Have you read all of the most popular 2018 posts from Quest for Health KC?
At the end of the year I like to take a look at which posts were popular to help identify what I should write about in the next year. It also gives me the opportunity to share with readers all the best posts they might have missed along the way.
10. Help! I’m sick and I have a baby at home!
Parenting is a tough job, even when you’re not sick. When you have an infant and you’re sick, not only do you have extra sleep needs, but you have to try to keep your baby healthy despite being around your germs. What can you do when you’re sick with a baby at home?
During the summer months one of the most uncomfortable reasons I see boys is that their penis and/or scrotum is swollen significantly. Learn what Summer Penile Syndrome is and what to do about it.
7. Dark Under Eye Circles
When kids have circles under their eyes, parents worry that something’s wrong. Sometimes there’s a treatable reason, sometimes not. Learn all the most common causes of under eye circles and what to do about them.
6. The flu shot doesn’t work
I’m pro-vaccine, so this title might surprise you. I hear the argument that the flu shot doesn’t work so often that it deserves to be addressed.
5. Flu Season Fears: What should you do?
Every flu season as we start to hear reports of kids dying from influenza the fear surfaces. This was written during one of the worst outbreaks in recent history. Be protected against each flu’s season fear with a flu vaccine and healthy habits!
When saliva gets on our skin, it breaks it down. Licking the lips leads to increased cracking and bleeding. Some kids have a wide ring of dry skin around their mouth from lip licker’s dermatitis. Learn what you can do to help them heal their smile.
I’m surprised at the popularity of a few of these and sad that some of my personal favorites didn’t make the list.
I wish more people would read what fever is so they worry less about a number. Learning the evolution of illness might also help parents understand why exam findings are different on different days. I hear far too often that an ear infection was missed, but it’s more likely that they developed since the first exam.
I’ve also written a little on insurance and the business of medicine, but it doesn’t surprise me that those are not as popular. Sadly, we all need to understand the intricacies of billing and insurance as well as how the business of medicine works. As more and more private practice physicians sell out to large corporations, we’ll all feel the negative impacts.
School’s back in session, which means sick season is approaching quickly! The pure volume of sick visits can be overwhelming for any clinic, whether visits are scheduled or walk in, but the nature of walk in clinics makes the volume unpredictable. Sometimes no one in walks in, other times several come at once. Urgent cares and walk in clinics are wonderful for the overall speed at which one can be seen, but how can you help streamline the process? How can you keep your primary care physician in the loop? Here are my top tips for a successful urgent care trip and knowing when to avoid them.
1. Write down symptoms.
It sounds crazy to write down things since you know your child better than anyone, but if your child is sick you are probably sleep deprived and might forget important details.
Writing things down helps everyone summarize what is going on and get facts straight. The diagnosis often lies in the history, and if the person bringing the child in does not know symptoms well, it’s difficult to make a proper diagnosis.
This also forces you to think about the symptoms, and you might realize that you don’t know everything that’s going on. This is especially true if your child spends time away from you at school, daycare, or with another parent. It’s better to recognize that you need more of the story before you get to the clinic!
2. Expect to be seen for one acute problem.
Illnesses typically have more than one symptom despite being a single illness. It’s appropriate to bring a child in for multiple symptoms, such as cough, fever, and sore throat.
It is not appropriate to bring them in for those issues as well as a wart and headache of 3 months off and on. If there are unrelated things, expect to deal with the most acute issue and then follow up with your usual physician to discuss the more chronic things at a scheduled appointment.
The nature of walk in clinics is that they move rapidly. The number of patients checking in at any given time can be large, so each visit must be quick. If you need more time to address many issues or one big condition, schedule an appointment.
3. Don’t attempt to get care for a chronic issue.
Chronic issues are always best managed by your Primary Care Provider (PCP), but exacerbations of chronic issues might need to be seen quickly.
This means that sudden changes to a condition, such as wheezing in an asthmatic, can be addressed at an urgent care, but routine asthma management should be done during a scheduled visit. Your child can go to the walk in for the wheezing, but should follow up with the PCP with a scheduled appointment to discuss any changes needed to the daily medication regimen (Action Plan) to prevent further wheezing.
This is especially important if you went to another urgent care or ER for initial treatment so that your doctor knows about the recent exacerbation of a chronic issue.
4. Do not add additional children to the visit.
Many parents bring additional kids to the visit and ask if we can “just take a peek” in their ears.
If you want them to be seen, check them in too. Again, walk in clinics move quickly and the “quick” peek often takes longer than you’d think because the child is running around the room or fighting the exam.
The quick peek also does not allow for documentation of findings in the medical record, which might be helpful in the future.
5. Have your insurance card and co-payment ready at check in.
Streamline checking in by having everything ready.
It’s surprising to me how many people must return to their car for their wallet. For safety reasons, never leave a purse or wallet in your car.
6. Try to bring only the child who is being seen.
It is difficult to focus on one sick child when another is running around the room, falling off the exam table, or constantly asking questions. This applies to scheduled as well as walk in visits.
I know this becomes a childcare issue, but it can really help focus on the child being seen if you leave additional children at home if at all possible. Think of friends who always offer to have a play date with the healthy child. Or maybe plan to bring one child when the other is at school.
If you must bring multiple kids, set the stage right by avoiding bringing tired and hungry kids. Don’t come at nap time if at all possible. Tired kids are miserable kids. Give them a healthy snack before going to the clinic. Don’t feed your kids at the office – another child could have a food allergy to whatever you’re feeding them, which can put other kids at risk. Bring books or toys that your kids can be entertained with during the visit.
7. Bring medications your child has recently taken.
Often parents have tried treatments at home, but are not sure what was in the bottle.
Bring all medications to help us advise on correct dosage and use of the medications. This includes prescription medicines as well as over the counter supplements, medicines, and natural therapies.
8. Use your regular doctor’s office if available.
I know not all doctor’s offices have walk in hours and most are not open all night long, but most walk in type visits are not emergent and they can wait until the next business day.
Treating symptoms with home remedies is quite acceptable for most illnesses for a couple days. This might even be beneficial to see how the symptoms change over time. Some kids are brought in at the first sign of fever, and look normal on exam, only to develop cough and earache over the next few days. When the symptoms change, so might the exam and treatments!
