Concussion Update

Concussion is an ongoing concern to healthcare professionals and people in all areas of sports and at levels from the pro’s to pee-wee leagues.  A large and fraught subject that evolves constantly is impossible to address fully here, so I wish only to review a few updated developments.  One reason the subject is so challenging is that a fully accepted definition still eludes us: a blow to the head followed by loss of consciousness; or is it followed merely by “change in mental status?” And “followed by” in what time frame?

Nowadays we are beginning to recognize various concussion “subtypes:”

  1. Vestibular (dizziness)
  2. Oculomotor (vision and balance)
  3. Post traumatic migraine
  4. Cervical (neck) symptoms
  5. Anxiety/mood
  6. Cognitive (concentration/confusion/fatigue)

Obviously, there is a veritable smorgasbord of overlap and combinations of the above.

A recent symposium of concussion experts noted that there are about 4 million concussions annually.  Ages 14-18 tend to have the longest course and recovery time for girls > boys.  Those with eye muscle problems (lazy eye, misalignment), motion sickness, or migraines are at greater risk for concussion.  The TEAM (Targeted Evaluation Active Management) group developed a 16 point statement of agreement generally stating that concussions are characterized by adverse symptoms, impairments, and evolving clinical profiles; recovery rates vary by injury severity, modifying factors, and treatments; and additional research is essential.

Notably they concluded that the “absolute rest” approach is no longer accepted as beneficial.  Medical literature and experience indicate that it is typically unhelpful and even sometimes detrimental to recovery.  Taking that approach conveys a sense of “punishment” to many children who then tend to sneak around or disregard recommendations out of a sense of defiance to that conclusion which can delay improvement; can increase anxiety and worry which often will itself exacerbate symptoms and hurt recovery; can of itself prolong or worsen vision or balance symptoms due to lack of use; and lead to de-conditioning which can cause re-injury when the athlete returns to competition (particularly if he/she is cleared to make it back just in time for “the big game”).

Therefore the “graded approach” now appears better.  I try and have the injured child begin homework and reading for at least short periods promptly and return to school by day 3-4 for at least part time attendance.  Light training first with cautious and step wise increase back to full sports participation, particularly for contact sports.  “If it hurts or causes symptoms, stop” is my motto.  Part time jobs later, and “blue light” entertainment(computer, cellphone, video games LAST (as always).

Of course we are just scratching the surface here.  If you have questions or concerns regarding head injury and your child please give me a call, and thanks for following.


Pain and Opiates

Anyone following news even occasionally is likely aware of the terrible scourge of opiate addiction sweeping our nation.  Many consider Ocean county to be an epicenter of the problem.  Both the origins and the treating factors are multifactorial–economic, social, educational, legal, technologic, even religious.  And medical–certainly physician prescribing practices contribute.  I think we doctors simply must endeavor to be more cautious and aware when faced with the challenge of treating pain.

There are several studies published currently that look at the use of opiate vs. non-opiates for post-operative pain management for common uncomplicated surgical situations.  Recently the Canadian Medical Journal compared ibuprofen to morphine after simple orthopedic procedures like fracture reduction.  154 children were enrolled from 2013-16 for either medicine.  Pain control was similar for both drugs after the first dose and after multiple treatments.  Not surprisingly, side effects were more common with morphine compared to ibuprofen: nausea (30% vs. 13%), vomiting (12% vs. 3%), drowsiness (31% vs. 15%), dizziness (20% vs. 4%), constipation (9% vs 3%) or “any” (45% vs 26%).

The results of this study were similar to one from 2015 in Pediatrics comparing the same drugs post-tonsillectomy.  There 91 children were observed and the ibuprofen group actually reported better pain relief (68% vs 14%) with fewer incidents of respiratory depression and no difference in post operative bleeding.

So where does that leave us? In each analysis there is very good evidence that the simpler, milder, non-addictive agent is at least as good as the “stronger” opiate painkiller.  Now, while there currently aren’t studies for every clinical situation, I think it is not unreasonable to extrapolate to comparable common surgical/trauma/pain issues like dental procedures and oral surgery, suturing, moderate burns, or outpatient abscess drainage: likely at least as effective to use the milder OTC analgesics like ibuprofen or acetaminophen.  And certainly safer for the child and for the larger community to stay away from the addictive stuff.  Please keep this in mind should your child require such interventions.

