Trisha Williams (Host 1): Hi, guys. Welcome to the Advanced Practice Perspectives Podcast. I'm Trisha Williams.

Tobie O’Brien (Host 2): And I'm Tobie O'Brien. This is a podcast created by advanced practice providers for advanced practice providers. Our goal is to provide you with education and inspiration. We will be chatting with pediatric experts on timely key topics and giving you an inside look at the various advanced practice roles at Children's Mercy.

Host 1: We are so glad that you're joining us today. So, sit back, tune in and let's get started. Today, we are so pleased to have one of our colleagues, Sara Ray, with us. She is a family nurse practitioner who specializes in Pediatric ENT at Children's Mercy. Welcome to the podcast, Sara.

Sara Ray, MSN: Thank you.

Host 2: Sara, we are so excited that you're joining us today. Will you tell our listeners a little bit more about yourself, please?

Sara Ray, MSN: I am a family nurse practitioner. I did my undergrad nursing degree. I received that from Washburn University in Topeka. I worked as a nurse at KU Med. I started out on the transplant unit working in the ICU, and then I transitioned to working with post-op open heart patients. I did my nurse practitioner degree at KU Med. And then, I have been at Children's Mercy in the ENT Department for almost eight years.

Host 1: Yeah. And you've done some general pediatric care as well in your nurse practitioning career, correct?

Sara Ray, MSN: I did a little. I did a short amount of time at a pediatric office. I had actually worked in the ENT department when I was getting my nurse practitioner degree. And so, I knew that that was ultimately where I wanted to end up, and a position opened up shortly after I had started at the pediatric office, so I transitioned to working at Children's Mercy.

Host 1: Very good. Some of our listeners may know, but Tobie and I are also nurse practitioners in the ENT clinic at Children's Mercy. So, we have the privilege and honor of working side by side with Sara.

Host 2: And Sara, a little other background. You kind of come from like a whole family of ENT, right? Like your brother's an ENT surgeon and recently your mom worked in an ENT office too, so like something you just-- it's in your blood, girl, right?

Sara Ray, MSN: I think so. Yeah, my mom was a nurse in an Ear, Nose and Throat office in Topeka. And then, my brother is a head and neck surgeon. So, he is a Ear, Nose and Throat surgeon, but he did additional training and specializes in head and neck cancer surgery, mainly working with adults.

Host 2: Well, it just gives you a little extra, you know, zing, I think. Well, we're glad you're joining us today, Sara. So, we are going to jump right in and talk about like all things ENT. We are hoping this can help our listeners kind of when they are working with their patients having common ENT problems and when they might want to think about referring to Children's Mercy ENT. So, let's start with some of the most common ENT problems. Sara, what do you think about recurrent ear infections? Will you kind of give our listeners a little background on those and kind of how we manage and how and when we like them referred?

Sara Ray, MSN: I would say that recurrent ear infections are probably one of the main things that we see as far as the mid-level providers. So, I don't even remember how many nurse practitioners we have now, and we have one physician's assistant. But a lot of times, those referrals come to us.

The criteria that we are looking for when these patients get referred to us is six ear infections in a year, four in six months, persistent middle ear fluid that has been there for three months or greater. Those are some general guidelines. Now, I tend to operate in the gray area sometimes. I think that you can't always get caught up in the, "Okay. Well, they've only had three air infections." Well, but if they've had three infections and it's taking multiple antibiotics to treat these infections, that's an appropriate referral. And those are those patients that we want to see.

Host 2: Absolutely. And also, there's those other caveats, right? Like speech delay or other things that pop up, like maybe febrile seizures or TM perforations.

Sara Ray, MSN: Yes. You know, when you have a kiddo that has had ear infections and you're noticing a speech delay or they're just not hitting their milestones, that's another reason to send them our direction. If they are having, you mentioned, febrile seizures, obviously, that's another reason to come and see us in the ENT clinic. If they're having ear infections that are leading to TM ruptures, that's another reason. So, it's not always just strictly based on number, you have to look at all the other factors, but those are some rough guidelines as far as when we want to see them and we want to be able to assess what's going on.

One of the things that I really like, and I feel like most of our pediatricians in the area are good about doing this. I really like it when they send the documentation with it, not only the referral, but the office visits. I know all of us take the time to look through those. And I like to go into a room and be able to show the family that I did take the time to look through the referral and go through and say, you know, "I saw that you had an infection on this date. It looks like your pediatrician treated with this antibiotic," to be able to review those things, because I know that it is overwhelming at times. When you're child's been sick so often, everything kind of runs together, and it's really hard for families sometimes to put all the pieces together the way that we're asking the questions, you know, because one of the first things I do is ask, you know, "How many ear infections have they had?" And a lot of times, I get the answer of, "I don't know, they've just had so many." So, it's nice to have the documentation that came from the pediatrician to help us kind of put that puzzle back together.

