Transcription:
Do You Need To See a Doctor, or Can it be Managed at Home?

Melanie Cole (Host): “Do I need to see a doctor or can I manage something that happens to my children at home?” is a question that so many people ask themselves all the time whenever an illness or injury occurs with their children. My guest today, is Dr. Jack Maypole. He’s a General Pediatrician and Director of the Comprehensive Care Program at Boston Medical Center. Welcome to the show, Dr. Maypole.

Dr. Jack Maypole (Guest): Thank you.

Melanie: There are a lot of things that might happen to our children – falling off a swing set or cutting themselves – and parents never know whether it’s something that is emergent or you call a Pediatrician and find out what to do, or you take care of it at home. Let’s bust up a few of these and see which ones you want people to know so that they know who to call.

Dr. Maypole: Sure.

Melanie: The first question, if you have a call into your pediatrician and you get the pediatrician or clinician on call, what do you want people to know about getting somebody who’s not their regular primary care physician?

Dr. Maypole: That’s a great question. It’s certainly something – as someone who takes on a lot of phone calls, meaning covering for their primary care practice -- would appreciate being put out there. I think, as with any time you’re dealing with someone with a clinical background – you show up in the Emergency Room or walk-in urgent care clinic, or in this case on the telephone -- it’s really important to be mindful a few different things and help the other person on the other end of the line – someone like me, for example – understand the context and situation.

First of all, who are you, and who is your child? What is the situation? What is the concern? And then – and thereafter, we’ll follow the usual back and forth – tell me what happened. When did it begin? What are your concerns? How does the child look now? What is your feeling that we can do now or what needs to get figured out in terms of does the child need to be seen? After that, I think for parents who have kids with a complicated illness or who have important things like medicine allergies, letting that information get communicated before you hang up. If you start just from there, you’re off to the races, and you’re off to a really good start.

Melanie: So let’s start with some of the simple things that kids come up with, cuts and scrapes.

Dr. Maypole: Okay.

Melanie: And so if they get one of these and the edges of a cut gape open, do they use Neosporin, Bacitracin? Do you like covered and moist? Do you like – oh, some people say let it air dry? What do you like and how much bleeding do we put up with before we call you guys freaked out?

Dr. Maypole: Yeah, well, I think I’m going to back off and say first of all, who are we talking about? It’s a very different question if you’re describing an infant or a toddler and having just fallen and scraped their knee in the dining room versus someone who had a more extensive injury. Really, we have to first step back as parents and caretakers and say, “There is a wound, but how is the child doing?” I think with that in mind the ones you should worry about are those that really seem to be associated with the child being inconsolable. Every child under at least the age of 12 tends to get teary or upset with a significant fall or skin injury, but if the usual stuff – the hugs, the kisses, the ice, the padding, and the distraction and the consolation really aren’t working, then it’s an immediate signal to do just a survey of how your kid’s doing. Are they making sense? Are they alert? Are they conscious or is there anything else that may suggest a deeper injury?

Okay, let’s pretend you’ve done all that and you’re reassured, and it looks like a more superficial scrape, which looks – I’ve heard described as road rash or raspberries. For that sort of thing, doing the usual putting a band-aid or maybe some clean gauze or a moist, clean towel over it to offer some cooling and to abate the bleeding is a good idea. If there’s a bruise, you may want to do some ice to the area for maybe ten or fifteen minutes thereafter and constantly reassess. Has the bleeding stopped? Do they seem to be okay? If it’s over a joint, are they moving that all right?

When it’s more extensive – if it’s deeper, and like you said, if it’s got a gaping aspect like a fish mouth, that might be something that needs some stitches or maybe some cinching shut with some skin glue, and might be a reason to snap a cell phone shot of it and call your doctor’s or your provider’s office and see if they can help you assess it and help you figure it out over the phone.

Melanie: I love that you brought up snapping a cell phone shot of it because that’s something --

Dr. Maypole: Oh, yeah. A tool in the toolbox.