9. Please don’t use walk in clinics to have health forms filled out.
I know it is tempting to get a quick physical to get a sports form or work physical signed, but doing so breaks the concept of a medical home.
If you get these forms completed outside your PCP’s office, you don’t get a comprehensive visit. The visit with your PCP should include reviewing growth, development, safety, immunization status, and more. It’s more than just filling out forms. You lose the opportunity to share what has happened in the past year and continue to build a trusting relationship.
If the medical home does all the well visits and vaccines, we have up to date records and can update them as needed. Some kids have missed school because vaccines were missed and they can’t return until they get them. Others have gotten extra doses of vaccines because a record of a shot was missing and parents can’t remember where they got the vaccine.
We request a well visit yearly in the medical home after age 3, more often for infants. If in need of a well visit, please call the office to schedule!
10. Call first if you’re not sure!
If you’re not sure if it’s okay to tough it out at home overnight, call your doctor’s office.
We can often give tips on how to manage symptoms to save the emergency room co pay and germ exposure. Sometimes we do advise going to be seen. If there are concerns about dehydration, difficulty breathing, mental status changes, or other significant issues, waiting overnight is not appropriate.
Most urgent care visits are really not that urgent. They can be handled during normal business hours in your medical home!
Meningitis occurs when a virus or bacteria causes inflammation of our brain or spinal cord. We use several different vaccines to prevent a few types of meningitis, but it’s all very confusing. Recent commercials have raised questions about what these vaccines are and if they’re needed.
Today we’ll go over what meningitis is and what types of germs cause it. Next time I’ll discuss some of the new meningitis vaccines in more detail.
What is meningitis?
Both viruses and bacteria can cause meningitis, but not everyone with these germs gets meningitis. Most people have less severe symptoms when they get these infections.
Not everyone gets all the symptoms listed below when they have meningitis. Some of these symptoms are common to many less serious infections, but if your child has these symptoms and appears more sick than normal, he or she should be evaluated immediately.
Symptoms of meningitis include:
body aches and pains
sensitivity to light
mental status changes
Viruses are the most common cause of meningitis. Thankfully viral meningitis tends to be less severe than bacterial meningitis.
Most people recover on their own from viral meningitis. As with many infections, young infants and people who have immune deficiencies are most at risk.
There are many types of viruses that can cause meningitis. It’s likely that you’ve had many of these or have been vaccinated against them.
We vaccinate against these typically at 12-15 months of age, so it is uncommon to see these diseases. The MMR and varicella vaccines can be given separately or as MMRV. (Rubella is the “R” and can lead to brain damage in a fetus, but does not cause meningitis.)
Bacteria that lead to meningitis can quickly kill, so prompt treatment is important. If you’ve been exposed to bacterial meningitis, you may be treated as well, but remember that most people who get these bacteria do not get meningitis.
Most people who get bacterial meningitis recover, but some have lasting damage. Hearing loss, brain damage, learning disabilities, and loss of limbs can result from various types of meningitis.
Causes of bacterial meningitis vary by age group:
Newborns can be infected during pregnancy and delivery as well as after birth. They tend to get really sick very quickly, so this is one age group we take any increased risk of infection very seriously.
Bacteria that tend to infect newborns include Group B Streptococcus, Streptococcus pneumoniae, Listeria monocytogenes, and Escherichia coli.
Mothers are routinely screened for Group B Strep during the last trimester of pregnancy. They are not treated until delivery because this bacteria does not cause the mother any problems and is so common that it could recur before delivery if it’s treated earlier. This could expose the baby at the time of delivery. If a mother does not get adequately treated with antibiotics before the baby is born, the baby may have tests run to look for signs of infection or might be monitored in the hospital a bit more closely.
Once the mother’s water breaks, we time how long it has been because this opens the womb up for germs to infect the baby. If the baby isn’t born during the safe timeframe, your delivering physician or midwife might suggest antibiotics. After delivery your baby might have tests done to look for signs of infection or might be monitored more closely in the nursery.
As children leave the newborn period, their risks change. Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b (Hib)are the bacteria that cause disease in this age group.
Thankfully we have vaccines against many of these bacteria. Infants should be vaccinated against S. pneumoniae and H. influenzae starting at 2 months of age. (Note: H. influenzae is not related at all to the influenza virus.)
Vaccines against N. meningitidis are available, but are not routinely given to infants at this time. High risk children should receive the vaccine starting at 2 months of age, but it is generally given at 11 years of age in the US.
Teens and young adults
Neisseria meningitidis and Streptococcus pneumoniae are the risks in this age group.
Thankfully most teens in the US have gotten the S. pneumoniae vaccine as infants so that risk is lower than in years past.
Sometimes vaccines are given too soon to count toward the required vaccine schedule. This can easily happen if there are changes to the standard vaccine schedule for any reason, but what does that mean for the child? Are they in danger? Do they need extra shots? Is that even safe???
Early vaccines don’t count.
Don’t try to sneak in early before a recommended age.
It’s not appropriate in most cases to give vaccines at shorter intervals or before the recommended age.
The 12-15 month vaccines are occasionally given before the 1st birthday, which does not count in every state. State laws can dictate a grace period in which vaccines can be given earlier than the standard schedule, but not all do.
This is an issue with some children moving from a more lenient state to one with a lesser (or no) grace period.
In some states they can get their MMR a couple days before their first birthday.
Does this protect them against measles, mumps, and rubella?
~ Probably. (Nothing’s 100%.)
Does every school count it?
~No. If they move to a state that doesn’t, they need to repeat it.
International travel changes things.
It is recommended for international travelers over 6 months to get an MMR early due to worldwide measles outbreaks.
This dose does not count toward the 2 doses typically given after the 1st birthday because younger children do not make immunity as reliably, but is felt to potentially benefit those at higher risk due to travel.
If the MMR vaccine is given when they are already protected, the vaccine doesn’t work.
We don’t know if a 6-12 month old is safe or not, so when the risks increase, as with international travel, it is recommended to give a shot to help if needed.
But that shot might not work, so it should be repeated after the 1st birthday.
Minimal intervals are important.
