July 26, 2009

Problems with Medical Ethics: Perimortal Obsession


Some of the most wrenching and difficult issues for us humans to resolve occur in circumstances near the end of life. The animal world has, I think, a pragmatic approach to leaving the crippled zebra behind for the lions as the rest of the herd runs away. It’s not so easy for us. It’s important to bring these difficult issues out into the open air. The current world of medical ethics continues to do an excellent job of figuring out what the issues are and helping the rest of us find rational ways of looking at these problems.

I did a search on PubMed, the National Library of Medicine online medical research reference source. I searched:

ethics AND death

and got 12,416 publications.

In pediatrics, there are grave and important decisions to make when babies are born with such severe developmental problems that their survival is in doubt. How much should we do? What interventions truly help this baby, and what interventions just prolong the suffering? Should we treat every such afflicted baby the same, or will it matter what State the baby is in, or what doctor it has? There’s a lot of healthy discussion in the bioethics world about babies on the edge of viability.

Likewise, it is partially to the credit of bioethicists that we now have ‘living wills’ and ‘advance directives’ which can guide our loved ones and caregivers if we cannot. This is a genuine advance in medical care, and has prevented a lot of suffering. (More on this in a later post.)

Despite this help with some of our most difficult choices in life, the bioethics field, in some ways, has chosen the easiest path. It’s true that one thing we all have in common is our mortality. Perhaps we also share a reluctance to deal with it, talk about it, and plan for it. About 65% of Americans die without a will.

This is the easy path because there are no right answers. The case will eventually end in a concrete way. Was the right thing done? Academically speaking, it doesn’t matter, since the focus will have shifted to the next edge-of-survival case.

I’ll say again that I’m glad that smart, literate people are concentrating on this. If I were ever pregnant with a severe brain injury and a fetus hovering at the age of survival, separated from my husband and father of this fetus but with a new live-in partner who doesn’t get along with my parents who are divorced because one of them is a fundamentalist believing in predestination and eternal afterlife so thinking that my demise will result in relief from suffering and ascent in grace and the other a devout believer in the sanctity of all life who insists that every possible intervention should be exhausted, then I’m sure I’d be happy there was an Ethics Committee at the hospital. That way, the burden would not fall on just one doctor to populate the daytime talk shows.

In fact, these cases do occur, and they highlight important topics we might never have thought of.

But they aren’t common. It’s also an easy path for professional bioethicists precisely because the situations are so vanishingly rare. The very fact that a medical case has ivory billed woodpeckermade it onto the news, that bioethics bloggers are blogging about it, means a priori that it’s a rare bird. For every case like this, there must be thousands and thousands of problems that occur every day for which doctors receive no guidance but their own gut feel. There are ethical questions that arise every day, but publications and debates on these issues are few. Nobody gets interviewed on TV for this.

Hank, a very bright 15-year-old patient, came to my office a few months ago to talk to me. He was sent by his mother because his unstable moods and erratic actions were a serious problem for him both at home and at school. His parents were divorced, and both had new partners. He came to the office by public transportation, after school. After we talked about what had been going on, I told him I thought he needed a mood-stabilizing medication. He thought that would be OK, and we talked about possible side effects. I asked him explicitly if he would be willing to try the medication, and take it just as prescribed. He said he would, but only if I didn’t tell his mother.

Though he moved between his father’s and mother’s homes, he was aware of differences in his life at each place. Mom had better food, a well-stocked refrigerator, and was easy-going about bedtimes and curfews. Dad had better video and video games, and was more lenient about computer access but stricter about curfew. His mother, he told me, had sometimes used his previous medications as a threat or as a crutch to explain his behavior. She’d say ‘you need a higher dose’ or ‘I liked you better when you were on….’ This hurt his feelings. If he was arguing with her, he figured, maybe there was a good reason for it. Maybe she was actually wrong about something. His dad never did this. As he told me this, he was completely calm and rational. I believed every bit of his description—and I thought he was right.

  1. Should I have seen him without a parent there in the office?
  2. Are there topics of discussion that are off-limits?
  3. Should I insist on telling his mother?
  4. What if his mother calls and asks me what we talked about? Am I required to tell her the substance of our conversation?
  5. What if she asks about my diagnosis and plan for him? Doesn’t she have a right to know that?
  6. What will happen to my relationship of trust with this teenager if I say I won’t tell his mother but then I do?
  7. What will happen to the teenager’s care if he stops trusting his doctor? He is my patient. I am responsible for his care. What’s best for him?
  8. If I tell the father, and he pays for and picks up the medication, is he obligated to tell the mother (with whom he hardly ever speaks)?
  9. If I want to monitor the patient once on medication, I will want him to return weekly for at least the first few weeks on medication. Who makes these appointments? Do I have to cover up the fact that the kid was even seen?
  10. Even if I agree not to tell his mother, do I lie to her? If she asks if her child is on medication, do I say no? (OK, this is an easy one, since I am not willing to lie.)
  11. In fact, California law does permit a minor to consent for certain mental health services without a parent. Other states vary, but many have similar provisions.

These are just some of the questions that arise from this one actual encounter.

From this single visit, the questions, I think, can be grouped as follows:

  • What are the doctor’s legal obligations?
  • Of the legal obligations, which are subject to interpretation and judgment? (Would my license be in danger if I did tell the parent, but not for a day or two?)
  • What are my obligations to the patient?
    • Do these obligation vary by chronological age?
    • What about developmental maturity? (Surely a mature 12-year-old should have more autonomy than an immature teenager?)
    • Are the obligations to the patient more important than the obligations to the parent?
  • What should I write in his chart? Should I document things he tells me that he doesn’t want a parent to know when they can request the chart at any time?
  • Is this mix of obligations changed when medication is involved? Is it changed when psychotropic medication is involved, as opposed to antibiotics, for example?

