Pediatrics - Pediatric Emergencies News Article | Who needs admission among infants with acute otitis media |3961771

Pediatrics - Pediatric Emergencies News Article | Who needs admission among infants with acute otitis media |3961771


We have had a few cases of acute otitis media in young babies & this dilemma always exists whether to admit & give intravenous antibiotics or oral antibiotics.Between me & referring pediatrician ,we take a joint decision of intravenous antibiotics in a neonate or very young baby.

This article describes below 2 months as very young babies who needed admission in their study.The older babies i.e. above 2 months were followed up out patient basis.Doing septic screening is also a valid point.

I always insist upon the parents the preventive aspect.No water should enter the babies ears for 4 weeks following infection & ear buds should never be used.As far as ear buds are concerned they should not be used in any baby or adults.Ear is self cleansing organ & people who produce lot of wax need ear suction done by a medical professional.

Nose bleeds or epistaxis

Nose bleeds can be very frightening experience.Though all nose bleeds are not dangerous,it is better to seek help if it is recurrent & of course continous/profuse.

1 in 7 of us will have some episode of nose bleeds in our lifetime.Nose bleeds are common in children aged 2-10 & the elderly.

The common causes of nose bleeds I see in my practice are

-Trauma:any fall or injury over the nose/face,nose picking

-Exposure to warm dry weather leading to dry crusty nose

-People on blood thinners eg Aspirin

-Medical conditions i.e.Liver conditions & high blood pressure

-Nasal foreign bodies in children

-Allergic rhinitis & deviated nasal septum

-Vigorous nose blowing


However there are less common causes of nose bleeds like bleeding disorders,leukemia,nasal tumors & autoimmune diseases like Wegeners disease.Especially with recurrent nose bleeds,we should be on the look out for more than common causes.We diagnosed two cases of Osler Weber Rendu disease last year in patients with recurrent nose bleeds.Careful examination revealed classical telangiectasia over the septum & nostrils.Proper diagnosis & treatment is a team work & we send them to other specialists for further work up & management.

Here I would like to mention that various medical conditions first present to ENT surgeons with initial symptoms.Though rare conditions are difficult to diagnose-if we are on the look out & pick it up early,it is of great benefit to the patients.For example:Wegeners Disease,Osler Weber Rendu Disease.
In children there is a vast range of symptoms which present to ENT's .It can be nasal polyposis in children leading us to cystic fibrosis or a speech delay child can have deafness or be in autistic spectrum.As an ENT surgeon,I need to be looking beyond just checking ear,nose & throat.

Coming back to nose bleeds-they can be divided as anterior or posterior bleeds.Anterior bleeds are from the Little's area (Kiesselbach's Plexus) over the septum & can be managed with chemical[silver nitrate] or electric cautery in the opd.
Posterior bleeds need much more attention & usually need admission in the hospital.Bleeds which do not settle with local pressure need anterior or posterior packing of the nose.
For refractory posterior bleeds which do not settle even with anterior & posterior packing need endoscopic ligation of artery commonly the sphenopalatine artery.

Below are the pictures of anterior & posterior bleeds & vessels/arteries mainly involved.

A-anterior nose bleeds
B-posterior nose bleed

In the end,I would like to write about what you should do first when facing a nose bleed :

• Remain calm.
  
• Sit up straight and lean slightly forward.
  
• Lean your head forward. Tilting your head back will only cause you to swallow the blood.
  
• Pinch the nostrils together and apply direct pressure with the thumb and index finger for approximately 10 minutes. Time it to make sure the nostrils are not released earlier.
  
• Spit out any blood in the mouth. Swallowing blood may make the affected individual vomit.
  
• This technique will stop the majority of simple nosebleeds

However anything more than this -you need to go to your nearest emergency department.

Food or Feed !

I had organised a workshop on swallowing difficulty i.e.dysphagia on 1st Feb.It was worth all the efforts I put in for the last one & half months.Indian Speaker Dr Jayakumar Menon's talk was taken very well by the audience.I am still getting phone calls from ENT's & Neurologists -thanking me for getting him to Bangalore.The U.S.faculty Dr Shirit Yarkony also presented her work which can be a good addition to dysphagia diagnostics & management.

As Hippocrates said
"The wise man should consider that health is the greatest of human blessings. Let food be your medicine."

As an ENT Surgeon,I come across patients with swallowing problems routinely.Swallowing is a sequential process in which food is prepared in the oral cavity then propelled into the back of the mouth & quickly it passes from the pharynx into the oesophagus.Finally from the oesophagus it reaches the stomach.The first two parts are under our control (voluntary) while the latter occurs involuntarily.