Most vaccines are given as a series, and each vaccine within a series needs to be separated by a minimal interval.
Before vaccine logic was built into our electronic health record, it could be difficult to know which vaccines were recommended if people got off the standard schedule.
Not all EHRs have smart vaccine logic, so if you’re off schedule, be sure to discuss intervals before giving vaccines.
The hepatitis vaccines are more commonly given off an appropriate schedule than other vaccines. I’ll touch on each of them and why they’re problematic.
Hepatitis A vaccine interval problems.
My office routinely gives the first Hepatitis A vaccine at 12 months and the second at 18 months. The CDC schedule states:
Hepatitis A (HepA) vaccine. (minimum age: 12 months)
2 doses, separated by 6–18 months, between the 1st and 2nd birthdays. (A series begun before the 2nd birthday should be completed even if the child turns 2 before the 2nd dose is given.)
Despite warning parents to schedule the 18 month visit 6 months or more from the 1 year visit, sometimes they don’t have the correct spacing. This generally happens when they do the 1 year visit several weeks after the birthday but then try to “get back on track” and do the 18 month exam on time.
The good news is our smart EHR tracks minimal intervals and doesn’t suggest the vaccine if it’s too early.
I typically wait until the 24 month visit to do the 2nd Hepatitis A vaccine if it is too early at the 18 month visit, but I ask the family to come in just before the 2nd birthday. This allows the child gets the vaccine before 24 months of age and fit the main recommendation of getting both doses between the 1st and 2nd birthdays.
Sidenote about HEDIS
A delay to wait until the 2 year well visit follows the CDC recommendation to have the doses separated by 6-12 months.
If a child gets the Hepatitis A vaccine after the 2nd birthday, the physician loses quality points.
These points help rank physicians for insurance company purposes.
As long as it doesn’t happen often, it’s not an issue.
But if schedules are off too often, a physician’s contracts with insurance companies could be at risk because they are seen as not high quality, regardless of why the vaccine is given after the 2nd birthday.
If you want to keep your favorite physician and use your insurance, please help them meet the standards of care for all metrics. This includes coming in for annual well visits and having regular follow up for chronic issues. It also means taking the recommended medications, such as preventative medicines for asthma and doing certain labs, such as lipid panels, or screenings, such as depression screenings.
Don’t confuse the HEDIS measures and insurance contracts with this Big Pharma farce. First off, we pay pharmaceutical companies to buy their vaccines. They don’t pay us. Sometimes they buy a lunch for our staff so they can have our attention when they talk about their products, but there is no big money to be made from vaccine companies.
Insurance companies pay us for the vaccine and the costs associated with giving vaccines. These costs are not only for syringes and band aides. We must carry insurance for the vaccine inventory. There must be a dedicated refrigerator and freezer to safely store vaccines. We should use a refrigerator alarm system to alert us if the temperature is too warm or too cold. We pay staff to keep logs about refrigerator temperatures and inventory. All of these costs add up.
Trust me, no one gets rich off of vaccines.
Some insurance companies offer bonuses if we meet HEDIS measures, but more often I think they just pay less if we don’t meet measures.
Why do they pay more if we give vaccines?
Because the insurance company comes out ahead if we vaccinate. Vaccine preventable diseases cost them much more than vaccines. They want to encourage us to vaccinate to save them money.
Hepatitis B Interval problems.
Hepatitis B vaccine is given in 3 doses, with the second 4 weeks after the first, then the 3rd at least 8 weeks from the 2nd and 16 weeks after the 1st.
There are vaccines that just have hepatitis B protection (monovalent vaccines) that can be given starting at birth. They can be used for all three doses.
There are other vaccines that combine the hepatitis B vaccine with other vaccines (combination vaccines). The combination vaccines are given at different intervals, depending on what is in the vaccine. They cannot be given under 6 weeks of age, but it’s still recommended to give the first dose within 24 hours of birth.
Yes, it’s confusing.
From the CDC guidelines:
A complete series is 3 doses at 0, 1–2, and 6–18 months. (Monovalent HepB vaccine should be used for doses given before age 6 weeks.)
Infants who did not receive a birth dose should begin the series as soon as feasible.
Administration of 4 doses is permitted when a combination vaccine containing HepB is used after the birth dose.
Minimum age for the final (3rd or 4th) dose: 24 weeks.
Minimum intervals: Dose 1 to Dose 2: 4 weeks / Dose 2 to Dose 3: 8 weeks / Dose 1 to Dose 3: 16 weeks. (When 4 doses are given, substitute “Dose 4” for “Dose 3” in these calculations.)
There are even additional recommendations if the mother is a known Hepatitis B carrier or if her status is unknown.
If any of the doses are given too early, they need to be given again. This is considered safe.
Live viruses need special attention.
Live viruses must be given either at the same time or at least 28 days apart. If they are given at a shorter interval, the second vaccine is presumed to not be effective and must be repeated.
This is another great reason to not alter the standard vaccine schedule your provider uses. If your child gets off track, you run the risk of him or her needing additional vaccines.
Common live virus vaccines include MMR, Varicella, MMRV, and Flumist.
Some vaccines, like the oral typhoid vaccine, cannot be given at the same time as antibiotics.
See if you know what vaccines your child needs.
To avoid vaccines that are given too soon:
Be sure that whoever is giving vaccines knows any recent vaccines and medicines your child has had recently.
Try to stay within the recommended vaccine schedule as much as possible to avoid needing extra doses.
Vaccine schedules for children birth – 6 years and 7-18 years:
Attempt to limit sharing of toys that young children mouth, and wash them between children.
If your child attends daycare, try to find one where there are fewer children per room.
One of the biggest causes of bacterial ear infections is pneumococcus. Your child will be vaccinated against this as part of the standard vaccine schedule.
If you know me, you know I often recommend saline to the nose.
Saline drops for babies followed by suctioning.
Nasal saline rinses for kids over 2 years of age. (Nasopure has a great library to teach proper use and even videos to get kids used to the idea.)
Saline is a great way to clear the mucus from our nose, which can help prevent cough, sinus infections, and ear infections.
Keep the pacifier in the crib.