I did a search on PubMed, the National Library of Medicine online medical research reference source. I searched:

ethics AND “primary care”

and got 837 publications. That’s about 1/15th as many as when I searched for 'ethics AND death.' I know the situations I’m in are common and happen every day, to me and thousands of doctors.

Of course this is the tip of a very big iceberg. There will be more dispatches from this ice field soon.


Epilogue: Here's what I did. I took the time to convince him to inform his mother. I told him that if he didn't and she found out he was on medication--and the chances were good that she'd find out somehow--she could use against him the fact that he wasn't honest with her. She could also stop trusting me, as part of this deception. That could change his access to me. I offered to call her directly, and explain in medical terms why I thought medication was a good idea at this time. Hank liked this and jumped on it. I told him that the next time she said something about his medication that he didn't like, he should say "Talk to Dr. Wolffe," and not argue with her about it. I would contact him directly and keep him informed about any conversations I have with either of his parents about his medication. I got a portable phone and took it into the exam room. I called his mother right then, with him there, and told her that I'd like him to start some medication. She was OK with that. Hank was visibly relieved.

July 23, 2009

Repeated Lessons

A little hydrocortisone cream was all that was needed to clear up the rash caused by the calendula. The parents had noticed a little rash, and did what parents everywhere would do. They went to the ‘natural pharmacy’ and asked what would be good for a rash.

The rash caused by the calendula cream cleared up within a day or so of starting hydrocortisone. This seemed to control the baby’s mild eczema. So maybe it was natural for me to suppose that this aspect of the baby’s care was under control. when I was in the house, examining the baby on her changing table, I noticed a bottle of moisturizer next to the table. I said to the parents, “That’s for you, right?” The mother said that she used it on the baby. I asked her why she used it on the baby—she said that it made the baby’s skin soft. Was the baby’s skin soft before using the moisturizer? We had a talk about what the baby actually needed on her skin. This baby in particular, given our experience with her eczema and reaction to calendula cream, had sensitive skin at very least.

These were the parents for whom I had to spend a half hour explaining why the hydrocortisone cream wasn’t a dangerous steroid. Even as their baby cried with her rash. How long did the sales clerk have to explain the safety of calendula?

So when they called and said that they need to put their baby to sleep on her stomach, I suspected some detective work might be needed.sheep toy on crib

It seems to be true that some babies just prefer to sleep on their fronts, and not on their backs. Unfortunately for them, the epidemiology is fairly convincing. Babies placed on their tummies to sleep have about 6 times the risk of SIDS. The right thing to do would be to try and convince these parents that putting her on her back would be the safest thing for the baby.

They told me that the baby didn’t mind being on her back when she was on the changing table. Didn’t mind when on a blanket on the floor. In fact, the baby didn’t mind so much when first placed in the co-sleeper at the beginning of the night. But she would wake up with increasing frequency as the night went on, and was screaming when put down on her back in the early hours of the morning. Desperate at this point, they put her down on her tummy, and she quickly fell asleep.

Maybe it wasn’t the position that was bothering her. I asked them to describe the co-sleeper for me. I asked for and was told all the details. The padded sides were of undyed fair-trade cotton, and the frame was of sustainably-harvested wood, unpainted and unstained. The baby was placed on a very soft unbleached untreated natural Australian fleece.fleece

I stopped them at the fleece.

Wool allergy is actually rare. Most of the people who get itchy with certain types of wool fabric are not truly allergic. They have sensitive skin and it’s irritated by the tough wool fibers. But people can be allergic to a class of natural chemicals called wool alcohols. These chemicals are a major sheep-fleececomponent of lanolin. Lanolin is in a lot of the skin lotions and creams, including medicated creams, that we put on our skin. It’s the major component of creams used on breastfeeding moms.

I suggested they remove the fleece completely, and use a folded towel as padding. They weren’t happy with this plan, since the fleece was sent to them direct from a relative in Australia. I suggested they use a plastic trash bag over the fleece, then a baby blanket or two to keep the baby from getting too sweaty on the plastic. That night, the baby slept on her back.

What was happening was contact dermatitis, an itchy eczema-like rash that we get from something we come in contact with. At the beginning of the night, it wasn’t a problem. As time passed, the baby’s back got more and more irritated. When it was irritated, it became more and more sensitive. Tsheep2he more sensitive it got, the more irritated it became with continued contact with the fleece. By the end of the night, the baby was really uncomfortable and unhappy. When they put her down on her tummy—which was not irritated—she calmed right away and went back to sleep.

These caring parents had the best intentions for the comfort of their baby. My role was really being a seasoned detective, who might know 'usual suspects' when I meet them.

This is a baby with sensitive skin. We should learn, eventually, to be sensitive to that.

July 19, 2009

Fever -- 8 hot days

In my last post, Fever, I urged parents not to ask a doctor 'What could it be?' The list of possibilities is invariably a long one, and includes some extremely scary diseases that your doctor—like most doctors—has never seen in person. Good physicians always have in mind that if it walks like a duck, quacks like a duck...it's probably a duck. Any sound of hoofbeats is much more likely to be from horses than from a herd of zebras.

