DMG said...
Now I have a question for the parents in the audience (Submariner is not allowed to answer).What would you do in this situation:
You have a 4-week old infant, who for a couple of weeks had been feeding OK, but now you notice
Projectile vomiting. (Forceful ejection of milk or formula up to several feet away) within a half hour after each feeding, which has gradually gotten worse. A couple of times you've seen blood.
And now your little one ALWAYS seems hungry and you notice contractions across his upper belly very soon after eating, and before vomiting.
Little man is crying like crazy but you don't see any tears and he seems weak. You've gone from changing several diapers a day down to maybe 3 or 4 per day, and he's lost weight.
Just curious what you all would do and how long it would take you to seek help, and what you would and would not allow.
Denmark Vesey said ...
Good question Doc.
"Projectile vomiting. (Forceful ejection of milk or formula up to several feet away) within a half hour after each feeding, which has gradually gotten worse. A couple of times you've seen blood."
If my 4 week old is projectile vomiting up blood, after he eats, I am going to assume there is a problem with what he eats. If he is eating milk or formula ... I'm going to KNOW the problem is milk or formula. My children drank breast milk and never had a problem with projectile vomit.
"And now your little one ALWAYS seems hungry and you notice contractions across his upper belly very soon after eating, and before vomiting. Little man is crying like crazy but you don't see any tears and he seems weak. You've gone from changing several diapers a day down to maybe 3 or 4 per day, and he's lost weight."
If my 4 week old infant has been drinking breast milk fine up until now, and is suddenly projectile vomiting, spitting up blood and having contractions, I would take him to the nearest hospital. To get a diagnosis. That's it.
If he's filling his diaper, I'm going to assume it's something viral. If he has a fever, I will be relieved and allow the body to fight the infection on its own.
If he doesn't have a fever I would take him to the nearest hospital. To get a diagnosis. That's it.
I would say thank you and immediately seek alternative holisitic natural treatment of whatever the diagnosis. Inevitably the Plantation doctors are going to recommend drugs. That would be my absolute last resort.
What would you do Doc?
27 comments:
So now you have your diagnosis. Infantile Hypertrophic Pyloric Stenosis. Food is not, and will not pass out of his stomach into his distal GI tract. It's a mechanical obstruction. Your little one needs rehydration, he needs to have his electrolytes replaced, and surgical intervention.
Your baby is wasting away, lethargic, dehydrated. The nurse in the pediatric emergency department is waiting to place an IV. My colleagues in the Peds ICU have made a bed ready. My colleague, the pediatric surgeon, has been consulted and has called for the pediatric laparoscopic instruments. We are waiting on you. What's your decision?
oh schnap...,
It is not known exactly what causes the thickening of the muscles of the pylorus — it may be a combination of several factors. Some researchers believe that maternal hormones could be a contributing cause. Others believe that the thickening of the muscle is the stomach's response to some type of allergic reaction in the body.
What do you think is the cause Doc?
I posted this comment in a post below where the question was originally posed -
What's crazy is that everything you've described is what my mother was experiencing when she had colon cancer and what three different geniuses of medical "science" misdiagnosed as food poisoning. Stage III colon cancer, distended belly and those douchebags with their haughty "I'm a doctor" told her to go home and recover from food fucking poisoning!!
But back to the question...
I'm sure I would do whatever was reasonably necessary to fix my daughter as soon as possible. The only problem with your hypothetical Doc is that it doesn't take into account how that kid ended up sick in the first place. It would become my mission to know how it happened so that it wouldn't happen again.
My approach is to not have preventable stuff happen. So I obsess about everything my angel eats, what she wears, what she bathes in, etc. I watch her reactions and adjust accordingly. If I feed her dairy, her nose runs like it's got somewhere to go. So we don't do dairy. And bingo, she's never had an ear infection, sinus infection or any other craziness that I'm told is something all kids just get. B.S. They don't JUST get anything and it's that fatalist approach by parents and doctors that keeps kids sick.
My sister tells me there are kids who are "frequent flyers" at her hospital, because the parents put ZERO thought into their parenting, the kids are always sick and the parents come to the hospital and expect the doctors to work magic. Because so many parents are like this, pediatricians become very dismissive of parents who actually do put in the effort and care to know how to prevent things.
Apparently, many parents just want doctors to drug their kids, so doctors get accustomed to that approach. It's a vicious cycle. When a doctor sees that so much, it gets very hard to get them to see you or your child as an individual. It is understandable, but it still isn't ok with me.
