Which brings me to, why do people think it’s the vaccines?

Sorry again; you ain’t gonna like the answer.

ASD is, for all practical purposes, a learning disability limited to interpersonal relationships.  Among other things, people with even mild  ASD cannot tell when someone is lying to them.  We responsible physicians tell them ASD is about genetics and parent age.  Translation: your children are growing up just like you but more so.

It’s as if we were saying: It’s all your fault.
From the other side, they are bombarded with another message.  Whether it’s MMR, mercury or microwaves, absence of evidence of connection is not interpreted as evidence of absence.  The more myths are debunked, the more fervently they are cherished, for at their core is this:

Someone did this to your child.

And what parent would not cling to that?

My own concerns with vaccines have nothing to do with either their safety or their efficacy.  I am concerned with the recent trend to require universal vaccination against diseases that are not significantly dangerous but rather unpleasant, which require school or work absence and medical care but are not likely to result in death or lasting damage.  I suspect that, as more children are crammed into day care for longer periods of time, other viruses will take their place — Norwalk and enteroviruses for Rotavirus,  Adenovirus for flu — negating the improvement from the vaccines.  Only if the current trend to place more and more children in day care is reversed will we see fewer sick children — and then the vaccines will really help.

Take home message:

(1) CDC recommends 2 doses of flu vaccine, 1 month apart, for certain patients, such as those under 9 years of age receiving the vaccine for the first time;

(2) Injectable vaccine is less effective than the nasal vaccine in preventing flu, but it is highly effective at preventing complications and hospitalizations;

(3) We have both, and will be happy to help you to select the right one for your needs.

(4) Two resources to find out about flu activity in our area:

http://www.google.org/flutrends/

http://cdc.gov/flu/weekly/

Stay healthy!

What this has to do with a pediatric blog is to understand why we don’t have all the answers.

This lesson was recently driven home to me in a most impressive fashion.  I drove my son to a weight-reduction camp, and returned a month later to pick up a much different person.  16 pounds lighter, yes, but that’s the least of it.  I picked up someone who learned responsibility, self-respect, self-reliance, confidence, and strength.  I picked up someone who was trained in all the values I had tried to teach, by precept and by example.  And I picked up a lesson in what pediatricians can and cannot do.

There was a three day seminar for parents on the last weekend of camp which I attended.  It was a full-time, all-day, three-day training session which tried to cram into our heads the same information and the same habits which the campers had a full 4 to 8 weeks to absorb.  For the parents, it was, of course, a partial failure — demonstrating the need for the 4 to 8 weeks in the first place.  It was a success in setting up for our continued education — by our highly trained children. 

At the seminar I had the unenviable task of listening to the parents relate the stories of how ineffective their pediatricians were at weight control.  Obviously I knew that already; not only have I not been effective with my patients, I have not even been effective with my own son.  This is where education is ineffective by definition, just as it cannot produce a driver, pilot, physician or carpenter; and training is beyond our capabilities: it requires a complete takeover of the patient’s life, with continued vigilance and sticking to the principles of healthy life when they are not necessarily enjoyable.  Physicians provide services; and weight control cannot be a service.  It is a way of life.  It can only come by breaking of prior habits and starting new ones.  It was no surprise that the camp director was a former paratrooper with a nursing degree; what the campers got was boot camp with compassion and care.  And for all our medical training, dammit, Jim, I’m a doctor, not a drill sergeant.

 So let this stand as a most enthusiastic endorsement of the camp in question.  As for your doctor, by all means, ask his or her advice.  Try the standard advice we all dispense: family meals (as opposed to eating in restaurants, especially fast food), not drinking your calories (not only are sweetened drinks not good for you, but, contrary to popular opinion, neither are juices), small portions, limiting screen time to less than 2 hours a day (that’s non-homework computer, video game, and TV combined), never eating while watching TV or using computer/video game, eating as much as possible fresh fruits or vegetables, whole grain foods, and low-fat meat and dairy, and increasing activity levels; but we will not come into your home and make you do it.  Because, to paraphrase a great man, I want to be your doctor, not your mother-in-law.

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!

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.

 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.

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

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.

They tell me why they brought their child. I ask questions to clarify. I do an exam, possibly follow up with tests, possibly not. Then I start telling them what I suspect is going on. There is a pause as it dawns on them that what I do is similar to identifying a suspect in an investigation, or enemy intentions in intelligence assessment. Then there is a change in the tone of the conversation: it becomes a council of colleagues. That is the moment we both realize that we are in the same business.

I said this before and I will say this again: Mother Nature is not our friend She is not our enemy, either, more like a disinterested observer in the competition between us and her other children — a group that includes both the Angus cow and the Anopheles mosquito. Being that I am basically on the human side, I have no problems with either carpaccio or carbenicillin.

Pediatrics, military and law enforcement are united, forst and foremost, by justified paranoia. In ten thousand children with fever, one will turn out to have meningitis. Of a million people who got parking tickets in 1977, one was Son of Sam. And of a dozen counter-attacks in the winter of 1944, one turned into the Battle of the Bulge. The ability to stay alert and ready for trouble through weeks or months of false alarms is what I call justified paranoia.

We are united in staying away from the magic bullet. Spies and informants may lie; aerial photographs, Xrays, and physical evidence may be misleading; big guns and antibiotics may fail. Cops and soldiers look at you funny when you say, this ONE test tells me WITH ABSOLUTE CERTAINTY that this is the diagnosis. If you tell them that these three or four or five things point in the direction of one of these two or three diagnoses, and this is what you need to do to be safest in all likely events, they look at you — well, they look at you like you are their colleague.

We are united in contempt for wishful thinking. Unilateral disarmament is positive assistance to the side that ignores pacifists; naturopathic medicine is positive assistance to diseases with naturally high mortality. Nature, like anarchy, is on the side of survival of the fittest. Survival of the beloved is as unnatural as one can imagine. This is where we come in.

And, having faced friendly fire and adverse events, we understand the difference between the best possible decision under the circumstances, and post-factum omniscience.

Where we part company is the question of personal risk. Not needing Kevlar apparel, my safety in in being behind those who do, and to them this post is dedicated.