Showing posts with label children. Show all posts
Showing posts with label children. Show all posts
Tuesday, March 15, 2011
How a dying child tells his parents he's ready to die
My good friend and Fort Worth pediatrician Gary Floyd relates this telling story about working with a family through the death of their child from cystic fibrosis. Gary's story is compelling, really...downright tear jerking. This video is part of a series from the Texas Medical Association that began as project from their creative social media guru Steve Levine. Check out other videos from that series here.
Injections: Does hurting children now, hurt their health care decisions later
For a long time I ran a large multi-specialty group medical practice in a relatively small town. One of our most active divisions was pediatrics.
Ruby was a nurse in the department for almost 30 years and she had seen probably half the community's children grow into fine healthy adults.
But one day I ran into Ruby at the local Walmart about the time that a group of small children rounded the corner. I also stopped to visit with the nice lady.
The children, though, turned, ran, and cried to their mother.
Ruby commented to me that this was a common but unfortunate occurrence for her.
She was the "shot lady."
Hypodermic injections are one of the earliest memories that children have about health care. In fact, if you ask a young child about the necessity to go to the doctor, the child (and many adults as well) will respond, "I don't need a shot."
Physicians, nurses, and mothers over the years have devised a whole host of tricks to encourage children to get the needle.
Bribery is a favorite of mine: "we'll go get ice cream," "we'll stop on the way home and ...", or the most recent experience for an 18 year old in my office -- "we'll stop at Nordstrom's and get your makeup done."
Threats seem to work for some children. It usually is a threat about "worse pain" than the actual injection. If children are old enough to reason even a little, then the fear of being beat with a belt is usually enough to motivate one for the measles shot.
But it doesn't always work that way. A couple of years ago a father threatened to whip a 14 year old in my office if she didn't submit to an injection.
(Just for the record, I'm opposed to corporal punishment.)
Some nurses and parents are particularly good at trickery. Either there is a ruse on coming to the doctor in the first place ("mommy is here to see the doctor" only to find out that "little Johnny is getting a flu shot"), or my absolute favorite: "this won't hurt a bit."
Well, it never hurts me.
Sometimes health care workers can't bring themselves to completely lie about the pain, so they'll compare it to something more familiar and hopefully more palatable.
Like a bee sting.
That one always makes me calm down.
"Yes, it will feel like a small furry creature is inserting a stinger into your skin and blasting poison away."
You're calm now, aren't you?
Brute force is sometimes an option, particularly if it's a young child.
There is a device for young children called a "papoose board" which is a politically correct way of saying "straight jacket."
Children are strapped in the device which has various holes and openings that allow physician or nurse access to desirable locations -- like those for an injection.
This isn't effective when children get above three or four. They are just too strong and our staff and parents are too weak.
Attempts are sometimes made with this modality and usually everyone ends up in positions that would rival team wrestling at the Dallas Sportatorium.
Negotiation is sometimes employed, with very mixed results (usually followed by one of the items listed above.)
You see with injections there's really no "compromise." So negotiation is doomed from the beginning.
You can't end up only "injecting the needle a little bit" or using a "very small needle" or avoiding the injection altogether -- which is the only solution that most children will agree with.
But in the end, most children are traumatized in some way by the experience. I'm not saying that they shouldn't be receiving injections, rather I'm just saying most children leave with short-lived tears and long-term fear of physicians and going to the doctor.
So the question is does this affect their desire to go the physician later in life for regular, and possibly preventative health care?
Particularly if the primal image of your first health care experience is clouded with pain.
Do you put off the flu shot? The breast exam? The prostate exam? Just your annual physical because of some underlying deep seated sub-cortical negative early experience.
I think many patients do.
Going to the doctor is often a painful experience. Some things just hurt.
But I do believe that anything that physicians and nurses can do to mitigate the pain has a positive effect on that person's future health care decisions.
I like to compare it to swimming. As a scuba diver and water lover I think it's essential for children to learn to swim.
Aside from the obvious reason that it helps to avoid drowning, it also opens up a wonderful world of water sport experiences that otherwise might be avoided.
Children who are taught to not to fear the water, but learn how to interact with it in a positive manner -- playing, floating, blowing bubbles -- usually learn to swim quickly.
Their fear is gone and what comes with it is a learning that water can be safe.
Health care is no different for children.
If they are taught that physicians and nurses shouldn't be feared, then the overall calm atmosphere raises the pain threshold for the children.
Anxiety is the biggest cause for most pain. Children, and even adults, have "fear of pain."
Teaching patients and especially children that pain does occur with procedures but you are there to help them with it can go a long way to prevent an adverse outcome.
Of course, some children are just too small to be able to understand, or they carry with them feelings and fears from other providers into the office. In that case it's, of course, more difficult.