So when Matthew's mother called me to say that her 21-month-old has had a fever for about 4 days, I wasn't particularly worried, and told her that. I cared much more about how the child was doing—how sick was he?

Not very, she said. He had a fever pretty much continuously, up to the mid 104's (40°C). He felt lousy at those times, but his mother said that he perked up right away when the Tylenol kicked in. He was eating, keeping up with his fluids, acting like his usual self when the fever was kept down. I didn't need to see him—what was I going to do for him? If he was OK, then I was OK.

On day 5 of the fever, I called the family to check on him. Nothing much was new. Still had high fevers, but nothing in particular was hurting. I told the parents that as a rule-of-thumb, I usually order some basic tests if a child has about 5 days of fever without giving us any clue of what its from.

Most of the time, we don't find anything when we do these tests. And very often, the tests come back normal just as the rash is starting. One of the most interesting and sometimes frustrating common diseases of toddlerhood is Exanthema Subitum, also known as Sixth Disease, also known as Roseola Infantum. It's probably a deep truth about medicine that if you or somebody you know has a disease which has 3 different medical names, it's a good bet that medicine doesn't know much about it. In the 19th century and earlier, the cause of most diseases was completely unknown. So the classification system was based not on the cause of an illness, but on how the physician would witness it progressing. These days, we think of illness as either from a cause of some sort. Back then, there were 6 numbered rashes of childhood. First Disease, for example, is measles. Sixth Disease was a longstanding mystery until 1988 when the viral cause of it was discovered. Luckily, it seems to be the least dangerous of the numbered diseases. What makes it frustrating, and often results in lab tests that turn out to be unnecessary, is the high fever for day after day. Just like Matthew, the kids aren't very sick when we control their fever, which can last for days—usually 3 to 5 days, but I've seen it go a week. Then, mysteriously, the fever goes away and the child gets an awful-looking red rash over their whole body in a matter of hours. The rash doesn't hurt, doesn't itch, and goes away in 1-2 days without a trace and without treatment.

So I knew it was just a matter of patience. The parents, both scientists, were fine with that when I explained the plan. We'd take it day by day, and wait for the rash to appear.

On the morning of day 6, I called for a report. Nothing much was new with Matthew. But in the back of my mind was the fact that this was a boy, with a father is of Asian descent. The longer he went without getting the rash, the more I needed to question if I was right. While I was on the phone, I asked his parents to look at him and tell me if he had any rash of any kind, or if his tongue looked odd or if his eyes were red. I made them describe to me the skin on his hands and fingertips.

About 6pm on day 6, I called and was told that his eyes were a little pink. I drove to their house to look at him. Matthew was watching TV with his older brother, eating a banana. The boys didn't look up when I came in. His eyes were, in fact, a little pink. He wasn't rubbing them, and there wasn't any goopy stuff in the eyes. Everything else looked just as usual. I told the parents that I could wait no longer, and insisted that they take him for a blood test first thing in the morning.

On the evening of day 7, his fever still going, I got the lab results. There wasn't any particular evidence of infection in his blood, but his platelets were about 550, about twice the normal level. That was enough for me. I told them to take him right then, as soon as we got off the phone, to the emergency room at Children's Hospital Oakland. I called the ER and spoke to the doctor in charge so they'd be prepared for him. I told them he had Kawasaki Disease.

I came to the hospital later that night. The treatment was just getting started. We give an intravenous product of filtered, donated human blood called IVIG [Intravenous Immunoglobulin]. It's a liquid packed with all the antibodies and immune cells and chemicals from lots of people, with all the other blood components removed. It's like an immune-system sponge, which vacuums the system of illness-causing agents. We also give them aspirin, the ancient concoction originally from willow bark. It keeps platelets from sticking together (which they are supposed to do in order to help stop bleeding and form blood clots). By day 8, the next day, his platelet count was 750. If it kept going higher, he could be in danger from so many platelets clumping together, making the blood sludge in narrow vessels and potentially causing damage to major organs or a stroke. Matthew was about 26 pounds or so, and we were giving him 4 adult aspirin a day.

Kawasaki disease has yet another mysterious feature. It can cause coronary aneurysms in children. Usually only seen in older adults, these can be serious. They are weaknesses in the walls of the blood vessels that provide the heart muscle with blood. They form bulges in the vessel wall. If the weakened vessel breaks, part of the muscle will not continue working.

This disease is baffling, and reminds me that in past generations there were always those who wondered why they didn't know the cause of some illness even with their incredibly sophisticated 'modern' technology. The disease was only really identified (by Dr. Kawasaki in Japan) in the 1960s. With every technique of current molecular biology, no one has any idea of what causes this.

Because it has occasionally appeared to occur in clusters, it might be something infectious. But if it is, it's very hard to get. It's a rare disease. Maybe some people have a genetic predisposition to be susceptibility to it—it's more common in boys than girls and about 10 times more common in children of Japanese ancestry than in average American children. It's more common in children of other Asian descent than Caucasian children, but less common than in Japanese. Some people think that it's a lot more common than we know. Maybe those old people with aneurysms had unexplained fevers when they were kids, and nobody made anything of it at the time. But it weakened their vessel walls and 60 or 70 years later, they come to the attention of a cardiologist. Maybe adults are getting this disease too, but their symptoms are different. Maybe in adults they're just tired, feel run down, and keep forgetting where they put their keys....

