Pediatric Center News

A long time ago, in a journal far, far away, an intrepid urologist ran a contest I cannot name for copyright reasons. It did, however, ask for medically relevant relapses od old and familiar works of art. I won a few, lost some, been baffled occassionally (I still cannot fathom why, in a contest of medical remakes of nursery rhymes, this one of mine won:

As I was going to St Ives

I met a man with seven wives

All on their way to Inverness

To find a cure for PMS

and this one did not:

Little Miss Moffet

Sat on a tuffet

Eating her curds and whey.

A member of PETA

proceeded to beat her

Till constables took him away.

But I digress…)

Well, here is a trial balloon, may it not come down with plumbism:

Much of the Monty Python oeuvre is already medically relevant, Graham Chapman having been a member of the tribe (”My brain hurts!” — “It will have to come out!”, or: “YOu haven’t got a womb! Where’s the fetus going to gestate, in a box?”). Let us, however, attempt to remedicate a Monty Python skit that lacked that healing touch. I have some humble examples here:

“…but other that blood typing, Xrays, TB diagnosis, Billroth I and II, sulfa and salvarsan — what else have the Germans done for us?”

…”We are veritably crawling with bacteria here…

-Salmonella?

-uh, no…

Shigella?

Fresh out…

Staph Aureus?

died yesterday.

MRSA, too?

Afraid so.

What! MRSA is the most resistant bug in the world, how did you manage to kill ot off?

Lab tech dropped the dish, sir…”

Entries may be submitted as comments; all will earn my undying gratitude, and winners the same, double. Enjoy!

A while ago I wrote of my small bit of civil disobedience – disobeying, for all of a minute and a half, the letter of the law governing the reporting of suspected child abuse. Here, in contrast, is a report of someone who obeyed the law perfectly. I will leave to the reader any judgement on whether this is a law sometimes best honored in breach and not the observation.

In addition to my own occassional outsider’s observations of the educational systems, I would like to recommend the blog of an old friend from Princeton, an educator whose stature within his field easily eclipses my own. Another old friend who humbly calls himself the “has-been” (well, he “has been” in the White House) will, more likely than not, be an important voice in future politics very shortly, and may (one hopes) have the opportunity to strip some of the collateral damage producing glitches in the laws currently on the books.

As a pediatrician, I hope to be judged on how I handle medical problems, both routine and bizarre. The government, however, assesses physician differently. For those who wish to wade through a lengthy .PDF document, the pattern that emerges is that what the government calls “improvement” in “quality of care” is actually an increase in efforts by physicians to reduce risk behaviors in patient populations. Again, I leave it up to the readers’ judgement whether they would like to wait with a sick child while their doctor lectures a bored teenager about safe sex, good food, wearing a helmet while biking, staying away from substance abuse, water safety, and not getting into cars with idiots — but attention paid to how well we handle acute disease is nowhere near the attention paid to enlisting pediatricians in mass indoctrination. This may be a health care service, but it sure ain’t medicine. In a 1969 Maigret mystery, Georges Simenon had a French doctor voice concerns that now, 40 years later, become ours — the US thus being 40 years behind France in enlisting medicine in the pursuit of social engineering.

Now, my own definition of freedom and liberty includes the freedom of stupidity and the liberty of taking risks, as well as a fairly broad interpretation of autonomy rights for individuals as both personal decision makers, and desision makers for their minor children. The first person to parachute was a brave fool, as well as the second person to try fugu, and our own liberties were purchased by the imprudent men at Lexington, Gettysburg, Belleau Wood, and Bastogne, and say what you will about Spartan (literally) upbringing, if not for them I could be writing this in Farsi now.

But… money talks, and a state that wants to pay for all health care expenses cannot afford to pay for diseases and injuries sustained in pursuit of thrills, highs, and gastronomic delights. Money talks, and it tells us to desist from living dangerously. When you support single-payor medicine, as you consider whether it will take a half a year to approve that MRI, or three months for cancer surgery, as is the case in many countries with socialized medicine, don’t forget to ask yourself which of your hobbies will next be banned as expensively hazardous.

As of today, both injectable and nasal flu vaccine is available for both VFC and non-VFC patients.

I generally stay out of politics for the same reason I don’t fly airplanes: I will not mess around with things I don’t fully understand where someone may get hurt.  Laws, as they apply to medicine, tend to run with a steamroller over problems best attacked with a scalpel, and the fewer of those we have, the fewer patients will suffer the consequences.  I have a story of a little girl who got better in spite of laws to the contrary.