In our office it is important to me that children have the least pain possible and the most positive experience. If we can find a less painful solution, we try to do that. If it's impossible, then we explain the procedure, and the pain, and we work with that patient to make it as comfortable as possible.
I would love to hear from parents and providers on their ideas and solutions to creating positive interactions with children and painful procedures. I'm sure I have a lot to learn.
And I don't want children to run away crying when they see me at Walmart!
- Posted using BlogPress from my iPad
Ruby was a nurse in the department for almost 30 years and she had seen probably half the community's children grow into fine healthy adults.
But one day I ran into Ruby at the local Walmart about the time that a group of small children rounded the corner. I also stopped to visit with the nice lady.
The children, though, turned, ran, and cried to their mother.
Ruby commented to me that this was a common but unfortunate occurrence for her.
She was the "shot lady."
Hypodermic injections are one of the earliest memories that children have about health care. In fact, if you ask a young child about the necessity to go to the doctor, the child (and many adults as well) will respond, "I don't need a shot."
Physicians, nurses, and mothers over the years have devised a whole host of tricks to encourage children to get the needle.
Bribery is a favorite of mine: "we'll go get ice cream," "we'll stop on the way home and ...", or the most recent experience for an 18 year old in my office -- "we'll stop at Nordstrom's and get your makeup done."
Threats seem to work for some children. It usually is a threat about "worse pain" than the actual injection. If children are old enough to reason even a little, then the fear of being beat with a belt is usually enough to motivate one for the measles shot.
But it doesn't always work that way. A couple of years ago a father threatened to whip a 14 year old in my office if she didn't submit to an injection.
(Just for the record, I'm opposed to corporal punishment.)
Some nurses and parents are particularly good at trickery. Either there is a ruse on coming to the doctor in the first place ("mommy is here to see the doctor" only to find out that "little Johnny is getting a flu shot"), or my absolute favorite: "this won't hurt a bit."
Well, it never hurts me.
Sometimes health care workers can't bring themselves to completely lie about the pain, so they'll compare it to something more familiar and hopefully more palatable.
Like a bee sting.
That one always makes me calm down.
"Yes, it will feel like a small furry creature is inserting a stinger into your skin and blasting poison away."
You're calm now, aren't you?
Brute force is sometimes an option, particularly if it's a young child.
There is a device for young children called a "papoose board" which is a politically correct way of saying "straight jacket."
Children are strapped in the device which has various holes and openings that allow physician or nurse access to desirable locations -- like those for an injection.
This isn't effective when children get above three or four. They are just too strong and our staff and parents are too weak.
Attempts are sometimes made with this modality and usually everyone ends up in positions that would rival team wrestling at the Dallas Sportatorium.
Negotiation is sometimes employed, with very mixed results (usually followed by one of the items listed above.)
You see with injections there's really no "compromise." So negotiation is doomed from the beginning.
You can't end up only "injecting the needle a little bit" or using a "very small needle" or avoiding the injection altogether -- which is the only solution that most children will agree with.
But in the end, most children are traumatized in some way by the experience. I'm not saying that they shouldn't be receiving injections, rather I'm just saying most children leave with short-lived tears and long-term fear of physicians and going to the doctor.
So the question is does this affect their desire to go the physician later in life for regular, and possibly preventative health care?
Particularly if the primal image of your first health care experience is clouded with pain.
Do you put off the flu shot? The breast exam? The prostate exam? Just your annual physical because of some underlying deep seated sub-cortical negative early experience.
I think many patients do.
Going to the doctor is often a painful experience. Some things just hurt.
But I do believe that anything that physicians and nurses can do to mitigate the pain has a positive effect on that person's future health care decisions.
I like to compare it to swimming. As a scuba diver and water lover I think it's essential for children to learn to swim.
Aside from the obvious reason that it helps to avoid drowning, it also opens up a wonderful world of water sport experiences that otherwise might be avoided.
Children who are taught to not to fear the water, but learn how to interact with it in a positive manner -- playing, floating, blowing bubbles -- usually learn to swim quickly.
Their fear is gone and what comes with it is a learning that water can be safe.
Health care is no different for children.
If they are taught that physicians and nurses shouldn't be feared, then the overall calm atmosphere raises the pain threshold for the children.
Anxiety is the biggest cause for most pain. Children, and even adults, have "fear of pain."
Teaching patients and especially children that pain does occur with procedures but you are there to help them with it can go a long way to prevent an adverse outcome.
Of course, some children are just too small to be able to understand, or they carry with them feelings and fears from other providers into the office. In that case it's, of course, more difficult.
In our office it is important to me that children have the least pain possible and the most positive experience. If we can find a less painful solution, we try to do that. If it's impossible, then we explain the procedure, and the pain, and we work with that patient to make it as comfortable as possible.