Matthew never got all the symptoms of the disease. Since we don't know what causes it, there's no test for it. By the time I saw him on the evening of day 8, his eyes were very red. Within 12 hours of starting treatment, his fever was gone and he felt fine. Fortunately, the examination of his coronary arteries showed no aneurysms. Who knows how his disease might have progressed if treatment had been delayed by a few days? It's remotely possible he could develop heart-related problems later on, and he will be getting follow-up from the cardiologists. He seems to be fine for now, and he takes a chewable aspirin every day.

Don't ask your kid's doctor what it could be. Just try to find a doctor who knows that there are zebras out there, and who might recognize one at a distance.

July 16, 2009


Fever is one of the things our bodies can do to fight infection. It isn’t fully understood, but we know that many bacteria and viruses find the higher temperature a less appealing environment. There are many, many causes. Infection is the most common, but it can be caused by other problems as well.

In the second year of medical school, students are taught about all kinds of diseases. Some, of course, are serious, and some are usually not a big deal. Some diseases are common, and some are very rare. But nearly every student gets ‘medical student disease.‘ Day after day, they hear about exotic diseases that start…with fatigue. Then there’s the feeling that it’s difficult to concentrate. Maybe occasional headaches. They can’t help but put 2 and 2 together and end up with 73. That’s about the time when they are taught a favorite expression among doctors. ‘When you hear hoofbeats in the distance, it’s much more likely to be horses than zebras.‘ Which is simply a way of saying that when your kid gets a bloody nose, it's probably not Congo-Crimean Hemorrhagic Fever. For this reason, and as I’ve said before, it’s a mistake to ask a doctor ‘what could it be?’ That’s what medical textbooks are for, and I use them as references when needed. ‘What could it be?’ could only be thoroughly answered with zebras (all 4 kinds), camels (both kinds), and an occasional Java Rhino. Of course, your kid doesn’t have any of the vanishingly rare diseases that a single symptom—fever, for example—could possibly be.

I get a lot of calls about fever. For the most part, I can be very reassuring. It’s the body’s natural way of fighting off an infection. Fever from illness, it is generally thought, doesn’t get high enough to cause brain damage. Even a high fever (to the 105’s (41C)).

Hyperthermia can. That’s when our bodies are exposed to heat way beyond what our bodies can generate on their own. People stranded in the desert, for example--there’s a reason they call it Death Valley; or those tragic stories we read about every summer about a baby left in a car. Our bodies usually do a reasonable job in keeping us cool, by sweating. But if we get dehydrated and don't sweat enough, we could be in trouble if it were hot enough. Hyperthermia, though it does cause an abnormally high body temperature, isn't a fever.

Fever , then, doesn’t generally worry me. But what’s causing the fever? If I treat the sick child, it will be for the underlying illness, not the fever. Here's the scenario I pose to parents. If your child has a fever, but looks OK, is breathing fine and playing and active as usual, would you worry? Something is causing the fever, so I'll concede the child might be coming down with something, but that wouldn't worry me. Compare that to your child acting in a worrisome way—complaining of pain, for example, or sleeping all day and refusing to walk—but not having any fever. Is that reassuring? To me, that's much more worrisome.

So why do we treat fever at all?

There are purists out there who think that we shouldn’t treat it, and let the child’s body fight off the natural infections as millenia has designed us to. There are conspiracy theorists who believe that the companies marketing fever medicine want to support the mass delusion that fever must be treated.

For me, trying to see this from the child’s point of view, an empathic approach, is helpful. True enough, treating the fever does nothing to help get the child better faster or treat whatever illness they might have. But whenever we have a fever, we feel really bad. Sometimes fever can cause a headache, but it can certainly worsen a headache. But even without any specific symptoms, fever makes us feel sick. When we reduce the fever, we just feel better. And making children feel better is, as I look at it, an important part of my job.

I think parents with sick children often feel helpless as they watch their sick child. The fever is the only objective marker of the illness, whatever it is, and so by lowering the fever they feel like they are taking a pro-active approach. And they get positive feedback when their children perk up as their body temperatures go down.

If the child has a fever but is OK, I think it's all right to watch them and not treat the fever. If they feel awful, I would treat the fever. I don't think making the child suffer accomplishes much from a medical standpoint. But there's a few points that should be mentioned.

All kid's fever medicines are not the same. There are generally 2 choices of ingredient: acetaminophen (in Tylenol and a lot of store brands), and ibuprofen (in Motrin and a few others). They both work in most people, but it does seem that one will work better than the other in some people. Acetaminophen is safe when the directions are followed. It shouldn't be used for more than a few days, however, because at doses much higher than we should be giving, it can be toxic. Besides, if your child is really having a fever for more than about 3 days, it's probably a good idea to try and figure out what the kid has. A doctor might be able to help with that.

About 1 in every 25 kids get febrile seizures. They don’t seem to have epilepsy, but when their temperature is high enough, they have a brief seizure. It’s almost always in toddlers. As you can imagine, this is really scary for the parents. Fortunately, it’s quite common (about 1 in 25 toddlers have one), and most of those who have one never have another. The seizures do not cause brain damage, usually only last less than a minute, and usually do not mean that the child will go on to have a seizure disorder.

Every now and then, I see a child with fever who has been covered in as many blankets as the parents can manage. This is not a difference in parenting philosophy—it's just wrong. When we have a fever, our bodies are too hot. Even if we feel cold or are even shivering. In order to relieve the symptoms of fever, we have to lower our temperature. So dress your child minimally, and get rid of the heavy quilt on the bed. One of the best techniques I have found is to put the child in a bath. Not a cold bath! That would annoy anybody, especially a sick child. So draw a regular-temperature bath for them. It will still be about 20 degrees below their elevated body temperature. After soaking for 15 minutes (with you there—don't leave them alone in the bath), the water will have absorbed some of their temperature, and they will feel much better. You can do this as often as needed, without concern of overdosing.