When kids play, they often drop their pacifier, which can encourage germs to accumulate on it before they put it back in their mouth.
There are several studies that suggest chewing gum with xylitol as its sweetener helps prevent ear infections in children who can chew gum. For younger infants, there are nose sprays with xylitol. Xylitol is a naturally occurring substance that is used as a sweetener is many products, many of which are reviewed here. I do not endorse any of these, but do find this a helpful resource.
Treat acid reflux.
This can include dietary changes, positional changes, or medications. Talk to your doctor to see which is right for your child.
Treating allergies can help decrease mucus production and improve drainage.
Most people want it gone now. (Or more likely, last week.)
Unfortunately despite our medical advancements over the years, we still have no cure for colds and coughs. Viruses do not get killed by antibiotics, and most colds and coughs are caused by viruses.
I don’t hold back on advice when I see kids with disturbing colds and coughs. I sympathize with the child and parents. I’ve been there: both as a person with a bad cold and as a parent watching my kids struggle with colds. But I still can’t make them better faster.
Blow the mucus out. If a child’s too young to blow his nose well, parents can suck the snot right out.
Honey for children over 12 months of age
Prop the head up during sleep
But then we still have the original question: How long will a cough or cold last?
One of my favorite graphs depicting the timeline of a typical upper respiratory infection is from research done in the 1960’s, but since we don’t have any better treatment now than we did back then, I find it to hold true to what I experience when I get a cold and what I see in the office.
Notice how the symptoms are most severe during the first 1-5 days, but still persist for at least 14 days. And at 14 days 20% of people still have a cough, 10% still have a runny nose. And the lines aren’t going down fast at that point, they both seem to linger.
Bear in mind that children tend to get about 8 colds per year, often in the fall/winter months, so a second virus might start developing symptoms right as the first cold is finally going away.
There’s an important distinction between back to back illnesses versus a sinus infection requiring antibiotics. This is why doctors and nurses ask (and re-ask) about symptoms. The history and timeline of symptoms are very important in a proper diagnosis.
It isn’t the color of the mucus (really!) We don’t want people to unnecessarily take antibiotics. That leads to bacterial resistance, side effects of medicine, and increased cost to families.
So if you’re struggling with cough and cold symptoms in your house, follow these instructions.
To help determine when your child needs to be seen:
Urgently or emergently:
If your child is breathing more than 60 times in a minute, ribs are going in and out with breaths, or the belly is sucking in and out with each breath, your child needs to be seen in the office, at urgent care or an ER (preferably one that specializes in children), depending on time of day and your location. Another complication that kids must be seen for is dehydration. Dehydration may be present when the child is unable to take in enough fluids to make urine at least 4 times a day for infants, twice a day for older children.
Routine office visits:
If your child has ear pain, trouble sleeping, or general fussiness but is otherwise breathing comfortably and well hydrated, he should be seen during regular office hours. If the cold is worsening after 10-14 days, bring your child in during regular office hours.
Hello. This is Dr. Stuppy. I’m returning your call about…
That’s how my phone calls start, then they take various turns. Some are easy, some not so easy. I’d like to discuss what makes a phone call to the doctor’s office more productive, so we can help you better.
All examples are entirely fictitious, made up of 18 + years of phone call experiences.
Many calls start off like this:
Hi. This is Mary Sue. My son has a rash and I want to know what to do.
I must ask many questions for more information.
Some callers don’t seem to know what to say, so they only answer direct questions. How old is your son? When did the rash start? What does it look like? Has it changed? Does it itch or hurt? Any other symptoms? What have you used to treat it? Did that help? Has he had any new ingestions, lotions, or creams? Does he have a history of allergies? Anyone else with a rash that looks like this?
On and on…
Other calls start like this:
Hi. Thanks for calling back. My son Jack is 3 years old. Well, really his birthday isn’t until next month, but he’s almost 3. He has had a fever for 2 days, maybe 3 days because he felt warm but he wasn’t acting funny or sick that first day he felt warm so I didn’t check his temperature. He actually was fussy last week, but I don’t think he ever had a fever then. I was thinking maybe he didn’t sleep well last week, but I don’t know why. His temperature was 100.3, that was on Tuesday around 7am. I gave Tylenol, and it went down to 97.9, but then 4 hours later it was back up to 99.7….
My thoughts so far: Get to the point.
Sorry, but that’s true. I care about my patients, but so far this phone call has taken me quite a bit of time and I really know nothing except this almost 3 year old has an elevated temperature (not even a true fever). I don’t even know what the parent’s main concern is.
just the facts, MA’AM.
When parents call, they need to summarize with pertinent facts. While they shouldn’t leave out important helpful information, they don’t need to mention every time they took a temperature.
Much like the evening news: they can’t do a play by play of every football game. There’s no time and it serves no purpose. A few highlights of the game and the score. That works well. People get a pretty good idea of how the game went.
It’s the same thing with phone calls to your doctor’s office or on call provider. We have thousands of patients. Not all call, but during peak cold and flu season, there are many calls all day and night. The phone nurse or on call provider simply can’t spend 15 minutes chatting about every detail. That’s for your friend and you to discuss over coffee.
During the cold and flu season, it’s not uncommon for me to be on the phone with one parent when another call comes in. This is at the same time I’m trying get groceries or do other things I need to do for my family on evenings and weekends. (Being on call after hours doesn’t mean that I don’t have to work during the day.) I really don’t want to sit and chat. I don’t have time for play by play action. Again, I really care about my patients, but I can do a better job at answering your questions if you are clear and concise.
Things that help us help you:
Know what’s going on.
When a parent calls and the child is at daycare or grandma’s so the caller doesn’t know details, we can’t really help. Yes, parents have called for advice when they’re on their way to daycare but don’t know any more than the child has to be picked up due to a symptom such as vomiting, fever or pink eye.
See your child first or have the person with the child call us. When you pick up the child, ask for details of their day. Learn how they ate/drank, how they acted, etc.
Sometimes you’ve been up several nights in a row with a sick child and things get jumbled in your head. It happens.
Write down the pertinent facts to get them straight if you need to.
Start with your child’s full name and birth date.
I can’t tell you how often parents jump right into their worries without stating who their child is. This is important not only for chart documentation of the call but also so we know how old your child is.