I would love to hear from parents and providers on their ideas and solutions to creating positive interactions with children and painful procedures. I'm sure I have a lot to learn.
And I don't want children to run away crying when they see me at Walmart!
- Posted using BlogPress from my iPad
Location:Dallas, Texas
Wednesday, March 9, 2011
Vaccinations: Is death the only motivator that works to promote immunization?
A recent conversation with my nurse and regular debating partner highlighted the passion that people have about vaccinations.
We were finishing up clinic and the topic of HPV came up.
(Now, don't be surprised. This issue is something that we deal with almost every hour of every day.)
There is a vaccination now for certain subtypes of HPV, which not only cause genital warts but also can lead to cancer in women and men.
Cervical cancer particularly is an epidemic disease among young women. And the "abnormal Pap smear" has become as frequent as many common diseases.
Women infected with the virus can develop dysplasia (atypical, precancerous cells) of the cervix which if not recognized and treated can lead to both a superficial and invasive malignancy.
The dysplasia needs to be treated with painful procedures like cryosurgery, or a cone biopsy where the affected tissue is surgically removed, to the possibility of a hysterectomy.
Aside from the fact that the vaccination is really directed to young women, it is clear that young men are also parties to the transmission of the virus. And, there is a cancer risk in men as HPV can lead to not just cometic genital warts, but also to penile cancer.
My nurse was adamant about her son not having the vaccination.
She is certainly entitled to her opinion and it's a common thought among many young parents these days.
Plus, lets face it, men serve as reservoirs of the disease for women.
So, why does she have such a strong opinion?
I mentioned this discussion to my father who in less than a month will be 91. He couldn't grasp why someone would ever turn down a vaccination.
His opinion is grounded in growing up where epidemic infections were a regular cause of death for young adults, including his family and friends.
"I can remember when my cousin died of polio. We burned all of her bed clothes and put phenol around the house," he told me.
"Then we buried her."
So what happened when the vaccine came about I asked?
"We lined up downtown at the community center. Everyone in town."
"No one felt like the government was forcing them to get vaccinated? Did anyone refuse?"
"I can't remember anyone who didn't want it. I mean, almost everyone had lost a member of their family, or a child. You didn't have to see many people in a wheel chair or an iron lung to put the fear of God in you about polio."
So that's the culture that I grew up in. My parents used every opportunity to have me punctured by a hypodermic to keep me from dying of polio, and lock jaw (tetanus), two kinds of measles, and whooping cough.
They must have also wanted to continue the blood line too because mumps was also put "at bay" and my testicles protected with a series of injections.
So maybe death is the big motivator for vaccination.
If you look at college campuses now almost all of them have been affected by meningitis. Students have died of the disease so frequently in the past few years and it is so contagious that most schools require vaccination before you can gain admittance.
I remember the first patient I ever admitted to the ICU as an intern almost 18 years ago now.
She was a 24-year old waitress at one of the Dallas cowboy bars. You know the drill: fever, chills, altered mental status, and finally collapse in the ER.
She got the finest treatment a major tertiary center could offer. But she still descended to the brink of death.
There was a ventilator, multiple consultants, loads of IV antibiotics, and plenty of hand holding from a pimple faced intern who saw someone younger than him dying.
There was no vaccination for meningitis in those days. We gowned and gloved when we took care of her. And we all took prophylactic antibiotics lest we succumb to the same fate.
And we waited, and yes, I prayed for her.
It's not that I just didn't want to strike out at my first bat with a patient in the ICU.
I met her family, her boyfriend, and friends. I got to know her.
And thankfully I witnessed her get better. It took the better part of a month, but we were able to give her the hospital equivalent of the perp-walk in a wheel chair to the front door with balloons, plants, and the to go bag containing the pink ice pitcher give-away from the hospital room.
But for the other diseases nobody dies.
Does this decrease motivation for vaccination?
It probably does. I can assure you my children will be vaccinated against meningitis.
Chicken pox maybe is an exception. Public health officials were successful in convincing parents in our state to require this for elementary school attendance.
I would like to think that it was because chicken pox can lead to devastating scars in children and to permanent pain in adults when it reappears as shingles.
More likely, the primary concern was the missed school days for the kids and missed work for the parents.
But today most parents line their kids up for chicken pox and also hepatitis B vaccinations without much consternation.
Oh, but not for the HPV vaccine.
It may be the social stigma of the disease, or the fact that their children either shouldn't be or won't be doing anything to put them at risk for the disease.
I even still the absurd argument I hear about the birth control pill: that it might promote promiscuity.
My opinion is no doubt clouded by practicing every day at a major urban metropolitan hospital. What I see is real world. But it may not be your world.
I guess I grew up with the values from my father. If modern medicine can protect children or adults from ailments or infirmities then I am easy to buy in.
