Progression of Illness: When It’s Not What You Thought It Was

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Since I’ve started this digital gig, I’ve had the opportunity to read a lot of healthcare patient feedback: reviews of doctors, physician assistants, and nurse practitioners, commentary on urgent care offices and hospitals, and opinions on nurses and reception staff. Lots of people report on things like cleanliness of surroundings and wait times and throughput. There are a fair number of comments about staff attitudes and “tone”. But I’m not going to talk about those aspects in particular today. Believe it or not, many of those topics I’ve just named are fairly straightforward to address: people can be given feedback to pay more attention to their behavior and to improve communication skills, and the facilities issues are mostly easily rectified. Billing disputes are typically solved after varying degrees of investigation.

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I also read occasional comments about “missed diagnoses” in the acute care setting.

Every now and again I’ll read a frustrated review from someone who sought medical care one day and was given a diagnosis, only to obtain a different one the next from another physician. Or an upset parent who got the news that his child had an ear infection a day after they were seen elsewhere and told that the ears looked clear. These situations require a more complex dissection, and each and every one of them must be reviewed and analyzed in detail to search for any discrepancy of standard of medical care. And they do happen, as we all know. Medicine is far from perfect. I’m sure that the term frustration doesn’t even BEGIN to describe how this must feel on the patient/family side of things. I can vouch for this personally.

What I DO want to highlight in these few paragraphs is the concept of “progression of illness”

and how that causes a lot of tough breaks and is at the heart of many negative reviews and bad feelings about various healthcare encounters, though I’m not sure it should be. I know it sounds obvious to state that “things change,” but clinical scenarios do. Diseases evolve, big and small. It’s really true that on a Tuesday night a child’s ears could look clear as day and by Wednesday they are red and fluid-filled. Or that the lungs sound great on Friday but by Sunday morning there’s an audible pneumonia. So progression of illness is the term we use when a disease takes its typical course. Kind of like a timeline. And on that timeline there’s an early, middle and late phase. The hard part about snapshot diagnostics, when clinicians only see patients once and briefly at that, is that if you catch someone on the early phase of a disease timeline, there’s a chance that an accurate diagnosis will be missed. Thankfully this doesn’t happen all that often.

There are several reasons to be careful about pulling the definitive diagnostic trigger too soon in the early phase of an illness.

For example, in the case of possible infection, incorrectly calling it “bacterial” and thus prescribing antibiotics too early can actually do more harm than good if the infection turns out to be a simple self-resolving virus. It won’t help a person get better any quicker, can potentially have some unpleasant side effects, and fosters the growth of antibiotic resistant superbugs. A little bit of “expectant observation” often allows for better accuracy, even if it means taking time out of busy schedules for another healthcare check. I understand the potential financial impact of this, which must be weighed into the equation, but I still stand behind the belief that doing the right thing medically should take precedence.

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Another example is the decision whether or not to give intravenous (IV) fluids to a child with the stomach flu. Nearly everyone who gets the stomach flu has some degree of dehydration, and I’ve seen situations where an IV is expected yet not necessarily indicated. Dehydration is a spectrum, and it’s nearly always better to use the stomach to rehydrate if at all possible, meaning to hydrate by drinking in frequent small sips or sucking on an ice cube. This can be slower and often takes more work than rapidly infusing some saline into someone’s veins, but in the end it avoids a needle-stick and helps keep the intestines at work. The tricky part in this scenario is being able to guarantee that a person will be successful at rehydrating by mouth: it’s impossible to predict. Sometimes that queasy feeling subsides sooner rather than later and tolerating fluids goes better, but sometimes not. Regardless of direction, there has been progression of illness, and as a result of that progression, a different therapeutic direction may need to be taken. No one’s fault, it just is.

I bring up the topic of progression of illness today because it’s what I ask myself every time I read a review or post or commentary or survey response that includes details about a delayed or missed diagnosis. “Could this have been simply part of the progression of illness?” is a worthwhile question, and I hope by bringing it up today it’s a question that you’ll ask too as you come across reviews and posts in the digital space.

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What can YOU do?

1. Ask your provider the question about progression of illness. Know what to expect in general, recognizing that every situation is slightly different.

2. Establish a plan of action at your first medical visit for what to do if things seem to be worsening. Are there specific signs to watch out for?

3. Know what else your clinician is thinking about in regards to your specific case. What other diagnoses are on the list? How will the determination be made, and does it matter (i.e. will it affect treatment)?

4. Don’t be afraid to call your provider if you have questions after your visit. He/she may tell you to come back in for evaluation or may be able to direct you right at home. Speaking from experience, we always want to help to provide the best care possible.