If more parents actually parented and put some damn thought into it, doctors would be kept on their toes, which would improve quality of care.
" The only problem with your hypothetical Doc is that it doesn't take into account how that kid ended up sick in the first place."
Bingo.
"They don't JUST get anything and it's that fatalist approach by parents and doctors that keeps kids sick."
(I don't even have to reply. Teach Insugent. Teach)
MOTI,
Screaming about how your kid got sick will not make the mechanical obstruction disappear.
Am I to assume that while your baby is literally wasting away in your arms, dehydrated, perilously close to slipping into a coma, that you would choose to posture?
Tick tock. What are you going to do?
I'm waiting on your answer. Your boy is grimacing in pain, but still seems to be lethargic. Every little bit of urine that comes out burns because it's more acidic. You see he's twitching and having spasms...
Sir, we'd like your consent...
DMG you are citing a very serious example of such an obstruction. You admitted earlier that sometimes these obstructions go away without invasive procedures. In order to convince me that my baby would need surgery, you would have to do the ultrasound/sonagram or x ray or whatever diagnostic tool to SEE its nature. If you could get away with hydrating the baby via IV I would consent, but you would have to show me a smoking gun to justify an invasive procedure.
As an aside, my Uncle suffered from that as a little little baby and got surgery, which corrected it.
My father in law (who is 78 going on 79) also had an obstruction as an infant but only had access to the colored hospital, which had limited resources.
They told his mother to take raw egg and give it to him daily and on her account and his own, the obstruction went away within a couple of weeks due to that treatment.
Thus, if you could show me alternative means of combating the problem I'd be game. If you would suggest that the problem is so severe that only surgery would help, with the picture as a smoking gun I'd listen.
I would do whatever it took for my baby to heal.
Now, you never answered MY question. You are doing a study of one sample. You use an instrument to measure some property of the subjects before an intervention. Then you perform an intervention and use that same instrument to measure the same property post intervention. What statistics are most appropriate for analysis of sample now?
Mahndisa,
You read wrong. I mentioned nothing about resolution without an invasive procedure. Yes, these obstructions may resolve after several months, however, you aren't going to let your child go that long without eating, so it's either several months in hospital being fed through a large vein in his neck (and all of the consequences of long term TPN), or I'm going to perform surgery anyway to place a feeding tube past the obstruction...with all of the consequences of a feeding tube.
Baby dies without intervention. Simplest and best thing to do is pyloromyotomy...in the hands of a pediatric surgeon.
Getting an ultrasound or X-ray after having felt the obstruction on physical exam isn't necessary, but if you'd like to have it done, no problem. Don't be upset about the cost if your insurance doesn't cover it. The smoking gun is the clinical presentation and physical findings. (I don't require CT's to diagnose appendicitis either).
I doubt your father had pyloric stenosis that resolved with raw eggs.
I don't understand where I read wrong. You said that sometimes these cases resolve themselves without surgery. I read that much myself. An IV is invasive, but it doesn't involve removing or cutting anything per se. And like I said, I'd allow an IV pending results from how the obstruction looks.
And it was my father in law with the raw eggs. I haven't looked this up in any old medical journals from the past to see if that was an acceptable course of treatment for that issue. But what I do know is that people have been finding ways to combat stuff without surgical intervention for years by making other drastic moves.
I have good insurance and I would get an authorization for diagnostics to be certain that the problem was diagnosed correctly or pay out of pocket to make sure.
You still didn't answer the question, but I did answer yours. What is the appropriate statistical analysis given the case I mentioned above?
If you have no idea, you could just say so. I am curious to see how much you know about statistics since you invoked them in previous posts.
Your lack of an answer tells me that you don't know the answer but are too ego ridden to admit it. Correct me if I'm wrong. After all, I'm not a doctor but answered your question.
Mahndisa,
I'm still waiting on our host. I'll assume he's busy, because I know he wouldn't wimp out.
I believe this is what I wrote:
"The next question is probably, can they get well without surgery? Recovery without surgery is possible, but that would take several weeks or even months...which would require long term feeding through a catheter in a large vein, accessed by going by the neck or under the clavicle."
I said it may resolve without surgical intervention--not medical intervention...and that it takes weeks to months likely in a hospital. I've you'd like to know how long an infant would last without any medical intervention...how long do you think a newborn can go without eating, and constantly throwing up?