ENT Surgeons take care of oropharyngeal part of swallowing difficulty  while gastroenterologists take care of oesophageal part of swallowing disorders.
The commonest presentations ,I am seeing & diagnosing in my practice are in the folowing order:
gastro esophageal reflux disease (GERD)
stroke or progressive neurological disorders, which may impair sensitivity, muscular coordination, or render individuals unable to control or move the tongue
The presence of a tracheostomy tube, vocal cord paralysis, tumors in the mouth, throat, esophagus, or surgery in the head, neck, or esophageal areas

The assessment starts with a detailed history & clinical examination.

The diagnostic evaluation includes
Trans nasal endoscopy,FEESST & Fluoroscopy/Barium swallow.

Some pictures of FEESST(flexible endoscopic evaluation of swallowing & sensory testing)

The gold standard radiodiagnosis is fluoroscopy in which the special dye coated liquid or solid food is given to the patient & the whole process of swallowing is examined.


After the level of  swallowing problem is diagnosed -the management is planned.Most of the GERD need medical management.The neurological cases need swallowing rehabilitaion therapy.Many cases will initially need tube feeding.

Some may need tube for long term & tube is inserted into the stomach as shown

However what they get is the feeds through these tubes-nutrition is taken care of .These patients always wait to taste & eat the food through the mouth.

Just to remember 1/3rd of stroke patients are at risk of aspiration pneumonia & there still stroke patients dying of this complication all over the world.

The swallowing rehabilitaion should be started as early as possible even though patient is tube fed.Surgery has a role to play in selected few cases.

The elderly population of the world is increasing & we need to understand & learn dysphagia mechanism far better even for these normals.

What we aim for is normal eating ......

 Nothing would be more tiresome than eating and drinking if God had not made them a pleasure as well as a necessity.
   ~Voltaire

Fact sheet: Hearing tests in newborns and babies - PubMed Health

Fact sheet: Hearing tests in newborns and babies - PubMed Health

Wishing you a 'No Complain" year ahead !

Its my first blog for the year 2012.I wish all a wonderful year ahead.

My resolution for this year is - Don't Complain.

However being a doctor by profession if I say this -it does not make sense.Patients see me when they have some complains..hence in medical language we write chief complain.

I meant this in a general way of living life.I think the environment also influences our thoughts & behaviour.When I relocated from UK to India,I was very happy.First few years flew...new work place,setting up new practice......& having my daughter.I did not complain much.I thank my family for all the support .

Things are only getting better over the years.Professionally,I have grown.But somewhere I have learnt to complain excessively.I also think people around me complain excessively.

I read spiritual books & also became member of a spritual networking site.I am proud to say that the spiritual site has promoted me from a 'Wandering Soul' to 'Seeker'.I am waiting to become a master.
I am complaining at the same rate though!

Again coming back to profession,I see a lot of patients also complain more now.Some are so stressed they do not stop with their main complain or they say the same complain again & again!(worried or stressed).Their is also a rise in patient complaints nowadays against doctors or professionals.

To understand patients better & become a part of their movement -I became member of participatory medicine.I paid to become a member & then realised I am anyway pracising or doing what patients expect.However I will next year pay for life membership as it is always nice to keep reading views & learn from them.

Where are we going wrong?Why complain has progressed to more of complaint now?
I did some thinking & my own research.

On a personal level of leading my life,I try to follow the mantra below......well most of the times.
If you don't like something,change it.
If you can't change it ,change your attitude.
Don't complain

At professional level,we need to undersand & implement changes in the way we deal with patients.(I do not like to call patients Consumer or Customer...too old to change that view in my head!)

Imagine telling the nurse "please send the next customer in ".......

First lets go through the dictionary meaning of each.
com·plain

   verb (used without object)

1. to express dissatisfaction, pain, uneasiness, censure, resentment, or grief; find fault: 

2. to tell of one's pains, ailments, etc.: to complain of a backache.

3. to make a formal accusation

complaint

In legal terminology, a complaint is a formal legal document that sets out the facts and legal reasons (see: cause of action) that the filing party or parties (the plaintiff[s] beliefs are sufficient to support a claim against the party or parties against whom the claim is brought [the defendant(s) that entitle(s) the plaintiff(s) to a remedy (either money damages or injunctive relief

Why the medicolegal cases in India have risen 25-30% or more in the last decade?Errors are bound to happen in any healthcare organisations which are complicated matrix organisations.