 It was 10 minutes to seven PM.  The mother ran in, scattering tears, clutching her little 2-year-old daughter, upset beyond words.  She had just picked her up from day care, and as she started to change her diaper –

she could talk no more.  Crying, she undressed her child, revealing a huge buttock bruise and bleeding in the diaper area.

Let’s stop for a second.  The law dictated for me to call the police at that point.  It is very specific that where a suspicion of child abuse exists, it must be immediately reported.  That’s not what I did.  Instead I ordered a CBC, a complete blood count, to be done.

Let’s stop again.  I have a CBC machine in the office.  It takes 90 seconds to return a result.  There is another law, called CLIA, designed to make it very difficult to operate a lab in the office.  This is actually a law we have been able to follow, at great expense and with considerable difficulty.  Most pediatricians do not have a lab, and must wait overnight for results from their patients.

90 seconds later I knew I was not going to be calling the police or Child Protective Services.  The platelet count was extremely low, 10 times less than normal.  Platelets are the blood cells that stop small bleeds.  The little girl had ITP, and less than an hour later was in the emergency room getting appropriate treatment (I called ahead and had them ready the immunoglobulin before she even got there, wasting no time on testing).  She went home to recover completely without further adventures.

Did my brief encounter with illegality save her?  Maybe.  I know I saved the day care center people, and I don’t even know who they are.

What brought this back (from ‘93 or ‘94, quite a while ago) is an entire issue of a respected pediatric journal devoted to “advocacy for children”.  That means, getting the legislatures to pass laws to help children.  I just hope they do a better job with these laws than with some of the others…

RE: Mr Chavez comment:

There was nothing to report.  ITP was responsible for all the bruising and bleeding — without platelets, the force of just sitting down on the floor is enough to produce hemorrhaging.

As usual, it is a bit complicated:

Fluzone (injectable, dead, inactivated vaccine):

between 6 months and 3 years of age — available both VFC and non-VFC (comes in 0.25 ml syringes)

over 3 years of age — available non-VFC only

 reminder: the VFC program covers children and adolescents who are either uninsured or have a government-funded insurance or Medicaid, up to their 19th birthday.  VFC vaccines are supplied free of charge, but are often shipped later than commercially purchased vaccines.  Insurances do NOT pay for immunizations for VFC-eligible patients.

Flumist (live, attenuated vaccine administered as nasal spray, for persons ages 2 to 49 years who do not have a significant chronic illness)

We have non-VFC Flumist.  As usual, we expect a delay in the shipment of the VFC vaccine.

 Flu and flu vaccine will of course be in the news shortly; some news will be at least generally accurate while others will exhibit varying degrees of departure from reality. 

 On a different note, I would like to thank the military families who have joined our practice recently.  The response to my War and Peace editorial has been astounding, and the thought that they might see in our work a fleeting reminder of the dedication and professionalism their loved ones show daily in harm’s way is an inspiration. 

Anatoly Belilovsky, MD

Yes of course we are working on Columbus Day (Monday October 8, 2007) — both Brighton and Staten Island offices, usual doctors, usual hours.

As the NYC public school system now requires TDaP vaccine for all 11-year-olds entering 6th grade, we have plenty of both the VFC and the non-VFC TDaP.

Hepatitis A and second chicken pox vaccines are strongly recommended by the Health Department (first chicken pox vaccine has been required for a while).  There is, however, a nationwide shortage of the chickenpox vaccine, and we have run out.

The story is even more complicated regarding flu vaccine.  The popular Flumist (nasal flu vaccine, not a shot) may or may not be available this season at all.  The shots should be available, but the 6-to-36 months variety should be available first, followed by the 3-year-and-over variety, and as before, we may see big differences in VFC and non-VFC vaccine shipping times.  We have had a number of complaints about it last year, and would urge all parties concerned to call Health Department to make VFC vaccine available as early as possible, as they are ultimately in charge of it.

As the school season approaches, I would urge everyone to read last year’s posts, either at the bottom of this page, or on the next.  As nothing has changed in the school system, I expect to see the same problems this year as well.

In my work as a pediatrician, every once in a while I am privileged to be asked to see a child of a military or law enforcement officer. Even if sometimes they do not identify themselves as such, there is often a moment when their professional identity becomes apparent. It usually goes like this:

Read the rest of this entry »

There are many things in my practice which I prefer to leave to experts, and it isn’t just brain surgery. Psychological and behavioral issues are complex enough to need not one but many specialties in medicine: psychology, psychiatry, behavioral and developmental pediatrics, neuropsychology — and, being a general pediatrician, I try stick to what I know.

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