Include any significant past history, such as your infant was born at 28 weeks gestation, or your coughing 3 year old has a history of wheezing.
Give pertinent facts related to the concern.
If your child has a fever, give the number of days of fever, the maximum temperature, and how it was taken.
If you have given a fever reducer, share that.
Find a quiet place to talk.
When my kids were little they always wanted to be held when they were sick. I get it.
If you’re on the phone and they’re crying in your arms, it’s very hard to have a conversation.
Please find a safe place for your child to rest while we talk if possible.
If they won’t leave you or stay quiet, have another adult talk to us after they’ve been briefed about all the symptoms.
Summarize symptoms and treatments.
Briefly describe symptoms and what you have done to help them as well as how your child responded to the treatment.
Mention All treatments
If you use a vaporizer or saline for a cold, or have stopped dairy and used gatorade for vomiting, let us know. If you use a traditional home remedy, please let us know.
Let us know any medications your child typically takes in addition to ones you have tried for the current symptoms.
Signs and symptoms can be tricky to describe
When there’s a rash, it’s typically best for us to see it, but if you call about a rash describe it in terms of location, color, and size. Many find it helpful to relate to common objects, such as quarter-sized.
Note if there is a pattern to the symptoms, such as headache every day after school or barky cough only at night.
Summarize, don’t tell a novel
Leave out details that don’t help. Trends and generalizations work well.
If we want more details, we can always ask.
Avoid words that could be interpreted other ways, use facts.
Commonly misused words are “lethargic” and “fever.”
Lethargy in a medical sense is ominous. Many parents use it when their child is only mildly ill and tired. Describe what you’re seeing instead. Saying “Johnny won’t even wake enough to drink or hold his cup,” gives me the thought he is lethargic. Saying “Johnny wants to sit on my lap and read books instead of playing with his sister,” shows that he’s not well, but definitely not lethargic.
Fever is a temperature over 100.4 F. Many parents use the word fever if their child feels warm to touch. It’s more clear if you state that they’re warm to touch or what the thermometer says and how you took it.
I’m calling about Joe Smith, birth date 9.12.08. He has had a fever for 3 days, up to 101.3 under the arm. It comes down with ibuprofen, but is right back up in 6 hours. He also has sore throat and headache. He’s drinking well but not eating much for 3 days.
I know this child’s name, age, pattern of fever and associated symptoms. The only thing I need now is the parent’s concern – so far they’ve been doing everything right. What made them call today? What’s their question?
Sally Smith, birth date 9.12.17, has vomited 6 times in the past 12 hours. If I give formula it immediately comes up. She is now dry heaving and hasn’t had a wet diaper in 12 hours. There’s no fever but she looks tired and it is hard to wake her to drink. She doesn’t have diarrhea. Her older brother had the stomach flu a few days ago but is now better.
Again, I know the child’s name and age and main problem – especially the fact that she sounds dehydrated. The parent didn’t use this word, but described dehydration (no wet diaper in 12 hours and it’s hard to wake her to drink).
Include pertinent history
John Smith, birth date 9.12.17, was in the NICU for 2 months due to prematurity. He has been fussy all day and is now breathing fast and hard and is not able to drink more than a few sucks at a time. He doesn’t have a fever, but I’m really worried.
Here I know the child’s age and that he was significantly premature – a big risk factor. He’s distressed because he can’t feed. Note: I made this baby not have a fever on purpose. He’s sick even without a fever.
Getting More Information
Knowing where to get reliable information is important. There’s a lot of bad advice online. Fancy websites aren’t always reliable.
My office’s website, PediatricPartnersKC, also has many pearls of wisdom. Often when we give advice it’s already stated on our site. Parents sometimes call multiple times because they can’t remember what we said. This is frustrating on both ends of the phone. We wrote it down and made it easily available for a reason. Use our site! (For patients in other practices, check out your own pediatrician’s site.)
Things that cannot be done by on call providers – at least not well:
Prior authorization for an ER or urgent care visit that is already done.
Prior authorizations are not usually needed, but if they are required, we should talk to you to be sure the visit is necessary before you go.
If I didn’t send you to the ER, I can’t fill out paperwork saying I did. That’s lying and using my license inappropriately. Often I would have chosen another location or given home care instructions to get you through the night.
Of course if you do talk to me (or one of my partners) overnight and we do send you to an urgent care or ER, we are happy to fill out forms if needed by insurance.
You should ask their triage nurse who can make that assessment.
I typically expect that your child is seen prior to most prescription refills for best medical care. If it’s urgent that your child have a refill, such as an inhaler, they should be seen to evaluate the concern.
There are exceptions to every rule, but don’t be upset if the on call provider or phone nurse refuses to call out a prescription.
This is in the best interest of your child, not to be difficult. It’s easier to just call in the script than it is to argue this point, believe me. But easier isn’t better care, and that’s what’s important.
Make a diagnosis.
We cannot see the ear, listen to the lungs, or feel the belly over the phone. A physical exam and sometimes labs or radiology studies are needed to make a diagnosis. If your doctor claims to be able to diagnose by phone to call out prescriptions, I would suggest that they’re not doing the best of care.
An example of a poor diagnosis by phone:
Just this week another child was seen in my office for a sore throat that wasn’t better on the amoxicillin prescribed by a telemedicine doctor through their insurance company. The exam clearly showed blisters on the child’s throat. The sore throat was from these blisters, which are from a virus, not a bacteria.
The antibiotic was never needed. In this case the child simply didn’t get better as expected with a presumed case of Strep throat, but fortunately she didn’t get diarrhea or have an allergic reaction to the antibiotic. Who knows if this contributed to more bacterial resistance and superbugs?
Not only did the family waste money on an unnecessary treatment, they also exposed their child to a treatment that could have caused harm.
I worry with the increasing use of telehealth that we will see more problems related to improper diagnoses and delay of proper diagnoses – some of which could be significant.
Swallowed poisons or medicine / drug overdose.
The United States has a great poison control system. They can give rapid advice that most doctors don’t have easily available.
Call (800) 222-1222 if you suspect your child has ingested something. PUT THIS NUMBER IN YOUR PHONE RIGHT NOW.