For questions about pain management or any other conditions, please don’t hesitate to call, and thanks for following.

Head Lice

  1. On vacation recently, Kim and I toured Santa Fe’s “Oldest House,” a >800 year old native American dwelling.  Among the displayed artifacts I noted an ancient lice comb made of bone.  I found it fascinating to contemplate–from such a distant, different time, yet they still struggled with the same annoying, familiar problem.  People are still just people.

Head lice have been with us for eons and probably troubled our pre-human ancestors >1.8 million years ago.  They are now “species specific”–just us folks.  They spend their entire life cycle on the scalp and, unable to fly or jump, die within 2 days of removal.  They primarily infect 3-11 year olds with between 6-11 million cases annually.  A few misconceptions:

  1. Head lice infestation is not indicative of poor hygiene.  They are spread by close contact, mostly in schools or camps.  So it no more suggests uncleanliness than picking up a cold or flu–just bad luck.
  2. Unlike their skeevy cousin, the body louse, there is no known disease spread by head lice.
  3. Sleeping in a bed previously used by an infested person does not spread disease (unless you are sharing the bed simultaneously)
  4. <2% of spread is caused by use of inanimate objects like hats or brushes; it’s almost always person-person
  5. Most important–nits do not cause spread

Given #5, there is no justification for school “no nit” policies.  Nits are egg husks and can no more spread disease than egg shells make egg salad.(Chemically bonded to the hair,  one can differentiate nits from dandruff by isolating the hair and gently sliding the little flake off with your fingers.  If it slides off its dandruff)  The official AAP position is that involved children need not be removed from class as, once treated, contagiousness is very limited.  So there is more negative impact of social stigma or lost school time for that child and little gained from dismissal.

While drug resistance occurs, AAP guidelines still recommend OTC treatments like Rid or Nix as first line.  Apply a generous amount to the hair and scalp, leave on for >10 minutes, then vigorously shampoo.  Long hair may need 2 bottles.  Be sure to re-treat in a week.  Then vigorously comb out the dead bugs and the nits with a metal fine tooth comb.  The teeth of plastic models will likely break and be ineffective (I suppose if one can scrounge up a bone model, like our long forgotten “Oldest House” friends–that would be ok too!).  If you notice a few straggles hanging on after treatment don’t be discouraged–that’s what the second dose is for.  Personally I recommend everybody in the house be treated together the first time.  Only infected people need the second dose.

These medications are quite safe.  However, repeated application can lead to toxicity, so don’t keep retreating–call me and we can talk about prescriptions.  One last word: dehydration with a heat treatment is often effective.  Other “non-medical” methods–essential or olive oil, petrolatum, mayonnaise(!)  fail often and are not recommended.

Send questions or comments; thanks for following.

CT and radiation exposure

My colleagues in the ER so often amaze me.  I have immense respect and admiration for how they manage such a challenging task.  Every day can bring catastrophe–or several–that can be heartbreaking or terrifying, and they face this while addressing a veritable flood of minor or chronic problems which, by training, are more outside their domain.  Yet there they are, juggling those diverse situations with such grace, compassion, and skill.

Not to sound critical, but as a primary caregiver there are circumstances when a cautious and deliberate approach may be preferable, but that can be immensely difficult in the ER where by necessity the focus must be on NOW.  That fraught difference may best be illustrated in the approach to CT imaging.  All good docs in and out of the ER nowadays try to keep in mind the risks of exposure to ionizing radiation.  People are subject to small amounts of radiation normally every day. A typical chest xray exposes one to 10 days and a CT scan to a whopping 8 months worth(that, itself, represents improvement in technology–it used to be 5x that amount)

Now, in many instances–and especially in the ER–the information obtained from CT scan is absolutely essential to make an accurate diagnosis and protect the patient.  But the reality is that we know that radiation exposure increases the risk of cancer.  We know the effect is cumulative and therefore greater for children. But we really don’t know HOW MUCH is a risk–where is the threshold?