Whether its small pox or HPV, I support vaccination and elimination of these diseases from the society I call home.
I no longer have to see someone die to become a cheerleader.
- Posted using BlogPress from my iPad
We were finishing up clinic and the topic of HPV came up.
(Now, don't be surprised. This issue is something that we deal with almost every hour of every day.)
There is a vaccination now for certain subtypes of HPV, which not only cause genital warts but also can lead to cancer in women and men.
Cervical cancer particularly is an epidemic disease among young women. And the "abnormal Pap smear" has become as frequent as many common diseases.
Women infected with the virus can develop dysplasia (atypical, precancerous cells) of the cervix which if not recognized and treated can lead to both a superficial and invasive malignancy.
The dysplasia needs to be treated with painful procedures like cryosurgery, or a cone biopsy where the affected tissue is surgically removed, to the possibility of a hysterectomy.
Aside from the fact that the vaccination is really directed to young women, it is clear that young men are also parties to the transmission of the virus. And, there is a cancer risk in men as HPV can lead to not just cometic genital warts, but also to penile cancer.
My nurse was adamant about her son not having the vaccination.
She is certainly entitled to her opinion and it's a common thought among many young parents these days.
Plus, lets face it, men serve as reservoirs of the disease for women.
So, why does she have such a strong opinion?
I mentioned this discussion to my father who in less than a month will be 91. He couldn't grasp why someone would ever turn down a vaccination.
His opinion is grounded in growing up where epidemic infections were a regular cause of death for young adults, including his family and friends.
"I can remember when my cousin died of polio. We burned all of her bed clothes and put phenol around the house," he told me.
"Then we buried her."
So what happened when the vaccine came about I asked?
"We lined up downtown at the community center. Everyone in town."
"No one felt like the government was forcing them to get vaccinated? Did anyone refuse?"
"I can't remember anyone who didn't want it. I mean, almost everyone had lost a member of their family, or a child. You didn't have to see many people in a wheel chair or an iron lung to put the fear of God in you about polio."
So that's the culture that I grew up in. My parents used every opportunity to have me punctured by a hypodermic to keep me from dying of polio, and lock jaw (tetanus), two kinds of measles, and whooping cough.
They must have also wanted to continue the blood line too because mumps was also put "at bay" and my testicles protected with a series of injections.
So maybe death is the big motivator for vaccination.
If you look at college campuses now almost all of them have been affected by meningitis. Students have died of the disease so frequently in the past few years and it is so contagious that most schools require vaccination before you can gain admittance.
I remember the first patient I ever admitted to the ICU as an intern almost 18 years ago now.
She was a 24-year old waitress at one of the Dallas cowboy bars. You know the drill: fever, chills, altered mental status, and finally collapse in the ER.
She got the finest treatment a major tertiary center could offer. But she still descended to the brink of death.
There was a ventilator, multiple consultants, loads of IV antibiotics, and plenty of hand holding from a pimple faced intern who saw someone younger than him dying.
There was no vaccination for meningitis in those days. We gowned and gloved when we took care of her. And we all took prophylactic antibiotics lest we succumb to the same fate.
And we waited, and yes, I prayed for her.
It's not that I just didn't want to strike out at my first bat with a patient in the ICU.
I met her family, her boyfriend, and friends. I got to know her.
And thankfully I witnessed her get better. It took the better part of a month, but we were able to give her the hospital equivalent of the perp-walk in a wheel chair to the front door with balloons, plants, and the to go bag containing the pink ice pitcher give-away from the hospital room.
But for the other diseases nobody dies.
Does this decrease motivation for vaccination?
It probably does. I can assure you my children will be vaccinated against meningitis.
Chicken pox maybe is an exception. Public health officials were successful in convincing parents in our state to require this for elementary school attendance.
I would like to think that it was because chicken pox can lead to devastating scars in children and to permanent pain in adults when it reappears as shingles.
More likely, the primary concern was the missed school days for the kids and missed work for the parents.
But today most parents line their kids up for chicken pox and also hepatitis B vaccinations without much consternation.
Oh, but not for the HPV vaccine.
It may be the social stigma of the disease, or the fact that their children either shouldn't be or won't be doing anything to put them at risk for the disease.
I even still the absurd argument I hear about the birth control pill: that it might promote promiscuity.
My opinion is no doubt clouded by practicing every day at a major urban metropolitan hospital. What I see is real world. But it may not be your world.
I guess I grew up with the values from my father. If modern medicine can protect children or adults from ailments or infirmities then I am easy to buy in.
Whether its small pox or HPV, I support vaccination and elimination of these diseases from the society I call home.
I no longer have to see someone die to become a cheerleader.
- Posted using BlogPress from my iPad
Location:Milwaukee, Wisconsin
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