Melanie: New that we can do. And following along that theme, bumps and bruises happen to everybody. When would you say okay, if your child has a bump or a bruise, this is when you do need to call the doctor?

Dr. Maypole: Yeah, great question again. I think a classic example is a toddler shin. Anyone age two, three, four, seven, it’s pretty much a hundred percent guarantee that I’m going to find bruises on their shin, which is a good sign that they’re running, and jumping, and crashing into things at low speed and having those badges of honor on their legs. I think for parents who have a really excellent spider sense over their kids it’s when they feel like the bruises that they see are out of scope or really seem much more exaggerated for the story of how the injury happened. Like, I bumped into a door, and I have – and the whole side of my arm is black and blue. Either it means we have to go over the story again, or there might be something else going on.

For parents, in the rare cases where there’s a concern, there may be a bleeding problem, or even rarer still something like cancer, it often goes with something more. Kids are having unexplained fevers or sweats at night. They may have pain that they can’t explain. They may have fluey symptoms or fevers, like I said, or that there is other bleeding involved. They may have bloody noses that last for more than a couple of minutes, bleeding in their gums, or even bleeding in their pee or their poop. Those would definitely be reasons that parents would – I’m sure would not escape their notice, but if they did come across that would merit a check in with their primary care doc.

Melanie: What about ear pain? You sometimes as pediatricians do the watch and wait, and sometimes we get ear drops, or sometimes a full antibiotic. When is ear pain something to go see if it’s an ear infection?

Dr. Maypole: Well, here’s Mr. – here’s Doctor Obvious. Again, it really does depend on who the kid is. It’s one thing if it’s an 18-year-old versus an infant or toddler. Let’s talk about the more commonly encountered ear pain in an infant, or toddler, or school-aged child. Assuming it’s one-sided, and assuming it happens over a day or two, sometimes just even over the phone we can get some important understanding. Does the child have a history of previous ear infections? Does the child have a history of getting surgery for those kinds of things? Those would be important details to share with the person you’re talking to on the phone.

And then in season, or depending what their activities are if they’re swimmers, that might help cue us to delineate if it’s a swimmer’s ear or external ear infection or a middle ear infection. But really, the gold standard, now available with new tools – smartphone dongles that can even look at ears and send images remotely to consulting providers or a visit to clinic with direct visualization -- that is, peaking through the otoscope at the eardrum – can help us make a diagnosis of ear congestion, some fluid that might be there for whatever reason, including allergy, or maybe an infection that could be viral or bacterial.

And then finally, the idea of treating ear infections or ear pain with antibiotics has changed a lot over the last 20 years, and we’ve become much less aggressive for good reasons. Most of these ear infections are either – don’t have any specific organism we can treat with antibiotics, or it’s viral. Only some are really bacterial in origin. Young age, persistent pain, high fever, these would be factors that would contribute to a game-time decision to treat with antibiotics, but pretty much never does that happen purely over the phone unless we have some visual data that can help us see what’s going on inside that ear canal.

Melanie: So many of our little guys are athletes now. They’re playing soccer, and they’re playing baseball, and they come home with an injury or a swollen ankle or a shoulder that hurts. Do we rush off to the orthopod or to our pediatrician or do we wrap, and ice, and do all of those things and wait and see what happens the next day?

Dr. Maypole: Yeah, so we if we have a child who has a question of a strain or sprain – let’s talk about the ankle first, one of the most commonly tweaked joints. There, if a child has had an injury, let’s say sports practice, and is able to bear some weight and is walking with a mild limp, I think that’s, right there, very reassuring that it’s more likely a mild muscle strain that can recover with some at-home supportive care like you described.