Anyway, my lack of answer to your stats question means that I just got back from my son's lacrosse practice, a 2.5 mile run, a late dinner, and chat with my family.
About the insurance thing. I don't think I'd hold anything up for insurance authorization. A third year med student could diagnose this disease without imaging (and one of my good ones did just that).
I'm not really interested in your question, to be honest I dislike the subject as it bores me and haven't put any thought into it, but I do understand it quite well. Really, if I wanted to know the answer if I were designing a study, I'd ask our research department...because that's what grad students and other minion are for. I'll think about your question and give you an answer, but I'm more interested in the subject of this thread right now (by the way attempting to goad me into a tit for tat with you isn't going to work, but I do appreciate your answer to my question).
You don't know the answer which is why you are obfuscating but are too ego driven to admit it. You say oh minions are supposed to answer that, which btw is a problem at ucsf people that design studies that have no understanding of what they are doing. Clearly you don't know stats. I only brought it up because you mentioned it previously and if you mention using stats to justify a position, then you likely should know what you are talking about.
Sure your life must be busy but you had enough time to concoct a non answer to my question. uh huh you are showing your ass. You cannot have it both ways.
Hehehehe the answer is only two words long! ahhahahahahah you really don't understand the issue at all!
Hey Mahndisa,
Since you are intent on giving our host cover by changing/hijacking the subject to something that is completely off topic (you could have invited me to your site to have a chat about statistics) and much less interesting, I'll bite...for the moment.
OK to your question (hmmm, sample size is 1). First I have some questions for you.
What is the instrument of measurement? (Am I measuring a small childs head circumference before and after treatment for hydrocephalus? Am I using a detailed memory test for someone with Alzheimers? Does my instrument only give me yes or no data)
What am I measuring? Am I measuring return of function (yes no answer)? Apgar score of one baby before and after nasal suctioning? Does my population usually follow a Gaussian or Non-Gaussian distribution? How many possible outcomes are there?
And my most important question: Why would I study only ONE sample, with one intervention. If my n=1 this is observational study at best, and I'd merely describe the change and wouldn't choose a test. (Example ONE child has hydrocephalus head circumference measures x before intervention. After a novel intervention his head measures y. I can report the percent change from his previous, and also compare it to norms for his age group).
Assuming you didn't make a typo, my sample size is still 1, even if I'm measuring a property that is post intervention.
MOTI,
I'm disappointed. I thought you would step up and stick close to your principled stance against all that is "plantation" medicine and give me an "alternative". But when it comes down to watching your baby dying in your hands all of this rhetoric goes out the window. I wanted to see how far you'd push this plantation medicine theme when it comes to your own seed. I suppose that if you acquiesced to even a hypothetical situation, you'd look like a hypocrite. If you notice the two mothers who are usually vehemently against me said they would do what it takes to protect their offspring. I will assume that your wife would have elbowed you out of the way and signed the consent to save her baby, and you wouldn't have interfered. Please correct me if I'm wrong. I'd still love to hear your response.
What I do is serious. I'll admit it's fun sometimes to debate this stuff and entertain silly ideas online, because nobody is getting hurt right? Except for maybe for the person who doesn't have enough sense in their head to realize that you are only a blogger with no real knowledge of medicine or even how the human body functions.
I haven't met the cat yet who reads this blog and takes the word of Denmark Vesey as gospel...
I've never seen any evidence of that here. On every topic, there are some cats challenging DV and some cats agreeing with him. Who is on what side seems to depend on the particular topic.
All evidence I've seen is that the readers of this blog are intelligent people with their own opinions and own minds who are not easily swayed by the talk of one man.
Hey Big Man,
I say that because I hear some of the same stuff in my place of business as I do here. Rumors begin and circulate somehow. I've had too many "WTF! NO, really W-T-F!!!" moments after walking into a room for a consult. Anyway, I think it's everybody's duty to point out nonsense.
DMG
I agree with you.
I just don't think it makes sense to claim that challenging DV is a way of eliminating harmful rumors.
The people who believe quack rumors immediately probably aren't the people who visit this blog.
Truthfully, and this is just a guess, I figure you challenge DV cause it's an intellectual contest. And, from what I've seen, everbody who vists this blog has a healthy ego when it comes to their intelligence.
So, you tweak DV cause you disagree with him, and cause you want to show other cats that he ain't as smart as he thinks he is. He does the same with you. It's pretty much the standard prodcedure for everybody here.