Medical error is the third most frequent cause of  death in Britain after cancer & heart disease.Medical errors have four times more chance of killing someone than being killed in all other types of accidents.

The key to prevent above is to develop & maintain a good patient doctor relationship.

The qualities a doctor needs (this includes busy surgeons also!!!) is communication skills & empathy.

The qualities a patient needs is to give proper information & be precise. Follow up & communicate.Your doctor may be busy in the clinic or not answering phone calls..get in touch with email.

I also wrote a blog on how to prepare for doctor visit.Its not for humour..we need to follow it as the doctor appointments are tight & you may need to be very well prepared.I do not worry if a patient comes with list of questions but do worry if he comes with googled printouts of what he thinks he is suffering from & his own differential diagnosis!!

Some busy doctors may have team members (qualified doctors ofcourse!) to answer patient queries or have their own website for patient education & getting in touch.If you have not reached this blog through my website,please visit www.entbangalore.in.

Lets hope a healthy & no complain year for all ahead.

Doc " I need a scan !"

Its not uncommon nowadays to see a patient & get this request of doing a scan.I am specifically talking here of a new patient who is visiting clinic for the first time.

Coming to a diagnosis is related to doing tests & scans & reports.

Are we treating a person or a patient or the scan ...I wonder.

One of my best teachers taught me "treat the patient..not the scan!"..

There is so much information to gather in history & clinical examination.
When i meet a new patient ,I try to give them time to talk & then start asking leading questions.If i feel the conversation is diversing,i try to bring them back to the purpose of their visit.

Since ENT  is vast speciality -history is very important for further course of action i.e.investigations or treatment.
Just to give an example -my approach to a recurrent sorethroat & swallowing problem will be standard in any patient but if its a tobbacco user -in the first visit -i will do an endoscopy.

I cannot stress upon the importance of followup's.

Rather than getting all tests & scans done in one visit -it's better to follow up & further tests are done accordingly.

Again interpretation of the tests differ.I always insist on looking at the CT/MRI myself than reading the report.
Depending on the presentation of the patient the tests results are acted upon.For eg even a mild hearing loss in a school going child is significant than a similar report in a 60 year old.Again a unilateral or onesided hearing loss though mild in a 40 yr old needs follow up or scan.

What i am trying to say is -approach could differ in each patient though the symptom may sound similar.

The doctor patient relationship is very important.As i have mentioned in my previous blog-prepare yourself for a doctor visit.If you feel as a patient that enough time was not spent & doctor was busy-have another medium of approaching your doctor-may be email-whatever suits your doc!

How to prepare your child & yourself for visit to the doctor?

I have been thinking for a while now how to make  the patient visits more time efficient-especially so for pediatric patients of mine.

I would like parents & child to be prepared -so that we make most of the time spent together in the clinic.As the practice gets busy -either overbooked or dealing with a complex medical issue,I would not like any child /parent to leave the clinic with any questions.Of course I can always be contacted on email or phone later for small queries.

As soon as we talk of parents being prepared many parents think they need to gather information from internet,bookstore or tv.I do not mean this at all!

It is not uncommon for me nowadays to meet a parent or patient who starts with their symptoms ...& somewhere in between ..  "But I do not have this symptom of tonsillitis "..,Basically they compare their symptoms with the diagnosis they think they have & do what I call "Match the Following"-matching their list with the one mentioned on the net.

I have compiled a small list of how to prepare for doctor visit..

• Good communication is a two-way street.It's good to ask questions, but let the doctor know that you want decisions, diagnoses, and prescriptions to be based on the best decision for the health of your child, not what's easier for you or makes you feel better.
• Explain the purpose of the visit to your kid & do not make it look like punishment.
  

  Tell the child the doctor may look in to her /his ear ,throat & nose.May listen to the chest or check the tummy.In younger children-a pretend game at home works!
• Let the child participate in making the list of  symptoms & questions to be asked.
• Be specific-write them down before the visit.Now this is very important for me as a doctor.For eg it will help if you say :my baby had 102° Fahrenheit (39° Celsius) temperature rather than "he is warm"!
• Be informed & focused.Do not distract the doctor by discussing non urgent issues
• Follow up..Follow up ..Follow up -If adviced. Doctor may have noticed some mild issues which they may not discuss [many times it may unnecessarily worry parents] but ask to follow up.Simple issue like ear fluid related hearing loss-follow ups are important as hearing loss can lead to learning delays.
Hope its helpful....
Sheelu
www.entbangalore.in