I’m not trying to make excuses for medical care that doesn’t measure up, or make light of the fact that it is often difficult, usually time-intensive, and frequently expensive to have more than one medical visit for an acute issue, but what I am trying to say is that progression of illness is always at play and sometimes the clinical care dictates some step by step management with observation and evolution in between. Being mindful of this amidst the plethora of commentary by understandably stressed and concerned people when considering various healthcare environments is important in the spirit of fostering the most positive clinician-patient relationships possible.

And THAT, I know, is good for everyone’s health.

Christina Johns, MD, MEd is the Senior Medical Advisor at PM Pediatrics and author of the blog, Dear Dr. Christina. As a parent, pediatrician and pediatric emergency physician with a master’s in education, she shares her own expertise, plus the wealth of knowledge from our highly skilled staff, with patients and families everywhere.

Dr.ChristinaJohns

Follow Dr. Christina online for everyday health tips, insightful articles and more.
Blog: https://www.pmpediatrics.com/dear-dr-christina/
Facebook: https://www.facebook.com/DrChristinaJohns/
Instagram: https://www.instagram.com/deardrchristina/
Twitter: https://twitter.com/DrCJohns
Pinterest: https://www.pinterest.com/deardrchristina/

Visit PM Pediatrics in Annapolis
Festival at Riva Shopping Center
Phone: 410-266-6767

PM Pediatrics is the specialized urgent care just for kids from cradle through college. Open every day until midnight, the practice’s kid-friendly themed offices are staffed by Pediatric Emergency Specialists and feature on-site digital X-ray and lab. PM Pediatrics treats a broad array of illnesses and injuries – from earaches, fevers, infections and abdominal pain to dehydration, asthma, fractures and wounds requiring stitches. The result is the highest quality after-hours pediatric care, delivered with comfort and convenience to both patients and their parents. To learn more about PM Pediatrics’ services and locations, visit pmpediatrics.com.

 

Breastfeeding and Returning to Work

By Kendra Nagey, CPNP, IBCLC at Annapolis Pediatrics

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Returning to work after maternity leave can be very difficult – it’s emotional for some, a logistical dilemma for others, and yet another big life change for everyone. For those mothers who are returning to work and also hope to continue breastfeeding their babies, pumping while you are away from your baby presents another complication.

As a Certified Pediatric Nurse Practitioner (CPNP) and an International Board Certified Lactation Consultant (IBCLC), I frequently encounter mothers who have questions about HOW breastfeeding after maternity leave actually works. I am often asked questions such as, “When do I pump?”, “How much should I pump?”, “What do I need to pump?” and “What do I do with pump parts when I’m at work?”

First, let’s review the goal of pumping. There are many reasons that mothers pump; however, the main reasons are usually to maintain your milk supply when you are away from your baby and to ensure that your baby continues to receive expressed breast milk while under the care of others.

Schedule: It’s important to think about pumping a few weeks before you actually return to work. Specifically ask yourself, what kind of flexibility will you have in your schedule? Where will you be able to pump, i.e. is there a private office available? Do you need to leave your desk to go to a lactation room or mothers’ lounge? If you have a flexible schedule and are able to pump whenever your baby typically feeds, transitioning from breastfeeding to pumping can be fairly straightforward. Unfortunately, this is not the case for everyone. Teachers, for example, may need to pump during their planning periods or lunch. Other professions might need to schedule meetings around their pumping time. Ideally, nursing mothers should be pumping every three hours while they are away from their baby.

Volume: Duration of these pumping sessions will vary from mother to mother; however, you should anticipate that pumping to empty your breasts will take fifteen to twenty-five minutes. The volume pumped during this time will also vary from mother to mother. A general rule of thumb is that your baby will require one ounce of expressed breast milk (EBM) for every hour that you are away from him or her. So, if between your commute and your work day, you are away from your baby for 9 hours, it can be expected that your baby will need 9 ounces of EBM.

Supplies: I highly recommend use of a double-electric breast pump. If you do not have a pump already, call your insurance company to inquire about which pumps are available to you through your policy. A good pumping bra makes things a lot easier (I tend to recommend the bras that actually attach to your nursing bra/camisole as opposed to the separate garments). Another consideration is how to clean your pumping parts between pumping sessions. As per the CDC, it is NO LONGER advised to put used pump parts in the refrigerator until their next usage. Instead, pump parts should be cleaned with soap and hot water and air dried between each use. If this will be difficult for you, it might be worth investing in addition assemblies for pumping. Finally, consider how you will be able to store your EBM until your return home. You might have a refrigerator available to you or you might need to bring a portable cooler with you to work. Please see the CDC website for up-to-date guidelines regarding the proper storage of EBM (https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm).