Host 1: Yeah. I love to get the records to, you know, mark exactly what antibiotics they have, had they escalated treatment? And then, you know, those extra caveats, I call those hardships. Like, what hardships have you had with your ear infections? Have you needed to get Rocephin injections? Or they've missed a lot of school or the family, you know, is going to get fired from their job because their kids are sick all the time. So, it's important to look at those factors too. And it's just not the numbers, right? It's not the six in a year or four in six months. It's all of those other things too, that we have to take into consideration. So, I'm always willing to sit and talk with families about it and kind of tell them what our guidelines are and our recommendations.

Sara Ray, MSN: And that's what I also want families to understand these are the guidelines, these are the reasons that you get referred to us, it's not necessarily that you're going to come in and we're going to say, like, "Yes or no," just based on that. We look at the whole picture. So, having all of the information is really important. You know, those are the things that get you the referral to come and see us.

Host 1: Right, right. I think ear infections is one of the biggest reasons why we see patients, but we also see quite a few patients for different types of tonsil disorders. So, would you mind kind of switching gears and talking about some tonsil disorders and why we see patients to make recommendations for tonsillectomies and kind of what we do in that avenue?

Sara Ray, MSN: Yeah. So a lot of the referrals for our tonsil patients are large tonsils. Pediatrician takes a look in the mouth, and tonsils are just big. They will get a referral for that. Snoring is another big one. You know, they have big tonsils and they snore. When they're getting recurrent strep infections or recurrent tonsillitis infections, those are also reasons that they come to see us and get evaluated, to see if we think that we can help them by taking their tonsils out. It's not always a yes, sometimes we have to take into account other things. You know, there are risks that go into taking the tonsils out, and we like to be able to sit down and talk with the families and weigh those things out. So, just because the tonsils are big, it doesn't always necessarily mean that we're going to recommend taking them out, but we do look at, are they snoring every night? Are they having signs of sleep disordered breathing? Or have they had a sleep study? And we can actually say, yes, they're having sleep apnea. How often are they having these strep throat infections or episodes of tonsillitis? And we actually have pretty straightforward guidelines on when we think that it can be beneficial to remove the tonsils.

Host 2: Sara, do you mind reviewing the criteria for tonsils and adenoids?

Sara Ray, MSN: So, actually, it's called the Paradise Criteria and it is seven infections in a year, five infections each year for two years in a row, or three infections each year for three years in a row. So, those can be documented strep infections. And again, I know I mentioned it with the ear infections, but this is where sending the records can be really helpful, because we can go back and look and say, "Yes, you've had these episodes." It also takes into account the episodes of tonsillitis where maybe they didn't test positive for strep, but they had all the symptoms. You know, they had lymphadenopathy, they had exudates on their tonsils, they had fever, they developed a rash related to the infection. So, those are things that we do look at.

 I know that we do because we have all talked about this. I really appreciate it when the primary care office sends the records so that I can just look through it and I can say, you know, "Hey, I was able to review all of this stuff. I know it's hard to keep track of, but this is what I'm seeing. Help me fill in the blanks if I'm missing something." And I feel like families really appreciate that, because it makes their visit a lot smoother.

Host 1: I would completely agree. I love having all the records just like for the ears, strep throat, give me those records.

Sara Ray, MSN: Well, and I know a lot of us will end up reaching out to the PCP office or if they've gone to urgent cares. Because I know, I mean, we get sick when it's the weekend and we can't go to our primary care office. You know, it happens. But a lot of times we do end up reaching out and trying to request those records. And a lot of times, it ends up being really difficult for us, for the family. It's not always easy. And so when, we can get those ahead of time, it really does help us provide better care to our patient.

Host 1: Right. Completely agree. Would you mind jumping in a little bit further in regards to large tonsils and sleep disordered breathing? You know, you had mentioned loud snoring with pausing and gasping. And what are some other things that our kiddos can kind of present with? And is there any type of treatment that maybe as a primary care provider, we, meaning our colleagues, could help like a medication management or something, so like all of those boxes are checked before they come to ENT for surgical recommendations.