Fever that has been relentless for more than 3 days, say 4 or 5 days, is worthy of a doctor visit. I'm still not worried about the fever causing damage, but I am concerned about finding a cause.

Elvis Presley live: Fever

Fever does, in fact, usually go up at night.

July 12, 2009

A Mistake

“Experience is the name everyone gives to their mistakes.” Oscar Wilde, from Lady Windermere's Fan, 1892

Yes, I know. Everyone makes mistakes. Every parent makes mistakes, nearly all of them invisible to a child. To a child, what we do has to be right just because we're doing it. Parenting books are filled with sure-fire techniques to get your kid to do everything from eating something besides white food to success in college. But those authors haven't met your children. Sometimes the best thing to do just isn't that clear.

Doctors make mistakes, too. In my particular line of work, I'm relieved to report, failure isn't usually associated with a really bad outcome--you know what I mean. Still, I look upon my job as making children feel better and making their lives better. I work hard at it and do my best.

Three days ago, a favorite patient came to the office with his mother. He had acquired a splinter in one of the worst places to get one, the center of the palm of his hand. It's a bad place for several practical reasons, not for elaborate medical reasons. The skin on our hands is quite thick, not quite as thick as the soles of the feet, but very thick. Unlike the soles of our feet, however, our palms are covered with sensitive nerves for feeling things. Our palms have a flexibility that makes it difficult for us to flatten our palms completely. And once we start grasping things as babies, we never stop, so the muscles of our grasp are very strong. Lastly, the palm is fully visible to the motivated child.

He had been healthy and was playful with me when they first came into the office. He was glad to show me the splinter. It was clearly visible, only about 2 or 3 mm long. But it was in an awkward position, as if it had been put straight in and then broken off at the surface. Because of this foreshortening, it was difficult to see a way to expose the deepest part of the splinter without digging a deep hole in the center of his hand. The nearest part, however, was close to the surface, and should be an easy grab with my sharpest surgical-quality tweezers. Because of the thickness of the skin in the palm, I thought I could get it on the first try without hurting him.

After about 20 minutes of the most upsetting screams possible, as this child stared at me, wearing a headlamp, using needle-sharp instruments on him, I gave up in a sweat. I had to try a different way.

I prescribed some numbing cream for him, and asked his mother to bring him back with the cream, for me to apply. The next day, I put the cream on, covered it, then wrapped his whole hand in an elastic bandage so he wouldn’t mess with the cream. He was happy to play with the office toys for about an hour. He didn’t mind the unwrapping, or cleaning off the cream. But the screaming started as soon as the tools came near him.

Granted, these are some fairly scary-looking tools. Everything was shiny and needle-sharp. We had a reasonable control ratio. (I have defined this invented term—I wonder if it’ll catch on—as the ratio of adults to the age of the child, in years. In this case, the ratio was a usually-effective 1.0: there were 3 fully grown adults to a single 3-year-old child. The 3 adults didn’t have a chance of restraining this warm and affectionate child. I though it might be helpful to use the numbness provided by the cream to allow a small injection of local anesthetic, to really be sure he wouldn’t feel anything.

I won’t keep you guessing. That didn't work, and the 3 of us never got his hand still enough even to get a good look. I never took out the splinter. Luckily, I haven’t been exaggerating about the patient’s mellow personality, and though he was absolutely impossible to restrain for even 20 or 30 seconds so I could get the thing out, he was immediately forgiving, both of me and his mother.

First, some information about splinters. Usually, they have to come out. By definition, they are little irregular slivers of something, torn or broken off of something else. Broken or torn edges are rough, though you might need a microscope to see that. These rough edges can be packed with bacteria that can cause nasty infections. It’s a sign that you absolutely must get the thing out if it becomes swollen and red and painful to touch. It’s a particularly bad sign if this red/swelling/pain develops just a few hours after getting the splinter in the first place. If that happens, either get it out yourself, or if you can’t, get to an ER. In this case, there was no redness after a day when I first saw it. There was still no redness the following day. No swelling. It hurt him a little to press right on it, but not too bad.

So this was my mistake. Honestly, I don’t think it’s a mistake I make very often. I think of myself as a minimalist, using the least possible intervention that will have the best result for the child. It just looked so easy, no big deal, right there near the surface...all it would take was a few seconds of him holding still. But that’s a common error in judgement. I focused on what would be reasonable medically for all kinds of rational reasons. That wasn't an empathic approach. What was in the best interest of the child? How did he look at this issue? He certainly didn’t see it as a problem that needed what appeared to be an inappropriately serious response.

He was right. Though most splinters need to come out, what happens if they don’t? If small enough, the body’s immune system can literally digest them, and make them disappear. Sometimes, the skin will push them out over time. And sometimes the body can wall them off with scar tissue, and they are with us forever. After a really long (maybe an hour) bath, the top layers of skin on his palm might be soft enough to come off with a vigorous drying, and that might take care of it.

His mother certainly thought it needed to come out, and I did too, at the time.

It's important to try and see things from the child's perspective. It's something I consciously try to do with all my medical encounters. This time, however, not so much.

Being sensitive to the child's viewpoint is really important--but that's not the same as letting that viewpoint dictate what has to happen. Part of the price we pay for having the privileges of being grown-ups is that sometimes we have to make tough, unpleasant decisions. Just because your children would like to play on the freeway doesn't mean you should let them!