Mindset: Like anything else, sometimes it takes a little trial and error to get into a good rhythm with routines – pumping is no different! Pumping can be frustrating, annoying, and sometimes emotional, but it can also be very rewarding. Remember, the point of pumping is to help you meet your individual nursing goals! For some mothers, getting into the right state of mind can actually benefit their pumping. For example, instead of catching up on email while you pump, can you take a minute to look at pictures or videos of your baby? Can you call their caregiver to check in? The release of breastmilk is, in part, mediated by oxytocin – our “love hormone.” Taking a moment to foster the release of this hormone may help you meet your pumping goals.

Hopefully, this basic introduction to pumping at work is helpful. If you have additional questions or concerns, please contact your primary care provider or an IBCLC.

About Annapolis Pediatrics:
For almost 70 years, Annapolis Pediatrics has provided superior healthcare to infants, children, adolescents, and young adults in Annapolis and the surrounding communities. In some cases, we have cared for three generations of families. We strive to provide high quality medical care, from excellent clinical care to a positive customer experience for our patients and their parents.

We have over 30 physicians and nurse practitioners in 5 locations: Annapolis, Crofton, Edgewater, Severna Park, and Kent Island. We also offer Monday through Friday walk-in hours at our Annapolis office for short sick visits.

For more tips and information from your local pediatrician, visit us at:
Website: https://annapolispediatrics.com/
Facebook: https://www.facebook.com/AnnapolisPediatrics/
Twitter: https://twitter.com/AnnapPeds
Instagram: https://www.instagram.com/AnnapolisPediatrics/

Bedwetters Anonymous

You know what’s great? That my 8 year old is not totally stressed out that she is still an occasional bed wetter. It happens to her about once every six months, and the way I’ve explained it to her is that she gets into such a deep sleep that she doesn’t even realize that it is happening until it does. She’ll tell me by saying, “Mom, I was in a really deep sleep last night....” And I know what’s coming.

Benign bed wetting is fairly common and can make kids quite anxious and avoid sleepovers and other situations where this might happen. When talking to patients & parents about this topic I think it’s important to get out of the way IMMEDIATELY actual physical causes of bedwetting—like urinary tract infections. Medical causes do happen, as do psychological ones—like a significant life change for a child— a new sibling, parent divorce, move, or other transition. And these are all important. But once these causes have been considered, then you’re back to my 8 year old, a random, occasional bedwetter.

Some kids wet the bed very regularly and there are some strategies that can be really helpful to aid in decreasing the number of sheets washed per week, such as:
• Limiting fluids by mouth after 6pm
• Waking them up for a bathroom trip once in the middle of the night
• Even trying out one of those bedwetting alarms can help make families’ lives much easier when they are dealing with this.

Older kids do NOT want to sleep in a pull up so I really recommending trial and error of some of the other strategies to help kids manage. One pediatrician colleague told me “kids won’t go to college as bedwetters” and I’ve repeated this over and over to try and reassure people far and wide that it’s simply a matter of time before it’ll all be in the rear view mirror.

Occasional bed wetting does seem to run in families, and most kids totally outgrow it by the time they are teenagers. For the “rare” or “occasional” crowd, I generally suggest NOT MAKING A BIG DEAL ABOUT IT. At all. I can guarantee that kids are never happy that it happens so there’s really no need to pile on here. The less anxiety, the better.

If you’re reading this and have experience in this area, I hope you’ll comment and share what you know; what has worked and what hasn’t. If you’re new to this gig I really suggest trying the “deep sleep” explanation: it shifts any and all blame from the child and puts it into some perspective for them. I’ve known kids who wet their beds up until 12 or 13 years old. They’re in college now, and you know what? They’re fine. And sleeping in a dry bed each night.

Christina Johns, MD, MEd is the Senior Medical Advisor at PM Pediatrics. As a parent, pediatrician and pediatric emergency physician with a master’s in education, she shares her own expertise, plus the wealth of knowledge from our highly skilled staff, with patients and families everywhere.