So there is reason for caution but certainly not for panic.  For example, in one specific instance–head trauma–CT scans are indicated if there was loss of consciousness, amnesia, severe or worsening headache, vomiting, of if the person was drinking when they were injured.  Outside of those situations, CT is unlikely to add useful information.

Generally speaking, when confronted with these choices in the ER (or anywhere) keep these principles in mind:

  • As a parent or caregiver you always have a choice.  It is important that you have all the information
  • Is there a clear medical benefit for conducting a CT scan
  • Are there other tests (such as an MRI or ultrasound) or actions (such as observation) that could safely take the place of the CT
  • If a CT is indicated, ask to make sure that the scan settings are adjusted to the size and weight of your child
  • Explain to your child that the scanner looks like a donut, they should lay flat and still, and that the test will be quick and will not hurt.  Sedation may be necessary for that purpose.
  • Avoid multiple scans.  Note the number of scans.  Keep my office informed so that we can track the total over time.

Remember that in the large majority of these situations the ER doctor is an experienced expert who is focused on what is best for your child and usually his advise is your best bet.  But also remember that the ER doc should listen to you, too.   In the unlikely event that you are unclear on that side of it, call–let me help to clarify the situation for you and to advocate on your behalf there.  That’s my job.

Thanks for following.


Teens and Tats

I don’t at all get the piercings and tattoos.  But why would I?  I’m 61 and a grandfather: this is not from my era.  However, that does not make it “bad” or “wrong.” For my generation it was love beads, long hair and sideburns, and bell bottoms.  As children advance to adolescence and young adulthood, its normal to endeavor to express one’s unique identity.  Often that entails some breaking of those conventions that these young people associate with established, parental authority.  By itself, this is not at all unhealthy and I counsel parents to maintain a light touch and give your emerging young adult significant freedom to chose here.

Please allow me to add that, given the above, I also think it fair for you to inform your teen seeking body modification that they are free to make their decisions about their bodies and they are also free to pay for those choices themselves–you parents who are disinclined are under no financial obligation in these areas.  Freedom cuts both ways–right?

A recent article in the New England Journal of Medicine reviewed current data on this fashion phenomenon.  Among its findings:

  • Current data no longer supports the concept that body modification occurs primarily among high risk youth and it should not be confused with non-suicidal self injury.
  • Body piercing jewelry generally consists of hoops, rings, studs, or barbell shapes and are made of stainless steel, gold, niobium, titanium, or alloys.  Most piercing guns are not sterilized.
  • Scarification creates words and images in the skin through cutting, burning, branding.  Artist experience in this field is quite variable, so caution is advised
  • Carefully monitor the establishment for essential hygiene: sterile gloves, use only equipment from freshly opened packages, sterile needles, use only fresh, unused ink poured into sterile containers
  • Adolescents should understand that visible body modification may negatively effect employment prospects
  • Serious complications are uncommon but include inflammation, bacterial or viral infections at the site, infected blood vessels at the site(rare)– typically 4-22 days after placement
  • “Q switched” laser is the preferred method
  • Cleanse new oral piercings with nonprescription oral cleansers (mouthwash).  Tongue piercings have a high rate of tooth chipping
  • Healing times are –clitoris, urethral meatus, tongue 2-6 wks; nipples 2-4 months; 9 months for navel or head of penis
  • Up to 35% of ear piercings develop mild complications including pain, bleeding, bruising, cysts, allergic reactions, hypertrophic scars (keloids). Scarification techniques carries similar risks
  • Children with diabetes, HIV, cystic fibrosis, or taking immunosuppressive agents are at increased risk for complications.

So let’s be safe.  But remember: you nurtured that little child so that (s)he can grow up to be a free thinking, independent, and autonomous person in their own right.  This is very much of that process, so it is to be managed but cherished as an important part of their growth, development, and self actualization.  As the French say–c’est la vie!!