I hope you keep challenging him because I like hearing the different opinions when it comes to medicine and other stuff.
But I don't think you do it 'cause you really believe it's going to alleviate the ignorance some of your patients display.
Big Man,
Nope. Ego wasn't involved. But kicking our hosts ass daily is a perk. And I know he can take and if I didn't like him, I'd ignore him.
My challenge to our host was for two reasons. First, I wanted to learn how people who are against modern medicine think in a situation where my services are unavoidable. Second, I wanted to see how far our host was ready to go with his rhetoric. Our hosts first answer was somewhat illuminating as he stated that he'd venture onto the "plantation" to seek out a diagnosis, but seek care from some alternative method...wasting valuable time that would unnecessarily risk the life of the baby. Anyhow, I know he'd eventually have found his way back to the emergency department. Because any real man would swallow his pride to protect his child. Our host seems to be a real man. In a real situation, I wouldn't hold a grudge or even pass judgment. After the infant is safe I'd suggest to the parents to think more carefully about their medical choices and tell them my doors are always open.
"But I don't think you do it 'cause you really believe it's going to alleviate the ignorance some of your patients display."
That's precisely why I do it. You don't really think I believe he's my equal when it comes to medicine or the sciences. Do you? I think he's a very intelligent guy. My personal belief is that he's got alot of potential brainpower that he's wasting touting all sorts of snake-oil and conspiracy theories. But that's his right. The difference between us is that I chose to fill my head with facts and evidence. I'm no more "intelligent" now than before I began medical school, but now I have several more volumes of information that I can access.
Actually, I do hope that some cat out there nodding to everything that spills from our hosts fingertips, at least pauses when he sees the curtain pulled back to reveal that our host is no more profound than the brother on the corner selling bean pies. I guess you can say that I enjoy giving away the magicians secrets. Hopefully by doing so, those currently blinded by the smoke and mirrors will have the sense to at least wipe their eyes. Maybe our host even did a double take to re-evaluate his beliefs. How often do we get a chance to work through these exercises of life and death without any real consequences?
DMG, DV would get that kid of his to you so fast time would stop.
You've obfuscated the idea once more. Firstly, I said the sample size was the same both before and after the intervention. IT doesn't matter what type of intervention you are doing. Your other statements are irrelevant. You don't know the answer. And no I haven't hijacked anything. I asked you this question a while ago. You are ignorant in this area and just don't have the balls to admit it.
Fair enough. You've showed your ass.
Mahndisa,
Everyone here it seems has a "tell". Our host rhymes, you start swearing.
Your question is boring and vague, but I put some thought into it anyway (I'm nice like that). Your aim isn't to enlighten, but is a thinly veiled attempt to boost yourself up and make a bogus statement.
But I'll give you the benefit of doubt. Maybe you didn't realize that your question was so vague. Perhaps you'd like to be more specific?
You made me go to my basement to dig out my Biostatistics text to review this boring subject. I've momentarily indulged your attention seeking. Either give me a better formulated question, with more specific details or go home.
^ DMG, you read the other players well. Do you live near a card room? Where you play poker at?
Must check out the Commerce Casino if you're ever in SoCal.
UBM,
I've been known to play with the neighborhood dads every once in awhile. My wife won't allow me to bring my wallet though...she packs me off with drivers license and no more than a $50 bill. If I'm bringing beers, she keeps the license...
I'll see if my brother wants to check it out with me, next time I'm out that way.
DMG I will say one more thing on this. This was not an attempt to boost my self in any way. I was trying to hold you to the same standard that you have held everyone else. You mentioned statistics to justify one of your positions. My contention is that most doctors don't know basic statistics and therefore, you are citing something you don't understand.
The question isn't vague at all and has a very simple and very clear answer. I asked my husband and he rattled off the answer within ten seconds.
It is clear that you feel yourself to be an educator but shirk when you are in a position to be educated.
I am very surprised that someone who has authored papers, as you have claimed, could not answer this simple question.
And to put this into perspective, this simple analytical tool I am referring to is the underlying basis for many a clinical trial study.
One more reason why people are more and more suspicious of doctors and the FDA.
Mahndisa,
Once more, the design of my study will be different if the data is measured (calipers) or ranked (scale of 1-10). If you are looking for me to answer paired t-test, you should have been more specific.
If you want to be paranoid about physicians and the FDA, that's on you. You should take a Biostats course you'd enjoy it.
Post a Comment