Dr.ChristinaJohns

Follow Dr. Christina online for everyday health tips, insightful articles and more.
Blog: https://www.pmpediatrics.com/dear-dr-christina/
Facebook: https://www.facebook.com/DrChristinaJohns/
Instagram: https://www.instagram.com/deardrchristina/
Twitter: https://twitter.com/DrCJohns
Pinterest: https://www.pinterest.com/deardrchristina/ 

PM Pediatrics: Now Open in Annapolis
Festival at Riva Shopping Center
410-698-6918

PM Pediatrics is the specialized urgent care just for kids from cradle through college. Open every day until midnight, the practice’s kid-friendly themed offices are staffed by Pediatric Emergency Specialists and feature on-site digital X-ray and lab. PM Pediatrics treats a broad array of illnesses and injuries – from earaches, fevers, infections and abdominal pain to dehydration, asthma, fractures and wounds requiring stitches. The result is the highest quality after-hours pediatric care, delivered with comfort and convenience to both patients and their parents. To learn more about PM Pediatrics’ services, visit pmpediatrics.com.

 

High-Risk Holiday Season Scenarios – Tips for Keeping Your Family Safe

Article written by: Samuel M. Libber, MD, Annapolis Pediatrics

The holidays are times of great joy, celebration, and sharing with family and friends. Our routines shift, our day-to-day patterns change, and life takes on a different pace. To a child, however, these changes can expose them to a number of risks both inside and outside of the house. Taking a few moments to remind ourselves of these risks may pay gigantic dividends....and maybe even save a life.

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According to the Centers for Disease Control, transportation-related accidents rate highest in terms of risk to children. Motor vehicle accidents, in particular, are the most problematic. At holiday time, long car trips, drivers impaired by alcohol or sleeplessness, crowded roads, and poor weather conditions present hazards to kids and their families. Heightened defensive driving, proper seat-belt and car seat use, frequent breaks, and timing trips to avoid high-risk scenarios will all help to lower these risks.

Household injuries, such as falls and burns, also pose threat to kids (and their family members). While celebrating, adults may temporarily let their guard down when supervising their children. Kids can easily fall, harming themselves and potentially requiring emergency care. Candles, electric fixtures, and lit fireplaces can be especially intriguing to small children and can lead to contact burns, scalds, and fires.

Be careful, too, about ingestions. Little children may find their way into bottles of brightly colored pills lying on tables or countertops, or in purses left open from visiting family and friends. In only a short time, a child may consume enough to have a serious or even fatal ingestion. Watch out for mistletoe and holly, both of which have potentially disastrous effects when consumed. Poinsettias have had a bad rap, which has been largely disproven for humans...although not necessarily for pets.

Enjoy your holidays and treasure the time with your family and friends, but remember to be mindful of potential hazards. You will thank yourself for the extra few minutes you take to prevent possible mishaps from happening. Happy---and safe---holidays!

----

For over 60 years, Annapolis Pediatrics has provided superior healthcare to infants, children, adolescents, and young adults in Annapolis and the surrounding communities. In some cases, we have cared for three generations of families. We strive to provide high quality medical care, from excellent clinical care to a positive customer experience for our patients and their parents.

We have over 30 physicians and nurse practitioners in 5 locations: Annapolis, Crofton, Edgewater, Severna Park, and Kent Island. We also offer M-F walk-in hours at our Annapolis office for short sick visits.

For more tips and information from your local pediatrician, visit us at:
Website: https://annapolispediatrics.com/
Facebook: https://www.facebook.com/AnnapolisPediatrics/
Twitter: https://twitter.com/AnnapPeds
Instagram: https://www.instagram.com/AnnapolisPediatrics/

Be Still My Beating Heart: 5 explanations for an elevated pulse that you should know

Today I want to talk about some vital signs. These are important, right; they’re VITAL. And we need to have them all working (fairly) smoothly in concert to remain vertical, so I think it’s fair to give them some attention. Most of the time at work, before I even go into a room to examine a patient, I take a look at the vital signs as a way to frame up my assessment.

Let’s first say what the vital signs are:
• Temperature
• Pulse (or heart rate)
• Respiratory rate
• Blood pressure
• Weight

One thing that I want everyone to know is that normal vital signs are different for different ages.


Kind of like in the animal kingdom, where little animals like hummingbirds have usual heart rates of over 200 beats per minute and elephants have rates of 40 per minute: the larger the creature gets, the slower the heart rate is. Same deal in humans. A heart rate of 145 in a baby is perfectly normal, but when I see that number for a teenager I get very concerned, or at least need a reasonable explanation for it.

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Temperature and weight get addressed a lot, don’t they?

Between fever and obesity, many a blog has been written. Respiratory rate is a vital sign that usually makes itself known when there’s a problem: it’s hard NOT to notice when a child is in true respiratory distress. They’re breathing so fast that their chest and abdominal muscles are visibly moving in and out, and they can barely feed (baby) or speak (older child) due to that rapid respiratory rate. Blood pressure is a squirrely one in children: high blood pressure in kids is relatively uncommon, but as the childhood obesity epidemic grows, we are starting see more of it. See how vital signs interrelate?