If it’s something where a child is unable to bear weight on a twisted ankle or worse, a knee, that’s something that may merit at least a check in with the primary care practice just to at least understand and maybe explore more deeply over the phone what might be going on and if they need to be referred for imaging in an Emergency Room, for example, or followed up in the next 24 to 48 hours if there is a lack of improvement. If there’s a question of injuries in what we call the upper girdle – the upper extremities, shoulders, elbows, wrists – similarly, gentle ranges of motion as with the legs. Never forcing a child to move beyond a point range if there’s tenderness or discomfort, and just doing that overall gut-check assessment that parents are so good at, if you’re really concerned that the child is not responding well to the usual care plus Motrin or Tylenol, it may be a good time to check in with their provider.

Melanie: Dr. Maypole, are there resources online that you – parents now, all we do is we go right to the internet, and we look up whatever it is – we see a rash on our children, and we go, “Hm,” and we go right to the internet. Are there some websites that should be avoided that you do not want people to be looking at or are there websites that you feel are very good and trustworthy, like the American Academy of Pediatrics, or Healthy Children, or one of those? Is there something that you want parents to know about looking this stuff up?

Dr. Maypole: Sure, the short answer is absolutely. I don’t necessarily have a campaign or a position on a short list of websites to avoid, but I do think there are some key qualities that might be markers or flags for parents who are shopping sources of information around their child’s health. First of all, trying to get a sense of who is the curator or who is the author of the website and if it’s an individual versus a medical establishment versus an academic or research entity, I think that will help understand if there is a bias or an agenda there. Do be very cautious if a website is spouting information has direct links to marketing or hawking their own products to address a malady or an injury, I would be very wary that there is some strong propensity towards bias or bad information. It’s very prudent for parents to explore things or share resources maybe with their provider to understand if they have a perspective and even for them to learn, which I find in my practice is very, very helpful.

There are somewhat we might call mainstream medicine sites that I like a lot. One is -- just a short list of them might be HealthyKids.org has some nice resources of all sorts. One that I find a lot of my parents enjoy is DrGreene.com, that’s G-R-E-E-N-E-dot-com. I think for young parents, BabyCenter, a site which parents might use during their pregnancy, has some very nice postpartum or first and second year resources about normal growth and development and health that parents can find very, very useful too. I think that’s a great start. WebMD ain’t so bad either, but I’ll stop there just because I’m talking too much.

Melanie: [LAUGHING]. No, you’re certainly not because it’s really great information. Wrap it up for us with two or three pearls of your best wisdom about calling that on-call doc, what to do if we feel uncomfortable with the advice that the on-call that’s not our normal primary care pediatrician might give us, what you want parents to know about managing these things at home or going into the emergency room or physician.

Dr. Maypole: I tell my patients and my parents something that I hope they take to heart and I think – I hope this can be shared here. If it’s two in the morning or it’s Saturday afternoon at three o’clock, and the practice is shuttering or is closed for the day, I think parents really want some reassurance or some piece of mind. I think that if parents embark upon a reach out to talk with a clinician covering for the practice and they have that conversation over the phone, really the goal – the mutual goal for everyone, the provider included, is to really make sure that their questions are answered, that their goals are met, and they have a clear understanding of what the next steps are. I can certainly say that I am as guilty as the next person sometimes falling into jargon or lingo, so if parents feel confused or if we just get into our own heads too much and are talking gobbledy-gook or really aren’t being clear I urge parents really to press on and to ask us to clarify what we’re saying.

And then at the end, sign off and be cool with the plan that was presented and make sure that there are clear steps of what to do if you need to escalate the level of care. When would I call back the practice? When should I come in if at all over the next few days? Why should I or when should I go to the ER? What would be the warning signs? I think you can usually do that in a conversation between three and five minutes. I think that is a really good place to start and I would say if someone has some misgivings after they’ve hung up the phone, don’t hesitate to call back.

Melanie: Great advice, Dr. Maypole. Thank you so much, for being with us today. This is Boston Med Talks with Boston Medical Center. For more information, you can go to BMC.org, that’s BMC.org. This is Melanie Cole. Thanks so much, for listening.