Send along questions or comments and thanks for following

Chronic Lyme’s symptoms–unorthodox treatment

A recent newspaper column published locally highlighted a child with serious health problems that was being treated as chronic lyme disease.  The author complained that the influential Infectious Disease Society of America “has declined to recognize” chronic lyme, spoke of “discrimination against an illness,” noting that “none of them(doctors) want to do anything.” The article goes on to review the prolonged course of antibiotic treatment being administered.  It’s  noteworthy that the article states that the child is improving with ongoing medicine but even there it only speculates as to when the child will be well enough to return to regular activities like school.

There’s a lot here.  Firstly there’s a sick child and a family seeking answers, let alone treatment.  We know that following treatment under accepted guidelines up to 20% of patients persist with unclear and nonspecific complaints (headaches, fatigue, insomnia, weakness, recurring illnesses) >6 months after completion of therapy–so called post treatment lyme disease syndrome.  I have witnessed during my career how doctors at all levels of expertise have–with usually (but not always) pure motives–identified and treated patients with these troubling problems with vague terms like chronic lyme, chronic mono or EBV, chronic fatigue, reactive hypoglycemia, and others.  I am not arguing whether these are “actual” diseases or not.  I am no expert in this area.  These people are suffering and need real help.

The problem is–how do we help? One very fair criticism of American medicine is its wastefulness–up to $900 billion/year according to a study in the Journal of the American Medical Association–much on unsubstantiated or unnecessary care.  Beyond the monetary costs is unproved treatments can do worse than nothing and sometimes cause actual harm.  I myself have personally treated children with serious complications after unapproved prolonged antibiotic therapy. Studies in the New England Journal of Medicine have found no benefit to this approach. Yet its use persists.

And that’s the thing.  It isn’t that nobody wants to do anything or wants to “discriminate” or “not recognize.”  Its hard to do it RIGHT–to be effective AND safe.  Anecdotal reports and personal testimonials–no matter how dramatic and heartfelt–are insufficient.  We need scientific studies–“controlled” (one group untreated for comparison) and “double blind”(neither subject nor studier knows who is in which group; this removes observation bias); peer reviewed (other experts look over the experiments to assess methods, accuracy, etc); and reproducible results (different studiers, similar outcomes).  That information is simply lacking with these various unorthodox lyme’s therapies.

Anybody who claims that scientists back each other up and cover for their peers clearly doesn’t know how these scholars operate.  They live to criticize each other.   Its very much how they define themselves.

So what do we do? When people are struggling in these confusing and debilitating situations, we must listen to them and work to figure out how to help.  We must give answers and we must be honest that sometimes the answer is “I don’t know.”  We should intervene where and how we can, but based on carefully gathered evidence.  With the oath we doctors take we promise to “first do no harm”–endeavor to never hurt the patient: the cure must never be worse than the disease. And these are exactly the situations where we must take those words closest to heart.

Thanks for following.

Flu shots 2017

Public health can be so hard.  Obesity, alcoholism, narcotic abuse–each a difficult and terrible scourge on our society.  Zika virus causing birth defects is a growing concern.

What do we as a nation do?  How do we design programs to address these issues?  How much money do we spend and where do we spend it?  Governments, businesses, academics, and nonprofits all devote great energies to try and solve these problems.  I’m proud that my own daughter received a Masters degree in the field and is devoting her professional life to the public health fight against cancer.

Each year from October through April anywhere from 5-20% of the US population contracts influenza; hospitalization rates are 34/100,000 population (14/100,000 ages 0-4).  The number of deaths is somewhat controversial (it depends on how the treating doctor classifies the terminal illnesses) but estimates range around 36,000 annually.  In 2016 there were 20 pediatric deaths but as recently as ’09 358 children died of flu. The flu costs the US economy $87 billion annually PLUS $16.3 billion in lost earnings.  Flu shots prevent approximately 48% of flu caused doctor visits annually, yet only 46% of Americans are immunized for influenza each year.  

So sometimes public health isn’t so difficult and is, in fact, quite straightforward.  Get your family immunized for influenza.  I have covered this topic previously and I invite you to review the information from those posts here and here.

Our flu shots are in.  Please give my office a call and schedule your children to be immunized.  This will benefit your entire family–especially your own parents and grandparents–as well as your friends, neighbors, and our entire community.

Call me with questions and thanks for following.