If the splinter had been infected, it would be out.

July 10, 2009


Let's be completely clear on this: we don't learn to like sugar. We are born with chemical receptors on our taste buds that, when they are contacted by sugar, send a signal directly to our brains. That signal does many things, including giving us a sense of well-being and relief from discomfort.

As an aside, the lab where I used to work has helped to figure out the truth about our taste buds. A brilliant scientist I worked with explains on her website that what we were taught about certain tastes having specific locations on the tongue (like sweet in front and bitter in the back) is bunk. Part of the most recent research on taste shows that there is a large genetic component to what we can and can't taste. Though our taste sensitivities can change during our lifetime, it seems that we are all born with a basic toolbox.

In the hospital, we have been using sugar water to help sick babies get through painful procedures. It really seems to help. While giving kids sugar water in the office isn't standard procedure, I think there is a medical benefit to some of the lollipops I give out.

I have posted before about 'concrete thinking' and the inability of children at certain developmental stages to predict the future and prepare for it. So an empathic approach to a child who has just had an immunization or had a splinter removed required us to see that the procedure came as an unpleasant surprise to them. They have a normal physiologic response to a sudden and unexpected painful event: shock. (It's not as bad as the shock we go into when we have an overwhelming infection, or some other really serious medical problem.) Our blood pressure drops, we feel weak, our hearts race, and our blood sugar goes haywire. In the intensive care unit, careful management of a shock victim's blood sugar can be very helpful.

After an unfortunate surprise, the lollipop causes a brief little rise in blood sugar. From a lollipop, the sugar is absorbed directly into the bloodstream through the tongue and mouth, and doesn't have to get through the digestive system, which would be much slower. So I think they get some quick pain relief like the babies as well as a rise in their blood sugar that really seems to make them feel better.

This is why I don't give out sugar-free lollipops. They just can't work the same way. (In fact, I do have some that are sugar-free for my diabetic patients. I keep them in a cabinet.)

Each Dum-Dum lollipop has less than 25 calories. Even for a kid, this isn't a significant risk for weight gain. To gain a pound, we'd have to eat about 150 of them. One lollipop will not cause tooth decay.

And, of course, there are behavioral aspects of giving out the lollipops. They are an incentive to clean up the toys at the end of a visit and something nice about going to the doctor.

(A lot of parents are concerned that the lollipop will worsen their child's hyperactivity. I have a post coming up that deals with this issue specifically.)

Most of the children in my office are not getting any kind of painful procedure. It's for them that I think the lollipops are most important. It's a reward for good behavior, a way of noticing that they did everything right (or even mostly). It is one of the great failures of parenting that we don't catch our children being good. We point out, sometimes angrily, when they don't do what we want. But somehow we have the irrational expectation that when they're doing what they should, they are somehow rewarded for it. In fact, the child can often feel that you're not noticing them being good, but their misbehavior really gets your attention. In my office, I notice their good behavior, explicitly point out one or two things they did that were good, and reward them for it. Since I can't give them the most treasured reward—a parent's attention—I have to get by with candy on a stick. Besides, they taste really good.

The photograph at the top is from my collection and is by Weegee.

July 7, 2009

Michael Jackson

I'd give all wealth that years have piled,
The slow result of Life's decay,

To be once more a little child
For one bright summer day.

~Lewis Carroll, "Solitude" March 16, 1853. It's the first time he used the pseudonym Lewis Carroll. He was teaching mathematics at Oxford, at the time, under his real name Charles Dodgson. The picture at right is from my collection and is by Lewis Carroll. It's a portrait of Xie Kitchin, who sometimes posed with Alice Liddell, of Alice in Wonderland fame.

Victorian writers had a very romantic idea about childhood. A hundred years ago, J.M. Barrie created Peter Pan, which as far as I can tell, gave birth to an ever-growing list of adult psychiatric diagnoses for people who just don't want to grow up. The artwork at the time, even more in the United States than in the UK, showed children as innocents—often at play, or with puppies, and in endearing situations. This has always fascinated me. On the one hand, grown ups have had this idea of childhood as a carefree time of non-stop fun and play, whose only interruption is for the occasional scraped knee.

On the other hand, adults have a fairly spotty record, to say the least, when it comes to making sure that children get some of this carefree time that Lewis Carroll seems to wish for. At the same time as a few wealthy Victorians imagined this fantasy world of childhood, Mark Twain and Charles Dickens were writing about a series of child characters who had to survive by their wits and the kindness of strangers. I wonder if Carroll read Oliver Twist or Huckleberry Finn? Was that the childhood he longed for?

All of this is related to some of my thoughts about the great Michael Jackson. Did he have the childhood of Oliver Twist? We all know he was a child star—touring, recording, perhaps supporting his large family, being advised and managed and publicized to optimize the return on this brand-identity investment. I'm sure there were some private jets involved, so it's not exactly a Victorian workhouse orphanage, I admit. But when we look at our lives and wish for a few days more of childhood, I don't think we're thinking about the best friends we never had, the family life we didn't have, the school friends we didn't have.

I've been working on a post about feral children—who grow up by themselves in the forest, or are raised by wolves—because I met a child once who I think sort of fits that category. Maybe Michael does too. How does a child grow up without a childhood? What happens to them?