Let’s get back to pulse.

That’s the number of times the heart beats in a minute. What I want to focus on today is on the heart rate, and specifically, a fast heart rate. The 25 cent word for this is tachycardia (pronounced ta-kick-ard-ee-uh), and it always gets my attention. I’m happy to say that most of the time in pediatrics it is easily explained by reasons OTHER than the heart, but that doesn’t diminish its importance. There are FIVE key reasons for the heart rate to be elevated in kids (adults too, for that matter):

1. Fever

Elevation of the body temperature alone causes the heart rate to increase. The chemicals in our cells that are associated with inflammation (due to whatever cause: infection, auto-immune reactions, etc.) produce a cascade of reactions that ultimately elevate our body temperature “set point”, and that’s why we have fever that hangs on until a fever-reducer medicine is given (acetaminophen or ibuprofen) or the infectious or inflammatory process goes away. Along with those chemical reactions come an increase in pulse, as the heart does its job to help pump along all the infection fighting inflammatory cells in the blood to the rest of the body where they are needed. Thanks, heart, for pitching in and doing your job.

2. Exercise

When we exercise, our muscles need more oxygen to keep going, and as such, the heart rate increases to make sure the oxygen delivery is adequate. Simple as that. As we get better conditioned our muscles “process” oxygen more efficiently and that’s why athletes have lower resting heart rates. Totally normal.

3. Dehydration

When the body is low on fluids, the circulating volume of blood and plasma in your body decreases, and this causes the heart to pump faster in order to get that smaller amount of oxygenated blood to the other organs and tissues where’s it’s needed. Refer to the animal analogy from earlier: the smaller the body, the less volume reserve the body has. That’s why babies get dehydrated quicker than older kids. And it’s one of the MOST common reasons that the heart rate goes up. Again, thanks heart. See #1.

4. Actual heart problems

Kids can get abnormal heart rhythms, called dysrhythmias (diss-rith-mee-uhs...25 cents!) that cause the heart rate to increase. These are typically quite dramatic; I’ve had families say that they could see their child’s heart beating rapidly underneath their shirt from across the room! It’s not unusual for a rapid heart rate due to an actual cardiac cause to yield markedly high heart rates of over 200 beats per minute (BPM), compared to only moderately elevated heart rates due to other causes. Needless to say, a heart rate elevated over 200 BPM in ANY age group warrants an immediate and emergent evaluation, usually with heart monitoring and an ECG (electrocardiogram) tracing. I’m not gonna thank the heart for this one, since it needs to straighten up and act right.

5. Poisons/Toxins/Medicines

Special shout out to THE most common medicine for causing kids to feel like their hearts are thumping away: ALBUTEROL, the friendly neighborhood wheezing medicine. Available in nebulizer or inhaler form, this medicine, while doing a beautiful job dilating and opening up the constricted airways, also has a direct effect on the heart to speed up the rate. In children, this is usually not a big deal and it goes away on its own after a bit of time, but it can be very annoying and distracting. I’ll take it temporarily though, if it means that breathing improves.

Other substances can cause the heart rate to increase: cocaine (yep, I’ve seen it in kids), and one that we always need to keep in the back of our mind- accidental ingestion of an adult family member’s medication. This happens more than we all think, even with our best intentions of keeping medicines away from children. Make sure you have the Poison Center’s phone number handy: 800.222.1222. Those folks are fantastic, and are available 24/7.

This list covers most of the important highlights of what goes through my mind when I see a child with an elevated heart rate. As you can probably conclude from a few of the points above, not every child who comes in with the complaint of “heart palpitations” needs a fancy ECG or X-ray. What they DO need is a full set of vital signs (and maybe a repeat set or two, to catch any potential discrepancies during the first set) and a thorough assessment by a solid clinician to determine the most likely cause. And now that YOU have some insight into what could be the explanation, you’ll be able to follow along the rationale without a stressful increase in YOUR heart rate as well.

Pulse check!

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Christina Johns, MD, MEd is the Senior Medical Advisor at PM Pediatrics. As a parent, pediatrician and pediatric emergency physician with a master’s in education, she shares her own expertise, plus the wealth of knowledge from our highly skilled staff, with patients and families everywhere.

Follow Dr. Christina online for everyday health tips, insightful articles and more.
Blog: https://www.pmpediatrics.com/dear-dr-christina/
Facebook: https://www.facebook.com/DrChristinaJohns/
Instagram: https://www.instagram.com/deardrchristina/
Twitter: https://twitter.com/DrCJohns
Pinterest: https://www.pinterest.com/deardrchristina/

 

 

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