, roll it up like a scroll and stick it in the ear. Do this as often as your child will allow. If it is the middle of the night and your child is screaming, you can try any of these pain relief options until you have an opportunity to have your child checked. Persistent unrelenting misery may warrant a trip to the ER.

It is not unusual for us to find a little surprise when we look in the ears. I kid you not, we have found little beads, unpopped popcorn kernels, and even the occasional insect.