A visit’s better than a phone call for:
If a child is having difficulty breathing and you don’t have treatments at home that work, he needs to be seen as soon as possible.
An infant who hasn’t urinated in 6-8 hours or an older child who hasn’t urinated in 12 hours might be dehydrated and should be seen as soon as possible.
Temperature above 100.4 F in an infant under 3 months or in an under immunized child can be serious and should be seen as soon as possible.
Fevers lasting more than 3-5 days or with other concerning symptoms require an evaluation.
Fevers are scary and can make kids miserable. There is no “magic” temperature that we worry about more. Look at how your child is acting, not the thermometer, to determine if they are sick. Not every child with a fever needs to even be treated. There is benefit to letting the fever do its job!
If you’ve used standard pain relievers and your child is still hurting, we cannot do anything by phone that will improve the situation. A careful exam might find a treatable cause of pain.
Though these don’t necessarily need to be seen emergently unless there are other concerns, rashes cannot be evaluated on the phone and a physical exam is needed.
If your child is otherwise well appearing, treat the symptoms of the rash.
If he’s otherwise sick and you’re concerned, then he should be seen.
If your child has been dealing with anything for more than a few days, it might help to schedule a visit with your usual provider. This is especially true if it relates to a chronic condition, such as asthma, constipation, or other issue.
Many parents deal with a problem for months (or years) but have NEVER been in to discuss it specifically. They might mention it at another visit as an aside, but we never really talk about it in depth and give it the attention it deserves.
Diagnosis vs information.
If you want a diagnosis, we need to see your child. We cannot tell if the ear is infected or if your child has Strep based on symptoms alone.
If you want advice of what to do with symptoms, we can generally give advice. Remember that the websites above can be helpful with this type of information too!
These are best discussed with your usual provider, not an on-call provider who doesn’t know your child. Most of these build up over time and are not emergent issues.
If it is an emergent issue, such as a child is in physical danger due to his actions or if a child is threatening another person, call 911.
If your child is suicidal, call the suicide hotline at 1-800-273-8255.
If your child has a significant injury, they often require prompt evaluation. Call 911 before calling your doctor’s office if your child is seriously injured.
Lacerations must be repaired as soon as possible, so don’t wait until office hours the next day if there’s a gaping wound!
Minor bumps and bruises can be handled at home, but if you’re not sure, give us a call to discuss what happened.
Help me help you!
Let me know what else you need to know to be an educated caller.
I’d be happy to answer questions about when to call, what to ask, and what to expect.
Healthcare is available at many locations, such as in the medical home (primary care office), at a specialty clinic, in a hospital or a surgery center, freestanding urgent cares, pharmacy based urgent cares, emergency rooms, telehealth companies, school health clinics and more. Convenience care is what I use to describe the care people desire here and now, when it’s convenient and where it’s convenient.
There are places that are best suited for one issue and others suited for other issues. Sometimes people choose a location based on what’s convenient at the moment, not necessarily when and where they will get the best care. This usually isn’t going to make much of a difference, but it can have implications of varying consequences. Convenience care is not equal to the best care, and sometimes not even equal to good care.
The one about the restaurant
My family likes to go to Primary Restaurant for great food. We know the food is high quality and the chef takes special care to make everything just right with healthy ingredients. The staff gives great service, always making sure we have what we need. Because there’s always room for improvement, they encourage quality development and the restaurant staff works to make things right to the best of their ability if a problem is identified.
But one night we decided to go to Convenience Cooks. We were hungry and Convenience Cooks was on the way home.
Were we starving to death? No. We had food at home we could have eaten, but Convenience Cooks was, well… convenient. Their menu was limited compared to what we are used to, but we were able to order something that was decent.
While we were waiting, I decided to call Primary Restaurant to see if it was a good choice or if we should leave and go to their restaurant. They said since I made the choice and was already waiting, I should just stay at Convenience Cooks.
The food wasn’t the quality we were used to, but we ate it. I had second thoughts at the end of the meal, so I called the Primary Restaurant to see what they thought. The staff who is usually so helpful wasn’t of any use helping me decide if what we ate was good for us or not.
Since none of us felt satisfied and left still hungry, I feel like Primary Restaurant should deliver food to our home, but they refused. They said we should go to Primary Restaurant to eat if we want their food. Why? I already paid Convenience Cooks and had most of a meal there.
Weeks later I get a bill from Convenience Cooks and am surprised about the cost of convenience, so I call Primary Restaurant to see if it’s usual for Convenience Cooks to bill added fees. Again, they said they couldn’t do anything to help with the bill. For a Restaurant that is usually so helpful, I feel like they are dropping the ball because they won’t help with anything that was done at Convenience Cooks. It’s like they don’t have any responsibility for what I eat elsewhere.
The one about specialists
In another scenario, you really want a good BBQ. Primary Restaurant specializes in All-American food, but they don’t offer slow-cooked BBQ, so they refer customers to BBQ-R-Us.
BBQ-R-Us is busy and requires reservations. Since you are used to same day seating at Primary Restaurant, you ask if they can get you preferential seating at BBQ-R-Us. After several phone calls back and forth with staff at each location, you realize you can be put on a waiting list, but no one was able to change your initial reservation.
When that time finally comes, you enjoy the ribs, but leave with questions. Instead of asking the BBQ specialists, you call Primary Restaurant to ask about how the ribs were prepared. You’re disappointed to hear that they can’t give details about the BBQ recipes and tell you to call BBQ-R-Us.
Even later you call Primary Restaurant to complain about the bill you got from BBQ-R-Us. You were surprised that the creamy corn was extra and they charged a seating fee. Again, Primary Restaurant isn’t very helpful in discussing the bill from BBQ-R-Us. They refer you back to BBQ-R-Us.
now change the names
Most people can see just how crazy it is for a restaurant to “fix” the problems with quality, cost, or service at another restaurant, yet many (MANY) people want their primary care physician to do just that after trips to convenience urgent cares or regarding specialist referrals. The scenarios above are based on real phone calls about medical care. These phone calls are not only time-consuming and costly for medical offices, but they’re also frustrating for the people on both sides.