Sara Ray, MSN: Sure. So, some of the things that I ask a family is, you know, you can have big tonsils and you can have light snoring and no other symptoms. And that would not be something that's super concerning. I think I already kind of mentioned, we don't always take tonsils out just because they're big. But if you are having snoring at night, every night or, more often than not and we're noticing pausing, gasping, sleep that's not restful. So, you know, your kiddo goes to bed at a normal time and they're sleeping all night. They're restless, they wake up in the night, but they're able to go back to sleep, but they're waking up frequently. You try to get them up in the morning for school or daycare and they're tired and they're hard to get up. They're having trouble focusing at school or they're falling asleep in the car all the time. Sometimes patients that have sleep disordered breathing or sleep apnea, they'll be older kids that still have accidents, they wet the bed. You can have really bad breath, despite brushing your teeth. You think about how we feel when we don't get a good night's sleep and it's not every night, but you have just one bad night. Think about these kiddos that are just not getting good sleep at all. They're cranky. They're fussy.

Those are sometimes the symptoms, but then you can also have the kids that go the other direction where they're just really hyper. You notice some of those things, like they're hard to wake up. But once they get up, they are just bouncing off the walls all day. And that's because they're tired and they're trying to stay awake. My son sometimes tells me he'll sit and kind of move his legs around or he's just always kind of moving. And I know that that's a sign of him being tired. And I'm like, "Hey, why are you moving around?" And he's like, "Well, if I stop moving, I'm going to fall asleep."

Those are things that, I usually ask families and those are reasons to sometimes consider taking tonsils out. If they're large and we're seeing all of these symptoms, those are reasons to consider tonsillectomy. A lot of times when we take the tonsils out, we do take the adenoid tissue out as well. A lot of times we'll see constant congestion, breathing with your mouth open. I think we've all seen those kids where you're just like, "Man, you always have your mouth wide open and you kind of sound like Darth Vader." That's usually coming from the adenoid tissue.

Things that primary care doctor or primary care provider could do ahead of coming to see us is start Flonase and start Zyrtec or Claritin, either one. Some people will notice an improvement in symptoms with just doing those things. But a lot of times when they come to see us, we're going to talk about that as an option anyways. the way I choose to practice as a provider is I don't ever see my job as necessarily telling a family what to do. I am here to explain why you can do what you can do, what your options are, and answer your questions so that you feel like you're making a good decision.

So, one of the options is always trying medication. I can't guarantee that it's going to help, but it is always an option. We can always try it. If they have already tried it prior to coming to see us, then it helps us make a decision sooner or provide better options. You know, you've already done these things, so now we have a couple of other options for you.

 One thing that we always offer families if they haven't already done it is you can get a sleep study. I have some families that really, they want to see the data, they want to see that their kiddo really is having trouble sleeping and that they really are having apnea. so that's always an option or in a lot of situations, we can just go ahead and move forward with tonsillectomy and adenoidectomy based on what families tell me in person and what the exam shows. But starting medication is always a great place, because then when they come to us, it doesn't delay their care.

Host 1: That's not something that has to be started for three months and then come back and see us. And, you know, if the families want that as an option, that can get started. And then, by the time it takes them to get into us, that trial period would have been over and they would have said, yes, there was results or no results, and then we move forward.

Sara Ray, MSN: Right. It just kind of helps streamline their care, I guess. It makes it quicker for them once they get in to see us.

Host 1: Yeah. That's a good way to put it.

Host 2: Yes. Okay. Well, thank you. I feel like that was very helpful at least one other topic I would like to cover is nosebleeds, because I know we get a lot of nosebleeds. So, let's talk about those and kind of what-- because I feel like there's a lot of management that could be done prior to coming to see us. So, let's talk a little bit about some options for kids to try before coming to see us in ENT.

Sara Ray, MSN: Sure. Nosebleeds, one of the main things that I find when patients come in, is it happens a lot starting in the fall. Fall, winter, those are the worst months. That's when the air is drier. That's when we start to see a lot of nosebleeds. Most of the time, I feel like we can manage those medically. I have had great success with just really-- the key is moisturizing the nose and that usually will take care of things and making sure that families know exactly how to manage it. Pinching the nostrils together. I have lots of families that come in and they, they show me where they're pinching. And that's always one of my biggest questions, is how do you get a nosebleed to stop? And they're like, "Well, I pinch my nose." And they're pinching up at the bridge of their nose on the bone. That's not going to actually stop the bleeding because most of the time the bleeding is coming from the front of the nose, so if they pinch their nostrils together, they're going to have much better luck with stopping the nosebleed. So, it really is just kind of fine tuning some of the things families are doing. So making sure they're pinching at the nostrils when they actually have a nosebleed, holding pressure there for at least 10 minutes. They can, you know, let up, make sure that things have stopped. If they haven't, go back to holding pressure again for another 10 minutes. If you have a nosebleed that is lasting longer than 20-30 minutes, then they really do need to go seek care at urgent care, ER, somewhere where somebody can take a look and see why is this nosebleed not stopping. That's kind of in the acute, I'm-having-an-active-nosebleed situation. But things that you can do when you're not having a nosebleed to help prevent them is really just moisturizing the nose. So, you can do Vaseline. I don't like Vaseline as much just because I am kind of a texture person and I don't like the way it feels. I think it's too goopy. I don't like that. And I think that's a technical term, goopy.