I wonder if Michael Jackson, once he had all the freedom that money could provide, still needed to live out some of the childhood that, as an adult, he was aware of having missed. But having missed it, he tried to experience some childhood that he saw in the movies or on TV. That was never anybody's real childhood--but it's not at all clear that he would know that. And adults can't experience childhood the way a child does. They can pretend to be children, but unless it's in the context of an improv performance or a sketch comedy show, that's just, well, odd.

There are things about superstars in every field that some of us envy. The money, of course, would ease certain important headaches and give us freedom most of us will never have. Some people would like the fame, the adulation, the star on Hollywood Boulevard. Some of us would love to be able to move like Michael. This photograph on the right was taken today, July 7th 2009, with a telephone camera at the memorial service in Los Angeles. It was sent to me directly.

I was sad when I heard he died. But I have been sad for him for a while, to be honest. Michael Jackson was not among the millions of people who wanted to be Michael Jackson. Clearly, he wanted to be something he wasn't. I don't know how much he wanted to be African-American, or really why his skin got so light. If it was by his choice, it was not so he could get into the right clubs, hail a taxi, or get treated right by a store clerk. I don't know why he felt he had to get a Grace Kelly nose or a cleft chin on a lantern jaw. But I do know this, it was his choice. Sure, I respect his choice to be whoever he wants to be—nobody else was hurt. But it made me sad to see so clearly that the person he wanted to be didn't really resemble the person we all saw.

How did that happen? I don't know, but maybe while his parents were promoting the band, it's easy as 1-2-3, they weren't spending a lot of time reminding little Michael (let alone Jermaine and Tito and Jackie and Marlon) about what a great kid he was, and how lucky they were to have him, and how great he looked just the way he is.

I don't worry so much when a worried parent brings me a teenager who doesn't dress the way the parent wants. Maybe it's too Goth, too Skater, too Emo, whatever. They are finding their tribe, searching for a group that feels right to them. It's a normal thing and they deserve our support. I worry more about the kid who doesn't dress like anybody else. A sequin quasi-military jacket with gold braid, like something from Sergeant Pepper but...more. Wearing a single glove. I would worry because there is no tribe for that person, no group he can relax with.

It's OK with me if you are grooming your child to be a rock star, or a major league athlete, or a CEO. But if they actually achieve your unlikely dream for them, if they survive what is most likely to be a fruitless quest for your selfish and unrealistic desire to live vicariously through them, and they are still talking to you, then your dream will be fulfilled, not theirs. Every child's quest is to make their parents happy. Show them with your words and actions that you are happy with them just as they are, and they will reward you with a happy adulthood of their own. Maybe they'll even visit you when you're old. That is what perceptive parenting, empathic parenting, good parenting, is all about.

Part 2:
I once dated a ballet dancer in New York. It didn't work out. (Neither did I, and that was just one thing we didn't have in common.) She made me go to at least a dozen 'modern dance' performances. These modern dance performances were the dullest activities that any group of about a dozen very athletic and flexible young men and women could ever work their tails off to do for very little pay. Not a physician at the time, I was nonetheless tempted, just a few minutes into each agonizing performance, to amputate first parts and then whole chunks of my own limbs just to distract myself.

Imagine, then, that one young black man from Gary Indiana could change this forever. This guy showed highbrow dance experts that there were moves and expressions in movement that were completely new. Every dance we see in theater or anywhere has been touched by Jackson.

I am still surprised when I'm in an elevator or mall and some familiar Beatles song is being played by synthetic instruments that have never touched human hands, music 40 or more years old. I've never really tried to predict the future (since I left Wall Street), but in 2050 and 2060, long after I'm gone, Beat It will be guiding our grandchildren's children down the supermarket aisle on their hovercarts. Maybe it's ironic that Muzak filed for bankruptcy just a few months ago.

And we'll always have Thriller. He got the brilliant John Landis, who directed the coolest werewolf movie ever made to direct this little movie, which follows Michael Jackson changing from nice guy to scary monster. (Yikes! That sounds like a one-line biography of the guy.) And that amazing leather jacket, designed by UCLA's Copley Professor of Costume Design.

This, from 1500 inmates in Cebu, Phillipines:

OK, the quality's really low--taken, maybe from a cellphone, at a live performance. But be patient. The song doesn't start for about 3 minutes. But those first 3 minutes.... I know that singing without music is called a capella. What is dancing without music? Unbelievable.

They gave us ABBA. I'll take MJ any day--and apparently so will they.

And his music will be around for a long, long time. This will change preconceptions:

July 4, 2009

Kicking the Blocks

It's easy to find examples of bad parenting. Much as each of us might love our own parents, we all can remember incidents (maybe isolated, maybe not) from our own childhoods in which their instincts weren't, well, optimal. So when I'm a witness to particularly good parenting, it makes an impression on me, and I usually learn something.

The 3-year-old was building rockets out of the wooden blocks I have in the room. Some of them were 10 blocks tall. He was so proud of these that he went out into the hall to tell me about them. He liked that I went to see them and was appropriately amazed by how tall they were.

His brother, almost 5, was in the room assembling a puzzle, but he kept looking over at the younger one, especially when I came in to look at his rockets. Their perceptive mother was there, too. She didn't hesitate to address her older son, who seemed occupied with his puzzle. She said, "Kevin, if you knock over your brother's blocks, you won't get a lollipop." At that moment, this seemed like a comment that came out of the blue. I wondered why she didn't warn him about setting fire to the building, too, as a reason to miss a treat.