Convenience Cooks = Urgent Cares
I’m sure I’m not alone when I get frustrated at the number of calls asking me to give an opinion of treatment received elsewhere, or to fix a problem that wasn’t fixed at an urgent care. I’m glad that patient families feel so comfortable with my office that they call to ask for help, but if I am not a part of the evaluation, I can’t help.
It’s not that I’m holding a grudge or trying to be mean, but I really can’t help. If I didn’t see the patient or at least have access to the medical record of the visit and know the provider well enough to understand their practice style, I have no idea what was really seen and done.
If you call my office because your child is having a problem with a medicine someone else prescribed, we will tell you to call the place that prescribed the medicine. We cannot manage what someone else prescribed. Often we hear that “they’re not open yet” or “they don’t do phone calls, they want us to come back.” Sorry. We will want to see your child before we treat him for this issue. You can bring him in or you can follow-up with the original prescriber.
On a similar note, if a patient sees someone else in my office, I can look at the medical record documentation. I know the people I work with well enough to know what they typically say and do, and along with their written plan I can usually offer assistance if they’re not available. Sometimes even then I will want to see a patient because symptoms change.
If someone outside my office sees a patient, I really don’t know what the level of exam was, the experience of the provider, or the specific details of the visit. Urgent cares are getting better at sending a summary of the visit to the primary care provider, but we still don’t receive any information a significant percentage of the time. Other than routine general advice, I can’t really say much about the issue. I cannot change or refill another provider’s order. I cannot order labs or x-rays based on another provider’s assessment. I believe that this is not good care and I would prefer to see the patient if they need advice or a change in the treatment plan from me. And I certainly can’t do anything about the bill from another provider.
Many problems seen at urgent cares can wait. I know it’s easier to get your child in tonight so they can maybe go to daycare/school tomorrow, but many of these things are viral and just take time. Even if it’s strep throat and they start an antibiotic at 8pm, they can’t go to school in the morning. If you would have called my office before going to the urgent care (or looked on our website for advice), chances are the issue could have waited until office hours by using some at home treatments to make it through the night.
The cost savings of staying out of an emergency room or urgent care can be substantial with many insurance plans. And my office would be available to help answer any questions that arise from that visit. (Note: sometimes when the symptoms change we still need to see a child again, but we are more likely to be able to help over the phone if we were the ones who saw the child than if they were seen anywhere else.)
There are now some urgent cares that are actually cheaper in dollars because of insurance contracts. I think this is a very short-sighted plan on the part of insurance companies and in the end will cost more in dollars and health complications. They are trying to save money by contracting with these urgent cares (or are merging with them). I worry that fragmented care will in the end increase costs because they won’t have access to a patient’s medical chart. Increased numbers of tests and prescriptions are often seen at ER/UCs compared to primary care offices because they don’t have a means to follow-up like the medical home does so they cover all the bases rather than take the watchful waiting approach that PCPs are able to take. At urgent cares patients will not have the benefit of seeing the same provider each time, so they will never develop the important doctor-patient relationship that can help if and when anything chronic develops.
BBQ-R-Us = Subspecialist Referrals
As for specialist referrals, I know it’s hard for people to wait for appointments, but I really can’t get people in any quicker than a schedule allows. If it is a real emergent or urgent need, I can talk to the doctor to see options, such as admitting to the hospital so they can be consulted, or having someone go to the ER, where they might stop by to see the patient. Usually it isn’t really that urgent from a medical standpoint, and waiting for the appointment is just what happens in the specialist world. I’m not saying that’s a good thing, it’s simply reality. Please don’t beg me to call them to get you in sooner. I cannot invent time and I can’t alter their schedule. Despite what the scheduler tells you, if the primary care doctor calls the specialist, the specialist rarely can get the appointment changed. I’ve done this frustrating scenario many times– often when I really want the child seen sooner than scheduled. Unfortunately it usually doesn’t significantly alter the appointment time. It just wastes my time and the time of the specialist.
After your appointment I cannot tell you if the treatment plan they propose is the best for your child. Once I refer, it’s usually because it is out of my knowledge base and needs specialist care. I can learn along with patients, but I rely on the specialist to know the latest and greatest in their field and they can give better advice than I can. I also don’t like to “step on toes” if I refer. If they are driving the bus, they need to drive. Back seat drivers can cause problems on the road. Let them drive the bus. If you really want another opinion, you’ll have to ask another specialist.
Expect higher fees any time you use a hospital based facility, whether it’s for an office visit, a lab, or a procedure. They not only have charges for the physician’s time, but they have facility fees to cover the costs of running the hospital.
The primary care physician cannot change the charges incurred at any other clinic or hospital. We recommend researching costs prior to care, but we know that this is very difficult unless you know exactly what will be done at every visit. We cannot tell you what another physician will do… I can’t even predict what I will do at a visit if you call me ahead of time. If your child has a fever and cough, I might send you home with at home treatment instructions without any expensive tests if the exam supports that. I might order labs or a CXR, prescribe a medicine, or admit your child to the hospital for treatment if the findings support that.
We try to help by keeping a list of all our most common charges in the parent book in each exam room, but that doesn’t help plan before the visit. It only tells the maximum that will be charged, not the actual amount that will be the patient responsibility after insurance adjustment and payment. I understand how frustrating medical costs can be, but I can only help with what is in my control. Changing how our billing and insurance system works is not in my power. I can only play by the rules.
When kids are sick, parents understandably want them to feel better quickly. They want a sound night’s sleep. They want to be able to return to work/school. They want to see a happy, healthy child again. They come to our office hoping for answers and a cure.
Sometimes there is no quick fix, just treating symptoms and time.
It’s been about 15 years, but I remember the frustrations of having a sick baby when my daughter had bronchiolitis. Some of the details are muddy, but I remember the feelings of inadequacy because I couldn’t help her feel any better any faster. I knew the illness tends to get worse before it gets better and there is little we can do to alter its course, but knowing this it didn’t make me feel any better as the mom who was helpless.