Host 1: I think it is.

Sara Ray, MSN: So, I don't like the way it feels. So, I like Ayr Gel. It's A-Y-R Gel. it is nasal saline in gel form. It sticks in the nose really well. I like that better. I don't think it's as goopy. You want to do that a couple times a day, two to three times a day, just to help moisturize the nose. Doing a humidifier at the bedside really helps also. One of our physicians, she's no longer at Children's Mercy, but she used to always call it "making a rain forest in the nose." That just always stuck in my head. I'm like, "Yeah, you just want it to be like warm and moist," and that's going to help prevent those blood vessels from cracking and bleeding. So, doing that consistently. Like I said, fall and winter are the worst. But if you are a person that is just more prone to nosebleeds, you might have to do it every day year round. But I think those are good places to start before you even come to see us. Once you come to see us, if you've been doing those things consistently, again, it helps streamline their care. Because then we know you've already done these things, and for a lack of better terms, you've failed medical management. You're not responding to the things that are less invasive. Putting some Vaseline or Ayr Gel in your nose is pretty easy, it's non-invasive. It doesn't really bother people. But if you're not noticing an improvement, we need to figure out what the next step is, which a lot of times is nasal cautery. Our physicians do that in the clinic for some kids, for some of our older kids. Some of our younger kids would have to go to the operating room for that. But again, it just helps us streamline care. Because you've already done these things, these things didn't work, so this is the next step.

Host 2: That is super helpful, Sara. The one other one I'd like to add is just those kids, specifically more of a kind of teen age that are boys, like, if they're only bleeding from one side, they should be more of a quick referral.

Sara Ray, MSN: They should because there is a nasal tumor. It's not common, but it is teenage boys that have bleeding, like you said, just from one side of the nose, that is concerning for this tumor. And we want to have eyes on them. We have a camera. It's a flexible scope camera that we're able to look in the nose and we're able to rule that out, and make sure that that is not what's causing the nosebleeds. I've been at Children's in the ENT clinic for, like I said, almost eight years. I've never actually seen it, but it is always something that all of our mid-level providers, we all know that that is a concern when it is , a boy, a teenager, specifically. It's not common in girls, it's not as concerning. But those are things that, we always think about when it's a teenage boy. And that's why we want to get them in faster.

Host 1: Very helpful words of wisdom today, Sara. Thank you so much for spending your, time with us and giving our listeners some wise words and things to do for our ear, nose and throat patients. It was great to speak with you today.

Host 2: I know we could go on and on and on, but we'll just have to have you on for a second time because we got to cover hearing loss, we got to cover all kinds of stuff, but we do not have time today. So, we'll cut it short today, but like, just be ready. We're going to probably ask you to come on again. So, thank you so much for helping us today. We always end with a question. So, this season's question is, what would your younger self high five you for now?

Sara Ray, MSN: Oh gosh. Wow. I don't know. Honestly, I think my younger self would probably high five me because in the last eight years, and I probably have Trisha to actually thank for this, because like she said, we share a brain and we are basically the same person. She's blonde, I have brown hair, but we're basically the same person.

Host 1: Basically.

Sara Ray, MSN: I think that I've just become way more confident in myself than being a provider. And I feel like my younger self would be proud of that. I feel like most situations, I'm pretty confident in what I see. And if I don't know exactly how to manage something or what the next step is, I feel confident going in and talking with somebody and figuring out the answer. So, I think my younger self would be proud of how confident I am. And I get a lot of that from Trisha. Trisha actually trained me when I first started in the Ear, Nose and Throat Clinic, so I have to thank her for a lot of that.

Host 1: Well, thank you. But I can't take all the credit, girl. I can't. You're amazing. So, I learn from you on a daily basis as well. What is that saying? Quid pro quo, they say, right?

Host 2: Sara, thanks again so much for joining us. You should be confident because you know what you're talking about. So, I really enjoyed having you on, and I think it will be super helpful to people to listen in. So, we thank you for sharing time with us today.

Sara Ray, MSN: Yeah. Thanks for having me.

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