I haven't tried to disguise where this is going, so don't be disappointed that there is no surprise twist to this story. As soon as the little brother and I started talking about his rockets, his brother calmly stood up, walked over and kicked the blocks down. He had a giant smile when he did this. Afterwards, he stood and admired his work. The younger brother gave a quick cry, but I told him I'd help put them back together and sat on the floor and started to make rockets with him.

His mother said, "You won't get a lollipop today."

This brought on a vigorous near-tantrum, in which he repeatedly asked, "Why don't I get a lollipop? It's not fair." This continued for a full minute or two before he sulked off into a corner. The rule in my office is that all the toys need to be picked up before anybody gets lollipops. So he said, "What if I pick up the toys? Will I get a lollipop?" His mother thought for a moment before saying that he would if he picked up the toys and apologized to his brother. When the visit came to a close, he was still sulking as his little brother and I picked up the blocks and toys. Kevin moved the blocks around with his feet.

As they left, his brother chose a lollipop from the basket. His mother was unflinching. Kevin got none and was unhappy about it.

At the same time, this mother was rock-solid, yet forgiving. She didn't negotiate or go back on her word. The child's behavior, was age-appropriate. He is just beginning to have an inkling of consequences from actions he can control. But exercising that control is just out of his reach.

So often, from a child's perspective, the rules adults create for them seem arbitrary and unpredictable. New rules appear invented for novel events that they can't expect. At Kevin's age, with his completely immediate concrete thinking, he doesn't have the ability to generalize a basic but vague rule, like 'Don't hit your brother,' and apply the rule to new situations. So an empathic approach allows us to understand that he might reason that the rule doesn't apply to hitting his brother in the car, or while watching TV, and so on. In the incident in my office, his mother made this easier for him by being very specific about the rule. She foresaw what he wanted to do to those tempting towers of blocks. While he clearly heard her, he couldn't make sense of how his action could result in a consequence he didn't like. Now he and his mother will have an example to point to when the issue of actions and consequences comes up again. And it will.

The sweet photograph at the top is not in my collection but is used with permission by the photographer, Courtney Coolidge, who takes great photographs of kids and families.

July 1, 2009

Teaching Empathy

I was flying last week. The rows are close together, but the flight was just an hour. There wasn't any room for my legs, however, because of a large suitcase jammed under the seat in front of mine. Very politely, I asked the person sitting in that seat to take the bag and put it under the seat in front of her seat. “I can't do that, she explained helpfully. Then there would be no room for my feet.”

Empathy is the currency of human relationships. Being able to walk in another person's shoes gives us the ability to understand where they're coming from and what they might be feeling. When you think about it, this is the skill behind all kinds of human interactions, including everyday courtesy, safe driving, and successful romantic relationships.

How do we learn this? Are we born with it?

Just like most other behavior, our parents model it for us. But my work with kids who have really difficult behaviors makes me suspect that there's more to it than that. How come some kids are so sensitive to the needs of others, while a sibling not so much—even though they grew up with the same parents? I believe there's a component of brain chemistry involved also.

But whatever the kids are born with, can we make a difference? As it turns out, we can. There are many different aspects to good parenting, but this just hasn't made it into parenting books. As regular readers, and my patients know, I think it's essential.

In one study, children were given a task to do with their mom and a friend. The interaction was observed at 3 and 4 years old. The scientists scored the interaction for conflict vs. cooperation. They found that the most influential factor was the actual words the mother used when talking to the child. Mothers who explained to their 3-year-olds how others might be feeling had, on average, more cooperative 4-year-olds a year later. This is supported by research in which mothers were observed with their children, and what they said was recorded. Children whose mothers often reminded them about what others might be feeling didn't remember the words but did remember the concepts. They showed more understanding of what others were feeling. Maybe these research results aren't surprising. I am impressed, however, by how much these young children can absorb from the little things said my their mothers. Lots of other studies support these findings.

Let's take a step back. Children can, in fact, learn how to appreciate the feelings of others, and this skill could improve their social understanding and relationships. They seem to gain this understanding by listening to the remarks and explanations of their parents. In my mind, this brings up some interesting questions. I didn't find any research on this, but I wonder if they also pick up the negative things we say. That SUV cutting us off on the freeway might deserve an out-loud expression of our analysis of the driver's motives and intelligence, but if our kid is in the back seat, even at a very young age, won't they remember that, too? What about the opinions we voice about our bosses or ex-spouses (or current spouses)? The research is so strong about positive influences that I suspect we may inadvertently provide some examples of insensitivity as well.

If there is a sunny side of the street that we're all supposed to walk on, I haven't found it. Parenting isn't just about only sharing your positive experiences with your children, and hiding the negative ones. How will they learn how to handle interactions that don't go as well as you hope? So a perceptive parent, an empathic parent, will find and use the teachable moments of everyday life, even with the youngest children.

When you see a child crying in the park, ask your child why. If they don't know, help them make up a reasonable explanation. This is an exercise in imaginative story-telling that can be as long or as short as your child likes. But it exercises their empathy muscles, both in trying to imagine why that child is crying, and by the fact that you are interested in why and are interested in why your child thinks the child is crying. As with any behavior, if your children think it's important to you, it will be important to them. It almost doesn't matter what, exactly, your child's scenario is. Maybe the kid fell down. Maybe they had to wait their turn on the slide. Or maybe they couldn't have the pink cookie shaped like a strawberry that probably tasted really really good that their mommy didn't buy for them when they were shopping in the supermarket to buy macaroni and cheese and milk and then get home right away because daddy would be home soon.

Parents translate the world for their children. When we talk to them about the feelings and motivations that make others act as they do, we equip them to manage successfully their lives with others.