I lost sleep for several nights as I watched her pant (not breathe, but pant). I resorted to giving asthma-type breathing treatments because my son had wheezing so we had everything we needed to give a treatment at home with a nebulizer. We did these treatments several times despite the fact that they didn’t seem to help her much. (Guidelines now say to not use bronchodilators for most infants with bronchiolitis but even then we knew it didn’t help much.) It was probably the humidified air from the nebulizer that helped more than anything. But the vaporizer in her room and the saline to suction her nose wasn’t helping, so I wanted to at least try the asthma medicine.
She kept wheezing.
We brought her in to the office three days in a row to have someone else check her. I can’t check oxygen levels at home and needed someone to objectively examiner her. So three days in a row we went in for repeat exams.
She was able to maintain her oxygen level and stay hydrated despite breathing 60-70 times per minute for days. I still don’t know how. I remember wishing her oxygen level would drop enough that we could hospitalize her ~ not critically ~ just enough. Then she’d be on monitors and maybe I could sleep a bit knowing someone else was watching her. Thankfully she never got that sick and eventually we were all sleeping again, but it took a long time for that.
So I understand the frustration when we tell parents things to do at home and ask that they come back in __ days or if ___, ____, ___ symptoms worsen. It really isn’t that we are holding out on a treatment that will fix the illness, it’s just that we don’t have a quick fix for many illnesses. We need to be able to examine at different points in the evolution of the illness to get a full picture of what is going on.
The exam can tell us a lot, but it doesn’t predict the future. One minute ears can look normal, the next they develop signs of an infection. I cannot say how many times I’ve heard a parent complain that someone else “missed” something on exam that I now see. Yes, sometimes things can be missed, but I suspect that most of the times the exam has simply changed.
I learned this phenomenon as a resident on the inpatient unit. I had a patient who had been admitted for an abdominal issue. I did a physical on the child in the morning before rounds, including looking at ears, which were normal. Late that afternoon the nurse paged me because he developed a fever. He had a new symptom, so another exam was indicated. This time the ears were red and full of pus. Within hours this child had developed a double ear infection. I examined the ears both times and they were definitely different.
I understand the frustration (and expense) to take kids back in to be seen if symptoms worsen, change, or simply just don’t resolve at home. If symptoms change, we need to re-evaluate, which includes an exam. Medical providers cannot look into the future to see what will develop. It is not appropriate (or effective) to put kids on an antibiotic or iv fluids to prevent the illness from taking its natural progression. Sometimes we need time to see how the illness progresses to see what other treatments might be needed.
When you hear that your child has a viral illness, do not take that to mean it’s “just a virus” and there’s nothing to be done. There are many supportive measures that can be done and things to monitor to be sure your child isn’t getting sicker. Dr. Jamie Friedman discusses the topic of Just a Virus and Dr. Chad Hayes also covers the difference between “just a virus” and the potential risks of a viral illness in “Just a Virus:” What Your Doctor Meant to Say.
When parents call back and want something else done, they are often upset that we want to see the child again. I hear many types of complaints.
Money is probably the biggest issue. It is not because we want your co pay. The “we” I use here is not just my office and I am not speaking of any particular situation. With online doctor rating sites, social media sites, and knowing doctors around the country, I write with many examples in mind. I’ve seen online complaints that doctors are just money hungry, trying to get someone to come back in just so we can charge more money. It is true that we charge for every visit. We are not able to waive the copay because we did “something wrong” or “missed a diagnosis” the first time. Each is a separate visit with updated information and a separate exam. Insurance contracts dictate that a separate copay is charged. We must adhere to legal contracts or it would be considered insurance fraud.
Increasing our numbers for “production” is sometimes brought up. It is not because we want to fill our waiting room with more children to increase the waiting time for everyone else. We don’t want to waste your time or ours. But we need to see a child to know what is happening at that moment to be able to give any valuable advice and treatment.
We want to see your child again because we need to see your child to know what to do. Maybe now the child’s symptoms have changed. Maybe not, but without the history and exam we do not know. The exam might now show wheezing, low oxygen levels, a new ear infection or sounds of pneumonia. Sometimes the exam still is overall normal, but the fever’s been going on long enough without any identifiable cause, which requires lab and/or x-ray evaluation.
Please remember that if you get a different answer at a different visit, it doesn’t mean that the first assessment was wrong. Usually it is due to a progression of the illness, and things change.
When we have newborns we don’t want them exposed to germs. We avoid large crowds, especially during the sick season. We won’t let anyone who hasn’t washed their hands hold our precious baby. We might even wash our hands until they crack and bleed.
But what happens when Mom or Dad gets sick? What about older siblings? How can we prevent Baby from getting sick if there are germs in the house?
In most circumstances it is not possible for the primary caretaker to be completely isolated from a baby, but there are things you can do to help prevent Baby from getting sick.
Wash hands frequently, especially after touching your face, blowing your nose, eating, using common items (phone, money, etc) and toileting.
Wash Baby’s hands after diaper changes too. Make this a habit even when you’re not sick… you never know when you’re shedding those first germs!
Wipe down surfaces
Viruses that cause the common cold, flu, and vomiting and diarrhea can live on surfaces longer than many expect.
Clean the surfaces of commonly touched things such as doorknobs; handles to drawers, cabinets, and the refrigerator; phones; and money frequently when there is illness in the area.
Avoid touching your face
Avoid touching your eyes, nose and mouth – these are the “doors” germs use to get in and out of your body.
Pay attention to how often you do this. Most people touch their face many times a day. This contributes to getting sick.
Kiss the top of the head
Resist kissing Baby on the face, hands, and feet.
I know they’re cute and you love to give kisses, but putting germs around their eyes, nose, and mouth allows the germs to get in. They put their hands and feet in their mouth, so those need to stay clean too.
Cover your cough
I often recommend that people cover coughs and sneezes with their elbow to avoid getting germs on their hands and reduce the risk of spreading those germs.
When you’re responsible for a baby, the baby’s head is often in your elbow, so I don’t recommend this trick for caretakers of babies. Cover the cough or sneeze with your hands and then wash them with soap and water or use a hand sanitizer if soap and water aren’t available.
If you’re vaccinated against influenza, whooping cough, and other vaccine preventable diseases, you’re less likely to bring those germs home. Encourage everyone around your baby to be vaccinated.
If you get your recommended Tdap and seasonal flu vaccine while pregnant, Baby benefits from passive immunity.